Case Report: Management of self-injurious habit in a pediatric patient using soft splint

Introduction

Mouth ulcer is a recurrent oral cavity clinical manifestation in the oral mucosa and is usually related to various causes and diseases.¹ The causes of check biting are Tooth deflection in the dental arch, depression-related cheek biting, Biting the cheek accidentally, Psychological, biting the cheek while sleeping during the night, malignant lesions, etc.² As a result, determining the exact cause of this oral lesion is challenging. Morsicato mucosae oris, or chronic biting of the oral mucosa is a type of accidental or intentional injury that commonly affects the buccal and labial mucosa and the lateral surface of the tongue. Such transient habitual injuries in children tend to become severe over time; howbeit, stressful situations including examinations, sports events, and other activities may intensify the condition.³

Pedodontists often encounter such behavioural patterns in children and are the ones who are consulted about it. Various treatment options, such as reconditioning the patient through strategic counselling, relaxation, and calmative, focusing the habit, and protecting the oral mucous membrane from injury by means of prosthesis such as a variety of removable appliances that guard the oral structures including buccal mucosa, tongue, and lips from chronic lesions, have been implemented and documented in the past to prevent and control repetitive accidental trauma to the oral mucosa.^4–6 The treatment procedure should be carefully considered based on the clinical stage and form of the ulcer. Therefore, the current clinical study outlines the treatment of chronic cheek biting with pain management and fabricating a specifically designed soft occlusal splint.

Case report

A nine-year-old male reported to the Department of Pedodontics and Preventive Dentistry at Datta Meghe Institute of Higher Education and Research, Wardha, with the chief complaint of mouth ulcers in the lower right and left back teeth region for four weeks. Medical, genetic, and family history was non-contributary. He had been examined and given systemic antibiotics for two weeks at another clinic, but no improvement had occurred. His parents decided to transfer him to our facility after becoming concerned when a clinic doctor requested a biopsy to make an initial diagnosis.

When the patient reported to the department, he was afebrile and unaware of the daytime cheek-biting habit. The patient had a swollen face with a 2 x 2 cm size of the submandibular lymph node. The patient had no crowded teeth and could bite usually. While observing his behaviour, he kept sucking his cheeks. Therefore, traumatic mucosal ulcers on both cheeks were made as the final diagnosis. (Figure 1 and 2) Differential Diagnosis can be aphthous ulcer and early squamous cell carcinoma or may be a result of infectious disease.

Figure 1. Pre-operative image of traumatic ulcer on the right side.

Figure 2. Pre-operative image of traumatic ulcer on the left side.

In the treatment plan, initially, the patient's parents informed consent was recorded and oral prophylaxis was performed, and the patient started his antibiotic coverage. The medication included amoxiclav (375mg maximum two times a day), ibuprofen (200mg maximum two times a day), and Metronidazole (200mg maximum two times a day) for three days. In the same appointment, an alginate impression was taken of both the arch, and a soft occlusal splint was made using a soft polyvinyl sheet of 2mm thick resilient material. The sheet was placed in a vacuum-formed pressure molding with a thermally controlled infrared heater. After one week, the occlusal splint was placed over the maxillary arch and extended laterally from molar to molar by releasing the area where the premolar erupted. (Figure 3) The patient was instructed to wear the appliance during the day after school and at night while sleeping. 5 ml of 2% chlorohexidine mouthwash was prescribed to the patient for seven days.

Figure 3. Soft-occlusal splint placed over maxillary arch.

After complete treatment patient was recalled after ten days, the lesion on both sides was almost healed.

After 30 days of treatment, the lesions on the left cheek were completely healed (Figure 4), and the one on the right cheek was almost healed. (Figure 5)

Figure 4. One-month follow-up with a traumatic ulcer on the left side.

Figure 5. One-month follow-up with a traumatic ulcer on the right side.

Discussion

With an average of 21.7 cases per 1000 patients, cheek biting was the fifth most frequent cause of mouth lesions.⁷ In which women are more likely than men to develop this habit.⁸ Biting repeatedly causes a severely traumatized lesion that is sometimes scarred, thickened, and paler than the neighbouring mucosa, or it can present as white wrinkled to dry surfaces that are tender or not. It can also present as swelling, purpura, and erosions.³ In the present case lesion was white frayed which was associated with swelling.

Various dental appliances for controlling oral mucosa biting have been reported in the literature. Examples include lip bumpers, mouth guards, and silicone soft relining material for tongue protection.⁹ In this case, an occlusal soft splint was used to provide total coverage of the functional cusps of the molars and to prevent repeated traumatic injury. Although an oral prosthesis does not address the underlying cause of oral mucosa biting, it effectively controls this self-mutilation.

In this case, a biopsy was not performed, as it was a pediatric patient. Biopsy tests performed during acute lesions may show incorrect results, promote further injury, and aggravate patients' pain and fear. According to Ngoc et al., a biopsy should be performed for malignant lesions, specifically for pediatric patients.²

Chlorhexidine has manifested activity against some enveloped viruses such as CMV, HSV, and Influenza.¹⁰ In the present case, 2% chlorohexidine mouthwash with antibiotics and multivitamin therapy was prescribed, which had an essential role in the healing of the ulcer in conjunction with the soft splint. To avoid any adverse events such as staining of tooth using 2% chlorhexidine, it was prescribed for a week.

The only limitation of this case was that the treatment plan was only custom suited for a case of habitual cheek biting.

Conclusion

Early detection of lesions and identification of risk factors allows for a more conservative clinical approach. As a result, before planning the treatment course for any oral soft tissue lesions, identification of the primary cause such as a repeated habit or other factors is a prime requisite. This is because neglecting the cause of such lesions and treating the same with a surgical approach like excision may lead to the recurrence of the lesion. The soft occlusal splint, fabricated using polyvinyl sheets, is an easy-to-wear simple prosthetic device that can be customized according to the patient.

Consent

Written informed consent for publication of their clinical details and the clinical image was obtained from the patient’s parent.