Masochistic habits in a child patient: A case report and its management.

This is a case report of diagnosis and management of masochistic habits, a special type of mechanical trauma to the gingival tissue known as self-inflicted lesions, also termed as gingivitis artefacta. Self-inflicted injuries can be premeditated, accidental, or can also result from an uncommon habit. The purpose of this article is to review clinical findings in a 6-year-old female patient who had a habit of left forearm sucking since birth and also presented with a nail-biting habit which caused a gingival stripping on the left buccal surface of maxillary first and second deciduous molars. A full-arm sleeve was advised to be used for habit breaking, selective grinding of cusps was done of lower left first and second deciduous molars, and also topical anesthetic gel was prescribed.

INTRODUCTION

Self-injurious behavior (SIB) may be defined as that which results in the infliction of physical damage and, perhaps, pain upon oneself.[1] The manifestations may be seen as finger biting, skin cutting, head banging, and trauma to the oral tissues and genital.[2]

Self-inflicted oral mutilation (masochistic habits) is defined as deliberate harm to one's own body without suicidal intentions.[2] Documented cases exist of tooth self-extraction, nail biting (NB), tongue mutilation, sucking digits, or sucking a variety of foreign objects. Pencils, pens, eyeglass, earpieces, toothpicks, knives, dental floss, thread, and pacifiers are some of the items that have been reported as instruments of self-inflicted gingival injury.[3]

NB is a common but unresolved medical problem in children. Its incidence in the ages of 4-6 years is more than earlier ages. Its rate increases in adolescence while it declines in later ages. NB is not gender dependent in children less than 10 years but its incidence in boys is more than girls in adolescence. Many modalities of treatment were tried including punishment or even pressure the children to stop but were not effective in the long term.[4]

CASE REPORT

A 6-year-old female patient with the chief complaint of pain along with burning sensation in relation to the gums between her upper-left back teeth for the past 10 days. At the time of the clinical examination, the patient had a healthy appearance and seemed relaxed and communicative, average in her studies at second standard with normal IQ level. Socio-economic status revealed that parents were from middle class socio-economic background leading a happy contented life.

During the intraoral examination a bite-wing radiograph was taken to rule out for any foreign body impaction or proximal caries. There was evidence of gingival stripping on the buccal surface extending 4 mm apical to the cement–enamel junction and a narrow zone of attached gingival margin measuring approximately 1 mm [Figure 1]. There was also loss of papilla height on the distal aspect of the first deciduous molar tooth. The gingiva in this region was edematous, reddish, and had an ulcerated appearance (“the ulcer looked raw”); plaque deposits were minimal.

Figure 1

Gingival stripping and loss of papilla height on the distal aspect of the first deciduous molar tooth

The parents were interviewed regarding any unusual practices or habits involving the child's mouth. Mother indicated that the child pricked at the area with her fingernails and also child patient had a habit of left forearm sucking, since birth for the past 6 years. A Hyperpigmented area of 12 × 7 mm was visible in the left forearm region [Figure 2].

Figure 2

Encircle the hyper-pigmented scar on left forearm

A detailed family history was taken to rule out untoward family background. All were negative and not supportive for the cause. It was concluded that severe gingival stripping and hyper-pigmentation on the forearm observed in this case was primarily the result of self-injury. It was recommended that a full arm sleeve covering the arm and fingers during sleeping and play hours can be used for habit breaking [Figure 3]. Selective grinding of cusps was done on the lower-left first and second primary molars. Topical anesthetic gel was prescribed.

Figure 3

Full arm sleeve covering the arm and fingers used for habit breaking

After 1-month follow-up, the gingiva in relation to the upper-left deciduous molars healed [Figure 4]. After 1-year follow-up, the parents reported that the child discontinued the habit of NB and also the forearm sucking frequency was reduced. Dermatological management for hyper-pigmentation on the left forearm scar was done.

Figure 4

One-month follow-up of the gingiva in relation to upper left primary molars healed

DISCUSSION

Management of SIB is still a challenge for the dental profession and for many clinicians it is a diagnostic challenge. SIBs often involve and can potentially compromise the form and function of the oral tissues. In these situations, dental management is required as the team approach to protect the patient's overall health. The dentist's goal in treating SIBs is focused on preventing harm to the soft tissue from the traumatizing dentition while minimizing the risks of compromised oral hygiene and other common oral illness secondary to any appliance therapy.

Stewart and Kernohan[5] have suggested a classification system for self-inflicted gingival injuries.

Type A: injuries are superimposed on a pre-existing condition, such as herpetic lesions or localized gingival infection.

Type B: injuries are secondary to established habits, such as finger sucking or NB.

Type C: injuries have unknown or complex etiologies. These would include injuries due to psychological problems.

The following guidelines might be useful to clinicians who confront patients with unusual self-inflicted gingival lesions: a detailed case history including oral hygiene practices, history of any deleterious oral habits, previous history of similar lesions, and present emotional status of the patient and parents.

Evaluate suspected lesions according to Stewart and Kernohan's features for self-inflicted gingival injuries.

If a diagnosis of self-inflicted injury cannot be established from the initial evaluation, the following may be used:

Lesion fails to regress with palliative therapy. Failure to remove the cause will result in persistence of the lesion.

A biopsy of a self-inflicted lesion reports a non-specific inflammation ‘microscopically’.

In this case, gingival recession was diagnosed as being caused by the patient's SIB. They did not correspond to any known disease. The ulcer was unilateral with a bizarre configuration, and in a position that can be easily reached by the patient's hand. The patient's mother confirmed the child's habit of scratching the gingival tissue.

The success of the treatment depends on above all of the identification of the patient's emotional status.[6]

There is no method to completely inhibit this self-mutilation. Many methods have been tried to palliate and prevent the trauma.

Treatments tried includes three main categories:

pharmacological,

behavior modification,

physical restraints.

Most of the existing literature on pharmacological treatment of SIB has addressed the postulated defects in the dopaminergic, opiate, or serotonine system.[7] But there are disadvantages to pharmacologic treatment as it usually requires chronic use of the drug(s) and these agents often place patients in a chronic stupor.[89]

The technique used for behavior's modification includes:

Continuous positive reinforcement while self-mutilative responses are absent.

Withdrawal of positive reinforcement upon self-mutilation.

At each consultation, the patient should receive instructions regarding the importance of habit interruption for the maintenance of gingival health until total removal of the appliance.[10]

Restraints may be the reliable means of preventing injury to the SIB-affected individual, physical restraints include mittens, arm-boards, facial masks, helmets and restrictive clothing, but requires constant wear if they are to be successful.[11]

CONCLUSION

Although the diagnosis of self-inflicted oral mutilation may be a challenge for the pediatric dentists, this should not prevent the consideration of this possibility when idiopathic lesions are present in a child. Appropriate preventive methods need to be developed for each patient based on reasonable consideration.