SciELO - Scientific Electronic Library Online

 
vol.23 número37Salud Bucal y Enfermedades no transmisibles en pacientes de un centro de enseñanza universitaria del área Salud, Montevideo-Uruguay. Parte 2Instrumento de Promoción de salud bucal para maestros sobre traumatismos dentarios en niños a través de la Red Ceibal índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Links relacionados

Compartir


Odontoestomatología

versión impresa ISSN 0797-0374versión On-line ISSN 1688-9339

Odontoestomatología vol.23 no.37 Montevideo  2021  Epub 30-Abr-2021

https://doi.org/10.22592/ode2021n37a3 

Articles

Association between generalized joint hypermobility and temporomandibular joint clicking

11Departamento de Trastornos Témporo Mandibulares y Bruxismo, Facultad de Odontología, Universidad de la República, Uruguay. dr.sanguinetti@hotmail.com

2Cátedra de Rehabilitación, Prostodoncia Fija y Trastornos Temporomandibulares, Facultad de Odontología , Universidad de la República, Uruguay


Abstract

This study analyzes whether generalized joint hypermobility (GJH) is a risk factor for temporomandibular joint disorders (TMD). Therefore, we evaluated the potential association between TMD clicking and GJH diagnosis. We worked with the following hypothesis: patients with GJH would have a higher prevalence of TMJ clicking than those without it, making GJH a risk factor for joint disorders.

Two hundred and fourteen students from the School of Dentistry of Universidad de la República del Uruguay (UdelaR) were examined: 161 female and 53 male, aged 18 to 30 (average age: 23.8 years, SD=2.7). Each participant was given a questionnaire, and a clinical examination was performed to diagnose GJH using the Beighton score (BS), clicking, history of maxillofacial trauma, orthodontics, full dentition, open lock, and shift. A calibrated blind researcher (kappa inter-rater click calibration = 0.68; intra-rater BS score=0.82, click=1) performed all the examinations. The Ethics Committee approved the study, and all the participants signed an informed consent. A multiple logistic regression model was used to analyze the data statistically.

GJH prevalence was 34.16% in women and 7.55% in men; clicking prevalence was 24.22% in women and 11.32% in men. There was a significant association between sex (OR=3.244, p-value 0.018) and history of trauma (OR=2.478, p-value 0.041) and the presence of clicking. No association was found between clicking and GJH.

Female sex and history of trauma could be risk factors for TMJ disorders. The lack of association between GJH and clicking in this age group (18-30) suggests that GJH may not be a risk factor for developing these pathologies.

Keywords: Temporomandibular Articulation; Joint Instability

Resumen

El objetivo del estudio fue analizar si la hiperlaxitud articular generalizada (HAG) es un factor de riesgo para los trastornos de la articulación temporomandibular (ATM). Para ello se evaluó la posible asociación entre chasquido de la ATM y el diagnóstico de HAG. Se trabajó con la siguiente hipótesis: el paciente con HAG, tendría mayor prevalencia de chasquido a nivel de la ATM que los que no la presentan, constituyendo la HAG un factor de riesgo para padecer un desorden articular (DA).

Se examinaron 214 estudiantes de facultad de odontología (FO) de la Universidad de la República (Udelar) de Uruguay, 161 participantes del sexo femenino y 53 masculino, de entre 18 y 30 años (edad media 23.8 años, DE=2.7). A cada participante se le realizó un cuestionario y un examen clínico para diagnóstico de HAG utilizando el índice de Beighton (IB), chasquido, antecedente de trauma maxilofacial, ortodoncia, dentición completa, bloqueo abierto y turno. Todos los exámenes fueron realizados por un investigador ciego calibrado (calibración interoperador chasquido kappa= 0.68; intraoperador Beighton=0.82, chasquido=1). El estudio fue aprobado por el Comité de Ética y todos los participantes firmaron un consentimiento informado. El análisis estadístico de los datos fue realizado en base a un modelo de regresión logística múltiple.

La prevalencia de HAG fue 34.16% en el género femenino y 7.55% en el masculino, de chasquido 24.22% para el femenino y 11.32% en el masculino. Las variables género (OR=3,244, p-valor 0,018) y antecedente de traumatismo (OR=2,478, p-valor 0,041) se asociaron significativamente a la presencia de chasquido. No se encontró asociación entre chasquido e HAG.

El género femenino y los antecedentes de traumatismo podrían ser factores de riesgo para desórdenes a nivel de la ATM. La ausencia de asociación entre HAG y chasquido en dicho grupo etario (18-30 años), sugiere que dicho factor podría no ser de riesgo para el desarrollo de dichas patologías.

Descriptores: Articulación Temporomandibular; Inestabilidad de la Articulación

Resumo

O objetivo do estudo foi examinar se a hiperlaxidade articular generalizada (HAG) é um fator de risco para disfuncao articulacao temporomandibular (DAT). Isso foi feito avaliando a possível associação entre cliques atm e diagnóstico hag. O trabalho foi feito com a seguinte hipótese: o paciente com HAG, teria maior prevalência de clique no nível atm do que aqueles que não o fazem, tornando a HAG um fator de risco para DAT.

Foram examinados 214 alunos de Odontologia da Universidad de la República (Udelar) do Uruguai, 161 do sexo feminino e 53 do sexo masculino, com idade entre 18 e 30 anos (idade média de 23,8 anos, DE:2,7). Cada participante recebeu questionário e exame clínico para diagnóstico de HAG utilizando o índice Beighton (IB), clique, antecedente de trauma maxilofacial, ortodontia, dentição completa, bloqueio aberto e turno. Todos os testes foram realizados por um pesquisador cego calibrado (calibração interoperadora kappa-click-0,68; intraoperador Beighton-0.82, clique-1). O estudo foi aprovado pelo Comitê de Ética e todos os participantes assinaram consentimento informado. A análise estatística dos dados foi realizada com base em um modelo de regressão logística múltipla.

A prevalência de HAG foi de 34,16% no sexo feminino e 7,55% no masculino, de clique 24,22% para o feminino e 11,32% para o masculino. As variáveis de gênero (OR-3.244, valor p 0,018) e antecedente do trauma (OR-2.478, valor p 0,041) estiveram significativamente associadas à presença de clique. Não foi encontrada associação entre clique e HAG.

O sexo feminino e o histórico de trauma podem ser fatores de risco para distúrbios no nível do articulacao temporomandibular . A ausência de associação entre HAG e click sugere que esse fator pode não estar em risco para o desenvolvimento de tais patologias.

Descritores: Articulação Temporomandibular; Inestabilidade Articular

Introduction

Temporomandibular disorders (TMD) have been defined as a heterogeneous group of conditions affecting the temporomandibular joint (TMJ), masticatory muscles, and related structures. It has recently been considered of multifactorial etiology, where several systems (psychological, genetic, hormonal, neurological) interact with anatomical factors ⁽²⁾. Within TMDs, we find TMJ joint disorders. Joint disorders often arise as mild pathological conditions and can evolve into more severe conditions ⁽⁾. Clicking noises and pain are clinical manifestations associated with early TMJ disorders ⁽⁾. A nationwide survey conducted in Uruguay reported a 29.77% clicking prevalence on the clinical examination in Montevideo and a 23.01% prevalence in the rest of the country. Approximately 19% of the Swedish population show joint disorder symptoms, 7%, reciprocal clicking, and chronic 12%, closed locking ⁽⁷⁾. Joint clicking is considered a predictive variable for joint disorder and has been considered its main clinical manifestation ⁽⁸⁾. Disc displacement with reduction (DDwR) has been associated with condylar flattening, and disc displacement without reduction (DDwoR) has been associated with degenerative bone changes9. The prevalence of TMDs and joint disorders is higher in women than in men ⁽6,10⁾. General and local risk factors could explain this difference8. Knowing these predisposing and triggering factors could help prevent TMDs while understanding perpetuating factors increases the chances of treatment success11.

Joint hypermobility (JH) has been studied as a risk factor for joint disorders and is defined as an increased joint mobility range compared to the general population. It may be observed as local joint hypermobility (LJH) or generalized joint hypermobility (GJH)(12. GJH may result from a collagen defect, such as in Ehlers-Danlos and Marfan syndromes, although it may also occur without an underlying collagen defect. These could be cases of benign GJH13.

The Beighton score (Fig. 1) has gained international acceptance and appears to be the most widely used index in the scientific literature to diagnose GJH(14.

The Beighton score has been validated for use in dentistry15. Several studies have been conducted to analyze the possible association between joint disorders and GJH.

Fig.1 

A single systematic review helped us establish the association, although GJH could not be shown as a risk factor for joint disorders 12. A higher prevalence of GJH and TMD was found in a case-control study in the 15-24 age group. Additionally, there was an association between GJH and clicking. The authors concluded that joint disorder risk is higher in individuals with GJH 16. A study of 701 young patients (77% female) found that 63% of joint disorder patients were diagnosed with GJH, which shows a strong connection17. A study of 1,600 individuals reported a GJH prevalence of 6.9% and a joint disorder prevalence of 14.8%. The authors concluded that GJH was associated with DDwR TMD 18. Ting-Han et al. conducted a retrospective study (19 on 975,788 randomly selected individuals. They concluded that confirming the association between joint disorder and GJH suggests that a multidisciplinary team should treat individuals with TMD and GJH. In a recent case-control study (20 applying the BS and RDC/TMD criteria, the authors concluded that the risk of developing a joint disorder is higher in patients with specific systemic pathologies such as GJH.

Barrerara Mora et al.(21 had opposite results in a study of 140 patients (male and female) needing orthodontic treatment. They reported a GJH prevalence of 28.%, finding no association between different types of TMD and GJH. The authors of a case-control design study including 60 cases and 60 control cases22 (mean age=25) concluded that GJH does not contribute to TMD onset, as it was a common finding in asymptomatic patients. Sáez-Yuguero et al. analyzed 66 young women being treated for TMD. They reported a BS of 51% and a DDwR of 40%, concluding that the BS and an MRI could not establish that GJH is a risk factor for TMJ23.

A cross-sectional and prospective study24 evaluated 34 young women diagnosed with joint disorder. GJH prevalence was 65%, but it was impossible to establish GJH as a risk factor for TMD.

A case-control study that included 42 surgical patients and 20 control cases found they were 9.6 times more likely to develop reciprocal clicking with GJH. They concluded that GJH is a significant etiological factor for developing reciprocal clicking and chronic closed lock(25. Another control case design26 used MRI technology for joint diagnosis. The authors concluded that GJH is not a predictor of joint disorder based on the Beighton score.

The results of these studies are controversial. Some studies have found an association between benign GJH and joint disorders, while others have been unable to prove such an association.

This study aimed to:

  • -assess the prevalence difference between GJH sex and clicking;

  • -study the potential association between joint clicks and GJH.

We worked with the following hypothesis: GJH patients would have a higher prevalence of TMJ clicking than those without it, making GJH a risk factor for joint disorders.

Materials and methods

Participants

A cross-sectional study was designed. Students at the School of Dentistry, UdelaR, aged between 18 and 30 were surveyed. They were selected consecutively, Monday through Friday, in the two shifts-from 8:00 am to 12:00 pm and from 7:30 pm to 11:30-pm during October, November, and December 2017, and March 2018. The study protocol was approved by the Ethics Committee of the School of Dentistry, UdelaR (Uruguay). Each participant was interviewed and clinically examined in a single session, including BS application.

Sample size

The prevalence rates previously reported were considered to calculate the sample size(21. Considering a level of 5% and a power of 80%, the resulting sample size was 200 (+25 to cover non-responses): 150 women and 50 men to find differences in GJH prevalence between sexes. Everyone agreed to participate.

The following selection criteria were considered:

Inclusion criteria:

  • -School of dentistry (UdelaR) students

  • -Men and women aged between 18 and 30

  • -Participants agreed to take part in the clinical study and expressed their consent in writing.

Exclusion criteria:

  • -History of TMJ surgery

  • -Any general disease affecting connective tissue or joints

  • -Injury with permanent joint mobility sequelae

  • -Joint prosthesis

  • -Extreme hypermobility (e.g., dancers, professional athletes)

Variables

Each participant was given a questionnaire, and a clinical examination was conducted in a single interview, which included the BS. The rater was blind to the study objectives. The rater is a member of the Department of Rehabilitation, Fixed Prosthodontics, and TMD, with field experience. The rater was calibrated and measured the variables studied (kappa inter-rater click calibration = 0.68; intra-rater BS =0.82, click=1). Table 1 shows the results of each calibration.

Table 1 

Clicking: We followed the DC/RDC concepts (3 and calibration protocol used by Riva et al. in 20116). The rater explained that TMJs would be examined for joint noise during opening and closing. The rater placed their index and middle fingers on the skin covering the sides of both TMJs simultaneously while the participant made three maximal opening and closing movements, starting and ending these movements in the maximum intercuspation position. When the noise occurred in one of three cycles, in one or both TMJs, both when opening and when opening and closing, the participant was diagnosed with click-type joint noise.

A differential diagnosis was made concerning shape alterations, discarding reciprocal joint noises in the same range in opening and closing; therefore, the result was negative for clicking.

The presence of full dentition (FDent) and the absence of molars 6, 7, and 8 (Molars) in the same quadrant were evaluated in an intraoral clinical examination with examination instruments, mirror, clamp, probe, periodontal probe, and dental light.

FDent was positive when all incisors, premolars, and molars were present, considering the absence or presence of some or all of the third molars.

Molars was positive when the rater detected the clinical absence of first, second, and third molars in the same quadrant.

Open lock and history of trauma were positive when the participant reported them in their medical history.

The Beighton score was applied as proposed by the author and expanded using a goniometer as per Juul-Kristensen et al.’s 2007 description(14.

Beighton score

  • 1.Passive dorsiflexion of the thumb with flexed wrist

  • 2.Passive dorsiflexion of little finger beyond 90° with extended wrist

  • 3.Active hyperextension of elbows beyond 10°

  • 4.Active hyperextension of knees beyond 10°

  • 5.Forward flexion of the trunk with the knees fully extended so that the palms of the hands rest flat on the floor

The score range was 0-9. The higher scores indicated higher hypermobility. A score of 4 or more points was considered Beighton positive. Patients were not classified based on hypermobile joints.

Statistical analysis

First, a descriptive analysis of the variables was conducted with frequency distribution for the qualitative variables. For quantitative data, however, the mean and standard deviations were calculated. Second, bivariate analysis of clicking and potential risk factors was conducted. Finally, these factors were assessed with multiple logistic regression (MLR) analysis, and the relevant odd ratios (OR) and intervals were calculated with a 95% confidence level.

Results

A total of 214 participants with an average age of 23.8 (SD=2.7) were included, of whom 161 were women and 53 men. Total GJH prevalence was 27.6%, clicking, 21.0%, and history of trauma, 15.0%. The frequency distribution of the other variables is presented in Table 2.

Table 2 

The prevalence of GJH by sex was higher in women (34.16%; SD=3.74%) than in men (7.55%; SD=3.66%) (Chart 1). Clicking prevalence was also higher in women (24.22%; SD=3.39%) than in men (11.32%; SD=4.39%) (Chart 2).

Chart 1: Prevalence of hypermobility by sex 

Table 3 shows the results of the first bivariate analysis.

Table 3: Bivariate analysis 

Molars, FDent, and lock were not included in the bivariate analysis or logistic regression model because they lacked sufficient variability to evaluate the association with the response variable. The independent variables used for clicking were age, sex, trauma history, orthodontics, shift, and BS.

The prevalence of clicking in participants with and without GJH was similar: 21.3% and 20.3% (Chart. 2).

Chart 2: Prevalence of clicking according to hypermobility 

Table 4 describes the results obtained for each BS component.

Table 4: Prevalence of each Beighton score component according to sex 

Table 5: Logistic regression for risk factors vs. clicking 

The proposed model attempted to measure the potential association between possible risk factors and joint clicking as a sign of joint disorder. Table 5 shows the MLR results. Female sex was associated with a potential risk factor for joint disorder with an OR=3.2 (p-value 0.018). A history of maxillofacial trauma had a clear association with clicking with an OR=2.5 (p-value 0.041).

Age, undergoing or having undergone orthodontic treatment, and shift were not associated with clicking prevalence. GJH was not significantly associated with clicking as a clinical sign (p-value: 0.408 95% CI (0.318 -1.542))

Discussion

Previously published studies generally applied various methodological designs, thus making it difficult to conduct a comparative analysis. The association between TMD and GJH has been reported in several studies, although results are not decisive. Some authors have proved the association, while others have not been able to prove it.

The studies that do not show a connection, as did our results, are bivariate statistical analysis, whose methodology poses statistical inference limitations 22-26. Creating an MLR model allowed us to control the potential risk factors for clicking most commonly reported in the literature. In contrast, two prospective design studies in general population samples concluded that GJH is a risk factor for TMDs15,20.

Although the BS is the most accepted criteria in the literature(27, other tests have been used: Carter and Wilkinson’s criteria, Rocabado’s Temporomandibular Pain Analysis for TMD, Brighton criteria. This could make it difficult to compare our results and theirs. Additionally, the studies surveyed that applied the BS showed that GJH ranged from 3 to 6 positive points. Deodato et al.(17) had a cut-off point of 3 and reached a GJH prevalence of 66%, while Pasinato et al.24 and Sáez Yuguero et al.23 used a cut-off point of 4 and reached 51% and 65% prevalences. This might question the validity of the BS as a diagnostic element. GJH prevalences in patient samples range from 4%(26 (Wang et al., 2012) to 65%23,17.

Our sample had a reduced age range (18-30), so age variability could not be studied compared to other studies with broader age ranges in non-patient samples18. A GJH prevalence of 43% has been reported in adolescents without TMD28. Our clicking prevalence results are similar to those reported in a national survey(6 and studies with general population samples(18. Our study distinguished GJH prevalence by sex. However, most studies have been conducted exclusively in women(24,26,28, reporting other ratios that reach up to 5:1 in their favor17. Primarily, there are no prevalence reports by sex. Hirsch et al.(18 reported a GJH prevalence of 6.9% in the general population, without age discrimination. This is lower than our results but with differences by sex.

Only one study25 included a history of trauma as a variable in bivariate analysis and with a negative association result. Our results showed that this control variable impacted joint clicking prevalence (p-value: 0.041 - 95% CI (1.016 -5.871)).

None of the studies surveyed included racial diversity in their samples. Some focus on populations of European descent (12,17-18,21-25,28 and others on Asian people (16,19,26, which makes it impossible to generalize results.

Only three studies18,20,26 described intra- and inter-rater calibration for both diagnostic methods. Calibration is necessary to ensure the methodological rigor that guarantees result reliability.

Conclusions

Generalized joint hypermobility diagnosed with the BS was equally prevalent in participants with and without signs of joint disorders. The study results suggest that GJH should not be considered a risk factor for TMJ disorders among young people (18-30 years). Female sex and history of maxillofacial trauma could be regarded as risk factors for developing

REFERENCES

1. McNeill C. Introduction. En: Temporomandibular Disorders: Guidelines for classification, assessment, and managment. Chicago: Quintessense, 1993: p11-13. [ Links ]

2. Manfredini D, Poggio C. Prosthodontic planning in patients with temporomandibular disorders and/or bruxism: a systematic review. J Prosthet Dent. 2017; 117(5):606-613 [ Links ]

3. Schiffman E,Orbach R, Truelove E, Look J, Anderson G, Goulet J, List T, Svensson P, González Y. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014; 28(1): 6-27. [ Links ]

4. Huddleston S, Lobbezoo F, Onland-Moret C, Naeije M. Anterior Disc Displacement with Reduction and Symptomatic Hypermobility in the Human Temporomandibular Joint: Prevalence Rates and Risk Factors in Children and Teenagers. J Orofac Pain. 2007; 21(1):55-62. [ Links ]

5. Okeson JP. Joint Intracapsular Disorders: Diagnostic and Nonsurgical Management Considerations. Dent Clin N Am. 2007; 51 85-103. [ Links ]

6. Riva R, Sanguinetti M, Rodríguez A, Guzzetti L, Lorenzo S, Álvarez R, Massa F. Prevalencia de trastornos témporo mandibulares y bruxismo en Uruguay. Parte I. Odontoestomatología. 2011; 17(13):54-71. [ Links ]

7. Lundh H, Westesson PL. Clinical signs of temporomandibular joint internal derangement in adults. An epidemiologic study. Oral Surg Oral Med Oral Pathol. 1991; 72(6):637-41. [ Links ]

8. Magnusson T, Egermark I, Carlsson G. A prospective investigation over two decades on signs and symptoms of temporomandibular disorders and associated variables. A final summary. Acta Odontol Scand. 2005; 63: 99-109. [ Links ]

9. Maddalena Dias I, Rocha Coelho P , Maria Souza N , Assis P, Pessoa F , Leite P, Lopes Devito K. Evaluation of the correlation between disc displacements and degenerative bone changes of the temporomandibular joint by means of magnetic resonance images. Int. J. Oral Maxillofac. Surg. 2012; 41:1051-1057. [ Links ]

10. Bueno C, Pereira D, Pattussi M, Grossi P, Grossi M. Gender differences in temporomandibular disorders in adult populational studies: a systematic review and meta-analysis. J Oral Rehabil. 2018; 45(9):720-729. [ Links ]

11. Marklund S, Wanman A. Risk factors associated with incidence and persistence of signs and symptoms of temporomandibular disorders. Acta Odontol Scand. 2010; 68: 289-299. [ Links ]

12. Dijkstra PU, Kropmans JB, Stegenga B. The Association between Generalized Joint Hypermobility and Temporomandibular Joint Disorders: A Systematic Review. J Dent Res 2002; 81(3):158-163. [ Links ]

13. Beighton P., Grahame R., Bird H. Assesment of hypermobility. En: Hypermobility of Joints. Inglaterra: Springer-Verlag, 1999. p9-20 [ Links ]

14. Juul-Kristensen B, Røgind H, Jensen DV, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology. 2007; 46:1835-1841. [ Links ]

15. Hirsch C, Hirsch M., John M., Bock J.J. Reliability of the Beighton Hypermobility Index to Determinate the General Joint Laxity Performed by Dentists. J Orofac Orthop. 2007; 68:342-52 [ Links ]

16. Kavuncu V, Sezai S, Ayhan K, Ayse K, Cihan A. The role of systemic hypermobility and condylar hypermobility in temporomandibular joint dysfunction syndrome . Rheumatol Int. 2006; 26(3):257-260. [ Links ]

17. Deodato F, Trusendi T,Giorgetti R, Scalese M. Predisposition for Temporomandibular Joint Disorders: Loose Ligaments. Cranio 2004; 24(3):179-183. [ Links ]

18. Hirsch C , John MT, Stang A. Association between generalized joint hypermobility and signs and diagnoses of temporomandibular disorders. Eur J Oral Sci. 2008 ; 116(6):525-30. [ Links ]

19. Ting-Han C, Da-Yo Y, Yung-Tsan W, Wan-Chien C, Fu-Gong L, Yi-Shing S, Earl F, Ren-Yeong H. The association between temporomandibular disorders and joint hypermobility syndrome: a nationwide population-based study. Clin Oral Investig. 2015; 19(8):2123-32. [ Links ]

20. Fredricson A, Khodabandehlou F, Weiner C, Naimi-Akbar A, Adami J, Rosén A. Are there early signs that predict development of temporomandibular joint disease?. J Oral Sci. 2018; 60(2):194-200. [ Links ]

21. Barrera-Mora JM, Espinar Escalona E, Abalos Labruzzi C, Llamas Carrera JM, Ballesteros EJ, Solano Reina E, Rocabado M. The relationship between malocclusion, benign joint hypermobility syndrome, condylar position and TMD symptoms. Cranio. 2012; 30(2):121-30. [ Links ]

22. Conti PC, Miranda JE, Araujo C.R. Relationship between systemic joint laxity, TMJ hypertranslation, and intra-articular disorders. Cranio. 2000; 18(3),192-7. [ Links ]

23. Sáez-Yuguero M, Linares-Tovar E, Calvo-Guirado JL, Bermejo-Fenoll A, Rodríguez-Lozano FJ. Joint hypermobility and disk displacement confirmed by magnetic resonance imaging: a study of women with temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107(6):54-57. [ Links ]

24. Pasinato F, Souza JA, Corrêa EC, Silva AM. Temporomandibular disorder and generalized joint hypermobility: application of diagnostic criteria. Braz J Otorhinolaryngol. 2011; 77(4):418-25. [ Links ]

25. Ögren M, Fältmars C, Lund B, Holmlund A. Hypermobility and trauma as etiologic factors in patients with disc derangements of the temporomandibular joint. Int J Oral Maxillofac Surg. 2012 ;41(9):1046-50. [ Links ]

26. Wang HY, Shih TT, Wang JS, Shiau YY, Chen YJ. Temporomandibular joint structural derangement and general joint hypermobility. J Orofac Pain. 2012; 26(1):33-8. [ Links ]

27. Remvig L, Jensen D, Ward R. Are Diagnostic Criteria for General Joint Hypermobility and Benign Joint Hypermobility Syndrome Based on Reproducible and Valid Tests? A Review of the Literature. Rheumatol 2007; 34:798-803. [ Links ]

28. Winocur E, Gavish A, Halachmi M, Bloom A, Gazit E. Generalized joint laxity and its relation with oral habits and temporomandibular disorders in adolescent girls. J Oral Rehabil. 2000; 27(7): 614-622. [ Links ]

Authors' contribution note:1.Conception and design of study 2.Acquisition of data 3.Data analysis 4.Discussion of results 5.Drafting of the manuscript 6.Approval of the final version of the manuscript. MS ha contribuido en: 1,3,4,5,6 MM ha contribuido en: 2,6 RR ha contriubido en: 1,4,5,6

Editor’s opinion: This article has been accepted by the Odontoestomatología’s editor Dra. Vanessa Pereira-Prado

Received: September 17, 2020; Accepted: February 02, 2021

Creative Commons License Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons