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Trismus: Diagnosis and Management Considerations for the Speech Pathologist

Melissa Walker, M.S. CCC-SLP Katie Burns, M.S. CCC-SLP ASHA November 16, 2006

Definition
From the Greek trismos; grating, grinding Traditional Definition
Tonic contraction of the muscles of mastication Tabers Cyclopedic Medical Dictionary

Current Definition
Any restriction in mouth opening, including restriction caused by infection, trauma, surgery, or radiation

Congenital or acquired

Definition
Uniform criteria is lacking! Various criteria for presence of trismus
Mouth opening <20mm (Jen et. al., 2002) Mouth opening <40mm (Nguyen et. al., 1988) Severity Scales
Mild, >30mm; Moderate, 15-30mm; Severe, <15mm (Thomas et. al., 1998)

Generally, opening of <35-40mm a functional guideline Less than 18-20mm, oral alimentation is difficult

Incidence
Reported incidence varies greatly, anywhere from 5% to 38% Incidence increases in irradiated patients Incidence increases with head and neck cancer diagnosis
36%, Nasopharyngeal tumors 55%, Parapharyngeal tumors Parotid gland

Complications of Trismus
Poor oral hygiene Complications of conditions associated with head and neck cancer treatments Reduced access for oral examination and dental procedures Dysphagia Aspiration and related complications Malnutrition Decreased access for medical procedures, including intubation Inability to use dentures or oral/ pharyngeal prosthetics Speech deficits Airway compromise Pain

Anatomy Review

Bones: The Mandible


Only moveable bone in skull Capable of rapid movement Moves in multiple planes Function:
http://zemlin.shs.uiuc.edu/Skull/defult.htm

Mastication House teeth Modify dimensions of vocal tract

Ligaments
Lateral Ligament
Limits & guides movement Stabilizes

Sphenomandibular Ligament
Limits protrusive and mediotrusive movements Limits passive jaw opening

Stylomandibular Ligament
Relaxes with jaw opening

Courtesy N. Capra

Muscles

Bumann & Lotzmann 2002

www.nidcr.nih.gov

Muscle Movement
Elevation
Masseter Temporalis Medial Pterygoid

Protrusion
External pterygoid Internal pterygoid

Retraction
Temporalis Mylohyoid Geniohyoid Anterior digastric

Depression
Digastric Mylohyoid Geniohyoid Lateral Pterygoid

Lateral
External pterygoid Temporalis

Vascular and Neural Supply


Vascular Neural

Temporomandibular Joint
Most active joint in the body Controls mandibular movement Complex and easily damaged joint
www.Dr.Spiller.com

Easily evaluated

TMJ Movement
Translation
Upper part of the joint capsule Bilateral movement Condyle slips forward and downward over the articular eminence Suprahyoid muscles

Rotation
Lower part of the joint capsule Condyle rotates within the glenoid fossa Lateral pterygoids

Jaw Opening
Initial Phase
Condyle rotates

Intermediate Phase
Condyle translates

Terminal Phase
Condyle reaches maximum rotation and translation
Bumann & Lotzman

Jaw Closing
Initial Phase Intermediate Phase Terminal Phase

The Masticatory System is a Biologic System


(Bumann Model)

A healthy system adapts and compensates in response to influences


Malocclusion Dysfunction Parafunctional activities Trauma

Symptoms arise when the adaptive mechanisms of connective tissue and the compensatory mechanisms of muscles have been exhausted

Differential Diagnosis

Trismus: Differential Diagnosis


Infectious Neurologic Craniofacial/ Dental Oncology Tumor, Treatment Congenital/ Developmental Trauma Iatrogenic

Differential Diagnosis: Infection


Odontogenic Infection
Pupal Periodontal Most frequently third molar Secondary to injection Tetanus Tonsillitis Meningitis Encephalitis

Non-odontogenic Infection

Differential Diagnosis: Drug Toxicity


Medications capable of causing trismus
Neuroleptic agents Phenothiazines Tricyclic antidepressants Metaclopromide Halothane (general anesthetic)

Differential Diagnosis: Trauma


Most commonly due to MVA, sport accidents, assault/ battery Most common mandibular fractures
Condylar (30%) Angle (25%) Body (20%)

Trismus secondary to fracture often exacerbated by prolonged immobility Bony Ankylosis


Hematoma formation within joint space and subsequent fibrosis and calcification

Differential Diagnosis: Neurologic Etiologies


CVA and TBI
May result in severe trismus secondary to masseter spasticity EMG will show abnormal tonic hyperactivity at rest

ALS
Mazzini et. al. (1995), 9% of patients unable to undergo PEG placement secondary to severe masseter spasticity

Restivo et. al. (2005) found masseter botulinum toxin denervation effective in reducing trismus caused by neurogenic spasticity

Temperomandibular Disorder (TMJ Syndrome)


TMJ pain and reflex spasm of muscles of mastication secondary to
Excessive tension or anxiety, jaw clenching Habits, including excessive gum chewing Disc displacement Malocclusion Bruxism

Symptoms may resolve on their own

Differential Diagnosis: Arthritis


True ankylosis unlikely TMJ Arthritis
50% of those with rheumatoid arthritis have some involvement Traumatic Degenerative joint disease

Differential Diagnosis: Congenital / Developmental


Coronoid Hyperplasia
Abnormal bony elongation of normal coronoid process Treatment is surgical

Hecht Syndrome (Trismus Pseudocamptodactyly Syndrome ) Trotter's Syndrome

Differential Diagnosis: Central Nervous System


Conditions affecting the CNS may result in trismus, including
Multiple Sclerosis Meningitis Parkinsons Disease Epilepsy Bulbar paralysis Brain tumor Scleroderma

Post-Surgical Effects
Dental injections hematoma formation and infection Nerve damage Misalignment Damage to muscles Hyperextension of joint Scarring

Radiation Therapy
Trismus most likely when RT to TMJ, pterygoids, or masseter RT for tumors in the nasopharynx, base of tongue, salivary gland, maxilla/ mandible RT in excess of 6000 grays Patients being treated for recurrence Patients treated concurrently surgery and RT Chemotherapy agents may exacerbate the condition

Time of Onset
Most often a gradual onset, 8 12 weeks after completion of treatment May develop at any time following treatment Damage progresses at a rate of approximately 2.4% loss per month Without intervention, mean reduction of 32% opening at 4 years post treatment
Sciubba & Goldenberg, 2006, The Lancet

Trismus Secondary to RT
Radiation results in rapid formation of collagen
Progression often slow, may not notice until opening is <20mm Patients may not be eating and not notice slow changes Patients may think reduced jaw opening is normal Radiation results in on muscle results in fibrosis and contracture

When muscles of mastication are in the field of radiation, edema, cell destruction, and fibrosis may result

Trismus: Physiologic Effects


Joint immobilization results in
Reduced strength Fatiguability Rapid joint and muscle degeneration Inflammation, pain Flexion contractures (common in muscles acting across a damaged joint) Shortening of muscle fibers Disuse atrophy
(Booth, F., 1987, Clin Orthop Relat Res, v219)

Pathophysiology of Trismus

www.atosmedical.com

Evaluation

The Trismus Team


Patient Speech-Language Pathologist Physical Therapist Dentist/ Orthodontist Oral Hygienist Oral Surgeon Physician Radiation Oncologist Nurse Social Worker

SLP Evaluation
History and Interview Questionnaire Measure
Interincisal opening Lateral movement Protrusion Retraction

Palpation

History and Interview


Medical/ Surgical/ Trauma History Medications Quality of life measurements Pain history
Headaches Jaw Neck

Dental status and history Speech and swallowing history

Mandibular Function Impairment Questionnaire (MFIQ)


(Stegenga et. al., 1993)

11 items assessing perceived difficulties


Social activities Speaking Taking a large bite Chewing hard, soft, and resistant foods Work and/ or daily activities Drinking Laughing Kissing Yawning
(Stegenga et. al., 1993)

Measurement
Screening
Three finger test

Measurement Tools
Boley Gauge Manufacturers scales Dynasplint Therabite

www.atosmedical.com

Influencing Factors
Dental alignment Age Gender Ramus length Gonial angle

Measurement
Reliability Norms (Bumann & Lotzman, 2002)
Jaw opening Laterotrusion Protrusion Retrusion 49-56mm 10-11mm 10-11mm 0-1mm
www.atosmedical.com

Hypomobility
<40mm (Bitler et. al., 1991) <35 (Dijkstra et.al.. et.al.. (2006)

Measurement Technique
Active Opening Passive Opening Lateral Movement Retraction Protrusion

Manual Functional Analysis


Screen neck mbility At rest and with movement
Look Listen Palpate
Joint Muscles of mastication

Instrumental Evaluation
General dental exam Panorex
Confirms degenerative joint changes Quantify level of asymmetry

CT MRI Casting Axiography


Evaluates trajectory

Traditional Treatments
None/ Compensation
Diet modification

Clothespins Screws Open your mouth Manual pressure Chewing gum Tongue depressors

Dental Treatments
Elimination of behaviors that strengthen antagonists Intraoral orthotics Distraction osteogenesis

Physical Therapy
Icing/ Heat Massage Manipulation/ Traction Compression TENS EMG biofeedback Ultrasound Manual lymph drainage Exercise

Facial-Flex
Two minutes/ 2x a day Isometric/ Isokinetic Reduces scar formation and lip contraction Open to maximum comfort, close and hold for two seconds

Treatment: Passive ROM


Passive
External force is applied Joint moves Surrounding muscles inactive

Benefits
Improved circulation Reduces inflammation Elongates muscle fibers Mobilizes joint Increases flexibility of connective tissue

Buchbinder & Currivan (1991)

Passive ROM Devices


Dynasplint
Passive Low load prolongedduration stretch Spring-loaded Hands-free option Adjustable Customized mouthpiece 3x/ day for 30 minutes Rented to patient
www.dynasplint.com

Therabite
Therabite
Efficacy is documented Dental pads Passive range of motion Patient controlled 7-7-7 protocol 5-5-30 protocol

www.atosmedical.com

Therapacer CPM
Programmable 18-61 mm 100% passive Motorized Continuous 4-6 hours/day for 4-6 weeks Lateral and protrusive attachments

The Final Word

Abdel-Galil et.al.

References
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Guralnick, W. and Kaban, L. (1976). Surgical treatment of mandibular hypomobility. Journal of Oral Surgery, 34, 343-348. Jen, Y.M., Lin, Y.S., Su, W.F., Hsu, W.L., Hwang, J.M., Chao, H.L., Liu, D.W., Chen, C.M., Lin, H.Y., Wu, C.J., Chang, L.P., & Shueng, P.W. (2002). Dose escalation using twice-daily radiotherapy for nasopharyngeal carcinoma: does heavier dosing result in a happier ending? International Journal of Radiation Oncology Biology Physics, 54, 14-22. Kadyan, V., Clairmont, A.C., Engle, M., and Colachis, S.C. (2005). Severe trismus as a complication of cerebrovascular accident. Archives of Physical Medicine and Rehabilitation, 86, 594-595. Marien, M. (1997). Trismus: causes, differential diagnosis, and treatment. General Dentistry, 45(4), 350-355. Mazzini, L., Corra, T., Zaccala, M., Mora, G., Del Piano, M., & Galante, M. (1995). Percutaneous endoscopic gastrostomy and enteral nutrition in amyotrophic lateral sclerosis. Journal of Neurology, 242, 695-698. McNeely, M.L., Olivo, S.A., & Magee, D.J.. (2006). A systematic review of the effectivenesss of physical therapy interventions for temporomandibular disorders. Physical Therapy, 86(5) 710-725

Miller,V.J., Karic, V., Myers,S.L. & Exner, H.V.(2000). The temporomandibular opening index(TOI) in patients with closed lock and a control group with no Temporomandibular disorders (TMD): an initial study. Journal of Oral Rehabilitation, 27, 815-816. Moipolai, V., Karic, V. & Miller, J. (2003). The effect of the gonial angle, ramus length, age and gender on the temporomandibular opening index. Journal of Oral Rehabilitation, 30, 1195-1199. Nguyen, T.D., Panis, X., Froissart, D., Legros, M., Coninx, P., & Loirette, M. (1988). Analysis of later complications after rapid hyperfractionated radiotherapy in advanced head and neck cancers. Journal of Radiation Oncology Biology Physics, 14, 23-25. Paterson, A.W., Ryan, W., & Rao-Mudigonda, V. (2006). Trismus: or is it tetanus? A report of a case. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 101, 437-441. Restivo, D.A., Maimone, D., Patti, F., Marchese-Ragona, R., Marino, G., & Pavone, A. (2005). Trismus after stroke/TBI: Botulinum toxin benefit and use prePEG placement. Neurology, 64, 2152-2153.

Rosted, P., Jrgensen, V. (2002). Acupuncture Treatment of Pain Dysfunction Syndrome after Dental Extraction. Acupuncture in Medicine 20 (4),191-192

Simon, J. (2006). Diagnosing and treating the patient with restricted mandibular opening: a new approach. The Compendium of Continuing Education in Dentistry, 27(4), 245-251. Schwerdtfeger, K. & Jelasic, F. Trismus in Postoperative, Posttraumatic and Other Brain Stem Lesions Caused by Paradoxical Activity of Masticatory Muscles (1985). Acta Neurochirurgica, 76, 62-66. Stegenga, B., DeBont, L., Leeuw, R., & Boreing, G. (1993). Assessment of mandibular function impairment associated with temporomandibular joint osteoarthrosis and internal derangement. Journal of Orofacial Pain, 7(2), 183-195. Thomas, F., Ozanne, F., Mamelle, G., Wibault, P., & Eschwege, F. (1998). Radiotherapy alone for oropharyngeal carcinomas: the role of fraction size (2 Gy vs. 2.5 Gy) on local control and early and late complications. International Journal of Radiation Oncology Biology Physics, 15, 1097-1102. Zemlin, W. (1997). Speech and hearing science: anatomy and physiology 4th Ed. New York: Allyn & Bacon.