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Treatment of headache attributed to temporomandibular disorder with a flat plane occlusal splint and injections of botulinum toxin
No full textNamen: Diagnoza »glavobol zaradi temporomandibularne motnje« je bila šele leta 2004 uvrščena v mednarodno klasifikacijo glavobolov. Glede na vzročno zvezo med temporomandibularnimi motnjami (TMM) in glavobolom zaradi TMM je razumljivo, da bi se moral glavobol zaradi TMM odzvati na zdravljenje TMM.
Namen dela je bil ugotoviti, ali se da z okluzijsko opornico in/ali injekcijami inkobotulinum toksina A učinkovito zdraviti glavobol zaradi TMM.
Preiskovanci in metode: Vzorec je obsegal 126 zaporednih odraslih pacientov, ki so bili zaradi TMM napoteni na Center za stomatološko protetiko (Stomatološka klinika, Univerzitetni klinični center v Ljubljani) in smo jim diagnosticirali glavobol zaradi TMM po diagnostičnih merilih tretje izdaje mednarodne klasifikacije glavobolov (ang. The International Classification of Headache Disorders 3rd Edition - ICHD-III).
Paciente z glavobolom zaradi TMM smo naključno razdelili v štiri skupine po 30 pacientov in jim predpisali terapijo. Terapevtske možnosti so pri vseh vključevale svetovanje, prva skupina je prejela michigansko opornico ter injekcije inkobotulinum toksina A, druga skupina michigansko opornico ter placebo injekcije, tretja skupina kognitivno opornico ter injekcije inkobotulinum toksina A, četrta pa kognitivno opornico ter placebo injekcije. Svetovanje je obsegalo navodila o izogibanju stresnim situacijam, uživanju mehke hrane, obojestranskem žvečenju, vajah za razgibavanje stomatognatnega sistema (SGS) in lahki aerobni vadbi (lahek tek, hoja itd.). Michigansko in placebo opornice smo izdelali s folijami za globoki vlek. Placebo opornica je izdelana brez dviga griza, zobje so v stiku, opornica ne pokriva okluzijskih ploskev. Injekcije inkobotulinum toksina A in placebo injekcije v temporalni in masetrni mišici je apliciral za to usposobljen nevrolog. Protokol injiciranja inkobotulinum toksina A v temporalni mišici za zdravljenje TMM je bil 20 enot simetrično in v masetrni mišici 30 enot simetrično v vsako masetrno mišico. Učinkovitost zdravljenja glavobola zaradi TMM smo vrednotili s pacientovimi samoocenami: kakovosti življenja, povezanega z ustnim zdravjem, kakovosti spanja, bolečine, depresije, anksioznosti in somatizacije s slovenskimi različicami psihometričnih testov na dan prvega pregleda, tik pred začetkom zdravljenja, en mesec in tri mesece po vstavitvi opornice in/ali aplikaciji inkobotulinum toksina A oz. placebo injekcije. Obenem smo v istih obdobjih po vstavitvi opornice in/ali aplikaciji inkobotulinum toksina A oz. placebo injekcije vrednotili tudi stanje TMM s prvim delom diagnostičnih meril za temporomandibularne motnje (ang. Diagnostic Criteria for Temporomandibular Disorders - DC/TMD).
Razlike med skupinami smo preverili s Kruskal-Wallisovim testom oziroma v primeru opisnih spremenljivk s testom hi-kvadrat ali Fisherjevim eksaktnim testom. Povezanost med rezultati psihometričnih testov in skupinami ter časom zdravljenja smo analizirali z linearnim mešanim modelom, v katerem so pacienti vključeni kot slučajni dejavnik, čas in skupina pa kot fiksna dejavnika. Interval zaupanja je bil določen na 95 %. Analiza je bila opravljena s programom R 4.1.3 (R Foundation for Statistical Computing, Dunaj, Avstrija).
Rezultati: Raziskavo je zaključilo 122 pacientov od 126 pacientov (4,8 % osip). Randomizacija v štiri skupine je bila uspešna, saj med skupinami pri demografskih spremenljivkah nismo zaznali statistično značilnih razlik. Po kliničnem pregledu po protokolu DC/TMD so bile pacientom določene diagnoze: mialgija (100 % pacientov), glavobol zaradi TMM (100 % pacientov), miofascialna bolečina (29 % pacientov), artralgija desno (28 % pacientov), artralgija levo (30 % pacientov). Na podlagi kliničnega pregleda in magnetne resonance čeljustnih sklepov smo postavili tudi posamezne diagnoze v čeljustnih sklepih, pri čemer je pri levem (24 % pacientov) in desnem čeljustnem sklepu (26 % pacientov) prevladoval premik sklepne ploščice z redukcijo ter degenerativne spremembe v čeljustnih sklepih tako v desnem (13 % pacientov) kot v levem (9,8 % pacientov) čeljustnem sklepu.
Bolečina ob palpaciji na treh mestih na vsaki masetrni in na treh mestih na vsaki temporalni mišici je pri vseh skupinah bila statistično značilno nižja ob 3. pregledu v primerjavi s 1. pregledom, vendar razlike med kontrolno in preostalimi skupinami niso bile statistično značilne.
Samoocena glavobola na tristopenjski lestvici je pokazala izboljšanje v vseh treh skupinah v primerjavi s kontrolno skupino, vendar ni bilo zaznati statistično značilnih razlik med skupinami pri merjenju ob časovno različnih pregledih.
Rezultati psihometričnih testov so bili vrednoteni v štirih časovnih obdobjih in pri vseh uporabljenih vprašalnikih je prišlo pri celotnem vzorcu do statistično značilnega izboljšanja tako v primerjavi s pregledom en mesec po terapiji kot tudi tri mesece po terapiji. V primerjavi s kontrolno skupino se je kakovost spanja statistično značilno izboljšala le v skupini z michigansko opornico. V primerjavi s kontrolno skupino se je kakovost življenja, povezana z oralnim zdravjem, statistično značilno izboljšala le v skupini z michigansko opornico. Pri preostalih vprašalnikih ni bilo statistično značilnih razlik med skupinami.
Zaključek: Pri vseh štirih skupinah je prišlo do statistično značilnega izboljšanja vseh konstruktov, tj. kakovosti življenja, povezane z oralnim zdravjem, kakovosti spanja, kronične bolečine, depresije, anksioznosti in somatizacije, vendar nismo dokazali statistično značilnega odstopanja med posameznimi načini zdravljenja.Aims. The diagnosis of headache attributed to temporomandibular disorder (HATMD) was included in the international classification of headaches in 2004. Given the causal relationship between temporomandibular disorders (TMD) and HATMD, it is supposed that HATMD should respond to TMD treatment.
This study aimed to determine whether occlusion splints and/or incobotulinum toxin A injections can effectively treat HATMD.
Subjects and methods. The sample consisted of 126 consecutive adult patients referred for TMD to the Department of Dental Prosthetics (Division of Stomatology, University Medical Center Ljubljana) and were diagnosed with HATMD according the International Classification of Headache Disorders 3rd Edition (ICHD-III).
Patients with HATMD were randomly divided into four groups and received therapy. Therapeutic options included counselling for all, the first group received a Michigan splint and incobotulinum toxin A injections, the second group received a Michigan splint and placebo injections, the third group received a cognitive splint and incobotulinum toxin A injections, and the fourth group received a cognitive splint and placebo injections. Counselling included instructions on avoiding stressful situations, eating soft food, chewing on both sides, and light aerobic exercise (light running, walking, etc.). Thermoformed occlusal and placebo splints were fabricated using vacuum-formed foils. The placebo splint was made without raising the bite, the teeth were in contact, and the splint did not cover the occlusal surfaces. A qualified neurologist administered incobotulinum toxin A or placebo injections into the temporal and masseter muscles. The incobotulinum toxin A injection protocol in the temporalis muscle to treat TMM was 20 units symmetrically, and in the masseter muscle, 30 units symmetrically in each muscle. The effectiveness of HATMD treatment was evaluated by the patient\u27s self-assessment of oral health-related quality of life, sleep quality, pain, depression, anxiety, somatization with Slovenian versions of questionnaires on the day of the first examination, on the day of the treatment, one month and three months after splint insertion and/or incobotulinum toxin A or placebo injection respectively. At the same time, TMD status was evaluated with the Axis I of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocol in the same periods after splint insertion and/or incobotulinum toxin A or placebo injection respectively.
The differences between the groups were checked with the Kruskal-Wallis test or, in the case of descriptive variables, with the chi-square test or the Fisher exact test. The correlation between the questionnaires’ scores and groups and treatment time was analysed with a linear mixed model, by which the patients were included as a random factor and time and group as a fixed factor. The confidence interval was set at 95%. The analysis was performed using software R 4.1.3 (R Foundation for Statistical Computing, Vienna, Austria).
Results. The study was completed by 122 patients (4.8 % dropout). Randomization into four groups was successful, as no statistically significant differences were detected between the groups in the demographic variables. After clinical examination according to the DC/TMD protocol, patients were diagnosed with: myalgia (100% of patients), TMM headache (100% of patients), myofascial pain (29% of patients), right TMJ arthralgia (28% of patients), left TMJ arthralgia (30% of patients). Based on clinical examination and magnetic resonance imaging of the jaw joints, we also made individual diagnoses of the jaw jointsthe left (24% of patients) and right jaw joints (26% of patients) had disc displacement with reduction and degenerative changes in the jaw joints, more in the right (13% of patients) than in the left (9.8% of patients) jaw joints.
Pain on palpation at three sites on each masseter and three sites on each temporal muscle was statistically significantly lower in all groups at the third examination compared with the first examination, but the differences between the control and the remaining groups were not statistically significant.
Self-assessment of headache on a three-point scale showed improvement in all three groups in comparison with the control group, but no statistically significant differences were detected between the groups measured at different time intervals.
The results of psychometric tests were evaluated in four-time periods, and in all questionnaires used, there was a statistically significant improvement in the whole sample compared to the one-month assessment after therapy, as well as three months after therapy. Compared with the control group, sleep quality improved statistically significantly only in the Michigan splint group. Compared with the control group, oral health-related quality of life improved statistically significantly only in the Michigan splint group. For the other questionnaires’ scores, there were no statistically significant differences between the groups.
Conclusion. In the whole sample, there were statistically significant improvements in all constructs, i.e., oral health-related quality of life, sleep quality, chronic pain, depression, anxiety, and somatization, but we did not demonstrate a statistically significant difference between both treatment modalities
Pogled uporabnikov na zdravstveni sistem v Sloveniji
Get PDFPri preučevanju odnosa ljudi do družbeno-političnih podsistemov, se raziskovalci osredotočajo na stopnjo legitimnosti političnih sistemov, ki se razlikuje glede na kulturne, zgodovinske in sociološke kontekste. Analiza političnega zaupanja se opira na občutek, da so lastni interesi upoštevani v političnem procesu. Zdravstveni sistem ima ključno vlogo pri doseganju najboljšega možnega zdravstvenega stanja prebivalstva, kar je osnovni cilj vsakega sistema zdravstvenega varstva. Vpliv spola na zadovoljstvo s storitvami v zdravstvu ni povsem jasen. Starejši pacienti običajno kažejo več zadovoljstva, delovno aktivni mlajši pa cenijo hitro dostopnost. Zadovoljni pacienti sodelujejo bolje pri zdravljenju, vendar resnejše zdravstvene težave lahko vplivajo na zadovoljstvo. Izobrazba, čustveno stanje in splošno zadovoljstvo vplivajo tudi na oceno storitev zdravstva. Nacionalni zdravstveni sistemi se soočajo s pritiski demografskih, gospodarskih in socialnih sprememb, kar zahteva nenehne prilagoditve in izboljšave v zagotavljanju kakovostnih zdravstvenih storitev pri čemer so odločevalcem lahko v pomoč izsledki standardiziranih raziskav kot je Mednarodna družboslovna anketa (ISSP) in rezultati nacionalne raziskave o izkušnjah pacientov z obravnavo v bolnišnici
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koamabayili/VECTRON-author-checklist: VECTRON author checklist
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