Trismus in a 6 year old child: a manifestation of leukemia?

Trismus is a firm closing of the jaw due to tonic spasm of the muscles of mastication from disease or the motor branch of the trigeminal nerve. Trismus may be produced by a variety of reasons such as dental abscess, trauma, following mandibular block with local anesthesia, as a result of radiation to the facial muscles, and patients after chemotherapy. A case of a referral of a six-year-old boy to a dentist from an ENT due to severe limitation in jaw opening is presented. Intraoral examination and panoramic radiograph demonstrated no signs of infection and/or other pathology. After a diagnosis of trismus was made, due to his icteric appearance, the general fatigue and loss of appetite in the last few days, palpated and sensitive lymph nodes in the submandibular and cervical regions, the child was referred for a complete blood count and sedimentation rate. The laboratory and clinical findings resulted in the diagnosis of acute lymphoblastic leukemia (ALL). Dental and oral manifestations of ALL are discussed, and the trismus may be explained by an intensive infiltration of leukemic cells into the deep portion of the contracting muscles of the face. This case emphasizes the importance of phys-ical examination and independent judgement made by dentists, even when patients are referred to them by other members of the medical communities.

1. Steadman’s medical dictionary. 25th edition, Williams and Wilkins, Baltimore, 1990.

2. Walton IN. Brain’s diseases of the nervous system. Oxford: Oxford University Press, pp 819-20, 1977.

3. Jaffe N, Toth BB, Hoar RE, Ried HL, Sullivan MP, McNeese MD. Dental and maxillofacial abnormalities in long-term survivors of childhood cancer: effects of treatment with chemotherapy and radiation to the head and neck. Pediatrics 73: 816-23, 1984

4. Dahllof G, Krekmanova L, Kopp S, Borgstrom B, Forsberg CM, Ringden O. Craniomandibular dysfunction in children treated with total-body irradiation and bone marrow transplantation. Acta Odontol Scand 52: 99-105, 1994.

5. Victor M,Adams RD. Diseases of cranial nerves. In G Thorn, RD Adams, E Braunwald, KJ Isselbacher, RG Petersdorf (Edst), Harrison’s Principles of Internal Medicine, 8th ed., Tokyo, McGraw-Hill Kogakusha Ltd., p 1820, 1977.

6. Lynch MA, Brightman VJ, Greenberg MS. Burket’s Oral Medi-cine. Diagnosis and Treatment, 9th ed., Philadelphia: Lippincott-Raven, pp 521-3, 1997.

7. Little JW, Falace DA. Dental management of the medically com-promised patient. 4th ed., St. Louis, Mosby, pp 445-9, 1993.

8. Wahlin YB, Matsson L. Oral mucosal lesions in patients with acute leukemia and related disorders during cytotoxic therapy. Scand J Dent Res 96: 128-36, 1988.

9. Cousin GC. Oral manifestations of leukaemia. Dent Update 24: 67- 70, 1997.

10. Fleming P. Dental management of the pediatric oncology patient. Current Opin Dent 1: 577-82, 1991.

11. Okamoto K, Hiral S, Honma M. Extensive leukemic cell infiltra-tion into skeletal muscles. Muscle Nerve 19: 1052-4, 1996.

12. Fukuzawa J, Akaishi T, Tanaka H, Nakanishi K, Okada M, Haneda T, Kikuchi K. Adult T-cell leukemia with invasion by malignant cells of both parotid glands diagnosed by an Ga-67 imaging: a case report. Clin Nucl Med 22: 61-3, 1997.

13. Fulp SR, Nestok BR, Powell DL, Evans LK, Geisinger KR, Gilliam JH. Leukernic infiltration of the esophagus. Cancer 71: 112- 6, 1993.

14. Anil S, Smaranayake LP, Nair RG, Beena VT. Gingival enlarge-ment as a diagnostic indicator in leukaemia. Case report. Aust Dent J 41: 235-7, 1996.