Category: Clinical Sciences/Health Conditions
Severe traumatic brain injury (TBI) complicated by post-traumatic bruxism.
A 21-year-old male suffered a severe TBI secondary to a motorcycle accident. CT showed subarachnoid hemorrhage, left subdural hemorrhage, and a 5-mm left-to-right midline shift. Left-sided decompressive craniectomy was performed. Course was complicated by paroxysmal sympathetic hyperactivity (PSH). Over the subsequent two weeks PSH resolved and the patient progressed to a minimally conscious state (MCS). On hospital day (HD) 15 the patient was noted to have bruxism causing lacerations to the lips, tongue, and cheek with return of PSH. Clinical examination revealed mouth opening of 0 mm making mouth guard fitting impossible. Twenty-five units of onabotulinumtoxinA were injected into each masseter muscle. After six days, a marked reduction in bruxism was noted with associated with resolution of PSH. The patient was discharged to inpatient rehabilitation on HD 26 and he emerged from MCS seven days later progressing to an oral diet with resolution of bruxism.
Bruxism associated with TBI and altered states of consciousness has been documented.
The onset of bruxism is frequently linked to the return of sleep-wake cycles in comatose patients potentially causing damage to the teeth and surrounding soft tissue structures. Pain associated with bruxism may trigger PSH. Botulinum toxin injection in the masseter muscles is an effective means of intervention in cases of severe post-traumatic bruxism especially in cases where a mouth guard cannot be utilized. In our patient the temporalis muscle was not injected due to the close proximity of the craniectomy site but this is also a muscle that could potentially be targeted.
Bruxism is a potential complication following TBI and injection of botulinum toxin into the masseter muscle and may be the only practical intervention available to treat post-traumatic bruxism and severe jaw clenching seen following TBI.