International Journal of Health & Allied Sciences

: 2019  |  Volume : 8  |  Issue : 1  |  Page : 38--43

Temporomandibular joint dysfunction in adults: Its relation to pain, general joint hypermobility, and head posture

Ahmet Cuneyt Akgol, Tulay Cevik Saldiran, Lacin Naz Tascilar, Begum Okudan, Gamze Aydin, Derya Azim Rezaei 
 Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Okan University, Istanbul, Turkey

Correspondence Address:
Dr. Tulay Cevik Saldiran
Okan University Tuzla Campus, 34959 Akfırat, Tuzla, Istanbul


BACKGROUND: The first objective is the questioning of the presence of general joint hypermobility (GJH) and temporomandibular joint dysfunction (TMJD) in adults and examining the existence of the relationship between GJH and TMJD. The secondary purpose of this study questions whether there is a relationship between the forward head posture and GJH. MATERIALS AND METHODS: GJH assessments were carried out with the Beighton Hypermobility Score. Participants were assessed by a plumb line for postural assessment. During mouth opening, the examination of temporomandibular joint (TMJ) was evaluated based on if the mandible shows deflection or deviation. Pain assessment in TMJ was evaluated through three different pain areas, during rest and chewing activity and at night with the visual analog scale. Masseter muscle pressure sensitivity was recorded by measuring it with a dolorimeter. RESULTS: There was a positive correlation between hypermobility status and temporalis muscle pain at night (r: 0.218, P < 0.005). It was observed that those who are not hypermobile had more pain caused by chewing activity in masseter muscle than hypermobile participants (P < 0.005). CONCLUSION: In the presence of GJH, in order to maintain rehabilitation in the most effective way and to anticipate the secondary problems that may occur, the TMJ should be thoroughly examined for pain, sensitivity, and functionality.

How to cite this article:
Akgol AC, Saldiran TC, Tascilar LN, Okudan B, Aydin G, Rezaei DA. Temporomandibular joint dysfunction in adults: Its relation to pain, general joint hypermobility, and head posture.Int J Health Allied Sci 2019;8:38-43

How to cite this URL:
Akgol AC, Saldiran TC, Tascilar LN, Okudan B, Aydin G, Rezaei DA. Temporomandibular joint dysfunction in adults: Its relation to pain, general joint hypermobility, and head posture. Int J Health Allied Sci [serial online] 2019 [cited 2019 Mar 23 ];8:38-43
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General joint hypermobility (GJH) is known as hereditary connective tissue disorder. Genetic defects bring about a number of extracellular matrix genes with skin and vascular fragility.[1] Owing to the fact that there are no common diagnostic criteria for GJH and it changes depending on age, gender, and ethnicity, the actual prevalence is not be able to known. GJH has a strong genetic basis. It shows multifactorial characteristics, but there is no specific genetic determinant. In healthy individuals with hypermobility syndrome, no joint pain has been reported in approximately 0.6%–31.5% of people. Although women are seen more frequently than men, the prevalence of hypermobility is higher in Asia and Africa compared to white races.[2] The temporomandibular joint (TMJ), as a component of chewing function, is part of a system that contains important functions such as chewing, speaking, swallowing, taste, and breathing. The TMJ is anatomically and biomechanically different from the other moving joints in the body. TMJ is the only joint that moves between the joints and that make up the head-and-neck system. TMJ is located between the caput mandibulae of the mandibular condyle and the mandibular fossa of the temporal bone occurs from the condyle in the lower jaw, mandibular fossa in temporal bone, and the joint disc that separates these two bone surfaces.[3]

Although there are many definitions of TMJ dysfunction (TMJD), generally, it is expressed as the general composition of the problems involving the chewing muscles, TMJ, and related structures.[3],[4] When epidemiological studies are examined, it appears that TMJD has emerged widely in society.[5] Although it is seen in all age groups, it is more common in the 20–40 age group. The incidence of TMJD in the United States has been reported to be between 40% and 78%. The incidence of TMJD in Turkey is expressed at 31%.[6],[7] Malocclusion, trauma, bruxism, parafunctional habits, pathophysiology of chewing muscles, emotional stress, psychosocial factors, age, and sex are shown in TMJD etiology.[4] The most common symptom in TMJD is pain. Pain usually occurs in chewing muscles and TMJ. A click on the joint, chewing difficulty, swallowing problems, decreased mouth opening, deviation in mandibular movements, slipping, and locking are shown as other symptoms.[8] GJH is shown as one of the risk factors involved in the etiopathogenesis of TMJ disc displacement and malocclusion of the joint.[9] Clinical studies have also shown a close relationship between GJH and TMJD.[9],[10],[11] A lax capsular or ligamentous structure causes temporomandibular condylar hypermobility that is associated with parafunctions, overuse, or trauma. A variety of complaints can be explained by the association of the locomotor system, which is more prone to mechanical overload due to excessive range of motion. Rather than this, the quality of collagen is poorer in GJH patients, and this can result in traumatic synovitis, dislocation of joints, and soft-tissue lesions.[9] This increased instability may lead to an increased risk of musculoskeletal injuries, especially in movements of the TMJ joint. TMJ misalignment because of hypermobility is also a factor which causes tension in the jaw muscles as well as trigger points on the masseter muscle. Patients with GJH also demonstrated some pathological changes such as pain, hypertrophy, atrophy, or contracture in their lateral pterygoid muscle.[9],[11],[12] Aydın et al. reported that severely hypermobile individuals have a decreased postural stability in head-extended and head-rotated positions when compared to individuals who are nonhypermobile.[13] The anterior and posterior tilts of head position alter the range of motion of the TMJ. Postural changes in head posture will cause altered loading on the TMJ. GJH is thought to be a predisposing factor for anterior tilt of head posture, which is known as forward head posture. The presence of GJH is associated with instability in the joints which can lead to poor head posture. The upper cervical segments are the most affected body part by this situation.[11] In the light of this information, the purposes of the study are questioning the presence of GJH and TMJD in adults and examining the existence of the relationship between GJH and TMJD. The secondary purpose of this study is to question whether there is a relationship between the forward head posture and GJH.

 Materials and Methods

The sample of the research study with the descriptive cross-sectional study plan consisted of 97 volunteer healthy adult individuals working and studying at Istanbul Okan University. The study was approved by the Istanbul Okan University Ethics Committee (number: 87 date: 08/09/2017) and written consent was obtained from the participants before the evaluation, in accordance with the principles of the Helsinki Declaration. Exclusion reasons included neurological or rheumatological disorder, having orthodontic treatment, head–neck–chin trauma or presence of surgical story, and presence of inflammatory acute pain in the head–neck–chin area, except the musculoskeletal system. Voluntary individuals between the ages of 18 and 65 years were included in the study. Sociodemographic characteristics (age, height, sex, weight, body mass index, smoking status, and the data of the inclusion criteria) of the participants were recorded in the demographic data form. The Beighton Hypermobility Score and GJH Assessment were carried out. The Beighton score is an easy way of scoring, using the application of five maneuvers with a total of nine points. The five maneuvers were: to bend the little finger more than 90° to the back (one point for each side), to twist the thumb until it touches the front arm (one point for each side), elbow and knee hyperextension > 10° (one point for each side in each joint), and to place the palms on a flat surface without twisting the knees (one point). If four of these maneuvers are positive, it is thought that the patient has hypermobility. The first four items are evaluated symmetrically in all extremity, and one point is given for every move that can be made. Only the fifth item is rated as one point. Afterward, all the scores received are summed up and evaluated over a total of nine points. If the Beighton score is 4 or more, the participant is called hypermobile.[14],[15]

Participants were assessed on one occasion by measuring their head while they stood in their socks in a position they felt was natural for them. The standing position was chosen because it was found to be the most commonly used by clinicians when assessing the head posture for participants. Participants were instructed to have a similar distribution of body weight through each foot, to place their feet slightly apart, and to have their arms by their sides. Participants were assessed by a plumb line for postural assessment of forward head. The angle formed by the line connecting C7 to the tragus of the ear and the horizontal, which gives the position of the head relative to the trunk when the gaze is horizontal or in natural head posture, with decreasing values indicative of a more forward head posture. Observed symptoms were recorded according to the presence or absence of forward head posture in the data form. The assessments related to the TMJ and hypermobility and the postural assessment were done by the same therapists. The examination of TMJD, mouth opening (cm), and right/left lateral deviation of mandible (cm) was recorded in centimeters using a ruler.[16]

During the mouth opening, whether or not the mandible shows deflection (s) or deviation (c) was evaluated and recorded observationally. Presence of sound during mouth opening/closing, presence of pain with palpation, and overbite/overjet presence in evaluation of resting occlusion were questioned. Pain assessment in TMJ was evaluated through three different pain areas (TMJ, deep part of m. masseter, and m. anterior part of temporalis muscles) during rest, during chewing activity, and at night with the visual analog scale (VAS). The VAS score is determined by measuring the distance (mm) on the 10-cm line between the "no pain" anchor and the patient's mark, providing a range of scores from 0 to 10. A higher score indicates greater pain intensity. The participants were asked to fill out the form with their level of agreement with pain for different locations during the past 7 days. Pain threshold assessments were made with measuring sensitivity to pain by using a dolorimeter (pressure gauge) on the masseter muscle. In localization of the masseter muscle, participants were asked to squeeze their teeth. During tooth clamping under the fingers of the assessor, the masseter muscle appears. The dolorimeter was applied at a right angle of 90° while the participants were in a sitting position. The dolorimeter (Baseline®) was applied to the masseter muscle, and then pressure was slowly increased by 0.2 lbs/s up to 2.2 lbs. The participants were asked when they began to sense pain (pain threshold) and that was recorded. Masseter muscle pressure sensitivity was recorded by measuring the right and left and taking the average.[17]

Statistical Package for the Social Sciences version 22.0 was acquired by IBM (New York, ABD 1968) was used for the analysis of statistical data. Descriptive statistics was performed at a 95% confidence level, and the statistical significance level was set at 0.05. The Kolmogorov–Smirnov test was used to assess the distribution of data before starting the statistical analysis. In the present study, data were distributed abnormally, and therefore, a nonparametric test was used for statistical analysis. A nonparametric test (Mann–Whitney U-test) was used for statistical analysis. Intercorrelations between the hypermobility, head position, maximal opening mouth, and pain parameters were analyzed using the Spearman's correlation analysis (specifically, r: 0.5–1.0 was large; r: 0.30–0.49 was medium; and r: 0.10–0.29 was small).


The age average of the participants (n = 97) was 35.03 ± 12.24, and the percentage of women in the study was 56.7% (n = 55). While the number of individuals with GJH was 24 (29.2%), 73 (70.8%) were not hypermobile. Participants' body mass index averages were found to be 24.79 ± 4.71, and the hypermobility score average was found to be 2.14 ± 2.23. The pain pressure threshold average of the masseter muscle (g) was 1314.59 ± 455.47. When the relationship between GJH and pain at different localizations was examined with correlation tests, there was a positive correlation between hypermobility status and temporalis muscle pain at night (r: 0.218, P < 0.05). It was observed that not hypermobile participants had more pain at chewing activity in the masseter muscle than hypermobile participants (P > 0.05). Ninety-seven cases (52.6%) were found to have a forward head posture. There was no statistically significant difference between GJH and forward head posture and maximal mouth opening and the pain pressure threshold of the masseter muscle (P > 0.05). TMJ examination results are shown in [Table 1].{Table 1}

Pain in TMJ in different regions is shown in [Table 2].{Table 2}

There was no significant relationship between maximal mouth opening and hypermobility (P > 0.05). There was no significant relationship between the pain pressure threshold of the masseter muscle and hypermobility status (P > 0.05). The relationship between maximal opening of mouth pain threshold of masseter muscle and hypermobility is shown in [Table 3].{Table 3}

When the relationship between GJH and pain at different localizations was examined, it was found that those who were not hypermobile had more pain caused by chewing activity in masseter muscle than those who were hypermobile. This difference is statistically significant (P < 0.05). The relationship between pain and GJH is shown in [Table 4].{Table 4}

There was no significant difference between forward head posture and hypermobility status (P > 0.05). The relationship between head position and GJH is shown in [Table 5].{Table 5}


TMJD prevalence in many studies is dispersed at different intervals, but it is over 10% in the majority of studies. While the prevalence was 36.2% in Brazil,[18] this rate was 19% in Pakistan, and 21.3% in Saudi Arabia.[12],[19] While it is impossible to make a comment related to the prevalence according to sociocultural differences, such as ethnicity, geography, and income level, and it is remarkable that the prevalence varies according to gender difference. Almost, every study is suggesting that women have more complaints of TMJD than men.[12],[20],[21] In this study, the prevalence of TMJD in 97 participants was 24.7% (n = 24), while the number of female participants was 56.7% (n = 55). The usage of TMJ function for eating, speaking, gesturing, and mimics in daily life activities constitutes the infrastructure for the high prevalence in the studies. The etiopathogenesis of TMJD was reported to involve excessive processing of chewing muscles, cartilage degeneration resulting from excessive use, and myalgia. It can be considered that high prevalence results are increased due to these reasons. There is no clear reason for the greater influence of women and theses that hormonal differences provoke complaints are being proposed.

GJH is one of the risk factors associated with the etiopathogenesis of TMJ disc displacement.[22],[23],[24],[25] There was no significant difference between the participants in the sign and symptom evaluation results, such as mouth opening and lateral deviation measurement, which are done for GJH and TMJ hypertranslation. Conti et al. found no relation between GJH and TMJ hypertranslation as a result of X-ray evaluation for different situations when the mouth is open and the mouth is closed.[10] Similarly, there were no differences between the individuals with and without GJH in the study of TMJ irregularity examined by magnetic resonance imaging.[26] According to the results of the research, GJH does not appear to be the causative agent in the etiopathogenesis of TMJ hypertranslation. Clinicians should evaluate joints independently of each other, while considering the joint dysfunctions that hypermobility will cause. In addition to joint pain, the myalgia table in chewing muscles is among the general symptoms of TMJD. It was also shown that muscle activations differ in different TMJ pathology in the pilot study that analyses the functions of chewing muscles with EMG by grouping individuals with pain and without pain, and also with disk displacement and without disk displacement.[27] Similarly, the pain pressure threshold of chewing muscles has been observed to decrease in the presence of pathology in the studies evaluating myofascial pain in TMJ disorders.[28],[29],[30] As a result of evaluation that we did with the hypothesis suggesting that GJH can cause a difference in the pain pressure threshold of the masseter and temporalis muscles from chewing muscles, there was no statistically significant difference, although hypermobile individuals have a lower pain pressure threshold compared to nonhypermobile individuals. In addition to this, it was shown that individuals with GJH have more pain in the temporalis muscle at night. It was observed that there is a difference in the location and duration of the pain in chewing muscles between the hypermobile and nonhypermobile individuals in accordance with the study output. Although chronic pain is still not well understood for different types of GJH as they are defined, it is indicated that it is a common symptom. It was reported that the possible contributors to the formation and chronicity of the pain might be structural changes that exist in muscles and ligaments, deteriorated proprioception, muscle weakness, nociceptive pain, and central sensitivity.[1] The participants reported that the most common pain complaints were in front part of temporalis muscle (22.7%) at rest in the pain assessment related to TMJ that we made. It was found that arthralgia in TMJ was present in 14.4% of people, and myalgia in the temporalis and masseter muscles was present in 13.4% of people during chewing. These percentages reflect a large percentage when considering the incidence of the population. The masseter muscle pain level was higher in the nonhypermobile group during chewing, and no significant difference was observed for other variables as a result of the examination between the hypermobile and nonhypermobile individuals. As an alternative to the cumulative assessment of data in the presence of central sensitization, which is thought to have played a major role in the pain mechanism of TMJ and GJH, this can be explained by the fact that participants' complaints should be evaluated as individual responses.[1],[28]

Due to scholarly knowledge, we hypothesized that proprioceptive loss of GJH was more likely to contribute to joint instability, leading to deviation in the head posture, which is mostly known as anterior tilt of the head. At the same time, this vicious cycle was also influenced by other factors, such as TMJs or cervical segments, according to our hypothesis. There was no significant correlation between GJH and cervical posture in our study. The findings of our study show that in individuals with generalized joint hypermobility, deviations in the cervical postural array need to be assessed by objective imaging methods other than observational-based methods. In this regard, it is possible to observe generalized joint hypermobility and the disorientation of the upper cervical segments, or similar results may be obtained with our study. It was reported that changes occurring in the cervical region mechanics are directly or indirectly among the causes of TMJD.[11],[21] Posture, pain, and hypermobility were evaluated in a clinical study with the participation of 35 healthy individuals aged 10–35 years, and there was no significant relationship between the neck position and GJH. In this study, researchers used Reedco's Posture Score method in postural evaluation, which is an observation-based application.[21] The relationship between forward head posture and TMJD was examined in the systematic review published by Rocha et al. and while it is considered that the cervical posture may also cause deterioration, it was suggested that the reverse is also possible. This is explained by the activation of the chewing muscles and the movement in the cervical vertebrae. While there was no relationship between cervical posture and TMJD in two articles of a total of 17 articles, there was a high correlation between these two parameters in a high-quality methodological study and five medium quality methodological quality studies. Despite these results, the researchers reported that the relationship between TMJ and head posture is still controversial and uncertain.[11]


The study findings are not parallel to the literature in the name of head position and TMJD. The reason for this is the complications of TMJD etiology and diagnosis. Relation of head-and-neck position with TMJD should be revealed with studies planned with more specific evaluations and larger number of participants because of the presence of anatomical variations and multiple factors. The high prevalence determined at the end of our study with adult healthy individuals, as a result of TMJ screenings and evaluations at an early age, we think that TMJD problems that may occur can be avoided. However, we would like to emphasize the importance of awareness at an early age with regard to the high prevalence determined in women. Based on the literature reviews and our findings from our study, in the presence of GJH, in order to maintain the rehabilitation in the most effective way and to anticipate the secondary problems that may occur, the TMJ should be thoroughly examined for pain, sensitivity, and functionality.

Consequently, there was no statistically significant relationship between TMJD and GJH table. GJH is one of the reasons to be questioned in the etiology when TMJ pain variable is examined.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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