What is trismus

Trismus commonly referred to as “lockjaw”, means inability to open your mouth (jaw) or difficulty with mouth opening due to variety of causes. Trismus isn’t a disease, trismus is a symptom that can come with problems related to the temporomandibular joint (TMJ), nerves and muscles of mastication that control the jaw ¹. Maximal inter-incisal opening in the healthy population ranges from 36–55 mm; measurements ≤ 35 mm are considered to be trismus ². Although unilateral trismus may occur, by definition, trismus is a bilateral process that results from increased tone mediated by the efferent portion of the reflex arch of the trigeminal nerve ³. Trismus can come on slowly or develops suddenly due to trauma from an accident or even a trip to your dentist. How bad trismus gets and how long it lasts depends on the cause. Trismus can be caused by tumor infiltrating the muscle of mastication, their nerves, and the temporomandibular joint or as a complication of surgery or radiation therapy ⁴. Trismus may cause difficulty in many aspects of daily living, such as impaired speech, difficulty eating, difficulty in maintaining proper oral hygiene and receiving dental intervention, thereby affecting the patient’s quality of life ⁵. Treating trismus usually means gradually stretching the mouth open and there are exercises and devices that help. Depending on the patients it could take days, weeks or even months to regain normal use.

The muscles responsible for mouth closure, namely the masseter, temporalis, and medial pterygoid muscles, exert a force 10 times greater than exerted by the muscles that open the mouth, which include the lateral pterygoid, digastric and hyoid muscles. Innervation for the majority of these muscles is provided by the mandibular division of the trigeminal nerve (fifth cranial nerve). The muscle groups that control jaw opening and closure act in antagonism, as neurogenic stimulation of one group causes reflex neural inhibition of the other. While the inciting insult may be unilateral, the reflex activated is bilateral.

The prevalence of trismus ranges widely, partly because no clear criteria have been established. Normal jaw opening is greater than 30 to 40 mm. Trismus has been defined as mouth opening less than 40 mm; others have defined it as an opening to 15 to 30 mm, or even less than 20mm. Additionally, some authors have graded trismus according to visual assessment of mouth opening (light/moderate/severe or grades 1 to 3, again corresponding to mouth opening). Its incidence is vastly variable and dependent on the inciting etiology. Importantly, trismus is a common finding in certain narrow patient populations, such as patients with congenital micrognathia syndromes or those undergoing radiation therapy for head and neck cancers ⁶. It can also be a relatively rare complication of common conditions, such as pharyngitis.

Trismus key facts

• Trismus most commonly occurs in the setting of uncomplicated common conditions (e.g., pharyngitis, wisdom tooth extraction); it may also be a relatively common complication of uncommon conditions (fibrosis following head and neck radiotherapy).
• Trismus is best addressed by identifying the inciting etiology and directing treatment to the underlying cause.
• Most cases of trismus resolve following symptom-directed treatment with heat therapy and nonsteroidal anti-inflammatory drugs (NSAIDs).
• Refractory chronic trismus may require physiotherapeutic interventions.
• The outcomes are good in most patients if the primary cause can be treated. However, in patients with severe trauma, scarring, and radiation therapy, trismus may be chronic and lead to a poor quality of life ⁷.

How long does trismus last?

Depending on the cause and patients, trismus could last days, weeks or even months to regain normal use. Most commonly trismus is temporary, and typically resolves in less than 2 weeks, but permanent trismus may also occur ³.

Trismus causes

There are countless number causes implicated in the development of trismus. Some authors classify trismus in relation to the involvement of the temporomandibular junction (TMJ) or intraarticular versus extraarticular causes ⁸. Others have outlined the causes into broad categories such as infectious, traumatic, and neoplastic sources ⁹. A disease entity may cause trismus, but conversely, it may also be iatrogenic, resulting from prescribed interventions and treatments. Below are some of the conditions associated with trismus:

Traumatic

• Hemarthrosis/hematoma
• Fracture or dislocation of the mandible or zygomatic arch
• Temporomandibular joint (TMJ) contusion
• Intraarticular bone islands/foreign bodies
• Displaced meniscus
• Direct injury to muscles of mastication

Inflammatory

• Osteoarthritis
• Soft tissue fibrosis
• TMJ ankylosis
• Rheumatoid arthritis
• Scleroderma
• Temporal arteritis

Infections

• Pyogenic arthritis
• Osteomyelitis of the mandible
• Tonsillitis
• Peritonsillar or other pharyngeal abscesses
• Tetanus
• Odontogenic abscess
• Mumps
• Parotid abscess

Congenital malformations ¹⁰

• Pierre-Robin sequence
• Trismus-pseudocamptodactyly syndrome

Head and neck cancers

• Pharyngeal carcinoma
• Parotid gland tumors

Odontogenic

• Impacted third molar (or following extraction thereof)

Iatrogenic

• Perioperative inflammation
• Radiotherapy for head and neck cancer

Neurogenic

• Tetanus
• Status epilepticus
• Parkinsonism
• Strychnine, phenothiazine poisoning
• Medication adverse effect (phenothiazines, metoclopramide, tricyclic antidepressants)
• Hypocalcemia, hypomagnesemia, respiratory alkalosis

Psychogenic (conversion disorder)

Trismus symptoms

Trismus means inability to open your mouth (jaw) or difficulty with mouth opening due to variety of causes. Trismus is a symptom that can come with problems related to the temporomandibular joint (TMJ), nerves and muscles of mastication that control the jaw ¹.

Patients presenting with trismus may note restricted mouth opening and sometimes pain with attempts to force open the mouth. However, patients often have complaints related to the causative condition rather than the resulting trismus. Those with odontogenic causes may complain of tooth or gum pain and swelling; patients with traumatic causes may note facial or mandibular pain. A review of systems should be performed to identify systemic causes. Fever may indicate an infectious source; weight loss may be notable among patients with neoplastic causes; carpopedal spasms and paresthesias may accompany trismus in patients with neurogenic or metabolic causes. A history of tobacco use, or of known cancer, could raise suspicion of a neoplastic cause ⁹.

More commonly, trismus is a physical exam finding encountered on attempts to visualize the oral and pharyngeal structures via mouth opening. This poses a challenge to the examining clinician attempting to ascertain the cause of trismus, as by definition this restriction limits the evaluation of intraoral structures that may be implicated in its origin. As much as possible, the exam should be targeted to the teeth and gums; facial bones and TMJ; pharyngeal pillars, tonsils, and uvula; and the neck. Assessment of the patient’s speech may be important; some pharyngeal infections implicated in trismus may also cause changes in the patient’s voice; a “hot potato voice” may be associated with tonsillitis or peritonsillar abscess. A directed neurologic exam should be performed to evaluate for neurogenic causes ⁸.

Trismus complications

Many of the infectious and traumatic causes of trismus may also have associated complications; for example, an odontogenic infection causing trismus may be further complicated by facial cellulitis or mandibular osteomyelitis. Trismus may also interfere with appropriate oral intake of nutrition and hydration. Furthermore, trismus may be associated with aspiration due to impaired swallowing mechanism. It should also be noted that intubation via oropharyngeal route may be impossible in patients with significant trismus, necessitating other approaches such as nasopharyngeal intubation or tracheotomy. When its duration is prolonged, trismus may lead to fibrosis of the TMJ, necessitating directed therapy ¹¹.

Trismus diagnosis

The diagnosis of trismus is clinical. Your doctor will perform a physical exam and ask about your medical history. Imaging adjuncts may be useful to determine its etiology and determine the articular involvement of the TMJ. Computed tomography (CT scan) may be useful to identify traumatic causes including hematomas or facial and mandibular fractures when suspected. Magnetic resonance imaging (MRI scan) may also be helpful in identifying space-occupying lesions or abnormalities in the pharyngeal or oral structures.

Tests may be used to rule out meningitis, rabies, strychnine poisoning, and other diseases with similar symptoms.

Trismus treatment

Treatment of trismus is directed at the underlying cause and is most commonly treated symptomatically. Dental or oral surgeon care may be enlisted for odontogenic causes, while an otolaryngologist is at times consulted for drainage of a peritonsillar abscess. Physiatrists may also be involved in a patient’s care when directed therapeutic interventions are necessary to treat refractory trismus ⁹. Symptom-directed interventions including heat therapy, analgesics such as non-steroidal anti-inflammatory agents, and muscle relaxants may be considered in the acute phase and have been described as mainstays of treatment of uncomplicated transient trismus. Patients with post-traumatic and post-operative trismus, especially when persisting longer than 1 week, may also require stretching exercises. The exercises typically consist of repeated attempts to open the mouth against applied resistance, usually divided into multiple sessions per day. Trismus may become chronic in the setting of fibrosis or ongoing radiotherapy; these cases may benefit from intensive physiotherapy, sometimes utilizing commercially-available jaw motion rehabilitation devices or microcurrent therapy, particularly in cases refractory to more conservative approaches. Some authors have also described treatment with xanthine derivatives such as pentoxifylline ¹¹.

Trismus prognosis

Trismus is most commonly self-limited and transient, typically resolving within 2 weeks. When identified in certain patient populations, e.g., in patients who develop fibrosis from radiotherapy, the course of trismus may be prolonged and more refractory to conservative treatment ⁶.

References

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2. Criteria for trismus in head and neck oncology. Dijkstra PU, Huisman PM, Roodenburg JL. Int J Oral Maxillofac Surg. 2006 Apr; 35(4):337-42.
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4. A preliminary report on the efficacy of a dynamic jaw opening device (dynasplint trismus system) as part of the multimodal treatment of trismus in patients with head and neck cancer. Stubblefield MD, Manfield L, Riedel ER. Arch Phys Med Rehabil. 2010 Aug; 91(8):1278-82.
5. Postradiation trismus and its impact on quality of life in patients with head and neck cancer. Lee LY, Chen SC, Chen WC, Huang BS, Lin CY. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 Feb; 119(2):187-95.
6. Loh SY, Mcleod RWJ, Elhassan HA. Trismus following different treatment modalities for head and neck cancer: a systematic review of subjective measures. Eur Arch Otorhinolaryngol. 2017 Jul;274(7):2695-2707
7. Petrovic I, Baser R, Blackwell T, McCarthy C, Ganly I, Patel S, Cordeiro P, Shah J. Long-term functional and esthetic outcomes after fibula free flap reconstruction of the mandible. Head Neck. 2019 Feb 13
8. Tveterås K, Kristensen S. The aetiology and pathogenesis of trismus. Clin Otolaryngol Allied Sci. 1986 Oct;11(5):383-7
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11. Dijkstra PU, Kalk WW, Roodenburg JL. Trismus in head and neck oncology: a systematic review. Oral Oncol. 2004 Oct;40(9):879-89