Dental Update 2002. Trismus - Aetiology Differential Diagnosis and Treatment
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ORAL SURGERY ORAL SURGERY Trismus: Aetiology, Differential Diagnosis and Treatment P.. D O. !A"RAA"# A"D O"A#DEL movement is 8–12 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 limi ted jaw openi ng, as s ome of t he 1 4 a)aila%le. conditions attribute d to it can be life threaten ing. ood perception of its Dent Upd ate *++* *-: /-0 1 ! causes can help the dentist to refer the Clinical Relevance: Dental $rofessionals s'ould reali1e t'at trismus &an % e a patient ea rly for spec ialist car e. &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 $otential &auses e2ist. 3AUSES O4 TR#S5US "everal conditions may cause or predispose an individual t o develop trismus. #he aetiology of trismus may be T classified as follows$ ri sm us is an i na bi li ty to open the ap pl ie d to restricti on s of movement mouth. %ccording to Dorland’s resulting from e&tra'articular joint infection( Illustrate d Medical Di ctionary tr is mus ab normal it ie s. #hi s l atte r t ype of trauma( 1 )ree* Trimos $ + gr at in g , + gr in di ng - is an*ylosi s i s what most c li ni ci ans *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, espec ially spasm see several patients each month with a drugs( of the masticatory muscles, with complaint of trismus. #his condition radiotherap y and chemotherapy ( difficulty in opening the mouth, a may impair eating, impede oral hygiene, congenital problems( characteristi c early symptom of restrict access for dental procedures and miscella neous disorders. tetanus. adversely affect speech and facial appearance. #hese are summaried 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'thre atening. 2 – 0 a a nj ian di vi de d an* ylos is of the #he no rmal ran ge of mou th op eni ng #he hallmar* of a masticato ry space temporomandi bula r jo int in to t rue an d va ri es f rom pa ti ent t o pa ti ent, wit hi n a infection is limited jaw opening. #rismus fa ls e. #h e t rue t yp e of a n* yl os is wa s ra ng e of 4 3– 03 mm, a lt houg h s ome may be related to dental infections and att rib ut ed to pat hol ogi ca l condit ion s of aut hor s place the lower limi t a t ! mm. must be systematically evaluated so that 5 ,1 3 the joint, and false an*y los is was #he width of the in de & fing er at the na il a potential life'threatening situation is bed is between 1 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–! mm- is the usual an odontogenic or non'odont ogenic P.J. Dhanraj ani , FR!D" , FD" R!" , FFD R!" I, wi dt h of open in g. 6v id ence sugges ts nature. 7dontogenic infections have !onsultant, #ral Medicine, and O. Jonaidel , $D", 1 1 ,1 2 that gender may be a factor in vertical M"c %#ral & Ma'il lofacia l "urgery( , "peciali st, three major origins$ 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. dis pla y grea ter mout h open ing . a ter al infection, particularl y around an 1 9ental :pdate – ;arch 2332 ORAL SURGERY TR#S5US 8Aetiology and differenti al diagnosis9 #ntraarti&ular ;. An<ylosis E2traarti&ular *. Art'ritis syno)itis =. 5enis&us $at'ology Infection #rauma 9ental'treatment #;9 #umours and 9r ugs <ad iotherapy and = ongenital ;iscellaneous related oral care chemotherapy 7dontogenic >on' ? @ost'e&traction ? @rimary and secondary ? 7steoradionecrosis ? Aysteria 7dontogenic ? ocal anaest hetic tumours of epiphar yngeal ? @ost'radiation fibrosis ? upus 6rythematosus injection and parotid region, jaws ? @ulpal ? #onsilli tis joint ? Aypertrophy of coronoid ? @eriodontal )@eritonsillar ? "ubmucus fibrosis ? #rismus–pse udo–camptodactyly ? @ericoronal abscess- ? ;yositis ossificans ? @henothiaine syndrome ? #etanus ? "uccinyl choline ? ;eningitis ? #rauma to #;B ? #ricyclic antidepressant ? Crain abscess due to wide and ? ;etaclopr amide ? @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 j oint )#;B- Ideally, the needl e should be placed in most common cause. "evere symptoms in which trismus was a the pterygoid space, which is bound by 1 ! od onto ge ni c infectio ns in volvin g t he spec if ic tr au ma ti c e ve nt . #he re cord s o f the int er nal obl iD ue ri dge o f t he mus cles of mast ication are of ten 5 pa tie nts were re vi ewed and .4E of mand ible on the la teral side and accompanied by trismus at initial cases had trismus within one wee* of pterygoman dibular raphe on the medial presentatio n. #his inf ection, if the event. side. 7cc asionally, th e medial pt erygoid unch ec *e d, ca n spr ea d to var io us fa ci al #r is mus ha s als o bee n r eporte d due to mu sc le is ac ci de nt al ly pe ne trat ed or a spaces of th e hea d and ne c* an d lea d t o th e acc id enta l inc or po ra ti on of fo re ig n ve ss el is pu nc tu re d and a sma ll bl ee d seriou s compl ic ati ons suc h as cervical bodies because of e&ternal t ra umatic foll ows $ a haemato ma can occur in t he cellulitis or mediastinitis. injury. %nother relatively rare cause of muscle bed and subseDuently organie, 1 0 1 5 >on'odontoge nic infecti ons such as trismus see n in genera l practice is causing a fi brosis. #r ismus due t o this tonsillitis, tetanus, meningitis, parotid trauma o f the ygomatic arch a nd cause can be protracted a nd 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 ,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. 9e pending upon the ty pe of 7r al surgic al pr oced ur es ma y result in inj ury and the di rec ti on of th e tr aumati c lim ite d ja w op eni ng. #he e&t rac tio n of Tem$oromandi%ular oint fo rc e, fr actu re s of t he ma ndib le may teet h may a ls o cause tr is mus as a r es ul t Disorders occur in d if fe re nt l ocat ions, pr oduc ing ei ther of infl amma ti on i nvol vi ng t he 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 1 2 1 devastating e ve nt ) e.g. s ports i njury-, %nother common cause of trismus associated with t rismus. #;9s may be ad mini str at ion of gene ral anaest he si a of ten seen in ge ne ral pr ac tic e is the di vi de d into e&t ra ca ps ul ar )m ai nl y an d pe rf orman ce o f a den ta l pr oc ed ur e li mit ed m outh o pe ni ng t ha t occ ur s 2–! my of as ci al - an d int ra ca ps ul ar pr ob le ms such as di fficul t e&tr acti ons or other da ys af te r a ma ndib ul ar bl oc * h as been )i nclu di ng disc di splace me nt, a rt hr itis, treatment reDuiring lengthy administered. #his is usually attributed fibrosis, etc.-. Intracapsular problems are appointment s. # he p urpose o f this to i na ccurate positioning of t he n eedle often caused by t rauma. @ain upon stu dy was t o i nvest igate the ons et o f whe n givin g t he inf erior ne rve bloc *. pa lpa tion , l ate ra l t o t he joi nt ca ps ul e, i s 9ental :pdate – ;arch 2332 -
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Transcript of Dental Update 2002. Trismus - Aetiology Differential Diagnosis and Treatment
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5/25/2018 Dental Update 2002. Trismus - Aetiology Differential Diagnosis and Treatment
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ORAL SURGERYORAL SURGERY
Trismus: Aetiology, Differential
Diagnosis and TreatmentP.. 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 ofarti&le dis&usses t'e $rimary &auses of t'is &ondition and t'e )arious treatments
limited jaw opening, as some of the1 4a)aila%le. conditions attributed to it can be life
threatening. ood perception of itsDent Update *++* *-: /-0 1 !
causes can help the dentist to refer theClinical 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 movementmouth. %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 summaried in /igure 1 and#rismus has a number of potential will be described below.
causes, which range from the simple6'at is "ormal O$ening ofand non'progressive to those that aret'e 5out'7 #nfe&tionspotentially life'threatening. 2 0
aanjian divided an*ylosis of the #he normal range of mouth opening #he hallmar* of a masticatory space
temporomandibular joint into true and varies from patient to patient, within a infection is limited jaw opening. #rismusfalse. #he true type of an*ylosis was range of 43 03 mm, although some may be related to dental infections andattributed to pathological conditions of authors place the lower limit at ! mm. must be systematically evaluated so that5 ,1 3
the joint, and false an*ylosis was #he width of the inde& finger at the nail a potential life'threatening situation isbed is between 1 and 15 mm. #hus, two discovered as early as possible.fingers breadth )43 mm- up to three Infections causing trismus may be offingers breadth )!4! mm- is the usual an odontogenic or non'odontogenicP.J. Dhanrajani, FR!D",
FD" R!",FFD R!"I,
width of opening. 6vidence suggests nature. 7dontogenic infections have!onsultant, #ral Medicine, andO. Jonaidel, $D", 1 1 ,1 2
that gender may be a factor in verticalM"c %#ral & Ma'illofacial "urgery(, "pecialist, three major origins$ 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. ateral infection, particularly around an1
9ental :pdate ;arch 2332
ORAL SURGERY
TR#S5US
8Aetiology and differential diagnosis9
#ntraarti&ular ;. An
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ORAL SURGERY
and can affect speech by restricting; Trauma: tongue and soft palate movements. #he
"urgical e&traction of mandibular molarse&act aetiology is un*nown but it is@ost'anaesthetic injections$most commonly attributed to betel nutInferior alveolar nerve bloc* 24
@ost'superior alveolar nerve bloc* chewing.24
9irect trauma$
/ractured mandible
7ther facial fractures
Drug T'era$y/acial laceration
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ORAL SURGERY
TREAT5E"T>the use of protective stents, jaw the motor dysfunction, permitting the5A"AGE5E"T O4 TR#S5USe&ercises and hyperbaric o&ygen to patient to open and allowing the
increase neovasculariation. #reatment of trismus varies depending practitioner to provide the appropriateon the aetiological factor. "ome treatment.
difficulty in opening the jaw on the day In virtually all cases of trismus that3ongenital>De)elo$mental following dental treatment in which a are managed as outlined above, patients3auses 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 theresult 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 beyondcoronoids against the anteromedial is usually mild. 48 hours, the possibility of infectionmargin of the ygomatic arch. #rismus' Hhen a patient reports mild pain and should be considered. %ntibiotics2 5
pseudo'camptodactyly syndrome is a dysfunction, an appointment for should be added to the treatment 3
rare combination of hand, foot and e&amination should be arranged. In the regimen and continued for 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 the5is&ellaneous 3auses heat therapy( case of severe pain or dysfunction, if no7ther rare causes of trismus are$ analgesics( improvement is noted within 2 days
a soft diet( and )if necessary- without antibiotics or ! days withhysteria )psychogenic-( muscle rela&ants antibiotics, or if the ability to open haslupus erythematosus, etc. become very limited, the patient should1
to manage the initial phase of muscle be referred to an oral and ma&illofacialAysteria, 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 beconversion 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 madeconflicts and ideas. #he presentations associated with trismus( its anti' before any type of therapy is applied.2
are varied and include paralysis, inflammatory properties are also
blindness, anaesthesia, anore&ia and beneficial. % narcotic analgesic may be3O"3LUS#O"vomiting in fact, this condition may reDuired if the discomfort is more
mimic practically any disease. #hrough intense. If necessary, diaepam )2.!! #rismus is a common complication of
the mechanism of conversion, the mg three times daily- or other dental treatment. In many ways, it isemotional conflict is converted into a benodiaepine 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,
patient from emotional conflict. #he Hhen the acute phase is over the including social injunctions that canonset of hysteria is usually before the patient should be advised to initiate cause an&iety and danger. In a fewage of !, and occurs mainly in women physiotherapy for opening and closing instances, lawsuits have beenand 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
every 4 hours. "ugarless chewing condition, its primary causes, and its !
gum is another means of providingtreatments.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 organied thought of having triggered the #;9 should beRprocess is more li*ely to yield an recorded in the patients dental record,
E4 ERE "3E S
1. #aylor 6B, ed. Dorlands Illustrated Medicalaccurate diagnosis. /or the clinician to as should the findings and theDictionary, 2th ed. @hiladelphia$ H.C."aunders,
diagnose trismus properly, he or she treatment. /urther dental treatment in1558( p.1!5.
must be able to determine the cause the involved region should be avoided 2. "tone B, aban C. #rismus after injection of local
from a variety of possibilities. It is until symptoms resolve and the patient anaesthetic. #ral "urg #ral Med #ral *athol155(0:252.
important to obtain a complete history is more comfortable., !. ;alamed "/. +andboo of -ocal nesthesia , rd ed.
and to perform a thorough clinical If further dental care is needed, as "t. ouis$=.. ;osby =o., 1553( pp.248245.e&amination.
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treatment. en Dent155( 0? )4- :
!3!!. owlin #@, Coeselt CB. =onsideration 21. Cerge #I, Coe 76. @redictor evaluation of pseudo'camptodactyly syndrome$ report of one
of linear and angular values of ma&imum postoperative morbidity after surgical removal of case. cta *aediatr "in
1554( =?:14414.
mandibular opening. !ompend !ontin 0duc Dent mandibular third molars. cta #dontol "cand1554( 1. Cade 9;, ovas*o BA, ;ontana B, Haide /. %cute
1552(;=: 020. ?*: 102105. closed loc* in a patient with lupus erythematosus$
1. 9wor*in "/, Auggins A, eutrition in "pace @reparation$ % /luid #ransportfrom a canal for any period of time,only si& )small- pages. #he digestion "tudy. I. %bramovit,
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