Received: 15 May 2023 Revised: 2 June 2023 Accepted: 21 June 2023

DOI: e-ISSN: https://jim.usk.ac.id/JCDDR

Journal of Community Dentistry & Dental Research

Case Report and Review

Anxiety Induce Morsicatio Oris in Young Patient: A Case

Report and Review
Yuli Fatzia Ossa 1* and Muhammad Rizki Maulana Fatah 2

1 Department of Oral Medicine, Dentistry Faculty of Universitas Syiah Kuala, Darussalam, Banda Aceh, Indonesia, 23111
2 Dental Student, Dentistry Faculty of Universitas Syiah Kuala, Darussalam, Banda Aceh, Indonesia, 23111;
e-mail: rizkyfatah461@gmail.com

* Correspondence: yulifatziaossa@usk.ac.id

Abstract: Mursicatio oris is a white lesion found in the oral cavity due to chronic frictional and can be associated with the
parafunctional habit. A twenty-two-year-old female patient with chief complaints of buccal mucosa feeling rough, and
this condition appeared a few years ago. She has parafunctional habits, such as nibbling her cheek when feeling anxious.
We assess the level of anxiety with the Hamilton Anxiety Rating Scale, and the total score she gets is 24. We diagnosed this
condition as morsicatio oris. Anxiety induces parafunctional habits such as nibbling, chewing, or biting lips or check,
Morsicatio is caused by self-induced injury and chronic tissue irritation like biting buccal mucosal, chronic nibbling, chew-
ing, or sucking and is more common in the second and third decades, and in those having severe stress or mental illness.
Anxiety can induce morsicatio oris. Dentists should be aware of the oral cavity condition. If we find morsicatio we can
suggest the patient assess their anxiety level.

Keywords: Anxiety; Mental Health; Mursicatio Buccarum; Cheek Biting; Oral Lesion

1. Introduction
Morsicatio buccarum, or cheek biting, is a white lesion found on the buccal mucosa, often caused by
habitual cheek biting. These lesions usually appear in patients with the parafunctional habit of biting lips,
cheeks, or tongue. The prevalence of this case occurs between the ages of 15-19 years (1.77%) and 20-24 years
(1.20%), with a predilection more often in females than males (57% and 43%), respectively [1]. Morsicatio
comes from the Latin ‘Morsus’, which means to bite, morsicatio buccarum refers to biting the buccal mucosa,
morsicatio labiorum bites the labial mucosa or lips, and morsicatio linguarum means biting both sides of the
lateral edges of the tongue. Morsicatio oris refers to morsicatio found in the tongue's buccal, labial, or lateral
edges [2-3]. The location of the lesion is usually bilateral, although occasionally, it may be confined to one
location depending on the patient’s habits. The clinical appearance of plaque and papule white lesions is
poorly demarcated, uneven, shaggy, and peeling [4]. Morsicatio has a relationship with self-inflicted injury
due to habits related to mental disorders such as anxiety or stress. Patients who tend to be excessively anxious
can bite their lips and cheeks unconsciously when they sleep, beside that Fatma et al also suggest morsicatio
buccarum is related to depression in their study [5-6].
This article reports a case of morsicatio triggered by excessive anxiety in a young adult patient and a
review of the case.

2. Case Report
A 22-year-old female patient went to dental hospital, Faculty of Dentistry, Universitas Syiah Kuala with
complaints of persistence white spots on buccal mucosa and felt no pain and had never been treated. The
patient denied that spotting appeared from birth, denied any history of systemic disease, denied history of

J. com. Dent. & Dental Res 2023.1(1) Ossa, et al. Page 05

taking routine drugs. History of the same lesion condition in the family was denied. During the anamnesis,
the patient admitted that she often bit her cheek and lips and this condition had occurred since junior high
school. Intraoral examination, the lower labial mucosa showed a white area and twitching visible white plaque
lesions on the right and left buccal mucosa were irregular, the spots could not be wiped, the surface of the
lesion was rough, and asymptomatic, white lesions were also seen on the lateral edges of the right and left
tongue (figure 1). Then we conducted a test to assess the level of anxiety experienced by the patient using the
Hamilton Rating Scale for Anxiety (HARS) questionnaire which consisted of 14 questions items posed to the
patient. Each question asked has a score of 0-4. Score 0: none, 1: mild, 2 moderates, 3: severe, 4: very severe.
The total scores are then combined to get the total score. If the total core is less than 14: no anxiety, 21-27:
moderate anxiety, 28-41: severe anxiety, and 42-56: very severe anxiety. From the result of the questionnaire
given to the patient, the total score obtained was 24, and according to HARS, this patient was indicated to be
experiencing moderate anxiety. We educated the patient to reduce her parafunctional habit, then we suggest
the patient reduce anxiety by doing something she likes and being more relaxed. If this anxiety persists and
gets worse, we advised her to consult a psychologist or psychiatrist.

3. Discussion
Anxiety is subjective experience that everyone can feel when facing a situation or hearing the news that
causes fear or worry. Anxiety can be normal if it is still under control and disappears after the triggering factors
for the emergence of anxiety are resolved, however, if feelings of anxiety tend to persist and even get worse
and interface with daily activities, this condition can be said to be an anxiety disorder and its part of mental
health disorders [7,8]. In this case report, based on anamnesis, the patient tends to have excessive anxiety
which is often felt by patients, when anxiety arises, the patient bites his lips and cheeks. We used Hamilton

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Rating Scale for Anxiety (HARS) questionnaire, this questionnaire is frequently used to measure anxiety symp-
toms and is widely used in clinical practice [9]. A previous study indicated a relationship between parafunc-
tional habits and anxiety. This parafunctional habit includes biting nails, biting checks, lips, clenching, and
bruxism. The severity of anxiety greatly contributes to the occurrence of parafunctional habits. Research con-
ducted by Almutairi AF et al (2021) in the Saudi Arabian population demonstrated a significant positive rela-
tionship between anxiety symptoms' severity and oral parafunctional habits [10].
Parafunctional habits that can manifest in the oral cavity include the appearance of white plaque lesions,
ulceration, attrition of teeth, and even temporomandibular disorder. In this patient, we found white lesions
that spread on the right-left buccal mucosa, the lateral edge of the tongue, and the labial mucosa with the
diagnosis is morsicatio oris. Morsicatio is caused by self-induced injury and chronic tissue irritation like biting
buccal mucosal, chronic nibbling, chewing, or sucking [11]. Morsicatio oris more common in the second and
third decades, and in those having severe stress or mental illness [12]. The most commonly affected site of
morsicario oris is the lateral border of the tongue (53.6%), buccal mucosa (31,2%), and labial mucosa (9%),
respectively [13].
Diagnosis of morsicatio oris sometimes based on clinical features and anamnesis only. It presents a white-
gray plaque and papule on buccal mucosa and labial mucosa (usually lower), loose thread-like keratin shreds,
desquamative areas are often seen on the surface of the mucosa, tissue tag, and there may be ulcers and ero-
sion. This lesion is evanescent and may resolve and recur. The treatment with protective screening devices is
of limited value. In some cases, the surface keratin may be peeled off leaving behind normal-appearing mu-
cosa, unlike pseudomembranous candidiasis or vesiculobullous lesions. However, morsicatio oris may some-
times appear as distinct, well-demarcated plaque and it is often misdiagnosis as leukoplakia, so it is necessary
to carry out with biopsy [4].
In this patient, we do not carry out any biopsy, this is due to the accompanying parafunctional habits,
therefore the diagnosis is only made on clinical appearance. We also educated patient to manage her anxiety.
Nine coping style to control anxiety that have been reported such as: searching for support (to get emotional
support, and advice from others), acceptance (Accepting reality), changing perspective (to see from a different
perspective to more positive), problem-solving (make the situation better), avoidance (believe the reality), self-
blame(criticize oneself), unfinalized activity (work or other activities to distract), religion (to pray or medicate),
substance use (medication). This coping management of anxiety is tailored for each person according to their
life events [14].

5. Conclusions
Anxiety can induce morsicatio oris. Dentists should be aware of the oral cavity condition. If we find mor-
sicatio we can suggest the patient assess their anxiety level.
Acknowledgments: we would like thanks to this patient.

Conflicts of Interest: The authors declare no conflict of interest.

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