RU2180570C1 - Method to treat pain syndrome at disfunctions of mandibular joint in women - Google Patents

Abstract

FIELD: medicine, stomatology. SUBSTANCE: additionally to combined therapy a hormonal correction is conducted by using a synthetic low- dosed estrogen-gestagenic preparation which contains a constant dose of both estrogen and gestagen. EFFECT: increased efficiency of therapy. 1 cl, 3 ex

Description

 The invention relates to medicine, namely to dentistry, and for the treatment of pain with dysfunction of the temporomandibular joint (TMJ) in women of reproductive age.

 According to the literature, functional disorders of TMJ are much more likely to affect women (70% -82%) than men [1,2]. TMJ dysfunctions accompanied by pain syndrome, which account for more than 30% of the total number of all patients with facial pain, cause particular suffering [3, 4]. At the same time, 79.7% of them are women [5, 6]. The highest prevalence of these conditions is recorded in them from 19 to 40 years old, and at an older age the signs of painful TMJ dysfunction are reduced [7].

 TMJ pain dysfunction is one of the clinical symptoms of occlusal disharmony in the dentition and malocclusion [8, 9]. However, in 57.3% - 80.9% of cases, this pathology occurs in individuals with intact dentition and orthognathic bite [10, 11]. This suggests that the reasons for the occurrence of these conditions can be not only violations of occlusion and malocclusion.

 In this regard, it is believed that the high prevalence of this pathological process in women of fertile age compared with men is due to a more labile hormonal background [12, 13].

 However, in the literature there is only sporadic information that among concomitant diseases in women with pain of TMJ dysfunction, diseases of the mammary glands and reproductive organs are quite common, accompanied by violations of the endocrine status of the body [14]. However, to date, treatment of patients with pain of TMJ dysfunction was carried out exclusively by dentists without taking into account the condition of the female genital area.

 A known method of treating TMJ dysfunction in relation to an orthognathic bite using the articulator "Stratos" company "Ivoklar" (Germany) [15]. The essence of the method is to model the occlusal surface, taking into account the occlusal movements of the lower jaw, the biomechanics of the chewing apparatus and involves the use of an articulator; the formation of the correct spatial arrangement of the jaw models in the space between the articulator frames in accordance with the location of the jaws of the patient in the facial skeleton; creation of correspondence of the incisal and articular paths in a patient in an articulator. However, this method does not allow the relief of pain without additional therapeutic measures.

 There is a method of complex treatment of pain with TMJ dysfunctions [16], which includes occlusal therapy, medication and physiotherapy in the complex of therapeutic measures. Occlusion therapy involves the use of occlusal splints that restore the spatial position of the lower jaw and the functional relationship between articular elements. Drug treatment includes the appointment of analgesics according to generally accepted schemes; tranquilizers (elenium, phenozepam) for muscle relaxation and relieving psychoemotional stress. Physiotherapeutic treatment includes magnetotherapy followed by laser therapy, ultrasound and percutaneous electroneurostimulation, electrical stimulation and massage of the masticatory muscles. However, when applying this method, a positive effect is not achieved in all cases, it is often of a short-term nature and has a high relapse rate.

 There is a method of treating pain with TMJ dysfunctions, using traditional methods of therapy in combination with local use of corticosteroids [16], taken as a prototype and including: orthopedic treatment (occlusal correction), medication (non-narcotic analgesics, small tranquilizers) and physiotherapy (microwave) therapy), as well as ultraphonophoresis with hydrocortisone (10-12 sessions) in the area affected by the TMJ. However, local use in the complex treatment of a steroid-derived drug does not allow for persistent relief of pain during TMJ dysfunctions in women of reproductive age with hormonal imbalance.

 To increase the effectiveness of treatment of pain of TMJ dysfunction in women of childbearing age (from 19 to 40 years old) with reproductive dysfunction during complex therapy (orthopedic, medication, physiotherapy), hormonal correction with estrogen-progestogen drugs containing a constant dose of estrogen and progestogen is carried out, for example, femodenom.

 The claimed method is as follows.

 After a diagnosis of pain of TMJ dysfunction has been established, the women’s dentist is referred for examination by a gynecologist.

 When identifying reproductive function disorders and changing the steroid hormone content in patients at the same time as complex therapy for pain of TMJ dysfunction, including: occlusal correction (occlusal splints), drug therapy (non-narcotic analgesics, small tranquilizers), physiotherapy (ultraphonophoresis, hydrocortisone, laser therapy) myogymnastics, they are treated with one of the monophasic combined oral contraceptives (femoden, rigevidon, nonlonon).

 The most optimal drug is femoden (Schering campaign, Germany), which contains a constant dose of estrogen - ethinyl estradiol (0.030 mg) and third-generation progestogen - gestoden (0.075 mg). The choice of this drug is due to the high bioavailability of gestodene (about 100%), which is part of it; the ability to clearly regulate the menstrual cycle and excellent tolerance due to the low content of hormones.

 The therapeutic effect of synthetic progestins is a short-term inhibition of the entire ring hypothalamic-pituitary-ovarian system due to their ability to suppress the secretion of releasing hormones by the hypothalamus, which ultimately leads to a decrease in the release of follicle-stimulating (FSH) and luteinizing (LH) hormones from the anterior lobe. In this case, the estrogen component of oral contraceptives (OK) inhibits the release of FSH, and progestogens - LH. When the drug is canceled, the so-called rebound effect is observed, i.e. restoration of the function of the hypothalamus, pituitary and ovaries, which leads to the normalization of the level of sex hormones.

 The method was tested on 30 women aged 19-40 years with dysfunctional pain in the TMJ, who were outpatient treatment in a dental clinic of the Chita State Medical Academy.

 The distribution of patients according to their gynecological diseases is shown in table 1.

 Depending on the type of treatment, patients were divided into 2 clinically equivalent groups. In the 1st (control) group, formed of 15 patients, conventional therapy was performed: occlusal therapy, which included the use of temporary medical and diagnostic devices (relaxation, reposition and stabilizing tires) with a term of use of up to 3 months; drug therapy (compresses on the joint area with camphor or yellow mercury ointment; non-narcotic analgesics - indomethacin, butadione, rheopyrin; small tranquilizers - elenium, seduxen; 4-6 blockages of the motor branches of the trigeminal nerve according to Egorov with an interval after 2-3 days); physiotherapy (10-12 sessions of ultraphonophoresis with hydrocortisone, laser therapy, magnetotherapy), myogymnastics; after relief of pain of the TMJ dysfunction, selective grinding of teeth was carried out in 4-5 visits at intervals of 7-10 days and correction of treatment and diagnostic devices. The course of traditional treatment was 3 months.

 In the 2nd (clinical) group, also formed of 15 women with pain of TMJ dysfunction, against the background of basic orthopedic, medical and physiotherapeutic treatment, femoden was prescribed 1 tablet per day from the 5th to the 25th day of the menstrual cycle. The course of hormone therapy amounted to 3 menstrual cycles (3 months).

 3 months after discontinuation of the drug, a control study of functional occlusion in the oral cavity and in the articulator was carried out, a clinical and X-ray examination of the TMJ, and steroid hormone levels were also determined. Within a year after the drug was discontinued, the dentist and gynecologist continued clinical monitoring of patients.

 Observations showed that after taking femoden as part of the complex treatment of pain dysfunctional TMJ syndrome in most women, not only pains in the joint area persistently stopped, but there was also a recovery or significant improvement from existing gynecological disorders. In no case during the year after the proposed method of treatment, we have not noted a relapse of pain in the TMJ.

 The treatment results are presented in tables 2 and 3.

 From the presented information it follows that the proposed method for the treatment of pain due to TMJ dysfunction has a positive effect in 100% of cases. In patients treated by the prototype method, the treatment efficiency is 46.67%. In addition, the proposed method of treatment has a more persistent clinical effect 2.1 times more often than when using the method of therapy according to the prototype method, with the conventional method of therapy.

 Examples.

 Example 1. Patient T., 36 years old, came to the dental clinic with complaints of restriction of opening the mouth, pain in the right TMJ, aggravated by eating rough food for 1 month. Denies injuries and related diseases. On examination, it was revealed: opening the mouth is painful, limited to 23 mm, accompanied by a click in the TMJ on the left and a shift of the lower jaw to the right; palpation of the chewing, temporal and lateral pterygoid muscles on the right is painful; dentition intact, orthognathic bite. Analysis of functional occlusion revealed balancing supercontacts on 16 and 46 teeth. When computed tomographic study of the TMJ in axial projection revealed a thickening of the lateral pterygoid muscle on the left.

 With a diagnosis of pain of TMJ dysfunction, she was sent to study the level of steroid hormones and consult a gynecologist. When examined by a gynecologist, the woman complained that during the last six months she was worried about painful long periods (up to 7-9 days) and pains periodically appeared in the lower abdomen on the right. From the anamnesis, a late onset of menarche (at 16 years), primary infertility (pregnancy occurred 5 years after the onset of sexual activity after hormonal therapy with synthetic progestin - marvelon) was revealed. An objective examination revealed an increase in the right ovary to 4.0 • 3.5 cm. An ultrasound revealed cystic degeneration of the right ovary. The content of the studied hormones in the second phase of the menstrual cycle was: estradiol - 238.53 pg / ml; progesterone - 2.07 ng / ml; testosterone - 1.28 nmol / l; cortisol - 20.12 mg / dl.

 Clinical diagnosis: Balancing supercontacts of the anterior-palatine tubercle of the 16 tooth and the posterior-cheek tubercle of the 46 tooth; hypertrophy of the lateral pterygoid muscle on the left; pain of the muscular-articular dysfunction of the TMJ. Cystic degeneration of the right ovary with menstrual dysfunction.

 A complex treatment was prescribed, including means for removing the hypertonicity of chewing muscles (6 blockages of the motor branches of the trigeminal nerve according to Egorov with solutions of local anesthetics with an interval of 3 days); for the relief of pain (analgin 0.25-0.5 g); to reduce emotional stress and intensity of pain (diazepam at 0.0025-0.005 g every other day); for symptomatic treatment, the use of a relaxation palatine tire with cross over wire clasps for 1 week; 12 sessions of ultraphonophoresis with hydrocortisone; myogymnastics; after relief of pain, elimination of balancing supercontacts of 16 and 46 teeth; selective grinding of teeth in 4-5 visits at intervals of 7-10 days; replacement of the relaxation tire with the uncoupling. The course of treatment at the dentist was 3 months.

 In parallel with the main therapy, treatment was started with a gynecologist femodenum 1 tablet per day from the 5th day of the cycle. After 2 weeks from the start of treatment, relief of pain in the TMJ was noted. The patient continued taking femoden for 3 menstrual cycles.

 3 months after the end of treatment, the woman was examined by a dentist and gynecologist. Pain in the TMJ does not bother, the mouth opens in full, palpation of the masticatory muscles is painless. When computed tomographic study of the TMJ in axial projection revealed the same size of the lateral pterygoid muscles on the right and left.

 The patient notes that the menstruation became painless, lasting no more than 4-5 days. A gynecological examination revealed no pathological changes; the right ovary is of normal size. The content of the studied hormones in the second phase of the menstrual cycle was: estradiol - 312.24 pg / ml; progesterone - 3.56 ng / ml; testosterone - 1.03 nmol / l; cortisol - 28.77 mg / dl, which corresponds to the physiological norm.

 With a follow-up examination after a year, there is no data for a relapse of both dental and gynecological diseases.

 Example 2. Patient Z., 34 years old, came to the dental clinic with complaints of severe pain when chewing in the parotid region on the left, frequent dizziness. From the anamnesis it was revealed that the pain appeared about a year ago, recently their intensity intensified, dizziness appeared, which made the patient seek medical help. Examination revealed hypertonicity and trigger points in the area of the chewing, temporal and lateral pterygoid muscles on the left. Palpation anterior to the ear tragus on the left is painful. Opening the mouth is painful, limited to 32 mm, accompanied by deviation of the lower jaw to the left. Dentitions preserved, orthognathic bite; the lower jaw is shifted to the right by 1/2 the width of the lower incisor. A computed tomographic study of the TMJ in the sagittal projection and in the usual bite revealed narrowing of the posterior articular fissure on the left.

 With a diagnosis of pain of TMJ dysfunction, she was sent to study the level of steroid hormones and consult a gynecologist. When examined by a gynecologist, the woman complained of engorgement and tenderness of the mammary glands, bloating, irritability, weakness, swelling of the face that occur 10-12 days before menstruation and persist during the first day of menstrual bleeding. Considers herself ill for 4 years. A history of 1 uncomplicated childbirth in 1995, after which she did not become pregnant, using barrier methods of contraception. With an objective study, the mammary glands are developed correctly, pathological changes were not detected. When gynecological examination of organic pathology was not found. Examined by a neurologist - healthy. The content of the studied hormones in the middle of the menstrual cycle was: estradiol - 278.80 pg / ml; progesterone - 1.96 ng / ml; testosterone - 1.31 nmol / l; cortisol - 14.18 mg / dl.

 Clinical diagnosis: Myofascial trigger points of the chewing, temporal and lateral pterygoid muscles of the left; pain of the muscular-articular dysfunction of the TMJ. Edematous subcompensated form of severe premenstrual syndrome.

 A complex treatment was prescribed, including 6 blockade of the motor branches of the trigeminal nerve according to Egorov with solutions of local anesthetics with an interval of 2-3 days; blockades were alternated with phonophoresis with hydrocortisone; when performing self-massage, lines of lesser skin stretch were taken into account; for reposition of the lower jaw and centering of the articular heads in the fossa using a repositional occlusal splint. In parallel with the main treatment, treatment with femoden was started, 1 tablet per day from the 5th day of the cycle.

 After 3 weeks from the start of treatment, relief of dizziness and pain in the parotid region on the left during meals was noted, palpation of the masticatory muscles and parotid region on the left was painless, opening the mouth was painless in a volume of 38 mm. The course of treatment at the dentist was 3 months; the patient continued taking femoden for 3 menstrual cycles.

 3 months after the end of treatment, the woman was examined by a dentist and gynecologist. Pain in the parotid region and dizziness are absent; palpation of the masticatory muscles is painless; the degree of opening of the mouth in a volume of 42 mm. Computed tomography examinations of the joints in the sagittal projection and in the position of central occlusion determine the symmetrical positions of the articular heads in the articular fossa and the uniform width of the joint space in the anterior, superior and posterior TMJ from both sides.

 The patient notes that of the previously existing symptoms, engorgement and moderate soreness of the mammary glands and irritability, which occur 7-8 days before the onset of menstruation and stop the day before its onset, persist. The content of the studied hormones in the second phase of the menstrual cycle was: estradiol - 322.16 pg / ml; progesterone - 3.72 ng / ml; testosterone - 0.97 nmol / l; cortisol - 27.73 mg / dl, which corresponds to the physiological norm.

 With a follow-up examination after a year, there is no data for a relapse of a dental disease. During a conversation with a gynecologist, he notes that in the past two months, 10 days before menstruation, all previously former symptoms of premenstrual tension reappear. The patient was prescribed a repeated course of hormone therapy with femoden for 4 months.

 During the second year from the first treatment and treatment, relapse of pain dysfunctional TMJ did not occur.

 Example 3. Patient S., 19 years old, came to the dental clinic with complaints of difficulty in painful opening of the mouth, clicks in the TMJ on both sides, a feeling of heaviness in the masticatory muscles for 3 months. Denies injuries and related diseases. During examination revealed: opening the mouth painfully, limited to 26 mm; when opening and closing the mouth, "reciprocal" clicks in the TMJ on both sides are determined; upon palpation of the chewing muscle proper, painful areas are determined on the right; dentition preserved, orthognathic bite. A CT scan of the TMJ determines a bilateral anterior dislocation of the articular disc.

 With a diagnosis of pain of TMJ dysfunction, she was sent to study the level of steroid hormones and consult a gynecologist. When examined by a gynecologist, the woman complained that during the last six months she was worried about painful menstruation. From the anamnesis it was revealed that the menarche came at 12 years old, however, the regularity of menstruation was established for 4 years. Menstruation for 5-6 days, painful (applies analgesics). 2 years ago, the diagnosis was made: cystic ovary, treatment was not carried out. Denies sexuality, does not use contraception. An objective study revealed the phenomena of hirsutism of the first degree. The content of the studied hormones in the second phase of the menstrual cycle was: estradiol - 123.53 pg / ml; progesterone - 1.87 ng / ml; testosterone - 1.82 nmol / l; cortisol - 23.25 mg / dl.

 Clinical diagnosis: Anterior dislocation of the TMJ disc on the right and left, pain of the muscular-articular joint dysfunction of the TMJ. Ovarian dysfunction with menstrual dysfunction.

 The traditional complex treatment has been prescribed, including drug treatment (tobitil, myolgin), physiotherapy (10 sessions of ultraphonophoresis with hydrocortisone), orthopedic treatment (application of a repositional occlusal splint), chewing muscle myogymnastics.

 After 2 weeks from the start of treatment, relief of pain when opening the mouth was noted, the feeling of heaviness in the chewing muscles disappeared. After 4 weeks from the start of treatment, the mouth opens up to 38 mm. The course of treatment at the dentist was 3 months.

 3 months after the end of treatment, the woman was examined by a dentist and gynecologist. According to the patient, it was found that periodically there is a feeling of stiffness of the masticatory muscles and clicks in the joint on both sides when the teeth are closed. Objectively revealed that the degree of opening of the mouth is 34 mm, palpation of the lateral pterygoid muscles is painful.

 In a laboratory study of the levels of steroid hormones in the blood during the second phase of the menstrual cycle, it was found that the content of estradiol (118.48 pg / ml); progesterone (1.92 ng / ml) and cortisol (22.13 mg / dl) are significantly lower, and testosterone (1.75 nmol / l) is higher than the physiological norm.

 The patient was prescribed a second course of occlusal therapy (selective grinding of the teeth, application of the uncoupling splint), myogymnastics and massage of the masticatory muscles. In parallel with the main treatment, treatment with femoden was started, 1 tablet per day from the 5th day of the cycle.

 After 2 weeks from the start of repeated symptomatic treatment, in combination with hormonal correction of femodenom, the feeling of heaviness in the masticatory muscles disappeared. The course of retreatment at the dentist was 1.5 months; the patient continued taking femoden for 3 menstrual cycles.

 3 months after the end of treatment, the woman was examined by a dentist and gynecologist. Opening the mouth is painless, in full up to 42 mm; there are no clicks in the joint when opening and closing the mouth, muscle palpation is painless. A CT scan of the TMJ revealed no bilateral anterior dislocation of the articular disc.

 The patient notes that menstruation became painless, lasting no more than 5-6 days. Gynecological examination revealed no pathological changes. The content of the studied hormones in the second phase of the menstrual cycle was: estradiol - 349.48 pg / ml; progesterone - 3.82 ng / ml; testosterone - 0.94 nmol / l; cortisol - 32.75 mg / dl, which corresponds to the physiological norm.

 With a follow-up examination after a year, there is no data for a relapse of both dental and gynecological diseases.

 Thus, the proposed method allows to achieve highly effective long-term relief of pain with dysfunction of the temporomandibular joint in women with impaired reproductive function due to normalization of steroid hormones at the level of the ring hypothalamic-pituitary-ovarian system; well tolerated by patients, has no side effects.

LITERATURE
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Claims (1)

 A method of treating pain syndrome in temporomandibular joint dysfunctions in women, including orthopedic, drug and physiotherapeutic treatment, characterized in that in addition to complex therapy, hormonal correction is carried out with synthetic low-dose estrogen-gestagen drug containing a constant dose of estrogen and gestagen.

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