Development of a Checklist to Improve Patient Safety

Temporomandibular disorders, IN BRIEF • Outlines possible causes of trismus. • Highlights that malignancy needs to be PRACTICE trismus and malignancy: considered in the differential diagnosis of causes of trismus. • Explains how the use of a checklist can improve patient safety. development of a checklist • Discusses the relevance of imaging to improve patient safety in TMD. H. P. Beddis,*1 S. J. Davies,2,3 A. Budenberg,2 K. Horner2,3 and M. N. Pemberton2,3 VERIFIABLE CPD PAPER Trismus is a restriction in the ability to open the mouth. Trismus can occur following trauma, surgery, radiation therapy, infection, inflammatory diseases, temporomandibular disorders (TMD) or less commonly as a result of malignancy. Following two cases of delayed diagnosis of carcinoma presenting with features of TMD to a specialist clinic, a checklist was developed for completion in cases of trismus, to alert the clinician to suspicious features suggesting a possible non- TMD cause. The use of this checklist, together with an increased awareness, has improved early recognition of atypical features in patients presenting with trismus and has contributed to the early diagnosis of a further case of malignancy presenting to this clinic. This article discusses the presentation of malignancy with trismus, the relevance of imaging in these cases, and the implementation of a checklist to reduce the risk of future misdiagnosis. INTRODUCTION disease, dysfunction or discomfort within Table 1 Possible causes of trismus Trismus is a restriction in the ability to open the masticatory system. the mouth. Eating, speech and other oral Two common types of TMD that may Possible causes of trismus functions may be affected by trismus. The result in trismus are myofascial pain (MP) TMD including myofascial pain, disc displacement lower limit of normal maximum opening is and disc displacement without reduction without reduction 35 mm for females and 40 mm for males. (DD-WR). Trismus can have many possible Infection A working group expanding upon the causes, listed in Table 1. taxonomy of the widely-used 1992 research It is rare for trismus to be the primary Forms of arthritis diagnostic criteria for temporomandibular presenting sign of a malignancy, but it can Haematoma in medial pterygoid following ID disorders (TMD) defined trismus as a happen. Consequently neoplasia should block injection ‘maximum assisted opening (passive be considered in a patient presenting with Fibrosis (eg post-radiotherapy, scleroderma) stretch) including vertical incisal overlap trismus. There are reports in the literature of Trauma of less than 40 mm.’1,2 However, many the misdiagnosis of malignancy in this way: clinicians working in the field consider for example, a temporal adenocarcinoma Surgery that this value is too high to be of clinical in a 62-year-old patient presenting with Malignancy relevance; the authors would propose an severe trismus and joint pain was initially upper limit of 30 mm. misdiagnosed as a TMD.4 A number of Ankylosis Many patients with trismus are likely to other case reports describe trismus resulting Hyperplasia of the head of the condyle have a temporomandibular disorder (TMD). from primary and metastatic carcinoma Myositis ossificans TMDs encompass a group of musculoskeletal affecting the antrum, nasopharyngeal and and neuromuscular conditions that involve parotid regions.5–7 Tetanus the temporomandibular joints (TMJs), the In 2001, a patient initially attended the Tetany masticatory muscles and all associated specialist TMD clinic at the University 3 CNS diseases (eg Parkinson’s disease, multiple tissues. These conditions may arise from Dental Hospital of Manchester, where sclerosis) malignancy was the underlying cause of Lack of patient co-operation 1Department of Restorative Dentistry, Leeds Dental their symptoms, but where the symptoms Institute, Clarendon Way, Leeds, LS2 9LU; 2University were initially diagnosed as TMD (Patient A, Dental Hospital of Manchester, Central Manchester Table 2). In 2009 a similar event occurred dental practitioners, dentists with a special University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Higher Cambridge (Patient B, Table 3). interest, and hospital specialists from Street, Manchester, M15 6FH; 3School of Dentistry, various disciplines including oral surgery, University of Manchester DISCUSSION OF CASES oral medicine, restorative dentistry and *Correspondence to: Hannah Beddis Email: [email protected] Patients with symptoms and signs of TMD oral and maxillofacial surgery (OMFS). This and trismus can present to dentists with heterogeneity of backgrounds may increase Refereed Paper a wide range of skills and experience. the potential for misdiagnosis unless the Accepted 19 June 2014 DOI: 10.1038/sj.bdj.2014.862 Consequently, TMD is managed by a clinician’s training has prepared him or her ©British Dental Journal 2014; 217: 351-355 wide variety of dentists including general for all potential diagnoses. Recent guidance BRITISH DENTAL JOURNAL VOLUME 217 NO. 7 OCT 10 2014 351 © 2014 Macmillan Publishers Limited. All rights reserved PRACTICE Table 2 Patient A’s journey Patient journey Presentation Working Treatment at that stage Comments diagnosis Referral from general dental practitioner to department of oral medicine with persistence of symptoms diagnosed by the GMP as trigeminal neuralgia, treatment with carbamazepine Consultant in ‘Lancinating pain,’ which had Trigeminal A soft bite guard was oral medicine initially been relieved by carbamaz- neuralgia fabricated and delivered epine (prescribed by the GMP) Myofascial pain Referral to the TMD clinic Click in the left TMJ Post-graduate Click had ceased Myofascial pain Physiotherapy was Physiotherapy was suspended following the student in TMD Tenderness to palpation of the requested physiotherapist’s report that despite the signs left TMJ, lateral pole and via an and symptoms being ‘strongly suggestive of intra-auricular approach myofascial pain,’ an initial improvement had Click had ceased: no joint noises or not been maintained. limitation of mouth opening Discomfort at 40mm opening TMD specialty dentist A Myofascial pain Stabilisation (Michigan) On review, the patient reported that the splint provided symptoms had improved TMD specialty dentist B Deterioration in signs and Disc displacement A request was made for Physiotherapy was unfortunately not then symptoms without reduction further physiotherapy provided prior to the patient’s subsequent Constant pain in the region 4-monthly review, when the patient reported of the left ear and neck no change in the condition. Tenderness to palpation of all the The left-sided muscles remained tender to left-sided muscles of mastication palpation, and mouth opening was 15 mm. Trismus with maximum opening The diagnosis of disc displacement without of 15 mm. reduction was maintained, and an arthrogram requested. Consultant in maxillofa- Arthrogram was carried out and The radiography report stated that ‘the disc cial radiology reported upon was mildly anterior in position in the closed position… that the disc was not translating normally over the condyle. Almost complete reduction eventually achieved on anterior translator movement.’ Lead clinician, TMD Disc displacement Arthrocentesis carried out The patient was from then on seen within the clinic and consultant in without reduction Oral and Maxillofacial Surgery Department. oral and maxillofacial Following arthrocentesis, no improvement surgery A was noted, and bilateral eminectomy advised. MR imaging was requested Specialist registrar Mouth opening was 10 mm MRI revealed an extensive tumour filling the in OMFS and consultant Constant left sided pain left antrum, with involvement of the hard in OMFS B Right-sided pain palate, lateral and posterior walls of sinus, Nasal congestion, discharge inferior medial wall of the orbit, ethmoid and epistaxis sinus, pharynx and infratemporal fossa. This tumour was subsequently diagnosed as an adenoid cystic carcinoma. Table 3 Patient B’s journey Patient journey Presentation Working diagnosis Treatment at that stage Comments TMD specialty Right-sided difficulty in opening the mouth Disc displacement Home physiotherapy dentist History of neuralgia-type pain in the right ear without reduction exercises Symptoms had been present for 2-3 months secondary to spasm No joint noises of the right lateral Tenderness of the right lateral pterygoid pterygoid muscle muscle to resisted movement test Maximum opening was 12 mm TMD specialty No improvements in symptoms Patient given a same- dentist New non-tender swelling under the right day appointment in body of mandible the Department of Oral New development of paraesthesia of the Medicine right side of tongue Pain in the right mandible Consultant in Palpable right-sided lymph nodes at levels OPG requested. Panoramic radiograph revealed oral medicine I and II Same-day onward erosion of the alveolar aspect of the Suspicious mucosal lesion adjacent to the referral to head and neck mandible plus area of radiolucency in lower right molars cancer surgeon, OMFS. the right ramus Subsequent EUA and biopsy confirmed the clinical suspicion of oral squamous cell carcinoma 352 BRITISH DENTAL JOURNAL VOLUME 217 NO. 7 OCT 10 2014 © 2014 Macmillan Publishers Limited. All rights reserved PRACTICE has been published for the assessment, of little value. Other authors have reiterated reported an ‘acceptable’ degree of sensitivity diagnosis and management of TMD within the clinical nature of

Load more