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

Risk factors associated with symptoms of temporomandibular disorders among women with hypermobile Ehlers-Danlos syndrome: Questionnaire-based study in Finland and Sweden

BACKGROUND

Generalized joint hypermobility as a characteristic feature of Ehlers-Danlos syndromes (EDS) is among the factors contributing to temporomandibular disorders (TMD).

OBJECTIVE

To evaluate the prevalence of TMD symptoms and their risk factors among women born in Sweden or Finland who were 27- to 78-year-olds with diagnosed hypermobile EDS (hEDS).

METHODS

A cohort of women with confirmed hEDS (n = 185) was constructed from the members of the National EDS Associations in both countries. Based on questionnaire data, frequency of independent variables in terms of socio-demographic, general health and oral health-related factors, comorbid symptoms and psychological distress for self-reported TMD symptoms as the dependent variables, were calculated first. Prevalence ratios (PR) and their 95% confidence interval (95% CI) were estimated for the association between independent and dependent variables.

RESULTS

Nearly all participants reported TMD symptoms (98%) with TMD pain (95%), TMJ clicking (90%) and jaw fatigue (80%) as the most common symptoms and TMJ crepitation (63%) and luxation (44%) as the least common symptoms. Risk factors for TMD among 27- to 50-year-olds participants were Finland as a country of birth, living alone and self-reported worst pain in the body (not the joints). The respective risk factors among the 51- to 78-year-olds were Finland as a country of birth, family history of EDS, tinnitus and regularly taking contraceptives.

CONCLUSIONS

Among adult women with confirmed hEDS, socio-demographic and health-related factors and comorbid symptoms were significantly associated with TMD but with differences regarding age group. Therefore, management of TMD requires a multidisciplinary approach among the affected.

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 joint anatomy, function and clinical relevance

The articulatory system comprises the temporomandibular joints (TMJs), intra-articular discs, mandibular/jaw muscles and occlusion. In the simplest terms, the TMJ is the articulation between the upper and lower jaws. The teeth form the contacts between the upper and lower jaws and the muscles are the motors that move the mandible. This system is unique in that the TMJs are paired; any stimulus that affects one joint or any other single part of the articulatory system can have a 'knock-on effect' in the rest of the system.It is important to have a good understanding of anatomy, not only to be able to differentiate between what is physiological and what is pathological, but also to understand the objectives of some treatment options. Sound knowledge of anatomy is essential and an appreciation of the anatomical features associated with the TMJ can serve as a foundation for understanding the clinical management of temporomandibular disorders.This article reviews the functional anatomical features of the articulatory system with a look at the clinical significance of this anatomy.

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.

Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes

The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.

Joint Hypermobility and Clinical Correlates in a Group of Patients With Eating Disorders

Background: The ability to move joints beyond the normal range of motion is called Joint Hypermobility (JHM). JHM has been associated with a plethora of physical problems and is a frequent sign of hereditary disorders of connective tissue. Neuropsychiatric conditions such as eating disorders (ED) have also been related to JHM. However, little is known about the clinical profile of people with ED and JHM. The aim of this study was to explore JHM in patients with ED and to compare the clinical characteristics of hypermobile ED patients with non-hypermobile ED patients. Method: Fifty-three outpatients diagnosed with ED were assessed using the Beighton score for JHM, the Eating Disorders Inventory 2, the Eating Disorder Examination, and the Detail and Flexibility Questionnaire. Information relating to patients' psychiatric and somatic comorbidities/symptoms was also collected. Results: Using the traditional Beighton score's cutoff of ≥4, 41.5% of the sample presented with JHM. Our results indicate that compared with non-hypermobile ED patients, those with JHM are significantly younger, suffer at a greater extent from joint pain and easy bruising, have a shorter duration of the ED, and have lower scores for cognitive rigidity. In addition, for those with anorexia nervosa, the restricting subtype represents a significantly lower proportion of hypermobile ED patients compared to non-hypermobile ED patients. Multivariate analyses showed that cognitive rigidity, age, and duration of the ED could predict the JHM status in this sample. Conclusion: These results suggest that JHM is frequent in patients with ED and is accompanied by signs of tissue fragility. Patients with ED and JHM seem to present a specific profile characterized by less cognitive rigidity and restricting behavior in the case of anorexia nervosa. Further research is needed in order to confirm these results.

Ehlers-Danlos Syndrome in the Field of Psychiatry: A Review

Ehlers-Danlos syndrome (EDS) comprises a series of rare hereditary connective tissue diseases characterized by joint hypermobility, joint dislocation, and hyperextensibility of the skin, as well as cardiovascular involvement. EDS is often associated with chronic widespread physical pain, which can lead to psychological pain. Poor awareness and limited diagnosis of EDS and related symptoms result in decreased self-esteem and confusion regarding physical sensation. Furthermore, EDS imposes substantial psychological burden on patients due to exercise restriction, scars, keloids, and subcutaneous fat accumulation on the extremities, which leads to parental overprotection and bullying experiences from other children at school age. Recent large-scale studies have suggested that patients with EDS have a higher risk of mood disorders than the general population. Other cohort studies indicated high prevalence of anorexia nervosa, addiction, obsessive compulsive disorder, and anxiety disorder were found in patients with EDS. Case reports instead indicated that some psychiatric disorders were secondary symptoms due to physical problems from EDS. Therefore, psychiatrists must be more knowledgeable and proactive about EDS in their practice. We review the previous case reports and literature for patients with EDS, along with our own case of complicated psychiatric problems, which are strongly related to early stressful situations through childhood and adolescence. This is to aid general psychiatrists in the discussion of appropriate medical management in such infrequent, yet challenging conditions.