Lesch-Nyhan syndrome: successful prevention of lower lip ulceration caused by self-mutilation by use of mouth guard

Oral Self-Mutilation in Lesch–Nyhan Patients: A Cross-Sectional Study

Lesch–Nyhan syndrome (LNS) is a rare genetic condition resulting from an inherited disorder of purine metabolism. It is characterized by the lack of one enzyme, hypoxanthine-guanine phos-phoribosyltransferase (HGPRT), which is responsible for purine salvage. The main manifestations of this syndrome are hyperuricaemia, reduction in cognitive abilities, self-aggressive behavior, choreoathetosis, spasticity, and retarded development. The aim of the study was to investigate the means of treatment and efficacy of prevention of oral self-injury behavior (SIB) in patients with LNS. Information regarding the type and treatment of oral SIB in 19 LSN Italian patients (mean age 23.3 years) was gathered via a structured telephone interview of their parents. A total of 84% of the patients showed some form of self-injury behavior; the first form to manifest itself was finger biting (37%), followed by lip biting (25%), and then tongue biting (18%). Furthermore, 74% of cases featured oral SIB, and tooth extraction was found to be the most frequent form of treatment practiced (71%). This study has revealed the great difficulty parents and carers face in managing forms of oral SIB; dental extraction was the most common choice, despite its invasive nature and far-reaching consequences in regard to the psychosocial status of the patients.

A modified intraoral resin mouthguard to prevent self-mutilations in lesch-nyhan patients

Lesch-Nyhan syndrome, described in 1964 by Lesch and Nyhan, is a X-linked recessive disorder, occurring in 1 : 100000 to 1 : 380000 live births. LNS is characterized by a decrease in activity of hypoxanthine guanine phosphoribosyl transferase, an enzyme involved in purine metabolism, resulting in overproduction of uric acid. Hyperuricemia and neurological features including choreoathetoid spasticity, self-mutilation, and mental retardation clinically characterize this syndrome. In LNS patients the typical feature is loss of tissue from biting themselves with partial or complete amputation of fingers, lips, and tongue. The self-mutilation compares with the eruption of the deciduous teeth. Several drugs trials have been administered to improve self-destructive behavior and invasive treatment approaches, such as extractions of teeth and orthognathic surgery, have been suggested with variable effectiveness. Nowadays prevention is, therefore, the standard of care. The role of dentistry is essential in the management of the self-mutilating behavior, because the teeth represent the main self-injury instrument. This report presents a revision of various therapeutic approaches to manage self-destruction, highlighting the effectiveness of a preventive treatment. It describes a new technique: a resin mouthguard, realized at Gaslini Hospital, to obtain immediate healing of the oral lesions, confirmed in the follow-up period.

Consequences of Delayed Dental Extraction in Lesch-Nyhan Disease

Patients with Lesch-Nyhan disease (LND) often engage in self-injurious biting. This problem requires difficult management choices, sometimes including removal of the teeth. Although many health care professionals are reluctant to remove teeth in a child because of the permanent negative cosmetic consequences of the edentulous state, disfigurement of the face and tongue from self-biting can be worse. We analyzed the records of 5 LND patients who used mouth guards to spare the teeth. Success was variable, and dental extraction ultimately was required in 4 cases. We also reviewed previously published cases on the use of dental devices to spare teeth in LND. Various devices have been recommended, but failure rates are high, and tooth extraction often is still needed. Although dental extraction is not required in all cases, it should not be delayed when biting is severe.

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.

Oral self-injurious behaviors in patients with developmental disabilities

Self-injurious behaviors (SIB) in patients who have developmental disabilities is a complex disorder, and its underlying etiologies are poorly understood. SIB is a significant factor in hospitalizations, decisions to use psychotropic medications, and institutional placement for people who have developmental disabilities. Because this group often manifests oral SIB, the dentist may be the first professional called upon to evaluate a patient. Dental therapy focuses on symptomatic treatment to minimize tissue damage caused by SIB, but addressing the underlying impetus for the behavior is essential for successful treatment. Determining definitive therapeutic interventions is difficult because of the mixed bio behavioral etiologies for SIB. This complication necessitates a team approach that includes medical and behavioral specialists.

Self-inflicted orodental injury in a child with Leigh disease

Leigh disease is an inherited progressive mitochondrial neurodegenerative disease that affects the neurological, respiratory and cardiovascular systems and is associated with retardation of the intellectual and physical development. This report describes the case of a 4-year-old boy with Leigh disease who presented with self-inflicted traumatic injury to the teeth, alveolar bone, lips and tongue during repeated episodes of intense orofacial spasms. Conservative management of the injury included repositioning the fractured alveolar bone, splinting the traumatized teeth and planning for a mouthguard. However, after a second incident of severe self-induced injury to the teeth and alveolar bone, extraction of the anterior teeth became inevitable to protect the child from further self-mutilation and to allow healing of the injured tissues.

Lesch-Nyhan syndrome: a preventive approach to self-mutilation

Lesch-Nyhan syndrome (LNS), a rare inborn error of metabolism, is characterized by self-injurious behaviour, which results in partial or total destruction of oral and perioral tissues and/or fingers and hands. Prevention of self-mutilation raises significant difficulties. Treatment modalities include drug therapy, extraction of teeth, oral appliances and orthognathic surgery, all with variable success. A case of a 10-year-old boy with aggressive behaviour and severe lower lip injuries is presented. A palatal plate fabricated to raise the anterior bite proved to have satisfactory results. Although two adjustments were required during the recall visits, the effectiveness of the appliance in assisting healing of soft tissue damage was immediate and still apparent during the 3 years and 8 month follow-up period.

Teeth grinding, tongue and lip biting in a 24-month-old boy with meningococcal septicaemia. Report of a case

This paper describes the management of a 24-month-old boy who presented with self-inflicted trauma to his lower lip and tongue, and teeth grinding, 21 days after developing meningococcal septicaemia. A decision to observe and prescribe palliative therapy was made. Extraction of the lower right deciduous canine, which had become non-vital, possibly due to bruxism, was carried out.

A review of behavioral treatments used for Lesch-Nyhan syndrome

Lesch-Nyhan syndrome is a genetic disorder resulting in hyperuricemia, choreoathetosis, mental retardation, and self-mutilation. The most salient feature of this disorder is the self-injurious behavior (SIB). Although the utility of behavioral interventions with SIB has been well documented, behavioral interventions with Lesch-Nyhan syndrome have been limited in number and long-term success. This article reviews the behavioral treatments that have been used in treating individuals with Lesch-Nyhan syndrome and discusses the strengths and weaknesses of these methods. Suggestions for future directions in the use of behavioral interventions for controlling SIB in Lesch-Nyhan syndrome are provided.

Oral self-mutilation by a 17-month-old child with Lesch-Nyhan syndrome

We report a 17-month-old boy who was a known case of Lesch-Nyhan syndrome and presented with self-inflicted oral ulcerations of his lips and cheeks. He had a normal complement of caries-free deciduous teeth. Initially a conservative approach was planned and a bite plate made, but as a result of poor compliance and persistent ulceration and after consultation with his parents it was decided to extract all deciduous teeth.