How do I treat a female patient in her early 60s with trismus (lockjaw)?

Treatment of Trismus (Lockjaw) in a Female Patient in Her Early 60s

Begin with gentle stretching exercises using tongue blades and custom mouth opening devices immediately, combined with analgesics (acetaminophen or NSAIDs like ibuprofen) for pain control, and consider nerve-stabilizing agents like gabapentin or pregabalin if muscle spasm is significant. 1

Initial Assessment: Identify the Underlying Cause

Before initiating treatment, you must determine what is causing the trismus, as this directly impacts management:

• Temporomandibular joint (TMJ) disease or arthritis - particularly relevant in this age group 2
• Dental/periodontal infection or recent dental procedures - iatrogenic injury from local anesthetic injections or dental work 1, 3
• Tumor invasion - especially if there are oral cavity lesions or masses 1, 4
• Post-radiation therapy - if she has history of head and neck cancer treatment 1
• Muscle spasm from trauma or inflammation 5, 6

Perform a thorough oral examination looking for dental caries, periodontal disease, oral masses, signs of infection, and assess maximal mouth opening (trismus is defined as <35mm) 4. Check for tooth loss, as edentulous patients are eight times more likely to have trismus 4.

Primary Treatment: Conservative Management (First-Line)

Exercise therapy is the cornerstone of treatment and should start immediately: 1

• Gentle stretching exercises with tongue blades - have the patient perform these multiple times daily 1
• Custom mouth opening devices for rehabilitation - these maintain range of motion and prevent progression to chronic hypomobility 1, 3
• Heat application to the affected muscles 3

Pain and spasm control to facilitate compliance with exercises: 1

• Analgesics: Start with acetaminophen or NSAIDs (ibuprofen) for pain control 1
• Nerve-stabilizing agents: Prescribe pregabalin, gabapentin, or duloxetine to combat pain and muscle spasms - these facilitate compliance with physical therapy 1
• Muscle relaxants may be added if spasm is prominent 3
• Corticosteroids (dexamethasone) can reduce inflammation and associated trismus 1

When Conservative Management Fails

If symptoms persist despite 2-4 weeks of conservative therapy, consider botulinum toxin type A injections into the affected masticatory muscles for refractory pain and spasm control. 1

Dental-Specific Considerations

If dental infection or post-injection trismus is identified:

• Treat active dental caries and periodontal disease promptly 2
• Manage oral candidiasis if present 2
• Avoid multiple injections in short periods if future dental work is needed 3
• Early institution of treatment prevents progression to chronic hypomobility and fibrous ankylosis 3

Critical Pitfalls to Avoid

• Do not delay exercise therapy - waiting allows progression to chronic restriction and fibrous ankylosis 3
• Do not assume benign etiology without examination - trismus can be the presenting sign of oral malignancy, occurring in 42% of patients with oral cavity cancers before treatment 4
• Do not ignore inadequate pain control - uncontrolled pain prevents compliance with the essential stretching exercises 1
• Screen for underlying malignancy if no obvious dental or TMJ cause is identified, especially with associated symptoms like unexplained weight loss, dysphagia, or oral lesions 2, 4

Prevention if At-Risk

If this patient has history of head and neck radiation or is undergoing such treatment:

• Maintain range of motion exercises throughout and after radiation treatment to prevent trismus development 1
• Monitor for xerostomia and dental complications that can contribute to trismus 2