Differential Diagnosis of Trismus
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Trismus - differential diagnosis
Dr Joel D’Silva
Resident
Department Of Oral & Maxillofacial Surgery
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Introduction
• Trismus, refers to reduced opening of the jaws caused by spasm of the muscles of
mastication, or may generally refer to all causes of limited mouth opening.
• It is a common problem and may interfere with eating, speech, oral hygiene, and
could alter facial appearance. There is an increased risk of aspiration.
• Temporary trismus is much more common than permanent trismus, and may be
distressing and painful, and limit or prevent medical examination or treatments
requiring access to the oral cavity.
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Trismus has a number of potential causes, which range from the
simple and non-progressive to those that are potentially life-
threatening.
Kazanjian divided ankylosis of the temporomandibular joint into true
and false.
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The true type of ankyloses was attributed to pathological
conditions of the joint, and false ankylosis was applied to restrictions
of movement resulting from extra articular joint abnormalities.
This latter type of ankylosis is what most clinicians know as trismus.
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Normal mouth opening
The normal range of mouth opening varies from patient to patient, within a range of 40- 60 mm, although some authors place the lower limit at 35 mm.
The width of the index finger at the nail bed is between 17 and 19 mm.
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Thus, two finger's breadth (40 mm) up to three fingers' breadth (54-57 mm) is the usual width of opening.
Evidence suggests that gender may be a factor in vertical mandibubropening.
In general, males display greater mouth opening .
Lateral movement is 8-12 mm.
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• Several conditions may cause or predispose an individual to developtrismus.
• The aetiology of trismus may be classified as follows:
•
infection
Trauma
Dental rx
Tmjdisorders
tumour
drugsRadio rxChemo rx
Congenital Miscellaneous
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TRISMUA : INTRA ARTICULAR (TMJ)
• 1. Ankyloses
• 2. Arthritis synovitis
• 3. Meniscus pathology
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EXTRA ARTICULAR
INFECTION
Non-Odontogenic
Quinsy
Tetanus
Meningitis
Brain abscess
Parotid abscess
Odontogenic
Pupal
Periodontal
Pericoronal
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TRAUMA
Fracture mandible
Fracture zygomatic arch
Incorporation of foreign bodies
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DENTAL TREATMENT RELATED
• POST EXTRACTION PAIN
• LOCAL ANESTHETIC INJECTION
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TMD
Trauma to wide and prolonged opening
Myofasical muscle spasms
Internal derangement
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TUMORS AND OTHERS
Primary and secondary tumours of epipharyngeal and parotid region,
jaws joints
Submucous fibrosis
Myositis ossificans
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DRUGS
Phenothiazine
Succinyl choline
Tricyclic antidepressant
Metaclopramide
Halothane
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RADIOTHERAPY AND CHEMOTHERAPY
Osteoradionecrosis
Post-radiation fibrosis
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CONGENITAL
Hypertrophy of coronoid
Trismus-pseudo-camptodactyly syndrome
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MISCELLANEOUS
Hysteria
Lupus Erythematosus
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INFECTIONS
The hallmark of a masticatory space infection is limited jaw opening.
Trismus may be related to dental infections and must besystematically evaluated so that a potential life-threatening situationis discovered as early as possible.
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Infections causing trismus may be of an odontogenic or non-odontogenic nature.
Odontogenic infections have three major origins:
pulpal,
periodontal and
pericoronal.
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The presence of an oral infection particularly around anerupting mandibular third molar, is the most common cause.
Severe odontogenic infections involving the muscles ofmastication are often accompanied by trismus at initialpresentation.
This infection, if unchecked, can spread to various facial spaces of the head & neck and lead to serious complications such as cervical cellulitis or mediastinitis
Non-odontogenic infections such as tonsillitis, tetanus,meningitis, parotid abscess and brain abscess may also causetrismus.
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TETANUS
Tetanus is an infective disease due to the inoculation of Clostridium tetani into
the tissues of man and animals.
Cl. tetani may remain in the tissues for months or even years until activated by
irritation or trauma.
There are a few reports claiming that tetanus developed after tooth extraction,
but the microbiological evidence for these is slight (Richter, 1971).
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ORAL MANIFESTATION
After a short period of non-specific prodromal symptoms the first
manifestation of tetanus is tonic rigidity of the muscles of
mastication.
The patient presents with stiffness of the face followed by difficulty
in chewing and swallowing.
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The spasm of the muscles of mastication often increases until the jaws are
finally locked and the mouth cannot be opened.
If the muscles of facial expression are involved, the corners of the mouth
are drawn back, the lips protruded and the forehead is wrinkled giving the
characteristic appearance of risus sardonicus
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Other muscle groups become involved, for example the trunk and the proximal
parts of the limbs.
The spine may become arched (opisthotonus), and the chest fixed in a state of
expiration.
There is often a board-like rigidity of the abdominal muscles and, as the infection
develops, the patient has difficulty in swallowing and breathing is embarrassed
because of restricted respiratory movements.
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Death occurs from exhaustion, aspiration pneumonia or asphyxia due to
respiratory muscle spasm.
Treatment
Treatment consists of the administration of antitoxin, preferably human
tetanus immunoglobulin, thorough wound debridement, antibiotics, usually
penicillin, & sedatives to control muscle rigidity and spasm.
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TRAUMA
Fractures, particularly those of the mandible, may cause limited jaw
opening.
Depending upon the type of injury and the direction of the traumatic
force, fractures of the mandible may occur in different locations,
producing mandibular hypomobility.
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Trismus has also been reported due to the accidental incorporation
of foreign bodies because of external traumatic injury.
Another relatively rare cause of trismus seen in general practice is
trauma of the zygomatic arch and zygomaticomaxillary complex
(ZMC), which interferes with the movement of the coronoid process.
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DENTAL PROCEDURES
Oral surgical procedures may result in limited jaw opening.
The extraction of teeth may also cause trismus as a result either of
inflammation involving the muscles of mastication or direct trauma to
the TMJ.
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Another common cause of trismus often seen in general practice is
the limited mouth opening that occurs 2-5 days after a mandibular
block has been administered. This is usually attributed to inaccurate
positioning of the needle when giving the inferior nerve block.
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Ideally, the needle should be placed in the pterygoid space, which is
bound by the internal oblique ridge of the mandible on the lateral
side and pterygomandibular raphe on the medial side.
Occasionally, the medial pterygoid muscle is accidentally penetrated
or a vessel is punctured and a small bleed follows:
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Trismus due to this cause can be protracted and quite severe.
Hot packs, stretching exercises using wooden spatulas and
reassurance are usually sufficient for this condition, although
sometimes the haematoma becomes infected and requires surgical
evacuation.
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TMD
There are numerous subcategories of TMD, a number of which may
be associated with trismus.
TMDs may be divided into extracapsular (mainly myofascial) and
intracapsular problems (including disc displacement, arthritis, fibrosis;
etc.).
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Intracapsular problems are often caused by trauma. Pain upon
palpation, lateral to the joint capsule, is a significant finding.
Clicking may indicate anterior disc displacement.
Painless clicking alone does not require treatment.
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Conditions such as fibrosis or unilateral condylar hyperplasia require
surgical consultation and treatment.
Suspicion of TMJ trauma or dislocation should be considered in
young patients who have dysphagia and Trismus but who do not have
a serious infectious aetiology.
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Acute closed-lock conditions may occur when the meniscus becomes
displaced anteromedial to the condyle.
In such instances, the patient usually has a history of paroxysmal
clicking and some discomfort.
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In closed-lock conditions of a mechanical nature, the patient can
often open his or her jaw 20-25 mm.
If the opening is significantly less than this the practitioner
should suspect a closed lock of muscular origin.
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TUMOURS
• A potential problem in treating patients with trismus is the risk of misdiagnosing the patient who has a neoplastic disease, either primary or metastatic, in the epipharyngeal region, parotid gland, jaws or TMJ.
Thorough clinical and radiographic examination must be performed to rule out neoplastic possibilities.
Rarely, trismus is a symptom of nasopharyngeal or infratemporal tumours or fibrosis of the insertion of temporalis tendon, resulting in limited jaw movement.
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Oral submucous fibrosis is a precancerous condition, commonly seen in
people from the Indian subcontinent.
This causes blanching of the mucosa and can affect speech by restricting
tongue and soft palate movements.
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DRUG THERAPY
Some drugs are capable of causing trismus as a
secondary effect; succinyl choline, phenothiazines and
tricyclic antidepressants being among the most common.
Trismus can be seen as an extrapyramidal side-effect of
metaclopramide, phenothiazines and other medications.
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Before administering sedative and analgesic medications, the surgeon must
be able to control the airway.
If trismus is present, insertion of a ratchet-type (molt) mouth prop between
the upper and lower canines and premolars is prudent.
The stability of these teeth should be checked to ensure that force applied
to them will facilitate mouth opening & not compromise their integrity.
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The mouth prop is opened until slight pressure against the teeth
makes the mouth prop stay in place.
As the sedative and analgesic medications are titrated, the ratchet-
type mouth prop gradually is opened by one-tooth increments on the
ratchet until adequate access is achieved.
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The patient should be instructed before the procedure that a brief
period of pain might ensue with each increment of opening the
mouth prop.
If the surgeon is unable to overcome the trismus, administration of
sedative and analgesic medications should be discontinued.
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GENERAL ANESTHESIA
Limitation of the interincisal opening to 30mm or less likely will cause
difficulty with direct laryngoscopy for intubation.
When a physical effect such as muscle spasm or the actual mass effect of
the infection causes the mechanical obstruction of the oral opening, it may
persist despite the induction of GA.
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When the trismus is caused by pain or mild inflammation, it may
disappear or at least partially resolve after the administration of anesthetic
medication.
An indication that of the potential for resolution of the trismus may be the
degree of resistance encountered when attempting to open the patient’s
mouth during initial examination.
•
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If a “spongy soft” stop is detected, the ability to substantially increase the mouth opening may be possible after achieving an appropriate anesthetic depth.
In such situations if no other factors compromise the integrity of airway, the clinician may plan to sedate the patient.
As the patient becomes more sedate an attempt is made to further open the mouth.
When adequate opening occurs, GA may be induced and intubation may be performed.
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RADIOTHERAPY CHEMOTHERAPY
Dentists are on occasion asked to provide treatment for patient
undergoing radiotherapy and chemotherapy.
Oral mucosal cells have a high growth rate and are susceptible to the
toxic effects of chemotherapy, which can lead to stomatitis.
• The severity of the stomatitis is dose related.
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Some drugs are capable of causing trismus as a secondary effect,
succinyl choline, phenothiazines and tricyclic antidepressants being
among the most common.
Although the damage reversible, this condition may cause severe
discomfort, pain, trismus and difficulty in swallowing.
• Radiotherapy is commonly used to treat squamous cell carcinoma of
the head and neck and regional lymphomas.
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The primary advantage of using radio-therapy to treat oral cancer is
the preservation of radiation given and function; however,
complications may develop, depending upon which healthy tissues
are in the of the the radiation beam, the amount of radiation given
and the course of treatment.
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Osteoradionecrosis may occur, resulting in pain, trismus, suppuration and occasionally a foul-smelling wound.
When the muscles of mastication are within the field of radiation, fibrosis may, result and lead to trismus, reducing the range of movement.
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Fibrosis and trismus have been attributed to the ischaemia caused by endarteritis obliterans.
Trismus complicates post-radiation dental care.
The recommendation to minimize the effects of radiation on the facial and masticatory muscles include the use of protective stents, jaw exercises & hyperbaric oxygen to increase neovascularization.
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CONGENITAL / DEVELOPMENTAL CAUSES
There has been a report of trismus as a result of hypertrophy of the coronoid process causing interference of the coronoids against the anteromedial margin of the zygomatic arch.
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• Trismuspseudo-camptodactyly syndrome is a rare combination of hand, foot
and mouth abnormalities and trismus.
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MISCELLANEOUS
Other rare causes of trismus are:
hysteria (psychogenic)
lupus erythematosus, etc.
Hysteria, or more accurately where a single symptom is concerned conversion hysteria, is the physical manifestation of suppressed emotional conflicts and ideas.
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The presentations are varied and include paralysis, blindness,-anaesthesia, anorexia and vomiting in fact, this condition may mimic practically any disease.
Through the mechanism of conversion, the emotional conflict is converted into a physical symptom, thus releasing the patient from emotional conflict.
• The onset of hysteria is usually before the age of 35, and occurs mainly in women and in those with a suggestible and parent-dependent personality.
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DIFFERENTIAL DIAGNOSIS
A systematic approach using a disciplined and
organized thought process is more likely to yield an
accurate diagnosis.
For the clinician to diagnose trismus properly, he or
she must be able to determine the cause from a
variety of possibilities.
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It is important to obtain a complete history and to perform a thorough clinical examination.
Radiographs should be ordered as deemed appropriate.
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1. TRAUMA ……
• Surgical extraction of mandibular molar.
Anaesthetic injections:
Inferior alveolar nerve block, Post-superior alveolar nerve block.
Direct trauma:
• Fractured mandible, other facial fractures.
Facial laceration
Recent dental restorative procedures
Radiation therapy
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2. INFECTION
• In cases where there are associated signs and symptoms:
tachycardia
tachypnoea
high temperature
increased white blood cell count
decreased oral uptake
dehydration
These may lead to the suspicion of more common facial spaces involvement. In the presence of neck rigidity, tetanus should be ruled out. These conditions should be considered life threatening if early treatment is not intervened.
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• 3. TMD:
• Chronic complaints usually seen in young females. Theydo not need any urgent attention.
• 4. Conditions that affect the central nervous system
• such as meningitis/encephalitis, brain tumour/abscessand epilepsy should be ruled out.
• 5. Drug history
• is very important in cases of trismus.
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• 6. Tumours/oral cancers:
• These conditions can be very obvious to diagnoseclinically, except some metastatic tumours in oropharynx.One should not forget oral submucous fibrosis indifferential diagnosis.
• 7. Psychogenic causes
• such as "hysterical trismus.
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MANAGEMENT OF TRISMUS
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TREATMENT / MANAGEMENT
Treatment of trismus varies depending on the aetiological factor.
Some difficulty in opening the jaw on the day following dental
treatment in which a superior alveolar or inferior alveolar nerve block
was administered is frequently encountered.
The degree of discomfort and dysfunction varies, but is usually mild.
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When a patient reports mild pain and dysfunction, an appointment for examination should be arranged.
In the interim, the practitioner should prescribe the following:
heat therapy:
analgesics; ANALGESICS
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a soft diet; and (if necessary)
muscle relaxants
to manage the initial phase of muscle spasm
Heat therapy consists of placing moist hot towels on the affected area for 15-20 minutes every hour.
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Barrett et al(1988) have described the adjunctive treatment modalities of
heat, cold, and electrotherapy for use in patients suffering from trismus.
Heat in particular is an effective adjunct to stretching.
It increases the extensibility of collagen tissue, decreases joint stiffness,
relieves pain and muscle spasm, increases blood flow, and helps to resolve
inflammatory infiltrates edema.
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Aspirin is usually adequate in managing the pain associated with trismus; its antiinflammatory properties are also beneficial.
A narcotic analgesic may be required if the discomfort is more intense.
If necessary, diazepam (2.5-5 mg t.i.d.) or other benzodiazepine may be prescribed for muscle relaxation.
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When the acute phase is over the patient should be advised to
initiate physiotherapy for opening and closing the jaws and to
perform lateral excursions of the mandible for 5 minutes every 3-4
hours.
Sugarless chewing gum is another means of providing lateral
movement of the TMJ.
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Any trauma or event that may be suspected of having triggered the
TMD should be recorded in the patient's dental record, as should
the findings and the treatment.
Further dental treatment in the involved region should be avoided
until symptoms resolve and the patient is more comfortable.
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If further dental care is needed, as with a painful
infected tooth, access for local anaesthesia may
be difficult when trismus is present.
The (closed mouth) nerve block usually provide
relief of the motor dysfunction, permitting the
patient to open and allowing the practitioner to
provide the appropriate treatment.
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In virtually all cases of trismus that are managed as outlined above,
patients report improvement within 48 hours.
Therapy should be continued until the patient is free of symptoms.
If pain and dysfunction continue unabated beyond 48 hours, the
possibility of infection should be considered.
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Antibiotics should be added to the treatment regimen and continued
for 7 days.
If trismus is suspected to be associated with infection, appropriate
antibiotics should be prescribed.
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• In the case of severe pain or dysfunction, if no improvement is noted within 2-3
days without antibiotics or 5-7 days with antibiotics, or if the ability to open has
become very limited, the patient should be referred to an oral and maxillofacial
surgeon for evaluation.
Treatment for trismus should be directed at eliminating its cause.
Diagnostic assessment should be made,before any type of therapy is applied.
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• Trismus appliances(Lund TW and Cohen JI. Quintessence Int 1993)
Ideally, trismus appliances are used in combination with the physical therapies.
Externally activated appliances
Mouth Gag
Threaded, tapered screw:
Use of this appliance is restricted for partially edentulous patients.
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Screw-type mouth gag:
Application is limited to dentate or partially edentulous patients.
Tongue blades
Used as a wedge, tongue blades are effective only in a dentate patient.
Internally activated appliances
These rely on the patient’s depressor muscles to stretch the elevator muscles.
e.g.: Tongue blades, Plastic tapered cylinder.
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CONCLUSION
Trismus is a common complication of dental treatment.
In many ways, it is mostly harmless, but it could give rise to many constraints for
the patient, including social injunctions that can cause anxiety and danger.
In a few instances, lawsuits have been instigated.
Therefore, it is important for clinicians to be aware of this significant condition, its
primary causes, and its treatments.
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REFERENCES
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