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Prevention of Habitual Cheek Biting: A Case RePort Martin Romero, MD, DDS, PhD'; Ascension Vicente, DDS, PhD'*; Luis A. Bravo, MD, DDS, MS, PhD3 'Integral Pediatric Dentistry, Dental Clinic, University of Murcia, Spain; 'Orthodontics, Dental Clinic, University of Murcia, Spain; 'Orthodontics. Dental Clinic, University of Murcia, Spain; "Corresponding author: e-mail: ascenvi@um.es.

Spec Care Dentist 25(4): 214-216, 2005

I n t r o d u c t i o n Self-injurious behavior (SIB) can be defined as the destruction or damage of body

tissue without suicidal intent. Typically, SIB occurs as head hitting or banging, body hitting, skin cutting, finger biting or self mutilation of ocular, genital or oral tissues.' Frequently, SIB affecting the oral and peri-oral structures involves biting the lip,' cheek,' or lateral surfaces of the tongue alone or with the buccal mucosa.'Depending on its frequency and severity, SIB can lead to various degrees of self-injury.

Self-injurious behaviors may occur as isolated incidents but are more often recurring.? Individuals both with and without psychological, mental or congen- ital conditions may have SIBS, although the behaviors are more common in the latter groups,' with serious injuries usu- ally occurring in individuals who have psychiatric problems.?

The prevalence of SIB in the general population has not been established, but it is estimated that such problems could affect about 750 out of every one million individuals.+ Prevalence is higher among females5

The origin of SIB is complex, and theories exist of both biological and

Figure 1. Wound on the right buccal mucosa caused by SIB.

functional origins. Biological theories maintain that SIB is the expression of an underlying genetic defect that may pro- duce neurotransmitter irregularities. Such behavior has been associated with severe syndromes and congenital problems.

Medina et aL5 list biological causes such as Lesch-Nyhan Syndrome, Cornelia de Lange Syndrome, Tourette Syndrome and X W Syndrome, as well as other conditions including mental retardation, encephalitis, congenital malformations, coma and epilepsy. Autism also is associated with SIB.b The typical cause of such behav- iors in children is Lesch-Nyhan Syndrome, followed by mental deficiency and infec- tious diseases such as encephalitis.'

Figure 2. Removable oral prosthesis designed to prevent oral self-injury using buccal shields.

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Functional theories maintain that SIB originates from psychological concerns, with self-mutilation resulting from mental and emotional conflicts such as hatred, jealousy, frustration and feelings of inferiority. Some propose that patients use such behavior as a means of mental or emotional escape or to get attention, and that SIB may become more frequent at times of stress.

According to Medina et al.,’ among the many proposed treatment modalities for SIB, the most common include med- ications, behavior modification or physical restraints. Prescribed medications include neutrotransmitter regulators and psy- chotropic drugs; however, most pharma- cological treatment is impirical, and further research is needed in this area.’ Some authors’,7 have discussed “alternative” therapies involving relaxation, behavior modification techniques, hypnosis or psy- chiatric treatment. Behavior modification techniques may be helpful for some patients with SIB, but these approaches are labor-intensive.’.R When used, physical restraints must provide the most effective protection with minimal restraint. Usually, no single treatment method guarantees the eradication of SIB.‘

When SIB affects the oral cavity or peri-oral structures, or when the teeth are used to inflict damage on other body parts, a dentist may be consulted. In such cases, a prosthesis can restrict self- injurious biting and protect the tissues.’ Although the prosthcsis will not treat the

Figure 3. Frontal view of the prosthesis on study models.

source of the problem, it is an effective means of controlling self-mutilation.’ Other treatment options to prevent severe SIB caused by the mouth include creation of an open bite using orthog- nathic surgery or, as the last resort, extraction of the tee1h.l

C a s e R e p o r t A 15-year-old girl sought treatment

for hypertrophic injuries of the right and left buccal mucosa caused by a cheek biting habit. She admitted that she had a nervous habit of biting her cheeks when studying for examinations. The fre- quency and severity of the biting was proportional to the level of stress she experienced. She stated that she sought treatment because of increased stress associated with upcoming examinations, and that she had developed buccal ulcer- ations from previous biting episodes.

There were no significant findings in her medical history. An oral examination showed trauma induced by her cheek biting habit (Figure 1 on the previous page). The irritation of the tissues had resulted in hypertrophy of the buccal mucosa with a characteristic diffuse white, flaky appearance.

A removable prosthesis was pre- scribed. The patient was instructed to wear the prosthesis, which protected the buccal mucosa using two lateral acrylic shields joined by a round stainless steel wire (diameter: 0.7 mm), when studying

Figure 4. Lateral view of the prosthesis on study models.

(Figures 2-4). After two months of using the prosthesis as prescribed, the patient was re-examined, and the buccal mucosa had regained normal color and texture (Figure 5 ) .

Discussion Various prostheses to prevent oral

self-injury have been proposed, including lip-shields,y occlusal bite planes,’O tongue protectors,” I 2 lip bumpers,’.” I’ a Hawley appliance modified with lateral acrylic ~ h i e l d s , ~ occlusal splints,’ splints with bite blocks to produce an anterior open bite,I5 splints using headgear to retain and stabilize the splint for patients with severe SIB,’ and a prosthesis attached to bubble helmets for children who self- injure the head.lh

Few reportsL7 document injuries caused by biting in patients who do not have psychological, mental or congenital disorders. Most studies that describe the use of oral prostheses to prevent injury involve patients with SIB associated with other conditions.’,’-h,H-’7

When prescribing a prosthesis such as the one described in this case report, it is necessary to choose a design that is appropriate for the patient’s age, general health, ability to cooperate with the treatment plan and the severity of the oral injuries.

Figure 5. Healed wound shown in Figure 1 , pictured two months following prescription of the prosthesis.

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According to Hanson et aI.,l7 a pros- thesis to prevent oral self-injury should be designed to:

deflect tissues likely to be damaged by involuntary mandibular movements away from the occlusal table;

patient;

motion;

avoid posing further injury to the

permit a full range of mandibular

allow for daily oral care; withstand breakage and displacement over time; allow healing of traumatized oral tissues; and be easily fabricated and installed with- out discomfort or risk to the patient.

C o n c l u s i o n The prosthesis described in this case

report fulfilled all these criteria, was esthetically acceptable and, by not covering the palate, did not interfere with speech. Our patient was aware of her SIB problem and wanted treatment. For these reasons, we opted for a removable prosthesis.

R e f e r e n c e s 1

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