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 TaberTabers s CyclopedicCyclopedic Medical DictionaryMedical DictionaryCurrent 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

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

MusclesMuscles

Bumann & Lotzmann 2002 www.nidcr.nih.gov

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 ParkinsonParkinsons 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

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 ManufacturerManufacturers scaless scales

DynasplintDynasplintTherabiteTherabite

Influencing FactorsInfluencing Factors Dental alignmentDental alignment AgeAge GenderGender RamusRamus lengthlength GonialGonial angleangle

www.atosmedical.com

MeasurementMeasurementReliabilityReliability

Norms Norms ((BumannBumann & & LotzmanLotzman, 2002), 2002) Jaw opening Jaw opening 4949--56mm56mm LaterotrusionLaterotrusion 1010--11mm11mm ProtrusionProtrusion 1010--11mm11mm RetrusionRetrusion 00--1mm1mm

HypomobilityHypomobility

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 modificationClothespinsClothespinsScrewsScrewsOpen your mouthOpen your mouthManual 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

www.atosmedical.com

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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ZemlinZemlin, W. (1997). , W. (1997). Speech and hearing science: anatomy and physiology 4th EdSpeech and hearing science: anatomy and physiology 4th Ed. . New York: New York: AllynAllyn & Bacon.& Bacon.

Trismus: Diagnosis and Management Considerations for the Speech PathologistDefinitionDefinitionIncidenceComplications of TrismusAnatomy ReviewBones: The MandibleMusclesMuscle MovementVascular and Neural SupplyTMJ MovementJaw OpeningJaw ClosingThe Masticatory System is a Biologic System(Bumann Model)Differential DiagnosisTrismus: Differential DiagnosisDifferential Diagnosis:InfectionDifferential Diagnosis:Drug ToxicityDifferential Diagnosis:TraumaDifferential Diagnosis:Neurologic EtiologiesTemperomandibular Disorder(TMJ Syndrome)Differential Diagnosis:ArthritisDifferential Diagnosis:Congenital / DevelopmentalDifferential Diagnosis:Central Nervous System Post-Surgical EffectsRadiation TherapyTime of OnsetTrismus Secondary to RTTrismus: Physiologic EffectsPathophysiology of TrismusEvaluationThe Trismus Team SLP EvaluationHistory and InterviewMandibular Function Impairment Questionnaire (MFIQ)(Stegenga et. al., 1993)MeasurementMeasurementMeasurement TechniqueManual Functional AnalysisInstrumental EvaluationTraditional TreatmentsDental TreatmentsPhysical TherapyFacial-FlexTreatment: Passive ROMPassive ROM DevicesTherabiteTherapacer CPMThe Final WordReferences