Efficacy of matrix rhythm therapy (MaRhyThe©) over conventional therapy on radiation induced trismus-A pilot randomised control trial

BACKGROUND AND OBJECTIVES

Prevalence of radiation induced trismus in head and neck cancer (HNC) is 38% to 42% globally. Radiation induced trismus depends on the dosage of the radiation therapy and the surgical procedure. Myofascial release (MFR) and Matrix rhythm therapy (MaRhyThe©) are techniques used to treat the myofascial pain and muscular restriction. The present study aimed to compare the effect of MFR and MaRhyThe© on pain, mouth opening, TMJ disability index (TDI), Gothenburg Trismuus Questionnaire (GTQ), Functional Intraoral Glasgow Scale (FIGS) and quality of life in participants with Radiation induced trismus.

MATERIALS AND METHODOLOGY

About 30 participants in age group of 18 to 65 years diagnosed with radiation induced trismus were included in the study. All the participants were randomly allocated in 2 groups MFR group and MaRhyThe© group. Both the group received structured exercise program. Primary outcomes were Visual Analogue Scale (VAS), Vernier Caliper reading for maximum mouth opening. Secondary outcome measure viz. GTQ, TDI, FIGS and Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN) all obtained values were analyzed at the end of 4th week.

RESULTS

The present study demonstrated significant improvement in terms of reduction in pain, improvement in maximum mouth opening and in GTQ, TMD, FIGS, and FACT-HN scores in all the participants in both group (p ≤ 0.05). However, the groups showed equal effectiveness in the treatment of radiation induced trismus.

A pilot study of intensive intervention using a novel trismus device

PURPOSE

Trismus secondary to head and neck neoplasm treatment impacts upon quality of life, nutrition, oral hygiene, and dentition. Current treatment options for trismus apply unquantified force to the jaw, and in many cases, the device costs are prohibitive. This study aimed to prospectively evaluate the impact of a novel trismus device.

METHOD

This single arm cohort study prospectively evaluated the impact of a novel trismus device on maximal incisal opening (MIO), trismus-related function and quality of life scores. Seventeen patients diagnosed with trismus were recruited to undergo a 10-week program using a novel device. The effect of the intervention was assessed by comparing pre- vs post-intervention validated measures.

RESULT

A significant improvement in MIO was observed post the 10-week intervention period (12.6 mm). This was associated with an improvement in patient reported trismus symptomology including quality of life, swallowing, speech, and jaw pain.

CONCLUSIONS

This pilot study demonstrates the feasibility of a novel device in the treatment of trismus. Further evaluation of this device is warranted to assess efficacy, safety, and cost-effectiveness in a larger cohort with appropriate controls.

Anesthetic Management of a Juvenile Hyaline Fibromatosis Patient With Trismus and Cervical Movement Limitation

Juvenile hyaline fibromatosis (JHF) is a rare autosomal recessive disease characterized by the presence of tissue nodules, joint contractures, and gingival hyperplasia. With a 1-year-9-month-old female patient scheduled for a gingivectomy and excision of a lower lip mass under general anesthesia, it was anticipated that airway management would be difficult because of trismus and limited cervical movement. Intubation with video-laryngoscopic assistance could not be achieved because gingival hyperplasia and trismus prevented blade insertion and manipulation. Therefore, 2 endotracheal tubes were used: 1 used as a nasopharyngeal airway for assisted ventilation, and 1 used for intubation along with a flexible fiberoptic scope. This case demonstrated a useful method for managing ventilation and intubation in patients with JHF, particularly when the use of oral airway devices is difficult.

Interventions for Trismus in Head and Neck Cancer Patients: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Current treatment for head and neck cancers (HNCs) have led to an improved survival. However, the sequelae of cancer treatment often result in trismus, or reduced mouth opening. The purpose of this report is to identify interventional studies for trismus management in HNC patients.

METHODS

A search of PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature, and the Cochrane Library was conducted in March 2020 for randomized controlled trials (RCTs) involving interventions for trismus for head and neck cancer within 10 years. Intervention could involve the use of an exercise regime, jaw rehabilitation device, technological device, medication or massage therapy. The primary outcome was the measurement of mouth opening.

RESULTS

Eleven RCTs involving a total of 685 patients with HNC were included. Six RCTs evaluated the effectiveness of a jaw mobilization device with exercises; there was no significant benefit of an exercise regime with a jaw mobilization device either initiated before, during or after treatment compared to no exercise. Two RCTs compared 2 intervention groups that involved exercises only, with 1 study assessing the benefit of weekly supervised physical therapy with gum chewing and another evaluating the benefit of immediate (1-2 days) versus delayed (7-10 days) initiation of exercise post-surgery; there was no significant difference between groups in either study. One RCT that recruited only patients with trismus demonstrated that an exercise regime in combination with low-level laser therapy or low-intensity ultrasound had superior results in mouth opening measurements compared to exercise alone. Two RCTs compared intervention groups with and without follow-up reminders; both studies showed a significant improvement in mouth opening measurements in groups with follow-up reminders.

CONCLUSION

This systematic review did not convey a clear consensus as to optimal intervention for trismus in HNC patients. A variety of exercise regimens and jaw rehabilitation devices appear to have comparable effectiveness. However, efforts focused on increasing adherence to a particular intervention protocol may positively impact mouth opening measures in head and neck cancer patients. Also, low-level laser therapy and low-intensity ultrasound coupled with exercise may be beneficial for patients with trismus.

Intraoral management of odontogenic infection associated with severe trismus under local anesthesia

Trismus is defined as a tonic contraction of the muscles of mastication. It can also refer to limited mouth opening of any cause. Trismus is a classical symptom of masticatory space infections and it can be a sign of an infection in the anterior compartment of lateral pharyngeal space. Common causes in clinical practice followed by trismus are odontogenic infection which can be periodontal or pericoronal. This article will present a clinical report on intraoral management of mandibular odontogenic infection accompanied by severe trismus under local anesthesia using modified Akinosi technique in an outpatient environment. Treatment and postoperative period were routine. This kind of approach provides access to the infection at an early stage without general anesthesia, it shortens the hospital treatment and it enables faster recovery. KEY WORDS: Local Anesthesia, Odontogenic infection, Trismus.

[Localised tetanus with no obvious entry site: about a case in Bamako (Mali)]

Tetanus is a major public health problem in sub-Saharan Africa. Localised tetanus is rare, unlike generalized tetanus which has been sufficiently described in the literature. We report a case of localised tetanus with no obvious entry site managed in the Department of Infectious Diseases in Bamako. The study involved a retired nurse aged 59 years who had not undergone tetanus booster immunisation within the last 10 years, corresponding to the date of her last delivery. She was referred to our Hospital with dysphagia associated with inability to open the buccal cavity. Patient's history was characterized by long-term therapy associated with many specialized consultations without any improvement. The diagnosis of localised tetanus with no obvious entry site was retained after having excluded any other local disorder. Outcome was favorable ten days after adequate management. Underdiagnosed or unknown to health-care providers, localised tetanus may mimic other diseases delaying diagnosis and management. Targeted campaign to build awareness should be implemented in order to improve adherence with immunization schedules.

The Efficiency of Three Irrigating Solutions after Surgical Removal of Impacted Mandibular Third Molars: A Cross-sectional Study

AIM

The present study was conducted to assess the effect of irrigation with three different irrigants, namely normal saline, chlorhexidine, and povidone iodine on pain, alveolar osteitis, swelling, trismus, infection, and food impaction during surgical removal of impacted mandibular third molar.

MATERIALS AND METHODS

Forty-eight patients, including 26 males and 22 females, fulfilling criteria for inclusion in this study were divided into three groups: group I where irrigant used was normal saline, group II as chlorhexidine, and group III as povidone iodine group.

RESULTS

The pain was significantly more in groups I and III in 24 hours and 7th day as well. Alveolar osteitis was noted in groups III and I, nil in group II. The facial swelling measured in millimeters on 24 hours and on 7th day was significantly higher in 24 hours in groups I and III than in group II. Trismus was significantly more in group I and group III than in group II (with p < 0.01) on 7th day.

CONCLUSION

It is concluded that chlorhexidine is effective in reducing pain, alveolar osteitis, swelling, and trismus when used as an irrigant following surgical removal of impacted third molar.

CLINICAL SIGNIFICANCE

Chlorhexidine as irrigating solution helps in reducing the postoperative consequences after third molar surgery. Further studies are required using large sample size.

Protocol for the trismus trial-therabite versus wooden spatula in the amelioration of trismus in patients with head and neck cancer: randomised pilot study

INTRODUCTION

Patients can develop trismus from their head and neck cancer or as a result of treatment. Trismus affects the jaw muscles and makes mouth opening difficult. To potentially combat trismus, patients could undertake proactive jaw stretching exercises prior to, during and after radiotherapy, although currently these are not the standard of care.

METHODS AND ANALYSIS

This is a randomised, open-label, controlled, two-centre feasibility study, to assess the objective and subjective effectiveness and cost-effectiveness of therabite use compared with wooden spatula in ameliorating trismus in patients treated for stage 3 and 4 oral and oropharyngeal cancer, managed either by primary surgery followed by (chemo)radiotherapy or primary (chemo)radiotherapy. The principal objective assessment is measurement of maximum jaw opening. Assessments in all cases will be performed preradiotherapy and again at 3 and 6 months postintervention.Secondary aims of the study will be (1) to assess whether therabite or the wooden spatula intervention improves patients' quality of life, (2) reduce the level of post-treatment clinical management/healthcare use and (3) a nested qualitative study will explore the experience of the patient taking part in the intervention; data will be transcribed verbatim and analysis will be based on content analysis methods using the interview questions as the framework for examination.

ETHICS AND DISSEMINATION

North West Greater Manchester granted ethical approval (REC Reference 11/NW/0744). Good Clinical Practice and the Declaration of Helsinki have been adhered to. The results will be presented internationally and submitted to a peer-reviewed journal. Head and neck cancer charities and information websites will also be approached.

TRIAL REGISTRATION NUMBER

NCT01733797.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

The effect of laser and botulinum toxin in the treatment of myofascial pain and mouth opening: A randomized clinical trial

This study conducted a randomized clinical trial in 15 patients, who sought care at the Dental Clinic of the University of Passo Fundo, in order to compare the use of low-level laser and botulinum toxin in the treatment of myofascial pain and whether they alter the mouth opening of patients with temporomandibular disorder. The patients were divided into two groups: the Laser group received low-level GaAlAs laser, 100mW of power at a wavelength of 830nm in continuous light emission; and the Toxin group received 30U of botulinum toxin type A (BTX-A) in the first session, and 15U after fifteen days. The assessments were performed by measuring pain with Visual Analogue Scale (VAS), and mouth opening with a digital caliper. Data were submitted to Student's t test at 5% significance level. Regarding pain symptoms, the results indicate that groups treated with laser and toxin registered 7U in VAS, at day 5 the scores were 4.75 and 4.86U, respectively. The laser worked faster (day 12) at 2.75U, and the group treated with BTX-A registered 2.86U at day 30. Both therapies investigated were effective in reducing pain, but the effect of low-level laser was faster than the use of BTX-A. Both treatments showed no statistically significant improvement in mouth opening.

Criteria for admission of odontogenic infections at high risk of deep neck space infection

OBJECTIVES

Many patients with odontogenic infections are hospitalised because of the risk of deep neck space infection. The objective of this study was to identify risk factors allowing more reliable selection of patients requiring hospitalisation for both specialists and emergency physicians.

MATERIAL AND METHODS

This retrospective study was based on a cohort of 97 patients hospitalised for odontogenic infection in the Department of Otorhinolaryngology and Head and Neck Surgery of Centre hospitalier Sud Francilien, Île-de-France, from January 2008 to June 2012.

RESULTS

The majority of patients presented with dental abscess (66 patients; 68%). Nineteen patients (20%) presented with deep neck space infection. The frequency of deep neck space infection was significantly higher in patients with mandibular odontogenic infection (16/55 patients (29%) than in those with maxillary odontogenic infection (3/42 (7%); P ≤ 0.009). The incidence of deep neck space infection was significantly higher in patients with dental abscess (17/66, (26%) than in those without dental abscess (2/31 (6%); P ≤ 0.03).

CONCLUSION

In addition to the well-known classical criteria (fever, neck swelling, dyspnoea, dysphagia, trismus, leukocytosis, elevated C reactive protein (CRP)), the criteria for admission for odontogenic infection should include mandibular odontogenic infection and/or the presence of dental abscess.

Juvenile Hyaline Fibromatosis: Impact of Periodontal Care on Quality of Life and a Patient Perspective

Juvenile hyaline fibromatosis (JHF) is a rare autosomal recessive inherited condition presenting early in life and characterized by the accumulation of hyaline-like tissue in the skin as well as various organs. Gingival overgrowth is a significant oral manifestation. This paper highlights how early and essential periodontal intervention may be necessary to improve mastication and subsequent weight gain, and to eliminate pain and improve the patient's quality of life. Here we highlight the key features of this condition and demonstrate how appropriate surgical management can have a significant impact on a patient's wellbeing. CPD/CLINICAL RELEVANCE: Juvenile hyaline fibromatosis has a significant impact on patient wellbeing and it is therefore important that clinicians are able to recognize the condition and ensure that patients receive appropriate care and management.

Oral complications of head and neck radiotherapy: prevalence and management

AIM

The aim of the study was to evaluate the short-term and long-term toxicity caused by radiation treatment in the head and neck with the technique of intensity-modulated radiotherapy (IMRT).

METHODS

We selected 20 patients, 18 men and 2 women aged between 21 and 71 years, undergoing radiation therapy (IMRT) in head and neck. Patients were visited during radiotherapy and followed for six months after the end of the therapy. We assessed the presence of: mucositis, xerostomia, dysgeusia, dysphagia, pain, trismus and, in the case of late-onset complications, radiation cavities.

RESULTS

Acute toxicity: in 20 patients, 18 reported mucositis, 19 xerostomia, 17, dysgeusia, 15 dysphagia, 18 had pain and 3 patients had trismus. Tardive toxicity: in 14 patients, 5 reported mucositis, 11 xerostomia, 6 dysgeusia, 2 dysphagia, 3 had pain, 4 trismus and in 4 patients were found radiation cavities.

CONCLUSION

Acute complications with higher prevalence were xerostomia (19 of 20 patients), dysgeusia of 2nd grade (11 patients of 20), mucositis of 1st grade and pain of 1st grade (10 patients of 20). Among the late complications it was noted a maintenance of the high prevalence of xerostomia (11 patients of 14) and an increase in prevalence of trismus (4 patients of 14) against a reduction of all other complications. The presence of radiation cavities in 4 patients of 14 was also recorded.

[DIAGNOSTICS OF POSITION OF THE MOTOR AND TRIGGER POINTS: OF THE CHEWING MUSCLES FOR ZYGOMATIC COMPLEX FRACTURES]

Existing treatment methods of zygomatic complex fractures, which are complicated by contrac- ture of the masseter as a result of displaced bone fragments, have to be improved. Lack of muscle relaxation leads to the formation of local hypertonicity. In spasmodic muscle fibers varies perfusion and hypoxia occurs, which is accompanied by the release of inflammatory mediators and activation of pain receptors. Over time, areas formed local hypertonicity specific trigger points that contain multiple sensory loci and include one or more sensitive nerve endings. A device for the effective electromyographic study of masseters as a source of their condition and the dynamics of changes in masticatory muscles during patient treatment by improving the fixation system on the face of the patient and the introduction of more perfect spatial coordinate system for mathematical calculations masseter motor position (or triggered) point. Patients were examined before and in the dynamics of treatment according to our methodology, which included proper masseter relaxation, reposition and fixation of bone fragments and further medical therapy.

Thirty-year follow-up of a TMD case treated based on the neuromuscular concept

AIM

Occlusal therapy is employed to alleviate the symptoms of a temporomandibular disorder (TMD) at times. However, the long-term effect of occlusal therapy in the masticatory system is not well understood. This case study aims to present a 30-year follow-up of a TMD case.

METHODOLOGY

The patient developed TMD with intermittent closed lock of the left temporomandibular joint (TMJ). Chief complaints included trismus, pain, and noise of the left TMJ during function. The patient's occlusal disharmony was assessed with use of electronic instruments and corrected based on the neuromuscular concept. A minimum-invasive and reversible approach using adhesive occlusal restorations was used.

RESULTS

The jaw movement and masticatory muscle activity assessed at the 7- and 23-year follow-ups revealed that the established occlusion was well adapted, and re-established the patient's functional occlusion system. The patient has been free from TMD symptoms with the corrected occlusion for 30 years.

CONCLUSIONS

Occlusal reconstruction based on the neuromuscular concept can be stably integrated into the patient's functional occlusion system.

Efficacy of mouth opening exercises in treating trismus after maxillectomy

BACKGROUND

Patients with maxillary tumor often suffer from trismus after maxillectomy, which could turn out to be a permanent sequela without proper intervention. In this study, the efficacy of mouth opening exercises in preventing and treating trismus was observed in patients with maxillary tumor early after their operations. At the same time, radiotherapy as an influencing factor for the mouth opening exercises was evaluated.

METHODS

In this study, 22 patients with maxillary oncology began their mouth opening exercises at an early stage (1-2 weeks) after maxillectomy. They were divided into two groups based on the principle of voluntariness: 11 patients in group 1 chose TheraBites as their instruments of mouth opening exercises, and the other 11 in group 2 chose stacked tongue depressors to help their exercises. All participants were trained to exercise 3-5 times a day, 30-40 oscillations at one time, with a 2-second pause at their maximum possible mouth open position. The maximal interincisor distances (MID) of patients were measured and recorded by a single investigator every week after the beginning of the mouth opening exercises. Medical information and the responses of patients were also recorded. Initial and final MIDs were calculated by SPSS 13.0.

RESULTS

The changes of the mouth aperture every week during exercises in both groups were described in figures, and there were statistical increases in the final MIDs compared with the initial ones. However, no significant differences were achieved between groups 1 and 2 (P > 0.05). Radiotherapy seemed to have no negative impact on the mouth opening results during the exercises.

CONCLUSION

Physical mouth opening exercises should be executed early after maxillectomy for the prevention and treatment of trismus, especially for those who had radiotherapy as part of antitumor treatments.

Oral complications of cancer and cancer therapy: from cancer treatment to survivorship

Answer questions and earn CME/CNE Oral complications resulting from cancer and cancer therapies cause acute and late toxicities that may be underreported, underrecognized, and undertreated. Recent advances in cancer treatment have led to changes in the incidence, nature, and severity of oral complications. As the number of survivors increases, it is becoming increasingly recognized that the aggressive management of oral toxicities is needed to ensure optimal long-term oral health and general well-being. Advances in care have had an impact on previously recognized oral complications and are leading to newly recognized adverse effects. Here, the authors briefly review advances in cancer therapy, including recent advances in surgery, oral care, radiation therapy, hematopoietic cell transplantation, and medical oncology; describe how these advances affect oral health; and discuss the frequent and/or severe oral health complications associated with cancer and cancer treatment and their effect upon long-term health. Although some of the acute oral toxicities of cancer therapies may be reduced, they remain essentially unavoidable. The significant impact of long-term complications requires increased awareness and recognition to promote prevention and appropriate intervention. It is therefore important for the primary oncologist to be aware of these complications so that appropriate measures can be implemented in a timely manner. Prevention and management is best provided via multidisciplinary health care teams, which must be integrated and communicate effectively in order to provide the best patient care in a coordinated manner at the appropriate time.

Treatment for TMD with occlusal splint and electromyographic control: application of the FARC protocol in a Brazilian population

The purpose of this study was to apply Functional Anatomy Research Center (FARC) Protocol of TMD treatment, which includes the use of a specific type of mandibular occlusal splint, adjusted based on the electromyographic index, in a group of 15 patients with disc displacement, classified according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and then analyzing the results compared with the control group. The clinical evaluations were completed both before and after the treatment. Electromyographic (EMG) data was collected and recorded on the day the splint was inserted (visit 1), after one week (visit 2) and after five weeks of treatment (visit 3). The control group consisted of 15 asymptomatic subjects, according to the same diagnostic criteria (RDC/TMD), who were submitted to the same evaluations with the same interval periods as the treatment group. Immediately after splint adjustment, masseter muscle symmetry and total muscular activity were significantly different with than without the splint (p < 0.05), showing an increased neuromuscular coordination. After treatment, significant variations (p < .05) were found in mouth opening and in pain remission. There were no significant differences among the three sessions, either with or without the splint. There were significant differences between the TMD and control groups for all analyzed indices of muscular symmetry, activity and torque, with the exception of total muscular activity. The use of the splint promoted balance of the EMG activities during its use, relieving symptoms. EMG parameters identified neuromuscular imbalance, and allowed an objective analysis of different phases of TMD treatment, differentiating individuals with TMD from the asymptomatic subjects.

The effect of manual therapy on masseter muscle pain and spasm

INTRODUCTION

Orofacial pain and pain in the muscles of mastication are frequent symptoms of temporomandibular disorder. The masseter is the closet masticatory muscle to the surface and has the function of raising and retracting the mandible. This muscle has considerable strength and is one of the main muscles involved in the shredding of food It is therefore of utmost importance in the masticatory cycle and generally the most affected by pain and spasms.

OBJECTIVES

The aim of the present study was to analyze the effect of manual therapy with transversal and circular movements on pain and spasm in the masseter muscle, using electromyography and a visual analogue pain scale (VAPS). Eight women who experienced pain upon palpation of the masseter greater than 6 on the VAPS were selected for participation in the study, which employed electromyography and a VAPS for assessment, followed by manual oral physiotherapy and reevaluation.

RESULTS

The statistical analysis revealed a reduction in pain, but there was no significant difference in electromyographic activity (p < 0.05).

CONCLUSION

It was concluded that massage therapy was effective on pain symptoms, but was not capable of altering the electrical activity of the masseter muscle.

Trismus-pseudocamptodactyly syndrome: case report ten years after

BACKGROUND

In 1969, Hecht and Beals described for the first time a rare dominant autosomal syndrome characterised by reduced mouth opening, pseudocamptodactyly, short stature, and foot deformities. Recent studies have confirmed that TPS is caused by a mutation of MYH8 that is common to another disease called Carney syndrome.

CASE REPORT

The authors describe the long term follow-up of a case presented in 2003, ten years after the first surgical procedure: a 14-year-old girl, affected by this rare syndrome, had underwent an early (at 4 years) surgical treatment of bilateral coronoidotomies to ensure safe airway management to allow subsequent surgical treatment to correct foot deformities. After six years, a complete relapse of the trismus occurred. Three years later, the patient underwent a second surgery of bilateral coronoidotomies to definitely solve trismus. At the 18 months follow-up, the mouth opening was stable.

Orofacial pain and neurosensory disorders and dysfunction in cancer patients

Orofacial pain and altered nerve sensation may be the initial sign of oropharyngeal or nasopharyngeal cancer. This article focuses on the most common orofacial pain conditions and neurosensory alterations that affect cancer patients, such as neuropathic pain, muscle spasm or contractures, mucositis, and increased or decreased sensory discrimination in the affected area. The various pharmacotherapeutic modalities for cancer pain management ranging from non steroidal anti-inflammatory drugs (NSAIDs) for mild pain to opioids for severe pain are discussed in detail.

Migration of aluminum silicate from the oral cavity to the submandibular region, with foreign body granuloma formation: report of a case

We present the first case of foreign body granuloma in the cervical (submandibular) region as a result of migration of noninjected aluminium silicate particles from the oral mucosa. This migration can be explained by macrophage phagocytosis and transport through the local lymphatic network and surgical disruption of fascial layers. The appearance of foreign body granulomas in distant sites may appear several weeks after the local event in a specific disposition according with the migration route. This entity must be born in mind in differential diagnosis of multiple nodules, pigmentation, or persistent swelling in the cervical-orofacial region.

Trismus: An unconventional approach to treatment

A 63 year-old man who had had an operation for adenocarcinoma of the left parotid gland presented with worsening trismus after the completion of radiotherapy. None of the treatments given were successful so he resorted to a "home-made" approach, and succeeded in improving his mouth-opening by 18 mm.

Aspiration of peritonsillar abscess in severe trismus

We present a novel method of aspirating a peritonsillar abscess in a patient with severe trismus. In our experience, this method is efficient, allows good access to the peritonsillar area and facilitates rapid resolution of the trismus before definitive drainage can be performed.

Oral complications of radiotherapy

Radiotherapy-induced damage in the oral mucosa is the result of the deleterious effects of radiation, not only on the oral mucosa itself but also on the adjacent salivary glands, bone, dentition, and masticatory musculature and apparatus. Biological response modifiers, cytoprotective drugs, salivary-sparing radiation techniques, and surgery have been introduced to combat and, more importantly, to prevent, the development of these complications. Radiotherapy-induced oral complications are complex, dynamic pathobiological processes that lower the quality of life and predispose patients to serious clinical disorders. Here, we focus on these oral complications of radiotherapy, highlight preventive and therapeutic developments, and review the current treatment options available for these disorders.

Diagnosing and treating the patient with restricted mandibular opening: a new approach

Patients with a restricted mandibular opening and related pain require a systematic process for differential diagnosis and treatment planning. This article considers the differential diagnostic process, treatment planning, and treatment delivery for a patient seeking a second opinion before surgery for a closed lock. A closed lock occurs when the disc in the joint has been pulled off the head of the condyle and forward, blocking the condyle from translating forward.

Mandibular Nerve Blocks for the Removal of Dentures During Trismus Caused by Tetanus

We report a case of trismus caused by tetanus in an 80-yr-old woman who developed severe and painful masseter spasms during which she violently bit the tip of her tongue with her dentures. Bilateral mandibular blocks were performed to remove the dentures. The patient fully recovered. We suggest that mandibular blocks are a useful tool in the management of oral events during trismus in conscious patients.

Comparative study of the therapeutic effect of a systemic analgesic and transcutaneous electrical nerve stimulation (TENS) on post-IMF trismus and pain in Nigerian patients

OBJECTIVES

To compare the therapeutic effect of paracetamol and Transcutaneous Electrical Nerve Stimulation (TENS), on post-Intermaxillary Fixation (IMF) trismus, and pain in some Nigerian patients.

PATIENTS AND METHODS

Twenty patients treated for mandibular fractures with IMF were randomly selected into two groups of ten patients each. After the release of IMF, they were started on jaw exercises with the aid of wooden spatulae to overcome trismus due to muscle spasm. Patients in Group I underwent jaw exercises before and after TENS therapy which lasted for 30 minutes while those in Group II had jaw exercises before and 30 minutes after ingestion of 100 mg of paracetamol. Their inter-incisal distances were recorded pre and post intervention.

RESULTS

Analysis of the data showed that for both therapeutic interventions, there was an appreciable gain in mouth-opening which was more prominent for patients with unusual difficulty in mouth-opening initially. However, a comparison between the mean improvements produced by TENS and analgesic revealed no significant difference between the two groups.

CONCLUSION

Both the TENS therapy and paracetamol provided similarly appreciable differences in inter-incisal distances (mouth-opening) after their applications.

The influence of cryotherapy on reduction of swelling, pain and trismus after third-molar extraction

BACKGROUND

Swelling, pain and trismus are undesirable consequences of impacted mandibular third-molar extraction. The authors conducted a study to evaluate the effectiveness of cryotherapy, the therapeutic use of cold, in reducing undesirable consequences after surgery.

METHODS

Fourteen patients aged 20 to 28 years comprised the sample. The authors extracted two impacted mandibular third molars at different times from each patient. Immediately after surgery, the patient underwent cryotherapy on one side for 30 minutes every one and one-half hours for 48 hours when he or she was awake. The patient did not receive cryotherapy on the other side. The authors performed clinical examinations to measure trismus and swelling before surgery, immediately after surgery and 24 and 48 hours after surgery.

RESULTS

The authors compared both sides for differences in swelling, pain and trismus in each patient. The results showed significant statistical differences in two of the five points that were used to measure the swelling (Wilcoxon nonparametric signed rank test of linear distances between the angle of the mandible to the pogonion and to the tragus). They found statistical differences between the two sides in relation to the pain; however, they found no significant differences in relation to trismus.

CONCLUSIONS

Cryotherapy was effective in reducing swelling and pain in this sample. Despite playing no role in the reduction of trismus, cryotherapy was effective in reducing swelling and pain in this sample, and the authors still recommend it be used.

CLINICAL IMPLICATIONS

Cryotherapy is helpful after third-molar extraction. Further studies need to be conducted that use larger samples of patients and other types of therapy, such as low-level laser therapy.

Trismus in head and neck oncology: a systematic review

The aim of this review was to identify systematically, criteria for trismus in head and neck cancer, the evidence for risk factors for trismus and the interventions to treat trismus. Three databases were searched (time period 1966 to June 2003) for the text "trismus" or "restricted mouth opening". Included in the review were clinical studies (> or = 10 patients). Two observers independently assessed the papers identified. In 12 studies nine different criteria for trismus were found without justifying these criteria. Radiotherapy (follow-up: 6-12 months) involving the structures of the temporomandibular joint and or pterygoid muscles reduces mouth opening with 18% (sd: 17%). Exercises using a therabite device or tongue blades increase mouth opening significantly (no follow-up), effect sizes (ES) 2.6 and 1.5 respectively. Microcurrent electrotherapy (follow-up 3 months) and pentoxifylline (no follow-up) increases mouth opening significantly (ES for both: 0.3).

Therapeutic effect of TENS on post-IMF trismus and pain

The study set out to investigate the therapeutic effect of Transcutaneous Electrical Nerve Stimulation (TENS) in the alleviation of pain and post-IMF trismus, in patients undergoing jaw exercises to hasten mouth opening after being treated for fractures of the mandible. Two groups of patients, with 10 patients in each group, were used for the study. The groups were the experimental and the control groups. They were all treated for mandibular fractures, and had their jaws immobilized for 6 weeks, immediately after which they were started on jaw exercises. The Inter-incisal distances and number of acceptable wooden spatulae that the jaws could accommodate were noted and recorded. The experimental group was then placed on the TENS therapy for 20 minutes, after which the new inter-incisal distances and the number of acceptable wooden spatulae were recorded. The control group had no TENS therapy; the patients only waited for 20 minutes without any stimulation, before the new inter-incisal distances and the number of acceptable wooden spatulae were measured and recorded. It was observed that the inter-incisal distance and the number of acceptable wooden spatulae significantly increased in patients in the experimental group compared to the control group. It was concluded that TENS could be useful in relieving the pain associated with forced mouth-opening exercises aimed at overcoming trismus caused by muscle spasm, which is associated with prolonged immobilization of the jaws for the treatment of facial fractures.

Oral complications in radiation therapy

The dentist is integral to managing care for patients with head and neck cancer. Oral complications may manifest during and/or following radiation therapy and can last for the lifetime of the individual. This article reviews a number of these complications as well as the resources available to dentists for managing care of radiation oncology patients and improving their quality of life.

Trismus-pseudocamptodactyly syndrome: a case report

BACKGROUND

Hecht and Beals in 1969 described an autosomal dominant syndrome characterised by severe restriction of mouth opening, camptodactyly, shortness of leg muscles and, as a direct consequence, foot deformities.

CASE REPORT

A case of a 4-year-old girl affected by this unusual syndrome is described. The patient underwent bilateral resection of coronoid processes by intraoral approach. An intraoral device was used in the immediate postoperative period in order to maintain mouth opening. Once at home, the patient has had, for six months, phisiokinesic therapy by means of a modified Darcissac device.

Cephalic tetanus as a result of rooster pecking: an unusual case

In this paper, a case of cephalic tetanus caused by rooster pecking to the face is presented. Cephalic tetanus is a rare type of tetanus defined by trismus and paralysis of 1 or more cranial nerves. On admission to hospital the patient had facial palsy and trismus. With proper medical management she recovered without any relapse.

[Initial results using extracorporeal low energy shockwave therapy ESWT in muscle reflex-induced lock jaw]

BACKGROUND

Post-traumatic reflex-mediated temporomandibular joint (TMJ) locking is one of the complications frequently observed after sophisticated and long dentoalveolar operations. Its severity can be up to 90%. Usually, therapy consists of mouth-opening exercises using tongue depressors. In difficult cases, the treatment regularly extends for weeks, often with only moderate improvement of this painful limitation.

USE OF ESWT

In three cases, it was shown that supportive treatment utilizing low-energy shock waves (ESWT) is significantly effective in the therapy of limited opening of the mouth. The patients reported relief of their complaints, especially over the mandibular angle region, through the daily application of ESWT and felt their condition improved after the fifth therapy course.

DISCUSSION

This in particular improved the patient's ability to eat, speak, and maintain good oral hygiene. Great physiotherapeutic benefit is imparted by the use of ESWT in the clinical management of these and other cases of dentomaxillofacial practice.

Mandibular nerve block treatment for trismus associated with hypoxic-ischemic encephalopathy

BACKGROUND AND OBJECTIVES

We describe the use of mandibular nerve block for the management of bilateral trismus associated with hypoxic-ischemic encephalopathy.

CASE REPORT

The patient was a 65-year-old man with bilateral trismus due to hypoxic-ischemic encephalopathy. Despite his impaired consciousness, we performed fluoroscopically guided bilateral mandibular nerve block. The bilateral symptoms were sufficiently improved, without obvious side effects, by injecting a local anesthetic near the right mandibular nerve and a neurolytic near the left mandibular nerve.

CONCLUSIONS

Mandibular nerve block may be an effective treatment for patients with bilateral trismus due to ischemic-encephalopathy, even when consciousness is impaired.

Trismus: aetiology, differential diagnosis and treatment

Trismus is a problem commonly encountered by the dental practitioner. It has a number of potential causes, and its treatment will depend on the cause. This article discusses the primary causes of this condition and the various treatments available.

Oral administration of milk from cows immunized with human intestinal bacteria leads to significant improvements of symptoms and signs in patients with oral submucous fibrosis

BACKGROUND

Previous studies have shown that the local and systemic upregulation of fibrogenic cytokines and downregulation of antifibrotic cytokine are central to the pathogenesis of oral submucous fibrosis (OSF). The milk from cows immunized with human intestinal bacteria (immune milk) contains an anti-inflammatory component that may suppress the inflammatory reaction and modulate cytokine production. Therefore, it was decided to test whether immune milk may have some beneficial effects on controlling the symptoms and signs in OSF patients.

METHODS

In this preliminary study, 26 OSF patients who received immune milk treatment (45 g of immune milk powder twice a day) for 3 months and oral habit intervention were included in the experimental group. Another 20 OSF patients who received only oral habit intervention served as the control group.

RESULTS

We found that the interincisor distance was significantly improved (> or =3 mm of the baseline measurement) in 18 of the 26 (69.2%) OSF patients in the experimental group at exit. However, in the control group none of the OSF patients had an increase in interincisor distance greater than 2 mm. In addition, disappearance or significant improvement of symptoms at exit was observed in 80% (16/20) of the patients with intolerance to spicy foods (P < 0.001) and 72.2% (13/18) of the patients with xerostomia (P < 0.005) in the experimental group, compared with 17.6% (3/17) of the patients with improvement of intolerance to spicy foods and 15.4% (2/13) of the patients with improvement of xerostomia in the control group. Partial regression of concomitant oral leukoplakia or erythroplakia (judged from the size reduction of the lesions) at exit was noted in 71.4% (5/7) of the patients in the experimental group (P < 0.05), compared with none (0/5) of the patients with improvement in the control group.

CONCLUSION

We conclude that oral administration of immune milk leads to significant improvements of symptoms and signs in OSF patients.

[A case of cephalic tetanus presenting with opisthotonus]

We report a case of cephalic tetanus presenting with opisthotonus. A 49-year-old man was admitted because of repeated convulsions. The patient was a garbage truck driver known to be alcoholic, who fell down to suffer an injury of the left face two days before the onset of convulsion. Intravenous administration of diazepam and phenytoin partially relieved the convulsions. Anti-tetanus human immuno-globulin was also administered despite absence of typical clinical sign. Six hours later, however, the patient became unable to open the mouth, i.e. lockjaw developed, and the diagnosis of tetanus was made. Additional anti-tetanus human immunoglobulin of 3,000 units and 4,500 units on the next day rapidly relieved the lockjaw, convulsion, and general muscle rigidity without sequalae. The patient showed transient bilateral facial palsy and rotatory nystagmus during the course. Cephalic tetaus is characterized by a history of an injury of the head and a short latency before developing generalized tonic convulsion or opisthotonus. While a typical case presents with lockjaw, our case presented with opisthotonus, presumably because of early systemic lymphatic spreading of tetanus toxin. Early diagnosis and treatment is important to prevent generalized convulsions which are more frequent and sometimes lethal in cephalic tetanus than the common form.

Management of pain in peritonsillar abscess

A prospective study was undertaken in 75 patients with peritonsillar abscess to determine the treatment that was most effective in relieving the excruciating pain associated with the condition. The patients were divided into three treatment groups: intravenous antibiotic, aspiration, and incision and drainage. The effect of treatment on pain was objectively assessed by serially measuring the upper to lower incisor distance and by giving the patient water to drink at regular intervals to determine the point at which swallowing was pain-free. The improvement of the mean upper to lower incisor distance 15 minutes after the initial treatment was five per cent in the intravenous antibiotic group, 38 per cent in the aspiration group, and 100 per cent in the incision and drainage group. None of the patients in the intravenous antibiotic group was able to swallow water two hours after the initial treatment. In the same time interval two patients (eight per cent) in the aspiration group and 23 patients (92 per cent) in the incision and drainage group were able to swallow water. The conclusion derived from this study is that incision and drainage is superior to intravenous antibiotic and aspiration in relieving the pain associated with peritonsillar abscess.