Th 278060

Factitial Injury

March 1, 2008
Case profile: While waiting on your next patient, an emergency patient arrives. The patient called this morning complaining of pain in the lingual area of the tongue and reported some previous bleeding.

by Nancy W. Burkhart, RDH, EdD

Case profile: While waiting on your next patient, an emergency patient arrives. The patient called this morning complaining of pain in the lingual area of the tongue and reported some previous bleeding. The patient is a 65-year-old male who is not a patient of record at your office. You have been asked to seat the patient, take a medical history, determine what is visible in the mouth, and report your findings to the dentist, who is currently with another patient.

The new patient is Mr. Saunders and his wife accompanied him to the appointment. As you question Mr. Saunders, you receive a great amount of information from his wife during the conversation. Mr. Saunders is on multiple medications for high blood pressure and high cholesterol, and is a borderline diabetic. He is able to control the diabetic problem with diet and says that he does well by watching his lifestyle factors. Although he reports that he is controlling his diabetes, you suggest that his physician clear him for further treatment.

He has a partial denture to replace missing teeth on the mandible and tells you that the appliance was fabricated at least 15 years ago. Since the initial partial was made many years ago, he has lost some teeth (Nos. 28 and 29), which leads you to his main problem and why he is in your office today. His wife tells you that they were driving on the interstate last night and his partial became dislodged and “stuck in his tongue,” bleeding profusely. It became necessary for them to pull off the highway and he was able to dislodge the partial from his tongue (Figure 1).

Figure 1. The sharp clasp entered the right side of the lingual frenum and exited on the left side of the frenum, causing profuse bleeding. Note the resulting ulcer to the left of the lingual frenum.
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The bleeding began to subside and they were able to drive home.

Etiology: Mr. Saunders has a factitial injury. Factitial injuries are injuries that are self-induced by the patient. The factitial injury is differentiated from the iatrogenic injury that is initially caused by the clinician in rendering treatment. An example of an iatrogenic injury may be the lesion that is caused by the use of a handpiece in restoration preparation. The handpiece may slip and cut into the tissue producing an injury to the tissue. The factitial injury is one that the patient has caused by inducing injury to himself or herself.

Examples of factitial injuries may be biting the lip after being anesthetized, placing an aspirin on the tissue to treat pain, or constant touching of an area with the tongue, causing ulceration. Sometimes the patient may be a constant cheek chewer producing ridges and ulcerations in the line of occlusion. In some instances, the cheek biting or morsicatio buccarum may be highly ulcerative and the source of the habit should be fully evaluated. Often stress is a strong factor in chronic cheek chewing.

Figure 2. Note the sharp, pointed edge of the appliance clasp.
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Epidemiology: Although most offices have patients of record who have caused an injury to themselves, the factitial injury is not uncommon and varies in degree of damage to the tissues. However, some of these injuries may be seen more often than other types. Chemical burns, lacerations, and focal types of repeated insult to the tissues are common. An example that I have seen is the patient who is too busy to come in for a professional cleaning and decides to use abrasive tub cleaner to get the teeth “really clean.”

Figure 3. The missing teeth caused extreme mobility of the appliance.
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Pathogenesis: Normally, the clinical sign of a factitial injury is one in which the patient has produced an ulceration, hard tissue damage, or trauma to any tissue. In this case, the appliance is to blame. Mr. Saunders was aware of the missing teeth and the unstable position of the appliance, but he continued to wear the appliance. He was not aware that the appliance could become imbedded in tissue, but as time has progressed, the end of the metal appliance clasp has continued to become worn and even somewhat pointed (Figures 2 and 3).

Figure 4. Poor oral hygiene contributes to tooth loss and inflammation.
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Dental implications: The appliance for Mr. Saunders obviously no longer fits his dentition since he has lost the teeth anchoring the appliance in place. This could be a dangerous situation for Mr. Saunders since he has already suffered an injury while driving an automobile. The appliance is moveable and does not remain safely in place. The appliance became dislodged while the patient was driving, and he may have quickly reacted, and forced the appliance clasp deep into the tissue. As the bleeding became evident, he became even more distraught and probably put additional pressure on the appliance.

Differential diagnosis: A patient may seek care because of the discomfort that is caused from the injury. In this case, the patient was able to tell us a history about the lesion, but the lesion could appear as an ordinary ulcer without a thorough history of the events that had caused the injury.

Treatment and prognosis: A new appliance is greatly needed for this patient. Although the appliance has continued to fit the dentition, it has become more mobile with time and easily dislodged. The patient also exhibits poor oral hygiene and this may have caused the loss of previous dentition in this area (Figure 4).

The oral hygiene of the patient should be improved before a new appliance is made and the patient should be fully evaluated for periodontal disease. Radiographs should be taken and the patient may need close monitoring to form new habits related to total health maintenance. Patients should be counseled about prosthetic appliances that do not properly fit, are rough, or jagged. The appliances should be repaired or replaced when in poor condition. Jagged crowns or those that are in danger of being dislodged should be removed, replaced, or repaired.

Photo credit: Delong L. & Burkhart N. General and Oral Pathology for The Dental Hygienist. Lippincott Williams & Wilkins, Baltimore, 2008.

About the Author

Nancy W. Burkhart, RDH, EdD, is an adjunct associate professor in the Department of Periodontics at Baylor College of Dentistry and Texas A & M Health Science Center in Dallas. Nancy is also a co-host of the International Oral Lichen Planus Support Group through Baylor ( She is the co-author of General and Oral Pathology for Dental Hygienists, published by Lippincott Williams & Wilkins. She can be contacted at [email protected].