This document outlines the etiology and management of trismus. It defines trismus as restricted mouth opening and describes normal ranges of opening. Common causes of trismus include infections, trauma, surgery, tumors, radiation, TMJ disorders, and drugs. Management involves thorough history and examination, investigations to diagnose the underlying cause, and various treatment approaches depending on the etiology such as heat therapy, medical management, physiotherapy, surgery, and appliances.
ORN is an inflammatory condition of bone that occurs after the bone has been exposed to therapeutic doses of radiation usually given for a malignancies.
ORN is an inflammatory condition of bone that occurs after the bone has been exposed to therapeutic doses of radiation usually given for a malignancies.
Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst.
Introduction
Epidemiology
Etiology
Manifestations
TNM staging
Squamous cell carcinoma is defined as malignant epithelial neoplasm exhibiting squamous differentiation as characterised by the formation of keratin and/or the presence of intercellular bridges.
( Pindborg et al, 1997).
an overview of muscle pain disorder which regularly create some discomfort for patient to live a normal life as well as to the doctor regarding diagnosis of the problem.
An overview of Trismus which is also called as Lock Jaw. Trismus is a symptom in various condition. In this seminar i will be discussing about the various condition and diagnostic modalities and management
Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst.
Introduction
Epidemiology
Etiology
Manifestations
TNM staging
Squamous cell carcinoma is defined as malignant epithelial neoplasm exhibiting squamous differentiation as characterised by the formation of keratin and/or the presence of intercellular bridges.
( Pindborg et al, 1997).
an overview of muscle pain disorder which regularly create some discomfort for patient to live a normal life as well as to the doctor regarding diagnosis of the problem.
An overview of Trismus which is also called as Lock Jaw. Trismus is a symptom in various condition. In this seminar i will be discussing about the various condition and diagnostic modalities and management
Trismus is defined as restricted mouth opening of 35 mm or less. Normal full opening is 40-50- millimeters. Trismus is not a disease it is well known complication of cancer in the oral cavity region(1). The prevalence of trismus ranges from 5 to 38%. It can result in problems with speech, oral hygiene dental treatment and mastication. Trisums impacts negatively on quality of life(2)Many stretching devices were adopted to enhance mouth opening like sledge hammer, surgical
mouthprop, a tapered screw, a screw-type mouth gag fingers, tongue depressor, interarch springs, intra operatively fabricated self-curing bite block, has been used(3,14). All the above studies has given little information about mouth opening, conventional exercise therapy using tongue depressors, fingers, rubber plugs had minimal effect .Hence, the aim of the study is to find out the influence of exercise with tongue depressors on pain and mouth opening, in post surgical oral cavity cancer
individuals with trismus. The pre and post experimental mean Results: value, t-test and p values of all the three outcomes that is pain (VAS), mouth opening, quality of life shows statistically highly significant values then the control group. Conclusion: There is increase in mouth opening and decreased in VAS with mandibular exercises in experimental group than conventional exercises in control group.
Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed
Arthrocentesis of the temporomandibular jointAhmed Adawy
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Arthrocentesis of the temporomandibular joint refers to lavage of the upper joint space, hydraulic pressure and manipulation to release adhesions of the “anchored disc phenomenon” and improve motion. The technique of arthrocentesis is discussed together with the indications and contraindications of the procedure. Further, the presentation includes modifications of the standard technique.
A medical document is a comprehensive written record used in the healthcare industry to capture and communicate important information about a patient's health and medical care. It typically includes:
Patient Information: Basic details like the patient's name, age, gender, contact information, and identification number.
Medical History: A summary of the patient's past medical conditions, surgeries, allergies, medications, and any relevant family medical history.
Diagnoses: Any medical conditions or diseases diagnosed by healthcare professionals, along with details about their severity and progression.
Treatment Plans: Information about prescribed treatments, medications, surgeries, therapies, and other interventions, including dosages and frequencies.
Progress Notes: Regular updates on the patient's condition, responses to treatment, and any changes in their health status.
Lab Results and Imaging: Recordings of laboratory tests, blood work, imaging (such as X-rays and MRI scans), and their interpretations by medical professionals.
Consultations: Notes from consultations with specialists or other healthcare providers, along with their recommendations.
Informed Consent: Documentation that the patient or their legal guardian has been adequately informed about potential risks and benefits of procedures or treatments and has given their consent.
Discharge Summaries: A summary of the patient's stay in a healthcare facility, detailing their diagnosis, treatment, and any follow-up instructions.
Legal and Ethical Documents: Any legal or ethical documents related to the patient's care, such as advance directives, do-not-resuscitate (DNR) orders, or living wills.
**Billing
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. OUTLINE
Introduction
Normal mouth opening
Measurement of mouth opening
Classification of trismus
Aetiology of trismus
Management of trismus
History taking
Examination
Investigations
Diagnosis
Treatment
Heat therapy
Medical management
Physiotherapy
Surgery
Trismus appliances
Conclusion
References
3. INTRODUCTION
Trismus refers to a sustained, tonic spasm of the masticatory muscles,
particularly the masseter and temporalis, which results in forced jaw closure
[Lai MM, Howard RS, 1994]
Trismus is derived from the greek word ‘trismos’ meaning gnashing
More recently, the term “trismus” has been used to describe any restrictions
to mouth opening including restrictions caused by infection, trauma, surgery
or radiation [Johnson J., et al, 2010].
This limitation in the ability to open the mouth can have serious health
implications, including reduced nutrition due to impaired mastication,
difficulty in speaking and compromised oral hygiene.
4. NORMAL MOUTH OPENING
The normal range of mouth opening varies from patient to patient, within a
range of 40– 60 mm, although some authors place the lower limit at 35
mm.
The width of the index finger at the nail bed is between 17 and 19 mm.
Thus, two fingers’ breadth (40 mm) up to three fingers’ breadth (54–57 mm)
is the usual width of opening.
Evidence suggests that gender may be a factor in vertical mandibular
opening. In general, males display greater mouth opening [Dwarkins SF, et al, 1990)
Lateral movement is 8–12 mm [Scully C, 2008], and normal protrusive movement
is approximately 10mm [Hupp JR, et al., 2008].
6. CLASSIFICATION OF TRISMUS
A. BASED ON RANGE OF MOUTH OPENING
Mild trismus = 30 – 40mm
Moderate trismus = 15 – 30mm
Severe trismus = ≤15
B. BASED ON DURATION
Acute trismus
Subacute trismus
Chronic trismus
C. BASED ON AETIOLOGY
Intra-articular
Extra-articular
7. AETIOLOGY OF TRISMUS
A. ACUTE TRISMUS
INFECTIONS
Pericoronitis
Odontogenic infection with spread involving masticatory muscles, TMJ,
bone or fascial spaces
Tonsillar or pharyngeal infections
Parotitis
Otitis
Tetanus
8. TRAUMA
Jaws
Soft tissues
POSTOPERATIVE
Third molar teeth removal
Other jaw and oral surgeries
Associated with haematoma
Local anaesthetic injection trauma to pterygoid muscles
DRUG RELATED
Psychotomimetics such as ecstasy
Extra-pyramidal reaction to anti-emetics (e.g metoclopramide)
Malignant hyperthermia
Temporomandibular joint disease (e.g gout, rheumatoid arthritis) and
pain dysfunction syndrome
9. B. SUB-ACUTE TRISMUS
Tumour infiltration of muscles or joint
Chronic infection
TMJ disease and pain dysfunction syndrome
C. CHRONIC TRISMUS
Soft tissue scar formation or TMJ damage after surgery, trauma, radiation or
burns
Submucous fibrosis
Scleroderma
Rheumatoid arthritis
TMJ disease and pain dysfunction syndrome
TMJ ankylosis
Masticatory muscle disorders (e.g myotonia, myositis ossificans,
fibrodysplasia ossificans, fibroslerosis)
Pseudobulbar palsy [reported by Lai MM, Howard RS, 1994]
10.
11. INFECTIONS
The hallmark of a masticatory space infection is limited jaw opening.
Infections causing trismus may be of an odontogenic or non-odontogenic
nature.
Odontogenic infections have three major origins: pulpal, periodontal and
pericoronal.
The presence of an oral infection, particularly around an erupting mandibular
third molar, is the most common cause of trismus [Nitzam DW, Shteyer A, 1986].
Severe odontogenic infections involving the muscles of mastication are often
accompanied by trismus at initial presentation.
Non-odontogenic infections such as tonsillitis, tetanus, and parotid abscess
may also cause trismus [Backland LK, et al, 1988].
12. TRAUMA
Fractures, particularly those of the mandible, may cause limited jaw opening.
Depending upon the type of injury and the direction of the traumatic force,
fractures of the mandible may occur in different locations, producing
mandibular hypomobility.
Another cause of trismus seen is trauma of the zygomatic arch and
zygomaticomaxillary complex (ZMC), which interferes with the movement of the
coronoid process [Azaz B et al, 1994].
13. TRISMUS RELATED TO DENTAL PROCEDURES
Trismus may occur after any oral surgery that involves the pterygoid muscles
or after which there is disuse of the TMJ.
Maxillectomy is the classical example of an oral operation that will lead to
trismus
The extraction of teeth may cause trismus as a result either of inflammation
involving the muscles of mastication or direct trauma to the TMJ.
Occasionally, the medial pterygoid muscle is accidentally penetrated or a
vessel is punctured during an IAN block and a small bleed follows: a
haematoma can occur in the muscle bed and subsequently organize, causing
a fibrosis.
Hot packs, stretching exercises using wooden spatulas and reassurance are
usually sufficient for this condition, although sometimes the haematoma
becomes infected and requires surgical evacuation.
14. TEMPOROMANDIBULAR JOINT DISORDERS
There are numerous subcategories of TMD, a number of which may
be associated with trismus.
TMDs may be divided into extracapsular (mainly myofascial) and
intracapsular problems (including disc displacement, arthritis, fibrosis,
etc.).
Intracapsular problems are often caused by trauma.
Pain upon palpation, lateral to the joint capsule, is a significant finding.
Clicking may indicate anterior disc displacement.
Painless clicking alone does not require treatment.
Conditions such as fibrosis or unilateral condylar hyperplasia require
surgical consultation and treatment.
15. Suspicion of TMJ trauma or dislocation should be considered in young
patients who have dysphagia and trismus but who do not have a
serious infectious aetiology.
Acute closed-lock conditions may occur when the meniscus becomes
displaced anteromedial to the condyle.
In such instances, the patient usually has a history of paroxysmal
clicking and some discomfort.
In closed-lock conditions of a mechanical nature, the patient can often
open his or her jaw 20–25 mm.
If the opening is significantly less than this the practitioner should
suspect a closed lock of muscular origin.
16. TUMOURS AND ORAL MALIGNANCIES
Trismus is a common complication of oncology
Tumours involving the mandible, muscles of mastication and
associated structures can cause limitation of mandibular movement
Also primary tumours occurring in any parts of the body could
metastasize to the epipharyngeal region, parotid, mandible or TMJ
and cause trismus
17. DRUG THERAPY
Some drugs are capable of causing trismus as a secondary effect,
succinylcholine, phenothiazines and tricyclic antidepressants being
among the most common [Cunningham PA, Kendrick RW, 1988].
It has also been reported that MDMA abusers are prone to clenching,
bruxism and/or trismus and TMJ dysfunction [Baylen CA et al, 2006].
18. RADIOTHERAPY
Radiotherapy is commonly used to treat squamous cell carcinoma of the
head and neck and regional lymphomas.
Complications may develop from its use, depending upon which healthy
tissues are in the path of the radiation beam, the amount of radiation
given and the course of treatment.
When the muscles of mastication are within the field of radiation,
radiation induced fibrosis may result and lead to trismus, reducing the
range of movement.
19. Fibrosis and trismus have been attributed to the ischaemia caused by
endarteritis obliterans.
Trismus complicates post-radiation dental care.
The recommendation to minimize the effects of radiation on the facial
and masticatory muscles include the use of protective stents, jaw
exercises and hyperbaric oxygen to increase neovascularization.
Results from a pilot study suggested that pentoxifyline may be
effective in treating radiation-induced trismus [Chua DT et al, 2001]
20. CONGENITAL/DEVELOPMENTAL CAUSES
There has been a report of trismus as a result of hypertrophy of the
coronoid process causing interference of the coronoids against the
anteromedial margin of the zygomatic arch [Daniele A, 1994].
Trismus pseudo-camptodactyly syndrome is a rare combination of
hand, foot and mouth abnormalities and trismus.
21. MANAGEMENT OF TRISMUS
HISTORY TAKING
Thoroughly review the patient’s dental and medical history
o Ask about onset, nature, progression, aggravation, radiation of pain
and relieving factors
o Ask about any dental treatment, joint clicking and locking, trauma,
infections, medical conditions, radiotherapy or drug intake.
o Inquire about pain in neck, shoulder and back muscles and joints.
o Inquire about sleep bruxism (clenching, grinding, tooth tapping) or
daytime parafunction (clenching, gum chewing, fingernail biting)
22. EXAMINATION
Perform a complete extraoral and intraoral examination
Check for facial asymmetry
Measure maximum mouth opening (check for interincisal distance) and
lateral range of jaw motion
Palpate the masticatory muscles in the jaw and check for tenderness
Check for visible muscle fasciculation, pathognomic for myospasm/trismus
diagnosis
Examine the TMJ (check for any tenderness, uncoordinated movement,
clicking sounds and crepitus)
Look for partially erupting third molars, carious teeth and gingival
inflammation
Check teeth for any wear facets and/or occlusal disharmony
23. INVESTIGATIONS
Periapical radiograph
To rule out caries in the teeth
Panoramic radiograph
Confirms degenerative joint diseases
Quantify levels of asymmetrty
CT
MRI
Casting
Axiography
Evaluates trajectory
24. OTHER DIAGNOSTIC AIDS
Nasendoscopy
Ultrasound
Biopsy
Microscopy, culture and sensitivity
Full blood picture
ESR
Serum uric acid
Antinuclear antibodies (ANA)
Anti-topoisomerase 1 antibodies (ATA or anti-Scl-70)
Anticentromere antibodies (ACA)
Rheumatoid factors (RF)
Psychological assessment
26. TREATMENT
Treatment of trismus varies depending on the aetiological factor.
The degree of discomfort and dysfunction varies, but is usually mild.
When a patient reports mild pain and dysfunction, the practitioner should
prescribe the following to manage the initial phase of muscle spasm.
Heat therapy;
Analgesics;
Soft diet; and
Muscle relaxants (if necessary)
27. HEAT THERAPY
Heat therapy consists of placing moist hot towels on the affected area
for 15–20 minutes every hour.
Heat increases the extensibility of collagen tissue, decreases joint
stiffness, relieve pain and muscle spasm, increase blood flow and
helps to resolve inflammatory infiltrates and oedema [Lund TW, et al, 1993]
28. MEDICAL MANAGEMENT
Aspirin is usually adequate in managing the pain associated with
trismus; its anti-inflammatory properties are also beneficial.
A narcotic analgesic may be required if the discomfort is more intense.
If necessary, diazepam (2.5–5 mg three times daily) or other
benzodiazepine may be prescribed for muscle relaxation.
29. One of the latest treatment modalities is the use of botulinum
treatment injections.
Its site of action is predominantly the synaptic terminal of the
cholinergic lower motor neurone.
This toxin causes flaccid paralysis due to neuroexocytosis block, i.e
acethycholine release, especially at the lower motor neurone terminal
presynaptically.
The dose recommended is 25IU injected into each masseter and 10IU
into the temporalis muscle.
The onset of action is somewhat delayed, hence it is desirable to start
the therapy early [Herrman H et al, 2008].
30. If further dental care is needed, as with a painful infected tooth,
access for local anaesthesia may be difficult when trismus is present.
The closed mouth nerve block usually provides relief of the motor
dysfunction, permitting the patient to open and allowing the
practitioner to provide the appropriate treatment.
If trismus is suspected to be associated with infection, appropriate
antibiotics should be prescribed.
31. PHYSIOTHERAPY
When the acute phase is over the patient should be advised to initiate
physiotherapy for opening and closing the jaws.
A good starting regimen for most patients is the ‘7-7-7’, which involves
opening and closing the mouth with assisted opening seven times.
Then holding the open position to the maximum opening that can be
sustained without pain for seven seconds.
They are to perform this exercise seven times a day.
Sugarless chewing gum is another means of providing lateral
movement of the TMJ.
Soft diet is prescribed if necessary
32. SURGERY
Surgical management in the case of trismus is rare.
Cases involving intracapsular TMJ pathosis, bony interferences from
styloid or coronoid processes, the presence of a foreign body or
restrictive maxillomandibular bands or dense scar tissues may require
surgical intervention.
If trismus is caused due to fibrotic band formation in the submucosa,
lysis of these bands can be done using laser.
Myotomy of the masseteric muscle helps in certain cases.
Treatment should be directed toward the aetiology.
33. TRISMUS APPLIANCES
Various appliances have been described for treating trismus.
Ideally they are used in combination with physical therapy.
According to their design, they act externally or internally.
34. EXTERNALLY ACTIVATED APPLIANCES
This appliances apply some mechanical means of forces stretching
the elevator muscles by depressing the mandible.
They impact forces that can be continuous or intermittent, light or
heavy, and elastic or inelastic.
Such appliances include the following:
Dynamic bite opener
Threaded tapered screw
Screw type mouth gag
Fingers
Tongue blades
Continuous dynamic jaw extension apparatus
Therabite jaw motion rehabilitation system
35. A. DYNAMIC BITE OPENER
This provides continuous elastic force to depress the mandible,
thereby the amount and direction of the force can be controlled
36. B. THREADED TAPERED SCREW
This appliance is commonly constructed with acrylic resin and is
usually placed between the posterior teeth.
With gradual turns of screw, the mandible is depressed and both
maxillary and mandibular teeth are forced apart.
37. C. SCREW TYPE MOUTH GAG
It employs a screw type component similar to the type incorporated
into orthodontic palatal extension appliances.
It provides a continuous unilateral and inelastic force.
38. D. FINGERS
Patient should use fingers to depress the mandible, stretch the
musculature to the maximum, and them maintained the position for a
slow count of 10.
This exercise is repeated by patient throughout the day.
39. E. TONGUE BLADES
Tongue blades have been used as a wedge or as a mouth prop to
sustain maximal opening
40. F. CONTINUOUS DYNAMIC JAW EXTENSION
APPARATUS
This appliance consists of a contra rotating extending screw attached
to the maxillary and mandibular arches by two resilient stainless steel
wire arms that are connected to acrylic resin splints.
The apparatus distributes the forces generated by the screw over the
entire dental arch covered by the splints.
The force provided is continuous, bilateral and elastic.
41. G. THERABITE JAW MOTION REHABILITATION
SYSTEM
The therabite system is a patient operated device used for passive
rehabilitation therapy of the TMJ
The TheraBite appliance has shown greater efficacy than any other
treatments [Buchbinder D, et al, 1993]
It is a useful appliance for patients with sustained trismus particularly
for those having undergone treatment for head and neck cancers.
42. INTERNALLY ACTIVATED APPLIANCES
These appliances rely on the patient’s depressor muscles to stretch
the elevator muscles, since the elevator muscles can generate forces
that are 10 times generated by the depressor muscles.
The amount of force delivered depends on the strength and motivation
of the patient, as do the frequency and duration of stretching.
Such appliances include the following:
Tongue blades
Plastic tapered cylinder
43. A. TONGUE BLADES
Tongue blades can be employed so that the force delivered is
imparted by the depressor muscle alone and thus the tongue blade
are not used as a wedge.
44. B. PLASTIC TAPERED CYLINDER
It is simple carrot shaped appliance which allows the patient to easily
identify the maximal maxillomandibular distance on initial stretching by
noting which ring on the taper is reached when both the maxillary and
mandibular teeth come into contact with the tapered cylinder.
This appliance relies on the patient depressor muscle to depress the
mandible.
45. CONCLUSION
Successful treatment depend on prompt recognition of its cause and
initiation of appropriate management, otherwise trismus may lead to
permanent functional imapairment
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