目的:现有疗法治疗与颞下颌关节紊乱病(TMD)相关的慢性疼痛的比较效果如何?
背景:TMD是仅次于下腰痛的第二常见的肌肉骨骼慢性疼痛疾病,影响全球6-9%的成年人。TMD与影响下颌和相关结构的疼痛有关,并可能出现头痛,耳痛,单击,爆裂,或者颞下颌关节发出crack啪声,下颌功能受损。当前的临床实践指南在很大程度上是基于共识的,并且提供了不一致的建议。
结论:对于患有与TMD相关的慢性疼痛(≥3个月)的患者,与安慰剂或假手术相比,指南小组发布:(1)支持认知行为疗法(CBT)有或没有生物反馈或放松疗法,治疗师辅助动员,手动触发点治疗,有监督的姿势练习,有或没有手动触发点治疗的监督下颌运动和伸展,和日常护理(如家庭锻炼,伸展,放心,和教育);(2)有利于操纵的有条件建议,动员监督下颌运动,CBT与非甾体抗炎药(NSAIDS),通过姿势练习进行操纵,和针灸;(3)有条件的建议,反对可逆咬合夹板(单独或与其他干预措施相结合),关节穿刺术(单独或与其他干预措施组合),软骨补充剂有或没有透明质酸注射,低水平激光治疗(单独或与其他干预措施结合使用),经皮神经电刺激,加巴喷丁,肉毒杆菌毒素注射,透明质酸注射液,放松疗法,触发点注射,对乙酰氨基酚(含或不含肌肉松弛剂或NSAIDS),局部辣椒素,生物反馈,皮质类固醇注射(有或没有NSAIDS),苯二氮卓类药物,和β受体阻滞剂;(4)强烈建议反对不可逆的口腔夹板,椎间盘切除术,和NSAIDS与阿片类药物。
■包括患者在内的国际指南开发小组,具有内容专业知识的临床医生,方法学家使用GRADE方法,按照值得信赖的指南标准提出了这些建议。MAGIC证据生态系统基金会(MAGIC)提供了方法支持。小组从患者的角度着手制定建议,而不是从人口或卫生系统的角度来看。
■建议由相关的系统评价和网络荟萃分析提供信息,总结了保守者的利弊的当前证据,药理学,和TMD继发慢性疼痛的侵入性干预措施。
■这些建议适用于患有与TMD相关的慢性疼痛(持续时间≥3个月)的患者,不适用于急性TMD疼痛的治疗。在考虑管理选项时,临床医生和患者应该首先考虑强烈推荐的干预措施,那么那些有条件推荐的人,有条件地反对。在这样做的时候,共同决策对于确保患者做出反映其价值观和偏好的选择至关重要,干预措施的可用性,以及他们可能已经尝试过的东西。需要进一步的研究,并可能在未来改变建议。
What is the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD)?
TMD are the second most common musculoskeletal chronic pain disorder after low back pain, affecting 6-9% of adults globally. TMD are associated with pain affecting the jaw and associated structures and may present with headaches, earache, clicking, popping, or crackling sounds in the temporomandibular joint, and impaired mandibular function. Current clinical practice
guidelines are largely
consensus-based and provide inconsistent recommendations.
For patients living with chronic pain (≥3 months) associated with TMD, and compared with placebo or sham procedures, the
guideline panel issued: (1) strong recommendations in favour of cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care (such as home exercises, stretching, reassurance, and education); (2) conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture; (3) conditional recommendations against reversible occlusal splints (alone or in combination with other interventions), arthrocentesis (alone or in combination with other interventions), cartilage supplement with or without hyaluronic acid injection, low level laser therapy (alone or in combination with other interventions), transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen (with or without muscle relaxants or NSAIDS), topical capsaicin, biofeedback, corticosteroid injection (with or without NSAIDS), benzodiazepines, and β blockers; and (4) strong recommendations against irreversible oral splints, discectomy, and NSAIDS with opioids.
An international
guideline development panel including patients, clinicians with content expertise, and methodologists produced these recommendations in adherence with standards for trustworthy
guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel approached the formulation of recommendations from the perspective of patients, rather than a population or health system perspective.
Recommendations are informed by a linked systematic review and network meta-analysis summarising the current body of evidence for benefits and harms of conservative, pharmacologic, and invasive interventions for chronic pain secondary to TMD.
These recommendations apply to patients living with chronic pain (≥3 months duration) associated with TMD as a group of conditions, and do not apply to the management of acute TMD pain. When considering management options, clinicians and patients should first consider strongly recommended interventions, then those conditionally recommended in favour, then conditionally against. In doing so, shared decision making is essential to ensure patients make choices that reflect their values and preference, availability of interventions, and what they may have already tried. Further research is warranted and may alter recommendations in the future.