Neuropathologic chewing in comatose children.

This paper reviews the etiology and management of neuropathologic chewing in 16 comatose children. These patients exhibited ruminant chewing and bruxism that often resulted in self-inflicted oral soft tissue trauma. The success of using various dental appliances was found to be associated with the neurologic status of these patients. Variables such as etiology, depth and duration of coma, and age of patient can influence the medical prognosis and hence the success of using these appliances. In cases where the use of dental appliances were not successful, other managerial techniques are discussed. Patients in corna, from whatever cause, may develop chewing movements presumably similar to those seen in healthy people during sleep. If coma is prolonged, these chewing movements may be so powerful and persistent as to cause self-inflicted trauma to the soft tissues of the oral cavity (Fig 1) and attrition of the teeth.1 Guyton has termed this condition neuropathologic cb.ewing. 2 The literature concerning neuropathologic chewing is scarce. The exact mechanism of the coordination of tongue and jaw movements during mastication is still unclear. Hanson et al. designed an intraoral dental appliance based on the neurophysiology of jaw movement in comatose patients. 3 Others fabricated tongue stents 4 and removable appliances 5 for adults to prevent self-inflected trauma to the tongue. Freedman et al. reported success in managing a 2-year-old patient with neuropathologic chewing with a removable bite block. 6 Peters et al. reported success in managing an 8-year-oht patient with a tongue stent and circummandibular wires. 7 Dental services in hospitals frequently are called upon to assist in the management of comatose patients who exhibit bruxism. Some of these cases are complicated by severe intraoral soft tissue laceration as a result of the uncoordinated movement of the tongue and jaw. Thus, it is desirable for dentists to understand this condition and develop effective methods for managing these patients in a hospital setting. A retrospective study was made on a series of 16 comatose patients with neuropathologic chewing who were referred to the dental service of the Children’s Hospital of Philadelphia between 1979 and 1984. Appliances were made for 10 of these patients. The criteria for fabrication of an appliance and the success of using different appliances are discussed in this paper. A standard methodology is proposed for managing hospitalized patients with neuropathologic chewing. The Comatose Patient Coma is a symptom closely related to the integration of functions of the cerebral cortex and the reticular activating system. It can be caused by any agent chemical, physical, or biological that is capable of interrupting the integrity of the arousal system. Functionally, the state of coma originates either from brain stem injury (e.g., herniation) or diffuse cortical injury, such as toxicity, anoxia, or metabolic imbalance. The various causes can be classified into supratentorial, subtentorial, or metabolic, s Evidence suggests that meningitis, encephalitis, hypoxia, epilepsy, and metabolic insults are the most common causes of coma in children. 9 The outcome of coma is either recovery, which can be complete or incomplete, or brain death. If recovery is incomplete, the remaining disability can be termed moderate, severe, or a form of vegetative state. The outcome of nontraumatic coma is more favorable in the child than it is for the adult, with almost 60% of patients either recovering completely or having only a mild handicap. 9 302 NEUROPATHOLOGIC CHEWING: Ngan and Nelson FIG 1. (fop) Typical self-inflicted trauma in a comatose patient. Immediate relief was achieved with a ratchet (Molt) mouth prop, FIG 2. (bottom) The McKesson rubber bite-block is hygienic and easy to insert.