Functional oral self-mutilation in physically healthy pediatric patients: Case report and analysis of 27 literature cases

Self-mutilation is a form of intentional injury or tissue destruction inflicted upon one’s own body without suicidal intent [1–3]. Van Sell et al. have estimated that 3 million people in the United States present self-injurious behavior, including cutting, burning, and other types of tissue destruction [4]. However, the exact prevalence of self-mutilation in the world population is uncertain and probably above the average reported [2], taking into consideration that such behaviors are not considered socially acceptable and therefore usually hidden from others [1]. In self-mutilation, physical pain is inflicted against one’s own body in an attempt to override intense emotional pain. Some authors identify self-inflicted injury as a ‘‘cry for help,’’ but the behavior is also associated with shame and consequently hidden practice [1,3,5,6,16]. Self-mutilation can affect all types of people, without distinction of sex, age, socioeconomic status, or educational level [1,7,8]. However, a higher incidence of self-inflicted injury has been reported among women and adolescents [3,6,8]. The etiology of self-mutilation can be classified into two categories: organic and functional [7]. In organic self-mutilation, injuries are inflicted unknowingly, unintentionally, and compulsively [7,9], e.g. as observed in comatose patients [10], patients with genetic syndromes, biochemical or enzymatic deficiencies such as Lesch-Nyhan, De Lange, and Tourette syndromes, congenital insensitivity to pain, and Leigh syndrome [7,11,12]. In turn, functional self-mutilation refers to self-injuries performed knowingly by physically healthy patients without detectable genetic defects [1,7], therefore representing a far greater diagnostic challenge to health professionals [9]. Functional self-mutilation is further divided into three subcategories: (A) injuries superimposed upon a pre-existing lesion; (B) injuries secondary to a chronic destructive habit (e.g. dummysucking); and (C) injuries of unknown or complex etiology (often including a psychological component). In the last subcategory, patients usually deny that they are producing the injury [13]. In addition to the etiologic classification of self-mutilation, differential diagnoses should bemade between this condition and other behaviors, such as cosmetic procedures, masochistic acts, and mental illnesses (e.g., depression followed or not by suicide attempt) [1]. Some cosmetic or esthetic procedures, such as body piercing, tattooing and plastic surgery, have been socially and culturally determined and can cause damage to oral tissues, but cannot be considered as self-mutilation [14]. Also, individuals who inflict injuries on themselves cannot be considered masochists, because the latter derive pleasure from their own pain, whereas self-mutilators seek relief fromoverwhelming emotional pain [1]. Finally, physical self-mutilation cannot be considered a suicide attempt, because self-mutilators do not intend to die, but rather to obtain relief [8,15]. With this regard, some authors have noted that suicide is a permanent solution to a temporary problem, whereas self-mutilation is a temporary solution to a permanent problem [15,16]. Oral self-mutilation is not uncommon. A literature search conducted in the PubMed database using the term oral selfmutilation yielded 296 papers. However, only 14 of these articles were found to describe cases of functional mutilation in nonsyndromic pediatric patients (these 14 articles are listed in Table 1) [5,7,13,17–27]. In cases of oral self-mutilation, the gingival area is the site most frequently affected, typically among pediatric female patients [5,7,13,17–19,21,23,26,27]. The most commonmethods of gingival self-inflicted injury are pocking with a pencil or scratching with fingernails [5,13,17,19,20,22,23,25–27], and etiologic factors usually include an emotional component, e.g. parent divorce, problems at school, birth or death of a sibling, or an unhappy home environment [5,13,19,20,23]. Treatment is based on correct diagnosis after a careful and thorough clinical examination, once functional oral self-mutilation is often denied or hidden by both the patient and family members [5–7,13,17–20,23,25–27]. Patients need to cease the habit [3,14], and psychological therapy acquires special importance in this process [1,5,16,17]. International Journal of Pediatric Otorhinolaryngology 75 (2011) 880–883