Trismus, commonly called ''lockjaw'' as associated with

tetanus Tetanus, also known as lockjaw, is a bacterial infection caused by ''Clostridium tetani'', and is characterized by muscle spasms. In the most common type, the spasms begin in the jaw and then progress to the rest of the body. Each spasm usually ...

, is a condition of limited

jaw The jaw is any opposable articulated structure at the entrance of the mouth, typically used for grasping and manipulating food. The term ''jaws'' is also broadly applied to the whole of the structures constituting the vault of the mouth and serv ...

mobility. It may be caused by

spasm A spasm is a sudden involuntary contraction of a muscle, a group of muscles, or a hollow organ such as the bladder. A spasmodic muscle contraction may be caused by many medical conditions, including dystonia. Most commonly, it is a muscle c ...

of the muscles of mastication or a variety of other causes. Temporary trismus occurs much more frequently than permanent trismus. It is known to interfere with eating, speaking, and maintaining proper oral hygiene. This interference, specifically with an inability to swallow properly, results in an increased risk of aspiration. In some instances, trismus presents with altered facial appearance. The condition may be distressing and painful. Examination and treatments requiring access to the oral cavity can be limited, or in some cases impossible, due to the nature of the condition itself.

Definition

Trismus is defined as painful restriction in opening the mouth due to a muscle spasm, however it can also refer to limited mouth opening of any cause. Another definition of trismus is simply a limitation of movement. Historically and commonly, the term ''lockjaw'' was sometimes used as a synonym for both trismus and

. Normal mouth-opening ranges from 35 to 45 mm. Males usually have slightly greater mouth opening than females. (40–60 mm, average of 50 mm). The normal lateral movement is 8–12 mm, and normal protrusive movement is approximately 10 mm. Some have distinguished mild trismus as 20–30 mm interincisal opening, moderate as 10–20 mm and severe as less than 10 mm. Trismus is derived from the Greek word ''trigmos/trismos'' meaning "a scream; a grinding, rasping or gnashing".

Differential diagnosis

Traditionally causes of trismus are divided into intra-articular (factors within the

temporomandibular joint In anatomy, the temporomandibular joints (TMJ) are the two joints connecting the jawbone to the skull. It is a bilateral synovial articulation between the temporal bone of the skull above and the mandible below; it is from these bones that it ...

MJ and extra-articular (factors outside the joint, see table).

Joint problems

Ankylosis

* True bony ankylosis: can result from trauma to chin, infections and from prolonged immobilization following condylar fracture ** Treatment – several surgical procedures are used to treat bony ankylosis, e.g.: Gap arthroplasty using interpositional materials between the cut segments. * Fibrous ankylosis: usually results due to trauma and infection ** Treatment – trismus appliances in conjunction with physical therapy.

Arthritis synovitis

Meniscus pathology

Extra-articular causes

Infection

* Odontogenic- Pulpal ** Periodontal ** Pericoronal * Non-odontogenic- Peritonsillar abscess ** Tetanus ** Meningitis ** Brain abscess ** Parotid abscess * The hallmark of a masticatory space infection is trismus or infection in anterior compartment of lateral pharyngeal space results in trismus. If these infections are unchecked, can spread to various facial spaces of the head and neck and lead to serious complications such as cervical cellulitis or mediastinitis. ** Treatment: Elimination of etiologic agent along with antibiotic coverage * Trismus or lock jaw due to masseter muscle spasm, can be a primary presenting symptom in tetanus, Caused by ''Clostridium tetani'', where tetanospasmin (toxin) is responsible for muscle spasms. ** Prevention: primary immunization (DPT)

Dental treatment

* Dental trismus is characterized by a difficulty in opening the jaw. It is a temporary condition with a duration usually not longer than two weeks. Dental trismus results from some sort of insult to the muscles of mastication, such as opening the jaw for a period of time or having a needle pass through a muscle. Typical dental anesthesia to the lower jaw often involves the needle passing into or through a muscle. In these cases it is usually the medial pterygoid or the

buccinator muscle The buccinator () is a thin quadrilateral muscle occupying the interval between the maxilla and the mandible at the side of the face. It forms the anterior part of the cheek or the lateral wall of the oral cavity.Illustrated Anatomy of the Head ...

s. * Oral surgery procedures, as in the extraction of lower molar teeth, may cause trismus as a result either of inflammation to the muscles of mastication or direct trauma to the TMJ. * Barbing of needles at the time of injection followed by tissue damage on withdrawal of the barbed needle causes post-injection persistent paresthesia, trismus and paresis. ** Treatment: in acute phase: *** Heat therapy *** Analgesics *** A soft diet *** Muscle relaxants (if necessary) *** Note: When acute phase is over the patient should be advised to initiate physiotherapy for opening and closing mouth.

Trauma

Fractures, particularly those of the mandible and fractures of

zygomatic arch In anatomy, the zygomatic arch, or cheek bone, is a part of the skull formed by the zygomatic process of the temporal bone (a bone extending forward from the side of the skull, over the opening of the ear) and the temporal process of the zygomati ...

and zygomatic arch complex, accidental incorporation of foreign bodies due to external traumatic injury. Treatment: fracture reduction, removal of foreign bodies with antibiotic coverage

TMJ disorders

* Extra-capsular disorders – Myofascial pain dysfunction syndrome * Intra-capsular problems – Disc displacement, arthritis, fibrosis, etc. * Acute closed locked conditions – displaced meniscus

Tumors and oral care

Rarely, trismus is a symptom of nasopharyngeal or infratemporal tumors/ fibrosis of temporalis tendon, when patient has limited mouth opening, always premalignant conditions like oral submucous fibrosis (OSMF) should also be considered in differential diagnosis.

Drug therapy

Succinyl choline,

phenothiazines Phenothiazine, abbreviated PTZ, is an organic compound that has the formula S(C6H4)2NH and is related to the thiazine-class of heterocyclic compounds. Derivatives of phenothiazine are highly bioactive and have widespread use and rich history. Th ...

and

tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications that are used primarily as antidepressants, which is important for the management of depression. They are second-line drugs next to SSRIs. TCAs were discovered in the early 1950s and wer ...

causes trismus as a secondary effect. Trismus can be seen as an

extra-pyramidal In anatomy, the extrapyramidal system is a part of the motor system network causing involuntary actions. The system is called ''extrapyramidal'' to distinguish it from the tracts of the motor cortex that reach their targets by traveling through t ...

side-effect In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequence ...

of metoclopromide, phenothiazines and other medications.

Radiotherapy and chemotherapy

* Complications of radiotherapy: ** Osteoradionecrosis may result in pain, trismus, suppuration and occasionally a foul smelling wound. ** When muscles of mastication are within the field of radiation, it leads to fibrosis and result in decreased mouth opening. * Complications of Chemotherapy: ** Oral mucosal cells have high growth rate and are susceptible to the toxic effects of chemotherapy, which lead to

stomatitis Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration. In its widest meaning, stomatitis can have a multitude of different cau ...

Congenital and developmental causes

* Hypertrophy of coronoid process causes interference of coronoid against the anteromedial margin of the zygomatic arch. ** Treatment: Coronoidectomy * Trismus-pseudo-camtodactyly syndrome is a rare combination of hand, foot and mouth abnormalities and trismus.

Miscellaneous disorders

* Hysteric patients: Through the mechanisms of conversion, the emotional conflict are converted into a physical symptom. E.g.: trismus * Scleroderma: A condition marked by edema and induration of the skin involving facial region can cause trismus

Common causes

Pericoronitis Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an ''operculum'', an ar ...

(inflammation of soft tissue around impacted third molar) is the most common cause of trismus. * Inflammation of muscles of mastication. It is a frequent sequel to surgical removal of mandibular third molars (lower

wisdom teeth A third molar, commonly called wisdom tooth, is one of the three molars per quadrant of the human dentition. It is the most posterior of the three. The age at which wisdom teeth come through ( erupt) is variable, but this generally occurs betw ...

). The condition is usually resolved on its own in 10–14 days, during which time eating and

oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried out ...

are compromised. The application of heat (e.g. heat bag extraorally, and warm salt water intraorally) may help, reducing the severity and duration of the condition. *

Peritonsillar abscess Peritonsillar abscess (PTA), also known as quinsy, is an accumulation of pus due to an infection behind the tonsil. Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. Pain is usually worse on one side. Com ...

, a complication of

tonsillitis Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and en ...

which usually presents with sore throat,

dysphagia Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a disease#Terminology, condition in its own right. It may be a sensation that suggests difficulty in the passag ...

fever Fever, also referred to as pyrexia, is defined as having a body temperature, temperature above the human body temperature, normal range due to an increase in the body's temperature Human body temperature#Fever, set point. There is not a single ...

, and change in voice. *

Temporomandibular joint dysfunction Temporomandibular joint dysfunction (TMD, TMJD) is an umbrella term covering pain and dysfunction of the muscles of mastication (the muscles that move the jaw) and the temporomandibular joints (the joints which connect the mandible to the sku ...

(TMD). * Trismus is often mistaken as a common temporary side effect of many

stimulants Stimulants (also often referred to as psychostimulants or colloquially as uppers) is an overarching term that covers many drugs including those that increase activity of the central nervous system and the body, drugs that are pleasurable and inv ...

of the sympathetic nervous system. Users of

amphetamines Substituted amphetamines are a class of compounds based upon the amphetamine structure; it includes all derivative compounds which are formed by replacing, or substituting, one or more hydrogen atoms in the amphetamine core structure with sub ...

as well as many other pharmacological agents commonly report bruxism as a side-effect; however, it is sometimes mis-referred to as trismus. Users' jaws do not lock, but rather the muscles become tight and the jaw clenched. It is still perfectly possible to open the mouth. *

Submucous fibrosis Oral submucous fibrosis is a chronic, complex, premalignant (1% transformation risk) condition of the oral cavity, characterized by juxta-epithelial inflammatory reaction and progressive fibrosis of the submucosal tissues (the lamina propria and d ...

. * Fracture of the

Other causes

* Acute

osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...

Ankylosis Ankylosis is a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease. The rigidity may be complete or partial and may be due to inflammation of the tendinous or muscular ...

of the TMJ (fibrous or bony) *

Condylar A condyle (;Entry "condyle"
in
Gaucher disease Gaucher's disease or Gaucher disease () (GD) is a genetic disorder in which glucocerebroside (a sphingolipid, also known as glucosylceramide) accumulates in cells and certain organs. The disorder is characterized by bruising, fatigue, anemia, low ...

which is caused by deficiency of the enzyme

glucocerebrosidase β-Glucocerebrosidase (also called acid β-glucosidase, D-glucosyl-N-acylsphingosine glucohydrolase, or GCase) is an enzyme with glucosylceramidase activity () that is needed to cleave, by hydrolysis, the beta-glycosidic linkage of the chemical g ...

. *

Giant cell arteritis Giant cell arteritis (GCA), also called temporal arteritis, is an inflammatory autoimmune disease of large blood vessels. Symptoms may include headache, pain over the temples, flu-like symptoms, double vision, and difficulty opening the mouth. ...

Sympathomimetic drug Sympathomimetic drugs (also known as adrenergic drugs and adrenergic amines) are stimulant compounds which mimic the effects of endogenous agonists of the sympathetic nervous system. Examples of sympathomimetic effects include increases in heart ...

s, such as

amphetamine Amphetamine (contracted from alpha- methylphenethylamine) is a strong central nervous system (CNS) stimulant that is used in the treatment of attention deficit hyperactivity disorder (ADHD), narcolepsy, and obesity. It is also commonly used ...

methamphetamine Methamphetamine (contracted from ) is a potent central nervous system (CNS) stimulant that is mainly used as a recreational drug and less commonly as a second-line treatment for attention deficit hyperactivity disorder and obesity. Methamph ...

MDA MDA, mda, or ''variation'', may refer to: Places * Moldova, a country in Europe with the ISO 3166-1 country code MDA Politics * Meghalaya Democratic Alliance (2018), ruling coalition government in the Indian State of Meghalaya led by National Pe ...

MDMA 3,4-Methylenedioxymethamphetamine (MDMA), commonly seen in Tablet (pharmacy), tablet form (ecstasy) and crystal form (molly or mandy), is a potent empathogen–entactogen with stimulant properties primarily used for Recreational dru ...

, MDEA,

methylphenidate Methylphenidate, sold under the brand names Ritalin and Concerta among others, is the most widely prescribed central nervous system (CNS) stimulant medication used to treat attention deficit hyperactivity disorder (ADHD) and, to a lesser extent, ...

ethylphenidate Ethylphenidate (EPH), also known as Baxtercaine in the United Kingdom is a psychostimulant and a close analog of methylphenidate. Ethylphenidate acts as both a dopamine reuptake inhibitor and norepinephrine reuptake inhibitor, meaning it effecti ...

, and related substances. * Infection *

Local anesthesia Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...

(dental injections into the infratemporal fossa) * Needle prick to the

medial pterygoid muscle The medial pterygoid muscle (or internal pterygoid muscle), is a thick, quadrilateral muscle of the face. It is supplied by the mandibular branch of the trigeminal nerve (V). It is important in mastication (chewing). Structure The medial ptery ...

* Oral submucous fibrosis. *

Radiation therapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...

to the head and neck. *

Tetanus Tetanus, also known as lockjaw, is a bacterial infection caused by ''Clostridium tetani'', and is characterized by muscle spasms. In the most common type, the spasms begin in the jaw and then progress to the rest of the body. Each spasm usually ...

, also called ''lockjaw'' for this reason *

Malignant hyperthermia Malignant hyperthermia (MH) is a type of severe reaction that occurs in response to particular medications used during General anaesthesia, general anesthesia, among those who are susceptible. Symptoms include tetany, muscle rigidity, hyperthermia ...

* Malaria severa * Secondary to

neuroleptic Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of oth ...

drug use *

Malignant otitis externa Otitis externa, also called swimmer's ear, is inflammation of the ear canal. It often presents with ear pain, swelling of the ear canal, and occasionally decreased hearing. Typically there is pain with movement of the outer ear. A high fever i ...

Mumps MUMPS ("Massachusetts General Hospital Utility Multi-Programming System"), or M, is an imperative, high-level programming language with an integrated transaction processing key–value database. It was originally developed at Massachusetts Gener ...

* Retropharyngeal or parapharyngeal abscess *

Seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with los ...

Stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...

Toothache Toothache, also known as dental pain,Segen JC. (2002). ''McGraw-Hill Concise Dictionary of Modern Medicine''. The McGraw-Hill Companies. is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the t ...

Diagnostic approach

X-ray/CT scan taken from the TMJ to see if there is any damage to the TMJ and surrounding structures.

Treatment

Treatment requires treating the underlying condition with dental treatments, speech therapy for swallowing difficulty and mouth opening restrictions,

physical therapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...

, and passive

range of motion Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...

devices. Additionally, control of symptoms with pain medications (

NSAID Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...

s),

muscle relaxants A muscle relaxant is a drug that affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeu ...

, and warm compresses may be used. Splints have been used.

History

Historically, the term trismus was used to describe the early effects of

tetany Tetany or tetanic seizure is a medical sign consisting of the involuntary contraction of muscles, which may be caused by disorders that increase the action potential frequency of muscle cells or the nerves that innervate them. Muscle cramps cause ...

, also called "lockjaw".

References

External links

{{Nervous and musculoskeletal system symptoms and signs Symptoms and signs: musculoskeletal system Pathology of temporomandibular joints, muscles of mastication and associated structures