The ABCs of TMD With EDS
Ehlers-Danlos Syndrome (EDS) is a complex condition that has a wide range of effects on the body, including how the jaw functions. Temporomandibular disorder (TMD) occurs when the jaw is not functioning optimally. Thankfully, there are unique ways to take care of jaw function and oral health while being mindful of the underlying effects of EDS. Here are the ABCs of TMD With EDS.
Overview of EDS
EDS is a hereditary connective tissue disorder. There are various types of connective tissue, and they provide the essential structure and support that all parts of our body need. EDS is unique in that it targets collagen production, which is an essential part of what makes up connective tissue.
There are thirteen types of EDS. Most types of EDS include the following features:
- Joint hypermobility
- Skin hyperextensibility (extra-stretchy skin)
- Tissue fragility (which can cause easy bruising and poor wound healing).
Each EDS type has other unique features. Of the people already diagnosed with EDS, about 90% of those individuals have the hypermobile EDS type. Even if two people have the same type of EDS, they can still experience the condition differently.
Overview of the Jaw
The jaw is divided into two parts: the upper jaw and the lower jaw. The upper jaw bone (the maxilla) connects to the upper teeth. The lower jaw bone (the mandible) connects to the bottom teeth. The mandible has two joints—one on each side of the head—that connect to the skull near the ears. These “jaw joints” are named the temporomandibular joints (TMJs).
The TMJs play a critical role in chewing, talking, yawning, and even breathing! The TMJs always impact each other because they are connected at the chin. TMD, which occurs when the TMJs are not functioning well, can cause pain, difficulty completing basic tasks, and decreased quality of life.
How Can EDS Affect the Jaw?
Unfortunately, TMD is a common concern for people with EDS. A recent exploratory study described the following data regarding individuals with EDS (mostly the hypermobile type).
- Almost 50% reported “painful or restricted jaw movements”
- Over 80% reported pain in their jaw muscles
- Almost 50% reported they already have a diagnosis of TMD.
So what impact does EDS have on jaw function? Let’s first discuss the impact of hypermobility on the jaw, as individuals with EDS most commonly experience hypermobility issues. The connection between TMD and hypermobility of the TMJs has been well-researched.
Hypermobility of the TMJ
Joint hypermobility of the jaw allows for more room to open the mouth. A standard range for mouth opening is about 40–50 mm. Often, someone who has hypermobile TMJs can open their mouth between 55–65 mm. This extra range is not necessary for daily tasks and can increase the risk of jaw injury. TMJs can dislocate if pushed to their limits. There is also potential for the cushioning discs within the TMJs to shift, limit jaw movement, and cause TMD.
People with joint hypermobility also tend to have a unique way of opening and closing the jaw. Often, they open their mouths in a “swivel” or “s-curve” pattern. Due to the excessive flexibility of both TMJs and the fact that they are connected at the chin, they can have a difficult time synchronizing the extra joint movements together. Thus, one TMJ usually opens and closes faster than the other, causing the chin to “swivel.” This can occur with or without joint clicking. The muscles of the jaw also become imbalanced, which can contribute to headaches, tooth pain, and difficulty keeping the jaw relaxed.
In some situations, someone who can usually open their mouth wide can suddenly experience loss of range in their jaw, pain, and sometimes a change in joint sounds. If this happens, it is important to seek care to assess the culprit of the range loss, regain jaw movement again, and then learn how to open and close the jaw in a more controlled manner.
The Neck and Jaw Relationship
Neck function also impacts jaw function. The upper neck joints and muscles are close neighbors to the TMJs. Nerves that affect the jaw and head also pass through the upper neck. Weak and aggravated neck muscles, poor neck control, and poor posture can significantly impact how the TMJs move.
Hypermobility is not the only feature of EDS that can affect jaw function. The collagen defects unique to EDS can also negatively impact oral health. Individuals with EDS are at an increased risk for the following conditions:
- Tooth abnormalities
- Gum disease
- Nerve issues
- Tooth decay.
Since the upper and lower jaw bones connect to the teeth, poor oral health can have serious effects on jaw function. For example, a tooth infection can cause someone to only chew on one side of their mouth. This imbalance causes one TMJ to overwork and one to overstretch, increasing the likelihood of TMD.
Managing TMD with EDS
As EDS is a genetic condition, it can not simply “go away.” Instead, there are multiple strategies to make the effects of EDS more manageable. Just like “A, B, C” is the start of the alphabet, below are the first three management strategies to implement to improve jaw function concerning the influence of EDS.
A: Adjust Your Posture
As previously mentioned, the neck plays an important role in jaw function. A rounded spine, forward head posture, and slumped shoulders can have a major impact on the neck and the jaw. A forward head posture, in particular, can cause the chin to jut forward and put a strain on the TMJs.
It is important to practice pulling your shoulders back, lengthening your spine toward the sky, and keeping your chin slightly tucked. At first, it can be tiring to stay in this posture for long periods, so be sure to take breaks. Over time, and with other strengthening exercises, it may become easier to maintain a neutral posture.
B: Break Habits
Teeth clenching, nail biting, lip chewing, oh my! Habits that involve the mouth for repetitive, non-useful tasks such as these are called parafunctional habits. These habits can cause added strain on the jaw and the mouth. For people with hypermobility, teeth grinding and clenching are known to be significant contributors to the development of TMD.
The first step in reducing these actions is to become more aware of the parafunctional habits you may have. Consider setting a timer that goes off every 30 minutes to check in with yourself. Have you been chewing on your tongue? Breathing through your mouth? Chattering your teeth? As you notice your habits, you can be better prepared to practice keeping your jaw in a neutral position and relaxed.
It is important to note that there may be underlying conditions influencing parafunctional habits. Parafunctional habits can be related to stress and anxiety. Teeth grinding, particularly while sleeping, can be related to breathing issues. Discuss this with your healthcare provider to determine if you may have underlying conditions that need to be addressed.
C: Control the Movement
As described above, excessive range of motion and unbalanced coordination between both TMJs can negatively impact the function of the jaw. To start to understand the way your TMJs work together, use the slow-motion video feature on a phone to watch how you open and close your jaw. Then, using a mirror, you can start to practice opening and closing your mouth more evenly. Keeping your tongue on the roof of your mouth while you open and close your mouth can help keep your movement more controlled.
Note
When seeking care for the jaw and mouth, you may work with professionals such as physical therapists, dentists, ENTs, and physicians. Because of the variety of effects EDS can have on the body—including poor wound healing, an increased tendency to bleed, and an increased risk for infection—healthcare professionals need to be aware of your EDS diagnosis.
During dental procedures, keeping your mouth open wide, especially for long periods, can increase your risk for injury. Do not open your mouth as wide as possible, and let your provider know when you need a break. You can consider using bite blocks, which are wedges put between your upper and lower teeth to keep your mouth open, to allow your mouth to relax during dental procedures. In addition, jaw splints and mouth guards are sometimes used for the treatment of TMD. It is important to choose an appliance that is smooth enough to not cause cuts to the fragile gum tissue.
Additional Letters to Consider: POTS, MCAS, and SDB
Individuals with EDS are also commonly diagnosed with postural orthostatic tachycardia syndrome (POTS), mast cell activation syndrome (MCAS), and sleep-disordered breathing (SDB). The following describes the way these conditions can also impact jaw function.
POTS
The majority of people with EDS also have been diagnosed with POTS—a nervous system condition that is affected by position changes such as standing and lying down. With prolonged standing, someone with POTS can feel dizzy, shaky, and short of breath as well as experience fainting episodes. Another symptom that can occur with prolonged standing or sitting is pain in the head, neck, and upper shoulders, which is thought to come from the loss of blood flow to these areas. These symptoms tend to be relieved when lying down. When getting care for TMD, it is important to assess if head and neck pain may be instead related to POTS.
MCAS
People with EDS are also often diagnosed with MCAS, which is a condition where the body’s mast cells create allergic reactions to harmless substances. Symptoms that someone with MCAS can experience include headaches, generalized pain, and fatigue. What is unique about MCAS is that these symptoms are exacerbated by triggers that vary from person to person. These triggers can include odors, stress, certain foods, and physical activity. If you have been diagnosed with MCAS and are also experiencing head and neck pain, it is important to monitor if these symptoms are closely related to MCAS triggers.
SDB
Another common concern people with EDS report is poor sleep quality and excessive fatigue during the day. There are many potential contributors to poor sleep and fatigue—one being SBD. People with EDS are at an increased risk for SDB, potentially due to the following:
- Facial structure changes that are common in those with EDS
- Loss of airway space due to lack of proper connective tissue support in the nose and throat.
As mentioned above, teeth grinding at night can be a sign of SDB because the constant activation of muscles used to grind the teeth together can also keep an airway more open. It is important to discuss sleep-related concerns with your doctor to determine if a sleep study or airway assessment is appropriate for you.
Conclusion
The alphabet soup of EDS and TMD and their related conditions can be complicated. Taking the time to adjust posture, break habits, control movement, evaluate related symptoms, and take precautionary measures can make a tremendous difference in having healthy jaw function with EDS.
Suffering from TMD and also have EDS? Schedule your appointment today!
References
Mitakides J, Tinkle BT. Oral and mandibular manifestations in the Ehlers-Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017;175(1):220-225. doi:https://doi.org/10.1002/ajmg.c.31541
Mitakides JE. The effect of Ehlers-Danlos syndromes on TMJ function and craniofacial pain. CRANIO®. 2018;36(2):71-72. doi:https://doi.org/10.1080/08869634.2018.1435092
The Ehlers-Danlos Society. Mast Cell Disorders in Ehlers-Danlos Syndrome (for Non-experts). https://www.ehlers-danlos.com/2017-eds-classification-non-experts/mast-cell-disorders-ehlers-danlos-syndrome-2/
The Ehlers-Danlos Society. What are the Ehlers-Danlos Syndromes? Published 2017. https://www.ehlers-danlos.com/what-is-eds/