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Mouth opening and trismus in patients undergoing curative treatment for

head and neck cancer

Article  in  International Journal of Oral and Maxillofacial Surgery · January 2015

DOI: 10.1016/j.ijom.2014.12.009

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Int. J. Oral Maxillofac. Surg. 2015; 44: 292–296
http://dx.doi.org/10.1016/j.ijom.2014.12.009, available online at http://www.sciencedirect.com

Clinical Paper
Head and Neck Oncology

Mouth opening and trismus in F. Steiner1, J. Evans2, R. Marsh1,

P. Rigby3, S. James3, K. Sutherland2,
R. Wickens2, N. Nedev4, B. Kelly1,
S. T. Tan1,3
patients undergoing curative 1
Gillies McIndoe Research Institute,
Wellington, New Zealand; 2Wellington Blood
and Cancer Centre, Wellington Regional

treatment for head and neck Hospital, Wellington, New Zealand;

3
Wellington Regional Plastic, Maxillofacial
and Burns Unit, Hutt Hospital, Wellington,

cancer New Zealand; 4Radiation Oncology

Department, Palmerston North Hospital,
Palmerston North, New Zealand

F. Steiner, J. Evans, R. Marsh, P. Rigby, S. James, K. Sutherland, R. Wickens, N.

Nedev, B. Kelly, S. T. Tan: Mouth opening and trismus in patients undergoing
curative treatment for head and neck cancer. Int. J. Oral Maxillofac. Surg. 2015; 44:
292–296. # 2014 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. This study documents mouth opening and the incidence of and factors
contributing to trismus (<35 mm mouth opening), as well as the associated impact
on quality of life, following curative treatment for head and neck cancer. Patient
demographics, cancer type and location, and treatments were documented. Mouth
opening was measured at >6 months after treatment completion. Patients rated the
impact of mouth opening on quality of life from 0 (no effect) to 10 (greatest effect).
The mean mouth opening in 120 patients was 40.1 mm (range 11–65 mm), with
trismus occurring in 34 (28.3%) patients. Surgery and radiotherapy, surgery and
chemoradiotherapy, and resection and reconstruction were associated with reduced
mouth opening. The mean effect of mouth opening on quality of life for those with
and without trismus was 3.8 and 1.5, respectively. There was a significant difference
Key words: trismus; radiotherapy; chemo-
between the mean effect on quality of life for patients with and without trismus for
therapy; surgery; cancer; head and neck;
those patients who underwent chemoradiotherapy or combined surgery and quality of life; treatment.
radiotherapy (4.0 vs. 1.0, and 3.6 vs. 1.6 respectively). Trismus impacts negatively
on patient quality of life. Multi-modality treatment is associated with decreased Accepted for publication 10 December 2014
mouth opening, an increased incidence of trismus, and reduced quality of life. Available online 7 January 2015

Head and neck cancer (HNC) was the
eighth leading cause of cancer deaths in
20001 and the seventh leading cause in
2004.2 The majority of HNC cases require
combined treatment with surgery and/or
radiotherapy (RT)3 and/or chemotherapy
(ChT).4
Trismus is defined as a progressive
tonic contraction of the muscles of masti-
cation that results in decreased mouth
opening.5,6 Factors that contribute to
the development of trismus include trau-
ma,7 infection,8 drugs (e.g. succinyl
choline, phenothiazines, and tricyclic
antidepressants),9 direct tumour invasion
of the masticatory muscles and/or tempo-
romandibular joint,10 submucosal fibro-
sis,11 and RT and/or ChT.9,12 Trismus can
lead to impairment of speech and eating,
malnutrition, poor oral hygiene, and dif-
ficulty with dental treatment.6,10 Severe

0901-5027/030292 + 05 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

trismus can cause difficulties with exam-
ination of and surgical access to the oral
cavity and oropharynx and difficulties
with intubation.12–14
Trismus is a well-recognized complica-
tion of treatment for HNC15 with a
reported incidence of 5–86%, depending
on the study and its definition of tris-
mus.6,15 The absence of a consistent defi-
nition of trismus and method of measuring
mouth opening makes it difficult to com-
pare research results.3,16 However, mouth
opening of <35 mm has been used to
define trismus in several studies.13,15,16
Few studies have addressed the impact
of mouth opening on quality of life
(QoL), and these have yielded inconsistent
findings.
Materials and methods
Consecutive patients who underwent
treatment for HNC with curative intent
between 1 January 2009 and 1 June
2012 were identified from HNC databases
at three New Zealand hospitals. Following
ethical approval by the internal review
boards of the three respective district
health boards, the data of these patients
were merged into a single database.
Patients were assessed in multidisciplin-
ary head and neck clinics and all under-
went surgery and/or RT or
chemoradiotherapy (CRT). They were cat-
egorized into three groups: those with
primary tumours located in (1) the oral
cavity, (2) the oropharynx or nasopharynx,
or (3) the parotid gland, or metastatic
disease in the parotid and/or neck from
a skin cancer or an unknown primary.
Patients were excluded from the study if
they had died, had recurrent disease during
the study period, had an unrelated jaw
fracture, had submucosal fibrosis, moved
overseas, were incarcerated, or declined
participation. Patient demographics, tu-
mour type, stage and location, presence
of regional metastasis, and treatment re-
gime were documented. Data were sup-
plemented by review of the patient
medical records.
All patients were staged using the TNM
staging system17 following clinical and
radiological assessment. They were trea-
ted with surgery and/or RT or CRT.
Patients with primary cancer located in
the oral cavity were more likely to under-
go surgical resection (with or without
adjuvant RT  ChT), whereas those with
oropharyngeal or nasopharyngeal cancer
mostly received RT usually combined
with ChT.4 Of the patients who underwent
surgery, those with less extensive disease
generally underwent resection alone,
Trismus in head and neck cancer
whilst those with more extensive disease
underwent resection and reconstruction.
All patients receiving RT were treated
with three-dimensional conformal RT or
intensity modulated RT (IMRT). ChT was
used together with RT either as a primary
treatment or in adjuvant settings after
surgery.
Patients were followed up routinely in
outpatient clinics and were assessed for
recurrence clinically and, if indicated, ra-
diologically. Patients with tumour recur-
rence during the study period were
excluded.
In order to assess the mouth opening
experienced by the patients on a day-to-
day basis, mouth opening was measured as
the distance between the upper and lower
incisors in dentate patients, or between the
maxillary and mandibular alveolar ridges
in edentulous patients who did not wear
dentures, using a TheraBite Range of Mo-
tion Scale. Patients who wore dentures
were measured with their dentures in situ.
Trismus was defined as mouth opening of
<35 mm, whilst severe trismus was de-
fined as mouth opening of <25 mm.
Patients completed a questionnaire asses-
sing the impact of mouth opening on QoL,
using a visual analogue scale from 0 (no
effect) to 10 (greatest effect). All non-
responders at 2 weeks were followed up
by phone.
The statistical analysis was performed
using the Student’s t-test for independent
variables.
Results
Two hundred and fifty-nine patients
were identified for inclusion in the study.
Table 1. Patient demographics and location of primary tumours.
Sex
Male
Female
Tumour location
Oral cavity
Nasopharynx
Oropharynx
Parotid
Metastatic disease to parotid
and/or neck from skin cancer
Metastatic disease to parotid
and/or neck from unknown primary
Dental status
Incisorb–incisor
Incisorb–alveolar ridge
Alveolar ridge–alveolar ridge
a
Defined as mouth opening of <35 mm.
b
Incisor of the native dentition or that of the denture.
293
Patients were excluded if they had died
(n = 94), developed recurrence during
the study period (n = 10), had an unre-
lated jaw fracture (n = 1), moved over-
seas or were lost to follow-up (n = 5),
were incarcerated (n = 1), were deemed
unable to give informed consent to par-
ticipate (n = 1), or did not consent to
participate (n = 27). Our final study
population was 120 patients; 43 were
females and 77 were males, and they
ranged in age from 34 to 87 years (mean
63.7 years) (Table 1). The locations of
the primary tumours are shown in Table
1. Due to small numbers of tumours at
each sub-site, they were categorized into
three groups based on anatomical prox-
imity and likely method of treatment.
The tumours were located in the oral
cavity (n = 45), oropharynx or nasophar-
ynx (n = 35), and parotid gland, or
metastatic disease in the parotid and/or
neck from a skin cancer or an unknown
primary (n = 40).
Patients were treated with surgery alone
(n = 18, 15%), surgery with postoperative
adjuvant RT (n = 56, 46.7%), surgery with
postoperative adjuvant CRT (n = 7, 5.8%),
primary CRT (n = 34, 28.3%), or RT alone
(n = 5, 4.2%). The mean follow-up period
between completion of treatment and the
measurement of mouth opening was 709.7
days (standard error of the mean 31.67,
median 654, standard deviation 34.5
days).
All patients who completed the ques-
tionnaire had their mouth opening mea-
sured; mean mouth opening was 40.1 mm
(range 11–65 mm). Trismus was identified
in 34 (28.3%) patients, with four (3.3%)
classified as having severe trismus (mouth
Total no. No. of patients
of patients with trismusa (%)
77 20 (26.0)
43 14 (32.6)
45 10 (22.2)
2 2 (100.0)
33 11 (33.3)
6 0
25 10 (40.0)
9 1 (11.1)
93 27 (29.0)
15 5 (33.3)
12 2 (16.7)
294 Steiner et al.

Table 2. The effect of site of cancer on mouth opening.

Mean jaw opening, mm Mean effect on QoLb
Total No. No. of patients (SEM) (SEM)
Location of cancer of patients with trismusa (%)
No trismus Trismus No trismus Trismus
Oral cavity 45 10 (22.2%) 46.4 (1.33) 27.3 (2.34) 1.51 (0.37) 3.50 (1.19)
Nasopharynx or oropharynx 35 13 (37.1%) 43.3 (1.33) 28.2 (1.72) 0.86 (0.32) 4.85 (0.84)
Parotid, skin or unknown primary with metastasis 40 11 (27.5%) 44.0 (1.08) 30.8 (0.98) 1.93 (0.73) 2.91 (0.42)
SEM, standard error of the mean; QoL, quality of life.
a
Trismus is defined as mouth opening of <35 mm.
b
Assessed using a visual analogue scale from 0 (no effect) to 10 (greatest effect).

opening < 25 mm). The dental status of
the patients is shown in Table 1.
Trismus occurred in 10 (22.2%) patients
with cancer in the oral cavity, 13 (37.1%)
patients with cancer in the nasopharynx or
oropharynx, and 11 (27.5%) patients with
primary parotid cancer, or metastatic dis-
ease in the parotid and/or neck from skin
cancer or an unknown primary (Table 2).
These patients had a mean mouth opening
of 40.5 mm, 38.5 mm, and 40.2 mm,
respectively. The mean effect of mouth
opening on QoL was 2.8, 2.8, and 2.2,
respectively. These differences in mouth
opening and its effect on QoL were not
statistically significant.
The difference in the effect of RT
alone on mouth opening was not statisti-
cally significant compared with that of
surgery alone (surgery alone vs. RT
alone; P = 0.44). However, the effects
of some treatments on mouth opening
were statistically significant: surgery
alone vs. surgery and RT (P = 0.04);
surgery alone vs. surgery and CRT
(P = 0.046); resection alone vs. resection
and reconstruction (P = 0.019). For all
treatment types, except for surgery when
combined with RT and ChT, there was a
significant difference between the mean
mouth opening for those with and with-
out trismus (Table 3).
The mean effect of mouth opening
on QoL was 1.5 in those without trismus,
compared to 3.8 in those with trismus
(P < 0.000) (Table 3). For those with
severe trismus (mouth opening < 25
mm), the effect on QoL was 6.5 com-
pared to 3.5 in those with moderate
trismus (mouth opening 25–34 mm)
(P = 0.03). A significant difference be-
tween the mean effect on QoL for
patients with and without trismus was
found for those patients who underwent
combined RT and ChT or combined
surgery and RT (Table 3).
The relationship between the extent of
the cancer (as determined by the TNM
staging system) and the development of
trismus was not statistically significant
(data not shown).
Discussion
Trismus is a well-recognized complication
of treatment for HNC,15 with a reported
incidence of 5–86%.6 Defining trismus as
mouth opening <35 mm, we found an
overall incidence of 28.3% in a cross-
section of patients undergoing curative
treatment for HNC. Multi-modality treat-
ment is associated with decreased mouth
opening. Patients who receive CRT, or
combined surgery and RT, have decreased
mouth opening and a higher incidence of
trismus when compared to those who re-
ceive single-modality treatment with sur-
gery or RT. For those patients who
received surgery, RT, and ChT combined,
the difference in mean mouth opening
between those with and without trismus
was not shown to be statistically signifi-
cant in this study. There was also no
statistically significant difference between
the effect on QoL for those with and
without trismus in patients undergoing this
treatment regime. However, this may re-
flect the small population size.
For patients undergoing surgery, the
decreased mouth opening for those receiv-
ing resection and reconstruction surgery,
compared to those who had resection sur-
gery alone, is most likely to reflect the
extent of the cancer in the former group.
The negative impact of trismus on pa-
tient QoL is not unexpected, considering
its effect on speech, nutrition, and oral
hygiene.6,10 The negative impact of
multi-modality treatment on QoL may
result from the cumulative adverse effects
of the treatments required, reflecting
the extent of the disease. However, few
studies have addressed the impact of
mouth opening on QoL, and these have
yielded inconsistent findings. A study of
40 patients receiving RT with/without

Table 3. The effect of treatment on mouth opening and quality of life.

No. of No. of patients Mean mouth opening, Mean effect on QoL
Treatment patients with trismusa Mean mouth mm (SEM) (SEM)
received (%) (%) opening, mm P-valueb P-valueb
Trismus No trismus Trismus No trismus
All patients 120 (100.0) 34 (28.3) 40.1 28.6 (0.99) 44.8 (0.74) <0.00* 3.8 (0.53) 1.5 (0.22) <0.00*
S 18 (15.0) 3 (16.7) 45.5 30.8 48.4 – 0.7 1.7 –
RT 5 (4.2) 0 (0) 41.0 – 43.0 – – 2.0 –
RT + ChT 34 (28.3) 10 (29.4) 41.3 30.5 (0.76) 44.9 (1.50) <0.00* 4.0 (0.68) 1.0 (0.34) <0.00*
S + RT 56 (46.7) 19 (33.9) 38.0 27.4 (1.67) 43.7 (0.88) <0.00* 3.6 (0.73) 1.6 (0.31) 0.03*
S + RT +ChT 7 (5.8) 2 (28.6) 37.9 27.0 42.2 – 9.5 2.2 –
Resection alone 45 (55.6) 13 (28.9) 40.7 28.9 45.7 <0.00* 3.6 (0.99) 1.8 (0.42) 0.10
Resection + 36 (44.4) 11 (30.6) 38.7 26.5 44.0 <0.000* 3.8 (1.06) 1.4 (0.40) 0.05
reconstruction
SEM, standard error of the mean; QoL, quality of life; S, surgery; RT, radiotherapy; ChT, chemotherapy.
a
Trismus is defined as mouth opening of <35 mm.
b
Two-tailed P-value.
*
Statistically significant differences.

ChT for HNC showed decreased QoL for
patients with trismus,3 while another study
showed a weak correlation between limit-
ed mouth opening and decreased QoL.15
A positive association between the tu-
mour stage and the incidence of trismus
has been reported in a previous study.15
However, our study did not demonstrate a
significant correlation, possibly due to our
small sample size. We could also find no
association between mouth opening and
the site of the primary tumour.
There are several limitations in this
study. First, no pre-treatment data on
mouth opening were collected, which lim-
its the assessment of the impact of treat-
ment on the incidence of trismus
compared to the possibility of pre-existing
trismus. A consecutive cross-section of
patients undergoing curative treatment
for HNC was included to minimize selec-
tion bias and to ensure treatment modali-
ties remained as consistent over time as
possible. Furthermore, a multivariate anal-
ysis could not be performed due to the
small sample size. These two limitations
prevent the evaluation of the extent that
the tumour itself versus the treatment ad-
ministered contributes to the development
of trismus.
It has been postulated that radiation-
induced trismus results from scarring of
the pterygomandibular raphes, and fibrosis
and contracture of the ligaments surround-
ing the temporomandibular joint.3,10,18
The abnormal proliferation of fibroblasts
may contribute to the development of
fibrosis.6 In addition to atypical fibro-
blasts, the presence of infiltrative inflam-
matory cells and different extracellular
matrix components has been noted in
post-radiation fibrosis.19 The inclusion
of the pterygoid muscles, masseter mus-
cle, or temporomandibular joint in the
radiation field has been considered to be
the main cause of trismus.6,18 The severity
of trismus is related to the field and dose of
RT,18,19 with doses above 70 Gy being
associated with a greater reduction in
mouth opening.15 One study noted an
increase in the probability of trismus by
24% for every additional 10 Gy above 40
Gy, to the pterygoid muscle.19 Trismus
has been shown in two publications to
start 9 weeks after the completion of
RT, with subsequent rapid progression
over the next 9 months, and then slow-
ing.12,20
Surgery involving the buccal mucosa,
tonsillar fossa, and retromolar trigone area
has also been shown to cause trismus,
which has been attributed to fibrosis and
shortening of the pterygoid muscle and
pterygomandibular ligament.13
Trismus often develops soon after treat-
ment, highlighting the need for early fol-
low-up and intervention for the patients.3
Delayed treatment may lead to a more
difficult recovery due to secondary changes
in the joints and muscles.21 Several treat-
ment methods for trismus have been pro-
posed, including manual stretching,12
jacking with tongue depressors,22 Thera-
bite,14 the Dynasplint Trismus System,23
and pentoxifylline administration.24 How-
ever, the long-term effectiveness of these
techniques has not been studied adequate-
ly3 and further research is needed.23
We have demonstrated that trismus is a
significant problem; it affected 28% of a
cross-section of patients undergoing cura-
tive treatment for HNC. This study shows
that combined modality treatment is asso-
ciated with a higher incidence of trismus
and that trismus is associated with poorer
QoL. Although in this study the patients
were requested specifically to rate the effect
of mouth opening on their QoL, our find-
ings could, in part, be a reflection of the
negative impact of increased morbidity that
is commonly associated with multi-modal-
ity treatment. Future studies should aim to
determine to what extent increased morbid-
ity contributes to the deterioration in
QoL. Further research is required to fully
understand the pathogenesis of trismus.
Advances in trismus prevention and treat-
ment are also needed to reduce morbidity
and improve the QoL of HNC patients.
Funding
None.
Competing interests
None.
Ethical approval
Ethical approval was granted for this study
by the internal review boards of the par-
ticipating district health boards.
Patient consent
Not required.
Acknowledgement. We thank Mrs Annette
Wikeepa for her assistance with this study.
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preliminary report on the efficacy of a 6242 Wellington
dynamic jaw opening device (Dynasplint New Zealand
Trismus System) as part of the multimodal Tel: +64 42820366
treatment of trismus in patients with head E-mail: swee.tan@gmri.org.nz