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

Characterization of Migraine in Children and Adolescents With Generalized Joint Hypermobility: A Case-Control Study

Background and Objectives

The prevalence of generalized joint hypermobility (GJH) is 5-65% in children and adolescents. The hypothesis of this study was to see whether there is an association between headache characteristics and GJH in children and adolescents with migraine.

Methods

We performed a primary retrospective case-control analysis of an established database of patients with headache aged 5-17 years.

Results

We included 5435 participants. Approximately 31.6% of participants (1,719/5,435) were diagnosed with GJH (Beighton score ≥ 6). Nausea (73.1% vs 67.5%, χ2 with 1 degree of freedom = 17.0, p < 0.0001), phonophobia (87.3% vs 78.8%, χ2 with 1 degree of freedom = 18.0, p < 0.0001), and the PedMIDAS score (48.2 ± 52.5, 95% CI 45.7-50.6 vs 41.6 ± 51.2, 95% CI 40.0-43.3, effect size = 0.13, p < 0.0001) were noted to be more severe in participants with GJH than those without GJH.

Discussion

Youths with GJH and migraine were noted to have more severe migraine characteristics.

Down syndrome: orofacial pain, masticatory muscle hypotonia, and sleep disorders

The aim of the present study was to investigate orofacial pain in individuals with Down syndrome (DS) and determine possible associations with masticatory muscle hypotonia (MMH), maximum mouth opening (MMO), and sleep disorders. Twenty-three individuals with DS underwent a standardized clinical examination using Axis I of the Diagnostic Criteria for Temporomandibular Disorders, for the diagnosis of pain in the masseter and temporal muscles and temporomandibular joint (TMJ). MMH was investigated using electromyography of the temporal and masseter muscles and the measurement of maximum bite force (MBF). MMO was measured using an analog caliper. Sleep disorders (obstructive sleep apnea [OSA], snoring index [SI], and sleep bruxism index [SBI]) were investigated using type II polysomnography. Statistical analysis was performed. Nonsignificant differences were found in muscle and TMJ pain between the sexes. However, myalgia and referred myofascial pain in the left masseter muscle were more frequent in males (69%) than females (40%). Electrical activity of the temporal (left: p = .002; right: p = .004) and masseter (left: p = .008) muscles was significantly lower in males than in females. MBF range was lower in males than females, indicating the highest MMH among males. OSA, SI, and SBI were identified in both sexes, but with no statistically significant differences. We concluded that myalgia and referred myofascial pain were found in some individuals with DS, especially in males. Arthralgia was found mainly in females. Temporal and masseter myalgia may have exerted an influence on the severity of MMH in males, particularly on the left side.

Temporomandibular disorders, bite force and osseous changes of the temporomandibular joints in patients with hypermobile Ehlers-Danlos syndrome compared to a healthy control group

Background

Ehlers‐Danlos syndrome (EDS) is a hereditary disorder that affects the connective tissue and collagen structures in the body characterised by joint hypermobility, skin hyperextensibility and tissue fragility.

Objective

The aim was to investigate temporomandibular disorders (TMD), bite force, teeth in occlusal contact and osseous changes of the temporomandibular joints (TMJs) in 26 patients with hypermobile EDS (hEDS), differentiated by a genetic test, compared to 39 healthy controls.

Methods

Clinical examination according to Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), radiological examinations of the TMJs by cone‐beam‐computed tomographic (CBCT) scans, registration of bite force and teeth in occlusal contact was performed. Statistical analyses included Fisher's Exact Test, multiple logistic and linear regression models adjusted for age, gender and Body Mass Index (BMI).

Results

Single symptoms and signs of TMD occurred significantly more often in hEDS (p = .002; p = .001; p = .003; p = <.0001; p = .012) and maximum mouth opening was significantly smaller in hEDS compared to controls (p = <.0001). The DC/TMD diagnosis myalgia, myofascial pain with referral, arthralgia, headache attributed to TMD, disc displacement disorders and degenerative joint disease occurred significantly more often in hEDS compared to controls (p = .000; p = .008; p = .003; p = .000; p = <.0001; p = .010, respectively). No significant differences were found in bite force and in teeth in occlusal contact between the groups (p > .05). On CBCT of the TMJs, subcortical sclerosis occurred significantly more often in hEDS compared to controls (p = .005).

Conclusion

Symptoms and signs of TMD and osseous changes of the TMJs occurred significantly more often in hEDS. Bite force and teeth in occlusal contact were comparable to controls.

Evaluation of Dental Status and Temporomandibular Joint in Children With Generalized Joint Hypermobility

OBJECTIVE

The aim of this study was to evaluate the dental status and temporomandibular diseases (TMDs)-related symptoms in children with generalized joint hypermobility (GJH) and compare them with healthy controls (HCs).

METHODS

This is a cross-sectional, observational study carried out between September 2016 and April 2017. A total of 124 children with GJH (n = 62) and HC (n = 62) were enrolled. The GJH was assessed with the Beighton hypermobility score. The subjects were screened for dental status and TMD-related symptoms. The assessment included the index for "decayed," "missing," and "filled teeth" (DMFT, dmft); plaque; gingival bleeding; tooth mobility; and temporomandibular joint (TMJ) evaluation.

RESULTS

The mean Beighton hypermobility score was 6.3 ± 1.2 in the GJH group. Visible plaque index and gingival bleeding index scores were found to be significantly higher in children with GJH then in the HC (p = 0.031, p = 0.023). No differences were found regarding the DMFT scores between the groups (p = 0.16). Temporomandibular disorder-related symptom frequencies were significantly higher in children with GJH (p < 0.001). The most common clinically determined sign of TMD was clicking with a maximum active mouth-opening. Combined TMJ symptoms and TMD were observed in approximately one third of the children with GJH.

CONCLUSIONS

The presence of GJH in a child may be indicative of future dental or TMJ problems, and it may cause dental problems due to increased gingival bleeding index and visible plaque index scores. Therefore, children with GJH require preventive dental and TMJ care.

The Beighton Score as a measure of generalised joint hypermobility

The Beighton Score (BS) is a set of manoeuvres in a nine-point scoring system, used as the standard method of assessment for Generalised Joint Hypermobility (GJH). It was originally developed as an epidemiological tool used in screening large populations for GJH, but later adopted as a clinical tool for diagnostic purposes. Its ability to truly reflect GJH remains controversial, as joints within the scoring system are predominantly of the upper limb and disregard many of the major joints, preventing a direct identification of GJH. Furthermore, a consistent finding in the literature whereby the BS failed to identify hypermobility in joints outside the scoring system suggests its use as an indirect indicator of GJH is also not viable. As such, the collective findings of this review demonstrate a need for a change in clinical thinking. The BS should not be used as the principle tool to differentiate between localised and generalised hypermobility, nor used alone to exclude the presence of GJH. Greater emphasis should be placed on a clinician’s judgement to identify or exclude GJH, according to its full definition.

Correlation of Condylar Translation During Maximal Mouth Opening with Presence of Signs of Temporomandibular Joint Disorders in an Asymptomatic Population of 18-25 Years Age Group of Northern India

Objective(s):

The objective of this study was to determine the frequency of “subluxation” and presence of clinical signs of Temporomandibular Joint Disorder (TMD) in asymptomatic individuals and its distribution according to age and sex.

Materials and Methods:

The material investigated comprised of 200 asymptomatic subjects with 400 joints. The subjects were divided into two groups of 18-25 years and 50-60 years of age consisting of equal number of males and females. Clinical examination involved measurement of maximal inter-incisal distance, joint sounds and deviation. For radiological examination, Temporomandibular Joint (TMJ) open mouth close mouth view option (TMJ1/2) was used on a Digital Panoramic Machine. All the radiographs were traced to assess subluxation and anterior translation of the condyle. The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 15.0 for Windows).

Results:

The prevalence of the signs of TMDs in the asymptomatic population was found to be very high and more predominant in females as compared to males. Furthermore, the older age group had comparatively less signs of TMDs. It was of interest that the subjects presenting with clinical signs of TMD were significantly less as compared to the subjects presenting with subluxation. The value of anterior translation was found to be more in females in the younger age group as compared to the males. Similarly, it was more in males as compared to females in older age group. But the mean anterior translation difference in females in 18-25 years and 50-60 years showed a statistically significant difference with P-value 0.017.

Conclusion:

Subluxation is a very common feature found in almost all the subjects in this study with a high prevalence. Hence, we may assume that the increased incidence of TMDs could be a direct result of the phenomena of subluxation. The decrease in mandibular length could be the cause of decreased mouth opening and increased subluxation.

Evaluation of Temporomandibular Disorders and Comorbidities in Patients with Ehler--Danlos: Clinical and Digital Findings

Objective

The objective of this study is to recognize representative cranio-cervico-mandibular features of patients with Ehler-Danlos syndrome and associated temporomandibular disorders (TMDs), to assess a targeted and integrated treatment plan.

Materials and Methods

After a diagnosis of disease, 38 individiuals with Ehler-Danlos syndrome and temporomandibular symptomatology referred were evaluated. Gnathological evaluation, according to the Diagnostic Criteria for TMDs, and radiographic imaging was performed. In addition, digital evaluation of occlusal and muscular balance, using surface electromyography of jaw muscles, was conducted. Statistical software for data analysis - STATA (StataCorp, College station, Texas, USA) - was used.

Results

Most common temporomandibular dysfunctions were arthralgia, myalgia, disc displacement with reduction and subluxation. Headache and neck pain were the most frequent comorbidities. Somatization, depression, anxiety, and obsessive-compulsive behavior were the most recurrent psychological disorders. Electromyographic analysis showed out of normal range data.

Conclusion

Early diagnosis and interception are requested to avoid injuries and repeated traumatism. Multidisciplinary treatments are available to approach all the aspects of the syndrome.

The Association between Generalized Joint Hypermobility and Temporomandibular Joint Disorders: A Systematic Review

To analyze conflicting evidence in the literature for the association between temporomandibular joint disorders (TMD) and generalized joint hypermobility (GJH), we performed a bibliographic search. The methodological quality of the 14 papers found was assessed according to 14 criteria. Papers were included in the analysis if the study population was clinically relevant, if range of motion of 2 or more joints was assessed on the left and right sides, and if cases had a TMD. Four studies fulfilled these selection criteria. Data from 3 studies, 113 cases and 95 controls, were available for analysis. Twenty-six cases and five controls were hypermobile (odds ratio, 5.4). In a sensitivity analysis, the odds ratio changed from significant to non-significant in 2 of 5 scenarios. As a result, it is not clear whether GJH is associated with TMD, and more rigorous studies are needed.

Oral and mandibular manifestations in the Ehlers-Danlos syndromes

The Ehlers-Danlos syndromes (EDS) are hereditary disorders that affect the connective tissue and collagen structures in the body. Several types of EDS have been identified. Oral and mandibular structures, which include oral soft tissue, dentition, facial and head pain, and the functioning of the temporomandibular joint (TMJ), are variably affected in the various types of EDS. These various manifestations of EDS have been noted for many years, but newer diagnostic techniques and studies are shedding additional light on the challenges faced by EDS patients in the area of oral and mandibular disorders. Further, the impact of temporomandibular disorder (TMD) on musculoskeletal dysfunction and vice versa, make this an important feature to recognize. Oral and mandibular hypermobility of the TMJ with associated consequences of EDS are noted. These features, diagnostic parameters and treatment procedures are presented. © 2017 Wiley Periodicals, Inc.

Investigating activity of masticatory muscles in patients with hypermobile temporomandibular joints by using EMG

Background

Temporomandibular joint hypermobility (TMJH) can manifest higher range of motions in mandible. The aim of this study was to investigate and compare the activity of masticatory muscle of TMJs in healthy individuals and patients with mild, moderate and severe TMJH.

Material and Methods

In this clinical study, 69 patients (between the ages of 22 to 42) with manifestation of TMJH were included. The patients were divided into three groups based on their maximum mouth opening (MMO): (light) with MMO of 50-55 mm; (moderate) with MMO between 55 to 65 mm; and (severe) with MMO >65 mm. Also, 20 healthy people with profiled tomography in the last 6 months were invited as control group (healthy) with normal MMO (<50 mm). All the groups subjected to electromyogram (EMG) in 2 steps: maximal voluntary clenching (MVC) of the jaws; and during chewing of bread by using one side of the jaws voluntary. The collected data were analyzed by Student T-test and Chi-Square tests using SPSS software version 15 at significant level of 0.05.

Results

Both TMJs of light, moderate and severe groups showed significant differences in frequency, time of activity and rest in comparison with healthy group during chewing and MVC (all p values < 0.01).

Conclusions

Masticatory muscles activity reduced in relation with the severity of TMJH and higher excessive mouth opening.

Key words:Electromyography, joint hypermobility, mouth opening, tempormandibular joint.

Temporomandibular joint vibrations from totally asymptomatic subjects

OBJECTIVE

Precisely characterize the TMJ vibrations of a youthful, adult and completely asymptomatic population.

METHODS

TMJ vibrations were recorded from 237 asymptomatic subjects (163 f, 74 m) at Dayananda Sagar Institute in India. The subjects were selected, examined and informed (WMA Helsinki Declaration). TMJ vibrations were recorded bilaterally during maximal open - close. 6 parameters of the vibrations were analyzed between the left and right sides, between genders and with respect to age.

RESULTS

Mean vibration intensity was greater for females (p < 0.01) than males. A portion of the frequency spectrum < 300 Hz was also more intense for females (p < 0.022). Females 18 - 20 years old exhibited higher Peak Amplitude than 27 - 30 year olds (p < 0.025) and lower Median Frequency (p < 0.005).

CONCLUSIONS

A significant difference in TMJ vibrations was present between males and females, increased with age in females but not in males.

The association between temporomandibular disorders and joint hypermobility syndrome: a nationwide population-based study

OBJECTIVES

This study aims to investigate the risk factors of temporomandibular disorders (TMDs), including disc or non-disc-related disorders, and joint hypermobility syndrome (JHS) retrospectively and to analyze the factors by estimating the magnitude of the association between the two conditions using a nationwide population-based dataset.

MATERIALS AND METHODS

A total of 975,788 eligible patients' de-identified data were obtained from a representative database composed of one million of Taiwan's population since 2004 to 2008. All associated factors, such as gender, age, facial trauma, and psychosis, which correlated with TMDs and JHS were examined. Multiple logistic regression modeling adjusted for confounding variables to determine the odds ratio of variables that made an important contribution to TMDs and JHS.

RESULTS

For all TMDs patients, only 1.47% patients had disc-related disorders. For all JHS patients, only 3.85% patients are diagnosed with concomitant TMDs. Statistically significant association was observed between joint hypermobility and TMDs. Furthermore, the prevalence of JHS patients shows significant difference within TMD subgroups, in which 9.52% of JHS patients have disc disorders and 90.48% of JHS patients do not. All associated factors, such as gender, age, JHS, facial trauma, and psychosis, had a significant impact on the TMDs. Interestingly, patients with TMJ articular disc disorders are 6.7 times more likely to be diagnosed with JHS compared to patients without disc-related disorders.

CONCLUSIONS

Our results confirm that there is a significant positive association between TMDs and JHS, highlighting that patients with disc-related TMDs are more likely to experience JHS than patients with TMDs without disc disorders.

CLINICAL RELEVANCE

Individuals with TMD associated with JHS should be carefully evaluated by inter-disciplinary specialists as these factors may eventually have impact on the prognosis of TMDs and JHS.

Condylar distances in hypermobile temporomandibular joints of patients with excessive mouth openings by using computed tomography

Objectives: hypermobility in Temporomandibular joint (TMJ) can manifest higher range of motions in mandible. The aim of this study was to compare the position and distances of the head of condyle to glenoid fossa in TMJs of healthy individuals and patients with mild, moderate and severe TMJ hypermobility. Material and Methods: In this clinical study, 69 patients (between the ages of 22 to 42) with manifestation of joint hypermobility were included and Computed tomography were administered for both TMJs. The patients were divided into three groups based on their maximum mouth opening (MMO): (A) with MMO of 50-55 mm; (B) with MMO between 55 to 65 mm; and (C) with MMO >65 mm. Also, 15 healthy people with profiled tomography in the last 6 months were assumed as control group (N) with normal MMO (<50 mm). The position of condyle from articular eminence while MMO; and the distances from anterior, superior and posterior border of condyle and facing wall of glenoid fossa were measured in closed mouth from the tomography of all contributors. The collected data were analyzed by one-way ANOVA, Post Hoc and Chi-Square tests using SPSS software version 15 at significant level of 0.05. Results: The superior and posterior distances were significantly higher in groups A, B and C than healthy individuals (all P values<0.01). The anterior distance was significant between groups B and N only in right TMJ (P=0.013). Conclusions: TMJ hypermobility showed the characteristic of increased condylar distance in posterior and superior specially in higher excessive mouth opening.

Key words:Computed tomography, joint hypermobility, mandibular condyle, mouth opening.

Psychophysiological Definitions of Clenching

This study tested the hypothesis that individuals show considerable variability in EMG activity produced by the masticatory muscles when they are instructed to clench than when they are instructed to make minimal or maximal contact. Twenty individuals without temporomandibular disorder (TMD) pain participated in a biofeedback-training task to establish a relaxed baseline. They were instructed to clench their teeth according to their personal definition of the term, while EMG data were collected. This process was repeated two more times, followed by similar instructions to make minimal and maximal contact between the teeth. Results showed that individual subjects were very consistent in their behavioral definition of clenching and that the subjects taken as a whole showed markedly greater variability. The precise behavioral meaning of clenching varies across individuals. The failure to account for these individual differences may explain in part reported discrepancies on the role of parafunctions in TMD.

The relationship between malocclusion, benign joint hypermobility syndrome, condylar position and TMD symptoms

The current study investigated the association between temporomandibular disorders, malocclusion patterns, benign joint hypermobility syndrome and the initial condylar position. One hundred sixty-two subjects were analyzed using the Rocabado Temporomandibular Pain Analysis; Helkimo Index parameters; the Carter-Wilkinson modified test; and a mounting cast with condylar position indicator registration (MPI). The study revealed a significant association between: 1. Delta H, skeletal pattern (p = 0.034); 2. Delta Y, transversal malocclusion (p = 0.04); 3. right and left, Delta Z, right and left posteroinferior synovial pain (p < 0.05); 4. hypermobility scale, gender (p < 0.001), malocclusion pattern (p = 0.021); 5. TMJ function impairment, gender (p = 0.043); 6. sagittal malocclusion pattern, right temporomandibular pain analysis joint (TPAJ) (p = 0.0034); 7. TMJ function impairment, left and right TPAJ (p = 0.007); and 8. mandibular motion, left and right TPAJ (p = 0.035, p = 0.015). The conclusion was that anterior crossbite and condylar displacements in the vertical plane are risk factors in developing TMJ symptoms.

Joint hypermobility and disk displacement confirmed by magnetic resonance imaging: a study of women with temporomandibular disorders

OBJECTIVE

The objective of this study was to test whether or not there is an association between generalized joint hypermobility (measured using the Beighton score) and temporomandibular joint disk displacement in women who had sought medical attention for temporomandibular disorders (TMD).

STUDY DESIGN

We studied 66 women who were attending the clinic for TMD. The patients were examined for joint hypermobility, and Beighton scores were calculated. When it was suspected that a patient suffered arthropathic complaints, magnetic resonance imaging of both temporomandibular joints was performed with the mouth closed and at maximal opening. The Pearson chi-squared test was used to test for an association between generalized joint hypermobility and disk displacement.

RESULTS

We were unable to confirm the existence of an association between generalized joint hypermobility and temporomandibular joint disk displacement in women (chi(2) = 1.523; P = .02).

CONCLUSION

Generalized joint hypermobility may be a factor related to TMD, but we did not find an association between generalized joint hypermobility and anterior disk displacement in women.

Association between generalized joint hypermobility and signs and diagnoses of temporomandibular disorders

The aim of this study was to analyze whether generalized joint hypermobility (GJH) is a risk factor for temporomandibular disorders (TMD). We examined 895 subjects (20-60 yr of age) in a population-based cross-sectional sample in Germany for GJH according to the Beighton classification and for TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD). After controlling for the effects of age, gender, and general joint diseases using multiple logistic regression analyses, hypermobile subjects (with four or more hypermobile joints on the 0-9 scale) had a higher risk for reproducible reciprocal clicking as an indicator for disk displacement with reduction (Odds Ratio (OR) = 1.68) compared with those subjects without hypermobile joints. Concurrently, subjects with four or more hypermobile joints had a lower risk for limited mouth opening (< 35 mm; OR = 0.26). The associations between GJH and reproducible reciprocal clicking or limited mouth opening were statistically significant in a trend test. No association was observed between hypermobility and myalgia/arthralgia (RDC/TMD Group I/IIIa). In conclusion, GJH was found to be associated with non-painful subtypes of TMD.

Hypermobility disorders in children and adolescents

It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.

The role of systemic hypermobility and condylar hypermobility in temporomandibular joint dysfunction syndrome

OBJECTIVE

To evaluate the risk of temporomandibular joint dysfunction (TMD), when both systemic joint hypermobility (SJH) and localized condylar hypermobility (LCH) exist.

MATERIALS AND METHODS

Sixty-four consecutive outpatients with temporomandibular joint clicking or pain, and 77 sex- and age-matched control subjects, were recruited in the study. LCH was diagnosed when condylar subluxation was present, and SJL was diagnosed by using Beighton's method. The frequency of symptoms, mean mouth opening, and the frequency of subjects with SJL and LCH were the main outcome measures.

RESULTS

Out of the 64 patients, 16 patients were suffering from pain, 20 patients from joint-clicking and 28 patients from both. Both SJH and LCH were more frequently observed in those patients with TMD than in control subjects. The risk of TMD was higher if LCH and SJH existed jointly.

CONCLUSION

Both systemic and localized hypermobility may have a role in the etiology of TMD.

MRI findings concerning the lateral pterygoid muscle in patients with symptomatic TMJ hypermobility

Clinical studies have shown a close association between temporomandibular joint hypermobility (TMJH) and temporomandibular disorders (TMD). While pathological change of the lateral pterygoid muscle (LPM) is one of the most emphasized in studies of TMD, there have been no detailed clinical reports of the LPM studies using magnetic resonance imaging (MRI) in TMJH. This study investigates structural and pathological alterations involving the LPM in patients with TMJH using MRI. A retrospective analysis was made of high-field MRI images from 98 patients with TMJH. LPMs of 143 joints were analyzed. In 110 joints (77%), hypertrophy, atrophy, and contracture were found in the superior belly and/or the inferior belly of the LPM. Pathological changes were more frequently found in the superior rather than the inferior belly of the LPM. In the cases with abnormalities in both bellies of the LPM, hypertrophy of the inferior belly was usually found combined with other changes of the SBLPM. The results of this study indicated that the pathological changes of the LPM or MRI are not infrequent in patients with symptomatic TMJH.