觀察顳顎關節疾病其磁振造影特徵與臨床診斷之相符性及相關因子影響之探討

Correlations between MRI findings and Clinical Diagnosis in Disc Displacement of Temporomandibular disorders with Evaluation of Influencing Factors

黃宇婷(U-Teng Wong)

指導教授 ： 黃逸岳

高雄醫學大學/口腔醫學院/牙醫學研究所/碩士(2011年)

https://doi.org/10.6832/KMU.2011.00094

摘要

前言：
顳顎關節疾病主要是藉由病史與臨床檢查來診斷，不同的顳顎關節疾病，卻有相似的臨床症狀，因此單純由病史與臨床檢查，可能仍無法正確診斷，而必須以影像檢查來輔助診斷，磁振造影能提供硬組織與軟組織的變化，是目前被視為診斷準則的工具。對於關節盤脫位的問題、骨性變化與關節腔炎症反應等，都能有很高的準確性。
研究動機及目的：
臨床上藉由許多臨床檢查與病史的回顧，即做出診斷而開始治療，只有少數醫療機構才能藉由MRI的協助，有更準確的診斷，提供適切的治療，為了建立臨床上可應用而且簡易的診斷方法，本研究想探討:
1. 以標準的臨床診斷程序所建立的診斷與經由MRI影像檢查的結果，其相符程度如何，是否能做為一般牙醫師斷診斷關節盤脫位的可靠指南。
2. 此外亦探討一些可能因子，是否亦能做為診斷此疾病的重要病史依據。
材料及方法：
本研究收集因顳顎關節疾病而接受磁振造影檢查的病人， 而至少有一側的關節在臨床被診斷為可復性前移位或不可復性前移位。 在2008年至2010年期間共收集了235位病人， 總關節數為470個。
臨床診斷均由同一為有經驗的臨床醫師根據1992年由Dworkin 所提出的診斷分類法(RDC/TMD)加上壓舌板檢查法作依據。 而磁振造影診斷側另外由兩位有經驗的臨床醫師判讀。
結果:
以卡方檢定比較臨床診斷跟磁振造影診斷的一致性， 結果發現兩者之間是有顯著的相關性(k=0.64)。 又以可復位性關節盤前移的準確性較高為81.1%(k=0.74); 而不可復位性關節盤前移的準確性則為74.4%(k=0.59)。
在影響因子的分析方面， 年齡跟疾病的發生有顯著的相關性，其他因子包括性別，夜間磨牙及慣用咀嚼側等跟疾病的發生沒有統計上的相關性。另外只有性別跟疾病的嚴重度有顯著相關，其他因子均沒有統計上的相關性。
結論:
本研究以較大的樣本數探討臨床診斷與磁振造影診斷的一致性。發現兩者有顯著相關性。尤其是可復性關節盤脫位的準確性達81.1%(k=0.74)，亦即以病史與簡易之臨床檢查如關節聲響與咬壓舌板的檢查為診斷依據。這對於無法以MRI做為確診的臨床醫師，可藉由標準診斷程序獲得高機率的正確診斷，即可逕行咬合板治療。
致於不可復位性的關節盤脫位，準確性是74.4%(k=0.59)，我們主要的診斷依據是病人是否曾有關節聲響，與是否有張口受限為依據，但有些病人因為有痛的感覺，致使張口度受限因此影響不可復位性的關節盤脫位診斷的正確性，有必要再尋求其他得診斷資料，以提高沒有MRI支持下的診斷率。

關鍵字

可復位性關節盤前移 ； 不可復位性關節盤前移 ； 磁振造影 ； 相關因子

並列摘要

Background and Aim：Diagnoses of temporomandibular disorders is mainly based on clinical findings, however, as the great variety of the disease, some may not be easily diagnosed under clinical conditions, especially those with mild clinical signs and symptoms, as a result, imaging techniques were introduced into this field to assist in defining diagnoses.
Different kinds of imaging techniques were used over decades, but magnetic resonance imaging (MRI) is best for both soft and hard tissue investigations, and is now the most frequently used imaging technique in this field.
However, MRI is an expansive imaging technique and may not be available in every single dental clinic, so low-cost high-accuracy diagnosing guidelines should be established for the purpose. But the accuracy rate of these guidelines is interested, therefore, the purpose of this study is to evaluate the accuracy rate of the most frequently used guideline when compared with MRI diagnoses, moreover, some influencing factors of TMDs are also discussed.
Materials and Methods: The study recruited 235 consecutive patients including 470 which were clinically diagnosed as anterior disc displacement and were sent for MRI taking. The clinical diagnosis was made by one highly experienced dentist under the guidelines given by Dworkin in Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). MRI images were examined by another experienced dentist. The clinical and MRI diagnoses were analyzed with Chi-square test for correlationship. Moreover, degree of influences of some commonly discussed factors, including gender, age, bruxism and chewing habit; were also analyzed.
Results: The correlation of clinical diagnosis and MRI diagnosis was proved to be significantly related (k=0.64), that is, the diagnosis made following the RDC/TMD guidelines had high accuracy. The accuracy of clinical diagnosis for anterior disc displacement with reduction was 81.1%(k=0.74) while for anterior disc displacement without reduction, the accuracy rate was 74.4%(k=0.59).
For evaluation of other influencing factors, age is a significant factor related to the incidence of anterior disc displacement. Gender, bruxism and chewing habit were proved to be not related to anterior disc displacement. (p>0.05) Moreover, gender is significantly related to the severity of disc displacement, other factors did not show any statistic significance.
Conclusion: In the present study, the results concluded that using RDC/TMD guidelines in clinical diagnosis of TMDs gave a credible accuracy even without the assistance of MRI findings. Even though the influencing factors did not show significant relation with anterior disc displacement disease, but further evaluation should be held to prove their relations with other TMDs.

並列關鍵字

ADDR ； ADDwoR ； MRI ； Associated factors

參考文獻

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