sign in sign up
<<
Home , Oral submucous fibrosis, Trismus

Review Article

Trismus: A review N. Monisha1, Dhanraj Ganapathy2, P. Sherlyn Sheeba3, Naveen Kanniappan1

ABSTRACT

One of the most common problems encountered by dental practitioners is restricted mouth opening, otherwise called . The word trismus is derived from the Greek word “Trismos” meaning grinding/rasping. Trismus means a limitation of mouth opening due to reduced mobility of the . A number of potential factors may cause trismus and its treatment will depend on the cause. The causes of this problem are usually of infectious, traumatic, pathological origin, or a combination of these. Trismus is not considered as a disease or injury; it is, in fact, a result or can also be said as concluding sequelae which follows the active healing stages. A thorough knowledge of this decreased mobility is very much essential to deliver proper treatment and also post-operative care to the patients to avoid permanent disability in function. The primary causes of this condition and the various possible treatments available have been discussed in this review. KEY WORDS: Dynamic bite appliance, Mouth opening, , Physiotherapy, Succinylcholine, Temperomandibular joint, Trismus

INTRODUCTION ETIOLOGY Trismus is defined as the motor disturbance of the Causes of trismus can be classified as follows: trigeminal nerve, especially the of the muscles 1. Infections of mastication with difficulty in opening the mouth • Pulpal (lockjaw), a characteristic early symptom of .[1] • Periodontal The restriction in mouth opening can have serious • Pericoronal health implications, which can dramatically affect • /mediastinitis the quality of life. Impaired mastication can lead to • reduced nutrition, speech difficulties, diminished vocal • Tetanus. quality, and compromised . An increased 2. Trauma risk of aspiration is also observed.[2] The causes of • Surgical extraction of mandibular third molars trismus range from simple to non-progressive to those • Post-anesthetic injections that are potentially life-threatening.[3] The treatment of • Inferior alveolar nerve block this condition may be relatively simple or complicated • Posterior superior alveolar block [4] depending on the etiological factors. • Fractures. 3. Temperomandibular joint disorders MOUTH OPENING • Extracapsular • Intracapsular. The normal range of mouth opening is usually 4. Tumors and oral malignancies 40–60 mm.[5] Two-fingers to three-fingers breadth is 5. Drug therapy the usual width of opening.[6] The vertical mandibular 6. Psychogenic causes.[1,8] opening is said to be influenced by the gender factor, with males having a larger mouth opening.[7] INFECTION/INFLAMMATION

Access this article online Trismus is the most common symptom of masticatory space infection. The infections could be of odontogenic Website: jprsolutions.info ISSN: 0974-6943 or non-odontogenic in nature.

1Undergraduate Student, Saveetha Dental College and Hospitals, Saveetha University, Chennai, Tamil Nadu, India, 2Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 3Department of General Anatomy, Saveetha Dental College, Saveeths University, Chennai, Tamil Nadu, India

*Corresponding author: P. Sherlyn Sheeba, No. 2, 6th Street, Sivasakthi Nagar, Korattur, Chennai - 80, Tamil Nadu, India. Phone: +91 9585710191. E-mail: [email protected]

Received on: 19-09-2017; Revised on: 15-10-2017; Accepted on: 22-11-2017

130 Journal of Pharmacy Research | Vol 12 • Issue 1 • 2018 N. Monisha, et al.

Odontogenic Infections Causing Trismus Include TEMPEROMANDIBULAR JOINT Pulpal infections - is commonly caused by DISORDERS dental caries that affect the enamel and dentine of the teeth to reach the pulp. Trauma/repeated thermal They can be classified as: injuries during dental treatment are also responsible Extra-articular: in causing pulpitis. In these conditions, excessive • Infection/inflammation, e.g., , pressure build up occurs within the pulpal cavity causing dental pain. Pain can also be caused due to • Hematoma increased pressure affecting adjacent tissues and this, • Trauma (post-operative edema, facial trauma) in turn, leads to irritation of the trigeminal nerve, • Myofascial pain dysfunction syndrome which causes masseteric muscle spasm causing • Tetany [9] trismus. • Tetanus • Systemic sclerosis and oral submucous Periodontal infections: The tissues that surround and • Neoplasm support the teeth are termed as the periodontium. • Fibrosis due to burns and radiation. Irritation of the free nerve endings due to periodontal Intra-articular: infections causes spasm of the masseter. This causes • Infective arthritis irritation of the trigeminal nerve which contributes to • Osteoarthritis trismus. • Rheumatoid arthritis Pericoronal infections - pericoronitis involves • of TMJ inflammation of soft tissues surrounding the crown of • Dislocation a partially erupted tooth. These infections also cause • Intracapsular condylar fractures and injections.[15] reflex irritation of trigeminal nerve throwing masseter muscle into a spasm causing trismus.[10] TUMORS AND ORAL

Cellulitis: Untreated dental infections can cause spread MALIGNANCIES into various neck spaces causing cervical cellulitis/ The patients with a primary or metastatic neoplasm, mediastinitis. in the epipharynx, , , or TMJ can cause trismus. A thorough clinical and radiographic Non-odontogenic Infections Causing Trismus examination must be performed to rule out Include any malignancy.[16] , a These include , tetanus, meningitis, parotid , commonly seen in Indians [11] , and brain abscess. is a juxta-epithelial inflammatory reaction causing progressive fibrosis of the submucosal tissue in the TRAUMA oral cavity. This causes blanching of the mucosa and [17] Fractures involving the mandible, zygomatic arch, affects mouth opening causing trismus. and zygoma may cause restriction of mouth opening. These cause disturbances in the movement of the DRUGS temperomandibular joint causing trismus. The type Some drugs such as succinylcholine, phenothiazines, of injury and the direction of force of trauma also and tricyclic antidepressants can cause trismus as an contribute to the mobility of the jaws. The accidental extrapyramidal side effect.[18] incorporation of foreign bodies due to external trauma also causes trismus.[12] MISCELLANEOUS CAUSES TRISMUS DUE TO DENTAL Psychogenic. TREATMENT erythematosus.[19] Surgical, dental procedures may lead to limitations in mouth opening.[13] The inflammation involving the MANAGEMENT OF TRISMUS during dental extractions and also direct trauma to the Treatment of trismus depends on the factor causing it. can cause trismus.[11] Another cause of trismus is the If trismus results due to fibrosis of tissue or immature limited mouth opening that occurs 2–5 days after the scar formation, physiotherapy and appliances can administration of local anesthesia. This is due to the be of help. If trismus results due to intracapsular wrong positioning of the needle while giving a nerve pathologies, causing dense fibrous tissue formation, it block.[14] may require surgical management.[20]

Journal of Pharmacy Research | Vol 12 • Issue 1 • 2018 131 N. Monisha, et al.

Conservative medical management for acute trismus: the masticatory muscles for about 10 min before using 1. Heat - Placement of moist hot towels on the affected the bite opener. Analgesic and anti-inflammatory area for 10–20 min/h. drugs may be of use in these patients. 2. Analgesic therapy - Aspirin is the most common. When discomfort is extensive, narcotic analgesic The bite opener should be kept in closed position (zero may be indicated. position). The patients’ mouth is opened as much as 3. Soft diet. possible and the mouthpiece of the bite opener should 4. Muscle relaxants - In extensive masticatory muscle be inserted in such a way that the teeth and rest spasm, benzodiazepines 2.5–5 mg 3 times a day may comfortably against the bite opener. The handle of the be indicated.[8] bite opener is turned slowly till the sensation of gentle stretch of mouth opening is felt. The increase in mouth Physiotherapy can be started after cessation of the opening should be performed only in a stepwise acute phase. pattern. This system should not be used for more than 5 min per sitting to start with. This is then increased by Physiotherapy: Exercises which relax the masticatory 2 min per sitting gradually till the maximum limit of muscles and strengthen them. Mouth opening can 30 min is reached. After each session, ice packs need be achieved in a gradual manner by devices such as to be applied to the muscles of mastication.[22] the wooden top or bunch of ice cream sticks inserted between the teeth to keep the mouth open. Threaded tapered screw This appliance made of acrylic resin resembles the toy The steps in physiotherapy include: top. This device should be placed between the posterior 1. Heat - This is used as an alternative to exercises teeth of the patient and should be gradually turned involving the masticatory muscles. The increase in such that the maxillary and mandibular teeth spread collagen tissue extensibility decreased stiffness of joint apart.[13] The force provided is not elastic in nature and and the science of pain and muscle spasm is achieved can be controlled by the patient. This device can be by heat. It also increases the flow of blood, thereby used only in dentulous patients. Prolonged usage of reducing the edema of the muscles of mastication. the device results in mobility of anterior teeth due to 2. Massage - This causes an increase of blood flow the extensive force generated.[23] and aids in relaxing of the masticatory muscles. 3. Exercise - This causes breakage of the fibrosis of Screw type mouth gag the muscles of mastication. Nakajima was the first person to describe this device. The goals of physiotherapy include: Unilateral continuous and inelastic force are provided 1. Edema reduction. by the screw component of this device. The dental 2. Softening and stretching of scar tissue. practitioner can adjust the force generated. This [24] 3. Increase in the range of joint movement. appliance cannot be used in edentulous patients. 4. Increase in the strength of masticatory muscles.[21] Fingers Under general anesthesia, forced opening of the Rouse was the first person to describe this method. can be indicated when all other modalities of treatment The patient depresses the mandible with his fingers. are exhausted.[22] Manipulation under anesthesia can This exercise should be repeated by the patient many cause instability of temporomandibular joint. times a day. The most important aspect of this method is the compliance of the patient.[25] TRISMUS APPLIANCES Use of tongue blades They are used in combination with physical therapy. Tongue blade can also be useful in mouth opening. These devices cause forcible stretching of the elevator Stack of wooden tongue blades can be used to keep muscles, externally. This is usually achieved by the mouth open. depression of mandible. Devices that are internally activated stretches the affected elevator muscles and Surgical management also other tissue that limits mandibular opening. Surgical management in the case of trismus is rare. If trismus is caused due to fibrotic band formation in the External Appliances submucosa, lysis of these bands is done using laser. Dynamic bite opener Myotomy of the masseteric muscle helps in certain cases. Drane was the first person to describe this appliance. Elastic force is provided in a continuous manner by CONCLUSION this device which causes depression of the mandible. The amount and direction of the force provided can be Trismus is a condition of rich clinical importance and regulated. It is always advisable to apply moist heat to helps in the provision of accurate diagnosis. The success

132 Journal of Pharmacy Research | Vol 12 • Issue 1 • 2018 N. Monisha, et al. in treating this condition depends on prompt identification retained foreign body in an adult. Oral Surg Oral Med Oral of the underlying cause and proper management of the Pathol 1992;73:546-47. patient to avoid its recurrence and also in prevention of 13. Kelly JF, Connole PW, Hiatt WR, Mainous EG, Messer EJ. Management of War Injuries to the Jaws and Related Structures. causing permanent damage of function. Despite reviews Bethesda MD: Naval Medical Research Inst; 1978. and research in literature, the knowledge of this medical 14. Stacy GC, Hajjar G. Barbed needle and inexplicable problem remains inadequate. Hence, more research into paresthesias and trismus after dental regional anesthesia. Oral the insight of trismus is needed in the near future. Surg Oral Med Oral Pathol 1994;77:585-88. 15. Trumpy IG, Lyberg T. Temporomandibular joint dysfunction and facial pain caused by neoplasms. Oral Surg Oral Med Oral REFERENCES Pathol 1993;76:149-52. 16. Hauser MS, Boraski J. Oropharyngeal carcinoma presenting 1. Marattukalam KT, Nayak K. Mouth openers-an innovative as an odontogenic infection with trismus. Oral Surg Oral Med approach to treat trimus. Guident 2015;8:64-67. Oral Pathol 1986;61:330-32. 2. Dhanrajani PJ, Jonaidel O. Trismus: Aetiology, differential 17. Ichimura K, Tanaka T. Trismus in patients with malignant tumours diagnosis and treatment. Dent Update 2002;29:88-92, 94. in the head and neck. J Laryngol Otol 1993;107:1017-20. 3. Luyk NH, Steinberg B. Aetiology and diagnosis of clinically 18. Cunningham PA, Kendrick RW. Trismus as a result of evident jaw trismus. Aust Dent J 1990;35:523-29. metoclopramide therapy. J Ir Dent Assoc 1988;34:128. 4. Marien M Jr. Trismus: Causes, differential diagnosis, and 19. Bade DM, Lovasko JH, Montana J, Waide FL. Acute closed treatment. Gen Dent 1997;45:350-55. lock in a patient with : Case review. J 5. Mezitis M, Rallis G, Zachariades N. The normal range of Craniomandib Disord facial Oral Pain 1992;6:208-12. mouth opening. J Oral Maxillofac Surg 1989;47:1028-29. 20. Lai DR, Chen HR, Lin LM, Huang YL, Tsai CC, Lai DR. 6. Nelson SJ, Nowlin TP, Boeselt B. Consideration of linear and Clinical evaluation of different treatment methods for oral angular values of maximum mandibular opening. Compendium 1992;13:362, 364, 366 passim. submucous fibrosis. A 10 year experience with 150 cases. 7. Dworkin SF, Huggins KH, LeResche L, Von Korff M, Journal of Oral Pathology and Medicine 1995;24(9):402-6. Howard J, Truelove E, et al. Epidemiology of signs and 21. O’brien PJ, Gropper PT, Tredwell SJ, Hall JG. Orthopaedic symptoms in temporomandibular disorders: Clinical signs in aspects of the trismus Pseudocamptodactyly syndrome. J cases and controls. J Am Dent Assoc 1990;120:273-81. Pediatr Orthop 1984;4:469-71. 8. Tveteras K, Kristensen S. The aetiology and pathogenisis of 22. Dijkstra PU, Kropmans TJ, Tamminga RY. Modified use of a trismus. Clin Otolaryngol 1986;11:3S3-fí7. dynamic bite opener-treatment and prevention of trismus in a 9. Douglass AB, Douglass JM. Common dental emergencies. Am child with head and neck cancer: A case report. CRANIO® Fam Physician 2003;67:511-16. 1992;10:327-29. 10. Bakland LK, Christiansen EL, Strutz JM. Frequency of dental 23. Lund TW, Cohen JI. Trismus appliances and indications for and traumatic events in the etiology of temporomandibular use. Quintessence Int 1993;24:275-79. disorders. Endod Dent Traumatol 1988;4:182-85. 24. Nakajima T, Sasakura H, Kato N. Screw-type mouth gag for 11. Berge TI, Bøe OE. Predictor evaluation of postoperative prevention and treatment of postoperative jaw limitation by morbidity after surgical removal of mandibular third molars. fibrous tissue. J Oral Surg Am Dent Assoc 1965 1980;38:46-50. Acta Odontol Scand 1994;52:162-69. 25. Rouse PB. The role of physical therapists in support of 12. Krishnan A, Sleeman DJ, Irvine GH. Trismus caused by a maxillofacial patients. J Prosthet Dent 1970;24:193-97.

Journal of Pharmacy Research | Vol 12 • Issue 1 • 2018 133