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Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery xxx (2010) xxxxxx

Longitudinal evaluation of restricted mouth opening

(trismus) in patients following primary surgery for oral and
oropharyngeal squamous cell carcinoma
B. Scott a, , J. DSouza b , N. Perinparajah b , D. Lowe b,c , S.N. Rogers b,c
a Physiotherapy Department, Aintree University Hospitals NHS Foundation Trust, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK
b Regional Maxillofacial Unit, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK
c Evidence-Based Practice Research Centre (EPRC), Faculty of Health, Edge Hill University, St Helens Road, Ormskirk, L39 4QP, UK

Accepted 17 February 2010

Abstract

Trismus is a serious problem for some patients after oral and oropharyngeal cancer, and it has a detrimental impact on quality of life and
function. We know of few published papers that include preoperative assessment in reports on the longitudinal outcomes of mouth opening after
oral and oropharyngeal surgery. We prospectively measured mouth opening in patients who had primary surgery for oral and oropharyngeal
cancer from baseline to six months to find out the characteristics at baseline and at discharge of those who develop trismus at six months.
Ninety-eight patients were eligible between February 2007 and March 2008, and 64 (65%) were recruited into the study. The range of mouth
opening was measured on three occasions: before operation, on the ward before discharge from hospital, and at follow-up six months after
operation. Using a criterion of 35 mm or less as an indication of trismus, 30% (19/63) had trismus before operation, 65% (37/57) at hospital
discharge, and 54% (26/48) at six month follow-up. Patients at high risk of trismus were those with T stage 3 or 4 cancers who required
free flap reconstruction and adjuvant radiotherapy; radiotherapy was the most significant factor at six months. Trismus at discharge was a
prediction of trismus at six months. Interventions such as spatulas or a passive jaw mobiliser should be targeted at patients at high risk early
in the postoperative phase. The efficacy of such interventions needs further research.
2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Trismus; Mouth neoplasm; Surgery; Radiotherapy; Questionnaires

Introduction opening was associated strongly with tumour stage, adju-

Trismus can be a serious problem after oral and oropharyn-
geal cancer, and can have a detrimental impact on quality
of life and function.13 It has been reported to affect up to
38% of patients,4 but this reflects a lack of clear definition
of trismus, and recent studies support a 35 mm cut-off.3,5 A
previous cross-sectional study reported that limited mouth
Corresponding author. Tel.: +44 0151 529 3335; fax: +44 0151 529 2409.
E-mail addresses: barry.scott@aintree.nhs.uk (B. Scott),
dsouzaj@mac.com (J. DSouza), drnishanthaperinparajah@gmail.com
(N. Perinparajah), astraglobeltd@btconnect.com (D. Lowe),
snrogers@doctors.co.uk (S.N. Rogers).
vant radiotherapy, and type of surgical intervention (free
tissue transfer).3 Trismus has also been noted to have a grad-
ual onset from nine weeks after completion of radiotherapy,
and to progress over a nine-month period.6 Further loss of
range of mouth opening has been reported at 12 months after
radiotherapy,7,8 with a continued progression of deteriora-
tion at four years.9 The inclusion of the pterygoid muscles
within the radiation field is also an important factor for the
development of radiation-induced trismus.7,10
There is a distinct paucity of published papers that report
longitudinal outcomes. To the best of our knowledge this
paper is the first to record measurements of mouth opening
from baseline and to look specifically at the early postoper-

0266-4356/$ see front matter 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.02.008

Please cite this article in press as: Scott B, et al. Longitudinal evaluation of restricted mouth opening (trismus) in patients following
primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg (2010), doi:10.1016/j.bjoms.2010.02.008
YBJOM-3323; No. of Pages 6
ARTICLE IN PRESS
2 B. Scott et al. / British Journal of Oral and Maxillofacial Surgery xxx (2010) xxxxxx

ative phase (to discharge from hospital), investigating how Table 1

mouth opening at this time might predict problems at six Participation and retention in study by clinical characteristics of eligible
patients.
months. Trismus has been shown to be present after opera-
tions for head and neck cancer,11,12 but without preoperative Mouth assessments No (%)
Before At discharge At 6 month
measurements the degree of movement lost from baseline operation follow-up*
cannot be calculated. Both studies indicated that surgery was
All patients 63/98 (64) 57/98 (58) 48/94 (51)
a direct cause of trismus, and patients required either a com-
posite free flap in addition to a midline mandibulotomy,11 or Male 39/61 (64) 38/61 (62) 32/59 (54)
Female 24/37 (65) 19/37 (51) 16/35 (46)
resection of the region of the pterygoid fossa.12
We therefore prospectively measured and recorded mouth <55 years 22/32 (69) 19/32 (59) 17/32 (53)
opening in patients who had primary operations for oral and 5564 years 27/43 (63) 25/43 (58) 23/42 (55)
65+ years 14/23 (61) 13/23 (57) 8/20 (40)
oropharyngeal cancer to establish the incidence of trismus
after operation, and to indicate which patients might go on Oral 51/82 (62) 46/82 (56) 38/78 (49)
Oropharynx 11/15 (73) 10/15 (67) 9/15 (56)
to develop trismus over time. Earlier recognition of those
Maxilla 1/1 (100) 1/1 (100) 1/1 (100)
patients at risk of developing trismus in the postoperative
phase would help to underpin strategies for intervention that T stages 12 38/64 (59) 36/64 (56) 30/63 (48)
T stages 34 25/33 (76) 21/33 (64) 18/30 (60)
are aimed at prevention.
N stage 0 41/69 (59) 40/69 (58) 31/67 (46)
N stage + 22/29 (76) 17/29 (59) 17/27 (63)

Methods No free-flap 16/37 (43) 13/37 (35) 11/37 (30)

This study was conducted at the Regional Maxillofacial Unit
at University Hospital Aintree between February 2007 and
March 2008. All consecutive patients with a diagnosis of
squamous cell carcinoma (SCC) of the head and neck who
had primary operations were included. Those treated previ-
ously for head and neck carcinoma were excluded.
Measurements of mouth opening were recorded on three
occasions: before operation, on the ward at discharge from
hospital, and at follow-up six months after operation. Mea-
surements were recorded using the Willis bite gauge (SS
White Group, Gloucester, UK) in millimetres (mm) for both
dentate and edentulous patients. Measurements were taken
from the top of the philtrum/bottom of the columella to the
under surface of the mandible with the mouth at rest (patients
were instructed to close the mouth without biting the teeth
together), and fully open (patients were instructed to open the
mouth fully with the words, please open your mouth as wide
as you can . . . even wider). For this paper mouth opening
was taken as the difference between the two measurements
recorded, and only one measurement was recorded for each
patient on each occasion.
Most preoperative assessments were done by two clini-
cians experienced in using the Willis bite gauge, and by the
author, but some were done by an experienced Senior House
Officer. Most measurements done at discharge from hospital
and at six-month follow-up were by the author.
In addition to clinical measurements, patients were asked
one question. Before operation they were asked, since your
diagnosis, have you found that you have less mouth opening?
while after operation they were asked, since your treatment,
have you found that you have less mouth opening?. They
responded using a five-point scale: not at all, slightly, mod-
erately, a lot, and extremely. This gave an insight into the
patients perspective, and supported previous work3 that jus-
tified 35 mm as a clinically meaningful cut-off. Throughout
Soft free-flap 32/44 (73) 32/44 (73) 27/42 (64)
Composite free-flap 15/16 (94) 12/16 (75) 10/14 (71)
No radiotherapy 32/56 (57) 27/56 (48) 19/53 (36)
Radiotherapy** 31/42 (74) 30/42 (71) 29/41 (71)
Denominator reduced to 94 because 6 patients had died between dis-
charge and 6-month follow-up.
Includes chemoradiotherapy.
Denominators for T stage and type of free-flap are lower (each by one
patient) because of unknown status.
the paper we use the term trismus to describe restricted mouth
openings of less than 35 mm.
The project was considered as a clinical outcomes audit
project and was registered with the Audit Department at Uni-
versity Hospital Aintree (proposal number 1155).
Statistical analysis focused on mouth opening at baseline,
discharge from the ward, and follow-up, but also on change
in mouth opening. Wilcoxon matched pairs test was used
to assess change in the whole group. Associations of mouth
opening (mm) with the patients characteristics were assessed
using MannWhitney (for 2 categories) or KruskalWallis
(for more than 2 categories) tests. Associations of trismus
(less than 35 mm compared with 35 mm or more) with char-
acteristics of patients were assessed using Fishers exact test
(for 2 categories) or chi-square (more than 2 categories) tests.
The Statistical Package for the Social Sciences (SPSS version
15) was used for all analyses.
Results
There were 98 eligible patients on the regional head and neck
cancer database, 65% (64) of whom participated in the study.
Participation was higher for patients with more advanced
tumours, and those who required free-flap surgery and radio-
therapy (Table 1). Seven previously untreated patients with
node negative T1 or T2 SCC of the anterior two-thirds of the

Please cite this article in press as: Scott B, et al. Longitudinal evaluation of restricted mouth opening (trismus) in patients following
primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg (2010), doi:10.1016/j.bjoms.2010.02.008
YBJOM-3323; No. of Pages 6
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B. Scott et al. / British Journal of Oral and Maxillofacial Surgery xxx (2010) xxxxxx 3

Table 2 Baseline assessments were done a median (IQR) of 1

Trismus (<35 mm) and mouth opening by clinical characteristics of patients (16) day before operation. Median (IQR) mouth opening
before operation.
was 39 mm (3244), and 30% (19/63) had trismus. Patients
Trismus (<35 mm) No (%) p-Value about to have free-flap surgery or radiotherapy had the
All patients 19/63 (30) most restricted mouth opening (Table 2). Their responses
Male 9/39 (23) 0.16 to being asked whether they had less mouth opening since
Female 10/24 (42) their diagnosis (at baseline) or since treatment (discharge and
<55 years 5/22 (23) follow-up) are shown in Table 3.
5564 years 8/27 (30) 0.44 Assessments at discharge were done at a median (IQR)
65+ years 6/14 (43) of 13 (9118) days after operation (Table 4). Median (IQR)
Oral** 15/51 (29) 0.99 mouth opening was 30 mm (2338); 65% (37/57) had tris-
Oropharynx** 3/11 (27) mus. It was present in a quarter (27%, 15/56) before and after
T stages 12 9/38 (24) 0.26 operation, and in 38% (21/56) after operation only. Thirty-
T stages 34 10/25 (40) four percent (19/56) had no trismus, and one patient had it
N stage 0 14/41 (34) 0.41 before operation only.
N stage + 5/22 (23) Follow-up assessments were done at a median (IQR) of
No free-flap 2/16 (13)
6 (58) months after operation. Median (IQR) mouth open-
Soft free-flap 9/32 (28) 0.04 ing was 32 (2642) mm; 54% (26/48) had trismus (Table 5).
Composite free-flap 8/15 (53) It was present in a fifth (21%, 10/47) before and after oper-
No radiotherapy 7/32 (22) ation, and in 32% (15/47) after operation only. Forty-three
Radiotherapy 11/25 (44) 0.15* percent (20/47) had no trismus, and two patients had it before
Chemoradiotherapy 1/6 (17) operation only.
Dentate 17/51 (33) 0.32 The median (IQR) change from hospital discharge to 6-
Edentulous 2/12 (17) month follow-up was +1 (2 to +6) mm (n = 46, p = 0.15).
p-values for radiotherapy are for no radiotherapy compared with (radio- One half (23/46) had trismus at discharge and at follow-up,
therapy/chemoradiotherapy). 30% (14/46) had no trismus, 7% (3/46) had deteriorated into
Tumour site denominator is lower (by one patient) as the maxilla patient
trismus after discharge, and 13% (6/46) had improved.
with trismus was not included. Outcomes at discharge were associated most notably and
adversely with free-flap surgery (Table 4) while those at six
months were more adversely associated with radiotherapy
tongue and floor of mouth who were in a randomised study (Table 5). Patients were grouped according to change in
were not recruited, and 27 were missed. No one refused to par- trismus and Table 6 shows the magnitude of change from
ticipate. Mean (SD) age at operation was 59 (10) years, 78% baseline to follow-up experienced by the three main sub-
(50/64) were under 65 years, and 63% (40/64) were male. groups. Features of the first two groups are the greater use of
Tumour sites were oral (52/64, 81%), oropharygeal (11/64, free-flap surgery and radiotherapy, and higher percentages of
17%) or maxillary (1/64, 2%). Twenty-six were staged at patients who reported moderate or a lot of mouth opening
T34 (41%), and 22 had affected nodes (34%). Half the lost.
patients (n = 32) had soft free-flap surgery, a quarter (n = 16)
had composite free-flap surgery, and a quarter had primary
closure or laser surgery. Half had radiotherapy in addition
to primary surgery, six of whom had chemoradiotherapy. Discussion
Most (51/64, 80%) were dentate before operation. Of the 64
patients analysed, one who had mouth opening measurements Limitation of mouth opening after surgery for head and neck
(mm) taken at discharge and at follow-up, but not at baseline, cancer has a direct impact on patients quality of life, and
did answer the question about having had less mouth opening often becomes a serious burden that affects eating, dietary
since diagnosis. consistency, speech, swallowing, and dental hygiene.2,3,13

Table 3
Responses of patients at baseline, discharge, and six-month follow-up. Data are number (%).
Do you now have less mouth opening since diagnosis? Do you now have less mouth opening since treatment?

Baseline (n = 64) Discharge (n = 57) 6-month follow-up (n = 48)

Not at all 49 (77) 21 (37) 16 (33)
Slightly 8 (13) 18 (32) 8 (17)
Moderately 3 (5) 13 (23) 17 (35)
A lot 3 (5) 5 (9) 6 (13)
Extremely 1 (2) - 1 (2)

Please cite this article in press as: Scott B, et al. Longitudinal evaluation of restricted mouth opening (trismus) in patients following
primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg (2010), doi:10.1016/j.bjoms.2010.02.008
YBJOM-3323; No. of Pages 6
ARTICLE IN PRESS
4 B. Scott et al. / British Journal of Oral and Maxillofacial Surgery xxx (2010) xxxxxx

Table 4
Trismus (<35 mm) and mouth opening (mm) at discharge by clinical characteristics of patients.
Trismus (<35 mm) Change in mouth opening from before operation to discharge (mm)

No (%) p-Value Median IQR No p-Value

All patients 37/57 (65) 6 14 to 1 56 0.001
Male 25/38 (66) 0.99 8 16 to 2 37 0.03
Female 12/19 (63) 2 11 to +1 19
<55 years 13/19 (68) 11 21 to 2 18
5564 years 15/25 (60) 0.79 4 13 to 1 25 0.14
65+ years 9/13 (69) 3 12 to +1 13
Oral** 28/46 (61) 0.30 7 14 to 2 45 0.83
Oropharynx** 8/10 (80) 5 16 to1 10
T stages 12 21/36 (58) 0.25 5 14 to 1 36 0.45
T stages 34 16/21 (76) 9 18 to 1 20
N stage 0 24/40 (60) 0.36 5 14 to 1 39 0.68
N stage + 13/17 (76) 8 16 to 1 17
No free-flap 3/13 (23) 2 9 to 1 13
Soft free-flap 23/32 (72) 0.001 6 16 to 2 32 0.22
Composite free-flap 11/12 (92) 11 12 to 0 11
No radiotherapy 13/27 (48) 8 14 to 2 27
Radiotherapy 20/25 (80) 0.01* 5 13 to +1 24 0.42*
Chemoradiotherapy 4/5 (80) 9 NA 5
Dentate 27/44 (61) 0.35 6 14 to 2 44 0.59
Edentulous 10/13 (77) 9 22 to 0 12
p-values for radiotherapy are for no radiotherapy compared with radiotherapy/chemoradiotherapy).
Tumour site denominator is lower (by one patient) as the maxilla patient with trismus was not included.

Table 5
Trismus (<35 mm) and mouth opening (mm) at 6-month follow-up by clinical characteristics of patients.
Trismus (<35 mm) Change in mouth opening from before operation to 6-month follow-up (mm)

No (%) p-Value Median IQR No p-Value

All patients 26/48 (54) 4 11 to +2 47 0.003
Male 16/32 (50) 0.54 5 11 to +2 31 0.31
Female 10/16 (63) 1 10 to +3 16
<55 years 10/17 (59) 6 11 to +1 16
5564 years 12/23 (52) 0.89 4 10 to +3 23 0.55
65+ years 4/8 (50) 5 NA 8
Oral** 18/38 (47) 0.14 4 10 to+2 37 0.46
Oropharynx** 7/9 (78) 9 NA 9
T stage 12 15/30 (50) 0.56 3 10 to +3 30 0.22
T stage 34 11/18 (61) 9 16 to +1 17
N stage 0 16/31 (52) 0.77 3 10 to +3 30 0.22
N stage + 10/17 (59) 8 13 to+1 17
No free-flap 3/11 (27) 1 10 to +4 11
Soft free-flap 17/27 (63) 0.12 5 11 to +1 27 0.61
Composite free-flap 6/10 (60) 4 NA 9
No radiotherapy 3/19 (16) 1 9 to +4 19
Radiotherapy 19/23 (83) <0.001* 7 15 to 0 22 0.05*
Chemoradiotherapy 4/6 (67) 7 NA 6
Dentate 17/36 (47) 0.18 4 10 to +3 36 0.12
Edentulous 9/12 (75) 10 -23 to 0 11
p values for radiotherapy are for no radiotherapy compared with radiotherapy/chemoradiotherapy.
Tumour site denominator is lower (by one patient) as the maxilla patient with trismus was not included.

Please cite this article in press as: Scott B, et al. Longitudinal evaluation of restricted mouth opening (trismus) in patients following
primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg (2010), doi:10.1016/j.bjoms.2010.02.008
YBJOM-3323; No. of Pages 6
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B. Scott et al. / British Journal of Oral and Maxillofacial Surgery xxx (2010) xxxxxx
Table 6
Patients grouped according to trismus (<35 mm) at baseline and at 6-month follow-up.
Group
1Trismus at baseline not improved by treatment (n = 10)
Baseline
Median 26
IQR 1831
6-month follow-up
Median 26
IQR 2130
Change (mm)
Median 1 11
IQR 2 to 7
Free flap surgery
No (%) 8 (80)
Radiotherapy*
No (%) 9 (90)
Moderate/a lot less mouth opening since treatment
No (%) 6 (60)
Includes chemoradiotherapy.
Clinical function is important to quality of life,14,15 and it
is surprising that to date we know of no reported prospective
studies of trismus that have included baseline assessments
taken before primary operation. A cut-off criterion of 35 mm
to identify trismus3,5 has helped to identify which patients
should be considered for physiotherapy. There is lack of evi-
dence about when trismus develops after operation, so our
study evaluated patients from baseline to six months after
operation.
The recruitment rate was acceptable (65%) and there
was no obvious bias in those missed (Table 1). Recruit-
ment reflects a busy inpatient ward and the relatively limited
research time of the main investigator.
Evidence of trismus before radiotherapy in a group of
patients at risk supports the rationale for targeted early inter-
vention that commences before and continues throughout
radiotherapy. This group was restricted to patients with oral
and oropharyngeal SCC who had primary operations. In
future, it would be interesting to compare this with data on
patients having primary chemoradiotherapy.
Management of existing trismus remains limited and is
a challenge, so consideration must be given to its preven-
tion. Various methods of treatment include spatulas,16 the
TheraBite device (Atos Medical, Sweden),11 and dynamic
splinting.17 Reports16,11 on the management of trismus using
the TheraBite device and spatula exercises show that the
TheraBite is significantly effective in the management of
radiation-induced trismus. To the best of our knowledge no
studies have been done on the prevention of trismus using
these two methods. Passive exercises may have a role in
the management and prevention of trismus unlike active
exercises, which have been reported to be of no effect.18 How-
ever, the TheraBite has been shown to be more effective
than other interventions in small sample sizes after primary
Please cite this article in press as: Scott B, et al. Longitudinal evaluation of restricted mouth opening (trismus) in patients following
primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg (2010), doi:10.1016/j.bjoms.2010.02.008
5
2Trismus developed after treatment (n = 15) 3No trismus (n = 20)
38 43
3643 3953
27 42
2530 3846
1
23 to 9 9 to 3
14 (93) 12 (60)
13 (87) 6 (30)
12 (80) 5 (25)
radiotherapy,19 although compliance was influenced by pain
and anxiety that is associated with oral mucositis during
radiotherapy.
This study has confirmed the clinical characteristics of a
group of patients most at risk of developing trismus, and has
shown for the first time that it is present at discharge from
hospital after operation and is therefore a potential problem
worthy of intervention at an early stage. The efficacy of inter-
vention however, remains uncertain, and the most appropriate
time for intervention, and compliance with treatment are two
important issues that need to be addressed. A longitudinal
multicentre randomised trail is required to evaluate the feasi-
bility of intervention before and during adjuvant radiotherapy
in this group.
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Please cite this article in press as: Scott B, et al. Longitudinal evaluation of restricted mouth opening (trismus) in patients following
primary surgery for oral and oropharyngeal squamous cell carcinoma. Br J Oral Maxillofac Surg (2010), doi:10.1016/j.bjoms.2010.02.008