Management of Self-Harm Injuries in the Maxillofacial Region: A Report of 2 Cases and Review of the Literature.

Clinicians face numerous challenges when managing psychiatric patients who self-inflict injuries within the maxillofacial region. In addition to a complex clinical examination, there are both surgical and psychiatric factors to consider, such as the risk of damaging vital structures, the exacerbation of the patient's psychiatric status, and the long-term psychosocial and esthetic sequelae. We present 2 cases of adolescents who repeatedly self-inflicted wounds and/or inserted foreign bodies (FBs) into the face, scalp, and neck. The different treatment modalities were based on full evaluation of the patient's clinical, medical, and diagnostic test findings coupled with a psychiatric assessment. The decision for conservative management or surgical intervention was made according to the presence and location of the FBs, degree of hemorrhage, signs and symptoms of infection, and unpleasant scars that could lead to long-term psychological impairment. In most cases, the FBs were removed and the wounds were toileted and closed under local or general anesthesia. We advocate a holistic approach via a multidisciplinary team, which is deemed essential to provide the highest quality of care for patients to reduce the risk of further relapses. Lastly, a satisfactory esthetic outcome is always paramount to achieve long-term psychological and physical welfare.

Oral self-injury: an update.

BACKGROUND: Self-inflicted oral injuries of organic origin are particularly common in certain diseases, syndromes, and systemic disorders. In this article, we discuss the characteristics of these oral lesions and their treatment. LITERATURE SEARCH: The authors have reviewed the most relevant literature relating to oral self-injury through a search in textbooks and published articles included in the Medline database for the years 1970-2010, and selected published cases from the last two decades. RESULTS: The majority of the literature on oral self-injury is in the form of case reports. Self-injury is particularly prevalent in patients with Lesch-Nyhan syndrome, a heterogeneous group of neurological disorders, congenital insensitivity to pain with anhidrosis, and mental retardation. It is most common in males in the early years of life, and the sites most frequently involved are the lower lip and the tongue. Therapeutic approaches in these patients have included psychological and pharmacological treatment, intraoral devices, and surgical procedures. CLINICAL IMPLICATIONS: Intraoral devices are the best therapeutic option for self-injury of organic origin, although this approach is not free of complications. The current lack of standardized treatment protocols for oral self-injury means that therapy must be individualized.

An approach to a repeated self-biting tongue injury in a toddler.

BACKGROUND: Children with tongue injuries often visit the pediatric emergency department. The vast majority of cases can be conservatively treated, while some injuries require operative repair. The aim of this article was to demonstrate a "back-to-basics" approach to a refractory bifid tongue injury in a toddler. CASE DESCRIPTION: A 1-year-old toddler with a tongue injury was unsuccessfully treated three times within a week by a surgeon in another specialty; all reconstructions were mucosal only. The case was then referred to our maxillofacial unit for proper management. On examination, the recurrent injury seemed to occur because of the patient's self-biting habit. We performed the fourth reconstruction of the tongue muscles and mucosa, and because of no dental prosthetic laboratory available in our hospital, we used transparent adhesive drapes fixed by resorbable sutures to cover the patient's anterior teeth instead of bite guards. The toddler was fed via a nasogastric tube for 1 week under 2-day antibiotic prophylaxis and routine oral care. The patient was discharged without any complications 1 week later. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The causes of repeated orofacial injuries should be identified and require particular attention to establish a proper treatment. For intraoral injuries in pediatric patients, self-biting habits should not be overlooked. The application of materials in an operating theater can help the treating clinicians improve the treatment outcomes.

Effective treatment of self-injurious oral trauma in Lesch-Nyhan syndrome: a case report.

Lesch-Nyhan syndrome (LNS) is an X-linked disorder originating from deficiency of the enzyme hypoxanthine guanine phosphoribosyl transferase. It is characterized by neurological manifestations, including the dramatic symptom of compulsive self-mutilation, which results in destruction of oral and perioral tissues. Several drug trials have been administered to improve the severe self-destructive behaviour, with questionable effectiveness. Invasive treatment approaches, such as extraction of teeth and orthognathic surgery, have been suggested with variable success. A conservative treatment with an intraoral appliance serving to prevent oral and peri-oral self-injury is presented in this report. The patient was a 14-year-old boy demonstrating the typical LNS behaviour, including compulsive self-biting, significant loss of lip and tongue tissue, spasticity and involuntary movements. An acrylic maxillary appliance was designed and constructed with an occlusal plate raising the bite. The appliance was retained by two Adams' clasps on the first premolars, along with three ball clasps between the incisors. Fabrication, insertion, and maintenance were uncomplicated and non-stressful to the patient. Periodic recall over 3-year period has confirmed the effective healing of the oral lesions and a high level of tolerance of the appliance.

Diagnostic dilemma of an ulcer in a child.

UNLABELLED: Careful history-taking and examination are important in diagnosing self-inflicted injuries, which are often very difficult to diagnose and manage. We describe a case of a misdiagnosed traumatic ulcer in a 9-year-old boy which meant that he went through months of pain and discomfort, missed school, was admitted to hospital and had a series of unnecessary investigations. CLINICAL RELEVANCE: This case highlights the importance of dental referral, careful history and examination in managing unusual oral ulceration.

Case Report of a Severe Recurrent Tongue Self-Injury in an Infant With Dystonia.

Dystonia is characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive movements, postures, or both that are typically patterned, twisting, and sometimes tremulous. It is often initiated or worsened by voluntary action and associated with overflow muscle activation. In this article we report a case of severe oromandibular dystonia, which is a specific form of dystonia characterized by involuntary, action-induced tonic or clonic spasms of the masticatory, lingual, and pharyngeal musculature. Episodes of repeated tongue biting in a 17-month-old girl caused her to stay in the PICU for 4 weeks. These episodes were the consequence of dystonia induced by a perinatal stroke. We highlight the specific dental management that enabled us to treat the child without extractions. Facing this type of complex illness, we insist on the importance of interdisciplinary work with the goal of avoiding outdated techniques. The use of botulinum toxin seemed relevant.

A review of behavioral and pharmacological treatments for habit disorders in individuals with mental retardation.

This paper reviews the prevalence and behavioral and pharmacological treatment-outcome studies for habit disorders exhibited by individuals with mental retardation. The treatment-outcome studies target the habit disorders identified previously by researchers including nervous habits (nail biting, bruxism, and trichotillomania), motor and vocal tics, and Tourette's disorder. The paucity of behavioral treatments and the lack of controlled pharmacological research warrants further experimental evaluation of treatments for habit disorders affecting individuals with mental retardation. Conclusions and recommendations for future research are made.

Autistic disorder: a review for the pediatric dentist.

Dental publications on autism have been sparse since the first comprehensive article geared for the dental profession. New findings on the etiology of autistic disorder (AD) have been discovered, suggesting that it is an organic disorder characterized by abnormalities in the brain, especially the cerebellum and limbic system. This article summarizes the latest medical findings on the etiology, diagnosis, and treatment approaches of AD, and reviews the dental literature since 1969. The main dental topics reviewed are: oral health status and dental needs of patients with AD, characteristics of patients with AD, and self-injurious behavior (SIB) in the context of AD. Clinical behavior-management issues such as pharmacological and communicative techniques and physical restraint and desensitization are described. The affect of the dental office's environment and appointment structure on a patient with AD are presented.

An analysis of the reinforcing properties of hand mouthing.

Hand mouthing often has been described as a stereotypic response that is maintained by nonsocial (automatic) reinforcement; however, data supporting this conclusion can be found in relatively few studies. This series of studies presents an experimental analysis of conditions associated with the maintenance of hand mouthing. In Experiment 1, a functional analysis was conducted for 12 individuals who engaged in chronic hand mouthing, to determine whether the behavior is usually maintained independent of social contingencies. Results obtained for 10 subjects were consistent with an automatic reinforcement hypothesis; the remaining 2 subjects' hand mouthing was maintained by social-positive reinforcement. Based on these results, Experiment 2 was designed to identify the specific reinforcing properties of hand mouthing. Each of 4 subjects was provided with a toy that substituted for hand mouthing, and preference for a specific topography of toy manipulation (hand-toy contact or mouth-toy contact) was measured. Results indicated that hand stimulation was the predominant reinforcer for all subjects. Experiment 3 provided an extension of Experiment 2 in that the same responses were measured across a variety of toys presented to each of 5 subjects. Results again indicated that hand stimulation was the predominant reinforcer for all subjects. Implications of these results are discussed with relevance to treatment.

Treatment of self-induced trauma in a patient with cerebral palsy.

Factitious illness can be a problem for disabled patients who experience recurrent trauma or irritation to a particular part of the body. In this case, the patient's recurring lip trauma combined with his overlying physical disability presented a problem not easily solved with prior methods of treating lip trauma. Modifying the standard orthodontic appliance solved the problem; after a short period of use, the patient dropped the harmful habit that caused the lip trauma. The appliance was no longer needed.

Oro-dental management of patients with familial dysautonomia.

Oro-dental abnormalities are quite frequent in familial dysautonomia. The practitioner should be familiar with this disorder, which represents a "human model" for chronic progressive oro-dental denervation. Self-injurious behavior is caused mainly by profound sensory loss. An appropriate preventive and therapeutic approach that was developed in our clinic and adapted for the special hazards of dentistry in youngsters with systemic autonomic dysfunction may improve the life quality of this particular population.

Alternative therapies in the treatment or oral self-injurious behavior: a case report.

This paper presents the case of a child with severe mental retardation and a history of oral self-injurious behavior (SIB). While the behavior was refractory to a number of dental interventions, some success was achieved through a combination of behavioral therapy techniques and therapeutic touch (a relaxation technique). Etiologies of SIB are discussed, along with descriptions of alternatives to traditional dental therapy for this difficult problem.

Lip-biting in patients with profound neuro-disability.

Profound neuro-disability due to severe brain damage affects approximately 1200 people per year in the UK. Approximately half of these patients exhibit exaggerated or abnormal oral reflexes. Biting, bruxism and ruminating movements may result in dental or soft tissue trauma, with severe lip or tongue lacerations. This paper describes 10 patients referred to the dental department at the Royal Hospital for Neuro-disability with lip bites and/or severe bruxism, during a 12-month period. Management options include: monitoring the lesion; smoothing teeth; providing a bite raising appliance; or extracting teeth. This paper discusses the difficulty in management of lip trauma in this group of patients and emphasizes the importance of an interdisciplinary approach.

Oral habits--part 2: beyond nutritive and non-nutritive sucking.

In addition to sucking habits, a range of other habits have been associated with short- and long-term dental and orthodontic problems. These habits include tongue thrusting and atypical swallowing, lip sucking, oral self-mutilation, mouth breathing, and bruxism. Although the association between form and function continues to be controversial, if habits are of sufficient duration they may lead to dental malocclusion and impede successful management. Oral self-injury and bruxism can lead to significant problems, such as soft tissue trauma and infection. Accurate history taking and examination are essential steps in formulating a diagnosis and management plan. Although a range of treatment options are often available, clear guidelines for treatment are difficult to develop due to a lack of high quality clinical trials. Optimal management is likely to be dictated by patient and severity variability. The purpose of this paper is to review and discuss the management of tongue thrust and atypical swallowing, lip sucking, oral self-mutilation, mouth breathing and bruxism.

Extrication of penile entrapment in a polyethylene terephthalate (PET) bottle: a technique of suture traction and Dundee and literature review.

OBJECTIVE: To describe the use of a technique of suture traction and Dundee in penile entrapment in the polyethylene terephthalate (PET) bottle case. MEASURES AND METHODS: The technique of suture traction in conjunction with Dundee was performed for the management of penile entrapment in PET bottle neck. First, the technique of Dundee (manual compression after multiple prepuce punctures) was used to alleviate and resolve the preputial edema; second, the persistent suture traction power was applied to achieve the removal with lubrication. A review of the literature is also summarized in this report. Current treatment options and outcomes are also evaluated. RESULT: The PET bottle neck was removed intact successfully in 50 min. Follow-up revealed he got full recovery without any complications. Literature review shows that penile incarceration in PET bottle is frequently described as an isolated case report or small series, the approach for dealing with these problems are often described using cutting instruments, the PET bottle could produce a fatal harm in extreme situation. CONCLUSIONS: The technique combined suture traction with Dundee could be easy to perform without any special tools required in the management of penile entrapment involving PET bottles. It could be applied safely for the low-grade penile injury.

Case report of self-injurious behaviour (SIB) presenting as gingivitis artefacta major.

The case report described here discusses gingivitis artefacta major, an oral presentation of self-injurious behaviour, in an adolescent. On presentation, the patient knew well the ramifications of her gum scratching behaviour, however, was unable to stop. At further presentations new lesions had appeared with further bone loss. The cause of her behaviour seemed to be of psychological origin and therefore no interventive dental treatment was possible until this issue was resolved. A more preventive approach was adopted in the meantime. Referral to appropriate services from the dental profession also proved to be challenging. In conclusion, gingivitis artefacta, although rarely seen to this extent, is extremely challenging to diagnose and treat fully in a dental setting.

An occlusal guard for preventing and treating self-inflicted tongue trauma in a comatose patient: a clinical report.

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.

A case of Tourette syndrome presenting with oral self-injurious behaviour.

Self-injurious behaviour (SIB) is deliberate harm to the body without suicidal intent, and the condition occurs in a number of psychiatric, behavioural and developmental disorders. This case report describes a 4-year-old female with SIB who presented to a paediatric dentist after the self-extraction of teeth as a result of oral motor tics. The girl repetitively ground her teeth in a monophasic lateral motion that resulted in luxation of her maxillary right primary canine, and produced generalized oral and facial pain. The parents consulted the dentist about their child's complaint of toothache. The oral findings were unexcephonable except for a mobile primary canine, but there was a history of unusual behaviour including hyperactivity, and after multidisciplinary consultation and exclusion of other systemic diseases, the subject was diagnosed as suffering from Tourette syndrome (TS). Preventive treatment using a dental splint was provided. Noncontingent reinforcement therapy was successfully used to diminish the subject's SIB.

Oral self-injurious behavior in the developmentally disabled: review and a case.

Self-injurious behavior occurs in conjunction with a variety of psychiatric disorders as well as various developmental disabilities and some syndromes. The behavioral and biochemical aspects of self-injurious behavior are poorly understood and several etiologies have been suggested. Treatments for self-injurious behavior in developmentally disabled individuals fall into three main categories: pharmacological, behavior modification and physical restraints. The dental management of self-injurious behavior is often difficult. Numerous appliances of various design have been reported in the literature. Osteotomies or extraction of the offending teeth may have to be considered if less invasive methods are unsuccessful. A case is reported where a child engaged in tonic lip biting secondary to a neurological and seizure disorder is treated using a removable lip-protruding device. No impression or lab construction is required. The appliance presents minimal interference with oral hygiene procedures and it can be removed and reinserted as needed. We conclude that a removable lip-bumper may be a viable option in treating transient and acute episodes of self-injurious behavior involving the lower lip and buccal mucosa.

The dental problems and management of a patient suffering from congenital insensitivity to pain.

Congenital insensitivity to pain is a rare condition usually manifested in childhood by a history of unrecognized trauma, indifference to painful stimuli or self-mutilation. This paper describes the management of a 13-month-old male who had severely lacerated his tongue by habitually chewing it, using soft polyvinyl mouthguards retained with a minimal amount of denture fixative.