Differential diagnosis of orofacial pain

Pain history
• A thorough pain history is crucial and time needs to be taken when taking it as it should
provide sufficient detail to guide clinicians to the most likely diagnosis.
• It is also important to institute relevant investigations.
• In 1936, Ryle’s classic analysis ofpain highlighted 11 essential questions to be included in
the pain history
• Onset;
• Frequency;
• Duration;
• Site;
• Radiation, deep or superficial;
• Triggering;
• Aggravating or relieving factors;
• Quality;
• Severity;
• Associated symptoms.
 Pain history
Orofacial pain
• interferes with daily life activities,
• impacting negatively on quality of life
• this impact should therefore be established.
Other aspects of the history considering chronic orofacial pain aetiologies and planing best
therapy :
• Previous management;
• Past medical and dental history;
• Medications and allergies;
• Social and family history, which may disclose psychological factors and aspects
• of a patient’s beliefs of the cause of pain,
• which may in turn influence the extent and nature of the pain.
• Chronic orofacial pain results in decreased quality of life and psychological effects
rarely seen in dental pain.
 Aetiology of orofacial pain

• Dento-alveolar:
Dental: dentine sensitivity, cracked tooth, pulpitis
Periodontal: periapical peridontitis, acute necrotizing ulcerative
gingivitis/periodontitis
• Mucosal disease: ulcerative and erosive disorders including
desquamative gingivitis
• Bony pathology: alveolar osteitis (dry socket), osteomyelitis, infected
dental cyst, osteonecrosis
• Sinusitis: maxillary, paranasal, ethmoidal, frontal
• Salivary glands: salivary duct calculi causing obstruction, infective
sialadenitis, salivary gland tumour
Aetiology of orofacial pain

• Musculosceletal: temporomandibular disorder

• Neuropathic: trigeminal neuralgia, glossopharyngeal neuralgia,
trigeminal neuropathic pain and dysaesthesia in relation to
pathology/iatrogenic nerve damage, postherpetic neuralgia, burning
mouth syndrome
• Vascular: migraine, tension type headache, temporal arteritis,
TAC(SUNCT,PH,CH)
• Other: chronic idiopathic facial pain, atypical odontalgia, central post
stroke pain, cancer
• Referred from: eyes, ears, intracranial, heart
Clinical examination

• Extraoral examination
• TMJ
• Regional lymph nodes
• Muscles of mastication
• Cervical muscles
• Salivary glands
• Face and eyes for any autonomic signs ( tearing, flushing,
ptosis,sweating)
• Cranial nerves examination
 Clinical examination
• At least gross examination of the facial and trigeminal nerves
• Sensation to light touch and pin prick
• Assessment of facial nerve: ability to
• Raise the eyebrow
• Close the eyes tightly
• Show the teeth whilst observing any facial assymmetry
 Clinical examination
• Signes of TMD:
• Limitation of mouth opening ( norm: 35-45mm)
• Deviation of the mandible on opening
• TMJ tenderness
• TMJ crepitus and clicking on palpation
• Loud clicking is audible
• and/or masticatory muscle pain or tenderness
• Facial swelling, (a)symmetry
 The intra-oral examination

• Should include a comprehensive oral examination:

• Assessing the teeth;
• Occlusion;
• Salivary glands;
• Oral mucosae; and
• Oropharyngeal region.
Dentoalveolar causes of orofacial pain

• Reversible pulpitis: mild to moderate, intermittent pain localized to

the tooth, the pain is sharp and evoked by stimulation (thermal,
tactile, chemical). It can radiate to the adjacent teeth, upper or lower
jaw. Associated factors can be: attrition, erosion, caries, cracked
tooth. Removal of the stimulus can relieve pain.
• Irreversible pulpitis: mild to severe, intermittent or continuous, sharp
or throbbing pain in the tooth. The pain can be evoked by heat,
chewing or lying supine. It can radiate regionally or in to the upper or
lower jaw. Cold( chlorethyl) provokes the pain on examination
Dentoalveolar causes of orofacial pain

• Acute periapical periodontitis: moderate to severe, deep,

continuous or paroxysmal in the tooth/gingiva/bone. Pain can
be evoked by biting.( pain on biting). It can be associated with
periapical erythema, swelling, tooth mobility. Removal of
trauma can relieve the pain.
• Acute pericoronitis: moderate to severe, continuous, aching
pain in the site of unerupted/partially erupted third molar,
mainly lower. It can be evoked by biting and can radiate to the
unilateral ear. Associated factors can be: fever, malaise,
regional lymphadenopathy. Removal of the trauma, irrigation
and antibiotics can relieve the pain.
Orofacial pain caused by bony pathology

• Alveolar osteitis (dry socket): moderate to severe, sharp, deep seated

ache in the site of affected bone. It begins 4-5 days after extraction.
Associated factors: loss of clot, exposed bone and halithosis.
Treatment: irrigation, local antiseptic, Chlumsky solution soaked
iodoform gauze, very rarely antibiotics, facilitation of new clot
formation ( curettage).
• It is important to correctly differentiate it from pulpitis. The most
frequently throbbing pain starts at the site of the extraction, often
spreads toward the adjacent teeth or the antagonist.
Orofacial pain caused by mucosal disease

• Mucosal pathology: mild to severe, sharp, burning or tingling,

intermittent pain of the affected mucosa.

• Example: aphta: a tiny lesion may cause intense pain, making drinking
and eating extremly painful
Orofacial pain caused by sinusitis

• Maxillary sinusitis: mild to moderate, dull or aching, continuus pain

over the affected sinus. It can be unilateral or bilateral. Touch,
bending, biting with upper teeth can evoke the pain. Associated
factors: history of URTI, purulent nasal discharge, fullness over cheek,
erythema over cheek.
• It often presents in form of uncertain pain of an upper tooth.
• It demands throrough history taking and dental examination.
Treatment: drainage and medication.
 Orofacial pain caused by salivary glands

• Blocked salivary gland: mild to severe, burning or aching paroxysmal ,

spasmodic pain, mainly in the submandibular area. It can be evoked by
the smell or taste of food and drink.
• Associated factors can be swelling, erythema, possible infection with pus
from salivary gland duct.
• Pain can be relieved by cessation of eating and removal of the cause.
Musculosceletal causes of orofacial pain

• TMD: mild to moderate, dull, aching, throbbing or sharp, continuous

or intermittent pain in the masticatory muscles or TMJs. It can be
evoked by prolonged chewing, opening wide- such as yawning,
stress. Associated factors: clicking, crepitus, limitation in mouth
opening, deviation of mandible on opening, ear pain, fullness,
tinnitus, depression, anxiety. Pain can be relieved by medication,
warm compresses, avoidance of triggering factors.
Neuropathic causes of orofacial pain

• BMS: mild to moderate, paroxysmal or continuous burning or

tingling in the tounge, palate, lips or pharynx. It can be evoked by
stress or spicy, acidic food. Associated factors: altered taste,
abnormal saliva, sensory change. Eating can relieve the pain.
• Postherpetic neuralgia: mild to moderate, continuous burning,
tingling or soothing pain localized to side of herpes zoster infection
intraoral, but more often extraoral. It can be associated with
allodynia, hyperalgesia and altered sensation. Pain can be releived by
medication and local anaesthetic.
 Neuropathic causes of orofacial pain

• Trigeminal neuropathic pain: mild to severe, continuous, burning, tingling, aching or

throbbing pain in neuroanatomical localization. It can be evoked by light touch.
Associated factors: allodynia, trauma, sensory change. Medication and local
anaesthetics can relieve pain.
• Trigeminal neuralgia: moderate to severe, sharp, shooting, stabbing or electric-shock
like pain in the trigeminal nerve. Paroxysmal, the onsets last for seconds, remits for
weeks/months. Light touch, cold air, or washing the face can evoke pain. Associated
factors: trigger points, sensory change. Medication and surgery can relieve pain.
• Glossopharyngeal neuralgia: moderate to severe, sharp, shooting or stabbing pain in
the ear, tonsils, neck. Paroxysmal, onsets last for seconds to minutes, remits for
weeks/months. It can be evoked by swallowing, coughing, touch. It can be
associated with trigeminal neuralgia. Pain can be relieved by medication.
Vascular causes of orofacial pain

• Cluster headaches: moderate to severe, boring or throbbing unilateral pain

in the periorbital or temple region. Regular, recurring 1-8 attacks per day,
lasting 15-180 mins, complete remission for months to years. It can be
evoked by smoking, alcohol, altitude seasonal. Associated factors: autonomic
features-nasal congestion, eye redness/injection. Pain can be relieved by
medication.
• Paroxysmal hemicrania: moderate to severe, boringunilateral pain in the
periorbital or temple region. Paroxysmal, 1-40 attacks per day lasting 2-30
minutes. It can be evoked by neck movement. Associates factors can be
autonomic features. Pain can be relieved by medication.
• SUNCT/SUNA: moderate to severe, stabbing unilateral pain mainly in the
area of first and second trigeminal division. Paroxysmal, recurring 1-200
attacks per day, 10-250 seconds each. It can be evoked by cutaneous
triggers. It can be associated with tearing, conjunctival injection or other
autonomic features. Pain can be relieved by medication.
 Vascular causes of orofacial pain
• Tension type headache: mild to severe, irregularly recurring ache or
pressure, „band around head”. It can be evoked by stress or body
postures. Medication, excercise and stretching can relieve the pain.
• Temporal arteritis: moderate to severe, continuous, throbbing, dull,
aching or tender pain in the unilateral temporal region. It can be triggered
by pressure over temporal artery. It can be assciated with jaw
claudication. Treatment: medication.
• Migraine: moderate to severe, paroxysmal, throbing pain in the unilateral
fronto-temporal region. It can be triggered by stress, food, excercise,
alcohol, oestrogen, barometric pressure. It can be associated with
nausea, vomiting, photophobia, phonophobia. Treatment: medication,
sleep.
Other causes of orofacial pain

• Atypical odontalgia: mild to moderate, continuous, dull, aching,

tingling, throbbing or sharp pain in tooth bearing area. It is
associated with prior dental treatment.
• CIFP: mild to severe, continuous or intermittent dull, aching, nagging,
sharp or throbbing pain in non-anatomical, intra-and extra-oral
regions. It can be evoked by stress, chewing, fatigue. It can be
associated with multiple body symptoms, life events. Treatment: rest.
 Non-dental causes of facial
pain
Oral malignancies, especially gingival or alveolar bone malignancy,
may present with
• facial pain.
• sensory changes
• trismus.
• Metastatic disease spreading to the jaws must also be considered.
• Evidence of oral candidosis or xerostomia may be relevant when
excluding a diagnosis of burning mouth syndrome (BMS).
 Non-dental causes of facial
pain
• Pain associated with the salivary glands due to salivary stones blocking
the ducts
• giving rise to intermittent pain typically associated with eating.
• There may be tenderness of the glands.
• Bimanual palpation of the submandibular glands is essential.
• Infections and tumours of the salivary glands may also give rise to
localized pain in the region of the glands
• Purulent discharge may be seen from the openings of the ducts within
the mouth, indicating infection.
• Pain may be relieved by massaging the glands involved.
 Non-dental causes of facial
pain: Maxillary sinusitis
• Symptoms:
• Acute sinusitis:
• constant boring pain with zygomatic and dental tenderness
• In chronic cases
• there may be no pain or just occasional mild diffuse discomfort.
• Diagnostic criteria for maxillary sinusitis include:
• Purulence in the nasal cavity;
• Simultaneous onset of headache and sinusitis;
• Pain over the antral area which may radiate to the upper teeth or forehead; and
• Headache disappearing after treatment of acute sinusitis.
• The character of the pain of maxillary sinusitis:
• dull, aching, boring and tender, of mild to moderate severity, is usually continuous
• May be either unilateral or bilateral commencing after an upper respiratory tract infection.
• Pain is triggered by bending forward, touching the area or biting on the upper teeth.
• Headache is located over the antral area.
• In the presence of the key diagnostic symptoms, investigations are not required
 Temporomandibular disorders

• encompass pain affecting the masticatory muscles and/or

• temporomandibular joints (TMJs).
• They consist of muscular pain (referred to by some as myofascial)
• TMJ disc interference disorders
• TMJ degenerative joint disease( rarely causes pain but results in
• limitation of opening.)
• Trauma (the pain is usually self-limiting, but psychological aspects may
contribute to chronicity of the pain, important to manage it early.
• TMD is more prevalent in females
• Natural history: intermittent pain with continuation for many years.
• Tension type headaches can be mistaken for TMD.
 : Temporomandibular disorders
• There is increasing evidence thatTMD is linked to many other chronic
pain conditions, such as headaches, migraine,
• post-traumatic stress disorder
• Fibromyalgia
• The relationship between TMD pain and clenching habit or bruxism
• is far from simple and daily variations in pain do not correlate with
self-reports of clenching or grinding.
 Trigeminal neuralgia
• Definition :( International Association for the Study of Pain)
• sudden,usually unilateral severe, brief, stabbing, recurrent in the
distribution of one or more branches of the Vth CN
• Idiopathic & secondary forms are recognized
• multiple sclerosis,
• benign or malignant lesions being contributory factors.
• Categorization: classical and atypical forms based on symptoms and not
etiology
• TN is being increasingly recognized , annual incidence now being
estimated around 12.8 per 100,000,
• Peak incidence in 50–60-year olds.
• TN symptoms arising in younger patients should alert the clinician to
the possibility of an underlying cause, such as multiple sclerosis.
 Glossopharyngeal neuralgia (GPN)
• Defined by the IASP as sudden severe recurrent pain in the distribution of the
glossopharyngeal nerve,
• GPN is very rare, with an incidence of 0.7 per100,000,
• more common in females and those aged over 50 years.
• Classic GPN is severe recurrent stabbing pain
• in the ear, base of tongue, tonsillar fossa or below the angle of the mandible.
• Precipitated by swallowing, talking or coughing.
• Secondary GPN presents with an additional ache that may persist between attacks
• Secondary to a cranial lesion demonstrable by investigations or surgery.
• The pain is unilateral in location and there are no obvious motor neurological defects.
• Episodes of pain may last from weeks to months.
• Although also rare, a syndrome known as Eagles syndrome should be considered with
classical symptoms of GPN.
• Eagles syndrome describes symptoms related to an elongated styloid process
• impinging on adjacent anatomical structures
• associated with pain and dysphagia on chewing and on turning the head to the affected
side.
 Classical TN
• presents with shooting, sharp, unbearable pain in the distribution
of one or more branches of the trigeminal nerve,
• Moderate to intense severity, lasting seconds.
• The right side of the face is affected in 60% of sufferers, it is
unilateral in 97% of cases
• rarely in first division only.
• It is precipitated by light touch, but may be spontaneous, and there
are often associated trigger points.
• Periods of remission may last days, weeks or longer.
• .
 Burning mouth syndrome (BMS)

• continuous burning pain of the oral mucosa

• any contributing local or systemic pathology absent
• an increasing number of studies suggesting not just a psychological condition but
is probably neuropathic.
• Most patients have continuous pain
• It can vary throughout the day.
• Most patients do not associate food or drink with the onset of pain
• But some will describe the pain as being exacerbated by spicy or acidic foods,
• whereas others find feeding relieves.
 Burning mouth syndrome (BMS)
• Many BMS patients : depression or anxiety,
• a thorough, systematic soft tissue examination is important when excluding an
organic cause for BMS
• Haematological and biochemical investigations to assess
• anaemia, low in iron, folate or vitamin B12, levels
• level of glucose;
• Microbiological tests for candidosis;
• Baseline saliva flow rate if there is any question of hyposalivation;
• Sensory testing;
• Allergy testing;
• Immunological testing for conditions such as Sjögren’s syndrome or SLE
• Detailed drug history will highlight any drugs that may be associated with
burning pain
 Trigeminal neuropathic pain

• Trigeminal neuropathic pain or traumatic induced neuralgia

• is a form of chronic facial pain
• arising as secondary to injury to the trigeminal nerve, such as facial trauma or a
dental procedure.
• rare but increasingly recognized
• pain is described as a continuous burning sensation localized to the injured area,
• but may be described as constant, dull, burning with or without intermittent sharp
stabbing pain.
• Numbness and tingling may also be present due to nerve dysfunction.
 Trigeminal neuropathic pain

• The pain symptoms may be classed under the following:

• Dysaesthesia (abnormal perception of pain);
• Allodynia (due to a stimulus which does not normally provoke pain
• Hyperalgesia (an increased sensitivityto pain).

• Proposed mechanisms for trigeminal neuropathy:

• Peripheral or central sensitization,

• Beta fibre reorganization
• Sympathetically maintained pain due to alpha receptor sprouting.
 Trigeminal neuropathic pain

• Trigeminal neuropathy, with and without pain, is associated with a number of

connective tissue disorders:
• Scleroderma;
• Sjögren’s syndrome;
• Mixed connective tissue disease;
• Systemic lupus erythematosus;
• Rheumatoid arthritis; and
• Dermatomyositis.

• The underlying pathology for trigeminal nerve dysfunction in these patients is

unknown but could be related to a form of vasculitis.
 Atypical odontalgia (AO)
• a form of trigeminal neuropathic pain
• both psychological and neuropathic origins.
• There is limited evidence on the incidence and prevalence of AO.
• Clinical features:
• Persistent, intra-oral, well localized pain, not associated with radiation to
adjacent areas or extra-orally.
• Often (80%) commencing in conjunction with some form of dental treatment
including local anesthesia
• particularly root canal therapy or extraction
• Most common site of pain: molar and premolar region.
• Associated features of
• hyperaesthesia
• allodynia at the pain site, with a prolonged response to ethyl chloride
 Atypical odontalgia (AO)

• often results in repeated,and possibly unnecessary, dental treatment

such as extractions, root canal therapy and apicectomies in the pursuit
of pain relief.

• A patient presenting with such pain and giving a history of multiple

extractions possibly preceded by root canal therapies should raise
suspicions of AO.

• Diagnosis and management as early as possible is vital to avoid

unnecessary invasive treatments
 Post-herpetic neuralgia (PHN)

• persistent burning pain

• can be an excruciating/severe pain
• with intermittent shooting sensation
• localized to the site of previous herpes zoster infection,
• 3–6 months after resolution of the infection.
• Allodynia, hyperalgesia and numbness in the affected area
• The neuralgia is dermatomal in location.
 Ramsay Hunt syndrome
• herpes zoster infection of the geniculate ganglion of the facial nerve,

• Signs: facial pain,lower motor neuron palsy, ipsilateral vesicles, on the skin of the
ear canal, auricle and/or mucous membrane of the oropharynx.
• Pain is usually localized,paroxysmal, deep within the ear,
• Can radiate externally and may become more dull and diffuse
• Onset of pain usually precedes the rash by several hours or days
• The disease is self-limiting.
• Affects 40% of patients
• most patients are more than 70 years of age.
• Following initial exposure to the herpes zoster virus from chicken pox,
the virus lies dormant in the trigeminal ganglion
• when activated, gives rise to the rash of shingles.
• PHN is the result of damage to the nerve by the virus.
 Chronic idiopathic facial pain
• Chronic (persistent) idiopathic facial pain (CIFP), (atypical facial pain,

• persistent facial pain which is poorly understood, but its persistence is likely to result in
psychological distress.
• The pain is aching, heavy, nagging, sometimes throbbing or stabbing.
• It does not follow anatomical pathways
• Can be local or very extensive,
• Radiating into the head and neck.
• Often constant but with varying intensity.
 Chronic idiopathic facial pain
• Psychological stresses or fatigue may worsen the symptoms
• therefore important to take a relevant psychosocial history
• and record associatedstress-related factors.
• Informationregarding marital status, family medicalhistory, employment
status,
• history of depression or anxiety and sleep problems are all relevant.
• Exploring patients’ belief sabout their pain can be particularly enlightening.
• There are no specific relieving factors
• patient may also suffer irritable bowel syndrome, back and neck pain and poor
sleep.
 Migraine

• Affects one in four women and one in 12 men in the UK.

• It is a chronic headache disorder affecting the frontotemporal region.

• It often co-exists with TMD, which may exacerbate migraines.

• The headache is typically unilateral, severely disabling ,
usually lasting 4–72 hours and is associated with
• photophobia, phonophobia, nausea and/or vomiting.

• It may be preceded by an aura in 15% of cases, visual disturbances being most

common.
• Changes in frequency, intensity and location are often found in women
• whose migraines are hormonally driven
ant cell ( temporal) arteritis (GCA)
• GCA is a form of vasculitis, cell-mediated immune damage to blood vessel walls
• mainly affects blood vessels in the head and neck
• Rare under the age of 50 years
• Females are about 3 times more likely than mento develop this disease.
• The temporal artery is commonly affected giving rise to temporal arteritis.
• Symptoms : unilateral or bilateral headache of aching or throbbing quality, often
intense and continuous
• scalp tenderness,
• visual changes and/or neurological changes.
Giant (temporal) cell arteritis (GCA)
• Criteria for a diagnosis of temporal arteritis :

• any new persistent headache in the temporal region,

• with either swollen tender scalp artery ,raised ESR or CRP,

• or temporal artery biopsy demonstrating giant cell arteritis.

• Major improvement or resolution of headache within 3 days of high dose steroid
treatment confirm the diagnosis.

• may be associated with polymyalgia rheumatica, jaw claudication,

• weight loss, altered sensation or loss of vision.
• Owing to the high risk of early visual loss as a result of anterior ischaemic optic
neuropathy, prompt diagnosis and treatment are necessary
 Tension type headache
Episodic and chronic forms of tension-type headache are recognized.

The episodic form lasts from 30 minutes to days, with a pressing quality, of mild to moderate
intensity,

is bilateral, with less than 15 attacks per month

no aggravating factors or associated symptoms, unlike the
chronic form: although of similar character and location,
occurs more than 15 times per month for at least 6 months

with associated nausea,

photophobia or phonophobia.
The pathophysiology of this form of headache is not fully understood,
its prevalence is quoted as 2.2%
more common in females.
It can mimic TMD MSK.
Differential diagnosis of trismus
Trismus

• Tonic contraction of masticatory muscles

• Any restriction in mouth opening

• Causes: simple, not progressive………………

• Progressive, life-threatening
• Congenital, acquired

• Infection, trauma, surgery, ionizing radiation

 Definition

• Uniform criteria is lacking!

• Various criteria for presence of trismus
• Mouth opening <20mm (Jen et. al., 2002)
• Mouth opening <40mm Nguyen et. al., 1988)
• Severity Scales: Mild, >30mm; Moderate, 15--30mm; Severe, <15mm (
Thomas et. al., 1998) Generally, opening of <35--40mm a functional guideline
• Less than 18--20mm, oral alimentation is difficult
Complications of restricted mouth opening

• Poor oral hygiene

• Complications of conditions associated with head and neck cancer
• Reduced access for oral examination and dental proceduresdental
procedures
• Dysphagia, Aspiration and related complications
• Malnutrition
• Decreased access medical procedures, including intubation
• Inability to dentures or oral /pharyngealpharyngeal prosthetics
• Speech deficits

• Airway compromise

• Pain
 Factors essentials for proper mouth opening
( Anushan)
• Integrity of nerves that supplies muscles of mastication
• Coordinated function of muscles of mastication.
• Proper function of TMJ.
• Skeletal integrity of mandible and Zygomatic bone
• Flexibility of mucosa, skin and soft tissue in cheek area.
 Intracapsular causes

True ankylosis

• Trauma: – Intracapsular comminuted fracture, penetrating trauma, forceps delivery

• Infection, - Otitis media - Mastoiditis –osteomyelitis of the jaw , hematogenic infection
• Tumors – chondroma, osteochondroma, osteoma, osteosarcoma, fibrosarcoma,
metastatic condylar head tumor
• Systemic arthropathies: juvenile osteoarthritis, osteoarthritis, rheumatoid arthritis,
Bechterews disease (ankylosing spondylitis )

• Chondromatosis (melon seed loose bodies)of the TMJ

 Intracapsular causes

Diseases of the articular disc

• Pain upon palpation, lateral to the joint capsule, is a significant finding.
• Clicking may indicate anterior disc displacement. Painless clicking alone does not requir
treatment.
• Acute closed-lock conditions may occur when the meniscus becomes displaced
anteromedial to the condyle.
• The patient usually has a history of paroxysmal clicking and some discomfort.
• In closed-lock conditions of a mechanical nature, the patient can often open his or her
jaw 20–25 mm.
• Opening significantly less than this should suggest a closed lock of muscular origin.
Pericapsular causes (fals ankylosis)

• trauma -periarticular fibrosis ( wounds, burns)

• Infections: bacterial, fungal or mycobacterial chronic periarticular
suppurative inflammation
• Tumors: fibrosarcoma of the articular capsule–chondroma from ectopic
tissues
• Radiation therapy – Periarticular fibrosis - Osteoradionecrosis – Dicrease
of condylar cellular activity.
 Extracapsular causes (pseudoankylosis)

Trauma
• Impressed fracture of the malar bone or zygomatic
• fibrous or bony zygomatico-coronoid ankylosis
• Coronoid hyperplasia
• – True ( increased activity of temporal muscle ), developmental disorder
• - Relatíve coronoid hyperplasia – acquired deformity of condyle due to the short ramus
Tumors
of the coronoid process (chondroma , osteochondroma, osteoma, sarcoma
Bucca carcinoma
Miscellaneous
• Myositis ossificans,
• oral submucous fibrosis ,
• extended facial scars from war injuries, noma
• Congenital anomalies
 Trismus

Infections
• Odontogenic infections: pulpal necrosis, parodontitis, pericoronitis
• Submasseteric, pterygomandibular and temporal abscess
• Non odontogenic infections: peritonsillar abscess, tetanus, meningitis,
parotid abscess, brain abscess

Trauma
• Fracture of the mandible, zygomatic arch
• Impaction of foreign body
• Laceration of the face
• Radiation therapy
 Trismus
Related to dental treatment:
• performance of a dental procedure such as difficult extractions or other
treatment requiring lengthy appointments. Oral surgical procedures may result
in limited jaw opening.
• The extraction of teeth as a result either of inflammation involving the muscles
of mastication
• or direct trauma to the TMJ.
• 2–5 days after a mandibular block, usually attributed to inaccurate positioning
of the needle
• when giving the inferior nerve block or tuberal anesthesia
• the medial pterygoid muscle is accidentally penetrated or a vessel is punctured
and a small bleed follows: a haematoma can occur in the muscle bed and
subsequently organize, causing a fibrosis. Trismus due to this cause can be
protracted and quite severe.
• Extraction of a Lower molar tooth Myofacial pain, muscle spasm
 Tumors
• A potential problem in treating patients with trismus is the risk of misdiagnosing
the patient who has a neoplastic disease, either primary or metastatic.
• Metastatic
• Epipharynx- Nasopharynx
• Parotid gland
• Infratemporal tumors
• Tumors of the mandible , TMJ
• Bucca carcinoma

• fibrosis of the insertion of temporalis tendon, resulting in limited jaw movement.

• Oral submucous fibrosis
 Drugs

Some drugs are capable of causing trismus as a secondary effect,

• succinyl choline, antipsychotics) e.g. chlorpromazin

• phenothiazines sok imipramin, desipramin, amitriptylin, clomipramin.

• tricyclic antidepressants being among the most common.
• Halothan

Trismus can be seen as an extrapyramidal side-effect of metoclopramide,

phenothiazines and other medications.
 Neurological causes

• Psychological: hysteric trismus

• Neurotoxic – Tetanus
•
• Neurological diseases: central and periferal lesions of the trigeminal motopr
nerves
• ( stroke )
 Tetanus, lock jaw
• Infective disease due to the inoculation of Clostridium tetani into the tissues. Its exotoxin, called Tetanospasmin is
responsible for the clinical manifestations. It travels by retrograde axonal transport from the wound to the spinal cord in 2-14 days. In the
spinal cord, it enters central inhibitory neurons. As a result, gamma-aminobutyric acid (GABA)-containing and glycine-containing vesicles are
not released, and there is a loss of inhibitory action on motor and autonomic neurons. The loss of central inhibition results in autonomic
hyperactivity as well as uncontrolled muscle contractions (spasms) in response to normal stimuli such as noises or lights.

• Cl. tetani may remain in the tissues for months or even years until activated by irritation or trauma.
• A few reports claiming that tetanus developed after tooth extraction, but the microbiological evidence for
these is slight (Richter, 1971).
• ORAL MANIFESTATION
• After a short period of non-specific prodromal symptoms the first manifestation of tetanus is tonic rigidity
of the muscles of facial expression ND mastication.
• The patient presents with stiffness of the face followed by difficulty in chewing and swallowing.
• 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
• Other muscle groups become involved, The trunk and the proximal parts of the limbs.
• The spine may become arched (opisthotonus,
• the chest fixed in a state of expiration.
• board-like rigidity of the abdominal muscles and,, the patient has difficulty in swallowing and breathing is
embarrassed because of restricted respiratory movements.
• Death occurs from exhaustion, aspiration pneumonia or asphyxia due to respiratory muscle spasm.