颞下颌关节类风湿性和青少年特发性关节炎的诊断和治疗。
The Diagnosis and Treatment of Rheumatoid and Juvenile Idiopathic Arthritis of the Temporomandibular Joint.
机构信息
Department of Oral and Maxillofacial Surgery, University Hospital Marburg UKGM GmbH, Marburg; Department of Nephrology, Agaplesion Markus Krankenhaus, Frankfurt/Main; Medical Department, Winsen Hospital; Department of Rheumatic Orthopedics and Hand Surgery, Waldburg-Zeil Kliniken, Klinik Oberammergau; German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen; Institute of Radiology, Olgahospital, Klinikum Stuttgart.
出版信息
Dtsch Arztebl Int. 2022 Jan 28;119(4):47-54. doi: 10.3238/arztebl.m2021.0388.
BACKGROUND
Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.
METHODS
The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.
RESULTS
Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrast-enhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intra-articular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.
CONCLUSION
Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.
背景
颞下颌关节受累可在 40-90%的类风湿关节炎和幼年特发性关节炎（JIA）患者中显现，尽管其通常为无症状。大约 20%的 JIA 患者可出现张口受限和颌痛（患病率：每 10 万人中有 70 人）。早期诊断和治疗基础疾病对获得良好的预后至关重要，但目前仍缺乏统一的、基于共识的治疗方法。
方法
本临床实践指南基于多项数据库的系统文献回顾和 Delphi 程序得出的推荐意见共识。
结果
大多数确定的研究为回顾性研究。JIA 患者应在儿童和青少年期每年接受一次临床筛查，包括使用结构化检查方案，此后如果颞下颌关节受累，也应进行筛查。慢性类风湿关节炎的颞下颌关节诊断需通过增强磁共振成像确立。不到 10%的患者经保守治疗（抗风湿基础治疗、局部措施）无效。在这种情况下，可采用关节镜和关节穿刺术暂时缓解症状和改善功能。关节内皮质类固醇注射仅应使用一次，且仅在其他方法无效的情况下使用。在所有其他方法均已用尽（<1%）的严重情况下，可以考虑开放式手术治疗，包括关节置换术。
结论
即使存在明显关节损伤的影像学证据，仍常见寡症状和无症状病例。必须牢记颞下颌关节可能存在风湿性受累，以避免发生严重并发症。建议对颞下颌关节进行定期临床评估，特别是对幼年特发性关节炎患者。
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