Hypermobility and the Jaw

Some individuals are more prone to these issues because of Generalized Joint Hypermobility (GJH). This condition means the joints can move beyond the normal limits. The Beighton Score (BS) is a simple nine-point test that clinicians use to assess GJH (Malek et al., 2021).

When the jaw joint is hypermobile, patients may notice:

• Clicking or popping sounds
• Jerky or irregular jaw movements
• Episodes where the jaw feels unstable or even gets “stuck” (Tuijt et al., 2018)

These symptoms can make wide opening, like yawning, biting into a large sandwich, or dental procedures, especially risky.

Practical Tips to Protect Your Jaw

1. Monitor your opening: Try to stay within the comfortable range (about 40 mm or two fingers).
2. Support during yawning: Place a hand gently under your chin to avoid excessive stretching.
3. Modify eating habits: Cut food into smaller pieces rather than taking large bites.
4. Communicate with your dentist: Let your provider know if you have hypermobility so they can adjust their techniques during dental care.
5. Practice jaw awareness: Notice when you tend to open wide (e.g., during laughter, stretching) and learn to limit the motion.

Why This Matters

Avoiding extreme movements helps reduce stress on the TMJ and lowers the risk of luxations, especially if you already experience joint hypermobility. A little daily mindfulness can go a long way in protecting your jaw health.

References:

Malek S, Reinhold EJ, Pearce GS. The Beighton Score as a measure of generalised joint hypermobility. Rheumatol Int. 2021 Oct;41(10):1707-1716. doi: 10.1007/s00296-021-04832-4. Epub 2021 Mar 18. PMID: 33738549; PMCID: PMC8390395.

Tuijt M, Parsa A, Koutris M, Berkhout E, Koolstra JH, Lobbezoo F. Human jaw joint hypermobility: Diagnosis and biomechanical modelling. J Oral Rehabil. 2018 Oct;45(10):783-789. doi: 10.1111/joor.12689. Epub 2018 Jul 19. PMID: 29972704.

What do you think is happening with your jaw?

→Clicking Jaw

Sometimes your jaw makes a clicking sound when you open or close your mouth. This happens to many people and usually doesn’t hurt or need any treatment. This is called disc displacement with reduction.

→Jaw Doesn’t Open All the Way

This is when your jaw can’t open fully because the disc inside the joint is fully sitting in front of the joint. It might hurt when you try to eat or talk. You also might not be able to move your jaw side to side very well. This is called disc displacement with no reduction.

→Jaw Gets Stuck Sometimes

Your jaw might get stuck closed for a bit. This is more likely to happen in people with a history of clicking noise in front of the ear, with the occasional jaw being stuck closed on waking. It often fixes itself. This is called episodic locking.

→Jaw Pops Out of Place

This happens when you open your jaw too wide, and get stuck open. It happens because the joint moved out of the socket. Seizure, trauma to your face, or hyper flexible jaw joints can cause this more frequently. This is called TMJ luxation.

→Jaw Gets Stuck Open

Sometimes your jaw can get stuck open, but you can close it yourself. This happens when the jaw joint moves out of the disc but not necessarily the socket. This is called open locking.

Why to deliver a medication through the oral mucosa?

1. To avoid the stomach and first-pass elimination
2. To avoid the influence of the presence of food
3. Direct access to a lesion or condition
4. Quick absorption

Intraoral Permeability

The oral mucosa is not a uniformly, highly permeable tissue like the gut, but shows regional variation. The keratinized areas (thicker), such as gingiva and hard palate, are least permeable and nonkeratinized lining areas (such as the tissue under the tongue) are most permeable. (Squier 1991)

Holding medication in place!

One of the major limitations associated with buccal delivery is low permeation of therapeutic agents across the mucosa. Various substances have been explored as permeation enhancers to increase the flux/absorption of drugs through the mucosa, but irritation, membrane damage, and toxicity are always associated with them and limit their use. (Sohi et al, 2010)

Technological advances in mucoadhesive, sustained drug release, permeability enhancers and drug delivery vectors are increasing the efficient delivery of drugs to treat oral and systemic diseases.  (Hearnden  et al, 2011)

It is possible to use a tissue coverage with an appliance similar to a bleaching tray. These oral appliances, whether used alone as a physical barrier or as a vehicle to deliver topical anesthetic, represent a safe and effective modality for the management of neuropathic orofacial pain disorders. (Bavarian  et al, 2022)

References

Sheikh S, Gupta D, Pallagatti S, Singla I, Gupta R, Goel V. Role of topical drugs in treatment of oral mucosal diseases. A literature review. N Y State Dent J. 2013 Nov;79(6):58-64. PMID: 24600767.

Squier CA. The permeability of oral mucosa. Crit Rev Oral Biol Med. 1991;2(1):13-32. doi: 10.1177/10454411910020010301. PMID: 1912142.

Kurosaki Y, Kimura T. Regional variation in oral mucosal drug permeability. Critical reviews in therapeutic drug carrier systems. 2000;17(5):467-508.

Sohi H, Ahuja A, Ahmad FJ, Khar RK. Critical evaluation of permeation enhancers for oral mucosal drug delivery. Drug Dev Ind Pharm. 2010 Mar;36(3):254-82. doi: 10.1080/03639040903117348. PMID: 19663558.

Hearnden V, Sankar V, Hull K, Juras DV, Greenberg M, Kerr AR, Lockhart PB, Patton LL, Porter S, Thornhill MH. New developments and opportunities in oral mucosal drug delivery for local and systemic disease. Adv Drug Deliv Rev. 2012 Jan;64(1):16-28. doi: 10.1016/j.addr.2011.02.008. Epub 2011 Mar 1. PMID: 21371513.

Bavarian R, Khawaja SN, Treister NS. Oral appliances in the management of neuropathic orofacial pain: A retrospective case series. Oral Dis. 2022 Apr;28(3):805-812. doi: 10.1111/odi.13824. Epub 2021 Mar 9. PMID: 33650141.

1. Wear your appliance as instructed.

2. Keep the appliance moist. If the appliance dries out it may wrap or crack.

3. Cleanse the appliance after each use with toothbrush and use a soft soap.  There are products available in the pharmacy for cleaning dentures.

4. If the appliance is uncomfortable or has been broken or cracked, call our clinic immediately for an appointment. Do not wear it until you have seen the doctor.

5. It is imperative that the appliance be adjusted by a dentist periodically. Please do not wear the appliance if it has not been checked.  NEVER ADJUST THE APPLIANCE YOURSELF.

6. Keep the appliance in a safe place, away from pets.

7. Some of the potential complications that can occur from using the appliance, include, but are not limited to:

1. increased symptoms
2. bite changes
3. jaw joint problems
4. jaw pain/muscle pain
5. muscle spasm
6. broken teeth
7. broken dental restoration

1.Assess: Determine the language barrier early on. If you notice the patient or their companions struggling to understand, assume there might be a language barrier.

2.Simple Language: Speak slowly and clearly, using simple words and short sentences. Avoid using medical jargon or slang.

3.Visual Aids: Draw diagrams, use charts, or show pictures to help convey information about symptoms, treatments, or procedures.

4.Use Technology: Use translation apps or devices to help facilitate communication. There are many apps available that can translate spoken or written language in real-time.

5.Professional Interpreters: If available, utilize professional interpreter services. Hospitals and healthcare facilities often have access to interpreters either in person, over the phone, or via video conferencing.

6.Bilingual Staff or Family Members: If there are staff members who speak the patient’s language, or if the patient has family members who can interpret, involve them in the conversation.

7.Be Patient and Respectful: Communicating through a language barrier can take time and patience. Be respectful, understanding, and avoid getting frustrated.

8.Ask Simple Questions: Break down questions into simple, yes-or-no questions or multiple-choice options to make it easier for the patient to respond.

9.Confirm Understanding: After providing information or instructions, ask the patient to repeat or demonstrate their understanding to ensure clarity.

10.Written Instructions: Provide written instructions or educational materials in the patient’s language whenever possible. This can help reinforce verbal communication.

11.Cultural Sensitivity: Be aware of cultural differences that may affect communication and healthcare decisions. Respect the patient’s cultural beliefs and practices.

12.Follow-up: Schedule follow-up appointments or check-ins to ensure the patient is following treatment plans and to address any further questions or concerns.

13. Mind wordless cues: Visual facial expressions are very important. For example, you always smile at people and speak gently. If you’re giving confident wordless mark, at least it can make it seem like you’re friends.

14. Use gestures: This approach can be helpful when directing different languages as well. For example, when people who don’t speak the same language are thirsty, they point to a cup and their mouth. It helps them understand what they want to say.

15. Prepare the environment: The patient is definitely nervous because he is in an unfamiliar environment. Therefore, it is important to relax him. For example, you can play music from their country, or prepare a card in their country’s language that means you don’t have to worry.

DISCLAIMER:  Document partially created using OpenAI. (2024). ChatGPT (version 3.5) https://chat.openai.com/ 

Chewing gum is the choice of preference among all candy in most age groups, and although it is not ingested, it is considered a part of an individual’s regular diet.

Although this may seem like a normal and harmless habit, gum-chewing is considered a parafunction that causes inflammation of the temporomandibular joint, and fatigue and pain in muscles of mastication.

• Gum-chewing on a regular basis = pain, clicking and locking of the jaw.
• Gum-chewing for several hours a day = pain, clicking and locking of the jaw, swelling and stiffness of the muscles of mastication.

Chewing gum can also be associated with headaches and limited mouth opening. The type and quality of pain will depend on the number of hours and type of chewing. If after chewing gum, the limit of pain has been reached, it can be treated with heat or ice, as well as over the counter medications like NSAIDS to decrease pain and inflammation.

There is enough evidence to support the idea of gum-chewing causing TMJ pain and headaches; ideally, gum should be eliminated entirely from a lifestyle.

References:

1. Tabrizi R, Karagah T, Aliabadi E, Hoseini SA. Does gum chewing increase the prevalence of temporomandibular disorders in individuals with gum chewing habits? The Journal of craniofacial surgery. 2014;25(5):1818-1821. doi:10.1097/SCS.0000000000000993
2. Martyn DM, Lau A. Chewing gum consumption in the United States among children, adolescents and adults. Food additives & contaminants Part A, Chemistry, analysis, control, exposure & risk assessment. 2019;36(3):350-358. doi:10.1080/19440049.2019.1567944
3. Mejersjö C, Ovesson D, Mossberg B. Oral parafunctions, piercing and signs and symptoms of temporomandibular disorders in high school students. Acta odontologica Scandinavica. 2016;74(4):279-284. doi:10.3109/00016357.2015.1114668
4. Olchowy C, Grzech-Leśniak K, Hadzik J, Olchowy A, Łasecki M. Monitoring of Changes in Masticatory Muscle Stiffness after Gum Chewing Using Shear Wave Elastography. Journal of clinical medicine. 2021;10(11):2480-. doi:10.3390/jcm10112480
5. Lippi G, Cervellin G, Mattiuzzi C. Gum-Chewing and Headache: An Underestimated Trigger of Headache Pain in Migraineurs? CNS Neurol Disord Drug Targets. 2015;14(6):786-90. doi: 10.2174/1871527314666150225143105. PMID: 25714969.

What can I do to help my jaw pain?

Temporomandibular disorders affect the temporomandibular joint, and muscles of mastication. The cause of this phenomenon is multifactorial, and can be associated with occlusal conditions, stress, trauma, and parafunction. Unfortunately, this disorder is irreversible; however, on the day-to-day basis, by restricting behaviors, any pain associated to the inflammation of the joints and surrounding muscles can decrease, as well as intercept further degeneration.

Basic in-home treatment:

• Diet: soft and in small bites, slow chewing; avoid gum.
• Teeth contact: disengage if in contact during other situations that do not involve chewing or speaking.
  • Tip: release a small puff of air and retain position.
• Avoid wide mouth-opening (cut food into pieces, press any food that requires large bites; yawn with limitation: place hand under chin, or move chin towards neck to limit opening.
• Find awareness of parafunctions: biting objects, clenching, grinding, and stop.
• Massage therapy: circular movements and pressure against the muscles until producing warmth, enhancing the blood flow in soft tissues – twice a week, 30 minutes per session.
• Thermotherapy: moist heat for 20 minutes a day in the affected regions.
• N-stretching exercises: tip of the tongue against palate (simulating letter “n”), open wide without removing tongue from the original position and hold for 6 seconds. This should be six times per session, and six times a day.

The purpose of general avoidance is to lessen joint pressure, regain muscle length, and decrease muscle activity.

Simple rule to follow: “if it hurts, don’t do it.”

References:

1. Liu F, Steinkeler A. Epidemiology, Diagnosis, and Treatment of Temporomandibular Disorders. The Dental clinics of North America. 2013;57(3):465-479. doi: 10.1016/j.cden.2013.04.006
2. Okeson, Jeffrey P., Management of Temporomandibular disorders, and occlusion, eighth edition, Elsevier, 2020.
3. Wieckiewicz M, Boening K, Wiland P, Shiau YY, Paradowska-Stolarz A. Reported concepts for the treatment modalities and pain management of temporomandibular disorders. J Headache Pain. 2015; 16:106. doi: 10.1186/s10194-015-0586-5. Epub 2015 Dec 7. PMID: 26644030; PMCID: PMC4671990.
4. Kraaijenga S, van der Molen L, van Tinteren H, Hilgers F, Smeele L. Treatment of myogenic temporomandibular disorder: a prospective randomized clinical trial, comparing a mechanical stretching device (TheraBite®) with standard physical therapy exercise. Cranio. 2014;32(3):208-216.

Opioids

Opioids are very potent and effective drugs; they are traditionally used for both acute and chronic pain conditions. However, opioids commonly cause vigorous side effects, some of which are likely to become lethal.

The opioid signaling system has the greatest receptor for tolerance development; consequently, requiring some cases to increase the intake amount of the drug to fulfill the analgesic effect.

Opioid Induced Hyperalgesia (OIH)

Opioid induced hyperalgesia (OIH), is defined as a heightened response to painful stimuli, caused by opioid consumption.

This manifests as either hyperalgesia (increased/extreme sensitivity to pain), or allodynia (pain caused by stimulus that normally does not provoke pain); it becomes more intense while the dose and exposition duration are increased. The outcome varies according to characteristics of each patient.

Diagnosis

OIH is difficult to recognize due to the variation of symptoms among patients, resulting in a diagnosis of exclusion. It should not be the first diagnosis of any case, even if the patient has been on long-term opioid treatment.

Clinicians should suspect OIH when opioid effect decreases, without disease progression, especially if there is unexplained pain reports or allodynia unassociated with the original pain, and increased pain with increasing dosages.

Common opioids

The opioids used, in order of frequency, are morphine, fentanyl, oxycodone, hydromorphone, and methadone. The administration can vary in all forms: oral, intravenous, transcutaneous, transmucosal, and intrathecal.     

Management

Opioid cessation, opioid rotation, and auxiliary pharmacotherapies, such as ketamine and dexmedetomidine. Adjuvant drugs appear to be the most effective approach in terms of absolute decrease in opioid use.

Opioid induced hyperalgesia can be resolved when this condition is diagnosed and managed.

• References
  1. Mercadante S, Arcuri E, Santoni A. Opioid-Induced Tolerance and Hyperalgesia. CNS Drugs. 2019 Oct;33(10):943-955. doi: 10.1007/s40263-019-00660-0. PMID: 31578704.
  2. Hayhurst CJ, Durieux ME. A Clinical Reality. Anesthesiology (Philadelphia). 2016;124(2):483-488. doi:10.1097/ALN.0000000000000963
  3. Turan A, Sessler DI. Opioid cessation: another teachable moment. Br J Anaesth. 2020 Sep;125(3):219-221. doi: 10.1016/j.bja.2020.05.004. Epub 2020 Jun 3. PMID: 32505336.
  4. Guichard L, Hirve A, Demiri M, Martinez V. Opioid-induced Hyperalgesia in Patients With Chronic Pain: A Systematic Review of Published Cases. The Clinical journal of pain. 2021;38(1):49-57. doi:10.1097/AJP.0000000000000994
  5. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011 Mar-Apr;14(2):145-61. PMID: 21412369

Saliva is of vital importance for the maintenance of oral health, including the lubrication and repair of oral tissues, oral acid neutralization, maintenance, enamel in children, tooth remineralization, digestion, and speech.

Systemic disorders can result in salivary gland dysfunction, for instance: Sjögren syndrome, diabetes, depression, head and neck radiotherapy, acquired immunodeficiency syndrome, etc. Nonetheless, the most common cause is the use of medications.

Medication induced hyposalivation increases the risk for oral diseases, such as: dental caries, candidiasis, bad breath, taste disturbances, difficulties in chewing, speaking, and swallowing.

Common medications that cause xerostomia are, but not limited to:

· Antibone-resorptives (osteoporosis)

· Anticonvulsants

· Antidementia

· Antidepressants

· Antihypertensives

· Antimigraine

· Antimuscarinics

· Antiparkinson

· Antiperistaltic

· Antipsychotics

· Appetite suppressants

· Diuretics

· Muscle relaxants,

· Opioid-analgesics

· Psychostimulant

· Sedatives

Prevention:

Gentle massage of the major salivary glands; adequate fluid intake; sugarless candies, wiping the oral cavity with glycerin swabs to stimulate salivary flow; sugarless antifungal agents such as nystatin powder or clotrimazole troches are recommended as well.

Treatment

Salivary-gland destruction is irreversible regardless of the method of damage. However, saliva substitutes are available as rinses and gels. Sipping water, as well as sugarless candy and chewing gum provide relief for some patients due to the taste and mechanical stimulation of salivation.

REFERENCES

1. Aliko A, Wolff A, Dawes C, et al. World Workshop on Oral Medicine VI: clinical implications of medication-induced salivary gland dysfunction. Oral surgery, oral medicine, oral pathology and oral radiology. 2015;120(2):185-206. doi:10.1016/j.oooo.2014.10.027

2. Barbe AG. Medication-Induced Xerostomia and Hyposalivation in the Elderly: Culprits, Complications, and Management. Drugs & aging. 2018;35(10):877-885. doi:10.1007/s40266-018-0588-5

3. Wolff, Joshi RK, Ekström J, et al. A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective SIalorhhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI. Drugs in R &D (Online). 2017; 17(1):1-28. Doi: 10.1007/s40268-016-0153-9

4. Grisius MM. XEROSTOMIA. 2nd. ed. Springer Publishing Company; 2008:821

Grid

Protecting Your Jaw: Why Avoiding Wide Mouth Opening Matters

My clicking jaw

Using a topical medication in the mouth!

Instructions for intraoral appliance use

How to overcome language barriers in a medical consultation:  tips for providers

Avoid chewing gum!

Sleep hygiene means having both a bedroom environment and daily routines that promote consistent, uninterrupted sleep.

SUGGESTIONS FOR BETTER SLEEP

• Keeping a stable sleep schedule
• Making your bedroom comfortable and free of disruptions
• Following a relaxing pre-bed routine
• Building healthy habits during the day

CDC recommends some habits that can improve sleep health:

• Be consistent. Go to bed at the same time each night and get up at the same time each morning, including on the weekends
• Make sure your bedroom is quiet, dark, relaxing, and at a comfortable temperature
• Remove electronic devices, such as TVs, computers, and smartphones, from the bedroom
• Avoid large meals, caffeine, and alcohol before bedtime
• Get some exercise. Being physically active during the day can help you fall asleep more easily at night.

Mayo Clinic has the following advice:

• Stick to a sleep schedule
• Pay attention to what you eat and drink
• Create a restful environment
• Limit daytime naps
• Include physical activity in your daily routine
• Manage worries

References