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Self-inflicted traumatic injuries of the gingiva-A case series

Article · January 2010

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J. Int Oral Health 2010 Case Report
All right reserved

Self-inflicted traumatic E-
P- ISSN
injuries of the gingiva- A 0976 – 7428
0976 – 1799
case series E- ISSN
0976 – 1799
Rajiv Subbaiah M.D.S. D.N.B* Biju Thomas M.D.S** Publication of
Maithreyi V P ***
*Senior Lecturer, Department of Periodontics, Rajarajeswari Dental
College and Hospital, Bangalore, Karnataka, India. **Professor & Head,
Journal
“West Indianof
Association of Public
Department Of Periodontics, A.B.Shetty, Memorial Institute Of Dental
International
Sciences, Mangalore, Karnataka, India. ***Postgraduate student,
Department of Periodontics, M.S.Ramaiah Dental College and Hospital,
health dentistry”
Bangalore, Karnataka, India. Email: subbaiah_rajiv@rediffmail.com Oral Health
(WIAPHD)
Abstract:
In the report on non-plaque induced gingival disease
(1999 World Workshop in Periodontics), traumatic injuries of Periodontics
the gingiva have been classified as due to thermal causes,
chemical causes and physical causes. Minor burns particularly
Journal of
Case Report
from hot beverages are seen occasionally. Traumatic lesions
induced by chemicals are usually caused by local application International
of certain chemicals. Physical injuries to gingival tissues can
be due to accidental, iatrogenic and factitious occurrences. A
special type of mechanical trauma to the gingival tissues is Oral
Received:Health
Apr, 2010
known as self-inflicted lesions, also termed as gingivitis Accepted: July, 2010
artefacta.Self-inflicted oral injuries can be premeditated,
accidental or can result from an uncommon habit. Patients can
inflict a variety of injuries upon their gingiva. These gingival Case Report
injuries can sometimes test the clinicians‘ diagnostic abilities.
Some of these in their minor form have been discussed in this
case series.These lesions do not correspond to any other
disease or anomaly, show distinct outline, usually single, and Bibliographic listing:
easily reached by the hand. The cause has been easily EBSCO Publishing
identified by clinical appearance corroborated with a good
history. In majority of the cases in this series, a locus of Database, Index
irritation or cause of irritation has been identified. The Copernicus, Genamics
elimination of these causes will result in the resolution of the
lesion. In others, where a habit has been identified, a Journalseek Database
conscious effort is required by the patient to quit the habit.

Key Words: non-plaque induced gingival disease, traumatic

injuries, gingivitis artefacta, self-inflicted gingival injuries,
factitious injury, self-mutilating injuries and injuries due to
masochistic habits.

JIOH, August 2010, Volume 2 (Issue 2) Page 43


Introduction
In the report on non-plaque induced
gingival disease1 (1999 World Workshop in
Periodontics), traumatic injuries of the gingiva
have been classified as due to thermal causes,
chemical causes and physical causes. While
extensive thermal burns of the oral mucosa are very
rare, minor burns particularly from hot beverages
are seen occasionally. Traumatic lesions induced
by chemicals are usually caused by local
application of certain chemicals such as aspirin,
cocaine, pyrophosphates, detergents (e.g., sodium
lauryl sulfate), smokeless tobacco, betel nut, and
bleaching agents. Physical injuries to gingival
tissues can occur due to accidental, iatrogenic and
factitious occurrences. A special type of
mechanical trauma to the gingival tissues is known
as self-inflicted lesions, also termed as gingivitis
artefacta.
Self-injurious behavior (SIB) may be
defined as that which results in the infliction of
physical damage and, perhaps, pain upon oneself.2
These self-inflicted injuries are sometimes referred
to as factitious injury, self-mutilating injuries and
injuries due to masochistic habits. Gingivitis
artefacta is deliberate self-injury of the gingiva, in
which the wounds are inflicted usually by patient‘s
fingernail. This disorder is seen mostly in younger
age groups. It occurs in both a major and a minor
form. 3 Gingivitis artefacta in its more common,
less severe form, is usually a localized lesion
termed "gingivitis artefacta minor," and is usually
due to some superimposed lesion or overzealous
tooth brushing habits. Extensive lesions, also called
"gingivitis artefacta major," are generally the result
of compulsive behavior.4 Women rather than men,
and children are most likely to exhibit this
condition. The history is characteristically vague,
and the lesions may persist longer and recur more
frequently than a clinician would expect. These
cases are found mostly among children with
JIOH, August 2010, Volume 2 (Issue 2)
44
emotional disturbances, and deserve careful
diagnosis and adequate treatment.5
Stewart and Kernohan4 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 nail biting. Type C injuries have
unknown or complex etiologies, which would
include injuries due to psychological problems.
Self-inflicted oral injuries can be
premeditated, accidental or can result from an
uncommon habit.6 Patients can inflict a variety of
gingival injuries upon themselves. These gingival
injuries can sometimes test the clinicians‘
diagnostic abilities. Some of these in their minor
form have been discussed in this case series.
Case 1: Finger nail trauma
A patient reported with burning sensation in
relation to the gums between his lower left back
teeth. The irritation increased after consumption of
food and was relieved after removal of the deposits
lying between his teeth. On examination,
inflammation and clefting was seen isolated to a
single interdental papilla between 45 and 46. The
interdental papilla had collapsed (Figure 1a).
Persistent enquiry revealed that he was using the
nail of his thumb to dislodge impacted food
between the teeth (Figure 1b). The patient was
asked to refrain from the habit and trim his
fingernail. The occlusion was checked and the
plunger cusp was reduced. Oral hygiene
instructions were given. He was also asked to
refrain from the overzealous brushing which was
causing the tooth loss. A local anesthetic gel was
prescribed. After a week the lesion disappeared
(Figure 1c).
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Fig 1a: The ulcerative Fig 1 b: The sharp nail Fig 1 c: 2 weeks
lesion with collapsed on the thumb being the later.
interdental papilla causative factor.
between 45 & 46.

Fig 2: Acid etched teeth and Fig3: Chemical trauma resulting in inflammation in relation
marginal soft tissue marginal gingiva of 37 and interdental papilla between 36-37 and
inflammation. 37-38. The rest of the adjacent gingival tissues appear unaffected.

Fig 4b: Two weeks later, a healed

Fig 4a: Laceration in relation to the
lesion.
attached gingiva of 33 & 34.

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 46

Fig 5: Soft tissue abrasion in relation

to the mesial aspect of 16 with
adjoining areas of keratosis and intact
interdental papillae

Fig 6a: Buccal

Fig 6b: Palatal
surface showing
surface between
bleeding in
premolars
relation to the
reveals absence
interdental
papilla between of any bleeding
14 & 15

Fig 6c:
Fig 6d: Broken
Radiograph
fragment of the
showing a
needle
radiopaque
foreign object
between
premolars

JIOH, August 2010, Volume 2 (Issue 2) www.ispcd.org


Case 2: Acid burn
Male patient aged 16 years had reported
with burning sensation in his entire oral cavity.
He gave a history of use of a mild acid
(unknown) to bleach his teeth.
On examination, the teeth had severe
intrinsic stains due to fluorosis and were smooth
in texture. The oral cavity appeared slightly
inflamed, especially in relation to 11 and 12
(Figure 2).
The patient was prescribed a local
anesthetic mouthrinse (Redirinse, Elder
Pharmaceuticals India- a diclofenac based oral
rinse) for palliative effects. Topical paste was
then prescribed [Tooth Mousse (CPP-ACP),
Casein Phosphopeptide Amorphous Calcium
Phosphate, GC India ] to re-calcify his teeth, and
the patient was educated regarding methods of
teeth whitening.
Case 3: Chemical burn
Male patient aged 45 years reported to the
clinic with burning sensation in relation to the
lower left back tooth region near his gums since 1
week. He also complained of severe pain in
relation to the last lower molar on the left side
since one month, the severity of which increased
since the last 2 weeks. The pain was throbbing in
nature, spontaneous and increased while lying
down. He did not give a history of any
medication for relief of the pain. However, there
was a pungent odor during examination
procedure. On persistent questioning the patient
revealed application of a pain balm (Iodex,
SmithKline Beecham Pharmaceuticals India, an
Ayurvedic balm containing wintergreen)
externally on the skin overlying the tooth, as well
as intra-orally onto his gums where it ached. He
repeated the applications when in pain.
On examination, deep caries was found in
relation to 38. There was inflammation in relation
marginal gingiva of 37 and interdental papilla
between 36-37 and 37-38. The inflamed gingiva
was red in color, edematous and there was severe
bleeding on probing. The rest of the gingival
tissues in relation to the adjacent teeth appeared
unaffected (Figure 3). The localized inflammation
JIOH, August 2010, Volume 2 (Issue 2)
47
was thought to be due to local application of the
pain balm.
The patient was educated regarding the ill
effects of local application of the balm. He was
also explained that the 38 needed to be extracted
and the rest of his dentition affected by caries
needed to be restored.
Case 4: Toothbrush irritation
Male patient aged 30 years appeared in
the clinic for oral prophylaxis. A laceration was
noticed on the attached gingiva extending from
the mesial surface of the canine to the distal
surface of the first premolar in the third quadrant
(Figure 4a).
The general oral hygiene was excellent.
He wanted to get rid of the yellowish
discoloration in the cervical areas of his teeth. In
an effort to do so, he overzealously brushed his
teeth thrice a day. The patient recalled
accidentally traumatizing his gingiva with his
toothbrush a month back. At that point of time he
felt a bit of bleeding, with burning sensation on
consumption of food (especially spicy and hot).
This lasted a couple of days after which he was
free of discomfort. He continued brushing with
the same vigor, which probably resulted in the
repeated traumatization and non-healing of the
ulceration.
The condition was diagnosed to be
toothbrush irritation causing inflammation of
protruding areas on the gingiva away from the
margin. Since he was free of discomfort, no
palliative measures were instituted. He was
educated on his oral hygiene needs and the
correct brushing technique. Two weeks later the
lesion was found to have healed (Figure 4b).
Case 5: Toothbrush abrasion
A 50 year old male patient reported to the
clinic with bad odor from his mouth since one
month. Patient had undergone oral prophylaxis
along with a restoration of his upper left back
tooth one year back. He revealed using excessive
force while brushing his teeth several times a day
in an effort to get rid of the foul odor.
Hard tissue examination shows cervical
abrasions on all the teeth in the third quadrant, the
most affected tooth being the first molar. Soft
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tissue examination shows gingival recession on
the mesial aspect of the first molar, with
inadequate width of attached gingiva. The region
around the recession shows areas of hyper-
keratinization appearing as white striations. The
adjoining interdental papillae were intact (Figure
5).
He was educated on the correct brushing
technique. Oral prophylaxis was performed and
patient placed on antiseptic mouthrinse (0.2%
chlorhexidine). The treatment plan also included
increasing the width of attached gingiva with root
coverage after an improvement in brushing
technique was seen.
Case 6: Foreign body used for oral hygiene,
wedged into gingiva
38 year old female patient reported to the
clinic complaining of bleeding and pain between
her upper right back teeth. She had chronic food
impaction between all her teeth for many years.
For the last few days she had been using a
metallic sewing needle to remove the chewing
tobacco wedged between her teeth. One day
previously, she accidentally fractured the needle
while dislodging the food debris between her
teeth. She was unable to locate the broken
fragment and had pain in relation to the entire
region.
On examination, bleeding was noted in
the interdental tissues between 14 and 15 bucally
(Figure 6a), but not palatally (Figure 6b). Peri-
apical radiograph showed that the broken
fragment of the needle was wedged between her
premolars (Figure 6c). The fragment was then
removed under local anesthesia (Figure 6d). The
patient was then educated and motivated on oral
hygiene measures. She was prescribed analgesics
to reduce the pain.
Discussion
Historically, majority of the cases have
been reported in children and females.7 The cases
in this series indicate a male predominance. The
reason could be due to lesser reporting of females
with these problems to the clinic. Majority of the
reports have indicated that the gingival injuries
were produced by the patient repeatedly ―picking
at‖ or ―scratching‖ their gingiva with a finger or
JIOH, August 2010, Volume 2 (Issue 2)
48
fingernail. A variety of other agents have
reportedly been employed, including knives,6,8
baby pacifiers,4,9 strands of hair,10 a stick of sugar
cane11 and toothpicks8,12.
Stewart and Kerohan have listed several
features which are also common to self-inflicted
gingival injuries:4
1. They do not correspond to those of any
known disease.
2. They are mostly of a bizarre configuration
with sharp outlines on an otherwise
normal background.
3. The grouping and distribution of the
lesions are unusual and in positions that
can easily be reached by the patient‘s
hand.
4. They may occur singly, but more often
they are multiple.
Many of the presented cases in this series
follow most of the above features. These lesions
do not correspond to any other disease or
anomaly, other than as stated in the patients
history. They also show distinct outlines, are
single, and easily reached by the hand (except for
the chemical burn). The case of the acid burn
however, does not conform to the second and
third characteristics.
The cause can be easily identified by
clinical appearance corroborated with a good
history. Majority of the cases in this series, fall
into Type A or B of Stewart and Kerohan‘s
classification, indicating a lack of psychological
component. Similarly, a locus of irritation or
cause of irritation (Type A, Stewart and
Kerohan‘s classification4) has been identified.
The elimination of these causes will result in the
resolution of the lesion. In others, a habit has
been identified (Type B, Stewart and Kerohan‘s
classification4), where conscious effort is required
by the patient to quit the habit. Many of the
patients did not return to the clinic for follow-up
and re-evaluation. This could have been due to
the relief from pain (which was their only
concern), their inability to quit the habit or
inability to keep up with the appointment
schedules.
The following guidelines might be useful
to clinicians confronted with patients with
unusual gingival lesions which may be self-
inflicted:
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 Record a good case history including oral
hygiene practices, history of any deleterious
oral habits, previous history of similar lesions
and present emotional status of the patient.
Oral hygiene practices should include
technique, material, duration and intensity.
Type, duration, frequency and intensity of the
deleterious oral habit should be noted. When
there is a suspected psychological component,
a specialist psychological referral is
recommended as the dentist may not be in a
position to judge the emotional status of the
patient.
 Evaluate suspected lesions according to
Stewart and Kerohan‘s four characteristic
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 will fail to regress with palliative
therapy. Failure to remove the cause will
result in persistence of the lesion.
 A biopsy of a self-inflicted lesion will
report a ‗non-specific inflammation‘
microscopically.
References
1 - Non-Plaque-Induced Gingival Lesions. Palle
Holmstrup. Ann Periodontol 1999; 4: 20-29.
2 – Spencer RJ, Haria S, Evans RD. Gingivitis
Artefacta—A Case Report of a Patient
JIOH, August 2010, Volume 2 (Issue 2)
49
Undergoing Orthodontic Treatment. British
Journal of Orthodontics 1999; 26:93–96.
3- Stewart DJ. Minor self-inflicted injuries to the
gingivae: gingivitis artefacta minor. J Clin
Periodontol 1976;3:128-32.
4- Stewart DJ, Kernohan DC. Self-inflicted
gingival injuries: gingivitis artefacta, factitial
gingivitis. Dent Pract Dent Rec 1972; 22:418-26.
5- Hoffman HA, Baer PN. Gingival mutilation in
children. Psychiatry 1968; 31:380-86.
6- Blanton PL, Hurt WC and Largent MD. Oral
factitious injuries. J Periodontol 1977; 48:33.
7- Pattison, G. L. (1983). Self-inflicted gingival
injuries: literature review and case report. Journal
of Periodontology, 1983; 54:299–304.
8- Golden S, and Chosack A. Oral manifestations
of a psychological problem. J Periodontol 1964;
35:349.
9- Stewart DJ. Traumatic gingival recession in
infants. The result of a dummy sucking habit. Br
Dent J 1973; 135:157.
10- Groves BJ. Self-inflicted periodontal injury.
Br Dent J 1979; 147:244.
11- Mendel RW. Self-inflicted injury to teeth and
supporting structures associated with an
occupational habit. J Ky Dent Assoc 1976; 28:15.
12- Bakdash MB. Anomalous destruction caused
by the use of toothpicks. Oral Surg 1978; 46:167.
Source of Support: Nil
Conflict of Interest: Not Declared
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