Case report
Self-inflicted injury as a potential trigger for carcinoma of lip – a case report Roopashri Rajesh Kashyap1 and Rajesh Shanker Kashyap2 1
Department of Oral Medicine and Radiology, A.J. Institute of Dental Sciences, Mangalore, Karnataka, India; 2Department of Periodontics, Yenepoya Dental College, Mangalore, Karnataka, India
doi: 10.1111/ger.12009 Self-inflicted injury as a potential trigger for carcinoma of lip – a case report Objectives: To report a case of an elderly patient with an unstable mental condition, presenting with the carcinoma of lip due to repeated toothpick injury. Background: Self-induced lesions of the face and mouth may be a manifestation of unusual or aggressive oral habits or an emotional disorder. The deliberate creation of orofacial lesions, is an indication of underlying psychiatric disease. Betel quid chewing is the major risk factor for oral cancer. It conditions the oral mucosa towards the development of cancer. Repeated trauma by self mutilation on such a conditioned mucosa can lead to the development of cancer. Materials and methods: A male patient aged 85 years reported the complaint of a growth on the left side of the lower lip. Trauma followed by self inflicted injury had predisposed to the formation of cancer. Conclusion: Diagnosis of self inflicted lesions are challenging as the histories of these lesions tend to be vague and misleading. Our knowledge in this particular pathology is limited mainly because of diagnostic difficulties and lack of solid statistical data. Keywords: carcinoma of lip, factitious injury, self-inflicted injury Accepted 6 September 2012
Introduction
Case report
Self-induced lesions of the face and mouth may be encountered in routine dental practice. They can be a manifestation of unusual or aggressive oral habits or an emotional disorder1. The aetiology of such lesions is diverse. Habits such as digit sucking, fingernail and lip biting, bruxism, chemical injury and placement of foreign objects in the mouth may be responsible for this phenomena2. Oral squamous cell carcinomas are among the tenth most common cancers worldwide3. The aetiology of oral cancer is multifactorial. The most established risk factors for oral cancer are tobacco use, excessive alcohol consumption and betel quid chewing habit4. Overexposure to ultraviolet light is implicated as the main aetiology of cancer of lip5. This is a short case report of a patient with carcinoma of the lip due to repeated toothpick injury.
A male patient aged 85 years, accompanied by an attendant, reported with the complaint of a growth on the left side of the lower lip of 1-month duration. History revealed injury to the lower lip during shaving, 1 month back. The patient constantly injured the wound with a toothpick. The wound had slowly grown to the present size. It was associated with pain only while taking spicy foodstuffs and with bleeding on pricking with toothpick. There was no associated paraesthesia. Past medical history revealed an unstable mental condition of the patient after being betrayed by his sons. The patient was habituated to betel quid chewing ten times per day since 20 years. Informed consent was obtained as a part of the routine protocol for clinical examination. On examination, three to four bilateral submandibular lymph nodes and single anterior left cervical node were palpable on both the sides measuring 1 cm in
236
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2013; 30: 236–238
Self-inflicted injury
Figure 1 Ulceroproliferative growth noted on lower lip.
diameter, non-tender and mobile. Local examination revealed a solitary ulceroproliferative growth noted on lower lip on left side measuring about 1 9 1 inches in size, extending anteroposteriorly from the midline to the commissural region, inferiorly 1 cm above vermilion border and intraorally extending to the lower labial mucosa up to labial sulcus. The surface was irregular and papillary (Fig. 1). Bloody crustations were seen over the growth. It was mildly tender, firm and fixed to underlying tissues. Bleeding was noted on palpation. Buccal mucosa appeared to be blanched. The case was provisionally diagnosed as carcinoma of the lip. Incisional biopsy was carried out. Histopathological analysis revealed dysplastic epithelium proliferating as large sheets in many areas into the connective tissue. Dysplastic features like cellular and nuclear pleomorphism, altered nuclear cytoplasmic ratio, prominent nucleoli, mitosis and individual cell keratinization were seen. These features were suggestive of moderately differentiated squamous cell carcinoma. The patient was advised to undergo radiotherapy followed by chemotherapy. The patient, however, denied to undergo the treatment and was not available for further review.
Discussion Self-inflicted injury can be a manifestation of unusual or aggressive oral habits or an emotional or psychological disorder. Self-injurious behaviour may be that which results in the infliction of physical damage and, perhaps, pain upon oneself.
237
These self-inflicted injuries are sometimes called factitious injury, self-mutilating injuries and injuries due to masochistic habits. Self-inflicted oral injuries can be pre-meditated, accidental or can result from an uncommon habit6. In general, the deliberate creation of orofacial lesions is an indication of underlying psychiatric disease of various types that usually involve a personal gain by the patient from having such lesions. Self-mutilation may be a feature of schizophrenia, mental handicap and psychiatric disorders6. Our patient was mentally unstable after being deserted by his sons. Stewart and Kernohan classified factitial oral lesions as type A being those superimposed upon a pre-existing lesion, type B, involving the injuries secondary to an established habit, and type C, as those of an unknown or complex aetiology2. Our patient was habituated to betel quid chewing for the past 20 years. Constant toothpick injury to the already conditioned mucosa had resulted in carcinoma of the lip. Betel quid chewing is the major risk factor for cancer. Besides the carcinogens present in the quid such as arecoline, arecaidine there is an additional injury to the oral mucosa from the chewing action. But betel quid chewing is rarely mentioned as a risk factor for lip cancer. Exposure to sunlight, particularly from outdoor employment and other outdoor activities has been considered as a major risk factor for lip cancer7. Trauma from toothpick pricking is the main aggravating factor that had resulted in lip carcinoma in our patient. Management of a patient with self-inflicted lesions can be difficult because the patient is often likely to have the difficulty in communicating his feelings verbally8. Management of these patients should include the lesion-specific treatment as well as psychiatric support to prevent the relapse of such lesions.
Conclusion Self-inflicted lesions with psychological symptoms are not a very uncommon pathology. Diagnosis of such lesions is challenging as the histories of lesions tend to be vague and misleading. Our knowledge in this particular pathology is limited mainly because of diagnostic difficulties and lack of solid statistical data.
References 1. Kotansky K, Goldberg M, Tenenbaum HC, Mock D. Factitious injury of the oral mucosa: a case series. J Periodontol 1995; 66: 241–245.
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2013; 30: 236–238
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R. R. Kashyap, R. S. Kashyap
2. Zonuz AT, Treister N, Mehdipour F, Farahani RM, Tubbs RS, Shoja MM. Factitial pemphigus-like lesions. Med Oral Patol Oral Cir Bucal 2007; 12: E205– E208. 3. Devadiga A, Prasad KV. Knowledge about oral cancer in adults attending a dental hospital in India. Asian Pac J Cancer Prev 2010; 11: 1609–1613. 4. Razak AA, Saddki N, Naing NN, Abdullah N. Oral cancer presentation among Malay Patients in Hospital Universiti Sains Malaysia, Kelantan. Asian Pac J Cancer Prev 2009; 10: 1131–1136. 5. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009; 45: 309–316. 6. Subbaiah R, Thomas B, Maithreyi VP. Selfinflicted traumatic injuries of the gingiva – a case series. JIOH 2010; 2: 43–49.
7. de Visscher JG, Schaapveld M, Otter R, Visser O, van der Waal I. Epidemiology of cancer of the lip in the Netherlands. Oral Oncol 1998; 34: 421–426. 8. Lamey PJ, McNab L, Lewis MA, Gibb R. Orofacial artefactual disease. Oral Surg Oral Med Oral Pathol 1994; 77: 131–134.
Correspondence to: Dr Roopashri Rajesh Kashyap, Department of Oral Medicine and Radiology, A.J. Institute of Dental Sciences, Mangalore, Karnataka 575004, India. Tel.: 09448910793 Fax: 0824-2224968 E-mail: [email protected]
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2013; 30: 236–238
Self-inflicted injury as a potential trigger for carcinoma of lip – a case report Roopashri Rajesh Kashyap1 and Rajesh Shanker Kashyap2 1
Department of Oral Medicine and Radiology, A.J. Institute of Dental Sciences, Mangalore, Karnataka, India; 2Department of Periodontics, Yenepoya Dental College, Mangalore, Karnataka, India
doi: 10.1111/ger.12009 Self-inflicted injury as a potential trigger for carcinoma of lip – a case report Objectives: To report a case of an elderly patient with an unstable mental condition, presenting with the carcinoma of lip due to repeated toothpick injury. Background: Self-induced lesions of the face and mouth may be a manifestation of unusual or aggressive oral habits or an emotional disorder. The deliberate creation of orofacial lesions, is an indication of underlying psychiatric disease. Betel quid chewing is the major risk factor for oral cancer. It conditions the oral mucosa towards the development of cancer. Repeated trauma by self mutilation on such a conditioned mucosa can lead to the development of cancer. Materials and methods: A male patient aged 85 years reported the complaint of a growth on the left side of the lower lip. Trauma followed by self inflicted injury had predisposed to the formation of cancer. Conclusion: Diagnosis of self inflicted lesions are challenging as the histories of these lesions tend to be vague and misleading. Our knowledge in this particular pathology is limited mainly because of diagnostic difficulties and lack of solid statistical data. Keywords: carcinoma of lip, factitious injury, self-inflicted injury Accepted 6 September 2012
Introduction
Case report
Self-induced lesions of the face and mouth may be encountered in routine dental practice. They can be a manifestation of unusual or aggressive oral habits or an emotional disorder1. The aetiology of such lesions is diverse. Habits such as digit sucking, fingernail and lip biting, bruxism, chemical injury and placement of foreign objects in the mouth may be responsible for this phenomena2. Oral squamous cell carcinomas are among the tenth most common cancers worldwide3. The aetiology of oral cancer is multifactorial. The most established risk factors for oral cancer are tobacco use, excessive alcohol consumption and betel quid chewing habit4. Overexposure to ultraviolet light is implicated as the main aetiology of cancer of lip5. This is a short case report of a patient with carcinoma of the lip due to repeated toothpick injury.
A male patient aged 85 years, accompanied by an attendant, reported with the complaint of a growth on the left side of the lower lip of 1-month duration. History revealed injury to the lower lip during shaving, 1 month back. The patient constantly injured the wound with a toothpick. The wound had slowly grown to the present size. It was associated with pain only while taking spicy foodstuffs and with bleeding on pricking with toothpick. There was no associated paraesthesia. Past medical history revealed an unstable mental condition of the patient after being betrayed by his sons. The patient was habituated to betel quid chewing ten times per day since 20 years. Informed consent was obtained as a part of the routine protocol for clinical examination. On examination, three to four bilateral submandibular lymph nodes and single anterior left cervical node were palpable on both the sides measuring 1 cm in
236
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2013; 30: 236–238
Self-inflicted injury
Figure 1 Ulceroproliferative growth noted on lower lip.
diameter, non-tender and mobile. Local examination revealed a solitary ulceroproliferative growth noted on lower lip on left side measuring about 1 9 1 inches in size, extending anteroposteriorly from the midline to the commissural region, inferiorly 1 cm above vermilion border and intraorally extending to the lower labial mucosa up to labial sulcus. The surface was irregular and papillary (Fig. 1). Bloody crustations were seen over the growth. It was mildly tender, firm and fixed to underlying tissues. Bleeding was noted on palpation. Buccal mucosa appeared to be blanched. The case was provisionally diagnosed as carcinoma of the lip. Incisional biopsy was carried out. Histopathological analysis revealed dysplastic epithelium proliferating as large sheets in many areas into the connective tissue. Dysplastic features like cellular and nuclear pleomorphism, altered nuclear cytoplasmic ratio, prominent nucleoli, mitosis and individual cell keratinization were seen. These features were suggestive of moderately differentiated squamous cell carcinoma. The patient was advised to undergo radiotherapy followed by chemotherapy. The patient, however, denied to undergo the treatment and was not available for further review.
Discussion Self-inflicted injury can be a manifestation of unusual or aggressive oral habits or an emotional or psychological disorder. Self-injurious behaviour may be that which results in the infliction of physical damage and, perhaps, pain upon oneself.
237
These self-inflicted injuries are sometimes called factitious injury, self-mutilating injuries and injuries due to masochistic habits. Self-inflicted oral injuries can be pre-meditated, accidental or can result from an uncommon habit6. In general, the deliberate creation of orofacial lesions is an indication of underlying psychiatric disease of various types that usually involve a personal gain by the patient from having such lesions. Self-mutilation may be a feature of schizophrenia, mental handicap and psychiatric disorders6. Our patient was mentally unstable after being deserted by his sons. Stewart and Kernohan classified factitial oral lesions as type A being those superimposed upon a pre-existing lesion, type B, involving the injuries secondary to an established habit, and type C, as those of an unknown or complex aetiology2. Our patient was habituated to betel quid chewing for the past 20 years. Constant toothpick injury to the already conditioned mucosa had resulted in carcinoma of the lip. Betel quid chewing is the major risk factor for cancer. Besides the carcinogens present in the quid such as arecoline, arecaidine there is an additional injury to the oral mucosa from the chewing action. But betel quid chewing is rarely mentioned as a risk factor for lip cancer. Exposure to sunlight, particularly from outdoor employment and other outdoor activities has been considered as a major risk factor for lip cancer7. Trauma from toothpick pricking is the main aggravating factor that had resulted in lip carcinoma in our patient. Management of a patient with self-inflicted lesions can be difficult because the patient is often likely to have the difficulty in communicating his feelings verbally8. Management of these patients should include the lesion-specific treatment as well as psychiatric support to prevent the relapse of such lesions.
Conclusion Self-inflicted lesions with psychological symptoms are not a very uncommon pathology. Diagnosis of such lesions is challenging as the histories of lesions tend to be vague and misleading. Our knowledge in this particular pathology is limited mainly because of diagnostic difficulties and lack of solid statistical data.
References 1. Kotansky K, Goldberg M, Tenenbaum HC, Mock D. Factitious injury of the oral mucosa: a case series. J Periodontol 1995; 66: 241–245.
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2013; 30: 236–238
238
R. R. Kashyap, R. S. Kashyap
2. Zonuz AT, Treister N, Mehdipour F, Farahani RM, Tubbs RS, Shoja MM. Factitial pemphigus-like lesions. Med Oral Patol Oral Cir Bucal 2007; 12: E205– E208. 3. Devadiga A, Prasad KV. Knowledge about oral cancer in adults attending a dental hospital in India. Asian Pac J Cancer Prev 2010; 11: 1609–1613. 4. Razak AA, Saddki N, Naing NN, Abdullah N. Oral cancer presentation among Malay Patients in Hospital Universiti Sains Malaysia, Kelantan. Asian Pac J Cancer Prev 2009; 10: 1131–1136. 5. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009; 45: 309–316. 6. Subbaiah R, Thomas B, Maithreyi VP. Selfinflicted traumatic injuries of the gingiva – a case series. JIOH 2010; 2: 43–49.
7. de Visscher JG, Schaapveld M, Otter R, Visser O, van der Waal I. Epidemiology of cancer of the lip in the Netherlands. Oral Oncol 1998; 34: 421–426. 8. Lamey PJ, McNab L, Lewis MA, Gibb R. Orofacial artefactual disease. Oral Surg Oral Med Oral Pathol 1994; 77: 131–134.
Correspondence to: Dr Roopashri Rajesh Kashyap, Department of Oral Medicine and Radiology, A.J. Institute of Dental Sciences, Mangalore, Karnataka 575004, India. Tel.: 09448910793 Fax: 0824-2224968 E-mail: [email protected]
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2013; 30: 236–238
