TMJs are not just TMJs

以牙醫界而言,當maximal intercuspation 存在於Dawson 所定義的C.R.時,筆者認為是Craniocevocalmandibular complex 最佳的運作狀態,雖然如前所述,Dawson的CR定義有缺陷,但在臨床上執行咬合調整時,仍不失為一個良好的guideline. 臨床上,以治療TMD而言, Occlusal Appliance(TMJ orthosis, splint, night guard)或咬合板是高度有效的治療模式. Occlusal Appliance的目的是為了重建一個完美的咬合,讓TMJs及肌肉的運作是協調且有效率的. 雖然完美的咬合只存在於當O.A.在口內時,理論上,拿掉O.A.後,咬合又恢復原本狀態,疼痛的症狀可能會回來,但實際臨床觀摩到的又未必是如此,有些人不帶O.A.後,疼痛的症狀也未復發. 所以Occlusal Equilibration 未必是所有人都需要的治療. 咬合對TMD及其相關症狀的產生,在筆者的臨床觀察扮演著極重要的角色. 但它不是唯一造成因素,雖然O.A.的治療模式是高度有效的,但也不是萬靈丹(panacea). 當我們運用O.A.無法得到理想的治療結果時,還有什麼治療模式可運用以緩解病人的疼痛? 1. 徒手療法: 對徒手療法熟悉的專業人員可能提供有效的治療,但似乎沒有充分的證據顯示友長期的療效. 2. 物理治療: 包括 TENS ,針灸,超音波等等,似乎僅提供短暫的緩解,沒有長期的療效. 3. Pharmacologic management 有些作用於中樞神經系統的藥物可能會有幫助,例如t如tricyclic antidepressant e.g. amitriptyline 或 Anticonvulsants e.g. neurontin (Gabapentin) 4. Physical Self-Regulation program: 1. Patient education 2. Optimal rest positions for structures in the orofacial region 3. Proprioceptive re-education: Postural positioning 4. A skill for relaxing upper back tension, mainly rhomboid muscle groups 5. Progressive relaxation procedure involving the positioning of body structures 6. Specific diaphragmatic breathing entrainment instructions 7. Sleep hygiene instruction and sleep in a relaxed position 8. Fluid intake, nutrition , exercise 據Okeson’s orofacial pains 的書中記載,PSR是非常有效的治療模式,筆者沒有完整的資料,但從以上大綱看來,姿勢矯正是很重要的一環,姿勢(posture)的定義: Posture: definition provided by Committee of the American Academy of Orthopedic Surgeons: Posture is usually defined as the relative arrangement of the parts of the body. Good posture is that state of muscular and skeletal balance which protects the supporting structure of the body against injury of progressive deformity, irrespective of the attitude ( erect, lying, squatting, or stooping ) in which these structures are working or resting. Under such conditions the muscles will function most efficiently and the optimum positions are afforded for the thoracic and abdominal organs. Poor posture is a a a faulty relationship of the various parts of the body which produces increased strain on the supporting structures and in which there is less efficient balance of the body over it’s base of support. 與頭頸肩疼痛最相關的不良姿勢是Forward Head Position ,或 Anterior Head Position, Forward Head Position可能經由咬合方面的處理獲得改善,其他的不良姿勢,在站立時,一個製作良好的足矯正器可能會有改善,但不一定顯著,在動態的姿勢(步態gait), 足矯正器會有顯著的改善. 肌肉放鬆是很困難的,如果肌肉能放鬆下來,大多數的骨骼肌肉疼痛幾乎不會發生,如果有不正確的呼吸模式,一定要矯正過來,否則很多的疼痛無法緩解. 慶幸的是,不正確的呼吸經由簡單的指導,很容易矯正過來. 睡眠與疼痛是息息相關的,通常睡眠品質不佳,很容易導致肌肉疼痛,肌肉