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 Table of Contents  
Year : 2016  |  Volume : 28  |  Issue : 3  |  Page : 317-319

Case report of gingivitis artefacta (Self-injurious behavior)

Department of Oral Medicine and Radiology, Government Dental College, Srinagar, Kashmir, India

Date of Submission28-Sep-2015
Date of Acceptance01-Dec-2016
Date of Web Publication13-Dec-2016

Correspondence Address:
Dr. Gowhar Y Peerzada
Department of Oral Medicine and Radiology, Government Dental College, Srinagar, Kashmir - 190 010
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-1363.195656

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This case report discusses gingivitis artefacta, an oral presentation of self-injurious behavior (SIB), in a 26-year-old male who also presented with excoriations on the chest, abdomen and back (dermatillomania) along with well-circumscribed areas of hair loss on the scalp (trichotillomania). Gingivitis artefacta is a type of periodontal disease caused by self-inflicted injuries to the gingival tissues. The injuries, most commonly, occur due to picking or scratching of the gingiva with fingernails or any foreign object. SIB is a complex disorder. The cause of his behavior appeared to be of psychological origin, and therefore, referral to the Department of Psychiatry was made. Gingivitis artefacta is rarely seen and practitioners need to be aware of such presentations in patients.

Keywords: Dermatillomania, excoriations, gingivitis artefacta, self-injurious behavior, trichotillomania

How to cite this article:
Chalkoo AH, Peerzada GY, Makroo NN. Case report of gingivitis artefacta (Self-injurious behavior). J Indian Acad Oral Med Radiol 2016;28:317-9

How to cite this URL:
Chalkoo AH, Peerzada GY, Makroo NN. Case report of gingivitis artefacta (Self-injurious behavior). J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2022 Dec 2];28:317-9. Available from: http://www.jiaomr.in/text.asp?2016/28/3/317/195656

   Introduction Top

Self-injurious behavior (SIB) is described as “self-inflicted damage without suicidal intent.”[1] It is believed to affect 4% of adolescents over a 12-month period. Prevalence in females aged 15–19 is greater than that in males; however, this trend is reversed in the 21–24 years age group.[2] The terminology, classification, diagnosis and treatment of self-inflicted dermatological lesions are subjects of open debate. A plethora of terms, such as self-harm, dermatitis artefacta, auto-destructive syndrome, self-injury, self-mutilation, neurotic excoriations and psychogenic excoriations have been used for overlapping symptoms and clinical features.[3]

A type of periodontal disease caused by such physical injury to the gingival tissue is termed as gingivitis artefacta, which has minor and major variants.[4] Gingivitis artefacta minor is the most common but less severe form, and is considered to be provoked by a pre-existing locus of irritation or overzealous tooth brushing habits. This form results from rubbing or “picking” the gingiva, using the finger nail or any foreign object.[5] Gingivitis artefacta major is more severe and widespread and can involve the deeper periodontal tissues. Other areas of the mouth such as the lips and tongue or even extraoral injuries may be found. This type of behavior is probably associated with an emotional disorder.[6]

Stewart and Kernohan differentiated between three types of injuries for patients of normal intelligence:

Type A: Injuries superimposed upon a pre-existing lesion (or irritation)

Type B: Injuries secondary to another established behavior (such as thumb sucking)

Type C: Injuries of unknown or complex etiology (often based upon some emotional disturbance or psychological illness).[7]

Clinically, irrespective of any physical or mental condition, SIB has a wide range of presentations [2] with 75% of the injuries reported to affect the head and neck.[8] A factitious dermatitis component of SIB may be found extraorally on the scalp, face or limbs. The behavior here is more commonly reported alongside an associated psychiatric disorder and underlying emotional disturbance.[2] Oral presentations include ulceration of the tongue from biting and cigarette burns,[9] and scratching of the gingivae causing recession (gingivitis artefacta) with bone loss.[10] In severe cases, this leads to auto-extraction.[11],[12] In this case report of a 26-year-old male with gingivitis artefacta, there was associated excoriation disorder and trichotillomania.

   Case Report Top

A 26-year-old male accompanied by his elder brother reported to our department with a complaint of pain and burning sensation in the mouth. According to his initial statement, the disease had appeared suddenly 5 months back. Clinical examination revealed multiple ulcerations ranging from 5–10 mm on labial gingiva in relation to teeth numbers 16, 13, 26, 36, 31, 41, and 46 [Figure 1]a,[Figure 1]b,[Figure 1]c. Ulcers were covered with a yellowish slough. There was no radiographic evidence of interdental and labial bone loss in these areas. Apart from stains and calculus, generalized abrasion of the labial aspect of the teeth was noticed. The clinical picture did not fit well into any chronic or recurrent condition.
Figure 1: Multiple ulcerations ranging from 5–10 mm on labial gingiva in relation to teeth numbers (a) 16, 13, 26, 36, 31, 41, 46, (b) 16, 13, 41, 46, and (c) 26, 36, 31

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On questioning, the patient admitted that, for the past 4 years, he had developed an urge to scratch his gingivae with his fingernails and any available instrument such as screw driver or scissors. Further questioning and examination revealed self-inflicted injuries in the form of linear excoriations and areas of crustations on the chest, abdomen and back of the patient. Healed lesions in the form of hyperpigmented macules were also present on the affected areas [Figure 2]a and [Figure 2]b. There were well-demarcated areas of hair loss on the scalp with normal color of the exposed skin [Figure 3]a and [Figure 3]b. The findings were suggestive of some underlying psychiatric illness. Patient's personal history also revealed that he was the only unemployed person in the family, and had to stay alone at home the entire day. Staying alone in the house would make him anxious and aggravate his urge to cause self-inflicted injuries. Frequency of such episodes decreased during family gatherings and special occasions. All this was attributing to some psychiatric disorder.
Figure 2: (a) Excoriations and areas of crustations on the chest and abdomen of the patient. Healed lesions in the form of hyperpigmented macules. (b) Similar lesions on the back

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Figures 3: (a and b) Well-demarcated areas of hair loss on the scalp with normal color of the exposed skin

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Based on the clinical examination and history, a diagnosis of gingivitis artefacta associated with excoriation disorder and trichotillomania was made and the patient was referred to the Department of Psychiatry, where he was diagnosed as a case of obsessive compulsive disorder with depression and was put on anxiolytics and behavioral modification therapy. At the same time, treatment for oral and skin lesions was commenced, which included chlorhexidine mouth rinses for oral lesions and neosporin ointment for skin lesions. Patient was put on periodic follow-up to evaluate conditions of pre-existing lesions and occurrence of any new lesions. There was a significant improvement in his conditions on 2-month follow-up, most of the lesions had healed and there were no new lesions. The patient did not turn up for further follow up.

   Discussion Top

SIB is a complex disorder. Different theories have been suggested regarding its etiology. Biological causes such as Lesch–Nyhan syndrome, Gilles de la Tourette syndrome, autism, familial dysautonomia and mental retardation have been well recognized. On the other hand, functional theories maintain that escape or attention seeking through SIB, which may arise in stressful situations, may be the etiological factor, especially in the absence of any known biological factors.[2]

Self-inflicted oral injuries can be premeditated or accidental or can result from an uncommon habit. These injuries usually result from a foreign object or patient's fingernails that habitually cause an erosion of the gingival tissue in a specific area.[9] Habitual fingernail scratching is a common behavior among children, however, such injuries are not limited to children.[6] The etiology of self-inflicted oral injuries in adolescents and adults includes some emotional disturbance.[13],[14]

In this case, although proper history was not immediately revealed, an underlying psychiatric cause was evident. In addition to his finger nails, the patient had a habit of using scissors and screw driver for inflicting the gingival injuries. Referral was made to the Department of Psychiatry. Breakdown of referrals and non-attendance in these type of patients can be high.[15] Gingivitis artefacta is rarely seen and practitioners need to be aware of such presentations in patients. Obtaining a comprehensive history and looking for factitious dermatitis component of SIB extraorally on the scalp, face or limbs could be helpful in making a diagnosis.

   Conclusion Top

Dentists must be aware of self-inflicted gingival injury. When a diagnosis of gingivitis artefacta major is made, the presence of an underlying emotional or psychiatric issue must be considered. It could be difficult to treat gingivitis artefacta major without treating the underlying psychiatric disorder. Uptake of care and patient compliance may prove problematic, and therefore, close liaison between all services is essential. Accurate diagnosis and appropriate psychiatric referral are of paramount importance.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Vogel LD. When children put their fingers in their mouths. Should parents and dentists care? N Y State Dent J 1998;64:48-53.  Back to cited text no. 1
Millen CS, Roebuck EM. Case report of self-injurious behaviour (SIB) presenting as gingivitis artefacta major. Br Dent J 2009;206:129-31.  Back to cited text no. 2
Gieler U, Consoli SG, Tomás-Aragones L, Linder DM, Jemec GB, Poot F, et al. Self-inflicted lesions in dermatology: Terminology and classification. Acta Derm Venereol 2013;93:4-12.  Back to cited text no. 3
Stewart DJ. Minor self-inflicted injuries to the gingivae: Gingivitis artefacta minor. J Clin Periodontol 1976;3:128-32.  Back to cited text no. 4
Subbaiah R, Thomas B, Maithreyi VP. Self-inflicted traumatic injuries of the gingiva- A case series. J Int Oral Health 2010;2:43-9.  Back to cited text no. 5
Dilsiz A, Aydin T. Self-inflicted gingival injury due to habitual fingernail scratching: A case report with a 1-year follow up. Eur J Dent 2009;3:150-4.  Back to cited text no. 6
Stewart DJ, Kernohan DC. Self-inflicted gingival injuries gingivitis artefacta, factitial gingivitis. Dent Pract Dent Rec 1972;22:418-26.  Back to cited text no. 7
Van Moffaert M. Localization of self-inflicted dermatological lesions: What do they tell the dermatologist? Acta Derm Venereol Suppl 1991;156:23-7.  Back to cited text no. 8
Blanton PL, Hurt WC, Largent MD. Oral factitious injuries. J Periodontol 1977;48:33-7.  Back to cited text no. 9
Medina AC, Sogbe R, Gomez-Ray AM, Mata M. Factitial oral lesions in an autistic paediatric patient. Int J Paediatr Dent 2003;13:130-7.  Back to cited text no. 10
Leksell E, Edvardson S. A case of Tourette syndrome presenting with oral self-injurious behaviour. Int J Paediatr Dent 2005;15:370-4.  Back to cited text no. 11
Plessett DN. Autoextraction. Oral Surg 1959;12:302-3.  Back to cited text no. 12
Josell SD. Habits affecting dental and maxillofacial growth and development. Dent Clin North Am 1995;39:851-60.  Back to cited text no. 13
Golden S, Chosack A. Oral manifestations of a psychological problem. J Periodontol 1964;35:349.  Back to cited text no. 14
McKay MM, Stoewe J, McCadam K, Gonzales J. Increasing access to child mental health services for urban children and their caregivers. Health Soc Work 1998;23:9-15.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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