How to prevent tongue biting in a comatose patient with decerebrate posturing in an intensive care unit (ICU) setting?

Prevention of Tongue Biting in Comatose Patients with Decerebrate Posturing

Place the unconscious patient in the lateral position immediately to maintain airway patency and prevent tongue trauma from discoordinate mandibular movements, and if self-inflicted oral trauma persists despite positioning, insert a custom intraoral prosthesis or modified bite guard to physically separate the jaws. 1, 2

Immediate Airway Management and Positioning

• Position the patient laterally (recovery position) as the first-line intervention to keep the airway clear and reduce the risk of tongue biting from uncontrolled jaw movements 1
• The lateral position prevents the tongue from falling backward and reduces aspiration risk while allowing gravity to assist in maintaining airway patency 1
• Ensure the head is positioned centrally without lateral rotation, particularly important in patients with potential increased intracranial pressure 1
• Maintain continuous monitoring of airway patency, as unconscious patients cannot protect their airways and are at high risk for obstruction 1, 3

Physical Barrier Devices for Persistent Tongue Trauma

When positioning alone fails to prevent self-inflicted oral injuries:

• Insert a custom intraoral prosthesis (tongue stent) designed specifically to prevent discoordinate mandibular chewing movements that occur in decerebrate and comatose patients 2, 4
• The prosthesis works by physically preventing jaw occlusion, thereby eliminating the mechanical ability to bite the tongue during pathologic chewing movements 2, 4
• For severe uncontrolled muscular activity, use a modified occlusal bite guard that prevents the jaws from fully occluding, which is more effective than simple bite raisers 5
• Fabrication requires joint collaboration between the intensive care team, neurosurgery, and oral surgery/dentistry services 2, 4

Neurophysiologic Rationale

• Decerebrate patients exhibit discoordinate or neuropathologic mandibular chewing movements due to loss of cortical inhibition of primitive brainstem reflexes 2, 4
• These involuntary movements create repetitive trauma to the tongue and other intraoral structures, leading to factitial lesions that cannot heal without mechanical intervention 2, 4
• Standard airway adjuncts (oropharyngeal or nasopharyngeal airways) do not address the specific problem of jaw closure and tongue biting 1

Device Maintenance and Monitoring

• Perform regular oral hygiene with warm saline mouthwashes or oral sponges to prevent secondary infection 1
• Apply white soft paraffin ointment to lips and oral mucosa every 2-4 hours to maintain tissue integrity 1
• Inspect the device and oral cavity daily for proper fit, displacement, or pressure injuries 1
• The prosthesis facilitates healing of pre-existing tongue lesions by eliminating the repetitive trauma mechanism 2, 4

Critical Pitfalls to Avoid

• Do not rely solely on soft bite blocks or gauze padding, as these are inadequate for the forceful, repetitive jaw movements seen in decerebrate posturing and will be quickly destroyed 5
• Do not assume the problem will resolve spontaneously; without intervention, tongue trauma will continue and worsen, potentially compromising the airway 2, 4
• Do not delay consultation with oral surgery or dentistry when tongue trauma is identified, as custom prosthesis fabrication requires specialized expertise 2, 4
• Avoid placing the patient flat supine, as this increases aspiration risk and does not address tongue positioning 1

Alternative Airway Considerations

• If the patient requires mechanical ventilation for other reasons, endotracheal intubation provides definitive airway protection and eliminates tongue biting risk 1, 3
• However, intubation solely for tongue bite prevention is not indicated if the patient has adequate spontaneous ventilation 1
• Semi-recumbent positioning (30-45° head elevation) is appropriate for hemodynamically stable patients to reduce aspiration risk, but does not prevent tongue biting 1