- Email: [email protected]
An occlusal guard for preventing and treating self-inflicted tongue trauma in a comatose patient: A clinical report
An occlusal guard for preventing and treating self-inflicted tongue trauma in a comatose patient: A clinical report Sudarat Kiat-amnuay, DDS, MS,a Sheila H. Koh, DDS,b and David J. Powner, MDc University of Texas Dental Branch at Houston, Houston, Tex; University of Texas Health Science Center at Houston, Houston, Tex This clinical report describes the treatment of a 48-year-old patient who demonstrated neuropathologic and reflex mastication of her tongue after an intracerebral hemorrhage. Standard medical interventions failed to address the oral condition, and the attending neurosurgeon consulted the dental team. A provisional soft occlusal guard was initially placed, followed by fabrication of a heat-polymerized, acrylic resin occlusal guard. The tongue injury improved after placement of the oral device and administration of systemic hydrocortisone. (J Prosthet Dent 2008;99:421-424)
Neuropathologic mastication is caused by uncoordinated myotonic activity of the masticatory muscles and tongue following neuronal damage in the cerebral cortex, hypothalamus, or reticular/pyramidal systems due to closed head injury, septic shock, and/or hypoxia.1 Reflex masticatory patterns during episodes of hyperactivity may include clenching, masticating, gnawing, and grinding, potentially producing severe injury to the tongue and/or orofacial structures.1-3 Previously reported treatment methods or techniques have included a silver cap splint,1 bite blocks,3,4 tongue guards,5-7 a modified retainer,8 and mouth guards.9,10 Materials used for these devices include silver and acrylic resin,1 rubber,3 acrylic rubber and molt,4 acrylic resin,5,8 acrylic resin with metal wire,6,7 and polymeric materials.9-11 Hanson et al5 reported desirable characteristics for such devices (Table I). The selection or design of an oral device depends on the severity of neuropathological mastication, the patient’s neurological status, and the
prognosis. Patients with mild neuropathological mastication may respond well to a bilateral bite block device which can be used short term.3 Patients with severe neuropathological mastication may require a custom-made fixed device made of firmer material.1,5-7,11 Compared to fixed devices, custom-made removable devices are easier to insert and remove and are more hygienic.9,10,1215 Other designs are made from less durable soft polymers9-11 or may not allow sufficient separation of maxillary and mandibular teeth to prevent further trauma to oral mucosa or the lips.5,7,9 This clinical report describes techniques used to fabricate a modified occlusal plane device to prevent and treat self-inflicted oral trauma in a comatose adult patient.
CLINICAL REPORT A 48-year-old African American woman sustained a large intracerebral hemorrhage in the right thalamus with extension to the third and fourth ventricles. The past medical
history included hypertension, mild chronic renal failure, chronic anemia, and congestive heart failure. The patient presented with severe hypertension, coagulopathy, seizure disorder, and respiratory failure, and was orally intubated and placed on mechanical ventilation. Initial medications included nicardipine, propofol, vitamin K, famotidine, chlorhexidine mouthwash, albuterol, and acetylcysteine by nebulization, bisacodyl, docusate, and metoprolol. On the third day of hospitalization, tongue swelling was noted. Progressive swelling occurred over several days and was complicated by reflex mastication against the endotracheal tube, producing secondary injury to the tongue (Fig. 1). The medication regimen was altered to eliminate possible etiologies of reflex mastication. Intravenous hydrocortisone sodium succinate followed by tapering dosing was initiated over 10 days to treat a possible reactive etiology for the tongue enlargement. The tongue swelling partially subsided over the next week. Dental consultation was obtained. Oral examina-
Assistant Professor, Department of Restorative Dentistry and Biomaterials, University of Texas Dental Branch at Houston. Associate Professor, Department of Restorative Dentistry and Biomaterials, University of Texas Dental Branch at Houston. c Professor, Department of Neurosurgery and Internal Medicine, University of Texas Health Science Center at Houston. a
b
Kiat-amnuay et al
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Table I. Criteria for successful device to prevent and manage self-inflicted oral trauma5 1. It should reflect away from occlusal table those tissues likely to be damaged by involuntary movements of mandible. 2. It should not be potential source of further injury to patient. 3. It should permit full range of mandibular motion. 4. It should permit daily oral care. 5. It should withstand breakage and displacement forces over indefinite period of time. 6. It should allow healing of traumatized oral tissues. 7. It should be easily fabricated and installed without discomfort or risk to patient.
1 Self-inflicted tongue lesion from neuropathologic mastication. tion revealed a partially edentulous maxilla and mandible. The remaining teeth had TM0 mobility (physiologic tooth mobility).16 Reflex mastication produced severe injury to the tongue, which was leather-like in texture and swollen. The ventral surface of the tongue had deep indentations from teeth in both arches. In addition, there was a traumatic ulcer at the lateral border of the tongue (Fig. 1). Maxillary and mandibular provisional soft occlusal guards9 were fabricated from thermo-forming material (Clear Surgical Tray 0.015 inches, 5 x 5 inches; Keystone Industries, Cherry Hill, NJ) and were placed the next day. During the follow-up visit, examination revealed that the patient still severely masticated her tongue using the soft occlusal guards. The decision was made to fabricate the acrylic resin occlusal guard described below, which
was inserted on the fourth day after dental consultation. Sedation and pharmacological paralysis of the patient using intravenous propofol or morphine sulfate were required to obtain access to the oral cavity. Maxillary and mandibular dental impressions were made using irreversible hydrocolloid impression material (Jeltrate; Dentsply Caulk, Milford, Del), and casts were poured with type III dental stone (Microstone; Whip Mix Corp, Louisville, Ky). An interocclusal registration using bimanual manipulation17 was made with wax (Delar blue wax; Great Lakes Orthodontics, Tonawanda, NY) at a vertical opening of approximately 15 to 20 mm. The casts were then mounted on an articulator (Model 2240; Whip Mix Corp) using the interocclusal registration with the incisal pin set at the zero position. The thickness of the 1-piece
The Journal of Prosthetic Dentistry
occlusal guard (15-20 mm at the incisors) was designed to prevent further trauma from the protrusion of the patient’s tongue between the occlusal guard and the teeth. However, if the occlusal guard was too thick, it would strain the patient’s facial muscles. In addition, this thickness allowed room for the suction tube. The casts were positioned in the dental surveyor (Dentsply Ceramco; Burlington, NJ) with the occlusal plane parallel to the floor, and heights of contour were marked on all teeth. In a manner similar to the techniques used for making an occlusal plane device,18 the occlusal guard presented in this report was designed to cover approximately 2-3 mm of the facial surfaces of the incisal edges of the teeth above the height of contour. The design incorporated coverage of the entire palatal surface of the teeth and 3-5 mm of the palatal
Kiat-amnuay et al
423
June 2008 DISCUSSION
2 Illustration of occlusal guard design.
3 Intraoral view of occlusal guard. soft tissue (Fig. 2). All of the undercuts above the heights of contour on palatal surfaces were blocked-out using plaster (Mounting Plaster; Whip Mix Corp). The wax pattern was then fabricated using pink wax (Baseplate Wax Tough Pink #5; Corning Rubber Co, Inc, Ronkonkoma, NY).18 A lingual extension of wax, 2 mm thick, was added to the pattern (Fig. 2). It was placed 3-5 mm posterior to the mandibular incisal contact points and extended entirely down the lingual surfaces, from the mandibular left to right premolars, to prevent the tongue from moving forward. The wax pattern was then invested and processed. Clear denture acrylic resin (Paragon; Coletene/Whaledent, Inc, Cuyahoga Falls, Ohio) was packed and heat polymerized using conventional complete denture techniques,
Kiat-amnuay et al
deflasked, and polished.19 A round opening (8-10 mm in diameter) was created in the occlusal guard between the maxillary and mandibular teeth to allow access for a cannula suction tube (Tyco Healthcare; Miami, Fla). The occlusal guard was then inserted (Fig. 3). Oral hygiene instructions were given to the patient’s caregiver to remove the occlusal guard once a day, when the patient was relaxed, to clean it with a toothbrush and toothpaste or with a denture cleansing tablet. It was to be worn continuously. Follow-up visits by the dental team were performed later on the same day as insertion, and at 1 and 2 weeks after insertion. There were no complications or modifications needed. The patient’s tongue condition improved dramatically thereafter, although the neurological status did not.
The self-inflicted trauma demonstrated in this patient not only produces the primary tissue injury, but is also likely to be self-perpetuating. The pain produced by the tongue swelling and injury may stimulate further uncontrolled, reflex, neuropathologic mastication, resulting in reflex mastication and additional injury. The potential for local infection is high and may result in a generalized systemic inflammatory response. Family members and caregivers are understandably distressed by both the appearance of the injury and the imagined discomfort for the patient. Careful attention to oral hygiene and early detection of neuropathologic mastication by the physician, nurse, and respiratory therapist within the intensive care unit should help prevent the subsequent morbidity demonstrated in this patient. The clinical interventions attempted for this patient, including commercially available oral airways, mouth guards, alternative methods and devices to secure the endotracheal tube, and deep sedation, were unsuccessful in preventing tongue injury. Pharmacological relaxation of the jaw and masticatory muscles only partially improved neuropathologic mastication. Considering that there was only partial improvement, the use of longterm medication was outweighed by the risks of drug side-effects. A team approach is needed to prevent and treat this type of injury, including early consultation by the physician and nurses with a dental team. The design of the occlusal guard presented in this report offers several advantages over other custom designs and other commercially available products in that it: (1) reflects oral tissue and the tongue from the occlusal table, which may accelerate healing of the traumatized tissues; (2) permits a full range of mandibular motion by using a flat occlusal plane design; (3) allows placement of a suction tube when rinsing and cleaning
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the mouth without removing and reinserting the prosthesis; (4) is easily fabricated and cleaned using procedures similar for conventional dental occlusal guards; and (5) is durable, rigid, resistant to fracture, odorless, and can be used over a long period of time. The possible disadvantages of this occlusal guard include: (1) it requires intraoral impressions; (2) it requires an additional laboratory fee; and (3) it involves the risk of possible dislodgement of the occlusal guard during powerful masticating movement.
SUMMARY A multidisciplinary approach is needed in the management and prevention of self-inflicted oral trauma during care of comatose patients. The occlusal guard described in this article effectively prevents further trauma and permits healing of the traumatized oral tissues.
REFERENCES 1. Hallett KB. Neuropathological chewing: a dental management protocol and treat-
ment appliances for pediatric patients. Spec Care Dentist 1994;14:61-4. 2. Hyman SL, Fisher W, Mercugliano M, Cataldo MF. Children with self-injurious behavior. Pediatrics 1990;85(3 Pt 2):43741. 3. Sheller B. Self-inflicted oral trauma: report of case. Spec Care Dentist 1992;12:28-9. 4. Ngan PW, Nelson LP. Neuropathologic chewing in comatose children. Pediatr Dent 1985;7:302-6. 5. Hanson GE, Ogle G, Giron L. A tongue stent for prevention of oral trauma in the comatose patient. Crit Care Med 1975;3:200-3. 6. Peters TE, Blair AE, Freeman RG. Prevention of self-inflicted trauma in comatose patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984;57:367-70. 7. Jackson MJ. The use of tongue-depressing stents for neuropathologic chewing. J Prosthet Dent 1978;40:309-11. 8. Fenton SJ. Management of oral self-mutilation in neurologically impaired children. Spec Care Dentist 1982;2:70-3. 9. Croglio DP, Thines TJ, Fleischer MS, Andres PL. Self-inflicted oral trauma: report of case. Spec Care Dentist 1990;10:58-61. 10. Kobayashi T, Ghanem H, Umezawa K, Mega J, Kawara M, Feine JS. Treatment of self-inflicted oral trauma on a comatose patient: a case report. J Can Dent Assoc 2005;71:661-4. 11. Hayward JR, Tefz BR, Robert RC, Yellich GM. Soft plastic mouth guards for use in prevention of self-inflicted oral trauma. J Hosp Dent Prac 1979;13:36-7. 12. Silva DR, da Fonseca MA. Self-injurious behavior as a challenge for the dental practice: a case report. Pediatr Dent
The Journal of Prosthetic Dentistry
2003;25:62-6. 13. Sonnenberg EM. Treatment of self-induced trauma in a patient with cerebral palsy. Spec Care Dentist 1990;10:89-90. 14. Fabiano JA,Thines TJ, Margarone JE. Management of self-inflicted oral trauma: report of case. Spec Care Dentist 1984;4:214-5. 15. Wood AJ. A tongue shield appliance: design, fabrication, and case report. Spec Care Dentist 1991;11:12-4. 16. Trejo PM, Weltman RL. Favorable periodontal regenerative outcomes from teeth with presurgical mobility: A retrospective study. J Periodontol 2004;75:1532-8. 17. Dawson PE. Functional occlusion: from TMJ to smile design. 3rd ed. St. Louis: Elsevier; 2006. p. 76-80. 18. Ash MM Jr, Ramfjord SP. Occlusion. 4 th ed. Philadelphia: WB Saunders; 1995. p. 276-84. 19. Zarb GA, Bolender CL. Prosthodontic treatment for edentulous patients. 12th ed. St. Louis: Elsevier; 2004. p. 396-9. Corresponding author: Dr Sudarat Kiat-amnuay 6516 M.D. Anderson Blvd, Suite 493 Houston, TX 77030 Fax: 713-500-4108 E-mail: [email protected] Acknowledgments The authors thank Drs Richard D. Bebermeyer, Lawrence Gettleman, and Arthur H. Jeske for editorial assistance. Copyright © 2008 by the Editorial Council for The Journal of Prosthetic Dentistry.
Kiat-amnuay et al
Neuropathologic mastication is caused by uncoordinated myotonic activity of the masticatory muscles and tongue following neuronal damage in the cerebral cortex, hypothalamus, or reticular/pyramidal systems due to closed head injury, septic shock, and/or hypoxia.1 Reflex masticatory patterns during episodes of hyperactivity may include clenching, masticating, gnawing, and grinding, potentially producing severe injury to the tongue and/or orofacial structures.1-3 Previously reported treatment methods or techniques have included a silver cap splint,1 bite blocks,3,4 tongue guards,5-7 a modified retainer,8 and mouth guards.9,10 Materials used for these devices include silver and acrylic resin,1 rubber,3 acrylic rubber and molt,4 acrylic resin,5,8 acrylic resin with metal wire,6,7 and polymeric materials.9-11 Hanson et al5 reported desirable characteristics for such devices (Table I). The selection or design of an oral device depends on the severity of neuropathological mastication, the patient’s neurological status, and the
prognosis. Patients with mild neuropathological mastication may respond well to a bilateral bite block device which can be used short term.3 Patients with severe neuropathological mastication may require a custom-made fixed device made of firmer material.1,5-7,11 Compared to fixed devices, custom-made removable devices are easier to insert and remove and are more hygienic.9,10,1215 Other designs are made from less durable soft polymers9-11 or may not allow sufficient separation of maxillary and mandibular teeth to prevent further trauma to oral mucosa or the lips.5,7,9 This clinical report describes techniques used to fabricate a modified occlusal plane device to prevent and treat self-inflicted oral trauma in a comatose adult patient.
CLINICAL REPORT A 48-year-old African American woman sustained a large intracerebral hemorrhage in the right thalamus with extension to the third and fourth ventricles. The past medical
history included hypertension, mild chronic renal failure, chronic anemia, and congestive heart failure. The patient presented with severe hypertension, coagulopathy, seizure disorder, and respiratory failure, and was orally intubated and placed on mechanical ventilation. Initial medications included nicardipine, propofol, vitamin K, famotidine, chlorhexidine mouthwash, albuterol, and acetylcysteine by nebulization, bisacodyl, docusate, and metoprolol. On the third day of hospitalization, tongue swelling was noted. Progressive swelling occurred over several days and was complicated by reflex mastication against the endotracheal tube, producing secondary injury to the tongue (Fig. 1). The medication regimen was altered to eliminate possible etiologies of reflex mastication. Intravenous hydrocortisone sodium succinate followed by tapering dosing was initiated over 10 days to treat a possible reactive etiology for the tongue enlargement. The tongue swelling partially subsided over the next week. Dental consultation was obtained. Oral examina-
Assistant Professor, Department of Restorative Dentistry and Biomaterials, University of Texas Dental Branch at Houston. Associate Professor, Department of Restorative Dentistry and Biomaterials, University of Texas Dental Branch at Houston. c Professor, Department of Neurosurgery and Internal Medicine, University of Texas Health Science Center at Houston. a
b
Kiat-amnuay et al
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Table I. Criteria for successful device to prevent and manage self-inflicted oral trauma5 1. It should reflect away from occlusal table those tissues likely to be damaged by involuntary movements of mandible. 2. It should not be potential source of further injury to patient. 3. It should permit full range of mandibular motion. 4. It should permit daily oral care. 5. It should withstand breakage and displacement forces over indefinite period of time. 6. It should allow healing of traumatized oral tissues. 7. It should be easily fabricated and installed without discomfort or risk to patient.
1 Self-inflicted tongue lesion from neuropathologic mastication. tion revealed a partially edentulous maxilla and mandible. The remaining teeth had TM0 mobility (physiologic tooth mobility).16 Reflex mastication produced severe injury to the tongue, which was leather-like in texture and swollen. The ventral surface of the tongue had deep indentations from teeth in both arches. In addition, there was a traumatic ulcer at the lateral border of the tongue (Fig. 1). Maxillary and mandibular provisional soft occlusal guards9 were fabricated from thermo-forming material (Clear Surgical Tray 0.015 inches, 5 x 5 inches; Keystone Industries, Cherry Hill, NJ) and were placed the next day. During the follow-up visit, examination revealed that the patient still severely masticated her tongue using the soft occlusal guards. The decision was made to fabricate the acrylic resin occlusal guard described below, which
was inserted on the fourth day after dental consultation. Sedation and pharmacological paralysis of the patient using intravenous propofol or morphine sulfate were required to obtain access to the oral cavity. Maxillary and mandibular dental impressions were made using irreversible hydrocolloid impression material (Jeltrate; Dentsply Caulk, Milford, Del), and casts were poured with type III dental stone (Microstone; Whip Mix Corp, Louisville, Ky). An interocclusal registration using bimanual manipulation17 was made with wax (Delar blue wax; Great Lakes Orthodontics, Tonawanda, NY) at a vertical opening of approximately 15 to 20 mm. The casts were then mounted on an articulator (Model 2240; Whip Mix Corp) using the interocclusal registration with the incisal pin set at the zero position. The thickness of the 1-piece
The Journal of Prosthetic Dentistry
occlusal guard (15-20 mm at the incisors) was designed to prevent further trauma from the protrusion of the patient’s tongue between the occlusal guard and the teeth. However, if the occlusal guard was too thick, it would strain the patient’s facial muscles. In addition, this thickness allowed room for the suction tube. The casts were positioned in the dental surveyor (Dentsply Ceramco; Burlington, NJ) with the occlusal plane parallel to the floor, and heights of contour were marked on all teeth. In a manner similar to the techniques used for making an occlusal plane device,18 the occlusal guard presented in this report was designed to cover approximately 2-3 mm of the facial surfaces of the incisal edges of the teeth above the height of contour. The design incorporated coverage of the entire palatal surface of the teeth and 3-5 mm of the palatal
Kiat-amnuay et al
423
June 2008 DISCUSSION
2 Illustration of occlusal guard design.
3 Intraoral view of occlusal guard. soft tissue (Fig. 2). All of the undercuts above the heights of contour on palatal surfaces were blocked-out using plaster (Mounting Plaster; Whip Mix Corp). The wax pattern was then fabricated using pink wax (Baseplate Wax Tough Pink #5; Corning Rubber Co, Inc, Ronkonkoma, NY).18 A lingual extension of wax, 2 mm thick, was added to the pattern (Fig. 2). It was placed 3-5 mm posterior to the mandibular incisal contact points and extended entirely down the lingual surfaces, from the mandibular left to right premolars, to prevent the tongue from moving forward. The wax pattern was then invested and processed. Clear denture acrylic resin (Paragon; Coletene/Whaledent, Inc, Cuyahoga Falls, Ohio) was packed and heat polymerized using conventional complete denture techniques,
Kiat-amnuay et al
deflasked, and polished.19 A round opening (8-10 mm in diameter) was created in the occlusal guard between the maxillary and mandibular teeth to allow access for a cannula suction tube (Tyco Healthcare; Miami, Fla). The occlusal guard was then inserted (Fig. 3). Oral hygiene instructions were given to the patient’s caregiver to remove the occlusal guard once a day, when the patient was relaxed, to clean it with a toothbrush and toothpaste or with a denture cleansing tablet. It was to be worn continuously. Follow-up visits by the dental team were performed later on the same day as insertion, and at 1 and 2 weeks after insertion. There were no complications or modifications needed. The patient’s tongue condition improved dramatically thereafter, although the neurological status did not.
The self-inflicted trauma demonstrated in this patient not only produces the primary tissue injury, but is also likely to be self-perpetuating. The pain produced by the tongue swelling and injury may stimulate further uncontrolled, reflex, neuropathologic mastication, resulting in reflex mastication and additional injury. The potential for local infection is high and may result in a generalized systemic inflammatory response. Family members and caregivers are understandably distressed by both the appearance of the injury and the imagined discomfort for the patient. Careful attention to oral hygiene and early detection of neuropathologic mastication by the physician, nurse, and respiratory therapist within the intensive care unit should help prevent the subsequent morbidity demonstrated in this patient. The clinical interventions attempted for this patient, including commercially available oral airways, mouth guards, alternative methods and devices to secure the endotracheal tube, and deep sedation, were unsuccessful in preventing tongue injury. Pharmacological relaxation of the jaw and masticatory muscles only partially improved neuropathologic mastication. Considering that there was only partial improvement, the use of longterm medication was outweighed by the risks of drug side-effects. A team approach is needed to prevent and treat this type of injury, including early consultation by the physician and nurses with a dental team. The design of the occlusal guard presented in this report offers several advantages over other custom designs and other commercially available products in that it: (1) reflects oral tissue and the tongue from the occlusal table, which may accelerate healing of the traumatized tissues; (2) permits a full range of mandibular motion by using a flat occlusal plane design; (3) allows placement of a suction tube when rinsing and cleaning
424
Volume 99 Issue 6
the mouth without removing and reinserting the prosthesis; (4) is easily fabricated and cleaned using procedures similar for conventional dental occlusal guards; and (5) is durable, rigid, resistant to fracture, odorless, and can be used over a long period of time. The possible disadvantages of this occlusal guard include: (1) it requires intraoral impressions; (2) it requires an additional laboratory fee; and (3) it involves the risk of possible dislodgement of the occlusal guard during powerful masticating movement.
SUMMARY A multidisciplinary approach is needed in the management and prevention of self-inflicted oral trauma during care of comatose patients. The occlusal guard described in this article effectively prevents further trauma and permits healing of the traumatized oral tissues.
REFERENCES 1. Hallett KB. Neuropathological chewing: a dental management protocol and treat-
ment appliances for pediatric patients. Spec Care Dentist 1994;14:61-4. 2. Hyman SL, Fisher W, Mercugliano M, Cataldo MF. Children with self-injurious behavior. Pediatrics 1990;85(3 Pt 2):43741. 3. Sheller B. Self-inflicted oral trauma: report of case. Spec Care Dentist 1992;12:28-9. 4. Ngan PW, Nelson LP. Neuropathologic chewing in comatose children. Pediatr Dent 1985;7:302-6. 5. Hanson GE, Ogle G, Giron L. A tongue stent for prevention of oral trauma in the comatose patient. Crit Care Med 1975;3:200-3. 6. Peters TE, Blair AE, Freeman RG. Prevention of self-inflicted trauma in comatose patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984;57:367-70. 7. Jackson MJ. The use of tongue-depressing stents for neuropathologic chewing. J Prosthet Dent 1978;40:309-11. 8. Fenton SJ. Management of oral self-mutilation in neurologically impaired children. Spec Care Dentist 1982;2:70-3. 9. Croglio DP, Thines TJ, Fleischer MS, Andres PL. Self-inflicted oral trauma: report of case. Spec Care Dentist 1990;10:58-61. 10. Kobayashi T, Ghanem H, Umezawa K, Mega J, Kawara M, Feine JS. Treatment of self-inflicted oral trauma on a comatose patient: a case report. J Can Dent Assoc 2005;71:661-4. 11. Hayward JR, Tefz BR, Robert RC, Yellich GM. Soft plastic mouth guards for use in prevention of self-inflicted oral trauma. J Hosp Dent Prac 1979;13:36-7. 12. Silva DR, da Fonseca MA. Self-injurious behavior as a challenge for the dental practice: a case report. Pediatr Dent
The Journal of Prosthetic Dentistry
2003;25:62-6. 13. Sonnenberg EM. Treatment of self-induced trauma in a patient with cerebral palsy. Spec Care Dentist 1990;10:89-90. 14. Fabiano JA,Thines TJ, Margarone JE. Management of self-inflicted oral trauma: report of case. Spec Care Dentist 1984;4:214-5. 15. Wood AJ. A tongue shield appliance: design, fabrication, and case report. Spec Care Dentist 1991;11:12-4. 16. Trejo PM, Weltman RL. Favorable periodontal regenerative outcomes from teeth with presurgical mobility: A retrospective study. J Periodontol 2004;75:1532-8. 17. Dawson PE. Functional occlusion: from TMJ to smile design. 3rd ed. St. Louis: Elsevier; 2006. p. 76-80. 18. Ash MM Jr, Ramfjord SP. Occlusion. 4 th ed. Philadelphia: WB Saunders; 1995. p. 276-84. 19. Zarb GA, Bolender CL. Prosthodontic treatment for edentulous patients. 12th ed. St. Louis: Elsevier; 2004. p. 396-9. Corresponding author: Dr Sudarat Kiat-amnuay 6516 M.D. Anderson Blvd, Suite 493 Houston, TX 77030 Fax: 713-500-4108 E-mail: [email protected] Acknowledgments The authors thank Drs Richard D. Bebermeyer, Lawrence Gettleman, and Arthur H. Jeske for editorial assistance. Copyright © 2008 by the Editorial Council for The Journal of Prosthetic Dentistry.
Kiat-amnuay et al