I. Definition of trismus: Symptoms and Norms a. Dorland's ...

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I. Definition of trismus: Symptoms and Norms a. Dorland's ...

  1. 1. Trismus:Trismus: Diagnosis and ManagementDiagnosis and Management Considerations for theConsiderations for the Speech PathologistSpeech Pathologist Melissa Walker, M.S. CCCMelissa Walker, M.S. CCC--SLPSLP Katie Burns, M.S. CCCKatie Burns, M.S. CCC--SLPSLP ASHAASHA November 16, 2006November 16, 2006
  2. 2. DefinitionDefinition From the GreekFrom the Greek trismostrismos;; grating, grindinggrating, grinding Traditional DefinitionTraditional Definition –– ““Tonic contraction of the muscles ofTonic contraction of the muscles of masticationmastication”” –– TaberTaber’’ss CyclopedicCyclopedic Medical DictionaryMedical Dictionary Current DefinitionCurrent Definition –– Any restriction in mouth opening, includingAny 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
  3. 3. DefinitionDefinition Uniform criteria is lacking!Uniform criteria is lacking! Various criteria for presence of trismusVarious criteria for presence of trismus…… –– Mouth opening <20mmMouth opening <20mm (Jen et. al., 2002)(Jen et. al., 2002) –– Mouth opening <40mmMouth opening <40mm (Nguyen et. al., 1988)(Nguyen et. al., 1988) –– Severity ScalesSeverity Scales Mild, >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 functional40mm a functional guidelineguideline Less than 18Less than 18--20mm, oral alimentation is difficult20mm, oral alimentation is difficult
  4. 4. 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 patients Incidence increases with head and neckIncidence increases with head and neck cancer diagnosiscancer diagnosis –– 36%, Nasopharyngeal tumors36%, Nasopharyngeal tumors –– 55%,55%, ParapharyngealParapharyngeal tumorstumors –– Parotid glandParotid gland
  5. 5. Complications of TrismusComplications of Trismus Poor oral hygienePoor oral hygiene Complications ofComplications of conditions associatedconditions associated with head and neckwith head and neck cancer treatmentscancer treatments Reduced access forReduced access for oral examination andoral examination and dental proceduresdental procedures DysphagiaDysphagia Aspiration and relatedAspiration and related complicationscomplications MalnutritionMalnutrition Decreased access forDecreased access for medical procedures,medical procedures, including intubationincluding intubation Inability to useInability to use dentures or oral/dentures or oral/ pharyngealpharyngeal prostheticsprosthetics Speech deficitsSpeech deficits Airway compromiseAirway compromise PainPain
  6. 6. Anatomy ReviewAnatomy Review
  7. 7. Bones: The MandibleBones: The Mandible Only moveable boneOnly moveable bone in skullin skull Capable of rapidCapable of rapid movementmovement Moves in multipleMoves in multiple planesplanes Function:Function: –– MasticationMastication –– House teethHouse teeth –– Modify dimensions ofModify dimensions of vocal tractvocal tract http://zemlin.shs.uiuc.edu/Skull/defult.htm
  8. 8. LigamentsLigaments Lateral LigamentLateral Ligament –– Limits & guides movementLimits & guides movement –– StabilizesStabilizes SphenomandibularSphenomandibular LigamentLigament –– Limits protrusive andLimits protrusive and mediotrusivemediotrusive movementsmovements –– Limits passive jaw openingLimits passive jaw opening StylomandibularStylomandibular LigamentLigament –– Relaxes with jaw openingRelaxes with jaw opening Courtesy N. Capra
  9. 9. MusclesMuscles Bumann & Lotzmann 2002 www.nidcr.nih.gov
  10. 10. Muscle MovementMuscle Movement ElevationElevation –– MasseterMasseter –– TemporalisTemporalis –– Medial PterygoidMedial Pterygoid DepressionDepression –– DigastricDigastric –– MylohyoidMylohyoid –– GeniohyoidGeniohyoid –– Lateral PterygoidLateral Pterygoid ProtrusionProtrusion –– External pterygoidExternal pterygoid –– Internal pterygoidInternal pterygoid RetractionRetraction –– TemporalisTemporalis –– MylohyoidMylohyoid –– GeniohyoidGeniohyoid –– AnteriorAnterior digastricdigastric LateralLateral –– External pterygoidExternal pterygoid –– TemporalisTemporalis
  11. 11. Vascular and Neural SupplyVascular and Neural Supply VascularVascular NeuralNeural
  12. 12. Temporomandibular JointTemporomandibular Joint Most active joint inMost active joint in the bodythe body Controls mandibularControls mandibular movementmovement Complex and easilyComplex and easily damaged jointdamaged joint Easily evaluatedEasily evaluated www.Dr.Spiller.com
  13. 13. TMJ MovementTMJ Movement TranslationTranslation –– Upper part of the jointUpper part of the joint capsulecapsule –– Bilateral movementBilateral movement –– Condyle slips forwardCondyle slips forward and downward overand downward over thethe articulararticular eminenceeminence –– Suprahyoid musclesSuprahyoid muscles RotationRotation –– Lower part of the jointLower part of the joint capsulecapsule –– Condyle rotates withinCondyle rotates within thethe glenoidglenoid fossafossa –– LateralLateral pterygoidspterygoids
  14. 14. Jaw OpeningJaw Opening Initial PhaseInitial Phase –– Condyle rotatesCondyle rotates Intermediate PhaseIntermediate Phase –– Condyle translatesCondyle translates Terminal PhaseTerminal Phase –– Condyle reachesCondyle reaches maximum rotation andmaximum rotation and translationtranslation Bumann & Lotzman
  15. 15. Jaw ClosingJaw Closing Initial PhaseInitial Phase Intermediate PhaseIntermediate Phase Terminal PhaseTerminal Phase
  16. 16. The Masticatory System is aThe Masticatory System is a Biologic SystemBiologic System ((BumannBumann Model)Model) A healthy system adapts and compensates inA healthy system adapts and compensates in response to influencesresponse to influences –– MalocclusionMalocclusion –– DysfunctionDysfunction –– Parafunctional activitiesParafunctional activities –– TraumaTrauma Symptoms arise when the adaptive mechanismsSymptoms arise when the adaptive mechanisms of connective tissue and the compensatoryof connective tissue and the compensatory mechanisms of muscles have been exhaustedmechanisms of muscles have been exhausted
  17. 17. Differential DiagnosisDifferential Diagnosis
  18. 18. Trismus: Differential DiagnosisTrismus: Differential Diagnosis InfectiousInfectious NeurologicNeurologic Craniofacial/ DentalCraniofacial/ Dental OncologyOncology –– Tumor, TreatmentTumor, Treatment Congenital/ DevelopmentalCongenital/ Developmental TraumaTrauma IatrogenicIatrogenic
  19. 19. 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
  20. 20. 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)
  21. 21. Differential Diagnosis:Differential Diagnosis: TraumaTrauma Most commonly due to MVA, sport accidents,Most commonly due to MVA, sport accidents, assault/ batteryassault/ battery Most common mandibular fracturesMost common mandibular fractures –– CondylarCondylar (30%)(30%) –– Angle (25%)Angle (25%) –– Body (20%)Body (20%) Trismus secondary to fracture often exacerbatedTrismus secondary to fracture often exacerbated by prolonged immobilityby prolonged immobility BonyBony AnkylosisAnkylosis –– HematomaHematoma formation within joint space andformation within joint space and subsequent fibrosis and calcificationsubsequent fibrosis and calcification
  22. 22. Differential Diagnosis:Differential Diagnosis: NeurologicNeurologic EtiologiesEtiologies CVA and TBICVA and TBI –– May result in severe trismus secondary toMay 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 toMazzini et. al. (1995), 9% of patients unable to undergo PEG placement secondary to severeundergo PEG placement secondary to severe massetermasseter spasticityspasticity RestivoRestivo et. al. (2005) foundet. al. (2005) found massetermasseter botulinumbotulinum toxintoxin denervationdenervation effective in reducing trismuseffective in reducing trismus caused bycaused by neurogenicneurogenic spasticityspasticity
  23. 23. TemperomandibularTemperomandibular DisorderDisorder (TMJ Syndrome)(TMJ Syndrome) TMJ pain and reflex spasm of muscles ofTMJ 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 –– BruxismBruxism Symptoms may resolve on their ownSymptoms may resolve on their own
  24. 24. Differential Diagnosis:Differential Diagnosis: ArthritisArthritis TrueTrue ankylosisankylosis unlikelyunlikely TMJ ArthritisTMJ Arthritis –– 50% of those with rheumatoid arthritis have50% of those with rheumatoid arthritis have some involvementsome involvement –– TraumaticTraumatic –– Degenerative joint diseaseDegenerative joint disease
  25. 25. Differential Diagnosis:Differential Diagnosis: Congenital / DevelopmentalCongenital / Developmental CoronoidCoronoid HyperplasiaHyperplasia –– Abnormal bony elongation of normalAbnormal bony elongation of normal coronoidcoronoid processprocess –– Treatment is surgicalTreatment is surgical Hecht Syndrome (TrismusHecht Syndrome (Trismus PseudocamptodactylyPseudocamptodactyly Syndrome )Syndrome ) Trotter's SyndromeTrotter's Syndrome
  26. 26. Differential Diagnosis:Differential Diagnosis: Central Nervous SystemCentral Nervous System Conditions affecting the CNS may result inConditions 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
  27. 27. PostPost--Surgical EffectsSurgical Effects Dental injectionsDental injections –– hematomahematoma formationformation and infectionand infection Nerve damageNerve damage MisalignmentMisalignment Damage to musclesDamage to muscles Hyperextension of jointHyperextension of joint ScarringScarring
  28. 28. Radiation TherapyRadiation Therapy Trismus most likely when RT to TMJ,Trismus most likely when RT to TMJ, pterygoidspterygoids, or, or massetermasseter RT for tumors in theRT for tumors in the nasopharynxnasopharynx, base of, base of tongue, salivary gland, maxilla/ mandibletongue, salivary gland, maxilla/ mandible RT in excess of 6000 graysRT in excess of 6000 grays Patients being treated for recurrencePatients being treated for recurrence Patients treated concurrently surgery and RTPatients treated concurrently surgery and RT Chemotherapy agents may exacerbate theChemotherapy agents may exacerbate the conditioncondition
  29. 29. Time of OnsetTime of Onset Most often a gradual onset, 8Most often a gradual onset, 8 –– 12 weeks12 weeks after completion of treatmentafter completion of treatment May develop at any time followingMay develop at any time following treatmenttreatment Damage progresses at a rate ofDamage progresses at a rate of approximately 2.4% loss per monthapproximately 2.4% loss per month Without intervention, mean reduction ofWithout 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
  30. 30. Trismus Secondary to RTTrismus Secondary to RT Radiation results in rapid formation of collagenRadiation results in rapid formation of collagen –– Progression often slow, may not notice until openingProgression often slow, may not notice until opening isis <<20mm20mm –– Patients may not be eating and not notice slowPatients may not be eating and not notice slow changeschanges –– Patients may think reduced jaw opening is normalPatients may think reduced jaw opening is normal Radiation results in on muscle results in fibrosis andRadiation results in on muscle results in fibrosis and contracturecontracture When muscles of mastication are in the field ofWhen muscles of mastication are in the field of radiation, edema, cell destruction, and fibrosisradiation, edema, cell destruction, and fibrosis may resultmay result
  31. 31. 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 actingFlexion contractures (common in muscles acting across a damaged joint)across a damaged joint) –– Shortening of muscle fibersShortening of muscle fibers –– Disuse atrophyDisuse atrophy (Booth, F., 1987,(Booth, F., 1987, ClinClin OrthopOrthop RelatRelat Res,Res, v219)v219)
  32. 32. PathophysiologyPathophysiology of Trismusof Trismus www.atosmedical.com
  33. 33. EvaluationEvaluation
  34. 34. The Trismus TeamThe Trismus Team PatientPatient SpeechSpeech--Language PathologistLanguage Pathologist Physical TherapistPhysical Therapist Dentist/ OrthodontistDentist/ Orthodontist Oral HygienistOral Hygienist Oral SurgeonOral Surgeon PhysicianPhysician Radiation OncologistRadiation Oncologist NurseNurse Social WorkerSocial Worker
  35. 35. SLP EvaluationSLP Evaluation History and InterviewHistory and Interview QuestionnaireQuestionnaire MeasureMeasure –– Interincisal openingInterincisal opening –– Lateral movementLateral movement –– ProtrusionProtrusion –– RetractionRetraction PalpationPalpation
  36. 36. History and InterviewHistory and Interview Medical/ Surgical/ Trauma HistoryMedical/ Surgical/ Trauma History MedicationsMedications Quality of life measurementsQuality of life measurements Pain historyPain history –– HeadachesHeadaches –– JawJaw –– NeckNeck Dental status and historyDental status and history Speech and swallowing historySpeech and swallowing history
  37. 37. Mandibular Function ImpairmentMandibular Function Impairment Questionnaire (MFIQ)Questionnaire (MFIQ) (Stegenga et. al., 1993)(Stegenga et. al., 1993) 11 items assessing11 items assessing perceived difficultiesperceived difficulties –– Social activitiesSocial activities –– SpeakingSpeaking –– Taking a large biteTaking a large bite –– Chewing hard, soft, andChewing 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)
  38. 38. MeasurementMeasurement ScreeningScreening –– ““Three finger testThree finger test”” Measurement ToolsMeasurement Tools –– BoleyBoley GaugeGauge –– ManufacturerManufacturer’’s scaless scales DynasplintDynasplint TherabiteTherabite Influencing FactorsInfluencing Factors –– Dental alignmentDental alignment –– AgeAge –– GenderGender –– RamusRamus lengthlength –– GonialGonial angleangle www.atosmedical.com
  39. 39. MeasurementMeasurement ReliabilityReliability NormsNorms ((BumannBumann && LotzmanLotzman, 2002), 2002) –– Jaw openingJaw 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)) www.atosmedical.com
  40. 40. Measurement TechniqueMeasurement Technique Active OpeningActive Opening Passive OpeningPassive Opening Lateral MovementLateral Movement RetractionRetraction ProtrusionProtrusion
  41. 41. Manual Functional AnalysisManual Functional Analysis Screen neckScreen neck mbilitymbility At rest and withAt rest and with movementmovement –– LookLook –– ListenListen –– PalpatePalpate JointJoint Muscles of masticationMuscles of mastication
  42. 42. Instrumental EvaluationInstrumental Evaluation General dental examGeneral dental exam PanorexPanorex –– Confirms degenerative jointConfirms degenerative joint changeschanges –– Quantify level ofQuantify level of asymmetryasymmetry CTCT MRIMRI CastingCasting AxiographyAxiography –– Evaluates trajectoryEvaluates trajectory
  43. 43. Traditional TreatmentsTraditional Treatments None/ CompensationNone/ Compensation –– Diet modificationDiet modification ClothespinsClothespins ScrewsScrews ““Open your mouthOpen your mouth”” Manual pressureManual pressure Chewing gumChewing gum Tongue depressorsTongue depressors
  44. 44. Dental TreatmentsDental Treatments Elimination ofElimination of behaviors thatbehaviors that strengthenstrengthen antagonistsantagonists IntraoralIntraoral orthoticsorthotics DistractionDistraction osteogenesisosteogenesis
  45. 45. Physical TherapyPhysical Therapy Icing/ HeatIcing/ Heat MassageMassage Manipulation/ TractionManipulation/ Traction CompressionCompression TENSTENS EMG biofeedbackEMG biofeedback UltrasoundUltrasound Manual lymph drainageManual lymph drainage ExerciseExercise
  46. 46. FacialFacial--FlexFlex Two minutes/ 2x a dayTwo minutes/ 2x a day Isometric/Isometric/ IsokineticIsokinetic Reduces scar formationReduces scar formation and lip contractionand lip contraction Open to maximumOpen to maximum comfort, close and holdcomfort, close and hold for two secondsfor two seconds
  47. 47. Treatment: Passive ROMTreatment: Passive ROM PassivePassive –– 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)
  48. 48. Passive ROM DevicesPassive ROM Devices DynasplintDynasplint –– PassivePassive –– Low load prolongedLow load prolonged-- duration stretchduration stretch –– SpringSpring--loadedloaded –– HandsHands--free optionfree option –– AdjustableAdjustable –– CustomizedCustomized mouthpiecemouthpiece –– 3x/ day for 30 minutes3x/ day for 30 minutes –– Rented to patientRented to patient www.dynasplint.com
  49. 49. TherabiteTherabite TherabiteTherabite –– Efficacy isEfficacy is documenteddocumented –– Dental padsDental pads –– Passive range ofPassive range of motionmotion –– Patient controlledPatient controlled –– 77--77--7 protocol7 protocol –– 55--55--30 protocol30 protocol www.atosmedical.com
  50. 50. TherapacerTherapacer CPMCPM ProgrammableProgrammable 1818--61 mm61 mm 100% passive100% passive MotorizedMotorized ContinuousContinuous 44--6 hours/day for 46 hours/day for 4--66 weeksweeks Lateral and protrusiveLateral and protrusive attachmentsattachments
  51. 51. The Final WordThe Final Word Abdel-Galil et.al.
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