[Temporomandibular disorders and Ehlers-Danlos syndrome, hypermobility type: A case-control study]

Temporomandibular disorders among Ehlers-Danlos syndromes: a narrative review

This narrative review aims to demonstrate and summarize the complex relationship between Ehlers-Danlos syndromes (EDS) and temporomandibular disorders (TMD) by reviewing the results of observational studies and case reports. EDS are a set of hereditary connective tissue disorders, where generalized joint hypermobility (GJH), especially in the hypermobile subtype (hEDS), is a key symptom. Mutations have been identified in genes that impact the production or assembly of collagen for all subtypes except hEDS. While the correlation between GJH and TMD has been analysed in various studies, fewer studies have examined TMD in patients with EDS, with most showing an increased prevalence of TMD. In case-control studies, an elevated prevalence of myalgia, arthralgia and disc-related disorders was found in individuals with EDS. Various therapeutic interventions have been reported within the literature in the form of case reports and observational studies, but there are no long-term clinical trials with results on the efficacy of different therapeutic approaches to date. This review demonstrates the high prevalence of different TMDs in different subtypes of EDS, but also shows that little is known about the success of treatment thus far. Further clinical research is necessary to provide adequate guidance on targeted treatment.

Treatments related to temporomandibular disorders among patients with prevalent types of Ehlers-Danlos syndrome in Sweden

The aim of this study was to assess the received TMD treatment modalities and the perceived outcome among the frequent types of EDS. A digital questionnaire was sent to the member of the National Swedish EDS Association during January-March 2022. The subsamples of hypermobile and classical EDS were constructed. Almost 90% reported TMD symptoms. Bite splint therapy, counselling, jaw training and occlusal adjustment were reported as the most common treatments with no statistically significant difference in terms of good effect between the two subsamples. Hypermobile and classical EDS might consider as an entity with regards to TMD.

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.

Management of chronic pain in Ehlers-Danlos syndrome: Two case reports and a review of literature

RATIONALE

Ehlers-Danlos syndromes (EDSs) are a heterogeneous group of heritable connective tissue disorders involving defective collagen synthesis. Patients with EDS are prone for chronic myofascial pain, apart from other comorbidities. Although the initial pathology is commonly nociceptive, progression of EDS leads to neuropathies and central sensitization of pain signals. Overall, approximately 90% or more EDS patients suffer from chronic pain. There are no existing guidelines to manage chronic pain in EDS patients. In this article, we illustrate 2 case reports of EDS patients with chronic pain and review the relevant literature regarding the pathological considerations and management of chronic pain in EDS.

PATIENT CONCERNS

Our first patient had worsening multiple joint pains despite treatment with medications and a recent diagnosis of EDS-type 3. The second patient had a complicated history including longstanding EDS and multiple previous surgeries. She was referred due to concern about complex regional pain syndrome (CRPS) in her upper extremity.

DIAGNOSES

For the first patient, apart from chronic pain due to her EDS, her history also revealed that she suffered from kinesiophobia. For the second patient, a detailed clinical assessment revealed no signs of CRPS but instead a generalized worsening of EDS symptoms.

INTERVENTIONS

Both patients were evaluated by the multidisciplinary team consisting of a pain physician, nurse, pain psychologist, and a kinesiologist. Their treatment involved optimization of daily medications, participation in pain self-management sessions that included cognitive behavioral therapy, graded exercises, coping, and relaxation strategies.

OUTCOMES

Both patients demonstrated significantly better pain control and achieved overall improvement in daily living.

LESSONS

EDS is a complex illness with a multitude of symptoms. As in our patients, EDS patients also suffer from panic and anxiety disorders that increase the burden of pain. Apart from optimization of medications, EDS patients are best managed by a multidisciplinary approach that includes pain education and life style changes. The caution that they are resistant to local anesthetics is unwarranted. Appropriate pain interventions in selected patients may have a role to decrease pain intensity.

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.