Oral self-mutilation in a child with congenital toxoplasmosis: a clinical report.

This clinical report involves self-mutilation of the lips and oral mucosa by a child who presented at 18 months with profound retardation secondary to congenital toxoplasmosis. The etiology of self-mutilation, dental management, and the need to individualize treatment are discussed. Self-mutilation -repetitive acts which result in obvious physical damage to the individual’s bodyis seen in 7.7-19% of the mentally retarded population.’-* As the severity of mental retardation increases so does the incidence of self-mutilation. Maisto et al. found that approximately 96 per cent of the self-mutilating residents in a state institution were severely or profoundly retarded, with the remaining 4 per cent moderately retarded. 2 Etiologies of self-mutilation may include organic or biologic factors not necessarily associated with mental retardation. These include a class of self-mutilafive activities occurring with syndromes in which biochemical or enzymatic deficiencies have been identified, such as in Lesch-Nyhan syndrome and de Lange’s syndrome. ~ However, much self-mutilation cannot be attributed directly to biochemical factors. Several interpretations can be made concerning the relationship between self-mutilation and level of intellectual functioning. It may be that biological factors such as conspicuous impairment of sensory apparatus of the nervous system contribute to self-mutilation. Maisto et a|. found that residents in a state institution who exhibited self-mutilation were more likely to have brain damage associated with low intellectual functioning. 2 Self-mutilation also may be a learned behavior. In a severely or profoundly retarded individual, selfmutilation is one of the few behaviors reliably reinforced (attention is gained). 2,4 The fact that behavior modification techniques are successful in terminating self-mutilation adds empirical support to this possibility.’, Various techniques are used in behavior modification of self-mutilation. These include continuous reinforcement while self-mutilative responses are absent and withdrawal of reinforcement upon self-mutilation,’-’ differential reinforcement of other behavior, extinction, 9 and painful electric shock.~’° No method is routinely successful for all individuals and frequently more than one type of behavior modification is used. Other methods of treatment for self-mutilation include the use of restraints, protective padding, and sedation. Use of restraints will control direct injury, but will not modify the underlying abusive behavior. There is little evidence to demonstrate that the longterm benefits from medication (primarily neuroleptics) outweigh the risks of these drugs to self-mutilafive individuals. ’,3 A frequent manifestation of self-mutilation is biting or chewing the lips, buccal mucosa, or tongue. Although the biting behavior may be seen in congenital absence of pain, it is associated more frequently with normal sensation since the person may scream as if in pain when biting. The biting may become so severe that behavior modification techniques are inadvisable due to the amount of damage which may occur if the self-mutilation is ignored. Because of this compulsive biting behavior, a dentist may join the team of professionals attempting to eliminate self-mutilation. A review of the literature describing treatment of these cases indicates that each presents unique challenges--no one treatment is indicated for self-mutilation due to biting of the lips and tongue. Some authors report extraction of all primary teeth in an effort to reduce trauma. ’’.~2 Others have suggested extracting only the anterior teeth to prevent chewing of the lip. ’’,’~ Budnick reported successful prevention of lip mutilation by covering the dentition with acrylic 98 ORAL SELF-MUTILATION: DenBesten and Mclver splints. In a review of cases involving Lesch-Nyhan syndrome, Dicks suggested a combination of these various treatments dependent on the severity and persistence of the self-mutilative behavior.