[Screening for temporomandibular disorders : A sensible approach?]
- 作者列表："Türp JC","Schindler HJ
BACKGROUND:Temporomandibular disorders (TMDs) are typically characterized by pain in the masticatory muscles and temporomandibular joints (TMJs) and by limitation of mandibular mobility. In June 2019, the German Society of Craniomandibular Function and Disorders presented a screening tool to identify individuals with TMDs. The assessment tool consists of patient history (three questions related to jaw pain, one question related to impaired mandibular mobility) and a clinical examination (palpation of masticatory muscles and TMJs; evaluation of maximum jaw opening; assessment of the presence of occlusal disturbances; documentation of TMJ noises). OBJECTIVES:The present article focusses on two questions: (1) Which of the nine parts of the tool are appropriate, and which are not? (2) In general, can screening for TMDs be recommended? CONCLUSION:While the anamnestic questions, as well as the assessment of maximum mandibular opening, reflect the clinically relevant symptoms and signs of TMD patients, the remaining four clinical measures do not. Furthermore, TMD screening for painful TMDs appears unnecessary because patients suffering from orofacial pain and/or restricted mandibular mobility are likely to consult a therapist by themselves. Therefore, the use of this screening tool may lead to overdiagnosis, possibly resulting in nonindicated diagnostic and therapeutic measures.
背景: 颞下颌关节紊乱病 (TMDs) 的典型特征是咀嚼肌和颞下颌关节 (TMJs) 疼痛和下颌活动受限。2019 年 6 月，德国颅颌功能和障碍学会提出了一种筛查工具，用于识别TMDs个体。评估工具包括患者病史 (三个与下颌疼痛相关的问题，一个与下颌活动度受损相关的问题) 和一个临床检查 (咀嚼肌和颞下颌关节的触诊; 最大颌开口的评价; 评估咬合紊乱的存在; 记录TMJ噪声)。 目标: 本文关注两个问题: (1) 工具的九个部分中哪一个是合适的，哪些不是？(2) 一般情况下，是否可以推荐进行TMDs筛查？ 结论: 虽然记忆问题以及下颌最大开口的评估反映了TMD患者的临床相关症状和体征，但其余四项临床措施没有。此外，TMD筛查疼痛性TMDs似乎没有必要，因为患有口面部疼痛和/或下颌活动受限的患者可能会自行咨询治疗师。因此，使用这种筛查工具可能导致过度诊断，可能导致无指征的诊断和治疗措施。
METHODS:OBJECTIVE:Patients with immune-mediated inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus are at increased risk of cardiovascular disease. However, the cardiovascular risk of patients with primary Sjögren's syndrome (SS) remains poorly studied. We aimed to investigate the association between primary SS and cardiovascular morbidity and mortality. METHODS:We performed a systematic review of articles in Medline and the Cochrane Library and recent abstracts from US and European meetings, searching for reports of randomized controlled studies of cardiovascular morbidity and cardiovascular mortality in primary SS. The relative risk (RR) values for cardiovascular morbidity and mortality associated with primary SS were collected and pooled in a meta-analysis with a random-effects model by using Review Manager (Cochrane collaboration). RESULTS:The literature search revealed 484 articles and abstracts of interest; 14 studies (67,124 patients with primary SS) were included in the meta-analysis. With primary SS versus control populations, the risk was significantly increased for coronary morbidity (RR 1.34 [95% confidence interval (95% CI) 1.06-1.38]; P = 0.01), cerebrovascular morbidity (RR 1.46 [95% CI 1.43-1.49]; P < 0.00001), heart failure rate (odds ratio 2.54 [95% CI 1.30-4.97]; P < 0.007), and thromboembolic morbidity (RR 1.78 [95% CI 1.41-2.25]; P < 0.00001), with no statistically significant increased risk of cardiovascular mortality (RR 1.48 [95% CI 0.77-2.85]; P = 0.24). CONCLUSION:This meta-analysis demonstrates that primary SS is associated with increased cardiovascular morbidity, which suggests that these patients should be screened for cardiovascular comorbidities and considered for preventive interventions, in a multidisciplinary approach with cardiologists.
METHODS:OBJECTIVE:We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS:Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS:We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION:In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
METHODS:OBJECTIVE:Reducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals' (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA. METHODS:Semi-structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach. RESULTS:Twenty-one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain. CONCLUSION:These findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs' accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.