Cephalic Tetanus and Tetanus of Dental Origin: An Overview and Case Studies

I became acutely aware of the controversy regarding dental professionals inquiring about patients’ vaccination status during the pandemic. Though some dental professionals thought that question should be off limits, I want to remind you that as a dental professional, you are also, and maybe even more importantly, a health care professional.

I am not implying that vaccination status should be discussed regularly during dental visits. However, this conversation should not be considered taboo if the patient presents with certain signs and symptoms.

The need to have a conversation is evident when it comes to cephalic tetanus and tetanus of dental origin. Though tetanus of dental origin is relatively rare in the U.S. due to high vaccination rates during childhood, it has happened.¹

Cephalic tetanus is most commonly a result of head/neck injuries and dental and/or ear infections.¹ Patients who experience cephalic tetanus report symptoms that include, but are not limited to, trismus, facial palsy, vertigo, dysphagia, flu-like symptoms, risus sardonicus (spasms of the masseter and other facial muscles), and difficulty breathing in severe cases.^2-5

Symptoms of tetanus and cephalic tetanus could be mistaken for temporomandibular disorder and may land patients in the dental chair before seeing a medical provider. Therefore, understanding that the risk is not zero may help identify tetanus, allowing for early intervention and the prevention of long-term effects associated with the disease.⁶

Overview of Tetanus Vaccination Protocols

Current tetanus vaccination protocols include five doses for initial vaccination at two months, four months, six months, 15 through 18 months, and four to six years of age. After the initial series, adolescents should receive a booster between 11 and 12 years of age. Adults should receive a booster every 10 years.⁷

However, as we age, we often miss getting tetanus boosters. The adult vaccination rate for tetanus was found to be 62.9% in 2019, leaving more than a quarter of the adult U.S. population unprotected and vulnerable.⁸

Contraindications for vaccination include allergic reactions to any component in the vaccine and a history of Guillain-Barré syndrome within six weeks after a previous dose of tetanus vaccine.⁷

Since tetanus is a result of the spores released by the bacteria C. tetani and not the bacteria itself, administering the vaccine soon after an injury can often prevent the development of tetanus and tetanus-induced complications. Current guidelines state for patients presenting with an injury, “If the last dose of a tetanus toxoid-containing vaccine was received 5 or more years earlier, then administer a booster dose of an age-appropriate tetanus toxoid-containing vaccine.”⁹

Cephalic Tetanus and Tetanus of Dental Origin Case Studies

I don’t want to misrepresent the incidence of cephalic tetanus or tetanus of dental origin, as it is considered rare. However, I would like to highlight a few case studies that will bring it to the attention of dental professionals as the biggest issue is delayed diagnosis and treatment, which can have lasting effects, some lifelong.⁸

Cephalic Tetanus From Tongue Piercing

A 24-year-old woman presented to the emergency department with symptoms, including right jaw pain, difficulty opening her mouth, slurred speech, and flu-like symptoms. The patient had a history of a tongue stud piercing three weeks prior but denied recent head trauma or dental issues. The patient had not received a tetanus booster immunization within the five years before presentation.²

Physical examination revealed facial nerve weakness, limited range of motion upon opening the mouth, and lymph node enlargement. Fiberoptic examination showed pooled purulent material in the supraglottis, and a CT scan revealed enlarged lymph nodes but no other abnormalities.²

Electrodiagnostic testing confirmed cephalic tetanus, likely due to the tongue stud. Treatment with tetanus immunoglobulin, metronidazole, and diazepam was initiated. The patient recovered slowly and was discharged after 10 days but had persistent facial weakness. Six months after discharge, the patient continued to have complications. The patient was referred and received physical therapy for ongoing rehabilitation.²

To be fair, body piercing is one of the rarer causes of tetanus. Nonetheless, being up to date on tetanus immunization could have protected the patient from the disease and the sequelae that were experienced.²

Cephalic Tetanus From Orbital Wound

A 79-year-old individual, whose vaccination history was unknown, suffered facial trauma following a fall into a moat. Initial examination showed severe symptoms on the right side, including complete eye muscle paralysis, bulging of the eye, unresponsive pupil, and a hematoma around the eye. Vision in the right eye was severely impaired.¹⁰

A CT scan revealed air bubbles in the orbit, indicating an infection. Surgery to drain purulent fluid and remove a wooden foreign body was performed. A tetanus booster and antibiotics were administered. However, by the third day after surgery, the symptoms worsened, and a second surgery was needed to drain an increased abscess.¹⁰

The patient developed facial nerve palsy, swallowing difficulties, and other neurological symptoms consistent with cephalic tetanus. The patient was transferred to intensive care, where they received intensive treatment, including antibiotics and tetanus immunoglobulins. After two weeks, the patient recovered and was discharged from the intensive care unit.¹⁰

Cephalic Tetanus From a Rooster Peck

A previously healthy 60-year-old woman was admitted to a hospital in Turkey with difficulty opening her mouth and swallowing following a rooster peck to her right orbital region ten days earlier. She had not received a tetanus immunization previously.¹¹

On admission, she exhibited trismus and right-sided facial weakness, with swelling and a minor scar near the wound. No other abnormalities were noted. Due to the lack of an open wound, microbiological sampling was impossible, but cephalic tetanus was diagnosed based on clinical signs and history.¹¹

She was hospitalized in a dark, isolated room, sedated with diazepam, and underwent a tracheotomy due to respiratory distress. She received equine tetanus antitoxin, antibiotics, and tetanus toxoid immunization. After a month-long hospitalization, she recovered gradually and had no relapse during a one-year follow-up.¹¹

Cephalic Tetanus From Minor Facial Abrasions

A 37-year-old man presented to the emergency department after a fall from a stepladder, resulting in minor facial trauma. He received a tetanus toxoid vaccine because he had not been vaccinated in the past five years. Four days later, he developed intense trismus and left-sided facial paralysis. He was diagnosed with cephalic tetanus and admitted to the intensive care unit.¹²

Treatment included tetanus immunoglobulin, penicillin, and diazepam. Despite treatment, his condition worsened with bilateral facial paralysis and severe trismus, leading to respiratory distress requiring tracheostomy. After 10 days, he showed improvement and was transferred to the neurology department. Twenty-five days later, he was discharged with complete resolution of symptoms.¹²

Cephalic Tetanus Associated With Dental Origin

A 47-year-old man initially visited the dentist due to tooth discomfort from a fractured crown. Over time, he experienced recurring dental issues and subsequent facial discomfort. Despite treatments, including root canal procedures on teeth #29 and #30 and antibiotics, his symptoms persisted and worsened. He developed severe facial and neck pain, along with involuntary muscle contractions and tongue protrusions.¹³

Panoramic radiographs revealed inadequate root canal treatment on tooth #19. Due to the unusual symptoms and lack of treatment response, the patient was referred to a specialist, which led to a diagnosis of progressive cephalic tetanus. He was hospitalized and treated with medications, including diazepam and antibiotics. Although his condition improved, he still experienced jaw spasms and anxiety after medication withdrawal. Further tests showed normal results, and he is currently medically stable.¹³

In another documented case, a 44-year-old male presented to the hospital with an inability to open his mouth. He had experienced stiffness in his neck and jaw a week prior, along with pain and difficulty swallowing. Despite having no fever, ear infection, neck trauma, or recent medication use, he had elevated liver enzyme levels and displayed symptoms consistent with tetanus, including risus sardonicus and trismus.¹⁴

The patient’s dental examination revealed poor oral hygiene, dental caries, and gingivitis. He was diagnosed with moderate tetanus and treated with human tetanus immunoglobulin, antibiotics, diazepam, and supportive care, including a nasogastric tube for feeding. He experienced abdominal stiffness, muscle spasms, and fluctuating blood pressure during hospitalization. These symptoms gradually resolved. He was discharged after two weeks with improvement in his condition.¹⁴

In Conclusion

Although cephalic tetanus and tetanus of dental origin are rare in the United States, the risk remains with over a quarter of the population unvaccinated. Patients with no history of vaccination or missed boosters are at the highest risk of developing tetanus.⁸

The clinical definition of tetanus is characterized by “painful muscular contractions, particularly of the masseter and neck muscles, and secondarily of the trunk muscles.”¹⁴ Head and facial pain is a more classic initial symptom than jaw/neck stiffness.¹³

Oral mucosa, odontogenic infections, and compromised teeth serve as potential entry points for C. tetani bacteria. Even in the absence of an obvious external wound, clinicians should always keep tetanus in mind when evaluating patients presenting with symptoms such as head/facial pain, trismus, and muscle spasms in the neck.^13,14

Therefore, knowing the patient’s vaccination status when patients present with symptoms of tetanus is vital in determining a proper diagnosis and referral to the proper medical provider.

Discussing a patient’s medical history should not be taboo in the dental office. Dental professionals are indeed health care professionals and require the proper information to provide optimal care. Ensure you are comprehensively reviewing your patient’s medical history, which might require further questions beyond what is found on the medical history form. Vaccination status for diseases that could affect the patient’s oral health should be discussed, including, but not limited to, HPV and tetanus vaccination.

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References

1. Immunization. (2024, April 15). Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/immunize.htm
2. Dyce, O., Bruno, J.R., Hong, D., et al. Tongue Piercing. The New “Rusty Nail”? Head & Neck. 2000; 22(7): 728-732. https://pubmed.ncbi.nlm.nih.gov/11002330/
3. Kagoya, R., Iwasaki, S., Chihara, Y., et al. Cephalic Tetanus Presenting as Acute Vertigo With Bilateral Vestibulopathy. Acta Otolaryngol. 2011; 131(3): 334-336. https://pubmed.ncbi.nlm.nih.gov/21133652/
4. Rauch, A., Droz, S., Zimmerli, S., Leib, S.L. Dysphagia in Elderly Women: Consider Tetanus. Infection. 2006; 34(1): 35-38. https://pubmed.ncbi.nlm.nih.gov/16501901/
5. Babajews A., Nicholls, M.W. Tetanus Associated With Dental Sepsis. Br J Oral Maxillofac Surg. 1985; 23(1): 36-40. https://pubmed.ncbi.nlm.nih.gov/3156623/
6. Bae, C., Bourget, D. Tetanus. (2023, May 31). StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK459217/
7. Diphtheria Vaccine Recommendations. (2024, September 24). Centers for Disease Control and Prevention. https://www.cdc.gov/diphtheria/hcp/vaccine-recommendations/index.html 
8. Jatlaoui, T.C., Hung, M. Srivastav, A., et al. (2024, July 22). Vaccination Coverage Among Adults in the United States, National Health Interview Survey, 2019-2020. Centers for Disease Control and Prevention. https://www.cdc.gov/adultvaxview/publications-resources/vaccination-coverage-adults-2019-2020.html
9. Clinical Overview of Tetanus. (2024, August 15). Centers for Disease Control and Prevention. https://www.cdc.gov/tetanus/hcp/clinical-overview/
10. Guyennet, E., Guyomard, J.L., Barnay, E., et al. Cephalic Tetanus From Penetrating Orbital Wound. Case Reports in Medicine. 2009; 2009: 548343. https://doi.org/10.1155/2009/548343
11. Kara, C.O., Cetin, C.B., Yalçin, N. Cephalic Tetanus as a Result of Rooster Pecking: An Unusual Case. Scandinavian Journal of Infectious Diseases. 2002; 34(1): 64-66. https://doi.org/10.1080/003655402753395201
12. De Paz, A., Izquierdo, M., Redondo, L.M., Verrier, A. Cephalic Tetanus Following Minor Facial Abrasions: Report of a Case. Journal of Oral and Maxillofacial Surgery. 2001; 59(7): 800-801. https://doi.org/10.1053/joms.2001.24296
13. Burgess, J.A., Wambaugh, G.W., Koczarski, M.J. Report of Cases: Reviewing Cephalic Tetanus. Journal of the American Dental Association. 1992; 123(7): 67-70. https://jada.ada.org/article/S0002-8177(92)37021-7/abstract
14. Akbar, M., Ruslin, M., Yusuf, A.S.H., et al. Unusual Generalized Tetanus Evolving From Odontogenic Infection: A Case Report and Review of Recent Literature. Heliyon. 2022; 8(9): e10810. https://doi.org/10.1016/j.heliyon.2022.e10810