Dislocation of the unilateral temporomandibular joint a very rare presentation of epilepsy.

Epilepsy can present in various forms, common and uncommon. Unilateral TMJ dislocation is one of the rare presentation of epilepsy. A case report of such unusual presentation of epilepsy.

INTRODUCTION

Chadwick[1] recommends defining an epileptic seizure as an intermittent, stereotyped, disturbance of consciousness, behavior, emotion, motor function or sensation that on clinical grounds is believed to result from cortical neuronal discharge.

Epilepsy can then be defined as a condition in which seizures recur, usually spontaneously.

The manifestations of epilepsy include facets of equal importance to the psychiatrist and the neurologist. Some aspects indeed stand firmly at the junction between the two disciplines. The seizure itself may take the form of the classic motor convulsion or consist of complex abnormalities of behavior and subjective experience. Associated disorders may sometimes include cognitive difficulties, personality disturbances or psychotic illnesses of various types and durations, all these with respect to the study of patients with epilepsy have played an important part in advancing our knowledge of brain function and dysfunction,

Epilepsy may be subdivided according to observed content of attacks, presumed aetiology and pathology, electroencephalographic manifestations or presumed site of origin of the abnormal activity within the brain.

CASE REPORT

Patient Miss. AC, a 9 year, weight 24 kg, student of 5th standard, was brought by her mother in psychiatry clinic with complaints of recurrent deviation of angle of mouth to right side. The patient had such 30-40 episodes of deviation of mouth in approximately 14 months, for these complaints the patient was taking treatment from Dental hospital, where the patient was clinically diagnosed to have hyper mobility of right Temporomandibular joint (TMJ) with subluxation. In the following days, she underwent multiple X-rays and MRI of TMJ which were found to be normal.

Stabilization splint was placed to avoid TMJ dislocation. The patient did not get relief, she was still suffering from similar symptoms, she was psychologically disturbed due to above symptoms, and her performance in school was getting deteriorated due to frequent visits to hospital and recurrent pain.

The patient was then referred for physiotherapy where she learnt gentle jaw stretching and relaxation exercises but it did not help in her symptom reduction. At last the patient learnt to fix her dislocated joint by her own or with the help of her parents. Still she was worried a lot until she visited psychiatr y clinic on the advice of one of her friend's mother, who herself was taking treatment from Psychiatry clinic for some neurotic illness.

In Psychiatry clinic detail history was explored from the patient and her parents. Her I.Q, MRI brain and EEG testing were done. Her I.Q and MRI brain were found to be normal, EEG was suggestive of focal epilepsy arising from left frontoparietal region and getting generalized, although the patient was having no symptoms suggestive of true seizures such as generalized tonic clonic limb movements, tongue bite, urinary or faecal incontinence, fainting attack or any symptoms suggestive of aura and most of her attacks were at night. Majority of the time dislocation occurred during sleep.

The patient was commenced on Divalproex Sodium Extended Release tablet 250 mg at bed time. For the next one month she had only one episode of TMJ dislocation. She visited the clinic again and her dose of divalproex sodium was increased to 500 mg HS. Since last 2 years she is asymptomatic. Now she is going to school regularly and performing well.

It is one of the rarest presentation of epilepsy. Dislocations or fractures of the limbs can arise from muscle contraction during epileptic seizures. Dislocation as a complication of the TMJ due to seizures is reported very rarely.

Similar case was previously reported where dislocation of the bilateral TMJ due to generalized tonic-clonic seizures was observed.[2] A 36-year-old woman, who had no history of epilepsy, presented recurrent dislocations of the bilateral TMJ and generalized tonic-clonic seizures. EEG showed intermittent generalized slow activity. They report a case of bilateral TMJ dislocation that occurred during generalized tonic-clonic seizures, which has not previously been reported in Korea.

Few more cases were reported in by Ugboko1 V.I.[3] In a retrospective study of TMJ dislocation in 96 Nigerian cases, 10 patients (10.4%) had an underlying systemic disease, the most common being epilepsy (four cases).