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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

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

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

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:

Mastication House teeth Modify dimensions of vocal tract

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


Bumann & Lotzmann 2002


Muscle Movement
Masseter Temporalis Medial Pterygoid

External pterygoid Internal pterygoid

Temporalis Mylohyoid Geniohyoid Anterior digastric

Digastric Mylohyoid Geniohyoid Lateral Pterygoid

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

Easily evaluated

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

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

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

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



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


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)

Three finger test

Measurement Tools
Boley Gauge Manufacturers scales Dynasplint Therabite


Influencing Factors
Dental alignment Age Gender Ramus length Gonial angle

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

<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

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

External force is applied Joint moves Surrounding muscles inactive

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

Buchbinder & Currivan (1991)

Passive ROM Devices

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

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


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.

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