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

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.

Oral parafunction and bruxism in Rett syndrome and associated factors: An observational study

OBJECTIVES

To explore patterns of parafunction, and bruxism, and its relationships with genotype and snoring in individuals with Rett syndrome (RTT).

METHODS

Retrospective observational data of those with confirmed MECP2 mutations in the InterRett database (n = 216) were used to investigate experience of parafunctional habits, and bruxism and their relationships with genotype and snoring using multivariable linear regression.

RESULTS

The prevalence of parafunction was 98.2%. Bruxism was reported (66.2%) with the patterns mostly both diurnal and nocturnal (44.1%) and exclusively diurnal (42.7%). Compared to individuals with C-terminal deletion, individuals with p.Arg106Trp mutations were less likely to have bruxism reported (aOR = 0.15; 95% CI 0.02-0.98, p = 0.05) and those with p.Arg168* mutation were more likely to have frequent bruxism than none or occasional bruxism reported (aROR 3.4; 95% CI 1.1-10.7 p = 0.04). The relative odds of having nocturnal bruxism constantly, compared to none/occasionally, were higher among those 'always' snoring (aROR 6.24; 95% CI 2.1-18.2, p = 0.001) than those with no snoring.

CONCLUSIONS

There appeared to be genotypic association with bruxism in p.Arg168* and p.Arg106Trp mutations and association between nocturnal bruxism and frequent snoring in an international sample of individuals with RTT. Clinical significance of the high prevalence of bruxism should be highlighted in relation to difficulty communicating pain and increased dental treatment need in RTT.

Efficacy of self-designed intraoral appliances in prevention of cheek, lip and tongue bite after local anesthesia administration in pediatric patients

BACKGROUND

The occurrence of self-inflicted soft tissue injuries following administration of local anesthesia in pediatric patients who have received dental treatment has been reported. Aim: To evaluate the attitudes and knowledge regarding cheek, lip, and tongue bite post administration of local anesthesia among dental practitioners in Saudi Arabia. Additionally, the efficacies of three types of intraoral appliances on the prevention of self-harm were evaluated in pediatric patients.

MATERIAL AND METHODS

A total of 301 practitioners were provided with a questionnaire consisting of 9 items. In addition, three types of intraoral appliances made of polyethylene terephthalate were designed as follows: design 1 (consisted of an anterior extension with numerous perforations); design 2 (had a buccal flap extension); and design 3 (comprised of serrated borders). The appliances were placed in the oral cavities of 45 children (age, 3-15 years) immediately after the completion of the dental procedure. The patient was asked to retain the appliance for 3 h. After 24 h, both parents and children were required to respond to a checklist to evaluate the effectiveness the appliances.

RESULTS

Almost half of the dental practitioners had never encountered self-inflicted soft tissue injury in children after local anesthesia administration. About 60% of the dentists were of the opinion that provision of adequate instructions after treatment could prevent the occurrence of lip, cheek, and tongue biting. Furthermore, among the three appliances used, design 1 was most well accepted.

CONCLUSIONS

Intraoral appliances used in this study may be considered for use to prevent self-inflicted soft tissue trauma in children following administration of local anesthesia. Key words:Cheek biting, lip biting, intraoral appliance, local anesthesia.

A Novel Approach for the Management and Prevention of Self-Induced Masticatory Lingual Trauma in the Neurologically Injured Patient

Self-induced masticatory trauma is an unfortunate complication of a variety of neurologic disorders, including epileptic seizures, cerebral palsy, mental retardation, psychiatric disease, and brain trauma, in addition to other described etiologies. While single or occasional occurrences of tongue biting are relatively benign, recurrent self-injury can pose major issues and predispose a patient to chronic, severe complications. To prevent the complications associated with ongoing trauma to the tongue, steps must be taken to protect individuals from chronic self-injurious behavior. Often, these interventions cause significant morbidity to the patient, such as elective removal of the dentition or complications in gaining access to the oral cavity/airway associated with maxillomandibular fixation. In the neurologically impaired patient, immobilization of the jaws is frequently associated with higher rates of agitation, aspiration, or development of complicating infections of the gingival tissues. We report a case of self-induced masticatory trauma managed with the fabrication of a custom-fabricated oral appliance. This treatment modality successfully prevents the recurrence or incidence of self-induced masticatory trauma to the tongue. The benefits of this modality are that it allows access to the oral cavity, prevents immobilization of the jaws, has minimal to no morbidity, and is completely reversible.

The Diagnosis and Treatment of Multiple Factitious Oral Ulcers in a 6-Year-Old Boy

Factitious ulcers are characterized by self-inflicted lesions with multifactorial origin. These lesions are frequently found in head, neck, and hands. This report shows a 6-year-old boy diagnosed with factitious oral ulcers that occurred after the self-biting of buccal vestibule and nail-scratching of gingival tissue. Clinically, a significant swelling was observed, hard on palpation, located at the right lower third of the face, next to the posterior area of the mandible. In the intraoral examination, ulcers at different healing stages were noted on the swelling area. During the anamnesis, the father reported a change in his familial structure that triggers psychological stress, providing the clues to the presumptive diagnosis of factitious oral ulcers. We prescribed the topical use of Gingilone® three times a day to control the local pain and inflammation. At 7-day follow-up, we noticed the reduction of extraoral swelling and the initial healing of the ulcers. The presumptive diagnosis was confirmed at 30-day follow-up, with the lasting remission of oral lesions. The treatments of factitious oral ulcers should be individually tailored for each patient, focused on a multidisciplinary approach, including psychotherapy and periodic clinical control. To the best of our knowledge, gaps of evidence lead to the lack of standardized clinical protocols on this issue.

Overcoming the oral aspects of -self-mutilation: description of a method

BACKGROUND/AIM

Self-injurious behavior (SIB) is a serious and chronic condition frequently seen in special needs populations, affecting 10% to 17% of individuals diagnosed with intellectual and/or developmental disabilities. A 2.5-year-old infant with SIB, whose presenting symptoms were severe tongue and lip lacerations accompanied by much hemorrhage, is presented here to illustrate the problem and to show how this may be prevented.

MATERIALS AND METHODS

An appliance is described which effectively limits the damage caused by SIB and permits rapid healing of existing injuries.

RESULTS

The method provides for a stable, retentive, and comfortable device on the infant's undererupted and largely nonretentive crowns of the deciduous teeth as well as for all permanent teeth in children, adolescents, and adults.

CONCLUSIONS

The appliance has been successfully employed for the past 10 years in patients with SIB who have attended for treatment in the Special Needs Clinic in our Department.

Successful treatment of self-inflicted tongue trauma patient using a special oral appliance

A 7-year-old male presented with a painful ulcerative lesion on the right lateral tongue and left lower buccal mucosa due to self-inflicted trauma. Antibiotic medication and use of a mouthwash agent were not effective. We made a special oral appliance to cover the maxillary arch and teeth to protect the tongue. The patient showed immediate improvement and did not suffer from any complications. Invasive procedures such as biopsy were not needed. We believe that accurate clinical diagnosis is important and treatment with an oral appliance is effective in self-inflicted oral trauma in children.

Role of a dentist in comprehensive management of a comatose patient with post traumatic head injury and neuropathological chewing

Injury of the head and neck region can result in substantial morbidity. Comprehensive management of such patients requires team work of several specialties, including dentists. A young female patient with extensive loss of cranium and associated pathological chewing was referred to the dental department. The lost cranium was replaced by a custom-made, hand-fabricated cranioplast. Trauma due to pathological mastication was reduced by usage of a custom-made mouthguard. Favorable results were seen in the appearance of the patient and after insertion of the mouthguard as evidenced in good healing response. The intricate role of a dental specialist in the team to manage a patient with post traumatic head injury has been highlighted. The take away message is to make the surgical fraternity aware of the scope of dentistry in the comprehensive management of patients requiring special care.

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.

Facial self-mutilation: an analysis of published cases

OBJECTIVES

Facial self-mutilation is rare. It is usually discussed from the psychiatric or psychoanalytic perspectives but has little prominence in general medical literature. Our objective was to describe facial self-mutilation in terms of its comorbidities, and to outline the different types of facial mutilation, as well as the basic approach to the patients with facial self-mutilation.

METHODS

We undertook a review of all published cases of facial self-mutilation (1960-2011).

RESULTS

We identified 200 published cases in 123 relevant papers. Four major groups of comorbidities emerged: psychiatric, neurological and hereditary disorders, and a group of patients without identified comorbidities. There were three general patterns of facial self-mutilation: (1) major and definitive mutilation, with the ocular globe as primary target--seen in patients with psychotic disorders; (2) stereotypical mutilation involving the oral cavity and of variable degree of severity, most often seen in patients with hereditary neuropathy or encephalopathy; (3) mild chronic self-mutilation, seen in patients with non-psychotic psychiatric disorders, acquired neurological disorders, and patients without comorbidities. About 20% of patients that mutilated their face also mutilated extra-facial structures. Patients with psychiatric conditions, especially those with psychotic disorders, had significantly higher (p<0.05) rates of permanent facial self-mutilation than others. Most treatment plans were very individually based, but some principles, such as prevention of irreversible loss of function and structure, or development of infection are applicable to all patients with facial self-mutilation.

CONCLUSIONS

Facial self-mutilation is a potentially severe manifestation of diverse conditions. Several aspects of facial self-mutilation remain to be fully characterised from a clinical perspective.

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.