This document discusses self-injurious oral habits. It defines self-injurious behavior as acts that result in self-inflicted physical damage. Examples mentioned include lip, cheek and tongue biting. The document classifies these habits into organic habits caused by medical conditions and functional habits which are learned behaviors. Treatment involves a multidisciplinary approach including dental appliances for injury prevention, behavior modification techniques, and restraints for severe cases. The conclusion emphasizes the importance of considering self-injurious habits in the differential diagnosis of idiopathic oral lesions in children.

2. Introduction
Definition
Incidence
Classification
Clinical Features
Treatment
Conclusion
References

3. Oral Habits:
A Habit can be defined as a
fixed or constant practice
established by frequent
repetition.

4. Nail Biting Habit
(Obsessive-
Intentional)

5. Tongue Thrusting habit
(Non Obsessive-Functional)

7.  Self-injurious behaviour (SIB) may be defined as that
which results in the infliction of physical damage
and, perhaps, pain upon oneself.
 The manifestations may be seen as finger biting, skin
cutting, head banging, and trauma to the oral
tissues and genital.
 Self-inflicted oral mutilation (masochistic habits) is
defined as deliberate harm to one's own body
without suicidal intentions.
 Documented cases exist of tooth self-extraction, nail
biting (NB), tongue mutilation, sucking digits, or
sucking a variety of foreign objects. Pencils, pens,
eyeglass, earpieces, toothpicks, knives, dental floss,
thread, and pacifiers are some of the items that
have been reported as instruments of self-inflicted
gingival injury.

8.  Repetitive acts that result in physical damage
to the person.
 Example: Gingival stripping, Cheek biting,
Tongue biting, Lip biting.

9.  Extremely rare in normal child.
 It is between 10-20% in mentally retarded population.
 Prevalence: Higher in females.
 In the general population, prevalence is estimated at 750 in
1,00,000.
 Increasing in developmentally disabled individuals from 7.7%
to 22.8% and reaching 40% in profoundly retarded individuals.

10. Lip Biting
Habit

11. Cheek Biting Habit

12. Tongue
Biting Habit

13.  Ayer and Levin(1974)
(based on the aetiology)
 1)Organic:-
This consists of syndromes and syndrome-like maladies such as
Lesch-Nyhan and de Lange’s which have been associated with self-
mutilation such as repetitive lip, tongue, finger, knee and shoulder
biting.
 2)Functional:-
This is subdivided by Stewart and Kernohan into:
 Type A behaviour are injuries superimposed on a pre-existing lesion.
E.g.: A skin lesion perpetuated by a skin biting habit.

14. • Type B are injuries secondary to another established habit.
E.g.: Rotating the thumb during sucking process causes
ulcerations on the palatal gingiva. If the established habit is
discontinued then the lesion disappears.
• Type C: Injuries of unknown or complex aetiology.
This has greater psychogenic component.
There may be multiple symptoms of great intensity.
These habits may serve as form on stress release.
Mallson and Robertson have concluded that castration fears,
failures to resolve oedipal conflicts, represented homosexual
impulses, severe guilt and self-punishment are ubiquitous
phenomenon in type C behaviours.

15.  These may produce factitial injuries, 75% of
which are located in the head and neck region.
 Oral structures such as gingiva, oral mucosa,
tooth supporting structures or teeth maybe
affected.
 They usually consists of putting fingernails or
foreign objects in the gingival sulcus, digital
pressure on the oral structures or biting of tissue.

16.  Factitial oral lesions (FOL) include factitial
gingivitis, factitial periodontitis, factitial
ulcer, and self-extraction.
 The symptoms of both the functional and
organic categories of self-injurious
behaviour appear to be exacerbated
during stressful situation.
 It has been observed that some children
experience a feeling of neglect,
abandonment, and loneliness, and through
the use of self-injurious behaviour they
attempt to solicit attention and love.
 Thus, some form of emotional stress, such as
personal unhappiness, loss of security, or an
unresolved pain producing dental condition
is an important etiological factor.

17.  It has been suggested that self-mutilation
is a learned behaviour.
 This maybe because attention is always
gained, reinforcing the behaviour.
 But any child who willingly inflicts pain to
himself should be considered
psychologically abnormal.

18. Lip Ulceration due to biting
(Factitial oral Lesion)

19. •Requires multidisciplinary approach.
•The role of paediatric dentist in treatment
is to elicit a thorough social and medical
history and correctly diagnose the
condition so as to distinguish it from one of
physiological aetiology solely.
•After the diagnosis has been determined,
referral to primary care physician usually
paediatrician is done.

20.  Adjunctive therapy maybe initiated by the dentist to aid in
the healing of oral ulcerations.
 A squib oral bandage is beneficial to healing of oral tissues,
as well as serving as a Habit Reminder.
Oral Bandage

21.  In addition, an ORAL SHIELD maybe fabricated and inserted
into the mouth at night.
 This appliance will deter the child from unconscious
continuation of the habit.
 This therapy should not be instilled alone, but used as part of
the multidisciplinary approach to the treatment of self-
injurious behaviour.
Oral Shield

22.  The technique used for behaviour modification includes:
1. Continuous positive reinforcement while self-mutilative
responses are absent.
2. Withdrawal of positive reinforcement upon self-mutilation.
 At each consultation, the patient should receive
instructions regarding the importance of habit interruption
for the maintenance of gingival health until total removal
of the appliance.
 Restraints may be the reliable means of preventing injury
to the self-injurious behaviour-affected individual, physical
restraints include mittens, arm-boards, facial masks,
helmets and restrictive clothing, but requires constant
wear if they are to be successful.

23. Physical
Restraints
(Arm Board)

24. Mittens

25.  Although the diagnosis of self-inflicted
oral mutilation may be a challenge for
the paediatric dentists, this should not
prevent the consideration of this
possibility when idiopathic lesions are
present in a child.
 Appropriate preventive methods need
to be developed for each patient based
on reasonable consideration.

26.  Masochistic habits in a child patient: A case report and its management
John Baby John, Vilvanathan Praburajan, Ariudainambi Stalin, and Murali Krishnan
(International Journal of Critical Illness and Injury Science 2013 Jul-Sep; 3(3): 211–
213)
(PMCID: PMC3883201)
 Textbook of Pedodontics, Dr.Shobha Tandon, 2nd
edition, Page:492
 Textbook of Pediatric Dentistry,Nikhil Marwah,3rd
edition,Page374
 Clinical Pedodontics,Finn,4th
edition,Page 370