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Author : Dr. Umesh Dharmani, Dr. Ajay Logani, Dr. Naseem Shah

Abstract
This paper presents an interesting case of self-harm that resulted from ignorance and ill advised self-treatment. A 27-year-old female, rubbed an acid on her anterior fluorosed teeth in an attempt to get cosmetic improvement, which gradually eroded the tooth structure and caused pulp exposure. The slow irritation from hyperaemic pulp led her to use a needle to relieve the itching and which further complicated the case due to fracture of the needle in the middle third of the root canal. The case is discussed with clinical presentation, management with special emphasis on its early diagnosis and prevention of complications through education and motivation.

Background:
Self harm is defined as the intentional, direct injury of body tissue without suicidal intent.1 It refers to a spectrum of behaviours where demonstrable injury is self-inflicted. The term ‘self-mutilation’ is also sometimes used. The most common form of self-harm is skin cutting but it also covers a wide range of behaviours including, burning, scratching, banging or hitting body parts, interfering with wound healing, hair pulling (trichotillomania) and the ingestion of toxic substances or objects. 2-5

It is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a symptom of borderline personality disorder. But patients with other diagnoses including depression, anxiety disorders, substance abuse, eating disorders, post-traumatic stress disorder, schizophrenia can also cause self-harm,.2,6
This paper reports a unique case of self-harm in a healthy young female patient who became a victim of ignorance and ill advised self-treatment by unprofessional persons.

Case reports:
A 27 year-old female reported with pain, swelling & localized tooth surface loss in upper front region. The patient medical history was cleared and denied any previous episode of self harm and had no history of mental illness .On the bases of chief complaint and questioning she revealed that she was Unhappy with discoloured teeth and was keen to have her teeth restored for aesthetic reasons.  In an attempt to get cosmetic improvement of her anterior fluorosed teeth, she was ill advised by a quack to rub an acid on the affected teeth, which gradually eroded the enamel and dentin leading to pulp exposure. The slow irritation from hyperaemic pulp led her to use a needle to relieve the itching. The case was further complicated by the fracture of needle inside the root canal.

 

 

Figure 1. Labial view showing damaged residual tooth surface.

Figure 2. Shows unusual foreign object lodged in the pulp canal.

Figure 3. Shows bypass fracture object with #15 K- file.


On examination patient appeared healthy and no sign of mental illness. An extra oral examination revealed nothing abnormal and intraoral there was swelling in relation to 21, severe labial erosion 11,21 and Moderate fluorosis 12,11,21,22 & 23(figure 1). Radiographic examination revealed a Radio-opaque object (# needle?) in the middle third of the root canal, periapical radiolucency measuring 2-3 mm and resorbed open apex in relation to 21.no other significant finding were seen (Figure 2).

Diagnosis was made by correlating the patient chief complaint, history and both clinical and radio graphical findings. The diagnosis was

 

 

 

 

  1. Acute periapical abscess 21
  2. Moderate fluorosis 12,11,21,22 & 23
  3. Self inflicted severe labial erosion 11,21

Treatment plan consists of:

 

 

 

 

  1. Non-surgical root canal treatment including removal/bypassing the fractured needle.
  2. Single visit apexification using MTA
  3. Aesthetic restoration of discoloured anterior teeth.

 

 

 

Figure 4. Shows  Prepared canal.

Figure 5. Shows Single visit apexification with MTA. Figure 6. Shows back filling with thermo plasticized Gutta Percha.


Since the labial surface was destroyed by erosive agent and pulp cavity was labially visible, root canal access cavity was prepared from labial aspect. There was spontaneous discharge of pus from the canal. The root canal system was copiously irrigated with alternate irrigation with normal saline and Chlorhexidine.
No.15 K-file was used to bypass the # instrument. The instrument was removed by engaging it with a 20 no. H-file (Figure 3 & 4). Ca (OH)2 dressing was packed in the canal and an interim restoration was given (IRM 3M ESPE) and reviewed after one week. Single visit apexification was done with MTA in apical third (figure 5). Remaining canal space was filled with thermo plasticized Gutta Percha (Elements System, Sybron Endo) and access cavity was restored with composite (Figure 6).

Esthetic rehabilitation of discoloured anterior teeth was done with all ceramic full crown for 21 and laminate for 13,12,11,22,23 (Figure 7 and 8).

Figure 7. Show intra-oral view with all ceramic full crown for #21 and laminate 13,12,11,22,23. Figure 8. Show extra-oral view with all ceramic full crown for #21 and laminate 13,12,11,22,23.


Discussion:
A wide variety of foreign bodies have been known to find their way into the orifices and cavities of the human body.7 The literature on foreign bodies includes case reports where foreign materials, not placed by dentists, have been found in the root canals of young individuals. In most cases it is the result of an accident but it may also be self-inflicted.8,9,10

Although the typical clinical features of oral self inflicted behaviour  are well documented (Stewart, 1976; Blanton et al.1977; Pattison, 1983), they often present a difficult diagnostic problem for the clinician and, even when recognized, the method of their development and their management are not clearly understood.2,3,4 Self-injurious behaviour occurs in conjunction with a variety of psychiatric disorders as well as various developmental disabilities and some syndromes.11

The behavioural and biochemical aspects of self-injurious behaviour are poorly understood and several aetiologies have been suggested.5,6 It is well documented that deliberate mutilation is practiced by certain groups for social, culture, or religious regions. Self inflicted injury also be seen in conjunction with psychiatric and neurological condition, e.g. Lesch–Nyhan syndrome, Autism, Tourette syndrome and some instances of central nervous system trauma especially in children with cerebral palsy.13,14,15,16,17 Self mutilation used by some children may be as a mean of gaining attention as many children have habit of placing of inanimate object in the mouth that result occlusal disharmony and hard-soft tissue injury.18 There have been several reports describing the placement of foreign object by the patient in to pulp chamber and canal. Sousa D (2010)19 describes a case of gingival abscess in a child due to a fingernail-biting habit. It was suggested that the deleterious habit was related to emotional tension and anxiety behaviours and the patient was referred for psychological treatment.

Richard P (2006)20 described the management of a case of localized anterior tooth loss with a pair of fabric scissor with an unusual etiology whilst suffering from bout of acute depression and anxiety.

Dilsiz A, Aydin T (2009) 21 Describe a case report that shows gingival injury and maintain the periodontal health of a patient with destructive habit. Patient compliance, regular dental follow-ups, and psychological support may be useful in stabilizing the periodontal condition of these patients. Dentists must be aware that self-inflicted gingival injury, although thought to be uncommon, is quite widespread.

Spencer RJ (1999)22 describes a case report of gingivitis artefacta in a patient undergoing orthodontic treatment.

Bagga S, and Bhat KM (2008)23 present case describes chemcial burn of oral mucosa caused by crushed garlic. To relieve toothache, the patient placed crushed garlic cloves in the buccal vestibule overnight and developed garlic burn injury manifesting as slough and ulceration in that region.  SIB Diagnosis was made on the basis of definitive history elicited from the patient.

Levinkind M & Ahlberg KF(1988)10 describe a case in which a traumatized maxillary incisor was receiving  endodontic treatment and this enabled the patient to force several foreign bodies through the tooths incompletely formed apex in to periapical tissue.

Taira K (2005)24 and colleague describe a simple solution to the problem of self-inflicted trauma to oral tissues in a Comatose Patient Because comatose patients lack cerebral control of the masticatory cycle, they can easily injure themselves.

Romero M (2008) 25 Present the dental management of oral self mutilation in neurological patient such as Hereditary sensory and autonomic neuropathy type IV is a rare disease characterized by fever episodes, mental retardation of different intensity, recurrent episodes of fever secondary to anhidrosis, little or no perspiration and congenital insensitivity to pain and oral self-mutilation .

Although many cases of self-inflicted oral injuries have been  reported since Neil (1958)26 first reported a case involving self-mutilation of the tongue, there do not appear to be any reports of factitious oral injuries that  result from ignorance and ill advised self-treatment. Patient with diseases of  such an unusual etiology that could result from ignorance and ill advised self-treatment, may be experience a significant amount of socially and domestically unrest. The clinician should be aware that when dealing with diseases of unknown etiology, the possibility of self inflicted injury may exist

In this case, it could be hypothesized that the stress and anxiety suffered by the patient both socially and domestically led to this episode of self-inflicted trauma, by rubbing an acid on the affected teeth in an attempt to get cosmetic improvement.

Conclusions:
Managing patients who have self-inflicted injuries is usually difficult because there are often not only physical but also psychological factors involved. Dental rehabilitation should be carried out in conservative way with special emphasis on its early diagnosis and prevention of complications in future through education and motivation.

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