CHEEK BITING es =—00ts Prevention of Habitual Cheek Biting: ABSTRACT __ ral and peri-oral structures can be traumatized by sol-njurious behavior (GIB). Various articles have described prostheses used to prevent SIB-related Injuries to the oral tiseues of pationts who have developmental or medical problems, such as psychological prob- lems, congenital syndromes or mental retardation: however, reports of oral SIB in individuals unaffected by the above Conditions are scarce. This case report describes the use of a removable pros- thesis to prevent a stress-induced cheek biting habit in 15-year-old girl who did ‘not have any of the commonly related conditions. The report importance of desi that protects tissues, while considering injury severity and the patients health 15 well as her ability to cooperate with treatment. Coe Cent behavior, SIB, cheek bitin 214 Spec Care Dentist 25(4) 2005 A Case Report Martin Romero, MD, DDS, PhD"; Ascensién Vicente, DDS, PhD”; Luis A. Bravo, MD, DDS, MS, PhD* Inuegral Pediatric Dentistry, Dental Clini, University of Murcia, Spin; “Orthadontcs, Dental Clinic University of Mula, Span; Orthodontics. Dental Clinic, University of Murcia, Spain, “Corresponding author: email: ascenvi@umnes, ‘Spec Care Dentist 25(4): 214-216, 2008 Introduction 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 oF self mutilation of ocular, genital or oral tissues. Frequently, IB affecting the oral and peri-oral structures involves biting the lip, check, 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 itis estimated that such problems could alfect about 750 out of every one million Individuals.’ Prevalence is higher among. females. ‘The origin of SIB is complex, and theories exist of both biological and Figure 1. Wound on the ight buccal mucosa ‘caused by SB. 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 al. list biological causes such as Lesch-Nyhan Syndrome, Cornelia de Lange Syndrome, Tourette Syndrome and XYY Syndrom conditions including mental retardation, encephalitis, congenital malformations, coma and epilepsy. Autism also is associated with SIB? The typical cause of such behav- ors in children is Lesch-Nyhan Syndrome followed by as well as other mental deficiency and infec- tious diseases such as encephalitis, Figure 2, Removable oral prosthesis designed to prevent ora slhinury using buceal shields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 authors" propose that patie wavior 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- ological treatment is impirical, and further research is needed in this area’ Some authors?” 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."® 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 restrietself- injurious biting and protect the tissues." Although the prosthesis will not treat the tase stich b Figure 3, Frontal view ofthe prosthesis on study model. Romero et al. source of the problem, itis 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 teeth.’ Case Report ‘A 15-year-old gil sought treatment for hypertrophic injuries ofthe right and left buccal mucosa caused by a cheek biting habit. She admited that she had a nervous babit of biting her ehecks when studying for examinations, The fe- quency and severity ofthe biting was proportional to the level of stress she ‘experienced. She stated that she sought treatment because of increased stess associated with upcoming examinations, and that she had developed buccal ulcer- tions from previous biting episodes There were no significant findings in her medical history. An oral examination ‘showed trauma induced by her check biting habit Figure 1 on the previous page). The ivtaton ofthe tissues had resulted in hypertrophy ofthe buccal mucosa with a characteristic difse white, flaky appearance ‘A removable prosthesis was pre- scribed. The patient was instructed to wear the prosthesis, which protected the buccal mucosa using wo lateral acrylic shields joined by a round stainless steel wire Giameter; 0.7 mm), when studying Figure 4. Lateral view ofthe prosthesis on study models, CHEEK BITING (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 sell-injury have been proposed, including lip-shields ocelusal bite planes, protectors, lip bumper: appliance modified with lateral acrylic ds occlusal splins? splins with blocks to produce an anterior open © splints using headgear to retain and stabi severe SIB,' and a prosthesis attached to bubble helmets for children who self= injure the head.” a Hawley the splint for patients with Few reports” 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." When prescribing a prosthesis such as the one described in this case report, iis necessary to choose a design that is appropriate for the patient’ 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 piotured two months following prescription of fhe prosthesis, ‘Spec Care Dentist 25(4) 2005 218CHEEK BITING According to Hanson etal,” 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; avoid posing further injury to the patient; permit a full range of mandibular motion; allow for daily oral care withstand breakage and displacement overtime; allow healing of traumatized oral tissues; and be easily fabricated and installed with- ‘out discomfort or risk to the patient Conclusion 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, Oe patient was aware of her SIB problem and wanted treatment. For these reasons, wwe opted for a removable prosthesis 216 Spec Care Dentist 25(4) 2005 References 1. 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