1
|
Williams CM, Welch JJ, Scheper M, Tofts L, Pacey V. Variability of joint hypermobility in children: a meta-analytic approach to set cut-off scores. Eur J Pediatr 2024:10.1007/s00431-024-05621-4. [PMID: 38801562 DOI: 10.1007/s00431-024-05621-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024]
Abstract
Current international consensus of the appropriate Beighton score cut-off to define if a child has generalised joint hypermobile or not is based upon expert opinion. Our aim was to determine the prevalence of Beighton scores of children worldwide to provide a recommendation for establishing the Beighton score cut-off to identify generalised joint hypermobility in children. We used AMED, OVID Medline, Embase and CINAHL to find published articles from inception to April 2024 describing Beighton scores of children up to and including 18 years from the general population. We extracted study demographics including country of publication, total number of participants, summary data about the age and sex of participant, Beighton scores and any cut-off used where authors deemed children hypermobile and how many children were rated at the corresponding Beighton scores. There were 37 articles reporting on the prevalence or incidence of hypermobility at cut-off scores from 28,868 participants. Using the cut-off of ≥ 6 resulted in a prevalence of 6% for studies reporting male data and 13% for studies reporting female data. Limited data reporting availability precluded further sub-analysis at a Beighton score of ≥ 7, age, pubertal status and ethnicity. Conclusion: The working threshold for identifying generalised joint hypermobility in children should be a Beighton score of 6 or more. Our analysis also suggests a Beighton score of 7 or greater may be appropriate in childhood, particularly for females. What is Known: • The working threshold for identifying generalised joint hypermobility in children previously was set based on expert opinion. What is New: • The threshold to identify hypermobility in children should be at a minimum of ≥ 6 on the Beighton score.
Collapse
Affiliation(s)
- Cylie M Williams
- School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, Frankston, VIC, 3199, Australia.
| | - James J Welch
- Ablefeet, 16 Terrace Road, Walton-on-Thames, Surrey, KT12 2SB, UK
| | - Mark Scheper
- Research Center Innovations in Care, Data Supported Healthcare, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
- Department of Health Sciences, Faculty of Medicine, Health & Human Sciences, Macquarie University, North Ryde, NSW, 2113, Australia
- Institute for Communication, Media and Information Technology, Program Responsible AI, Rotterdam University of Applied Sciences Rotterdam, Rotterdam, The Netherlands
- Livinglab Responsible AI, Creating010, Rotterdam University of Applied Sciences Rotterdam, Rotterdam, The Netherlands
| | - Louise Tofts
- Department of Health Sciences, Faculty of Medicine, Health & Human Sciences, Macquarie University, North Ryde, NSW, 2113, Australia
| | - Verity Pacey
- School of Primary and Allied Health Care, Monash University, 47-49 Moorooduc Hwy, Frankston, VIC, 3199, Australia
- Department of Health Sciences, Faculty of Medicine, Health & Human Sciences, Macquarie University, North Ryde, NSW, 2113, Australia
| |
Collapse
|
2
|
Ulmner M, Sugars R, Naimi-Akbar A, Reseland JE, Lund B. General joint hypermobility in temporomandibular joint disease; clinical characteristics, biomarkers, and surgical aspects. Heliyon 2023; 9:e23051. [PMID: 38149208 PMCID: PMC10750043 DOI: 10.1016/j.heliyon.2023.e23051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/23/2023] [Accepted: 11/24/2023] [Indexed: 12/28/2023] Open
Abstract
Objectives This study aimed at identifying biomarkers in the temporomandibular joint (TMJ) synovial tissue analysing 28 extra cellular matrix proteins in TMJ diseased patients, classified with either general joint hypermobility (GJH) or normal joint mobility (NJM), and to compile clinical and protein characterisation to reveal potential surgical predictive factors. Study design A prospective observational cohort study including 97 consecutive patients scheduled for TMJ surgery was performed. Joint mobility and several other predefined clinical variables were recorded. Synovial tissue was harvested during surgery followed by examination using multi-analytic profiling. A multivariate quantile regression model was used for analysis purposes. Results The GJH/NJM ratio was 2:5. The GJH cohort were younger (P = 0.001) and more likely to be women (P = 0.026) compared to the NJM cohort. None of the protein concentrations could be correlated to joint mobility in the multivariate regression model, but often to the variable TMJ diagnosis. The surgical outcome after the six-month follow-up were equal between GJH and NJM patients. Conclusions GJH was more common in the study cohort compared to general population frequencies, but GJH was not a negative factor for surgical outcome. Young age and female gender correlated to GJH. No TMJ biomarkers were GJH specific, and the results suggested that TMJ diagnosis more strongly correlated to the protein profile compared to GJH and the other investigated variables.
Collapse
Affiliation(s)
- Mattias Ulmner
- Medical Unit of Plastic Surgery and Oral and Maxillofacial Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Department of Dental Medicine, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Rachael Sugars
- Department of Dental Medicine, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Aron Naimi-Akbar
- Health Technology Assessment-Odontology, Malmö University, 205 06, Malmö, Sweden
| | - Janne Elin Reseland
- Department of Biomaterials, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, 0317, Oslo, Norway
| | - Bodil Lund
- Medical Unit of Plastic Surgery and Oral and Maxillofacial Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
- Department of Dental Medicine, Karolinska Institutet, 171 77, Stockholm, Sweden
| |
Collapse
|
3
|
Ghosh A, Horn PS, Kabbouche Samaha M, Kacperski J, LeCates SL, White S, Powers SW, Hershey AD. Characterization of Migraine in Children and Adolescents With Generalized Joint Hypermobility: A Case-Control Study. Neurol Clin Pract 2023; 13:e200188. [PMID: 37840826 PMCID: PMC10573031 DOI: 10.1212/cpj.0000000000200188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 07/17/2023] [Indexed: 10/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ankita Ghosh
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Paul S Horn
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Marielle Kabbouche Samaha
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Joanne Kacperski
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Susan L LeCates
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Shannon White
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Scott W Powers
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| | - Andrew D Hershey
- Division of Neurology (AG), Le Bonheur Children's Hospital, Memphis, TN; Division of Neurology (AG, PSH, MKS, JK, SLL, SW, ADH), Cincinnati Children's Hospital; Department of Pediatrics (PSH, MKS, JK, SWP, ADH), University of Cincinnati College of Medicine; and Division of Behavioral Medicine and Clinical Psychology (SWP), Cincinnati Children's Hospital Medical Center, OH
| |
Collapse
|
4
|
Willich L, Bohner L, Köppe J, Jackowski J, Hanisch M, Oelerich O. Prevalence and quality of temporomandibular disorders, chronic pain and psychological distress in patients with classical and hypermobile Ehlers-Danlos syndrome: an exploratory study. Orphanet J Rare Dis 2023; 18:294. [PMID: 37726791 PMCID: PMC10510186 DOI: 10.1186/s13023-023-02877-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/24/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The Ehlers-Danlos syndromes are a group of clinically and genetically heterogeneous hereditary diseases affecting the connective tissue. They are characterized by hypermobility of the joints, hyperextensible skin and friable tissue. According to current classification, 13 subtypes can be distinguished, of which the hypermobile and the classical subtype are the most prevalent. This study aimed to evaluate patients with classical (cEDS) and hypermobile (hEDS) Ehlers-Danlos syndrome regarding temporomandibular disorder (TMD), chronic pain, and psychological distress. METHODS Support groups from Germany, Austria, and Switzerland were contacted, and social media were used to recruit participants. Free text questions, the German version of the Depression Anxiety and Stress Scale (DASS), and the German version of the Graded Chronic Pain Status (GCPS) were used. RESULTS 259 participants were included (230 hEDS/29 cEDS). At least 49.2% of the participants had painful or restricted jaw movements, and at least 84.9% had pain in the masticatory muscles, with 46.3% already having a diagnosed TMD. Multivariate analysis showed a significant correlation between TMJ involvement and chronic pain with a 2.5-fold higher risk of chronic pain with a diagnosed TMD. 22.8% of participants had a critical score for depression, 53.3% had a critical score for anxiety, and 34.0% had a critical score for stress. CONCLUSION There is a high prevalence of TMD problems and chronic pain in patients with cEDS and hEDS. The lack of knowledge about these problems can create psychological distress. More research is needed to provide adequate treatment for patients with EDS.
Collapse
Affiliation(s)
- Leon Willich
- Department of Prosthodontics, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W30, Münster, D-48149, Germany
| | - Lauren Bohner
- Department of Oral and Maxillofacial Surgery, University Hospital Münster, Münster, 48149, Germany
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Münster, Schmeddingstraße 56, Münster, D- 48149, Germany
| | - Jochen Jackowski
- Department of Oral Surgery and Policlinical Ambulance, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 45, Witten, 58448, Germany
| | - Marcel Hanisch
- Department of Oral and Maxillofacial Surgery, University Hospital Münster, Münster, 48149, Germany.
- Department of Oral Surgery and Policlinical Ambulance, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 45, Witten, 58448, Germany.
| | - Ole Oelerich
- Department of Prosthodontics, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W30, Münster, D-48149, Germany.
| |
Collapse
|
5
|
Lund B, Ulmner M, Bjørnland T, Berge T, Olsen-Bergem H, Rosèn A. A disease-focused view on the temporomandibular joint using a Delphi-guided process. J Oral Sci 2020; 62:1-8. [DOI: 10.2334/josnusd.19-0128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Bodil Lund
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen
- Department of Dental Medicine, Karolinska Institutet
- Department of Oral and Maxillofacial Surgery, Haukeland University Hospital
| | - Mattias Ulmner
- Department of Dental Medicine, Karolinska Institutet
- P.F. Craniofacial diseases, Karolinska University Hospital
| | - Tore Bjørnland
- Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo
| | - Trond Berge
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen
- Department of Oral and Maxillofacial Surgery, Haukeland University Hospital
| | - Heming Olsen-Bergem
- Department of Oral Surgery and Oral Medicine, Faculty of Dentistry, University of Oslo
| | - Annika Rosèn
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen
- Department of Oral and Maxillofacial Surgery, Haukeland University Hospital
| |
Collapse
|
6
|
Gupta D, Sheikh S, Pallagatti S, Singh R, Aggarwal A. 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. Open Dent J 2018; 12:770-781. [PMID: 30369987 PMCID: PMC6182881 DOI: 10.2174/1745017901814010770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/18/2018] [Accepted: 09/11/2018] [Indexed: 11/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Deepak Gupta
- Department of Oral Medicine and Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
| | - Soheyl Sheikh
- Department of Oral Medicine and Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
| | - Shambulingappa Pallagatti
- Department of Oral Medicine and Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
| | - Ravinder Singh
- Department of Oral Medicine and Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
| | - Amit Aggarwal
- Department of Oral Medicine and Radiology, M.M. College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
| |
Collapse
|
7
|
Affiliation(s)
- John E Mitakides
- a Private Practice , Beavercreek , OH , USA.,b Member, Medical Board of the Ehlers-Danlos Society.,c Staff of The Ehlers-Danlos Society Center for EDS Research & Clinical Care at The Greater Baltimore Medical Center , Towson , MD , USA.,d The Kettering Medical Center , Dayton , OH , USA.,e The Children's Medical Center , Cincinnati , OH , USA
| |
Collapse
|
8
|
Ulmner M, Kruger-Weiner C, Lund B. Patient-Specific Factors Predicting Outcome of Temporomandibular Joint Arthroscopy: A 6-Year Retrospective Study. J Oral Maxillofac Surg 2017; 75:1643.e1-1643.e7. [DOI: 10.1016/j.joms.2017.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 03/06/2017] [Accepted: 04/01/2017] [Indexed: 11/27/2022]
|
9
|
Dijkstra P, Kropmans T, Stegenga B. The Association between Generalized Joint Hypermobility and Temporomandibular Joint Disorders: A Systematic Review. J Dent Res 2017. [DOI: 10.1177/0810158] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- P.U. Dijkstra
- Dept. of Oral and Maxillofacial Surgery,
- Dept. of Rehabilitation,
- Pain Center,
- Northern Center for Health Care Research, and
- Institute for Medical Education, Dept. for Education Development and
Quality Assurance, Faculty of Medical Sciences, University of Groningen
| | - T.J.B. Kropmans
- Dept. of Oral and Maxillofacial Surgery,
- Dept. of Rehabilitation,
- Pain Center,
- Northern Center for Health Care Research, and
- Institute for Medical Education, Dept. for Education Development and
Quality Assurance, Faculty of Medical Sciences, University of Groningen
| | - B. Stegenga
- Dept. of Oral and Maxillofacial Surgery,
- Dept. of Rehabilitation,
- Pain Center,
- Northern Center for Health Care Research, and
- Institute for Medical Education, Dept. for Education Development and
Quality Assurance, Faculty of Medical Sciences, University of Groningen
| |
Collapse
|
10
|
da Silva CG, Pachêco-Pereira C, Porporatti AL, Savi MG, Peres MA, Flores-Mir C, Canto GDL. Prevalence of clinical signs of intra-articular temporomandibular disorders in children and adolescents. J Am Dent Assoc 2016; 147:10-18.e8. [DOI: 10.1016/j.adaj.2015.07.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/13/2015] [Accepted: 07/19/2015] [Indexed: 10/22/2022]
|
11
|
Chang TH, Yuh DY, Wu YT, Cheng WC, Lin FG, Shieh YS, Fu E, Huang RY. The association between temporomandibular disorders and joint hypermobility syndrome: a nationwide population-based study. Clin Oral Investig 2015; 19:2123-32. [PMID: 25687768 DOI: 10.1007/s00784-015-1422-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/02/2015] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ting-Han Chang
- Department of Dentistry, Taiwan Adventist Hospital, Taipei, Taiwan.,Department of Oral and Maxillofacial Surgery, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Da-Yo Yuh
- Department of Periodontology, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Yung-Tsan Wu
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Wan-Chien Cheng
- Department of Periodontology, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Fu-Gong Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Shing Shieh
- Department of Oral Diagnosis and Pathology, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Earl Fu
- Department of Periodontology, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Ren-Yeong Huang
- Department of Periodontology, School of Dentistry, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan.
| |
Collapse
|
12
|
Salé H, Bryndahl F, Isberg A. Temporomandibular joints in asymptomatic and symptomatic nonpatient volunteers: a prospective 15-year follow-up clinical and MR imaging study. Radiology 2012; 267:183-94. [PMID: 23249569 DOI: 10.1148/radiol.12112243] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the incidence, prevalence, and progression of temporomandibular joint (TMJ) magnetic resonance (MR) imaging findings and symptoms during 15 years in adult asymptomatic and symptomatic volunteers (nonpatients). MATERIALS AND METHODS A regional committee for medical research ethics approved the study, and informed volunteer consent was obtained. Fifty-three volunteers were examined at study inception. For clinical assessment, a self-administered questionnaire was given, followed by an interview with each volunteer at study inception, at 1 year later, and at 15 years later. Bilateral TMJ MR imaging and clinical examination were performed at inception and at 15-year follow-up. The MR images were assessed for disk position, bone status, and joint fluid. All 53 volunteers participated at 1-year follow-up, and 50 of 53 volunteers participated at 15-year follow-up; of these 50 volunteers, 47 underwent MR imaging. The Fisher exact test was used to determine differences between groups, and the Wilcoxon signed-rank test was used to determine differences in prevalence of TMJ symptoms among the three examination times. RESULTS At study inception, TMJ disk displacement was observed in 31% of asymptomatic volunteers (nine of 29) compared with 89% of symptomatic volunteers (16 of 18, P < .001). Inceptive TMJ status was maintained after 15 years in 91% (43 of 47). Unilateral progression was observed in four volunteers (9%); one was symptomatic and three were asymptomatic. Progression involved development of new disk displacement (n = 1), development of new bone changes (n = 2), and aggravation from reducing to nonreducing disk displacement (n = 1). Prevalence of TMJ symptoms did not change significantly between examination times (P = .77). TMJ clicking was the most common clinical symptom. CONCLUSION Volunteers with mild symptoms had a prevalence of disk displacement of the same magnitude as that reported in patients, although most volunteers, symptomatic as well as asymptomatic, maintained their TMJ status during 15 years.
Collapse
Affiliation(s)
- Hanna Salé
- Oral and Maxillofacial Radiology Division, Department of Odontology, Faculty of Medicine, Umeå University, Umeå, Sweden.
| | | | | |
Collapse
|
13
|
Naeije M, te Veldhuis AH, te Veldhuis EC, Visscher CM, Lobbezoo F. Disc displacement within the human temporomandibular joint: a systematic review of a ‘noisy annoyance’. J Oral Rehabil 2012. [DOI: 10.1111/joor.12016] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M. Naeije
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE; University of Amsterdam and VU University Amsterdam; Amsterdam The Netherlands
| | - A. H. te Veldhuis
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE; University of Amsterdam and VU University Amsterdam; Amsterdam The Netherlands
| | - E. C. te Veldhuis
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE; University of Amsterdam and VU University Amsterdam; Amsterdam The Netherlands
| | - C. M. Visscher
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE; University of Amsterdam and VU University Amsterdam; Amsterdam The Netherlands
| | - F. Lobbezoo
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE; University of Amsterdam and VU University Amsterdam; Amsterdam The Netherlands
| |
Collapse
|
14
|
Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint. Int J Oral Maxillofac Surg 2012; 41:1046-50. [DOI: 10.1016/j.ijom.2012.02.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 12/27/2011] [Accepted: 02/20/2012] [Indexed: 11/21/2022]
|
15
|
|
16
|
Hirsch C, John MT, Stang A. Association between generalized joint hypermobility and signs and diagnoses of temporomandibular disorders. Eur J Oral Sci 2009; 116:525-30. [PMID: 19049522 DOI: 10.1111/j.1600-0722.2008.00581.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Christian Hirsch
- Department of Pediatric Dentistry, School of Dentistry, University of Leipzig, Leipzig, Germany.
| | | | | |
Collapse
|
17
|
Kraus S. Temporomandibular disorders, head and orofacial pain: cervical spine considerations. Dent Clin North Am 2007; 51:161-93, vii. [PMID: 17185065 DOI: 10.1016/j.cden.2006.10.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Head and orofacial pain originates from dental, neurologic, musculoskeletal, otolaryngologic, vascular, metaplastic, or infectious disease. It is treated by many health care practitioners, such as dentists, oral surgeons, and physicians. The article focuses on the nonpathologic involvement of the musculoskeletal system as a source of head and orofacial pain. The areas of the musculoskeletal system that are reviewed include the temporomandibular joint and muscles of mastication--collectively referred to as temporomandibular disorders (TMDs) and cervical spine disorders. The first part of the article highlights the role of physical therapy in the treatment of TMDs. The second part discusses cervical spine considerations in the management of TMDs and head and orofacial symptoms. It concludes with and overview of the evaluation and treatment of the cervical spine.
Collapse
|
18
|
Hakim AJ, Sahota A. Joint hypermobility and skin elasticity: the hereditary disorders of connective tissue. Clin Dermatol 2006; 24:521-33. [PMID: 17113970 DOI: 10.1016/j.clindermatol.2006.07.013] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The hereditary disorders of connective tissues (HDCTs) encompass a spectrum of conditions linked pathophysiologically by abnormalities of collagen, fibrillin, and matrix proteins. The clinical picture ranges from morbidity because of musculoskeletal, skin, ocular and visceral pathologies to mortality from acute vascular collapse. For many of the conditions, there is a considerable overlap in clinical features, although severity varies; appreciating the subtle differences in presentation is vital to the clinician in determining the diagnosis. Though conditions associated with severe vascular pathology are rare, other hereditary disorders of connective tissues such as the joint hypermobility syndrome and Stickler's disease are common and probably underrecognized. Abnormal skin elasticity and scaring, joint hypermobility, and chronic arthralgia are important clues that should trigger the clinician to search for underlying hereditary disorders of connective tissues. In this article, we discuss the spectrum of clinical findings, management, and genetic screening of the more common hereditary disorders of connective tissues, highlighting their diagnostic criteria and their differences.
Collapse
Affiliation(s)
- Alan J Hakim
- Department of Rheumatology, Whipps Cross University Hospital, Leytonstone, London, UK.
| | | |
Collapse
|
19
|
Kavuncu V, Sahin S, Kamanli A, Karan A, Aksoy C. The role of systemic hypermobility and condylar hypermobility in temporomandibular joint dysfunction syndrome. Rheumatol Int 2005; 26:257-60. [PMID: 15988598 DOI: 10.1007/s00296-005-0620-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2004] [Accepted: 03/06/2005] [Indexed: 10/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Vural Kavuncu
- Department of Physical Medicine and Rehabilitation, Medical Faculty, Afyon Kocatepe University, Afyon, Turkey.
| | | | | | | | | |
Collapse
|
20
|
Silveira EB, Rocabado M, Russo AK, Cogo JC, Osorio RAL. Incidence of systemic joint hypermobility and temporomandibular joint hypermobility in pregnancy. Cranio 2005; 23:138-43. [PMID: 15898570 DOI: 10.1179/crn.2005.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The purpose of this study was to establish a possible correlation between systemic hypermobility and temporomandibular hypermobility during pregnancy. One hundred (100) healthy pregnant women were evaluated: 7% in the first trimester (1T), 38% in the second trimester (2T), and 55% in the third trimester (3T) of gestation. In the series, the authors analyzed systemic joint hypermobility (SJH), range of mandibular movement (MMR), head and shoulder posture, head lateralization, and the presence of noise, pain, and parafunction in the temporomandibular joint. They observed that pain is present to a mild degree mostly in the head and ears of all pregnant women who presented with pain. Most of the subjects had some type of parafunction, but only 42.8% had noises. Mild SJH was seen in 50% of the 2T and 3T subjects, and in 28.5% of 1T subjects. Mild mandibular hypermobility was found for jaw opening (46%) and lateralization to the right (44%) or to the left (46%). Most of the subjects had hypomobility for jaw protrusion and retraction. The subjects had head protrusion and anterior posture as a result of the change in their center of gravity brought about by pregnancy. The authors found no association between systemic joint hypermobility (SJH) and temporomandibular hypermobility, although hormonal changes and complex factors during pregnancy may represent a risk factor for both types of mobility change.
Collapse
|
21
|
Hakim A, Grahame R. Joint hypermobility. Best Pract Res Clin Rheumatol 2003; 17:989-1004. [PMID: 15123047 DOI: 10.1016/j.berh.2003.08.001] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2003] [Accepted: 08/01/2003] [Indexed: 11/16/2022]
Abstract
Joint hypermobility is an area of neglect in rheumatology. That is not to say it is overlooked by rheumatologists. It is spotted when sought, but for many unfortunate patients, here the story ends. The act of recognition becomes the goal in itself rather than the medium through which effective therapy can be provided. This chapter serves to reinforce the clinical and epidemiological importance of a common disorder whose significance is under-appreciated and impact largely ignored. In contradistinction to our earlier chapter, published in 2000, which took for its remit the heritable disorders of connective tissue in general, the current one focuses on the commonly encountered (so-called benign) joint hypermobility syndrome, its recognition, epidemiology, clinical features and management according to the most recent literature.
Collapse
Affiliation(s)
- Alan Hakim
- Whipps Cross University Hospital, Leytonstone, London E11 1NR, UK
| | | |
Collapse
|
22
|
Pahkala RH, Qvarnström MJ. Mandibular movement capacity in 19-year-olds with and without articulatory speech disorders. Acta Odontol Scand 2002; 60:341-5. [PMID: 12512883 DOI: 10.1080/000163502762667360] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Associations between articulatory speech disorders and mandibular movement capacity, as well as between malocclusions and jaw movements, were examined in two groups of adolescents, i.e. 52 individuals with and 45 without misarticulations of speech. The mean age of the whole sample was 19.2 years. Articulatory speech disorders and functioning of the speech articulators were diagnosed by a phoniatrician. Mandibular movement capacity, malocclusions, occlusal interferences, and signs of temporomandibular dysfunction were recorded by an orthodontist. Multiple regression analyses showed that subjects with articulatory speech disorders were likely to have smaller opening capacity than subjects with a correct speech articulation. Excessive overjet, lateral cross bite, and a tendency to anterior open bite were associated with large movements of the jaw. These results suggest that in young adulthood mandibular movement capacity seems to vary depending on occlusion and is related to misarticulations of speech.
Collapse
Affiliation(s)
- Riitta H Pahkala
- Department of Oral and Maxillofacial Surgery, Division of Phoniatrics, Kuopio University Hospital, Finland.
| | | |
Collapse
|
23
|
Cooper B, Oberdorfer M, Rumpf D, Malakhova O, Rudman R, Mariotti A. Trauma modifies strength and composition of retrodiscal tissues of the goat temporomandibular joint. Oral Dis 1999; 5:329-36. [PMID: 10561723 DOI: 10.1111/j.1601-0825.1999.tb00099.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Temporomandibular pain is often accompanied by pathologic changes to joint retrodiscal tissues. The substantial representation of females in this condition has encouraged hypotheses which link genetic or hormonally induced abnormalities in tissue composition (type III collagen, type I collagen, type III/type I ratio) to the development of temporomandibular disorders. As this condition is often associated with a history of orofacial trauma, we investigated the functional impact of retrodiscal trauma on the composition and biomechanics of retrodiscal tissues. DESIGN AND METHODS Retrodiscal tissue of female goats received trauma or sham trauma. Following a healing period of 30 days, the tissues were pulled to failure on an extensometer. OUTCOME MEASURES Assessments were made of tissue biomechanical properties (failure force, elastic stiffness, strain distribution). Tissue fragments were assayed for collagens I and III. RESULTS Thirty days after surgical section of retrodiscal tissues, the tissue had reformed, but the composition and biomechanics were substantially changed. Healed tissue manifested less than half the strength of normal tissue (P = 0.02). In addition, the development of tissue strain shifted from a relatively even distribution to a confined region near the retrodiscal-discal attachment zone. It appeared that a large increase in the expression of type III collagen (179.6%; P = 0.038) and the ratio of type III/type I collagen (180.9%; P = 0.011) accounted for these functional changes. CONCLUSIONS We suggest that shifts in collagen expression following injury create shifts in strain development which focus tissue stresses near the interface of the disc and retrodiscal tissue, and that this shift dramatically weakens the tissue and increases the probability of re-injury, inflammation and pain.
Collapse
Affiliation(s)
- B Cooper
- Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida, Gainesville FL 32610, USA
| | | | | | | | | | | |
Collapse
|
24
|
Khan FA, Pedlar J. Generalized joint hypermobility as a factor in clicking of the temporomandibular joint. Int J Oral Maxillofac Surg 1996; 25:101-4. [PMID: 8727578 DOI: 10.1016/s0901-5027(96)80050-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Twenty-six patients with clicking or locking of the temporomandibular joint (TMJ) and 28 age- and sex-matched controls were assessed for generalized joint hypermobility by BEIGHTON's method. Function of the masticatory apparatus was measured with FRICTON's Craniomandibular Index. The TMJ patients had significantly higher joint mobility scores, but within the patient group there was no correlation between either the dysfunction or palpation scores and the hypermobility scores. The findings are interpreted as supporting multiple causes of TMJ internal derangement, one of which is a systemic joint factor.
Collapse
|
25
|
Abstract
In 193 non-patient adolescents, unilateral contacts in retruded contact position (RCP) were seen more often in girls than in boys (P < 0.001) and were more frequent in subjects with than without general joint instability (P < 0.05). A negative correlation (r = -0.70***) was found between the side of the temporomandibular joint sound and the side of unilateral contact in RCP. Boys with unilateral contacts in RCP had more non-reciprocal clicking than girls. No signs were found indicating that a unilateral contact in RCP is an aetiological factor for development of temporomandibular disorders. Unilateral contacts in RCP may in adolescents be considered a predictive factor for temporomandibular joint disturbance. Contradictory causes may determine the sagittal distance between RCP and ICP.
Collapse
Affiliation(s)
- L Westling
- Department of Stomatognathic Physiology, Faculty of Odontology, University of Göteborg, Sweden
| |
Collapse
|
26
|
Westling L, Holm S, Wallentin I. Temporomandibular joint dysfunction. Connective tissue variations in skin biopsy and mitral valve function. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1992; 74:709-18. [PMID: 1488224 DOI: 10.1016/0030-4220(92)90395-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- L Westling
- Department of Stomatognathic Physiology, Faculty of Odontology, University of Göteborg, Sweden
| | | | | |
Collapse
|
27
|
Westling L, Helkimo E. Maximum jaw opening capacity in adolescents in relation to general joint mobility. J Oral Rehabil 1992; 19:485-94. [PMID: 1453260 DOI: 10.1111/j.1365-2842.1992.tb01112.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mandibular jaw opening was related with general joint mobility in a non-patient adolescent group. The angular rotation of the mandible at maximum jaw opening was slightly larger in females than in males and significantly larger in hypermobile individuals. No significant relationship between linear measuring of maximal mandibular opening capacity and peripheral joint mobility was found either at active (AROM) or at passive range of mandibular opening (PROM). PROM was strongly correlated to the mandibular length. Clinical signs in the great jaw closer muscles could not be associated to decreased AROM. The mean value of the difference between PROM-AROM (DPA) was 1.2 mm. Frequent clenching and/or grinding was correlated to increased DPA only in hypermobile adolescents (r = 0.49***). Those with DPA exceeding 5mm had all reciprocal clicking.
Collapse
Affiliation(s)
- L Westling
- Department of Stomatognathic Physiology, Faculty of Odontology, University of Göteborg, Sweden
| | | |
Collapse
|