Generalized joint hypermobility and temporomandibular disorders: inherited connective tissue disease as a model with maximum expression

AIMS: To study the relationship between generalized joint hypermobility (GJH) and temporomandibular disorders (TMD) by assessing prevalence and patient characteristics of TMD in a population of patients with maximum expression of GJH as a symptom of inherited connective tissue disease. In addition, diagnostic reliability of a series of clinical signs indicative of temporomandibular joint (TMJ) hypermobility was tested. METHODS: The study sample consisted of 42 subjects with GJH, 24 with Marfan syndrome and 18 with Ehlers-Danlos syndrome. A subgroup of 27 individuals was selected by age (> or = 18 yrs) and was compared to 40 controls with TMD and normal peripheral joint mobility. TMD diagnoses were assigned to each subject according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). RESULTS: In the GJH sample (n = 42), 71.4% of the subjects were symptomatic for TMD. Of those, 13.3% had sought treatment. A myofascial pain diagnosis was made in 69%, disc dislocation with reduction was diagnosed in 85.7%, and TMJ arthralgia in 61.9%. Multiple TMD diagnoses were assigned in 69% of the subjects; of these, 57% had 3 or more subgroup diagnoses. Joint noises (P < .01) and recurrent TMJ dislocations (P < .01) were a frequent finding in adult GJH subjects (n = 27) compared to controls, with symptomatic GJH subjects presenting more and more prolonged dislocation events than asymptomatic subjects (P < .001). TMJ hypermobility signs were expressed significantly more often in GJH compared to controls with TMD and normal joint mobility. CONCLUSION: This study indicates a positive relationship between GJH and TMD.     

Relationship between systemic joint laxity, TMJ hypertranslation, and intra-articular disorders

The aim of this study was to evaluate the correlation between general joint hypermobility, temporomandibular joint (TMJ) hypertranslation and signs and symptoms of TMJ intra-articular disorders. One hundred twenty individuals constituted the sample, divided into two groups: Group I (symptomatic) included 60 patients with complaints of joint noises, pain, or jaw locking, and Group II (nonsymptomatic) included 60 people with no TMD complaints. The Beighton's hypermobility score addressed the systemic laxity while lateral x-rays taken in both closed and full open mouth positions measured TMJ mobility (condyle hypertranslation). No association was found between intra-articular disorders and systemic hypermobility (p > 0.05). A significant negative correlation (p < 0.05) was found between age and systemic hypermobility, while no correlation was detected between systemic and TMJ hypermobility (condyle hypertranslation).     

Dental implants in patients with Ehlers-Danlos syndrome: a case series study

Ehlers-Danlos syndrome (EDS) encompasses six types of hereditary connective tissue disorders, with skin hyperextensibility, joint hypermobility, and connective tissue fragility as the main findings. Oral health is also affected, sometimes including periodontitis and tooth loss. This is the first report on dental implant treatment for patients with hypermobility or classic EDS. Five female patients aged 19 to 68 years who tolerated treatment under local anesthesia and did not require bone augmentation were enrolled in the study and received 16 implants. They were observed for 2 to 12 years. No implants were lost, bone loss was minimal, and all patients were pleased with the treatment outcomes.     

Temporomandibular joint dysfunction. Connective tissue variations in skin biopsy and mitral valve function.

Ten women with temporomandibular joint dysfunction and general joint hypermobility (score, 4 to 8) and 10 symptom-free female volunteers without systemic laxity (score, 0 to 2) were selected for the study. A biopsy of connective tissue from arm skin found that the total collagen concentrations were lower and the proteoglycan values were higher in the hypermobile TMJ patients than in the control subjects. The mitral region of the heart was inspected by echocardiography. Eight patients and four controls had slightly abnormal echocardiographic findings. Two patients fulfilled the criteria for mitral valve prolapse. The patients had significantly more musculoskeletal complaints than did the controls. The study suggests an association between joint hypermobility, abnormal skin connective tissue composition, mitral valve malfunction, and musculoskeletal disorders in young women with TMJ dysfunction, especially internal derangement.     

牙周病型Ehlers-Danlos综合征研究进展

Ehlers-Danlos综合征（Ehlers-Danlos syndromes，EDS）是一组罕见的遗传异质性结缔组织疾病，表现为广泛的不同程度的皮肤、韧带、血管和内部器官结缔组织脆性增加，主要临床特征包括皮肤脆弱、易擦伤、皮肤弹性过度和关节活动过度等。2017年，国际EDS联盟重新修订了EDS分类方法，根据临床表现、分子诊断及致病基因将其分为13型，其中造成早期牙周组织严重破坏和牙齿松动脱落的主要是牙周病型EDS。文章就牙周病型EDS的研究进展做一综述。     

The treatment of temporomandibular disorders with stabilizing splints in general dental practice: one-year follow-up

BACKGROUND: The authors evaluated temporomandibular disorder (TMD) outcomes in general dental practice one year after treatment with stabilizing splints (SS) or nonoccluding control splints (CS). METHODS: Seventy-two randomly allocated subjects completed initial treatment. The outcomes measures were a pain visual analog scale (VAS), muscle tenderness, temporomandibular joint (TMJ) tenderness, interincisal opening, TMJ clicks and headaches. After initial treatment, 81 percent of the subjects were found to have been treated satisfactorily. The dentists referred the remaining subjects to a dental hospital. At one year, the authors recalled 52 of the original subjects for evaluation. RESULTS: Improvements after initial treatment were maintained at one year for all outcomes, except for TMJ clicking, which returned to pretreatment levels. Eighty-one percent of the subjects rated their treatment as either good or excellent in reducing jaw pain. The authors found that subjects were aware of more of their TMJ clicks than dentists observed at the one-year clinical examination, but most subjects thought their clicking or the associated pain had been reduced. Fifty-five percent subjects had used their splints in the previous six months, but only 31 percent of these had done so daily. There were no significant differences between splint groups. CONCLUSION: At one year, a good response to TMD treatment in general practice had been maintained, but many subjects still had clicking TMJs. CLINICAL IMPLICATIONS: Trained dentists can manage TMD satisfactorily, with only a small proportion of patients needing specialist attention.     

Dental and skeletal maturation in female adolescents with temporomandibular joint osteoarthritis

Occurrence of temporomandibular disorders (TMDs) and temporomandibular joint (TMJ) osteoarthritis (OA) during adolescence may have interactions with mandibular and dental development. The aim of the present study was to investigate relationships between occurrence of TMD and TMJ OA and extents of dental and skeletal development in juvenile female patients. In total, 95 female adolescents (age range, 11–15 years) were selected. Among them, 15 subjects (control) had no signs of TMD, 39 TMD patients did not have OA (TMDnoOA), 17 TMD patients were at initial stage of TMJ OA (TMJOA), and 27 patients showed progressive stage of TMJ OA (TMJOA). Dental age was estimated by Demirjian's stages used in a previous study with Korean adolescents. Craniofacial parameters and cervical vertebrae maturation (CVM) stages, representing skeletal maturity levels, were measured using lateral cephalograms. The estimated dental age was significantly lower than chronological age in all groups, but CVM differences were not statistically significant. Dental age was the lowest, and differences between the chronological age and estimated dental age were the highest among initial stage of TMJOAs followed by progressive stage of TMJOAs, TMDnoOAs and control and were not associated with CVM stages. Cephalometric parameters revealed significant clockwise rotation of the mandible among the TMJOAs compared with controls and TMDnoOAs and were not associated with CVM stages as well. The juvenile female patients with TMD, particularly TMJ OA, showed retarded dental development, mandibular backward positioning and hyperdivergent facial profiles. The TMJ OA may be associated with retarded dental development but not with skeletal maturations.     

Correlation between cervical spine and temporomandibular disorders

Neuroanatomical interconnections and neurophysiological relationships between the orofacial area and the cervical spine have been documented earlier. The present single-blind study was aimed at screening possible correlations between clinical signs of temporomandibular disorders (TMD) and cervical spine disorders. Thirty-one consecutive patients with symptoms of TMD and 30 controls underwent a standardised clinical examination of the masticatory system, evaluating range of motion of the mandible, temporomandibular joint (TMJ) function and pain of the TMJ and masticatory muscles. Afterwards subjects were referred for clinical examination of the cervical spine, evaluating segmental limitations, tender points upon palpation of the muscles, hyperalgesia and hypermobility. The results indicated that segmental limitations (especially at the C0–C3 levels) and tender points (especially in the m. sternocleidomastoideus and m. trapezius) are significantly more present in patients than in controls. Hyperalgesia was present only in the patient group (12–16%). Received: 18 January 1998 / Accepted: 29 April 1998     

Ehlers-Danlos syndrome (classic type): report of a case presenting with an unusual dental anomaly

Ehlers-Danlos syndrome (EDS) comprises a group of generalised connective tissue disorders. Deficiency or alteration of the collagen present in the tissues results in some classic signs such as skin hyper extensibility, joint hypermobility, and vascular fragility. Multiple supernumerary teeth, congenitally missing teeth, and odontogenic keratocysts have been reported in some patients with EDS. To the author's knowledge, transposition of permanent canines has not previously been reported in any case of EDS. This case report presents the dental findings of a sporadic case of classic-type EDS in a 14-year-old Chinese male who had transposition of a permanent maxillary canine as well as the presence of two supernumerary premolars in the mandible.     

Prevalence of temporomandibular disorder pain,jaw noises and oral behaviours in an adult Italian population sample

To evaluate the prevalence of temporomandibular disorder pain (TMD‐pain), temporomandibular joint (TMJ) noises, oral behaviours in an Italian adult population sample, their possible association with gender, oral behaviours, self‐reported facial trauma and orthodontic treatment. Subjects older than 18 years were recruited from general population in public spaces during their daily life. A specific questionnaire was developed to collect data on TMD‐pain, TMJ noises, oral behaviours, orthodontic treatment and facial trauma. A total of 4299 subjects were included in the study. The most common symptom in the sample was TMJ clicking (30.7%), followed by TMD‐pain (16.3%) and TMJ crepitus (10.3%). Oral behaviours were reported in 29% of the sample; 43.6% of the sample reported a previous or ongoing orthodontic treatment. TMD‐pain and TMJ clicking were significantly associated to gender, oral behaviours and a positive history of previous facial trauma. Crepitus was significantly associated to oral behaviours, facial trauma and higher age. Ongoing orthodontic treatment was significantly associated to TMD‐pain and TMJ sounds. In a general Italian adult population sample, TMD‐pain is associated to female gender and is less prevalent than TMJ clicking. TMDs are associated to trauma and oral behaviours.     

‘I was cracking more than everyone else’: young adults' daily life experiences of hypermobility and jaw disorders

Most studies on general joint hypermobility (GJH) and temporomandibular disorders (TMD) are quantitative and have concluded that joint hypermobility is a risk factor for development of TMD. The present qualitative study aimed to explore young adults' daily life experiences of GJH, specifically these relating to jaw function, and their experiences of medical and dental care providers. Semi-structured interviews were conducted with nine young adults (18–22 yr of age) and data were analysed using qualitative content analysis. The overarching thematic category that emerged was ‘Hypermobility in daily life’, which was broken into six subthemes and three themes: ‘emotional perception’, ‘dealing with symptoms’, and ‘outside influences’. Participants' narratives centred on experiences of complex symptoms, awkward jaw function and joint noises, feeling different, and a lack of support from general medical and dental care providers. The findings show that young adults with joint hypermobility need early support from medical and dental care providers for managing their symptoms and conditions related to GJH. Future studies are warranted to develop guidelines for professionals in medical and dental care to detect and prevent forthcoming problems and to offer relevant support to hypermobile youths.     

Generalized joint laxity and its relation with oral habits and temporomandibular disorders in adolescent girls

A group of 248 girls, aged 15-16 years, were randomly selected and examined both clinically and by questionnaire with regard to the signs and symptoms of temporomandibular disorders (TMD), generalized joint laxity (GJL), range of mandibular opening, temporomandibular joint (TMJ) hypermobility and presence of oral parafunctions. The prevalence of GJL was 43% and that of TMJ hypermobility (TMJH) was 27.3%. A significant, albeit weak, correlation was found between the two. In the presence of joint click, both active and passive opening were significantly larger. When either muscle or joint sensitivity to palpation was present, the difference between the active and passive range of mouth opening increased significantly. The presence of reported clicks was negatively associated with GJL. This association was not valid in the presence of parafunction. Some of the signs and symptoms of TMD affected the range of mouth opening. In the presence of joint clicks, the mean active and passive mandibular opening were significantly larger. In the presence of joint and muscle sensitivity to palpation, the difference between passive and active mouth opening was larger. This was possibly because of the effect of pain on the full active range of opening, which was invalid in the registration of the passive mandibular opening. GJL, when present, did not seem to jeopardize the health of the stomatognathic system as expressed in the signs and symptoms of TMD. There was a negative association between GJL and the presence of reported joint clicks and catch. When a parafunction was present in addition to GJL, this association was invalid but not reversed, as has been previously reported.     

The association between wear facets,bruxism, and severity of facial pain in patients with temporomandibular disorders

STATEMENT OF PROBLEM: It is unclear whether patients with temporomandibular disorders (TMD) who report high levels of bruxism have more severe signs and symptoms of TMD and more advanced tooth wear than patients with TMD who report lower levels of bruxism. PURPOSE: The purpose of this study was to determine whether there was a significant association between tooth wear, the parafunctional oral habit of bruxism, temporomandibular joint (TMJ) pain, and muscle pain severity in a TMD population. MATERIAL AND METHODS: A total of 84 subjects previously diagnosed with TMD, according to the Research Diagnostic Criteria for TMD (RDC/TMD) and who met 10 specific inclusion/exclusion criteria underwent a thorough multiaxial examination and classification recommended by the National Institute of Dental and Craniofacial Research (NIDCR). Measurement of tooth wear facets by use of a 4-point scale were graded in 10 zones on mandibular casts. One calibrated examiner performed all scoring. Bruxism was assessed in a standardized pretreatment questionnaire and in the dental history and interview (RDC/TMD) to indicate how frequently (0 = never to 3 = very often) subjects performed a list of oral habits, which included bruxism. The Kappa reliability coefficient (range from: -1.0 to 1.0) was used to correct for chance agreement, and was computed for each of the 10 study sites designated for rating. Subjects were also compared for muscle and joint pain. Muscle pain was a summed measure derived from the dental examination findings (range 0 to 20), calculated from the presence or absence of pain induced by palpation of 20 predetermined muscle sites. Similarly, joint pain was a summed measure of the presence or absence of pain in the TMJs induced by palpation of the joints on the outer surface and in the external auditory canal in 5 different positions of the mandible. A Pearson product-moment correlation was used to compute the summed severity of tooth wear and the subjects' age. Analysis of covariance was used to determine whether the number of wear facets was significantly higher in patients with TMD who reported a history of bruxism, compared with patients with TMD who reported no or minimal bruxism, after controlling for the effect of age. Multivariate analysis of variance was used to determine whether the number of painful muscles of mastication and joint sites on standardized examination were significantly higher in patients with TMD with a history of bruxism (alpha=.05). RESULTS: In the population tested, tooth wear was modestly correlated with age (r =.40, P<.001). Of the 84 subjects studied, 11.9% reported no bruxing activity, 32.1% reported some or occasional bruxing activity, and 47.6% had frequent bruxism activity; the remaining 8.4% were eliminated from analysis because they provided inconsistent responses. Bruxism activity was not correlated with muscle pain on palpation and was inversely associated with TMJ pain on palpation. Tooth wear was not significantly correlated with bruxism, TMJ pain, or muscle pain. CONCLUSIONS: In this TMD population, tooth wear factors did not differentiate patients with bruxism from those without. The amount of bruxism activity was not associated with more severe muscle pain and was associated with less pain in the TMJ on palpation.     

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重度、不均匀的磨耗导致的咬合关系异常是咬合病最常见的一种形式。过度磨耗引起咬合过低的病例在临床中很多见,尤其是年龄较大的中老年患者居多。往往由于延误治疗时机及患者本身的不重视,就诊患者均伴有面型改变、牙体牙髓组织病变,甚至颞下颌关节异常等症状。在临床工作中,对此种病例采用咬合重建的治疗方法,达到了理想的治疗效果。所建立的新型的咬合接触关系不仅改善了面型及牙齿的美观,并且恢复了咀嚼系统的功能、牙周支持组织和颞下颌关节的组织结构功能。     

Risk factors associated with symptoms of temporomandibular disorders in a population of 50- and 60-year-old subjects

summary The aims of this study were first to investigate, by means of a mail questionnaire, variables from three domains: (i) socio‐economic attributes; (ii) general and oral health; and (iii) dental attitudes and behaviours in a large sample of 50‐ and 60‐year‐old subjects, and second to compare subjects with or without reported temporomandibular joint (TMJ) pain with respect to these variables. In 2002, a questionnaire was mailed to all 50‐ and 60‐year‐old subjects in two Swedish counties, Örebro and Östergötland (n = 17 138; n₅₀ = 8878; n₆₀ = 8260). Individuals not responding within 2 weeks were given a reminder. If still not answering, a new questionnaire was sent. The final response rate was 72·8% (n = 12 468). The reported responses to questions regarding ‘pain in the TMJ region’ and ‘difficulty to open the mouth wide’ were dichotomized into two groups: (i) no temporomandibular disorders (TMD) symptoms; and (ii) some, rather great or severe TMD symptoms. Striking differences in demographic, occupational, general and oral health conditions were found between the groups with and without TMD symptoms. The strongest risk indicator for both pain and dysfunction was reported bruxism. Women, younger subjects (50 years old) and blue‐collar workers were significantly more prevalent in the TMD symptom groups. Variables related to impaired general and oral health were more common in the groups with reported TMD problems, whereas satisfaction with received dental care and with teeth was lower. Individuals with reported TMD symptoms differed significantly from those without TMD symptoms in socio‐economic attributes, general and oral health symptoms, dental conditions and satisfaction with their teeth.     

Signs of temporomandibular disorders in tinnitus patients and in a population-based group of volunteers: results of the Study of Health in Pomerania

The literature has documented a controversial discussion on the possible relationship of otogenous symptoms and craniomandibular dysfunction since the 1920s. Therefore, an investigation was conducted which consisted of two parts: a case study with population-based controls and a cross-sectional study. The aim of the first study was to screen a group of patients suffering from acute or chronic tinnitus for temporomandibular disorders (TMD) in comparison with a population-based group of volunteers without tinnitus. To this end, 30 patients (13 females and 17 males, age 18-71 years) suffering from acute hearing loss associated with tinnitus, isolated acute tinnitus, and chronically transient tinnitus were examined for symptoms of craniomandibular dysfunction. The results were compared with those of clinical functional analysis from 1907 subjects selected representatively and according to age distribution from the epidemiological 'Study of Health in Pomerania' (SHIP); the occurrence of tinnitus was ruled out in these control subjects. Statistical analysis was performed with Chi-square and Mann-Whitney U-tests. Sixty per cent of the tinnitus patients and 36.5% of the control subjects exhibited more than two symptoms of TMD (P = 0.004). Tinnitus patients had significantly more muscle palpation pain (P < 0.001), temporomandibular joint (TMJ) palpation pain (P < 0.001), and pain upon mouth opening (P < 0.001) than the general population group. No statistical differences were found in TMJ sounds, limitation of mandibular movement, or hypermobility of the TMJ. Furthermore, 4228 subjects of the population group examined in the epidemiological study were screened for co-factors of tinnitus with the help of a multivariate logistic regression model which was adjusted for gender, age, and a variety of anamnestic and examined data. Increased odds ratios (OR) were found for tenderness of the masticatory muscles (OR = 1.6 for one to three painful muscles and OR = 2.53 for four or more painful muscles), TMJ tenderness to dorsal cranial compression (OR = 2.99), listlessness (OR = 2.0) and frequent headache (OR = 1.84) A relationship between tinnitus and TMD was established in both examinations. Tinnitus patients seem to suffer especially from myofascial and TMJ pain. A screening for TMD should be included in the diagnostic survey for tinnitus patients.     

The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders

Because the concept of whiplash as a causative factor for temporomandibular disorders (TMD) is highly controversial, we decided to do a retrospective analysis of patients treated in our office who had sustained whiplash injuries and were treated for cervical and temporomandibular disorders. The records of 300 patients with TMD preceded by a motor vehicle accident were examined retrospectively. The most common presenting symptoms, in order, were: jaw pain, neck pain, post-traumatic headache, jaw fatigue, and severe temporomandibular joint (TMJ) clicking. The most common TMD diagnoses were: masseter trigger points, closing jaw muscle hyperactivity, TMJ synovitis, opening jaw muscle hyperactivity, and advanced TMJ disk derangement. Based primarily on the physical examination, we concluded that the TMJ and surrounding musculature should be examined similarly to other joints, with no preconceived notion that TMD pathology after whiplash is unlikely.     

Prevalence, intensity, and correlation of different TMJ symptoms in Lebanese and Italian subpopulations

AIM: The aim of this study was to compare self reported joint related temporomandibular disorder (TMD) symptoms in Lebanese and Italian dental and non-dental students and to detect any correlation between different symptoms. METHODS AND MATERIALS: A questionnaire was distributed in Sardinia (Italy) to dental and psychology students and in Lebanon to dental, physical therapy, and biology students to investigate the prevalence, intensity, and correlation of four temporomandibular joint (TMJ) symptoms. RESULTS: Prevalence of earache varied among the groups from 10.1% to 29.2%, ear stuffiness from 22.5% to 30.8%, TMJ pain from 13.2% to 21.2%, and TMJ sounds from 18.4% to 46.2%. DISCUSSION: Different prevalence and intensity of earache and TMJ sounds were found in the examined sub-populations diverse in cultural background and education. However, prevalence and intensity of ear stuffiness and TMJ pain were similar. Association between TMJ sounds and TMJ pain was detected in selected sub-populations, and correlation between one symptom on one side of the head with the same symptom on the contralateral side were noted suggesting most of these symptoms are bilateral. CONCLUSION: The results of the study might be useful to anticipate the possible occurrence of associated symptoms or the same symptom on both sides of the head. Correlations with cultural background and education are difficult to establish.     

下颌骨矢状劈开后退术对颞下颌关节的影响

目的:评价下颌骨矢状劈开后退术对颞下颌关节(TMJ)的影响.方法:研究我院50 例术前有颞下颌关节病(TMD),且行下颌骨矢状劈开后退术的患者,从关节压痛、弹响、张口度、张口型等方面量化评估术前、术后颞下颌关节症状变化情况.结果:从关节压痛、弹响、张口度、张口型等各方面评估均显示术后颞下颌关节症状评分均显著低于术前(P<0.05).结论:对于术前有颞下颌关节病的患者,行下颌骨矢状劈开后退术可以有效改善颞下颌关节症状.     

Mood spectrum in patients with different painful temporomandibular disorders

The purpose of this study was to investigate for difference in the prevalence of mood disorders between patients with different painful temporomandibular disorders (TMD). After a sample size necessary for the study was calculated, 60 patients with a painful TMD were selected and divided into the following groups: myofascial pain (n=20), temporomandibular joint (TMJ) pain (n=18), combined myofascial and TMJ pain (n=22). Two distinct comparison groups were selected: subjects with a nonpainful TMD (n=25) and TMD-free subjects (n=29). All participants filled out a self-report validated instrument (MOODS-SR) to evaluate psychopathological symptoms related to mood disturbances. A one-way analysis of variance (ANOVA) with Bonferroni's post hoc test for multiple comparisons was performed to investigate for significant differences among the groups. The three groups of patients with painful TMD scored significantly higher than comparison groups in all MOODS-SR domains investigating depression, but no difference was shown between subjects with myofascial pain and those with TMJ pain. No significant differences among the groups emerged for the presence of manic symptoms, indicating that depressive disorders associated with TMD are not an expression of a more complex manic depressive illness. The study concluded that the presence of depressive symptoms in TMD patients seems to be related to the presence of a painful condition and seems to be unrelated to the location of pain. Furthermore, depressive disturbances in painful TMD patients affect the whole spectrum of depressive psychopathology.