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CHAPTER12 The lower jaw andface
TMJ (OPT) will demonstrate gross irregularity of the joint and loss of
joint space. In children, severe ankylosis can result in asymmetric facial
growth. This requires an outpatient referral.
bRadiotherapy- induced brosis
This arises following radiotherapy where the ir radiated elds include the
TMJ or muscles of mastication. Radiotherapy to the muscles results in
atrophy and brosis of the muscle bres. Onset is often gradual, usually noticeable 8 – 12 weeks af ter completion of treatment. However, it
can continue to develop. Without inter vention, mouth opening can be
reduced by up to a third after several years. Studies have demonstrated
that nearly half of all patients who receive curative intent radiotherapy to
the head and neck will experience some limitation of opening.
bOral submucous brosis
Oral submucous brosis is a chronic debilitating disease of the oral cavity
characterized by inammation and progressive brosis of the submucosal tissues. It causes progressive limitation of opening which if untreated
can progress to total inabilit y to open the mouth. The buccal mucosa is
the most commonly involved site, but any part of the oral cavity can be
involved, including the pharynx. The condition is well recognized for its
malignant potential and is par ticularly associated with areca nut chewing,
the main component of betel quid. It is usually associated with a marbled
appearance of the buccal mucosa and the presence of taut palpable
brous bands withinit.
bMyositis ossicans
This is heterotopic calcication of muscle. There are twoforms:
• Myositis ossicans is when calcication occurs within an injured
muscle.
• Myositis ossicans progressiva (also referred to as brodysplasia
ossicans progressiva) is a condition in which ossication can occur
without injury. It is inherited.
Imaging will show ha zy densities approximately 1month after injury, and
denser opacities at 2months. Treatment is usually conser vative (NSAIDs
and physiotherapy). Surgical removal of the myositis ossicans is rarely
required.
bCoronoid hyperplasia
This is a condition of unknown aetiology but is seen in association with
submucous brosis and TMJ ankylosis. As elongation of the coronoid
process occurs, it results in progressive limitation of opening from
impingement on the under- surface of the zygoma and its arch. In severe
cases, the coronoid can be excised.
Trismus
This is an important sign and should always be taken seriously, especially in
infections. Trismus is limitation in mouth opening due to muscle spasm.
Most commonly, the spasm is in the masseter muscle, but it can occur in
the medial pterygoid or temporalis muscles. It is a marker indicating that
any infection is advanced and it is often taken as a sign that the patient
needs admission. Untreated infection will rapidly progress, eventually
resulting in dysphagia and potential airway problems. Anaesthetists need
to be aware of any trismus if the patient is going to theatre, as breoptic
intubation is required.
Trismus can be graded 35 – 40mm normal. Mild opening 30– 35mm,
moderate 15 – 30mm, and severe <15mm.
Causes oftrismus
Most causes can be considered under the headings of infection, trauma,
and tumour. If you remember these three pathologies you won’t overlook
serious conditions:
• Muscle spasm (following injury/ infection)
• Post- surgical oedema (especially following removal of wisdomteeth)
• Recent dental treatment
• Following an inferior alveolar nerve block (usually from a haematoma
in the medial pter ygoid)
• Dental infections/ pericoronitis/ submasseteric abscess
• Peritonsillar abscess
• Cerebrovascular accident/ braininjury
• Acute parotitis (e.g.mumps)
• Tet a n u s
• Malignancy (intraoral and extraoral).
The most common causes will be trauma and abscesses which cause
spasm of the medial pterygoid. Following injury there does not have to
be a fracture. Occasionally a displaced fracture of the zygomatic arch
may impinge on the movement of the coronoid process and prevent normal opening. This is not trismus, but it still requires treatment.
bOral surgery procedures
Removal of the lower molar teeth may cause trismus as a result of inammation in the muscles of mastication, direct trauma to the masticatory
apparatus, or postoperative infection. Infections require antibiotics.
Following this, heat therapy, analgesics, a sof t diet , and gentle jaw exercises should eventually resolve the remaining symptoms.
cInferior alveolar nerve injections
Medial pter ygoid haematoma can occur following a dental injection to
anaesthetize the inferior alveolar nerve. These patients will present with
progressive trismus within a few days of under going dental treatment. Be
mindful of the possibility of secondary infection. Asimple haematoma is
managed by prescribing NSAIDs and starting the patient on gentle jaw
stretching exercises. If infection is suspected, commence antibiotics and
avoid exercises. Refer severe limitation or infections to maxillofacial.
TRISMUS
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CHAPTER12 The lower jaw andface
cPeritonsillar abscesses (quinsy)
(See also E Chapter 8.) These are common infections arising when
infection of the tonsil spreads to the surrounding tissue. As the per itonsillar abscess increases in size it is often associated with trismus resulting
from spasm of the medial pterygoid muscle. Often they can be drained
in the emergency department but if they threaten the airway, general
anaesthesia is required.
cNeurological causes ofspasticity ofthe muscles
ofmastication
Cerebrovascular accident and traumatic brain injur y may result in severe
trismus secondary to masseter spa sticity. Many patients with severe
neurological injury undergo PEG placement secondary to severe masseter spasticity. Botulinum toxin may be eective in reducing this type
of trismus.
eTetanus- induced trismus
Tetanus toxin, the product of Clostridium tetani, causes muscle rigidity
and spa sms. This results in trismus, dysphagia, opisthotonos (severe
hyperextension and spasticity), and spasms of respirator y and laryngeal
muscles. Treatment is with tetanus immunoglobulin, IV antibiotics, and
muscle rela xant s. Patients may need intubation.
cOropharyngealcancer
(See E Chapter 13.) Oral cancer typically presents as a non- healing
ulcer, with raised rolled edges. Although they can occur anywhere in
the mouth, the most common locations are the oor of mouth and
posterolateral tongue. The patient may have a history of r isk factor s,
including smoking and alcohol. Any ulcer which is progressively enlarging,
and persists >2 weeks, should be referred for urgent biopsy to exclude
dysplasia or malignancy. Management involves further imaging to deter-
mine whether there is regional lymph node involvement or distant
spread. Following review at a head and neck multidisciplinary team
meeting, treatment may be curative or palliative, involving surgery,
chemotherapy, and radiotherapy.
Any cancer inltrating into the muscles of mastication (skin, parotid, sarcoma) can result in trismus.
cBleeding fromthe lower jaw
(non- traumatic)
(See also E Chapter 13.) Bleeding from the gums and the mouth in general can be a common symptom. The commonest cause is local inammation caused by inadequate tooth- brushing— ‘gingivitis’. However,
gingival bleeding may be a marker of an underlying systemic disease and
recognition of this fact is important for early diagnosis and management.
Certain medical conditions and drugs are known to aect the gingivae.
Where oral hygiene is ver y good consider these other causes. Rare
causes include vitamin K deciency and scurvy.
BLEEDING FROM THE LOWER JAW (NON-TRAUMATIC)
bDentalcauses
Oft en the caus e of bleedin g gums is obvi ous and easi ly treate d. Tr eatment
of infection involves removing the cause— either plaque in the case of
gingivitis, or treatment of a dental infection (root canal ther apy, extraction). The patient’s dentist can treat and advise on or al hygiene/ arrange
for the patient to see a hygienist.
bPregnancy
The hormonal changes that are associated with pregnancy will rever se
following deliver y, but during the pregnancy excellent oral hygiene
should be maintained. Local gingival bleeding may also be associated with
a pregnancy epulis. This may need to be surgically removed if troublesome, although they usually regress after delivery.
cDrugs
Drug- related gingival bleeding must be managed in close association with
the physician who prescribed the medication. Simply stopping any dr ug
thought to be the cause of bleeding may have adverse eects that are
potentially far worse for the patient. The degree of urgency in altering a
prescription is related to the severity of gingival bleeding as well as the
presence of bleeding from other sites (e.g. nasal mucosa and GI tract).
In the case of some drugs, immediate reversal is possible (e.g. warfarin),
whereas for other s it isnot.
cIdiopathic thrombocytopenic purpura
This is thought to be an autoimmune disorder and probably the most
common cause of thrombocytopenia. Close liaison with a haematologist
is essential. Regional local anaesthetic block s may be contra- indicated
if the platelet count is <30 x 109/ L. The va st majority of cases can be
adequately managed by the administration of corticosteroids. If a major
surgical procedure is required, platelet transfusions and/ or the use of
immunoglobulins may be necessary.
cLeukaemia
It is not uncommon for leukaemias, especially the acute types, to present
with oral signs and symptoms. These include:
• Bleeding gums— a hyperplastic gingivitis (red, spongy, fragile gums),
which bleed spontaneously.
• Infection— the gingivae are highly susceptible to infection. Secondary
acute ulcerative gingivitis may beseen.
• Localized masses of leukaemic inltrates.
• Candida/ herpes simplexvirus.
cBleeding dyscrasias
Occasionally persistent bleeding following minor injuries is the presenting sign of an underlying clotting disorder such as haemophilia.
Bleeding sockets following dental extractions are rarely life- threatening.
However, in the presence of signicant co - morbid disease (e.g. in the
elderly with poor cardiovascular reserve), a continually bleeding socket
may quickly become a problem. You will need to decide whether it is sufcient to simply deal with the local problem, or whether it is necessar y
to investigate further.
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CHAPTER12 The lower jaw andface
Management ofbleeding sockets
Most cases need only simple reassur ance and getting the patient to bite
rmly on a clean handkerchief or gauze swab placed over the wound for
at least 20 minutes. In the vast majority of cases bleeding set tles and no
further action is required other than care of the air way, if necessar y using
gentle suction. If bleeding persists, rinse the mouth out to clear any clots
and look for the bleeding site. Depending on where the problem is this
can be dealt with by further suturing or packing the wound with a haemostatic dressing, such as Surgicel®. Other measures include antibrinolytic
agent s, such as tranexamic acid. Patients rarely need to go to theatre. If
all else fails, patients need to be admitted for bed rest and investigations
for bleeding disorders or liver disease.
cOropharyngealcancer
(See E Chapter 13.) Oral cancer is described elsewhere. Ulcers can
occasionally bleed. Tumours invading bone can present with bleeding.
Bleeding from the throat is a poor prognostic sign, indicating a deeply
invasive cancer. These all need urgent referral.
cCutaneous sinuses and fistulae
overlying thelowerjaw
A sinus is an abnormal, blind- ending tract, opening onto an epithelial surface.
This is not restricted to skin only, but includes any epithelial surface,
including mucosa (mouth, pharynx, anus, rectum, vagina, etc.), intestinal epithelium, bronchial epithelium, bladder epithelium, and so on. A
stula is an abnormal communication between two such epithelial surfaces.
In the lower jaw the two most common causes of these are infection and
tumour. Causes include:
• Dental abscesses
• Chronically infected dentalroot
• Chronic osteomyelitis
• ORN
• BRONJ
• Foreign body in theskin
• Ingrowinghair
• Infected osteosynthesisplate
• Necrotic lymphnode
• Underlyingtumour
• Furuncles and carbuncles
• Jawcysts.
See Figures 12.10 and12.11.
Clinically a sinus on the skin appears as a small opening, sometimes
with surrounding induration. There is often a chronic discharge of pus
from the sinus. Astula may occur if the abscess drains both intra- orally
and onto the sk in. Amicrobiological swab should be taken from any discharge. If there is no obvious dental or jaw pathology, consider actinomy-
cosis. Clinically, this is presents as ‘sulphur granules’ discharging onto the
skin, although they are not always present.
CUTANEOUS SINUSES AND FISTULAE
Figure12.10 Beware dischargi ng sinuses of t he lowe r face — consider dental
causes.
383
Figure12.11 The cause of t he sin us in Figure 12.10 was an infecte dtooth.
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CHAPTER12 The lower jaw andface
Management
The treatment of a sinus is primarily the elimination of the underlying
condition. Aspecimen should always be sent for histopathology.
Don’t just excise sinuses on the face. They will probably recur. Try to nd
the underlying cause (often dental). Consider also Actinomyces infec tion.
Pain inthe lowerjaw
bTMJDS
This is described elsewhere in this chapter (see E ‘Temporomandibular
joint dysfunction syndrome’, pp. 375–6). Acommon cause ofpain.
bToothache
Odontalgia
This is a shor t- lasting diuse pain due to exposed dentine that is pro voked by local stimuli (hot, cold, touch). The pain can be sharp or dull
and is usually mild to moderate in intensity, lasting less than a second to
minutes. Treatment is usually with a dressing or restoration and simple
analgesics.
Pulpitis
This is a pain due to inammation of the dent al pulp provoked by local
stimuli. It can var y from a sharp, poorly localized, dull ache, to throbbing pain which can be severe. Pain can last minutes or hours, with episodes that may continue for several days. Treatment requires removal
of the pulp or ex traction of the tooth and analgesics (e.g. NSAIDs and
paracetamol).
Periapical periodontitis and abscess
These cause severe throbbing pain arising from the periodontal tissues.
It is a continuous, well- localized, mild to intense aching.
cAtypical odontalgia
This is a severe throbbing pain in the tooth and jaw without major pathology. Of ten described as a severe continuous throbbing pain, it may vary
from mild to intense pain, especially with hot or cold stimuli. It may be
widespread or well localized and may move from tooth to tooth. It may
last a few minutes to several hour s. This is often a symptom of hypochondriacal psychosis or depression and there is often excessive concern with
oral hygiene. Counselling, avoidance of unnecessary dental treatments
or extractions, and sometimes antidepressants are required.
bPostoperativepain
For these patients prevention is better than cure. NSAIDs are good for
relieving bone pain. They may be given per ioperatively as ‘pre- emptive’
analgesia and then continued postoperatively to minimize discomfort.
Short- acting opioids, such as IV fentanyl, are commonly used for perioperative analgesia. Many analgesic regimensexist.
PAIN IN THE LOWERJAW
cDrysocket
This is localized inammation of the cortical bone of a socket following dental
extraction, most commonly the lower wisdom teeth. Typically, the patient
complains of severe dull throbbing pain, around 4– 5days af ter surgery and
often has a bad taste in the mouth. Pain is often exquisite, with inammation,
exposed bone and halitosis. They are multiple predisposing factors:
• Mandibular extractions
• Dicult extraction
• Pre- existing infection
• Poor blood supply (e.g. Paget’s disease, following radiotherapy)
• Smoking— nicotine is a vasoconstrictor
• Systemic disorders (e.g. diabetes)
• Oral contraceptives.
Management
The socket is irrigated with warm saline. It is then dressed with an anti septic pack, e.g. Alvogyl®. This contains iodoform (antiseptic), eugonal
(sedative), and seaweed (for bulk)— this is resorbed as healing occur s.
Antibiotics may be necessary.
cHerpes zoster (shingles)
This is an acute herpetic infection in any dermatome, commonly the fth
(V)cranial nerve. Involvement of the lower jaw is unusual but can occur.
It presents with burning and tingling pain in the skin with eruptions on the
lower lip. Post- her petic neur algia is chronic pain with skin changes following acute herpes zoster. There may be a burning sensation or itching
and crawling dysaesthesias in skin. In the acute phase, stellate ganglion
block s using local anaesthetic such as bupivacaine, may help for severe
pain. Transcutaneous nerve stimulation (TENS), capsaicin cream, and
tric yclic antidepressants are also useful.
cTrigeminal neuralgia (‘tic douloureux’)
Trigeminal neuralgia is most commonly a disorder seen in middle- aged
and elderly patients. It is more common in women with a peak incidence
between 50 and 60years of age. In young patients it may be an early feature
of MS, HIV disease, or as a consequence of a lesion irritating the trigeminal
nerve. Patients complain of a sharp, intense, lancing/ ‘electric- type’ pain
induced by a specic trigger point that r adiates across the distribution
of a branch of the trigeminal ner ve. The pain is almost always unilater al,
with over 30 – 40% of patient s showing a distribution aecting both the
maxillary and mandibular divisions. In approximately 20% of patients, the
pain is conned to the mandibular division, and the ophthalmic division
in 3%. Episodes may last up to several hour s. The aetiology of trigeminal
neur algia is presumed to be multifactorial, with local nerve microcompression within the skull base and possible demyelination.
Management
• Always consider skull base pathology and intracranial disease/
demyelination. Imaging may be required.
• The mainstay of treatment remains medical, typically with
anticonvulsant agents. Usually, trigeminal neuralgia responds well to
carbamazepine and/ or amitriptyline, and a muscle relaxant such as
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CHAPTER12 The lower jaw andface
baclofen. Carbamazepine remains the dr ug of choice with an initial
regime of 100 mg three times daily being gradually increased to a
maximum of 120 0 mg daily titrated against eect. 20% of patient s
may develop side eects such as tremor, dizziness, double vision,
and vomiting, which will obviously limit its use. They should have
regular monitoring of FBC, electrolytes, and LFTs. Approximately
20% can develop folic acid decienc y with megaloblastic anaemia, and
hyponatraemia in the elderly. Withdraw therapy slowly.
• Alternative agents include phenytoin, sodium valproate, lamotrigine,
and baclofen.
• Local sur gical procedures may be considered in trigeminal neur algia
not responsive to medical management. This can include cryotherapy
to the nerve, alcohol/ glycerol injections.
• Neurosurgical decompression in severe cases following imaging
conrming there is nerve compression.
• Gamma Knife® (stereotactic radiosurgery). High- resolution imaging
provides excellent denition and allows a focus beam of ionizing
radiation to irradiate the proximal trigeminal ner ve at its entry into the
pons. Results are very promising (see http:// www.gammaknife.org.uk).
cAtypical facialpain
Atypical facial pain has many distinguishing features that make it a clinical
entity in it s own right and not just a ‘catch all’ diagnosis for seemingly
unexplained facial pains. It is, however, essentially a diagnosis of exclusion
that should only be made after all other possible organic causes have been
excluded. These patients therefore often undergo extensive investigation.
Clinical features
Patients of ten have a ‘at aect’ and the more they are questioned about
the pain, the more vague their answer s become. The pain is t ypically
described as being a deep, dull ache, sometimes uctuating, sometimes
continuous, with intermittent severe episodes that the patient can nd
no causative factor for. Often the pain has been present for several years
and analgesics rarely aect its nature. It is most commonly bilateral, but
ill dened, and its distribution cannot be explained on an anatomical
basis. The patient may say they are kept from sleeping by the pain but
usually look well rested. When they do admit to sleeping, the pain does
not wake them. Aproportion of these patients may show symptoms of
depressive illness or anxiet y states, and patients often complain of other
symptoms such as back and neck pain and irritable bowel syndrome.
The patient’s mood often does not correlate to the descr iption of their
symptoms and they may show exaggerated responses to examination
and report stressful life events.
Management
Often the ill- dened nature of the patient’s pain result s in unnecessary
dental work being carried out. In light of the association of atypical facial
pain with the neuroses (particularly depression), and the belief that it
essentially has a psychogenic basis, emphasis has been placed on the use
of antidepressant agents as the main treatment option:
• Dothiepin, a tr icyclic antidepressant, has been shown to be eective
in reducing the painful symptoms (as it has in TMJDS).
• Selective serotonin re- uptake inhibitors (SSRIs).
PAIN IN THE LOWERJAW
Salivary gland pathology
Salivary gland pathology can either be obstructive, infective, or neoplastic in origin. Regardless of the origin of the pathology salivary gland
disea se can present with swelling and pain around the lower jaw. This
pain can mimic jaw pain because of the intimate relationship of the major
salivary glands to the mandible.
bCystic lesions ofthe mandible
(See E Chapter 11.) Cystic jaw lesions comprise an extremely varied
group of conditions and to consider each individually is beyond the scope
of this book. Slow- growing c ysts can present with painless rm swellings of the jaw. But they can present acutely following infection. Oral
bacteria gain access to the cavit y and a superimposed infection arises.
Larger cysts may also present with a pathological fracture. Malignant or
invasive lesions can present with par aesthesia of the inferior alveolar
nerve. Consequently the most likely presentation of cystic lesions in the
emergency department will be pain and swelling.
cTumours ofthe mandible
Tumours of the mandible canbe:
• Invasive tumours from oral mucosa squamous cell carcinomas
• Primar y bone tumours
• Metastatic tumour.
Presentation can be varied. Swelling of the lower jaw and associated
cervical lymphadenopathy will usually be present as these tend to be
advanced by the time patients seek help. Pain, although not an initial feature, will become more signicant as the disease progresses regardless
of the type of tumour. Bony involvement may result in paraesthesia of
the inferior alveolar nerve or pathological fracture. There is often some
degree of trismus. Larger tumour s will present with stulae to the skin,
bleeding and occasionally airway compromise. Urgent referral is then
required for management of acute symptoms and fur ther investigation
(see http:// bahno.org.uk/ docs/ head_ and_ neck_ cancer.pdf ).
Referredpain
In the emergency setting always be aware of the common causes of
referred pain in the lower jaw. These include:
• Cardiac
• Neoplasms of pharynx, nasophar ynx, base oftongue
• Lesions of the ear and Eustachiantube
• Major salivaryglands
• Intracranial lesions.
cGiant cell arteritis
Patients can present with lower jaw pain and claudication of the muscles
of mastication. This results from involvement of the maxillary artery.
Diagnosis is histologically (biopsy of the supercial temporal artery) but
this should not delay commencement of treatment with glucocorticoid
steroids. Suspect in any elderly patient with a highESR.
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