ORAL SURGERY ORAL SURGERY

Trismus: Aetiology, Differential

Diagnosis and Treatment
P.. D O.
!A"RAA"# A"D O"A#DEL
movement is 812 mm.
Abstract:
Trismus is a $ro%lem &ommonly en&ountered %y t'e dental $ra&titioner. #t
It is very important that dentists are
'as a num%er of $otential &auses, and its treatment (ill de$end on t'e &ause. T'is
familiar with the differential diagnosis of
arti&le dis&usses t'e $rimary &auses of t'is &ondition and t'e )arious treatments
limited jaw opening, as some of the
1 4
a)aila%le.
conditions attributed to it can be life
threatening. ood perception of its
Dent Update *++*, *-: ../-0
1 !
causes can help the dentist to refer the
Clinical Relevance:
Dental $rofessionals s'ould reali1e t'at trismus &an %e a
patient early for specialist care.
&ommon $ro%lem. Treatment of trismus may %e relati)ely easy or &om$li&ated. #t is
im$ortant to remem%er t'at multi$le $otential &auses e2ist.
3AUSES O4 TR#S5US
"everal conditions may cause or
predispose an individual to develop
trismus. #he aetiology of trismus may be
T
classified as follows$
rismus is an inability to open the applied to restrictions of movement
mouth. %ccording to Dorlands resulting from e&tra'articular joint infection(
Illustrated Medical Dictionary trismus abnormalities. #his latter type of trauma(
1
)ree* Trimos$ +grating,, +grinding,- is an*ylosis is what most clinicians *now
dental treatment(
as trismus.
temporomandibular joint disorders(
8
a motor disturbance of the In a busy practice, it is not unusual to
tumours and oral care(
trigeminal nerve, especially spasm see several patients each month with a drugs(
of the masticatory muscles, with complaint of trismus. #his condition radiotherapy and chemotherapy(
difficulty in opening the mouth, a may impair eating, impede oral hygiene,
congenital problems(
characteristic early symptom of restrict access for dental procedures and
miscellaneous disorders.
tetanus. adversely affect speech and facial
appearance. #hese are summari.ed in /igure 1 and
#rismus has a number of potential will be described below.
causes, which range from the simple
6'at is "ormal O$ening of
and non'progressive to those that are
t'e 5out'7
#nfe&tions
potentially life'threatening. 2 0
1a.anjian divided an*ylosis of the #he normal range of mouth opening #he hallmar* of a masticatory space
2
temporomandibular joint into true and varies from patient to patient, within a infection is limited jaw opening. #rismus
false. #he true type of an*ylosis was range of 43 03 mm, although some
may be related to dental infections and
attributed to pathological conditions of authors place the lower limit at 4! mm.
must be systematically evaluated so that
5 ,1 3
the joint, and false an*ylosis was #he width of the inde& finger at the nail
a potential life'threatening situation is
bed is between 12 and 15 mm. #hus, two discovered as early as possible.
fingers, breadth )43 mm- up to three Infections causing trismus may be of
fingers, breadth )!4!2 mm- is the usual
an odontogenic or non'odontogenic
P.J. Dhanrajani, FR!D", FD" R!",FFD R!"I,
width of opening. 6vidence suggests
nature. 7dontogenic infections have !onsultant, #ral Medicine, and O. Jonaidel , $D",
1 1 ,1 2
that gender may be a factor in vertical
M"c %#ral & Ma'illofacial "urgery(, "pecialist,
three major origins$ pulpal, periodontal
#ral & Ma'illofacial "urgery, Riyadh Dental
mandibular opening. In general, males and pericoronal. #he presence of an oral
!entre, Riyadh, )ingdom of "audi rabia.
display greater mouth opening. 8ateral infection, particularly around an
1 4
.. 9ental :pdate ;arch 2332
ORAL SURGERY
TR#S5US
8Aetiology and differential diagnosis9
#ntra:arti&ular ;. An<ylosis E2tra:arti&ular
*. Art'ritis syno)itis
=. 5enis&us $at'ology
Infection #rauma 9ental'treatment #;9 #umours and 9rugs <adiotherapy and =ongenital ;iscellaneous
related oral care chemotherapy
7dontogenic >on' ? @ost'e&traction ? @rimary and secondary ? 7steoradionecrosis ? Aysteria
7dontogenic ? 8ocal anaesthetic tumours of epipharyngeal ? @ost'radiation fibrosis ? 8upus 6rythematosus
injection and parotid region, jaws
? @ulpal ? #onsillitis joint ? Aypertrophy of coronoid
? @eriodontal )@eritonsillar ? "ubmucus fibrosis ? #rismuspseudocamptodactyly
? @ericoronal abscess- ? ;yositis ossificans ? @henothia.ine syndrome
? #etanus ? "uccinyl choline
? ;eningitis ? #rauma to #;B ? #ricyclic antidepressant
? Crain abscess due to wide and ? ;etaclopramide
? @arotid abscess prolonged opening ? Aalothane
? ;yofascial muscle spasm
? Internal derangement
? /racture mandible
? /racture
.ygomatic arch
? Incorporation of
foreign bodies
Figure 1. etiology of trismus.
erupting mandibular third molar, is the temporomandibular joint )#;B- Ideally, the needle should be placed in
most common cause. "evere symptoms in which trismus was a the pterygoid space, which is bound by 1 !
odontogenic infections involving the specific traumatic event. #he records of the internal obliDue ridge of the
muscles of mastication are often 225 patients were reviewed and 44.4E of mandible on the lateral side and
accompanied by trismus at initial cases had trismus within one wee* of pterygomandibular raphe on the medial
presentation. #his infection, if the event. side. 7ccasionally, the medial pterygoid
unchec*ed, can spread to various facial #rismus has also been reported due to muscle is accidentally penetrated or a
spaces of the head and nec* and lead to the accidental incorporation of foreign vessel is punctured and a small bleed
serious complications such as cervical bodies because of e&ternal traumatic follows$ a haematoma can occur in the
cellulitis or mediastinitis. injury. %nother relatively rare cause of muscle bed and subseDuently organi.e, 1 0 1 5
>on'odontogenic infections such as trismus seen in general practice is causing a fibrosis. #rismus due to this
tonsillitis, tetanus, meningitis, parotid trauma of the .ygomatic arch and cause can be protracted and Duite
abscess and brain abscess may also .ygomaticoma&illary comple& )F;=-, severe.2 2
cause trismus. which interferes with the movement of Aot pac*s, stretching e&ercises using 1 2 ,1 8
the coronoid process. wooden spatulas and reassurance are 2 3
usually sufficient for this condition,
Trauma
although sometimes the haematoma
Trismus Related to Dental
/ractures, particularly those of the becomes infected and reDuires surgical
Pro&edures
mandible, may cause limited jaw evacuation.
opening. 9epending upon the type of 7ral surgical procedures may result in
injury and the direction of the traumatic limited jaw opening. #he e&traction of
Tem$oromandi%ular oint
force, fractures of the mandible may teeth may also cause trismus as a result
Disorders
occur in different locations, producing either of inflammation involving the
mandibular hypomobility. muscles of mastication or direct trauma #here are numerous subcategories of
Cac*land et al. defined trauma as a to the #;B. #;9, a number of which may be 12 2 1
devastating event )e.g. sports injury-, %nother common cause of trismus associated with trismus. #;9s may be
administration of general anaesthesia often seen in general practice is the divided into e&tracapsular )mainly
and performance of a dental procedure limited mouth opening that occurs 2! myofascial- and intracapsular problems
such as difficult e&tractions or other days after a mandibular bloc* has been )including disc displacement, arthritis,
treatment reDuiring lengthy administered. #his is usually attributed fibrosis, etc.-. Intracapsular problems are
appointments. #he purpose of this to inaccurate positioning of the needle often caused by trauma. @ain upon
study was to investigate the onset of when giving the inferior nerve bloc*. palpation, lateral to the joint capsule, is
9ental :pdate ;arch 2332 .-

ORAL SURGERY
and can affect speech by restricting
; Trauma:
tongue and soft palate movements. #he
"urgical e&traction of mandibular molars
e&act aetiology is un*nown but it is
@ost'anaesthetic injections$
most commonly attributed to betel nut
Inferior alveolar nerve bloc* 24
@ost'superior alveolar nerve bloc*
chewing.
24
9irect trauma$
/ractured mandible
7ther facial fractures
Drug T'era$y /acial laceration
<ecent dental restorative procedures
"ome drugs are capable of causing
<adiation therapy
trismus as a secondary effect, succinyl
* #nfe&tion:
choline, phenothia.ines and tricyclic
In cases where there are associated signs and symptoms$
antidepressants being among the most
tachycardia
common.
tachypnoea 2 0
high temperature
#rismus can be seen as an
increased white blood cell count
e&trapyramidal side'effect of
decreased oral upta*e
metaclopramide, phenothia.ines and
dehydration
#hese may lead to the suspicion of more common facial spaces involvement. In the presence
other medications.
of nec* rigidity, tetanus should be ruled out. #hese conditions should be considered life
threatening if early treatment is not intervened.
Radiot'era$y>3'emot'era$y = T5D:
=hronic complaints usually seen in young females. #hey do not need any urgent attention.
9entists are on occasion as*ed to
provide treatment for patients
0 3onditions t'at affe&t t'e &entral ner)ous system such as meningitisGencephalitis, brain
tumourGabscess and epilepsy should be ruled out.
undergoing radiotherapy and
chemotherapy. 7ral mucosal cells
? Drug 'istory is very important in cases of trismus.
2 2 ,2 8
have a high growth rate and are
@ Tumours>oral &an&ers:
susceptible to the to&ic effects of
#hese conditions can be very obvious to diagnose clinically, e&cept some metastatic tumours
chemotherapy, which can lead to
in oropharyn&. 7ne should not forget oral submucous fibrosis in differential diagnosis.
stomatitis. #he severity of the stomatitis
A Psy&'ogeni& &auses , such as hysterical trismus.
is dose related. %lthough the damage is
able 1. Differential diagnosis of trismus.
reversible, this condition may cause
severe discomfort, pain, trismus and
difficulty in swallowing.
<adiotherapy is commonly used to
Tumours and Oral
a significant finding. =lic*ing may treat sDuamous cell carcinoma of the
5alignan&ies
indicate anterior disc displacement. head and nec* and regional
@ainless clic*ing alone does not reDuire % potential problem in treating patients lymphomas. #he primary advantage of
treatment. =onditions such as fibrosis or with trismus is the ris* of misdiagnosing using radiotherapy to treat oral cancer
unilateral condylar hyperplasia reDuire the patient who has a neoplastic is the preservation of normal tissue and
surgical consultation and treatment. disease, either primary or metastatic, in function( however, complications may
"uspicion of #;B trauma or the epipharyngeal region, parotid gland, develop, depending upon which
dislocation should be considered in jaws or #;B. #horough clinical and healthy tissues are in the path of the 2 4
young patients who have dysphagia radiographic e&amination must be radiation beam, the amount of radiation
and trismus but who do not have a performed to rule out neoplastic given and the course of treatment.
serious infectious aetiology. possibilities. <arely, trismus is a 7steoradionecrosis may occur, resulting 2 4 , 2 !
%cute closed'loc* conditions may symptom of nasopharyngeal or in pain, trismus, suppuration and
occur when the meniscus becomes infratemporal tumours or fibrosis of the occasionally a foul'smelling wound.
displaced anteromedial to the condyle. insertion of temporalis tendon, resulting Hhen the muscles of mastication are
In such instances, the patient usually in limited jaw movement. within the field of radiation, fibrosis may
has a history of paro&ysmal clic*ing 7ral submucous fibrosis is a result and lead to trismus, reducing the
and some discomfort. In closed'loc* precancerous condition, commonly range of movement. /ibrosis and trismus
conditions of a mechanical nature, the seen in people from the Indian have been attributed to the ischaemia
patient can often open his or her jaw subcontinent. %sian migrants in caused by endarteritis obliterans.
232! mm. If the opening is 6uropean countries also present with #rismus complicates post'radiation
significantly less than this the trismus due to fibrosis of the dental care. #he recommendation to
practitioner should suspect a closed submucosal tissue in the oral cavity. minimi.e the effects of radiation on the
loc* of muscular origin. #his causes blanching of the mucosa facial and masticatory muscles include
-+ 9ental :pdate ;arch 2332

ORAL SURGERY
TREAT5E"T>
the use of protective stents, jaw
the motor dysfunction, permitting the
5A"AGE5E"T O4 TR#S5US
e&ercises and hyperbaric o&ygen to
patient to open and allowing the
increase neovasculari.ation. #reatment of trismus varies depending
practitioner to provide the appropriate
on the aetiological factor. "ome
treatment.
difficulty in opening the jaw on the day
In virtually all cases of trismus that
3ongenital>De)elo$mental
following dental treatment in which a
are managed as outlined above, patients
3auses
superior alveolar or inferior alveolar
report improvement within 48 hours.
#here has been a report of trismus as a nerve bloc* was administered is
#herapy should be continued until the
result of hypertrophy of the coronoid freDuently encountered. #he degree of
patient is free of symptoms. If pain and
process causing interference of the discomfort and dysfunction varies, but
dysfunction continue unabated beyond
coronoids against the anteromedial is usually mild.
48 hours, the possibility of infection
margin of the .ygomatic arch. #rismus' Hhen a patient reports mild pain and
should be considered. %ntibiotics
2 5
pseudo'camptodactyly syndrome is a dysfunction, an appointment for
should be added to the treatment
4 3
rare combination of hand, foot and e&amination should be arranged. In the
regimen and continued for 2 days.
mouth abnormalities and trismus. interim, the practitioner should prescribe
If trismus is suspected to be
the following$
associated with infection, appropriate
antibiotics should be prescribed. In the
5is&ellaneous 3auses
heat therapy(
case of severe pain or dysfunction, if no
7ther rare causes of trismus are$ analgesics(
improvement is noted within 24 days
a soft diet( and )if necessary-
without antibiotics or !2 days with
hysteria )psychogenic-( muscle rela&ants
antibiotics, or if the ability to open has
lupus erythematosus, etc.
become very limited, the patient should
41
to manage the initial phase of muscle
be referred to an oral and ma&illofacial
Aysteria, or more accurately where a spasm. Aeat therapy consists of placing
surgeon for evaluation.
single symptom is concerned moist hot towels on the affected area for
#reatment for trismus should be
conversion hysteria, is the physical 1!23 minutes every hour. %spirin is
directed at eliminating its cause.
manifestation of suppressed emotional usually adeDuate in managing the pain
9iagnostic assessment should be made
conflicts and ideas. #he presentations associated with trismus( its anti'
before any type of therapy is applied.
42
are varied and include paralysis, inflammatory properties are also
blindness, anaesthesia, anore&ia and beneficial. % narcotic analgesic may be
3O"3LUS#O"
vomiting in fact, this condition may reDuired if the discomfort is more
mimic practically any disease. #hrough intense. If necessary, dia.epam )2.!!
#rismus is a common complication of
4 4
the mechanism of conversion, the mg three times daily- or other
dental treatment. In many ways, it is
emotional conflict is converted into a ben.odia.epine may be prescribed for
mostly harmless, but it could give rise to
physical symptom, thus releasing the muscle rela&ation.
many constraints for the patient,
4
patient from emotional conflict. #he Hhen the acute phase is over the
including social injunctions that can
onset of hysteria is usually before the patient should be advised to initiate
cause an&iety and danger. In a few
age of 4!, and occurs mainly in women physiotherapy for opening and closing
instances, lawsuits have been
and in those with a suggestible and the jaws and to perform lateral
instigated. #herefore, it is important for
parent'dependent personality. e&cursions of the mandible for ! minutes
clinicians to be aware of this significant
4 4
every 44 hours. "ugarless chewing
condition, its primary causes, and its
4 !
gum is another means of providing
treatments.
D#44ERE"T#AL D#AG"OS#S
lateral movement of the #;B. %ny
% systematic approach using a trauma or event that may be suspected
disciplined and organi.ed thought of having triggered the #;9 should be
R
process is more li*ely to yield an recorded in the patient,s dental record,
E4 ERE "3E S
1. #aylor 6B, ed. Dorlands Illustrated Medical
accurate diagnosis. /or the clinician to as should the findings and the
Dictionary, 22th ed. @hiladelphia$ H.C."aunders,
diagnose trismus properly, he or she treatment. /urther dental treatment in
1558( p.12!5.
must be able to determine the cause the involved region should be avoided 2. "tone B, 1aban 8C. #rismus after injection of local
from a variety of possibilities. It is until symptoms resolve and the patient
anaesthetic. #ral "urg #ral Med #ral *athol 1525(
0.: 2542.
important to obtain a complete history is more comfortable.4, !
4. ;alamed "/. +andboo, of -ocal nesthesia , 4rd ed.
and to perform a thorough clinical If further dental care is needed, as
"t. 8ouis$=.I. ;osby =o., 1553( pp.248245.
e&amination. <adiographs should be with a painful infected tooth, access for 4. @eterson 8B, 6llis 6 III, Aupp B<, #uc*er ;<.
ordered as deemed appropriate. #he local anaesthesia may be difficult when
!ontemporary #ral and Ma'illofacial "urgery.
#oronto$ =.I. ;osby =o., 1588( pp.224, 2!2, 484
possible causes that should be trismus is present. #he )closed mouth-
48!.
considered are listed in #able 1. nerve bloc* usually provides relief of
!. ;arien ;. #rismus$ causes, differential diagnosis and
-* 9ental :pdate ;arch 2332

ORAL SURGERY
treatment. .en Dent1552( 0? )4- :4!34!!. <eport of two cases and review of literature. / malignant tumors in the head and nec*. / -aryngol
0. 8eonard ;. #rismus$ Hhat is it, what causes it and #ral Ma'illofac "urg155!( ?=: 234238. #tol1554( ;+A: 13121323.
how to treat itJ Dentistry Today1555( une: 2422. 12. Cac*land 81, =hristiansen 68, "trut. B;. 20. =unningham @%, 1endric* <H. #rismus as a result
2. 1a.anjian C. %n*ylosis of the temporomandibular /reDuency of dental and traumatic events in the of metoclopramide therapy. / Irish Dental ssoc
joint. m #rthod 1548( *0: 11811230. etiology of temporomandibular disorders. 1588( =0: 128125.
8. 8u*y >, "ternberg =. %etiology and diagnosis of 0ndodont Dent Traumatol 1588( 0: 18218!. 22. #oth CC, /rame <#. 9ental oncology. #he
clinically evident jaw trismus. ust Dent /1553( =?: 18. 1itay 9. 8ateral pharyngeal space abscess as a management of disease and treatment'related
!24!25. conseDuence of regional anesthesia. / m Dent oralGdental complications associated with
5. ;e.itis ;, <allis , Facharides >. #he normal ssoc 1551( ;**: !0!5. chemotherapy. !urr *robl !ancer1584( A:24!.
range of mouth opening. / #ral Ma'illofac "urg 15. 1rishnan %, "leeman 9B, Irvine A. #rismus 28. >guyen %;A. 9ental management of patients
1584( 0A: 13281325. caused by a retained foreign body in an adult. #ral who receive chemo and radiation therapy. .en
13. <ieder =6. ;a&imum mandibular opening in "urg #ral Med #ral *athol 1552( A=: !40!42. Dent 1552( 0+: 43!411.
patients with and without a history of #;B 23. %.a. C, Feltser <, >it.an 9H. @athoses of 25. 9aniele %. #rismus due to hypertrophy of the
dysfunction. / *rosthet Dent1528( =-: 441440. coronoid process as a cause of mouth opening coronoid processes. Minerva "tomatol 1554( 0=:
11. "hah 1. #rismus$ bi.arre finding. )8etter to 6ditor- restrictions. #ral "urg #ral Med #ral *athol 1554( 18!185.
$r / #ral Ma'illofac "urg2333( =.: 452458. AA: !25!84. 43. #eng <B, Ao ;;, Hang @B, Awang 1=. #rismus'
12. >elson "B, >owlin #@, Coeselt CB. =onsideration 21. Cerge #I, Coe 76. @redictor evaluation of pseudo'camptodactyly syndrome$ report of one
of linear and angular values of ma&imum postoperative morbidity after surgical removal of case. cta *aediatr "in1554( =?: 144142.
mandibular opening. !ompend !ontin 0duc Dent mandibular third molars. cta #dontol "cand 1554( 41. Cade 9;, 8ovas*o BA, ;ontana B, Haide /8. %cute
1552( ;=: 402404. ?*: 102105. closed loc* in a patient with lupus erythematosus$
14. 9wor*in "/, Auggins 1A, 8e<esche 8 et al. 22. "tacy =, Aajjar . Carbed needle and ine&plicable =ase review. / !raniomandib Disord 1552( @:238212.
6pidemiology of signs and symptoms in paresthesias and trismus after dental regional 42. Irvine A, <owe >8. Aysterical trismus$ a
temporomandibular disorders$ clinical signs in cases anesthesia. #ral "urg #ral Med #ral *athol 1554( diagnostic problem. $r / #ral Ma'illofac "urg1584(
and controls. / m Dent ssoc1553( ;*+: 224281. AA: !8!!80. **: 22!225.
14. #ravell B. #emporomandibular joint pain referred 24. #rumpy I, 8yberg #. #emporomandibular joint 44. "almon #>, #racy >A Br, Aiatt H<. Aysterical
from muscles of the head and nec*. / *rosthet dysfunction and facial pain caused by neoplasms. trismus )conversion reaction-. <eport of a case.
Dent1553( ;+: 24!204. #ral "urg #ral Med #ral *athol 1554( A@: 1451!2. #ral "urg Med #ral *athol 1522( =0: 182151.
1!. >it.am 9H, "hteyer %. %cute facial cellulites and 24. Aausser ;", Coras*i B. 7ropharyngeal carcinoma 44. ;asbach BB. Aysterical trismus. % study of si& cases.
trismus originating in the e&ternal auditory meatus. presenting as an odontogenic infection with 12 "tate Dent / 1550( =*: 414410.
#ral "urg #ral Med #ral *athol 1580( @;: 202204. trismus. #ral "urg #ral Med #ral *athol1554( AA: 4!. 8und #H, =ohen BI. #rismus appliances and
10. Feitoun I;, 9hanrajani @B. =ervical cellulites and !25!84. indications for their use. 3uint Int 1554( *0: 22!
mediastinitis caused by odontogenic infection. 2!. Ichimura 1, #ana*a #. #rismus in patients with 225.
the root canal. Indeed, the authors many of the basic areas the material
BOOC RED#E6
Duote references that an apical ! mm
covered is not even sufficient for %
seal will be effective. Aowever, in
level students. #he author suggests
critici.ing the results of previous 3on&ise Te2t%oo< of P'ysiology for that this boo* might by suitable for
research, these wor*ers developed a
Dental Students. Cy A. @ispati. postgraduate dental students and
novel fluid transport assay techniDue. 7&ford :niversity @ress, 7&ford, 2331 further that even postgraduate medical
#hey found that removal of the
)442pp., K12.5! hGb-. I"C> 3'15' students might find it useful. I thin*
coronal part of a root filling had a
!0!235'0. this is unli*ely to apply to such
significant effect on the resistance of students in the :1.
the remaining seal to microlea*age,
#his te&tboo* of physiology covers Professor 5aggie Smit'
although they found no significant the basic systems in physiology. Uni)ersity of Birming'am Dental
difference between a remaining seal of
#hese systems are covered in 12 S&'ool
4 mm or 0 mm.
chapters and they are dealt with in a
#he significance of this report to very concise manner. #he te&tboo* is
general practice is two'fold. /irst,
aimed at dental students but the level
ABSTRA3T
dentists should be aware of this at which most areas are addressed
increased potential for failure of their
and the brevity and paucity of detail
endodontic treatment if temporary
ma*es it inadeDuate for students of T!E R#SCS O4 POST SPA3E
crowns lea* whilst the permanent dentistry in the :1. #hus, for PREPARAT#O"
restoration is being constructed.
e&ample, Cody /luids are covered in #he :npredictability of "eal after @ost
"econd, if a post crown has been lost just a few paragraphs and >utrition in "pace @reparation$ % /luid #ransport
from a canal for any period of time,
only si& )small- pages. #he digestion "tudy. I. %bramovit., <. 8ev, F. /uss
there is potential for the root canal
and absorption of all nutrients is and F. ;et.ger. /ournal of
seal to be compromised. It may be wise covered in appro&imately five pages. 0ndodontics 2331( *A: 25225!.
to consider this before recementation
"ubjects where one might e&pect more
or construction of a new crown. detail in a dental course, such as the It is always assumed that the root
Peter 3arrotte
functions of the mouth and pain, are filling remaining after post space
Glasgo( Dental S&'ool
not e&empt from this approach. In preparation will still effectively seal
-0 9ental :pdate ;arch 2332