Trismus
Trismus, commonly called lockjaw, is reduced opening of the jaws. It may be caused by spasm of the muscles of mastication or a variety of other causes. Temporary trismus occurs much more frequently than permanent trismus. It is known to interfere with eating, speaking, and maintaining proper oral hygiene. This interference, specifically with the patient's ability to swallow properly, results in an increased risk of aspiration. In some instances, trismus presents with altered facial appearance. The condition may be distressing and painful for the patient. Examination and treatments requiring access to the oral cavity can be limited, or in some cases impossible, due to the nature of the condition itself.
Definition
Trismus is defined as painful restriction in opening the mouth due to a muscle spasm, however it can also refer to limited mouth opening of any cause. Another definition of trismus is simply a limitation of movement. Historically and commonly, the term lock jaw was sometimes used as a synonym for both trismus and tetanus.Normal mouth-opening ranges from 35 to 45 mm. Males usually have slightly greater mouth opening than females.. The normal lateral movement is 8-12 mm, and normal protrusive movement is approximately 10 mm. Some have distinguished mild trismus as 20–30 mm interincisal opening, moderate as 10–20 mm and severe as less than 10 mm.
Trismus is derived from the Greek word trigmos/trismos meaning "a scream; a grinding, rasping or gnashing".
Differential diagnosis
Traditionally causes of trismus are divided into intra-articular and extra-articular.Joint problems
Ankylosis
- True bony ankylosis: can result from trauma to chin, infections and from prolonged immobilization following condylar fracture
- * Treatment – several surgical procedures are used to treat bony ankylosis, e.g.: Gap arthroplasty using interpositional materials between the cut segments.
- Fibrous ankylosis: usually results due to trauma and infection
- * Treatment – trismus appliances in conjunction with physical therapy.
Arthritis synovitis
Meniscus pathology
Extra-articular causes
Infection
- Odontogenic- Pulpal
- * Periodontal
- * Pericoronal
- Non-odontogenic- Peritonsillar abscess
- * Tetanus
- * Meningitis
- * Brain abscess
- * Parotid abscess
- The hallmark of a masticatory space infection is trismus or infection in anterior compartment of lateral pharyngeal space results in trismus. If these infections are unchecked, can spread to various facial spaces of the head and neck and lead to serious complications such as cervical cellulitis or mediastinitis.
- * Treatment: Elimination of etiologic agent along with antibiotic coverage
- Trismus or lock jaw due to masseter muscle spasm, can be a primary presenting symptom in tetanus, Caused by Clostridium tetani, where tetanospasmin is responsible for muscle spasms.
- * Prevention: primary immunization
Dental treatment
- Dental trismus is characterized by a difficulty in opening the jaw. It is a temporary condition with a duration usually not longer than two weeks. Dental trismus results from some sort of insult to the muscles of mastication, such as opening the jaw for a period of time or having a needle pass through a muscle. Typical dental anesthesia to the lower jaw often involves the needle passing into or through a muscle. In these cases it is usually the medial pterygoid or the buccinator muscles.
- Oral surgery procedures, as in the extraction of lower molar teeth, may cause trismus as a result either of inflammation to the muscles of mastication or direct trauma to the TMJ.
- Barbing of needles at the time of injection followed by tissue damage on withdrawal of the barbed needle causes post-injection persistent paresthesia, trismus and paresis.
- * Treatment: in acute phase:
- ** Heat therapy
- ** Analgesics
- ** A soft diet
- ** Muscle relaxants
- ** Note: When acute phase is over the patient should be advised to initiate physiotherapy for opening and closing mouth.
Trauma
Treatment: fracture reduction, removal of foreign bodies with antibiotic coverage
TMJ disorders
- Extra-capsular disorders – Myofascial Pain Dysfunction Syndrome
- Intra-capsular problems – Disc displacement, arthritis, fibrosis, etc.
- Acute closed locked conditions – displaced meniscus
Tumors and oral care
Drug therapy
, phenothiazines and tricyclic antidepressants causes trismus as a secondary effect. Trismus can be seen as an extra-pyramidal side-effect of metoclopromide, phenothiazines and other medications.Radiotherapy and chemotherapy
- Complications of radiotherapy:
- * Osteoradionecrosis may result in pain, trismus, suppuration and occasionally a foul smelling wound.
- * When muscles of mastication are within the field of radiation, it leads to fibrosis and result in decreased mouth opening.
- Complications of Chemotherapy:
- * Oral mucosal cells have high growth rate and are susceptible to the toxic effects of chemotherapy, which lead to stomatitis.
Congenital and developmental causes
- Hypertrophy of coronoid process causes interference of coronoid against the anteromedial margin of the zygomatic arch.
- * Treatment: Coronoidectomy
- Trismus-pseudo-camtodactyly syndrome is a rare combination of hand, foot and mouth abnormalities and trismus.
Miscellaneous disorders
- Hysteric patients: Through the mechanisms of conversion, the emotional conflict are converted into a physical symptom. E.g.: trismus
- Scleroderma: A condition marked by edema and induration of the skin involving facial region can cause trismus
Common causes
- Pericoronitis is the most common cause of trismus.
- Inflammation of muscles of mastication. It is a frequent sequel to surgical removal of mandibular third molars. The condition is usually resolved on its own in 10–14 days, during which time eating and oral hygiene are compromised. The application of heat may help, reducing the severity and duration of the condition.
- Peritonsillar abscess, a complication of tonsillitis which usually presents with sore throat, dysphagia, fever, and change in voice.
- Temporomandibular joint dysfunction.
- Trismus is often mistaken as a common temporary side effect of many stimulants of the sympathetic nervous system. Users of amphetamines as well as many other pharmacological agents commonly report bruxism as a side-effect; however, it is sometimes mis-referred to as trismus. Users' jaws do not lock, but rather the muscles become tight and the jaw clenched. It is still perfectly possible to open the mouth.
- Submucous fibrosis.
- Fracture of the zygomatic arch.
Other causes
- Acute osteomyelitis
- Ankylosis of the TMJ
- Condylar fracture or other trauma.
- Gaucher disease which is caused by deficiency of the enzyme glucocerebrosidase.
- Giant cell arteritis
- Sympathomimetic drugs, such as amphetamine, methamphetamine, MDA, MDMA, MDEA, methylphenidate, ethylphenidate, and related substances.
- Infection
- Local anesthesia
- Needle prick to the medial pterygoid muscle
- Oral submucous fibrosis.
- Radiation therapy to the head and neck.
- Tetanus, also called lockjaw for this reason
- Malignant hyperthermia
- Malaria severa
- Secondary to neuroleptic drug use
- Malignant otitis externa
- Mumps
- Peritonsillar abscess
- Retropharyngeal or parapharyngeal abscess
- Seizure
- Stroke
- Toothache
Diagnostic approach
Treatment
Treatment requires treating the underlying condition with dental treatments, speech therapy for swallowing difficulty and mouth opening restrictions, physical therapy, and passive range of motion devices. Additionally, control of symptoms with pain medications, muscle relaxants, and warm compresses may be used.Splints have been used.