TMJ, Joint Hypermobility Syndrome and Ehlers-Danlos syndrome.

Ross Hauser, MD.

In this article, we will discuss research that TMJ can be more than a problem of the TMJ disc but a problem of jaw instability from connective tissue disorders. A person will often find out that they have suspected Ehlers-Danlos syndrome when they are treated for a TMJ or joint dislocation. Sometimes the Ehlers-Danlos syndrome is made in the emergency room when the patient has a dislocated jaw that seems to have occurred for no reason.

For doctors and researchers not only does the proper diagnosis of Joint Hypermobility Syndrome and Ehlers-Danlos syndrome need to be uncovered, but the concurrent symptoms as well.

This article is a companion to the article Ehlers-Danlos syndrome, Joint hypermobility, and temporomandibular disorders in younger patients.

9 out of 10 patients with TMJ diagnosed patients with Joint Hypermobility Syndrome – pain does not come from degenerated TMJ discs.

Like any joint, excessive movement in the Temporomandibular joint and/or chronic subluxation/dislocations of the Temporomandibular is caused by weakness of the connective tissue that holds the joint in place. In the jaw important connective tissue include the Temporomandibular ligament, the stylomandibular ligament, and the sphenomandibular ligament which provides limitation of mandibular movements.

In a late 2015 publication date, national defense and university medical researchers in Taiwan combined to release their research findings in the journal Clinical Oral Investigations (1) on the TMJ/TMD – Joint Hypermobility Syndrome connection.

What is Joint Hypermobility Syndrome? It is a common musculoskeletal disorder that makes your joints too flexible. For some people, this is very advantageous, especially in gymnastics, dance, and swimming. For others, it leads to chronic dislocations.

The research aimed to investigate the risk factors of temporomandibular disorders, including disc or non-disc-related disorders, and Joint Hypermobility Syndrome retrospectively and to analyze the association between the two conditions.

What is so fascinating about this study is that in patients who had TMJ and were found to have Joint Hypermobility Syndrome, 9.52% of JHS patients have disc disorders and 90.48% of JHS patients do not. 9 out of 10 patients with TMJ diagnosed patients with Joint Hypermobility Syndrome – pain does not come from degenerated discs.

So what does this mean to you? The source of your TMJ pain does not need to involve a displaced disc it can be a weakness of the jaw/TMJ ligaments. Any treatment should involve a determination of ligament weakness.

TMJ is more than a physical problem related to the jaw

Any treatment should involve a determination of ligament weakness. What does this mean? As pointed out by Spanish researchers in the medical journal European Psychiatry: the Journal of the Association of European Psychiatrists, problems of jaw pain (TMJ) may be an indication of a body-wide problem with loose joints, and further, joint hypermobility syndrome and TMJ may manifest themselves as a potential link to the neural bases of anxiety and related somatic symptoms (pain that causes major emotional distress) (2)
What does this mean? As doctors writing in the Journal of Oral and Facial Pain and Headache point out TMJ is more than a physical problem related to the jaw. (3)

A 2017 paper in the American Journal of Medical Genetics. Part C, Seminars in Medical Genetics (4) presents information for the dentist to understand in identifying EDS in the TMJ patient.

” . . . while proper diagnosis and precise treatment of temporomandibular disorder are always complex, it is far more so in the EDS patient. Even practitioners highly trained in the area of the temporomandibular disorder can face unexpected challenges in diagnosing and treating an EDS patient if they do not have an in-depth understanding of EDS. Some symptoms are obvious to the practitioner familiar with the disorder, and some are very subtle. Yet, while proper diagnosis and precise treatment of temporomandibular disorder are always complex, it is far more so in the EDS patient. Even practitioners highly trained in the area of TMD can face unexpected challenges in diagnosing and treating an EDS patient if they do not have an in-depth understanding of EDS.”

“Assuming TMJ hypermobility and generalized joint hypermobility increases the prevalence of the temporomandibular disorder, all EDS patients should be treated prophylactically (Prevention of TMJ). Prevention of TMJ injury should be paramount. Postural alignment as well as the upper back and cervical issues need to be addressed. Lifestyle changes can include alteration of chewing patterns, diet, stress reduction techniques, and management of physical activities.”

This paper then discusses various preventative treatment options to prevent the worsening of TMJ symptoms in EDS patients.

Deep heat
Cold laser (Superpulsed Low-Level Laser Therapy)
Friction muscle massage
Custom splints to stabilize the TMD
Prolotherapy
Medications
Botulinum toxin
Physical therapy

In our article The evidence and comparisons of TMJ injection treatments we also add information on:

Corticosteroid injections
Hyaluronic acid injections
PRP or Platelet Rich Plasma Therapy
Stem Cell Therapy or Bone Marrow Aspirate Concentrate injection

Physical therapy

An August 2021 examination of the benefits of physical therapy in patients with TMJ and Hypermobility Joint Syndrome was published in the Journal of Clinical Medicine. (5) Here is this study’s findings:

The study involved 322 patients with symptoms of TMJ and Hypermobility Joint Syndrome. These patients were divided into two groups. People with TMJ and another group with Hypermobility Joint Syndrome + TMD.
These patients completed 3-week physiotherapy management.
Before and after physiotherapy, the myofascial pain severity on the Numeric Pain Rating Scale, linear measurement of maximum mouth opening, and opening pattern were assessed.
A statistically significant improvement was obtained in decreasing myofascial pain in both groups. Coordination of mandibular movements was achieved in both groups.

Prolotherapy injections for TMJ hypermobility

Prolotherapy is a nonsurgical regenerative injection technique that introduces small amounts of an irritant solution to the site of painful and degenerated tendon insertions (entheses), joints, ligaments, and in adjacent joint spaces during several treatment sessions to promote the growth of normal cells and tissues in the TMJ.

Introduction video
Danielle R. Steilen-Matias, MMS, PA-C

Summary highlights:

By the time we see a patient with TMJ problems, they’ve tried splints, night guards, advanced dental work, pain medication, cortisone shots even and nothing has helped long term.
We treat TMJ with simple dextrose Prolotherapy injections into the TMJ joint. The treatment which is explained in great detail below strengthens the ligaments of the TMJ and reduces and eliminates the jaw hypermobility that can cause degenerative TMJ disease.

Prolotherapy research in treating TMJ in hEDS and joint hypermobility patients

In June 2017, Dr. Hamida Refai of Cairo University reported these findings in the British Journal of Oral and Maxillofacial Surgery:(6)

Sixty-one patients with symptomatic TMJ hypermobility were treated with four sessions of intra-articular and pericapsular (around the joint) Prolotherapy injections at six-week intervals.
Each injection comprised 10% dextrose/mepivacaine (a numbing agent) solution 3ml.
The patients were then assessed for:
- the severity of pain on movement according to the numerical 0 – 10 rating scale (NRS) with 10 being the worst pain.
- maximal interincisal mouth opening,
- clicking,
- and frequency of locking was measured before the first treatment, during treatment or between the first and second treatment, (just before the third session of injections), at the short-term follow-up (three months after treatment), and at the long-term follow-up (1-4 years after fourth treatment).
Condylar translation (movement of the TMJ joint) and osseous (bony) changes of each joint were evaluated before the first treatment and after the fourth treatment using tomography.
- There was a significant reduction in all variables before the second treatment.
- The pain scores and clicking had decreased significantly by the third treatment.
- Linear tomograms of each joint at first treatment and fourth treatment showed no alteration in the morphology of the bony components of the joint, and at fourth treatment, tomographic open views of all joints showed condylar hyper-translation.
Dextrose Prolotherapy provided a significant and sustained reduction of pain and recovery of constitutional symptoms associated with symptomatic hypermobility of the TMJ without changing either the position of the condyle or the morphology of the bony components of the joint.

This study was a continuation of Dr. Refai’s work. Earlier in 2011 Dr. Refai and colleagues published in the Journal of Oral and Maxillofacial Surgery (7) these findings specific to TMJ hypermobility.

“Prolotherapy with 10% dextrose appears promising for the treatment of symptomatic TMJ hypermobility, as evidenced by the therapeutic benefits, simplicity, safety, patients’ acceptance of the injection technique, and lack of significant side effects. However, continued research into Prolotherapy’s effectiveness in patient populations with large sample sizes and long-term follow-up is needed.” The studies presented in this article represent these studies.

It should be noted that Prolotherapy was seen as a possible effective treatment in hypermobility of the TMJ as early as 1937, more than 80 years ago. (8)

The controversy over surgery

In October 2021, a case history was presented in the Journal of Oral and Maxillofacial Surgery (9) from the University of Cincinnati, Department of Surgery, Division of Oral & Maxillofacial Surgery. The case history was presented under the title: “A Decade of Complications Following Total Temporomandibular Joint Reconstruction in a Patient with Ehlers-Danlos Syndrome. Another Surgical Misadventure or An Absolute Contraindication for Temporomandibular Joint Reconstruction?” Here is the summary abstract of that paper: “This report describes an extensive surgical journey for a patient with Ehlers-Danlos syndrome (EDS) who underwent a total temporomandibular joint reconstruction and illustrates an ongoing challenge for oral and maxillofacial surgeons treating patients with connective tissue disorders and managing chronic pain symptoms. The surgical team attempted multiple procedures including 2 failed total temporomandibular joint replacements and a myocutaneous vascularized free flap (A flap of skin used in facial reconstruction). This case demonstrates the potential for postoperative complications in patients with Ehlers-Danlos syndrome.”

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding TMJ issues. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

1 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 Feb 17. [Google Scholar]
2 Mallorquí-Bagué N, Bulbena A, Roé-Vellvé N, Hoekzema E, Carmona S, Barba-Müller E, Fauquet J, Pailhez G, Vilarroya O. Emotion processing in joint hypermobility: A potential link to the neural bases of anxiety and related somatic symptoms in collagen anomalies. European Psychiatry. 2015 Jun 30;30(4):454-8. [Google Scholar]
3 Reissmann DR, John MT, Seedorf H, Doering S, Schierz O. Temporomandibular disorder pain is related to the general disposition to be anxious. J Oral Facial Pain Headache. 2014 Fall;28(4):322-30. doi: 10.11607/ofph.1277. [Google Scholar]
4 Mitakides J, Tinkle BT. Oral and mandibular manifestations in the Ehlers–Danlos syndromes. In American Journal of Medical Genetics Part C: Seminars in Medical Genetics 2017 Mar (Vol. 175, No. 1, pp. 220-225). [Google Scholar]
5 Kulesa-Mrowiecka M, Piech J, Gaździk TS. The Effectiveness of Physical Therapy in Patients with Generalized Joint Hypermobility and Concurrent Temporomandibular Disorders—A Cross-Sectional Study. Journal of Clinical Medicine. 2021 Jan;10(17):3808. [Google Scholar]
6 Refai H. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: a single-arm study with 1-4 years’ follow up. Br J Oral Maxillofac Surg. 2017 Apr 28. [Google Scholar]
7 Refai H, Altahhan O, Elsharkawy R. The efficacy of dextrose prolotherapy for temporomandibular joint hypermobility: a preliminary prospective, randomized, double-blind, placebo-controlled clinical trial. Journal of Oral and Maxillofacial Surgery. 2011 Dec 1;69(12):2962-70.
8 Rechtin M, Krishnan DG. A Decade of Complications Following Total Temporomandibular Joint Reconstruction (TJR) in a Patient with Ehlers-Danlos Syndrome. Another Surgical Misadventure or An Absolute Contraindication for TJR?. Journal of Oral and Maxillofacial Surgery. 2021 May 19. [Google Scholar]
9 Schultz LW. A treatment for subluxation of the temporomandibular joint. Journal of the American Medical Association. 1937 Sep 25;109(13):1032-5. [Google Scholar]

This article was last updated February 26, 2022