Reduced Mouth Opening Research Articles

Comparison of the trapezius and the adductor pollicis muscle as predictor of good intubating conditions: a randomized controlled trial

BackgroundAdequate muscle relaxation is important for ensuring optimal conditions for intubation. Although acceleromyography of the adductor pollicis muscle is commonly used to assess conditions for intubation, we hypothesized that acceleromyography of the trapezius is more indicative of optimal intubating conditions. The primary outcome was the difference between both measurement sites with regard to prediction of good or acceptable intubating conditions.MethodsNeuromuscular blockade after injection of rocuronium 0.3 mg/kg IV was measured simultaneously with acceleromyography of the adductor pollicis muscle and the trapezius muscle in sixty female patients, American Society of Anesthesiologists physical status I to III, undergoing general anesthesia for gynecologic surgery. Exclusion criteria were: expected difficult tracheal intubation (e.g. history of difficult intubation, reduced mouth opening (< 2 cm) and/or Mallampati Score 4), increased risk of pulmonary aspiration (e.g. gastroesophageal reflux or delayed gastric emptying) allergies to drugs used during the study, pregnancy, neuromuscular diseases, medication with potential to influence neuromuscular function (e.g. furosemide, magnesium, cephalosporins) and hepatic or renal insufficiency (serum bilirubin >26 μmol/L, serum creatinine >90 μmol/l). Patients were randomized to 2 groups: group A (n = 30): endotracheal intubation after onset of the neuromuscular block at the adductor pollicis muscle. Group B (n = 30): endotracheal intubation after onset at the trapezius muscle. Intubating conditions were compared between both groups by means of a standardised score (the Copenhagen score) with Fisher’s exact test.ResultsOnset of the block after rocuronium injection was observed at the adductor pollicis muscle compared to the trapezius with 2.8 (1.1) versus 2.5 (1.1) min (mean ± SD; P = 0.006). Intubating conditions were poor in 2 patients (7%) of group A, and in 1 patient (3%) of group T. They were acceptable (either excellent or good) in 28 patients (93%) in group A, and in 1 patient (97%) in group T (P = 0.82).ConclusionsPerforming acceleromyography at the trapezius muscle reduced the time between injection of neuromuscular blocking agents and intubation by 18 s (11%). Thus, trapezius muscle acceleromyography is an acceptable alternative to adductor pollicis muscle acceleromyography in predicting acceptable intubating conditions, which allows for earlier indication of adequate intubating conditions.Trial registrationClinicalTrial.gov Identifier: NCT01849198. Registered April 29, 2013.

Dexamethasone seems to reduce pain, swelling, and mouth opening reduction compared with diclofenac after third-molar extraction

Dexamethasone seems to reduce pain, swelling, and mouth opening reduction compared with diclofenac after third-molar extraction

Perioperative supplementation with a fruit and vegetable juice powder concentrate and postsurgical morbidity: A double-blind, randomised, placebo-controlled clinical trial

Surgical trauma leads to an inflammatory response that causes surgical morbidity. Reduced antioxidant micronutrient (AM)a levels and/or excessive levels of Reactive Oxygen Species (ROS)b have previously been linked to delayed wound healing and presence of chronic wounds. We aimed to evaluate the effect of pre-operative supplementation with encapsulated fruit and vegetable juice powder concentrate (JuicePlus+®) on postoperative morbidity and Quality of Life (QoL)c. We conducted a randomised, double-blind, placebo-controlled two-arm parallel clinical trial evaluating postoperative morbidity following lower third molar surgery. Patients aged between 18 and 65 years were randomised to take verum or placebo for 10 weeks prior to surgery and during the first postoperative week. The primary endpoint was the between-group difference in QoL over the first postoperative week, with secondary endpoints being related to other measures of postoperative morbidity (pain and trismus). One-hundred and eighty-three out of 238 randomised patients received surgery (Intention-To-Treat population). Postoperative QoL tended to be higher in the active compared to the placebo group. Furthermore, reduction in mouth opening 2 days after surgery was 3.1mm smaller (95% CI 0.1, 6.1), the mean pain score over the postoperative week was 8.5mm lower (95% CI 1.8, 15.2) and patients were less likely to experience moderate to severe pain on postoperative day 2 (RR 0.58, 95% CI 0.35, 0.95), comparing verum to placebo groups. Pre-operative supplementation with a fruit and vegetable supplement rich in AM may improve postoperative QoL and reduce surgical morbidity and post-operative complications after surgery. ClinicalTrials.gov Identifier: NCT01145820; Registered June 16, 2010.

Exercise therapy for trismus secondary to head and neck cancer: A systematic review.

Effects of exercise therapy for trismus secondary to head and neck cancer have not been reviewed systematically since 2004. Four databases were searched. The quality of observational studies and randomized controlled trials was assessed. Two hundred eleven articles were found, 20 studies were included. A large variation in research methodology, stretching techniques, duration of stretch, and repetition of exercises was found. The overall quality was moderate. Five of the 8 preventive studies found that exercises during (chemo)radiotherapy could not prevent a reduction in mouth opening. In 4 therapeutic case studies, mouth opening increased between 17 and 24 mm. In 8 other therapeutic studies, mouth opening increased between -1.9 and 13.6 mm. No exercise therapy was clearly superior to the others. Changes in mouth opening ranged considerably and no stretching technique was superior to others regarding either prevention or treatment of trismus. Clinical guidelines cannot be given based on this systematic review. © 2016 Wiley Periodicals, Inc. Head Neck 39: 160-169, 2017.

Effects of Fat Grafting Containing Stem Cells in Microstomia and Microcheilia Derived from Systemic Sclerosis.

Systemic sclerosis (SSc) is an autoimmune disease with multisystem involvement, dominated by a general fibrosis. The early stage of the disease is associated with progressive damage to microcirculation, particularly in the respiratory tract, the gastrointestinal tract and skin. The face assumes a typical appearance characterized by microstomia (reduction of mouth opening) and microcheilia (thinning of the lips). These conditions cause a considerable reduction in performance status of patients. We treated them by fat grafting, rich in adipose stem cells, and we evaluated through time clinical, functional and aesthetic evaluation of oral pathology associated with SSc. From September 2014 to May 2016, we enrolled and treated seven patients in the plastic, reconstructive and aesthetic surgery clinic. Through time, we evaluated the following parameters: evaluation of mouth opening (maximum opening in superior-inferior and lateral directions) and lip thicknesses, both measured by doctors of the aforementioned operating unit; variation in the quality of life as perceived by patients according to the MHISS scale (Mouth Handicap Systemic Sclerosis); variation in severity of labial fibrosis assessed by microscopic analysis of pre- and post-fat transfer samples in the pathology clinic; safety of the protocol, according to the management of side effects resulting from the procedure; aesthetic evaluation, made by external observers and non-experts in the field, on pre- and post-operative photographs. We reported satisfying results, both functionally and aesthetically, for all parameters except one, for which the sample size might have proven critical. These data should be a starting point for further experimental research and clinical trials. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre.

Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target-controlled infusions of remifentanil and propofol. Oxygenation was achieved with high-flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over-sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.

Aloe vera in the management of oral submucous fibrosis

Oral submucous fibrosis is a pre-malignant condition commonly prevalent in India, Pakistan, Taiwan and Sri Lanka. Patients characteristically exhibit progressive reduction in mouth opening. The disease has a high malignant potential and thus should be diagnosed and treated at the earliest. However, none of the currently used medical therapies show promising results. The current article briefly reviews the role of Aloe vera in the management of oral submucous fibrosis.

Rehabilitation of a hemimaxillectomy patient having microstomia with two-piece hollow obturator

Eradication of head and neck carcinoma with surgical resection usually leave behind the patient with a large tissue defect and to rehabilitate such patients to optimum function and esthetics is a challenging task for the maxillofacial prosthodontist. The patients undergoing partial or total maxillary resections have difficulty in mastication, swallowing, speech, and social interaction. This article presents a case report of a hemimaxillectomy patient treated with a two-piece hollow acrylic bulb obturator. This case report presents a modified impression technique with a specially designed sectional tray as the patient had reduced mouth opening. The prosthesis improves the hypernasality, mastication, and speech of the patient.

Temporomandibular Joint Pain: Clinical Presentations and Response to Conservative Treatments in a Nigerian Tertiary Hospital.

Aims and Objectives:The aims of this study are to determine the prevalence, pattern of presentation, and response to conservative (medical) interventions among patients who presented with temporomandibular joint (TMJ) pain in a Nigerian teaching hospital.Material and Methods:Consecutive patients who presented in Oral Medicine and Periodontology Clinic of Obafemi Awolowo University Teaching Hospitals' Complex on account of TMJ pain from January 2015 to December 2015 were recruited for the study. They were all interviewed and examined. The severity of pain was recorded using visual analog scale (VAS). Patients were treated with medications and physiotherapy. They were reviewed at 2, 4, and 6 weeks. Those who could not make the appointment were contacted through phone. The findings were recorded and analyzed using STATA version 11.Results:A total of 401 participants were seen, 55 presented on account of TMJ pain. The mean age of patients with TMJ pain was 54 ± 16.9 with 60% being female. Pain was present in all participants; other signs include clicking joint sound (85%), jaw deviation (64%), attrition (24%), and reduced mouth opening (23%). The left joint was more frequently affected (75%). Following 6 weeks of conservative treatments, none of the respondents had VAS score of more than 3.Conclusion:The prevalence of TMJ pain was 13%. TMJ was found to be more common in participants above 50 years with female predilection. Pain was most common symptom seen, and response to conservative treatments as assessed using VAS following 6-week of treatment showed complete remission of the pain.

Efficacy of oral colchicine with intralesional hyaluronidase or triamcinolone acetonide in the Grade II oral submucous fibrosis.

Background and Objectives:Oral submucous fibrosis (OSMF) is a potentially malignant disorder of oral mucosa affecting mainly population in South and Southeast Asia. The aim of this study is to compare the effectiveness of oral colchicine with intralesional injection of hyaluronidase or injection triamcinolone acetonide in patients with Grade II OSMF.Materials and Methods:The study included thirty patients of clinically diagnosed Grade II OSMF. Patients were divided randomly into two groups: Group A patients were treated by administrating tablet colchicine 0.5 mg twice daily with an intralesional injection of hyaluronidase 1500 IU with 0.5 ml of lignocaine hydrochloride at weekly interval for 12 weeks. Group B patients were treated by administering tablet colchicine 0.5 mg twice daily with an intralesional injection of triamcinolone acetonide 10 mg/ml at weekly interval for 12 weeks. Clinical diagnosis was based on burning sensation in mouth, blanching of mucosa, presence of vesicles or ulceration in oral cavity, and reduced mouth opening. Outcome assessment was done at intervals of 3 weeks, 6 weeks, 3 months, and 6 months.Results:Improvement in mouth opening and reduction in burning sensation was seen more in Group A patients. Improvement in blanching of mucosa was seen in both the groups.Conclusion:In conclusion, use of injection hyaluronidase with oral colchicine gave better results in terms of increase in mouth opening and improvement in burning sensation without notable side effects. However, for a definite conclusion, further study with large sample size and long follow-up is required.

Congenital Alveolar Synechiae in a Neonate: Case Report and Review of Literature

ABSTRACTAimThis case report highlights the management of congenital alveolar synechiae (CAS) in a 4-day-old neonate to alleviate the parent’s anxiety and associated problems.IntroductionCongenital alveolar synechiae is a rare developmental anomaly found in neonates characterized by adherence of both the jaws by the fibrocollagenous bands. It will cause difficulty in feeding, has reduced mouth opening, and also affects the development of the jaws, if not excised at an early age.Case reportA 4-day-old neonate reported with inability to open the mouth properly. A diagnosis of CAS was made and managed under inhalation general anesthesia.ConclusionEarly management results in resolution of the feeding difficulty and adequate mouth opening. These cases should be managed as early as possible to prevent possible complications.How to cite this articleKumar N, Kumari R, Gauba K, Kapur A. Congenital Alveolar Synechiae in a Neonate: Case Report and Review of Literature. J Contemp Dent 2017;7(2):135-138.

Osteoblastoma of the temporal articular tubercle misdiagnosed as a temporomandibular joint disorder

The case of a 17-year-old female with a benign osteoblastoma in the temporomandibular joint (TMJ) is reported. The patient had a 2.5-year history of reduced mouth opening accompanied by tenderness and swelling in the left TMJ. Initial treatment included stabilization of the occlusion with a splint, jaw exercises, and analgesics. At first the patient's symptoms decreased, but they then increased 18 months later, prompting a cone beam computed tomography (CBCT) evaluation of the joint. The radiographic findings showed a somewhat ill-defined, radiolucent, expansile lesion containing small scattered calcifications located in the temporal articular tubercle. The lesion was removed under general anaesthesia and sent for histopathological examination. At the 12-month follow-up, the patient had normal TMJ function without clinical symptoms. CBCT examination showed a small recurrence of 3mm. Another 12 months later, CBCT showed a 1-mm increase in the recurrence. Her function was normal, with slight tenderness lateral to the left TMJ. The decision from a multidisciplinary meeting was further annual follow-up. The present case illustrates the importance of initial radiographic examination together with clinical examination in patients with TMJ dysfunction.

The performance of rigid scopes for tracheal intubation: a randomised, controlled trial in patients with a simulated difficult airway.

We compared the Bonfils™ and SensaScope™ rigid fibreoptic scopes in 200 patients with a simulated difficult airway randomised to one of the two devices. A cervical collar inhibited neck movement and reduced mouth opening to a mean (SD) of 23 (3) mm. The primary outcome parameter was overall success of tracheal intubation; secondary outcomes included first-attempt success, intubation times, difficulty of intubation, fibreoptic view and side-effects. The mean (95% CI) overall success rate was 88 (80-94)% for the Bonfils and 89 (81-94)% for the SensaScope (p = 0.83). First-attempt intubation success rates were 63 (53-72)% for the Bonfils and 72 (62-81)% for the SensaScope (p = 0.17). Median (IQR [range]) intubation time was significantly shorter with the SensaScope (34 (20-84 [5-240]) s vs. 45 (25-134 [12-230]) s), and fibreoptic view was significantly better with the SensaScope (full view of the glottis in 79% with the SensaScope vs. 61% with the Bonfils). This might be explained by its steerable tip and the S-formed shape, contributing to better manoeuvrability. There were no differences in the difficulty of intubation or side-effects.

Need of Oral Pre Cancer Awareness Initiatives in India.

Need of Oral Pre Cancer Awareness Initiatives in India.

The spectrum of orofacial manifestations in systemic sclerosis: a challenging management.

Systemic sclerosis (SSc) is a rare multisystem connective tissue disorder characterized by the triad fibrosis, vasculopathy and immune dysregulation. This chronic disease has a significant impact on the orofacial region that is involved in more than two-thirds of the cases. SSc patients can show a wide array of oral manifestations, which are usually associated with a severe impairment of the quality of life. They often present a decreased the salivary flow and a reduced mouth opening that contribute substantially to the worsening of the oral health status. Therefore, SSc patients require specific and multidisciplinary interventions that should be initiated as early as possible. The identification of specific radiological and clinical signs at the early stage will improve the management of such patients. This study reviews the wide spectrum of orofacial manifestations associated with SSc and suggests clues for the oral management that remains challenging.

Clinical Practice and Risk Factors for Immediate Complications of Endotracheal Intubation by Intensive Care Unit Doctors in a Regional Hospital in Hong Kong

Background Endotracheal intubation in critically ill patients is often challenging and is associated with a high complication rate. Intensive Care Unit (ICU) doctors are often responsible for emergency intubation but local data about their experience is lacking. Objective To describe the ICU team's practice of endotracheal intubation in critically ill patients in a regional hospital; to evaluate the incidence of immediate complications; and to identify risk factors for complications and predictors for successful intubation. Design Retrospective, observational study Patients All patients who received endotracheal intubation by the ICU team of the study centre between the 1st July 2013 and 31st December 2013. Results Complete data from 325 endotracheal intubations were analyzed. The commonest diagnosis was pneumonia (41.5%) and the mostly frequently cited indication for endotracheal intubation was respiratory failure (50.8%). Complications occurred in 25.5% of all intubations including 4 cases of cardiac arrest after the procedure. Haemodynamic alterations (hypotension and hypertension occurred in 9.2% and 7.4% respectively) were the most common complications. Overall, 96.6% of intubations were successful on the first two attempts. Logistic regression analyses showed that reduced mouth opening was a significant risk factor for immediate complications (odds ratio [OR] 15.98, 95% confidence interval [CI]: 2.71 to 94.41, P=0.006). Cormack-Lehane laryngoscope grading below 2b (OR 0.2, 95% CI: 0.07-0.59, P=0.003) and operator with more than 6 months of formal anaesthetic training (OR 7.06, 95% CI: 1.63 to 30.62, P=0.009) were independent predictors for successful intubation. Conclusion The ICU team achieves a high successful rate of emergency endotracheal intubation. High rates of anticipated and unanticipated difficult airway are encountered. Reduced mouth opening is a significant risk factor for complications occurrence. Cormack-Lehane laryngoscopic grading below 2b and intubation performer with more than 6 months of formal anaesthetic training are significant independent predictors for successful intubation. (Hong Kong j.emerg.med. 2016;23:135-144)

PO-0635: Dose to the masseter muscle and risk of trismus after chemoradiation for advanced head & neck cancer

Purpose / objective: Head and neck cancer patients treated with chemoradiation are at risk for developing trismus (reduced mouth opening). Trismus is often a persisting side-effect and difficult to manage. It impairs eating, speech and oral hygiene, affecting quality of life. Although several studies identified the masseter muscle (MM) as one of the main organs at risk, currently this structure is rarely considered during treatment planning. Prospective studies for chemoradiation are lacking. The aim of our study was to quantify the relationship between radiation dose to the MM and development of radiation-induced trismus in an IMRT-VMAT population. Results: At the first evaluation, 6-12 weeks post-treatment, fourteen patients had developed radiation-induced trismus (15%). On average, mouth opening decreased with 4.1 mm, or 8.2 % relative to baseline. Mean dose to the ipsilateral MM was a stronger predictor for trismus than mean dose to the contralateral MM, as indicated by the lowest -2 log likelihood (Table 1). Figure 1A shows the correlation between the ipsilateral mean masseter dose and the relative decrease in mouth opening, with trismus cases indicated in red. No trismus cases were observed in 33 patients (35%) with a mean dose to the ipsilateral MM 50 Gy. Patients with tumors located in the oropharynx were at highest risk.

Exercise therapy for trismus secondary to head and neck cancer: A systematic review.

Effects of exercise therapy for trismus secondary to head and neck cancer have not been reviewed systematically since 2004. Four databases were searched. The quality of observational studies and randomized controlled trials was assessed. Two hundred eleven articles were found, 20 studies were included. A large variation in research methodology, stretching techniques, duration of stretch, and repetition of exercises was found. The overall quality was moderate. Five of the 8 preventive studies found that exercises during (chemo)radiotherapy could not prevent a reduction in mouth opening. In 4 therapeutic case studies, mouth opening increased between 17 and 24 mm. In 8 other therapeutic studies, mouth opening increased between -1.9 and 13.6 mm. No exercise therapy was clearly superior to the others. Changes in mouth opening ranged considerably and no stretching technique was superior to others regarding either prevention or treatment of trismus. Clinical guidelines cannot be given based on this systematic review. © 2016 Wiley Periodicals, Inc. Head Neck 39: 160-169, 2017.

Donor site morbidity in buccinator-based myomucosal flaps: A retrospective study

BackgroundBuccinator-based myomucosal flaps can be used as a lining in oral cavity, pharyngeal, esophageal, and nasal reconstructions. Donor site morbidity is an important factor in selecting a flap, therefore, it was decided that donor site morbidity of this type of flap should be evaluated. MethodIn a retrospective study, patients for whom this flap had been used for oral, nasal, or pharyngeal reconstruction in 2008–2012 were recalled. Donor site morbidity including reduction in maximal interincisal opening (MIO), obliteration of the mandibular vestibule, injury to the Stensen duct, and vertical fibrous band in buccal mucosa were evaluated. ResultsTwenty-two buccinator-based myomucosal flaps (20 patients) had been used for oral, nasal, or oropharyngeal reconstruction. The most common flap used was the Facial Artery Musculomucosal (FAMM) flap (50%), and the commonest cause for flap use was the presence of a cleft lip/palate sequel in patients (45%). Four patients had developed complications (minimal reduction in MIO) related to the donor site. ConclusionDonor site morbidity associated with buccinator-based myomucosal flaps is low. However, minimal reduction of mouth opening occurred in 20% of the patients.

Assessment of Function of Eustachian Tube in Oral Submucous Fibrosis - A Tympanometric Study.

Oral Submucous fibrosis (OSMF) is a chronic insidious disease of oral mucosa that occurs due to areca-nut chewing, consumption of chillies, autoimmunity and genetic predisposition. The disease starts with burning sensation and inability to tolerate spicy foods with gradual reduction in mouth opening due to fibrosis of the oral mucosa. The extension of fibrosis into the naso pharynx leads to reduction in hearing efficiency. It is a potentially malignant lesion and can transform into oral cancer. To assess the functional impairment of eustachian tube by audiogram and tympanometry in both ears in stage IV and stage III OSMF cases. This was a case-control study in which 30 cases of OSMF, which included 15 stage IV (30 ears), 15 stage III (30 ears) were compared with 15 normal controls. 1) Stage IV cases showed 76.3% positive audiogram with 63.3% of cases having Sclerosis of tympanic membrane i.e. As curve in Tympanogram; 2) 43.3% of Stage III cases showed positive audiogram with 46.7% of cases having Sclerosis of tympanic membrane i.e. As curve in tympanogram; 3) 100% negative audiogram with 100% normal A curve was seen in all controls. From this study, it is evident that functions of Eustachian tube were affected as fibrosis of oral mucosa progressed.