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Trismus is defined in Taber's Cyclopedic Medical Dictionary as a tonic contraction of


the muscles of mastication. In the past, this word was often used to describe the effects
of tetanus, also called 'lock-jaw'. More recently, the term 'trismus' has been used to
describe any restriction to mouth opening, including restrictions caused by trauma,
surgery or radiation. 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. In persons who have received radiation to the
head and neck, the condition is often observed in conjunction with difficulty in
swallowing.

   

Trismus can dramatically affect quality of life in a variety of ways. Communication is


more difficult when one is suffering from trismus. Not only is it difficult to speak with the
mouth partly closed, thus impairing articulation, but trismus can decrease the size of the
resonating oral cavity and thus diminish vocal quality. Severe trismus makes it difficult
or impossible to insert dentures. It may make physical re-examination difficult, if limited
mouth opening precludes adequate visualization of the site. Oral hygiene is
compromised, chewing and swallowing is more difficult, and there is an increased risk of
aspiration.

  

Limited jaw mobility can result from trauma, surgery, radiation treatment, or even TMJ
problems. The limitation in opening may be a result of muscle damage, joint damage,
rapid growth of connective tissue (i.e. scarring) or a combination of these factors.
Limitations caused by factors external to the joint include neoplasms, acute infection,
myositis, systemic diseases (lupus, scleroderma, and others) pseudoankylosis, burn
injuries or other trauma to the musculature surrounding the joint.

Limitations caused by factors internal to the joint include bony ankylosis (bony in growth
within the joint), fibrous ankylosis, arthritis, infections, trauma and (perhaps) micro-
trauma that may include brusixm.

Central Nervous System disorders can also cause limitations to mouth opening.
Tetanus, lesions that affect the trigeminal nerve and drug toxicity may all be suspects in
this condition.

Finally, there are iatrogenic causes, such as third molar extraction (in which the muscles
of mastication may be torn, or the joint hyperextended) hematomas secondary to dental
injection and late effects of
intermaxillary fixation after mandibular fracture or other trauma.
The muscles of mastication (also called the 'elevator muscles') consist of the
Temporalis, Masseter, Medial pterygoid and Lateral pterygoid. Each muscle plays an
important role in mastication, and when damaged, each can cause limitations in
opening. When any muscle is damaged, a pain reflex may be stimulated. This condition,
called "muscle guarding" results when muscle fibers engender pain when they are
stretched. This pain causes the muscles to contract, resulting in loss or range of motion.
This contraction is truly a reflex; it cannot be controlled by the patient. Thus, in treating
this condition it is important to recall that rapid motion, or the use of powerful forces may
be self-defeating. Rapid motion may create the reflex that causes muscles to contract,
thereby making stretching of connective tissue difficult or even impossible. Gentle,
passive motion has been shown to be efficacious in treating the condition.

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Regardless of the immediate cause, mandibular hypomobility will ultimately result in


both muscle and joint degeneration. Studies have shown that muscles that fail to move
through their range of motion for as little as three days begin to show signs of atrophy.
Similarly, joints which are immobilized quickly begin to show degenerative changes in
the joint, including thickening of synovial fluid and thinning of cartilage. In the case of
patients receiving radiation treatment of the head and neck, trismus may progress
slowly, even unnoticed for months, causing secondary changes to both muscles and
joints. Thus treatment, consisting of gentle passive motion, should begin as soon as
practicable.

 

The most obvious effect of trismus is difficulty in opening the mouth. As discussed
above, in cancer patients this frequently results from scar tissue from radiation or
surgery, nerve damage, or a combination of factors. In stroke patients, the general
cause is central nervous system dysfunction. Difficulty in speech and swallowing often
accompany the limitation in mouth opening, and create a combination of symptoms that
may be difficult to treat.

In cases of trismus caused by radiation treatment, patients also frequently present with
Xerostomia, mucusitis, and pain as a result of radiation burns. There may also be
associated symptoms such as headache, jaw pain, ear ache, deafness, or pain on
moving the jaw. In cases of Temporomandibular tightness, the joint itself may become
fibrotic, or even (in rare cases) ankylotic. Each of these factors may affect the treatment
provided to the patient.

    

 
Limited mouth opening frequently results in reduced nutrition. The inability to open the
mouth to receive more than a very small amount of food makes eating quite difficult.
Patients with this condition may experience significant weight loss, and may have
significant nutritional deficits. This is of particular importance at a time when the patient
is attempting to recover from surgery, chemotherapy, or radiation treatment. It is
generally accepted that weight loss of more than 10% of initial body weight is
considered significant, and indicates inadequate nutritional intake.

Limited mouth opening may also result in compromised airway clearance. Limited
mouth opening may make proper mastication of food more difficult. A normal swallow
requires an individual to manipulate the food into a cohesive bolus prior to propulsion. If
the tongue cannot move properly due to limited mouth opening, the bolus may not be
formed properly leading to post-swallow excess residue. The combination of
compromised mastication, poor bolus organization and increased residue has the
potential to lead to aspiration of part or all of the bolus.


   

Limited mouth opening can result in compromised oral hygiene. In cancer patients who
have received radiation to the mandible, oral hygiene is of particular importance. While
rare, osteoradionecrosis can be severely debilitating, or even fatal. Poor oral hygiene
can result in dental caries (cavities) which can lead to infection. Infection of the
mandible can lead to further complications, including osteoradionecrosis. This condition,
in which the bone of the mandible dies from radiation or infection can be quite serious.
In the best cases, the treatment entails hyperbaric oxygen, and is time consuming and
expensive.

   

Many persons with limited mouth opening also present with difficulty in swallowing and
speech. Speech is compromised when the mouth is unable to open sufficiently to create
normal sounds. Swallowing is compromised when, due to muscle damage, surgery or
radiation, the larynx is unable to be properly elevated, or when the timing of the
elevation does not coincide with the passage of the bolus.

 

Although the most apparent signs of trismus involve the ability to open the mouth, it is
important to realize that there are likely to be problems within the joint, as well. When a
joint is immobilized, degenerative changes occur within the joint. These changes may
mimic arthritic changes, and may be accompanied by inflammation and pain. If left
untreated, degenerative processes may continue, ultimately becoming permanent.
Degenerative changes in the muscle are also highly likely. Disuse atrophy, as seen by
reduction in muscle mass and strength, as well as shortening of muscle fibers is
observed within days of immobilization.


Early treatment of trismus can prevent or minimize many of the conditions described
above. Passive motion, applied several times per day has been shown to be more
effective than static stretching. Recent research at the University of Pittsburgh has
shown that passive motion provides significant reduction in inflammation and pain.

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Not every person who receives radiation to the head and neck will develop trismus.
While there are few published studies, the range of prevalence of the condition is
between 10 and 40 percent. The severity of the condition also varies widely, with some
patients reporting no limitation to opening, while others are restricted to four or five
millimeters. In rare cases, persons with trismus must be intubated due to severe
limitation to opening. The severity of the condition varies with the placement of the
radiation, the amount of radiation received, and the patient's own ability to tolerate the
treatment. In some cases, there is anecdotal evidence that certain chemotherapy
agents may exacerbate the condition.

Radiation that affects the temporomandibular joint, the pterygoid muscles, or the
masseter muscle, is most likely to result in trismus. The tumors related to this type of
radiation include nasopharyngeal, base of tongue, salivary gland, and cancers of the
maxilla or mandible. Radiation in excess of 60 Gr. is more likely to cause trismus, than
is radiation at levels below that amount. Patients who have been previously irradiated,
and who are being treated for a recurrence, appear to be at higher risk of trismus than
those who are receiving their first treatment. This would seem to indicate the effects of
radiation are cumulative, even over many years.

Radiation induced trismus may begin toward the end of radiation treatment, or at any
time during the subsequent 12 months. Most often, we observe tightening that
increases slowly over several weeks or months. On occasion, however, we see cases
where the condition suddenly worsens with no apparent instigating factor. The condition
may worsen over time, remain the same, or the symptoms may reduce over time, even
in the absence of treatment. However, the condition is most likely to worsen if not
treated.

Some patients who have not received radiation treatment may develop trismus
secondary to scarring and edema after surgery. In spite of the difference in the cause of
the condition, it appears that diagnosis and treatment is similar for both types of
patients. Experience suggests the combination of surgery and radiation to treat cancers
of the head and neck places patients at an increased risk to develop trismus.

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The primary factor in limiting jaw motion in the irradiated patient or surgery patient is the
rapid formation of collagen secondary to radiation damage or surgery. In planning
treatment, it is important to recall that immobile joints also suffer degenerative changes.
Thus, while the initial cause of limited motion lies with the connective tissue,
degradation of the joint can compound the problem. Joints which are immobilized show
very rapid degenerative changes which can make remobilization difficult. Treatment that
incorporates motion to the joint in addition to simple stretching has been shown to be
more efficacious than treatment that simply stretches connective tissue.

It should be noted that trismus is frequently overlooked. Patients may assume that the
reduction in jaw mobility is 'normal', or that it will resolve on its own. It is also easy for
radiation oncologists, surgeons and their nurses to overlook the condition. Patients
receiving radiation therapy or combined radiation and chemotherapy often require
feeding tubes or limit their intake to mostly liquids during treatment. Thus they may not
realize the slow progressive onset of trismus, until they attempt to resume intake of soft
or solid foods. In its mild form, it is not life threatening and easy to ignore. If left
untreated, however it has the potential of making recovery more difficult, as well as
increasing problems associated with speech, oral hygiene and swallowing.

  

Trismus tends to develop slowly. In some patients, it progresses so slowly that they may
not notice it until they can only open their mouth to 20mm or less. Treatment that begins
early in the progression of the condition is likely to be more effective, and easier on the
patient. Because of this, it is important to be proactive in looking for early signs of
trismus. One simple test is the 'three finger test'. Ask the patient to insert three fingers
into the mouth. If all three fingers fit between the central incisors, mouth opening is
considered functional. If less than three fingers can be inserted, restriction is likely.



If the examination reveals the presence of limited mouth opening, and diagnosis
determines the condition to be trismus, treatment should begin as soon as is practical.
As restriction becomes more severe, the need for treatment becomes more urgent. If
treatment is delayed, the difficulty in reversing the condition increases.

Over the years, there have been a wide array of apparatus that have attempted to treat
limited movement of the jaw. These devices range from a variety of cages that fit over
the head, to heavy springs that fit between the teeth, screws that are placed between
the central incisors, and hydraulic bulbs placed between the teeth. The most commonly
used treatment appears to be tongue depressors. These are stacked, forced and held
between the teeth in an attempt to push the mouth open over time.

Devices range widely in cost. Many devices must be custom made for each patient,
thus increasing the cost of treatment. Others, such as continuous passive motion
devices are rented on a daily or weekly basis, at rates of up to several hundred dollars
per week. The least expensive option is the use of tongue depressors. This low-cost
alternative has been used for many years to attempt to mobilize the jaw. However, low
cost should not be confused with cost effective. In order to be cost effective, a treatment
must be effective.
A search of the literature failed to reveal any studies that could demonstrate significant
improvement in treating trismus with tongue depressors.

A number of studies have demonstrated the efficacy of one particular product; the
Therabite Jaw Motion (http://www.atosmedical.com) Rehabilitation System. Buchbinder
(results) studied a population of patients with radiation-induced trismus. Over a ten-
week period, the researchers compared the effectiveness of three different protocols to
improve mandibular mobility. At the end of ten weeks, the group using the Therabite
System had improved an average of more than 13mm, while the group using tongue
depressors improved less than 5mm. A third group, using their fingers to force their
mouth open, showed even less improvement.

In another study, researchers at NYU found significant improvement in persons


suffering from trismus. This study, which lasted 16 weeks, also found that the use of
tongue depressors was not helpful in improving the condition.

One of the benefits of the Therabite System is that it not only stretches the connective
tissue that causes trismus, but also allows for proper mobilization of the
temporomandibular joint, thus addressing a secondary cause of pain and tightness. This
device is generally covered by medical insurance and Medicare, and is well tolerated by
the patients. We have found that early use of this device helps to improve mobility of the
mandible and also to improve speech and swallowing in a patient population that is at
risk of having difficulties with these functions.

 

It is important to measure initial opening (central incisor to central incisor) before


beginning therapy and to record this opening. Also, record the opening after each
session, and note any pain or discomfort, as well as the number of exercises performed.
The Therabite device comes with patented range of motion scales and a patient log-
book that is specifically designed for this purpose.

A good starting regimen for most patients is '7-7-7'. Open and close the mouth with
assisted opening seven times. Hold the open position to the maximum opening that can
be sustained without pain for seven seconds. They should perform these exercises
seven times per day.

If the patient is capable of performing more than seven sessions, this can only add to
the benefit. Patients who are extremely motivated may hold the stretch for more than
seven seconds, or perform more than seven stretches per session. In all cases, be alert
for signs of pain and muscle soreness, and advise against following the 'no pain-no
gain' philosophy.
Pain should be avoided, as it will result in muscle guarding that may reduce the
effectiveness of the therapy and reduce compliance.

The total time needed to complete this protocol is less than 10 min/day.

Over time, the regimens may be reduced. At first, it is better to reduce the number of
stretches per session, rather than reducing the number of sessions. Later, as the patient
continues to make progress, the number of sessions may be reduced.

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A typical patient will gain from 1-4 mm of opening in the first session (about one
minute). However, most, if not all, of this gain will be lost within the next two hours. Only
by continuing to stretch and mobilize for many sessions per day will any lasting benefit
be achieved.

In most studies, patients using the Therabite system gain between 1-1.5mm of
sustainable gains per week. Thus, to gain 10 mm of 'permanent gain', a patient may
need to exercise from six to ten weeks.

Most patients will continue to need to mobilize and stretch at least once per day for the
rest of their lives.