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Trismus:Trismus:Diagnosis and Management Diagnosis and Management
Considerations for the Considerations for the Speech PathologistSpeech Pathologist
Melissa Walker, M.S. CCCMelissa Walker, M.S. CCC--SLPSLPKatie Burns, M.S. CCCKatie Burns, M.S. CCC--SLPSLP
ASHAASHANovember 16, 2006November 16, 2006
DefinitionDefinition
From the Greek From the Greek trismostrismos; ; grating, grindinggrating, grindingTraditional DefinitionTraditional Definition–– ““Tonic contraction of the muscles of Tonic contraction of the muscles of
masticationmastication”” –– TaberTaber’’s s CyclopedicCyclopedic Medical DictionaryMedical Dictionary
Current DefinitionCurrent Definition–– Any restriction in mouth opening, including Any restriction in mouth opening, including
restriction caused by infection, trauma, restriction caused by infection, trauma, surgery, or radiationsurgery, or radiation
Congenital or acquiredCongenital or acquired
DefinitionDefinition
Uniform criteria is lacking!Uniform criteria is lacking!Various criteria for presence of trismusVarious criteria for presence of trismus……–– Mouth opening <20mm Mouth opening <20mm (Jen et. al., 2002)(Jen et. al., 2002)
–– Mouth opening <40mm Mouth opening <40mm (Nguyen et. al., 1988)(Nguyen et. al., 1988)
–– Severity ScalesSeverity ScalesMild, >30mm; Moderate, 15Mild, >30mm; Moderate, 15--30mm; Severe, 30mm; Severe, <15mm <15mm (Thomas et. al., 1998)(Thomas et. al., 1998)
Generally, opening of <35Generally, opening of <35--40mm a functional 40mm a functional guidelineguidelineLess than 18Less than 18--20mm, oral alimentation is difficult20mm, oral alimentation is difficult
IncidenceIncidence
Reported incidence varies greatly, Reported incidence varies greatly, anywhere from 5% to 38% anywhere from 5% to 38% Incidence increases in irradiated patientsIncidence increases in irradiated patientsIncidence increases with head and neck Incidence increases with head and neck cancer diagnosiscancer diagnosis–– 36%, Nasopharyngeal tumors36%, Nasopharyngeal tumors–– 55%, 55%, ParapharyngealParapharyngeal tumorstumors–– Parotid glandParotid gland
Complications of TrismusComplications of TrismusPoor oral hygienePoor oral hygieneComplications of Complications of conditions associated conditions associated with head and neck with head and neck cancer treatmentscancer treatmentsReduced access for Reduced access for oral examination and oral examination and dental proceduresdental proceduresDysphagiaDysphagiaAspiration and related Aspiration and related complicationscomplications
MalnutritionMalnutritionDecreased access for Decreased access for medical procedures, medical procedures, including intubationincluding intubationInability to use Inability to use dentures or oral/ dentures or oral/ pharyngeal pharyngeal prostheticsprostheticsSpeech deficitsSpeech deficitsAirway compromiseAirway compromisePainPain
Anatomy ReviewAnatomy Review
Bones: The MandibleBones: The MandibleOnly moveable bone Only moveable bone in skullin skullCapable of rapid Capable of rapid movement movement Moves in multiple Moves in multiple planesplanesFunction: Function: –– MasticationMastication–– House teethHouse teeth–– Modify dimensions of Modify dimensions of
vocal tractvocal tracthttp://zemlin.shs.uiuc.edu/Skull/defult.htm
LigamentsLigamentsLateral LigamentLateral Ligament–– Limits & guides movementLimits & guides movement–– StabilizesStabilizes
SphenomandibularSphenomandibular LigamentLigament–– Limits protrusive and Limits protrusive and
mediotrusivemediotrusive movementsmovements–– Limits passive jaw openingLimits passive jaw opening
StylomandibularStylomandibular LigamentLigament–– Relaxes with jaw openingRelaxes with jaw opening
Courtesy N. Capra
Muscle MovementMuscle MovementElevationElevation–– MasseterMasseter–– TemporalisTemporalis–– Medial PterygoidMedial Pterygoid
DepressionDepression–– DigastricDigastric–– MylohyoidMylohyoid–– GeniohyoidGeniohyoid–– Lateral PterygoidLateral Pterygoid
ProtrusionProtrusion–– External pterygoidExternal pterygoid–– Internal pterygoid Internal pterygoid
RetractionRetraction–– TemporalisTemporalis–– MylohyoidMylohyoid–– GeniohyoidGeniohyoid–– Anterior Anterior digastricdigastric
Lateral Lateral –– External pterygoidExternal pterygoid–– TemporalisTemporalis
Vascular and Neural SupplyVascular and Neural Supply
VascularVascular NeuralNeural
Temporomandibular JointTemporomandibular JointMost active joint in Most active joint in the bodythe body
Controls mandibular Controls mandibular movementmovement
Complex and easily Complex and easily damaged jointdamaged joint
Easily evaluated Easily evaluated www.Dr.Spiller.com
TMJ MovementTMJ MovementTranslationTranslation–– Upper part of the joint Upper part of the joint
capsulecapsule–– Bilateral movementBilateral movement–– Condyle slips forward Condyle slips forward
and downward over and downward over the the articulararticular eminenceeminence
–– Suprahyoid musclesSuprahyoid muscles
RotationRotation–– Lower part of the joint Lower part of the joint
capsulecapsule–– Condyle rotates within Condyle rotates within
the the glenoidglenoid fossafossa–– Lateral Lateral pterygoidspterygoids
Jaw OpeningJaw Opening
Initial PhaseInitial Phase–– Condyle rotatesCondyle rotates
Intermediate PhaseIntermediate Phase–– Condyle translatesCondyle translates
Terminal PhaseTerminal Phase–– Condyle reaches Condyle reaches
maximum rotation and maximum rotation and translationtranslation
Bumann & Lotzman
Jaw ClosingJaw Closing
Initial PhaseInitial Phase
Intermediate PhaseIntermediate Phase
Terminal PhaseTerminal Phase
The Masticatory System is a The Masticatory System is a Biologic SystemBiologic System
((BumannBumann Model)Model)
A healthy system adapts and compensates in A healthy system adapts and compensates in response to influences response to influences –– MalocclusionMalocclusion–– DysfunctionDysfunction–– Parafunctional activitiesParafunctional activities–– TraumaTrauma
Symptoms arise when the adaptive mechanisms Symptoms arise when the adaptive mechanisms of connective tissue and the compensatory of connective tissue and the compensatory mechanisms of muscles have been exhaustedmechanisms of muscles have been exhausted
Differential DiagnosisDifferential Diagnosis
Trismus: Differential DiagnosisTrismus: Differential Diagnosis
InfectiousInfectiousNeurologicNeurologicCraniofacial/ DentalCraniofacial/ DentalOncology Oncology –– Tumor, TreatmentTumor, TreatmentCongenital/ DevelopmentalCongenital/ DevelopmentalTraumaTraumaIatrogenicIatrogenic
Differential Diagnosis:Differential Diagnosis:InfectionInfection
OdontogenicOdontogenic InfectionInfection–– PupalPupal–– PeriodontalPeriodontal–– Most frequently third molarMost frequently third molar–– Secondary to injectionSecondary to injection
NonNon--odontogenicodontogenic InfectionInfection–– TetanusTetanus–– TonsillitisTonsillitis–– MeningitisMeningitis–– EncephalitisEncephalitis
Differential Diagnosis:Differential Diagnosis:Drug ToxicityDrug Toxicity
Medications capable of causing trismusMedications capable of causing trismus–– NeurolepticNeuroleptic agentsagents–– PhenothiazinesPhenothiazines–– TricyclicTricyclic antidepressantsantidepressants–– MetaclopromideMetaclopromide–– Halothane (general anesthetic)Halothane (general anesthetic)
Differential Diagnosis:Differential Diagnosis:TraumaTrauma
Most commonly due to MVA, sport accidents, Most commonly due to MVA, sport accidents, assault/ batteryassault/ batteryMost common mandibular fracturesMost common mandibular fractures–– CondylarCondylar (30%)(30%)–– Angle (25%)Angle (25%)–– Body (20%)Body (20%)
Trismus secondary to fracture often exacerbated Trismus secondary to fracture often exacerbated by prolonged immobility by prolonged immobility Bony Bony AnkylosisAnkylosis–– HematomaHematoma formation within joint space and formation within joint space and
subsequent fibrosis and calcificationsubsequent fibrosis and calcification
Differential Diagnosis:Differential Diagnosis:NeurologicNeurologic EtiologiesEtiologies
CVA and TBICVA and TBI–– May result in severe trismus secondary to May result in severe trismus secondary to massetermasseter
spasticityspasticity–– EMG will show abnormal tonic hyperactivity at restEMG will show abnormal tonic hyperactivity at rest
ALSALS–– Mazzini et. al. (1995), 9% of patients unable to Mazzini et. al. (1995), 9% of patients unable to
undergo PEG placement secondary to severe undergo PEG placement secondary to severe massetermasseter spasticityspasticity
RestivoRestivo et. al. (2005) found et. al. (2005) found massetermasseter botulinumbotulinumtoxin toxin denervationdenervation effective in reducing trismus effective in reducing trismus caused by caused by neurogenicneurogenic spasticityspasticity
TemperomandibularTemperomandibular DisorderDisorder(TMJ Syndrome)(TMJ Syndrome)
TMJ pain and reflex spasm of muscles of TMJ pain and reflex spasm of muscles of mastication secondary tomastication secondary to……–– Excessive tension or anxiety, jaw clenchingExcessive tension or anxiety, jaw clenching–– Habits, including excessive gum chewingHabits, including excessive gum chewing–– Disc displacementDisc displacement–– MalocclusionMalocclusion–– BruxismBruxismSymptoms may resolve on their own Symptoms may resolve on their own
Differential Diagnosis:Differential Diagnosis:ArthritisArthritis
True True ankylosisankylosis unlikelyunlikelyTMJ Arthritis TMJ Arthritis –– 50% of those with rheumatoid arthritis have 50% of those with rheumatoid arthritis have
some involvementsome involvement–– Traumatic Traumatic –– Degenerative joint diseaseDegenerative joint disease
Differential Diagnosis:Differential Diagnosis:Congenital / DevelopmentalCongenital / Developmental
CoronoidCoronoid Hyperplasia Hyperplasia –– Abnormal bony elongation of normal Abnormal bony elongation of normal coronoidcoronoid
processprocess–– Treatment is surgical Treatment is surgical Hecht Syndrome (Trismus Hecht Syndrome (Trismus PseudocamptodactylyPseudocamptodactyly Syndrome )Syndrome )Trotter's SyndromeTrotter's Syndrome
Differential Diagnosis:Differential Diagnosis:Central Nervous System Central Nervous System
Conditions affecting the CNS may result in Conditions affecting the CNS may result in trismus, includingtrismus, including–– Multiple SclerosisMultiple Sclerosis–– MeningitisMeningitis–– ParkinsonParkinson’’s Diseases Disease–– EpilepsyEpilepsy–– Bulbar paralysisBulbar paralysis–– Brain tumorBrain tumor–– SclerodermaScleroderma
PostPost--Surgical EffectsSurgical Effects
Dental injections Dental injections –– hematomahematoma formation formation and infectionand infectionNerve damageNerve damageMisalignmentMisalignmentDamage to musclesDamage to musclesHyperextension of jointHyperextension of jointScarringScarring
Radiation TherapyRadiation Therapy
Trismus most likely when RT to TMJ, Trismus most likely when RT to TMJ, pterygoidspterygoids, or , or massetermasseterRT for tumors in the RT for tumors in the nasopharynxnasopharynx, base of , base of tongue, salivary gland, maxilla/ mandible tongue, salivary gland, maxilla/ mandible RT in excess of 6000 grays RT in excess of 6000 grays Patients being treated for recurrencePatients being treated for recurrencePatients treated concurrently surgery and RT Patients treated concurrently surgery and RT Chemotherapy agents may exacerbate the Chemotherapy agents may exacerbate the conditioncondition
Time of OnsetTime of Onset
Most often a gradual onset, 8 Most often a gradual onset, 8 –– 12 weeks 12 weeks after completion of treatmentafter completion of treatmentMay develop at any time following May develop at any time following treatmenttreatmentDamage progresses at a rate of Damage progresses at a rate of approximately 2.4% loss per monthapproximately 2.4% loss per monthWithout intervention, mean reduction of Without intervention, mean reduction of 32% opening at 4 years post treatment32% opening at 4 years post treatment–– SciubbaSciubba & Goldenberg, 2006, The Lancet& Goldenberg, 2006, The Lancet
Trismus Secondary to RTTrismus Secondary to RTRadiation results in rapid formation of collagenRadiation results in rapid formation of collagen–– Progression often slow, may not notice until opening Progression often slow, may not notice until opening
is is <<20mm20mm–– Patients may not be eating and not notice slow Patients may not be eating and not notice slow
changeschanges–– Patients may think reduced jaw opening is normal Patients may think reduced jaw opening is normal
Radiation results in on muscle results in fibrosis and Radiation results in on muscle results in fibrosis and contracturecontracture
When muscles of mastication are in the field of When muscles of mastication are in the field of radiation, edema, cell destruction, and fibrosis radiation, edema, cell destruction, and fibrosis may resultmay result
Trismus: Physiologic EffectsTrismus: Physiologic Effects
Joint immobilization results inJoint immobilization results in……–– Reduced strengthReduced strength–– FatiguabilityFatiguability–– Rapid joint and muscle degenerationRapid joint and muscle degeneration–– Inflammation, painInflammation, pain–– Flexion contractures (common in muscles acting Flexion contractures (common in muscles acting
across a damaged joint)across a damaged joint)–– Shortening of muscle fibersShortening of muscle fibers–– Disuse atrophy Disuse atrophy
(Booth, F., 1987, (Booth, F., 1987, ClinClin OrthopOrthop RelatRelat Res, Res, v219) v219)
PathophysiologyPathophysiology of Trismusof Trismus
www.atosmedical.com
EvaluationEvaluation
The Trismus Team The Trismus Team Patient Patient SpeechSpeech--Language PathologistLanguage PathologistPhysical TherapistPhysical TherapistDentist/ OrthodontistDentist/ OrthodontistOral HygienistOral HygienistOral SurgeonOral SurgeonPhysicianPhysicianRadiation OncologistRadiation OncologistNurseNurseSocial WorkerSocial Worker
SLP EvaluationSLP Evaluation
History and InterviewHistory and InterviewQuestionnaireQuestionnaireMeasure Measure –– Interincisal openingInterincisal opening–– Lateral movementLateral movement–– ProtrusionProtrusion–– RetractionRetraction
PalpationPalpation
History and InterviewHistory and Interview
Medical/ Surgical/ Trauma HistoryMedical/ Surgical/ Trauma HistoryMedicationsMedicationsQuality of life measurementsQuality of life measurementsPain historyPain history–– HeadachesHeadaches–– JawJaw–– NeckNeck
Dental status and historyDental status and historySpeech and swallowing historySpeech and swallowing history
Mandibular Function Impairment Mandibular Function Impairment Questionnaire (MFIQ)Questionnaire (MFIQ)
(Stegenga et. al., 1993)(Stegenga et. al., 1993)
11 items assessing 11 items assessing perceived difficultiesperceived difficulties–– Social activitiesSocial activities–– SpeakingSpeaking–– Taking a large biteTaking a large bite–– Chewing hard, soft, and Chewing hard, soft, and
resistant foodsresistant foods–– Work and/ or daily activitiesWork and/ or daily activities–– DrinkingDrinking–– LaughingLaughing–– KissingKissing–– YawningYawning
(Stegenga et. al., 1993) (Stegenga et. al., 1993)
MeasurementMeasurementScreening Screening –– ““Three finger testThree finger test””
Measurement ToolsMeasurement Tools–– BoleyBoley GaugeGauge–– ManufacturerManufacturer’’s scaless scales
DynasplintDynasplintTherabiteTherabite
Influencing FactorsInfluencing Factors–– Dental alignmentDental alignment–– AgeAge–– GenderGender–– RamusRamus lengthlength–– GonialGonial angleangle
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MeasurementMeasurementReliabilityReliability
Norms Norms ((BumannBumann & & LotzmanLotzman, 2002), 2002)
–– Jaw opening Jaw opening 4949--56mm56mm–– LaterotrusionLaterotrusion 1010--11mm11mm–– ProtrusionProtrusion 1010--11mm11mm–– RetrusionRetrusion 00--1mm1mm
HypomobilityHypomobility–– <40mm <40mm ((BitlerBitler et. al., 1991)et. al., 1991)
–– <35 <35 ((DijkstraDijkstra et.alet.al.. (2006.. (2006))
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Measurement TechniqueMeasurement TechniqueActive OpeningActive Opening
Passive OpeningPassive Opening
Lateral MovementLateral Movement
RetractionRetraction
ProtrusionProtrusion
Manual Functional AnalysisManual Functional Analysis
Screen neck Screen neck mbilitymbility
At rest and with At rest and with movementmovement–– LookLook–– ListenListen–– PalpatePalpate
JointJointMuscles of masticationMuscles of mastication
Instrumental EvaluationInstrumental EvaluationGeneral dental examGeneral dental examPanorexPanorex–– Confirms degenerative joint Confirms degenerative joint
changeschanges–– Quantify level of Quantify level of
asymmetryasymmetry
CTCTMRIMRICastingCastingAxiographyAxiography–– Evaluates trajectoryEvaluates trajectory
Traditional TreatmentsTraditional Treatments
None/ CompensationNone/ Compensation–– Diet modificationDiet modificationClothespinsClothespinsScrewsScrews““Open your mouthOpen your mouth””Manual pressureManual pressureChewing gumChewing gumTongue depressorsTongue depressors
Dental TreatmentsDental Treatments
Elimination of Elimination of behaviors that behaviors that strengthen strengthen antagonistsantagonists
Intraoral Intraoral orthoticsorthotics
Distraction Distraction osteogenesisosteogenesis
Physical TherapyPhysical TherapyIcing/ HeatIcing/ HeatMassageMassageManipulation/ TractionManipulation/ TractionCompressionCompressionTENSTENSEMG biofeedback EMG biofeedback UltrasoundUltrasoundManual lymph drainageManual lymph drainageExerciseExercise
FacialFacial--FlexFlexTwo minutes/ 2x a dayTwo minutes/ 2x a day
Isometric/ Isometric/ IsokineticIsokinetic
Reduces scar formation Reduces scar formation and lip contractionand lip contraction
Open to maximum Open to maximum comfort, close and hold comfort, close and hold for two secondsfor two seconds
Treatment: Passive ROMTreatment: Passive ROMPassivePassive–– External force is appliedExternal force is applied–– Joint movesJoint moves–– Surrounding muscles inactiveSurrounding muscles inactive
BenefitsBenefits–– Improved circulationImproved circulation–– Reduces inflammationReduces inflammation–– Elongates muscle fibersElongates muscle fibers–– Mobilizes jointMobilizes joint–– Increases flexibility of connective tissueIncreases flexibility of connective tissue
BuchbinderBuchbinder & & CurrivanCurrivan (1991)(1991)
Passive ROM DevicesPassive ROM DevicesDynasplintDynasplint–– Passive Passive –– Low load prolongedLow load prolonged--
duration stretchduration stretch–– SpringSpring--loadedloaded–– HandsHands--free optionfree option–– AdjustableAdjustable–– Customized Customized
mouthpiecemouthpiece–– 3x/ day for 30 minutes3x/ day for 30 minutes–– Rented to patientRented to patient
www.dynasplint.com
TherabiteTherabite
TherabiteTherabite–– Efficacy is Efficacy is
documenteddocumented–– Dental padsDental pads–– Passive range of Passive range of
motionmotion–– Patient controlledPatient controlled–– 77--77--7 protocol7 protocol–– 55--55--30 protocol30 protocol
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TherapacerTherapacer CPMCPM
Programmable Programmable 1818--61 mm61 mm100% passive100% passiveMotorizedMotorizedContinuousContinuous44--6 hours/day for 46 hours/day for 4--6 6 weeksweeksLateral and protrusive Lateral and protrusive attachmentsattachments
The Final WordThe Final Word
Abdel-Galil et.al.
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