Anaesthesia, 1992, Volume 47, pages 972-973 APPARATUS
The use of a bite raiser in the intensive care unit
P. A. WILKINSON
AND
G.R. WILKINSON
Summary The use of a simple bite raiser is described to prevent self-injticted tongue trauma in patients whose tracheas are intubated or who have tracheostomies during recovery .from head injury or tetanus. Key words Intensive care. Complications; trauma .
Most clinicians working in the Intensive Care Unit (ICU) are familiar with the head injured patient who traumatises the tongue and lips during the first few weeks of recovery from prolonged coma [ 1,2]. Also, patients who suffer from tetanus may traumatise the lips and tongue severely as a result of the severe spasm [3] that persists for many weeks. We have used a simple bite raiser (Fig. 1) in many cases over the last 10 years and present three illustrative examples. Apparatus The bite raiser is simple to construct, insert, remove and clean, and allows continued mouth care. It is cosmetically acceptable to patient’s relatives and inflicts no trauma to the patient during removal and insertion. The bite raiser is produced from a 3 mm sheet of soft polyvinylchloride which is vacuum moulded on to a stone model cast from an upper dental arch impression. It can be prepared in 1-2 h in an appropriately equipped dental laboratory. Similar types of device are currently in widespread use for sportsguards, temporomandibular joint disorders and dental splints following trauma [4]. The dental impression involves the use of a disposable or custom-made tray, and usually an alginate or alternatively a silicone-based impression material. If the patient’s trachea is intubated with an oral tube, it is necessary to adjust the tube to one angle of the mouth; the resulting impression registers only about 75% of the arch but this is normally adequate. A full arch impression
can be obtained from patients with a tracheostomy. In all patients, it is necessary to pack the oropharynx to facilitate the removal of excess impression material from the mouth. Increased sedation, if necessary supplemented by a muscle relaxant, may be required whilst making the impression. Case histories
Case I A 4-year-old male patient suffered a fractured skull and cerebral oedema as a result of a road traffic accident. His lungs were ventilated for several days via a Jackson-Rees tube and he was noted to be chewing and biting his tongue during the weaning stage. Attempts at preventing this by McKesson props and various mouth gags were unsatisfactory due to the trauma inflicted on his small mouth. An impression was taken of the upper jaw and a simple bite raiser constructed in the orthodontic laboratory. When this was inserted, he stopped traumatising his tongue. The device was easily removed and inserted by the nursing staff for cleaning and mouth care, and was cosmetically undetectable to relatives and observers. The patient seemed to tolerate the bite raiser well. Case 2 A 17-year-old male was admitted to the hospital with cerebral oedema and fitting after traumatic asphyxiation. He required mechanical ventilation, fluid restriction and an infusion of thiopentone. Respiratory support was required for nearly 10 days, during which time he also suffered a chest infection. During weaning from the ventilator, he was noted to be chewing and biting his tongue.
P.A. Wilkinson, MB, ChB, FFARCS, Consultant, Department of Anaesthetics, Royal Hallamshire Hospital, Sheffield, SIO 2RX, G.R. Wilkinson, BSc, BChD, Lecturer, Department of Child Dental Health, Charles Clifford Dental School and Hospital, Sheffield S10 2SZ. Accepted 24 March 1992. 0003-2409/92/110972
+ 02 %08.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
972
A bite raiser in the ICU
Fig. I . Plaster/stone model and soft vacuum-moulded bite raiser.
making mouth care very difficult. A bite raiser was constructed. The tongue healed, and no further trauma was inflicted. Case 3 A 5 I-year-old male who had contracted tetanus received mechanical ventilation in ICU for 5 weeks as part of the therapy for the disease. During this time, despite huge doses of diamorphine, benzodiazepines and atracurium, he continued to traumatise his lips and tongue because of the intense spasms associated with tetanus. The nursing staff, who had cared for Case 2, requested a biteraiser, which was used successfully and resulted in complete healing of the trauma.
973
use (more than a few hours) is not without hazard. We believe that the use of the simple bite raiser offers a safe and novel solution to the problem. Although the device requires a certain amount of technical expertise to construct, it should be within the capabilities of the Orthodontic o r Oral Surgery departments of most District General Hospitals. Appliances described by Piercell et al. [ 5 ] and Hanson et al. [ 2 ] seem to have been equally effective in similar circumstances, but are more difficult to prepare, need to be wired in place and cannot be removed for cleaning and performing oral hygiene. They fit over the mandibular rather than the maxillary arch. We suggest that the use of this simple device is a more universally acceptable solution to the problem of self-inflicted oral trauma in the ICU.
Acknowledgments The authors thank the nursing staff of the ICU at the Royal Hallamshire Hospital, Sheffield, for their innovative use of this device, and also M r R. Phillips, of the Dental Hospital, Sheffield, for his technical assistance. Our special thanks are given to Emeritus Professor P.H. Burke, Department of Child Dental Health, Sheffield, whose original suggestions stimulated the development of this device.
References Discussion Self-inflicted trauma to the lips and tongue can be a problem in the ICU patient. Solutions suggested previously by our oral surgical colleagues have included the use of various props and gags, e.g. McKesson prop, Boyle-Davis gag and simple wooden or plastic wedges. These devices present many disadvantages, the major one being the risk of further trauma to the oral soft tissues during insertion. They are also difficult for nursing and medical staff 10 insert and remove, easy to dislodge, and may be totally ineffective during periods of intense spasm. Their long-term
[ I ] BRICOLOA. Prolonged post-traumatic coma. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology. Amsterdam, Oxford: North Holland Publishing. New York: American Elsevier Publishing, 1976; 2 4 699-756. [2] HANSONGE, OGLERG, GIRONL. A tongue stent for the prevention of oral trauma in the comatose patient. Crilical Care Medicine 1975; 3: 200-3. [3] EDMONDSON RS.Tetanus. Briiish Journal of Hospiral Medicine 1980; 23: 596-602. 14) ANDRAESEN JO. Traumaiic injuries to ihe ieeih, 2nd edn. Copenhagen: Munksgaard, I98 1 : 434. [5] PIERCELLMP, WAITE DE, NELSON R. Prevention of selfinflicted trauma in semi-comatose patient. Oral Surgery 1974; 3 2 903-5.
The use of a bite raiser in the intensive care unit
P. A. WILKINSON
AND
G.R. WILKINSON
Summary The use of a simple bite raiser is described to prevent self-injticted tongue trauma in patients whose tracheas are intubated or who have tracheostomies during recovery .from head injury or tetanus. Key words Intensive care. Complications; trauma .
Most clinicians working in the Intensive Care Unit (ICU) are familiar with the head injured patient who traumatises the tongue and lips during the first few weeks of recovery from prolonged coma [ 1,2]. Also, patients who suffer from tetanus may traumatise the lips and tongue severely as a result of the severe spasm [3] that persists for many weeks. We have used a simple bite raiser (Fig. 1) in many cases over the last 10 years and present three illustrative examples. Apparatus The bite raiser is simple to construct, insert, remove and clean, and allows continued mouth care. It is cosmetically acceptable to patient’s relatives and inflicts no trauma to the patient during removal and insertion. The bite raiser is produced from a 3 mm sheet of soft polyvinylchloride which is vacuum moulded on to a stone model cast from an upper dental arch impression. It can be prepared in 1-2 h in an appropriately equipped dental laboratory. Similar types of device are currently in widespread use for sportsguards, temporomandibular joint disorders and dental splints following trauma [4]. The dental impression involves the use of a disposable or custom-made tray, and usually an alginate or alternatively a silicone-based impression material. If the patient’s trachea is intubated with an oral tube, it is necessary to adjust the tube to one angle of the mouth; the resulting impression registers only about 75% of the arch but this is normally adequate. A full arch impression
can be obtained from patients with a tracheostomy. In all patients, it is necessary to pack the oropharynx to facilitate the removal of excess impression material from the mouth. Increased sedation, if necessary supplemented by a muscle relaxant, may be required whilst making the impression. Case histories
Case I A 4-year-old male patient suffered a fractured skull and cerebral oedema as a result of a road traffic accident. His lungs were ventilated for several days via a Jackson-Rees tube and he was noted to be chewing and biting his tongue during the weaning stage. Attempts at preventing this by McKesson props and various mouth gags were unsatisfactory due to the trauma inflicted on his small mouth. An impression was taken of the upper jaw and a simple bite raiser constructed in the orthodontic laboratory. When this was inserted, he stopped traumatising his tongue. The device was easily removed and inserted by the nursing staff for cleaning and mouth care, and was cosmetically undetectable to relatives and observers. The patient seemed to tolerate the bite raiser well. Case 2 A 17-year-old male was admitted to the hospital with cerebral oedema and fitting after traumatic asphyxiation. He required mechanical ventilation, fluid restriction and an infusion of thiopentone. Respiratory support was required for nearly 10 days, during which time he also suffered a chest infection. During weaning from the ventilator, he was noted to be chewing and biting his tongue.
P.A. Wilkinson, MB, ChB, FFARCS, Consultant, Department of Anaesthetics, Royal Hallamshire Hospital, Sheffield, SIO 2RX, G.R. Wilkinson, BSc, BChD, Lecturer, Department of Child Dental Health, Charles Clifford Dental School and Hospital, Sheffield S10 2SZ. Accepted 24 March 1992. 0003-2409/92/110972
+ 02 %08.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
972
A bite raiser in the ICU
Fig. I . Plaster/stone model and soft vacuum-moulded bite raiser.
making mouth care very difficult. A bite raiser was constructed. The tongue healed, and no further trauma was inflicted. Case 3 A 5 I-year-old male who had contracted tetanus received mechanical ventilation in ICU for 5 weeks as part of the therapy for the disease. During this time, despite huge doses of diamorphine, benzodiazepines and atracurium, he continued to traumatise his lips and tongue because of the intense spasms associated with tetanus. The nursing staff, who had cared for Case 2, requested a biteraiser, which was used successfully and resulted in complete healing of the trauma.
973
use (more than a few hours) is not without hazard. We believe that the use of the simple bite raiser offers a safe and novel solution to the problem. Although the device requires a certain amount of technical expertise to construct, it should be within the capabilities of the Orthodontic o r Oral Surgery departments of most District General Hospitals. Appliances described by Piercell et al. [ 5 ] and Hanson et al. [ 2 ] seem to have been equally effective in similar circumstances, but are more difficult to prepare, need to be wired in place and cannot be removed for cleaning and performing oral hygiene. They fit over the mandibular rather than the maxillary arch. We suggest that the use of this simple device is a more universally acceptable solution to the problem of self-inflicted oral trauma in the ICU.
Acknowledgments The authors thank the nursing staff of the ICU at the Royal Hallamshire Hospital, Sheffield, for their innovative use of this device, and also M r R. Phillips, of the Dental Hospital, Sheffield, for his technical assistance. Our special thanks are given to Emeritus Professor P.H. Burke, Department of Child Dental Health, Sheffield, whose original suggestions stimulated the development of this device.
References Discussion Self-inflicted trauma to the lips and tongue can be a problem in the ICU patient. Solutions suggested previously by our oral surgical colleagues have included the use of various props and gags, e.g. McKesson prop, Boyle-Davis gag and simple wooden or plastic wedges. These devices present many disadvantages, the major one being the risk of further trauma to the oral soft tissues during insertion. They are also difficult for nursing and medical staff 10 insert and remove, easy to dislodge, and may be totally ineffective during periods of intense spasm. Their long-term
[ I ] BRICOLOA. Prolonged post-traumatic coma. In: Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology. Amsterdam, Oxford: North Holland Publishing. New York: American Elsevier Publishing, 1976; 2 4 699-756. [2] HANSONGE, OGLERG, GIRONL. A tongue stent for the prevention of oral trauma in the comatose patient. Crilical Care Medicine 1975; 3: 200-3. [3] EDMONDSON RS.Tetanus. Briiish Journal of Hospiral Medicine 1980; 23: 596-602. 14) ANDRAESEN JO. Traumaiic injuries to ihe ieeih, 2nd edn. Copenhagen: Munksgaard, I98 1 : 434. [5] PIERCELLMP, WAITE DE, NELSON R. Prevention of selfinflicted trauma in semi-comatose patient. Oral Surgery 1974; 3 2 903-5.
