2008年 日本顎関節学会 初期治療のための診療ガイドライン

1 2010 7 .. 1.. Step . 5 . Step .. bruxism . 4 . bruxism . Step . Step 2 .. 5 .. 2.. GRADE 2C / . 2010 3 31 .. 0.. 3.. 1998 . ---------------------------------------- ---------------------------------------- .. bruxism . ( 2001 ). ---------------------------------------- ---------------------------------------- .. a . b .. 25mm .. 4.. NTI splint based on the concept of nociceptive trigeminal inhibition .. 5.. bruxism .. 2 . 2 .. 1.. 2.. 3. IV-3 .. 4. V-4 .. 5.. V-3 V-4 .. 6.. V-9 V-10 .. 7.. 8.. 9. 2 .. 6.. 70 .. I .. II .. III .. IV .. V .. VI .. IV-3 . V-3 V-4 . V-9 V-10 .. 170-0003 1-43-9.. TEL(03)3947-8891 FAX(03)3947-8341.. 7 Copyright 2010.. I . 1.. 2.. I-1 . 3 . 3-1 .. 3-2 . 3-3 . I-2 . I-3 Patient Question Clinical Question .. II . 1 . 2.. 3 .. 4 SoF . 5 . II-1 . 6 Benefits downside( ) .. II-2 4 . 7 . 8 . II-3 [GRADE 2005] .. II-4.

2 9 . 10.. III . 1 . 2 . 2-1 . III-1 1998 . 2-2 . III-2: 2001 . 8. 2-3 . III-3 . 3 . 3-1 . 3-2 . 3-3 . 3-4 . 4 . III-4 . IV . 1.. IV-1 . 2.. 3.. IV-2 . 4 . IV-3 . 5 . IV-4 . IV-5 . IV-6 . V .. 1 . V-1 . V-1 . 2 . V-2 .. V-3 .. V-4(1) SoF .. V-4(2) SoF .. V-5 .. V-6 SoF .. V-7 SoF .. V-8 .. 9. V-9 SoF .. V-10 SoF . 3 . 3-1.. 3-2.. V-2 . V-3 . V-4 . V-5 .. 4 . V-6 . 5 . V-7 . VI . 1 : .. 2 .. 3.. 4.. VI-1 .. VI-2 . VII . 1 . 2 .. A . B . C . C . D . E .. 10.. 50 .. 2005 .. 2007 .. GRADE . WHO .. GRADE .. Clinical Question (CQ) . GRADE . CQ. 1 . GRADE .. CQ .. 11. 12.. 2007 . 20 2008 21. 11 .. 2008 2009 . 2,600,000 .. GRADE . Clinical Question Patient Question .. 13.. 2007 2008 .. 2 .. 2 .. 2008 2009 2010 .. "Literature Review" "Grade Evidences profiles" 2007 2008 2009 .. 14.. "Recommendations" 2009 .. 2 . 2 .. 15.. 21 .. 19 .. 16. I . 1.. 15-34 62 5 17 27 30.

3 4 [ 1989][ . 2006] .. 5 [ 2007] . 20% [ . 2007] [ 2007] .. [Kurita K 1998] . 1 . [Gatchel RJ 2006] .. Evidence-Based Medicine EBM i . ii,iii .. Clinical Question(CQ) iv .. 5 . [ 2001] [ . 2002] [Okeson JP 1996] .. i Evidence-Based Medicine EBM .. EBM .. ii .. iii .. iv Clinical Question(CQ) .. PICO (P:patient, I:intervation, C:control, O:outcome) .. 17.. i .. MRI .. 2.. I-1 . ii .. III .. I-1 .. Bruxism .. 2 . 2 iii .. i .. ii outcome .. iii 2 .. 18. i . 3 I-2 . (Minds)ii . Minds 2007 . GRADE [ 2007] . GRADE . 2007 . iii .. 2008 7 [ . 2007] . 2 .. 21 . 2009 1 . 3-1 . I-3 .. (Patient Question(PQ)) . [SING 2003] [ 2005]iv .. i . [ , 2008]. ii Minds .. 16 5 . 2007 6 12 Minds . 2007 . 2010 4 25 . iii . GRADE .. iv .. 19. 3-2 .. A [Palda VA 2007] .. [Kunz R 2006] . 2000 40 40. 50 GRADE working group Grading of Recommendations Assessment, Development and Evaluation(GRADE).

4 [GRADE 2004]i,ii GRADE iii . GRADE . iv .. (benefits) (downsides) [Guyatt G, Gutterman D 2006][Schunemann HJ 2006][Guyatt G 2007] .. [Donat R Spahn 2007] . 3-3 . Systematic Review(SR) v,i[Cooper H. i ASCO More recently, ASCO Panels have chosen not to use these classification schemes to assign levels and grades to recommendations.. [ASCO 2006] . ii GRADE . [ 2006][ . 2005] . GRADE .. iii GRADE GRADE .. iv 2007 . 51 2 5 Q . Grade c . Grade c Grade a .. GRADE . Minds 2007 GRADE . [ 2007] . v Systematic Review(SR) .. 20. 1994][ 2004] ii,iii iv,v [Oosterhuis WP 2004][AGREE 2001] [The Cochrane Collaboration 2008] . I-2 . Clinical Question(CQ) . ( Patient Question(PQ)) . I-3 .. GRADE .. V .. 2010 . GRADE: Grading of Recommendations Assessment, Development and Evaluation I-3 Patient Question Clinical Question .. "Patient Question" . 2007 [ 2007].

5 "Patient Question" . 2008 . "Patient Question" . 2009 .. i Systematic Review SR .. ii AND OR NOT .. iii .. iv .. [AGREE 2001] . v 2010 . 21.. "Clinical Question" . 2007 [ . 2008] : . 2007 .. "Clinical Question" . 20 . 2007 [ 2008]. 22. II . SIGN . [SING 2003] .. V5[Cochrane Collaboration 2008] .. GRADE i,ii[GRADE 2005][ . 2008] .. 1 . [ 2007 2008 2008] iii . iv . 2.. Medlinev vi vii . viii . 3 . ix .. i GRADE . 2010 [ 2010] .. ii .. iii CQ CQ .. iv .. v Medline Medical Literature Analysis and Retrieval System On-Line . NLM (National Library of Medicine) 2 . vi The Cochrane Central Register of Controlled Trials (CENTRAL) . Randomized Controlled Trial(RCT) Controlled Clinical Trial (CCT) Medline CDSR The Cochrane Database of Systematic Reviews (CDSR: Cochrane Reviews) . EMBASE . vii . viii . 2008 3 6 . ix V5 Characteristics of included reviews Risk of bias summary.

6 23.. 4 SoF i . GRADE SoF .. SoF . ii,iii . SoF . iv .. v . Visual analog scale 0-100 .. 5 . confidence . vi GRADE .. II-1 . i . SoF . ii SoF GRADE .. SoF . iii Modified GRADE profile economic evidence . [NICE 2009] NICE . GRADE . iv SoF SoF .. v SoF SoF V-4(1) .. vi A:RCT B: RCT . C D .. 24. II-1 [GRADE 2005]i high . " " ii .. moderate . " " " " .. low . " " . " ( " . very low . " " " " " . " " " . 6 Benefits downside( )iii .. GRADE II-2 4 (JAMA users'. guides 2008 [Gyuatt 2008]) .. II-2 4 . (1) Balance between desirable and undesirable effects . (2) Quality of evidence . (3) Values and preferences . (4) Resource utilization (Cost) . 7 . i .. ii Jadad Jadad .. iii GRADE downsides . benefits .. 25. Cost-Effectiveness Analysis .. GRADE . net benefits) [Guyatt G, Baumann MH 2006][Guyatt G 2007] .. 8 i . "Literature Review" "Grade Evidences profiles".

7 [ 2006] .. A . B C D 4 . ii 1 2 .. GRADE .. Spahn DR [Spahn DR 2007] .. II-3. iii,iv [GRADE 2005] . i downside( )i . 6 Benefits . 7 . ii . GRADE . iii .. [ 2007] . iv . 26. II-3 [GRADE 2005] .. GRADE (1 strong) . recommendation .. GRADE (2 weak) . suggest .. II-4 . i [Verkerk K 2006] . GRADE . GRADE Grid B [Jaeschke R 2008]. [Dellinger RP 2008]ii,iii . II-4 . 3 .. 3 .. 50% . i .. ii Dellinger RP The guidelines group was evenly split on the issue of SDD, with equal numbers weakly in favor and against recommending the use of SDD (Appendix H). The committee therefore chose not to make a recommendation for the use of SDD specifically in severe sepsis at this time. The final consensus on use of SDD in severe sepsis was achieved at the last nominal committee meeting and subsequently approved by the entire committee (Appendix H provides the committee vote).

8 [Dellinger RP 2008] . iii GRADE . 2009 12 27 . GRADE Grid . 2009 12 27 . GRADE Grid .. 27. 20% . 70% .. 9.. 10.. 28. III .. 1 . 1956 . [ 1956] . Foged temporomandibular arthrosis[Foged 1949] . Temporomandibular disorders(TMD) . i . [ . 1996 1998] 5 [ . 2001] .. ii . 2 . 2-1 .. III-1 . Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) [Dworkin SF 1992]. 1 Muscle disorders, including myofascial pain with and without limited mandibular opening, 2 Disk displacement with or without reduction or limited mandibular opening, 3 Arthralgia, arthritis and arthrosis . III-1 1998 [ 1998].. i 2007 . Hyaluronate for temporomandibular joint disorders (Review) Occlusal adjustment for treating and preventing temporomandibular joint disorders (Review) TMD . ii . 2007 Occlusal adjustment for treating and preventing temporomandibular joint disorders (Review) TMD.

9 The occurrence of recurrent headache. Pain in the jaws, face, throat, neck, shoulders or back. Ear symptoms. Pain in the temporomandibular joint (TMJ) at rest and during chewing. Day and night time grinding or clenching. Vertigo. Stiffness in jaws. Difficulties in swallowing.. Globus symptoms. Joint sounds. Spontaneous luxation or locking of the jaws. 2 .. 29.. 1.. 2.. 3.. 2-2 . III-2 [ 2001] .. 18 .. 18 18 .. i I II III IV I IV .. bruxism .. bruxism . [Macedo CR 2007]ii,iii . III-2: ( 2001 ) 2001].. a . b . i RDC/TMD [Dworkin SF 1992] I 3 . [Wassell RW 2004] . ii Minds .. iii bruxism . [ 2009] . 30.. 2-3 .. III-3 [ 2007]. 25mm . 2 .. 3 . 3-1 .. PICO P Patient .. PICO .. IV-1 i,ii,iii .. i . ii .. iii . 2007 . Recommendation: Pulmonary rehabilitation improves the symptom of dyspnea in patients with COPD. Grade of Recommendation: 1A COPD.

10 1A [Andrew L 2007] . 31.. III-1 .. 3-2 .. i . 3-3 .. 3-4 .. 4 .. III .. III-4 ii .. pain pain of the temporomandibular joint pain of muscles range of mandibular movement sound i 2008 .. CQ . ii Canadian Agency for Drugs and Technologies in Health Appendix 3 All identified outcomes and their finalranking by CERC [Canadian Agency for Drugs and Technologies in Health 2008] . 32. harm/ adverse effect dysfunction score QOL quality of life muscular tenderness overall improvement depression . cost tenderness of TMJ. headache widespread pain secondary otalgia .. limitations in chewing .. (global symptoms) .. parafunctional activity was assessed as the mean intensity of tooth contact measured on a four-point scale .. 33. IV . 1.. [ 2008] 20 . [ . 2008] .. IV-1 .. 3 .. [ 2009] 21.. IV-1 .. 2.. D . 3.. stabilisation splint . Tanner appliance Fox appliance Michigan splint.