Review Article

Trismus: A review
N. Monisha1, Dhanraj Ganapathy2, P. Sherlyn Sheeba3, Naveen Kanniappan1

ABSTRACT

One of the most common problems encountered by dental practitioners is restricted mouth opening, otherwise called trismus.
The word trismus is derived from the Greek word “Trismos” meaning grinding/rasping. Trismus means a limitation of mouth
opening due to reduced mobility of the mandible. A number of potential factors may cause trismus and its treatment will
depend on the cause. The causes of this problem are usually of infectious, traumatic, pathological origin, or a combination of
these. Trismus is not considered as a disease or injury; it is, in fact, a result or can also be said as concluding sequelae which
follows the active healing stages. A thorough knowledge of this decreased mobility is very much essential to deliver proper
treatment and also post-operative care to the patients to avoid permanent disability in function. The primary causes of this
condition and the various possible treatments available have been discussed in this review.

KEY WORDS: Dynamic bite appliance, Mouth opening, Phenothiazines, Physiotherapy, Succinylcholine, Temperomandibular
joint, Trismus

INTRODUCTION ETIOLOGY
Trismus is defined as the motor disturbance of the Causes of trismus can be classified as follows:
trigeminal nerve, especially the spasm of the muscles 1. Infections
of mastication with difficulty in opening the mouth • Pulpal
(lockjaw), a characteristic early symptom of tetanus.[1] • Periodontal
The restriction in mouth opening can have serious • Pericoronal
health implications, which can dramatically affect • Cellulitis/mediastinitis
the quality of life. Impaired mastication can lead to • Tetany
reduced nutrition, speech difficulties, diminished vocal • Tetanus.
quality, and compromised oral hygiene. An increased 2. Trauma
risk of aspiration is also observed.[2] The causes of • Surgical extraction of mandibular third molars
trismus range from simple to non-progressive to those • Post-anesthetic injections
that are potentially life-threatening.[3] The treatment of • Inferior alveolar nerve block
this condition may be relatively simple or complicated • Posterior superior alveolar block
depending on the etiological factors.[4] • Fractures.
3. Temperomandibular joint disorders
MOUTH OPENING • Extracapsular
• Intracapsular.
The normal range of mouth opening is usually
4. Tumors and oral malignancies
40–60  mm.[5] Two-fingers to three-fingers breadth is
5. Drug therapy
the usual width of opening.[6] The vertical mandibular
6. Psychogenic causes.[1,8]
opening is said to be influenced by the gender factor,
with males having a larger mouth opening.[7]
INFECTION/INFLAMMATION
Access this article online Trismus is the most common symptom of masticatory
Website: jprsolutions.info ISSN: 0974-6943
space infection. The infections could be of odontogenic
or non-odontogenic in nature.

Undergraduate Student, Saveetha Dental College and Hospitals, Saveetha University, Chennai, Tamil Nadu, India,
1

Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 3Department of
2

General Anatomy, Saveetha Dental College, Saveeths University, Chennai, Tamil Nadu, India

*Corresponding author: P. Sherlyn Sheeba, No. 2, 6th Street, Sivasakthi Nagar, Korattur, Chennai - 80, Tamil Nadu, India.
Phone: +91 9585710191. E-mail: sherlynsheeba@gmail.com

Received on: 19-09-2017; Revised on: 15-10-2017; Accepted on: 22-11-2017

130 Journal of Pharmacy Research | Vol 12 • Issue 1 • 2018

 N. Monisha, et al.
Odontogenic Infections Causing Trismus Include
Pulpal infections - Pulpitis is commonly caused by
dental caries that affect the enamel and dentine of
the teeth to reach the pulp. Trauma/repeated thermal
injuries during dental treatment are also responsible
in causing pulpitis.  In these conditions, excessive
pressure build up occurs within the pulpal cavity
causing dental pain. Pain can also be caused due to
increased pressure affecting adjacent tissues and this,
in turn, leads to irritation of the trigeminal nerve,
which causes masseteric muscle spasm causing
trismus.[9]
Periodontal infections: The tissues that surround and
support the teeth are termed as the periodontium.
Irritation of the free nerve endings due to periodontal
infections causes spasm of the masseter. This causes
irritation of the trigeminal nerve which contributes to
trismus.
Pericoronal infections - pericoronitis involves
inflammation of soft tissues surrounding the crown of
a partially erupted tooth. These infections also cause
reflex irritation of trigeminal nerve throwing masseter
muscle into a spasm causing trismus.[10]
Cellulitis: Untreated dental infections can cause spread
into various neck spaces causing cervical cellulitis/
mediastinitis.
Non-odontogenic Infections Causing Trismus
Include
These include tonsillitis, tetanus, meningitis, parotid
abscess, and brain abscess.[11]
TRAUMA
Fractures involving the mandible, zygomatic arch,
and zygoma may cause restriction of mouth opening.
These cause disturbances in the movement of the
temperomandibular joint causing trismus. The type
of injury and the direction of force of trauma also
contribute to the mobility of the jaws. The accidental
incorporation of foreign bodies due to external trauma
also causes trismus.[12]
TRISMUS DUE TO DENTAL
TREATMENT
Surgical, dental procedures may lead to limitations
in mouth opening.[13] The inflammation involving the
muscles of mastication during dental extractions and
also direct trauma to the temporomandibular joint
can cause trismus.[11] Another cause of trismus is the
limited mouth opening that occurs 2–5 days after the
administration of local anesthesia. This is due to the
wrong positioning of the needle while giving a nerve
block.[14]
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TEMPEROMANDIBULAR JOINT
DISORDERS
They can be classified as:
Extra-articular:
• Infection/inflammation, e.g.,  pericoronitis,
sialadenitis
• Hematoma
• Trauma (post-operative edema, facial trauma)
• Myofascial pain dysfunction syndrome
• Tetany
• Tetanus
• Systemic sclerosis and oral submucous fibrosis
• Neoplasm
• Fibrosis due to burns and radiation.
Intra-articular:
• Infective arthritis
• Osteoarthritis
• Rheumatoid arthritis
• Ankylosis of TMJ
• Dislocation
• Intracapsular condylar fractures and injections.[15]
TUMORS AND ORAL
MALIGNANCIES
The patients with a primary or metastatic neoplasm,
in the epipharynx, parotid gland, jaws, or TMJ can
cause trismus. A thorough clinical and radiographic
examination must be performed to rule out
any malignancy.[16] Oral submucous fibrosis, a
precancerous condition, commonly seen in Indians
is a juxta-epithelial inflammatory reaction causing
progressive fibrosis of the submucosal tissue in the
oral cavity. This causes blanching of the mucosa and
affects mouth opening causing trismus.[17]
DRUGS
Some drugs such as succinylcholine, phenothiazines,
and tricyclic antidepressants can cause trismus as an
extrapyramidal side effect.[18]
MISCELLANEOUS CAUSES
Psychogenic.
Lupus erythematosus.[19]
MANAGEMENT OF TRISMUS
Treatment of trismus depends on the factor causing it.
If trismus results due to fibrosis of tissue or immature
scar formation, physiotherapy and appliances can
be of help. If trismus results due to intracapsular
pathologies, causing dense fibrous tissue formation, it
may require surgical management.[20]
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 N. Monisha, et al.
Conservative medical management for acute trismus:
1. Heat - Placement of moist hot towels on the affected
area for 10–20 min/h.
2. Analgesic therapy - Aspirin is the most common.
When discomfort is extensive, narcotic analgesic
may be indicated.
3. Soft diet.
4. Muscle relaxants - In extensive masticatory muscle
spasm, benzodiazepines 2.5–5 mg 3 times a day may
be indicated.[8]
Physiotherapy can be started after cessation of the
acute phase.
Physiotherapy: Exercises which relax the masticatory
muscles and strengthen them. Mouth opening can
be achieved in a gradual manner by devices such as
the wooden top or bunch of ice cream sticks inserted
between the teeth to keep the mouth open.
The steps in physiotherapy include:
1. Heat  -  This is used as an alternative to exercises
involving the masticatory muscles. The increase in
collagen tissue extensibility decreased stiffness of joint
and the science of pain and muscle spasm is achieved
by heat. It also increases the flow of blood, thereby
reducing the edema of the muscles of mastication.
2. Massage - This causes an increase of blood flow
and aids in relaxing of the masticatory muscles.
3. Exercise - This causes breakage of the fibrosis of
the muscles of mastication.
The goals of physiotherapy include:
1. Edema reduction.
2. Softening and stretching of scar tissue.
3. Increase in the range of joint movement.
4. Increase in the strength of masticatory muscles.[21]
Under general anesthesia, forced opening of the jaw
can be indicated when all other modalities of treatment
are exhausted.[22] Manipulation under anesthesia can
cause instability of temporomandibular joint.
TRISMUS APPLIANCES
They are used in combination with physical therapy.
These devices cause forcible stretching of the elevator
muscles, externally. This is usually achieved by
depression of mandible. Devices that are internally
activated stretches the affected elevator muscles and
also other tissue that limits mandibular opening.
External Appliances
Dynamic bite opener
Drane was the first person to describe this appliance.
Elastic force is provided in a continuous manner by
this device which causes depression of the mandible.
The amount and direction of the force provided can be
regulated. It is always advisable to apply moist heat to
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the masticatory muscles for about 10 min before using
the bite opener. Analgesic and anti-inflammatory
drugs may be of use in these patients.
The bite opener should be kept in closed position (zero
position). The patients’ mouth is opened as much as
possible and the mouthpiece of the bite opener should
be inserted in such a way that the teeth and gums rest
comfortably against the bite opener. The handle of the
bite opener is turned slowly till the sensation of gentle
stretch of mouth opening is felt. The increase in mouth
opening should be performed only in a stepwise
pattern. This system should not be used for more than
5 min per sitting to start with. This is then increased by
2 min per sitting gradually till the maximum limit of
30 min is reached. After each session, ice packs need
to be applied to the muscles of mastication.[22]
Threaded tapered screw
This appliance made of acrylic resin resembles the toy
top. This device should be placed between the posterior
teeth of the patient and should be gradually turned
such that the maxillary and mandibular teeth spread
apart.[13] The force provided is not elastic in nature and
can be controlled by the patient. This device can be
used only in dentulous patients. Prolonged usage of
the device results in mobility of anterior teeth due to
the extensive force generated.[23]
Screw type mouth gag
Nakajima was the first person to describe this device.
Unilateral continuous and inelastic force are provided
by the screw component of this device. The dental
practitioner can adjust the force generated. This
appliance cannot be used in edentulous patients.[24]
Fingers
Rouse was the first person to describe this method.
The patient depresses the mandible with his fingers.
This exercise should be repeated by the patient many
times a day. The most important aspect of this method
is the compliance of the patient.[25]
Use of tongue blades
Tongue blade can also be useful in mouth opening.
Stack of wooden tongue blades can be used to keep
the mouth open.
Surgical management
Surgical management in the case of trismus is rare. If
trismus is caused due to fibrotic band formation in the
submucosa, lysis of these bands is done using laser.
Myotomy of the masseteric muscle helps in certain cases.
CONCLUSION
Trismus is a condition of rich clinical importance and
helps in the provision of accurate diagnosis. The success
Journal of Pharmacy Research | Vol 12 • Issue 1 • 2018
 N. Monisha, et al.
in treating this condition depends on prompt identification
of the underlying cause and proper management of the
patient to avoid its recurrence and also in prevention of
causing permanent damage of function. Despite reviews
and research in literature, the knowledge of this medical
problem remains inadequate. Hence, more research into
the insight of trismus is needed in the near future.
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