Trismus

IJDA, 2(3), July-September, 2010 303

Senior lecturer1, 2

Professor and head3

Professor4

Email for correspondence:[email protected]

Article InfoReceived: April 5, 2010Review Completed: May 10, 2010Accepted: June 15, 2010Available Online: July, 2010© NAD, 2010 - All rights reserved

REVIEW

ABSTRACT:

Trismus, a severely restricted mouth opening is a problemcommonly encountered by the dental practitioners. It is veryimportant that dentists are familiar with the differential diagnosisof limited jaw opening. Treatment of trismus may be easy orcomplicated. It is important to remember that multiple potentialcauses exist. Trismus is a condition that impairs eating, interfereswith oral hygiene, restricts access for dental procedures and mayadversely affect speech and facial appearance.

Key words: Trismus, extra articular and intra articular

Oral Medicine and RadiologyM.R Ambedkar Dental College and HospitalBangalore

Trismus

Vaishali M R1, Roopashri G2, Maria Priscilla David3, Indira A P4

INTRODUCTION

The term trismus denotes a motor distributionof the trigeminal nerve, especially spasm of themasticatory muscle, with difficulty in opening themouth.1,2 According to Dorland’s illustrated dictionarytrismus means (Greek trimos; grating, grinding)2,3

Trismus has a number of potential causes whichcould range from simple and non progressive tothose that is potentially life threatening. In a busypractice, it is not unusual to see several patients eachmonth with a complaint of trismus.2

Trismus impairs the ability to incise and masticatethe food, interferes with the oral hygiene and restrictsaccess to dental procedures. It may adversely affectspeech and it can also compromise or prevent theconstruction and use of removable or fixedappliances.1

INDIAN JOURNAL OF DENTAL ADVANCEMENTS

Jour nal homepage: www.nacd. in

The knowledge about normal range of mouthopening is very essential in the diagnosis of trismus.It varies from patient to patient within a range of 40-60mm.

2 finger breadth (40mm) and 3 finger breadth(54-57mm) is usual width of opening.

Trismus has been defined variously as a mouthopening less than 20mm. other authors have used aclassification for trismus such as

Mouth opening of > 30 mm indicated light trismus

Mouth opening of 15-30mm indicated moderatetrismus

Mouth opening of < 15 mm indicated severe trismus

Etiology

The etiology of trismus may be classified as Extraarticular and Intraarticular

IJDA, 2(3), July-September, 2010304

Trismus Vaishali M.R., et, al.

Extra articular causes

Infections

The hallmark of masticatory space infection islimited jaw opening.2,8 Infections causing trismus maybe of an odontogenic nature. Odontogenic infectionsare Pulpal, periodontal and pericoronal and nonodontogenic causes include tetanus which is a lifethreatening infection and is rare in the developingworld. Trismus and dysphagia are the most commonpresenting symptoms.4, 9, 10

Tetanus is an infectious disease that results fromwound contamination with clostridium tetani, ananaerobic, gram positive, motile, spore forming rodwhich may survive for years in some environment.Trismus is the common presenting symptom, butpatients often develop dysphagia as well as pain andstiffness of the musculature. Markedly increased tonein the central muscle (face, neck, chest, back andabdomen) with superimposed generalized spasmstrongly suggest tetanus.4

Sustained contraction of the facial muscle causes‘risus sardonicus’- the so called ‘sneering grin’expression. With severe trismus there is opisthotonos,caused by generalized spasm and resulting in flexionof the arms, extension of the legs and rigidity of theabdominal wall, followed by rigidity of the trunk andlimbs4.

The spatula test is the simple bedside test todiagnose tetanus. The posterior pharyngeal wall istouched with spatula and reflex spasm of themasseter occurs (positive) instead of the normal gagreflex (negative).

Trauma

1. Surgical extraction of the mandibular molars

2. Post anesthetic injections; inferior alveolar nerveblock, posterior superior alveolar nerve block

3. Direct trauma

Fracture of the mandible.

Other facial fractures.

Patients who have had mandibular third molarsurgically removed frequently have mild to moderate

trismus. This interferes with patients normal oralhygiene and eating habits. Patients should be warnedthat they will be unable to open their mouthsnormally after surgery. The trismus graduallyresolves.13

Post anesthetic infections.

Limitations of oral opening and occasionallyparesthesia after local anesthetic injections for dentaltreatment continue to be problems in dentistry.Although the incidence of such morbidity is low, it isaccompanied often by distress for both patient andattending clinician and could lead to litigations.14

It is hypothesized that the barbing of the needlesat the time of the injection followed by tissue damageon withdrawal is a likely explanation for some rarecases of post injection persistent paresthesia. Postinjection trismus is related to tearing of masticatorymuscle by penetration of the needle during injectioninto the muscle. Most commonly involved muscle ismedial pterygiod during inferior alveolar nerve block.Good injection technique by staying lateral to thepterygomandibular raphae during penetration willavoid the medial pterygiod muscle, since this musclelies medial to the raphe.15

Drug therapy

Some drugs are capable of causing trismus as asecondary effect. Phenothiazine, Succinyl choline andtricyclic antidepressants being more among the mostcommon.

Trismus can be seen as extra pyramidal sideeffects of metaclopromide, Phenothiazine and othermedications.

Radiotherapy

Radiotherapy is commonly used to treatsquamous cell carcinoma of head and neckmalignancy and regional lymphomas. The primaryadvantage of using radiotherapy to treat oral canceris the preservation of normal tissue and function,however complications may develop, dependingupon which healthy tissue are in the path of radiationbeam, the amount of radiation given and the courseof treatment.2



Osteoradionecrosis may occur, resulting in pain,trismus, suppuration and occasionally a foul smellingwound. When the muscles of mastication are withinthe field of radiation, fibrosis may lead to trismusreducing the range of movements. Fibrosis andtrismus have been attributed to the ischemia causedby endarteritis obliterans. Trismus complicates postradiation dental care.

Trismus is present at the time of diagnosis inabout 2% of the patients suffering with a head andneck cancer due to tumor growth. For Tumors ofnasopharynx, trismus may be the first sign.6

Trauma

Fracture of the mandible may cause limited jawopening. Backland et al defined as devastating eventse.g. sports injury, administration of general anesthesiaand performance of dental procedure such as difficultextractions requiring lengthy appointments.2

Trismus has also been reported due to accidentalincorporation of foreign bodies because of externaltraumatic injury.11

Another relatively rare cause of trismus is traumato the zygomatic arch and zygomaticomaxillarycomplex, which interferes with movements ofcoronoid process

Temporomandibular joint disorder

Temporomandibular joint disorder may bedivided into extra articular and intra articularproblems (including disc displacement, arthritis,fibrosis.) intracapsular problem are often caused bytrauma2.

Congenital/developmental cause

Trismus have been reported as a result ofhypertrophy of the coronoid process causinginterference of coronoid against the anterior medialmargin of the zygomatic arch. Coronoid exostosis,congenital or acquired coronoid hyperplasia,coronoid osteochondroma, osteoma also results inlimited mouth opening.5 Trismuspseudocamptodactyly syndrome is a rare

combination of hand, foot, mouth abnormalities andtrismus.

Miscellaneous causes

Oral submucous fibrosis is a potentiallymalignant condition, commonly seen in people fromindian subcontinent. Patients presents with trismusdue to fibrosis of the submucosal tissue in the oralcavity. This causes blanching of the mucosa and canaffect speech by restricting the tongue and soft palatemovements2.

Hysterical trismus refers to muscular limitationthat is a consequence of psychological trauma17. Thepresentations are varied and include paralysis,blindness, anesthesia, anorexia and vomiting. Theonset of hysteria is usually before the age of 35 andoccurs mainly in women.2

A muscle in spasm is acutely shortened grosslylimited in range of motional and painful. Other termsfor this disorder include myospasm, acute trismus,charley horse or cramp. If left in a contracted state,pain decreases, but fibrous scarring and contracturewill begin developing in several weeks as a result ofdecreased function. Contracture is also referred to aschronic trismus or muscle fibrosis.17

Differential diagnosis

A systemic approach using a disciplined andorganized process is more likely to yield an accuratediagnosis. To diagnose trismus, the clinician must beable to determine the cause from variety ofpossibilities. A thorough history and clinicalexamination has to be taken and appropriateradiograph has to be taken to arrive at a definitivediagnosis.

Possible causes are summarized in table-1

Management of trismus

The success of treatment depends on therecognization of the cause and initiation ofappropriate management. To manage the initialphase of muscle spasm, the practitioner shouldprescribe the following



Heat therapy

Analgesics

Soft diet

Muscle relaxants.

Heat therapy consists of placing moist hot towelon the affected area for 15-20 minutes every hour.

Analgesics- aspirin is usually adequate in painmanagement associated with trismus in managingtrismus associated pain.

Diazepam (2.5-5mg 3 times daily) orbenzodiazepam may be prescribed for musclerelaxation.2

When the acute pain is over the patients shouldbe advised to initiate physiotherapy for opening andclosing the jaws and to perform lateral excursions ofthe mandible for 5 minutes every 3-4 hours. Sugarlesschewing gums is another means of providing lateralmovements of the TMJ. When trismus is thepresenting feature and if any infected tooth has tobe removed then closed mouth nerve block usuallyprovides relief.

If the trismus is suspected to be associated withthe infection, appropriate antibiotics should beprescribed.

In addition, trismus appliances are used inconjunction with physical therapy and are mosteffective when the condition is the result of musclefibrosis or scar tissue that is not yet matured. Trismusappliance act either externally or internally and theforces they impart and the force they impact can becontinue or intermittent, light or heavy and elastic orinelastic.1

Treatment objectives are to remove edema,soften and stretch fibrous tissue, increase the rangeof joint motion, restore circulatory efficiency, increasemuscular strength.

Seven appliances have been described inliterature.

Dynamic bite opener; this appliance wasdescribed by Drane and later by Brown. This applianceprovides continuous elastic forces to depress themandible, and the amount and direction of the forcecan be controlled.

Threaded, tapered screw: this appliance isconstructed of acrylic resin and is placed by thepatient between the posterior teeth. With gradualturns of the screw, the mandible is depressed and themaxillary and mandibular teeth are forced apart.

Screw – type mouth gag: employs a screw–typecomponent similar to the type incorporated intoorthodontic palatal expansion appliance. It providescontinuous, unilateral and inelastic force.

Fingers: patient should use the finger to depressthe mandible, stretch the muscular to the maximum,and then maintain the position for a slow count often. This exercise is repeated by the patientthroughout the day.

Tongue blades: for years, tongue blades have beenrecommended for use as a wedge or as a mouth propto sustain maximal opening. Tongue blades areeffective only in a dentate patient.

Continuous–dynamic jaw extension apparatus:this appliance consist of a contra rotating extendingscrew attached to the maxillary and mandibulararches by two resilient stainless steel wire arms thatare connected to acrylic resin splints. The apparatusdistributes the forces generated by the screw over theentire dental arch covered by the splints. The forceprovided is continuous, bilateral and elastic.1

II. Internally activated appliances: rely on thepatients depressor muscle to stretch the elevatormuscles. Since the elevator muscles can generateforces that are ten times greater than those generatedby the depressor muscles, the mechanical advantagegained through the use of depressor muscle is limited.

The amount of force delivered depends on thestrength and motivation of the patient, as do thefrequency and duration of stretching.



Examples include

Tongue blade: Tongue blade can be employed sothat force delivered is imparted by the depressormuscle alone, and thus the tongue blades are notused as a wedge. A stack of tongue blades heldtogether with adhesive tape can provide a goal orstandard for opening the masticatory muscles.

Plastic tapered cylinder: this simple, carrot-shaped appliance has proven effective and it allowsthe patient to easily identify the maximal maxillo-mandibular distance on initial stretching, by notingwhich ring on the taper is reached when both themaxillary and mandibular teeth come into contactwith the tapered cylinder. This appliance relies on thepatients depressor muscles to depress the mandible.

Modified spatula technique: Trott described, thismethod for patients with severe, non irritable but longstanding temporomandibular restriction of mouthopening. Clinically this method is also useful forpatients with disc displacement without reductionand for trismus patients16.

The principle is that the elevator muscles areinhibited by contract-relax technique includingpassive forces towards mouth opening.

Starting position and method

The patient opens the mouth as far as possible.The clinician inserts as many spatulas as can be fittedbetween the upper and lower molar teeth. The patientwill experience an increased tension in themasticatory muscles and the muscle relief becomesclearly visible.

A contract – relax technique is applied. Thepatient is asked to gradually increase the closing forcefor a few seconds.

After asking the patient to open the mouth wider,the clinician attempts to insert another spatulabetween two others. The patient usually reports anincrease of muscle tension that will decrease after afew seconds due to decreased activity in thecontractive tissue.

Afterwards, passive mobilization, contract relax,

mouth opening and inserting more spatulas isrepeated.

The mouth opening occurs in the transverse axisof the head of the mandible the distance betweenthe upper and lower molar teeth will always besmaller than between the incisors spatulas are around2mm wide, therefore only 3-7 spatulas are needed foran opening range of 20-30mm.

Recommended activities of daily living

Self regulating activities performed at home,during work significantly influence craniofacialmuscular pain in both the short and long term. Threeprinciples of mechanical influence, reflex inhibitionand facilitation of sensomotor cortex apply. They maybe performed with or without appliance.

With appliance.

Cork and spatula exercise: with a cork cut to theappropriate size, exercise may be performed in endof range aperture. For example, performing rollingmovements with the cork may have a positiveinfluence on maximum aperture. Changes of neckposition in flexion and extension may also lead topositive results.

Without appliance

Thumb depression technique is ideal. Thisexercise can be performed anywhere withoutappliance and without neck appliances.

Conclusion:

Trismus, in many ways is mostly harmless, but itcould give rise to many constraints for the patient,including social injunctions that can cause anxietyand danger. Therefore, it is important for the cliniciansto be aware of this significant condition, its causesand the treatment for trismus should primarily bedirected towards its cause and unless treatedproperly, trismus may lead to permanent impairmentof function. Treatment objectives are to removeedema, soften and stretch the fibrous tissue, increasethe range of joint motion, restore circulatoryefficiency increase the muscular strength and retainmuscular dexterity.


Table-1: Trismus (Aetiology and differential diagnosis)

Intra-articular Extra-articular

1. Ankylosis 1. Infection a. Odontogenic, Pulpal, Periodontal, Pericoronal

b. Non- Odontogenic

Tonsillitis (peritonsillar abscess)

Tetanus, meningitis

2. Arthritis 2. Trauma Brainabscess, parotidabscesssynovitis

Fracture mandible

Fracture zygomatic arch

Incorporation of foreign bodies

3. Meniscus 3. Dental treatment related Post extraction, Local anesthetic injectionpathology

4. TMD Trauma toTMJ, Myofacialmusclespasm, Internal derangement

5. Tumor Primary and secondary tumors, of epipharyngeal and parotid region

6. Drugs Phenothiazine, Succinylcholine, Tricyclic antidepressants

7. Radiotherapy & Osteoradionecrosis, Postradiation fibrosis

chemotherapy

8. Congenital Hypertrophy of coronid, Trismus pseudo-camptodactyly, syndrome

9. Miscellaneous Hysteria, Lupus erythematosis

REFERENCES

1. Lund TW, James I, Cohen. Trismus appliance and indicationsfor their use.Quientiesence int 1993; 24:275-279.

2. P.J.Dhanrajani and O. Jonadiel. Trismus: aetiology, differentialdiagnosis and treatment. Dent update 2002;29:88-94.

3. Taylor e j. ED. Dorland’s illustrated medical dictionary.27th

ed. Philadelphia: W.B. Saunders, 1988;p.1759

4. A.W. Paterson, W. Rayan, Rao-mudgonjda Carlisle: trismus oris it tetanus? A report of a case: Oral Surg Oral Med OralPathol Radiol Endol. 2006;101:437-441

5. BadriAzaz, Repheal Zelster, Dorrit.W. Nitzan, Jerusalem:Pathoses of coronoid process a cause of mouth openingrestrictions: Oral Surg Oral Med Oral Pathol 1994; 77:579-584.

6. P.V. Dijkstra, P.M. Huisman, and J.L.N. Rodenburg: Criteria fortrismus in head and neck oncology: Int J. Oral MaxillofacSurg.2006; 35:337-342.

7. Spiro. C.Karras & Larry.M.Wollford: trismus-pseudodactylysyndrome report of a case: J. Oral Maxillofac Surg:1995;53:80-84.

8. Text book of Oral & Maxillofacial infections. TopazianGoldberg Hupp.4th ed. pg 171.

9. Text book of principles and practice of medicine, Davidson,19th ed. pg 1201

10. A Todd smith and Stephenie .J. Drew: Tetanus: a Case reportand review. American Association of Oral & Maxillofacialsurgeon: 95; 278-239.

11. Krishna, D.J. Sleeman and G.H. Irvine. Trismus caused byretained foreign body in an adult: Oral Surg Oral Med OralPathol: 1992; 73:546-7.

12. Text Book of Oral and Maxillofacial disease. Crispian Scully,Stephen.R.Flint, Stephen. R. Porter, Khurshed f moos: 3rd ed.

13. Text book of Contemporary Oral and Maxillofacial Surgery:James. R. Hupp, Edward Ellis III, Myron.R. Tucker: 5th ed.

14. G. C. Stancy, And G. Hajjar: Barbed needle and inexplicableparasthesia and trismus after dental regional anesthesia. :Oral Surg Oral Med Oral Pathol 1994; 77:585-588.

15. Text book of Oral & Maxillofacial Surgery. Daniel.m.Laskin.vol-1

16. Text book of craniofacial pain: Harry .J.M. Piekartz.2007

17. Text book of TMJ and craniofacial pain- diagnosis andmanagement: Fricston’s. Millennium edition.


Trismus

Documents

Transcript of Trismus