Dental self-injury in a child with attention deficit hyperactivity disorder and obsessive-compulsive disorder: Review of literature and a case report

ABSTRACT

This review examines self-injurious behavior (SIB) in individuals with attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD), focusing on teeth autoextraction, a rare occurrence in this group. The study centers around an 11-year-old girl who, as a new patient, was missing two teeth and later extracted two more. It analyzes documented SIB cases, particularly teeth autoextraction in ADHD and OCD contexts. Few documented cases show teeth autoextraction in ADHD and OCD individuals, highlighting a lesser-known form of SIB. Early recognition and multidisciplinary management are vital to address this behavior. Identifying autoextraction in ADHD and OCD patients is crucial for dental and healthcare professionals. Collaborative care can prevent SIB escalation and provide holistic support for these individuals.

INTRODUCTION

Self-injurious behavior (SIB) refers to the deliberate act of causing harm or injury to oneself, which can include actions such as hitting one’s head against hard surfaces, self-harming activities including head-hitting, self-biting, minor injuries such as scratches or bruises, and autoextraction.[1,2] SIB is often associated with certain diseases and syndromes, including autism spectrum disorders (ASDs), intellectual disabilities, Lesch–Nyhan syndrome, and Cornelia de Lange syndrome.[3,4] Dentists need to stay attentive to dental injuries and oral signs of SIB in children with attention deficit hyperactivity disorder (ADHD).[5,6] ADHD, defined by symptoms of inattention, hyperactivity, and impulsivity as per the American Psychiatric Association (2013), is a common psychiatric condition impacting 4%–6% of children and adolescents, and a majority of whom may have ongoing challenges into adulthood.[7,8,9] Research shows that people with ADHD tend to have a lower quality of life than those without the condition.[10,11] In addition, over 60% of individuals with ADHD have at least one other psychiatric disorder, which can include both externalizing and internalizing issues.[12,13]

Nonsuicidal self-injury (NSSI) was officially acknowledged as a separate diagnosis in the DSM-5, falling under Section III as a condition warranting further investigation.[14] The DSM-5 underscores the deliberate, non-suicidal aspect of NSSI, noting its lack of cultural approval. The prevalence of NSSI varies across different age groups, with rates ranging from 13% to 45% among adolescents, 4% among adults, and 40%–80% in clinical adolescent populations.[15]

Researchers are increasingly investigating the potential association between ADHD and self-injury, particularly NSSI. Two systematic reviews have highlighted a strong correlation between the two.[16,17] A shared trait between these phenomena is poor response inhibition, linked to impulsivity.[18]

Research in the dental field suggests that about 32% of children with ADHD could encounter dental injuries around the age of 11.[6,19] The research highlights that among children with ADHD, the maxillary central incisors are often affected, with common injuries like crown fractures and subluxations.[20]

Obsessive-compulsive disorder (OCD) is a severe mental health condition marked by significant and enduring challenges in daily life, featuring several distinct subcategories.[21,22] Conditions marked by impulsivity, such as NSSI, may be considered as part of a shared spectrum with individuals who have OCD, as both groups face challenges in regulating behavioral patterns. This hypothesis suggests that disorders within this category would exhibit similarities in phenomenology, heritability, and responses to interventions with similar topographical approaches.[23,24]

Notably, our report introduces a unique finding, as there has been no prior documentation of self-inflicted dental injuries, specifically autoextraction, in children with ADHD and OCD.

CASE REPORT

The patient was an 11-year-old female who was first examined on December 5, 2022, at the Oral Health Department of Tehran Azad University. Her chief complaint had been the repeated self-extraction of her teeth. She was accompanied by her mother, who reported ongoing behavioral disturbances and prior incidents of autoextraction.

At the time of her first dental visit, general examination indicated no systemic disease based on laboratory findings. Oral examination revealed multiple missing teeth due to autoextraction, signs of trauma, and significant mobility in the remaining anterior mandibular teeth.

The medical history revealed that she had been diagnosed with ADHD and OCD at the age of four by a child psychiatrist. Her dental history included multiple replantation attempts by a pediatric dentist due to self-extraction episodes.

In terms of familial history, the patient’s parents had divorced when she was 3 years old, and she had since lived with her mother and grandmother. This family situation had potentially contributed to increased emotional stress.

Psychologically, she presented with a complex psychiatric profile, including compulsive self-mutilation behaviors such as oral and anal self-injury, and symptoms typical of ADHD – such as an inability to concentrate and poor academic performance. Her pharmacological treatment included aripiprazole 5 mg twice daily (BD), fluvoxamine 50 mg BD, atomoxetine 25 mg BD, and melatonin 3 mg at bedtime (HS). Despite this regimen, she continued to exhibit severe compulsive behaviors, leading to the autoextraction of her permanent teeth.

She was referred for further psychiatric evaluation, and a second psychiatrist diagnosed her with mild ASD. Although ASD symptoms were present, there was no intellectual disability, and her cognitive function was within the normal range.

This case highlights the blurred boundaries between psychiatric disorders. Co-occurrence of ADHD, OCD, and ASD complicates diagnosis and treatment, illustrating that many psychiatric conditions overlap and may not present with distinct borders. Their shared traits – such as impulsivity, compulsivity, and behavioral dysregulation–require clinicians to approach diagnosis and treatment comprehensively, recognizing that rigid categorization may not reflect the clinical reality. Continued psychiatric consultation and a multidisciplinary approach were required to manage her care.

Trauma history

The right central mandibular incisor was initially avulsed by the child on November 28, 2022, and was promptly replanted and splinted with wire-composite on the same day by a pediatric dentist. According to the parent’s report, the child used her fingers to repeatedly and persistently apply pressure on the tooth, gradually loosening it until avulsion occurred. Four days later, the right lateral mandibular incisor was also avulsed in the same manner. Both teeth were again replanted and splinted with wire-composite by the same pediatric dentist on the same day. However, on December 2, 2022, the child self-extracted both teeth once more using her fingers. As the mother was employed and unable to supervise the child at all times, especially during working hours, it was difficult to control this gradual and obsessive SIB. The teeth were subsequently replanted and splinted with composite on the same day.

Two days later, on December 4, 2022, the child removed the replanted and splinted teeth. Following this incident, the child was referred to the Oral Health department of Tehran Azad University on December 5, 2022. A laboratory examination – including complete blood count, thyroid function tests, serum calcium, phosphorus, and alkaline phosphatase – was conducted, all of which showed values within normal ranges, ruling out any underlying systemic condition that could contribute to the oral manifestations. Consequently, the child was further referred to the Pediatric Dentistry Department of Tehran Azad University on December 11, 2022 [Figures 1-3].

Figure 1.

Frontal intraoral view immediately after autoextraction of a mandibular central incisor.

Figure 3.

Panoramic radiograph with an anterior mandibular defect consistent with a recent extraction.

Figure 2.

Mandibular occlusal view immediately after autoextraction of a mandibular central incisor.

Both teeth underwent a 20-minute immersion in a 2% NaF mouthwash. Subsequently, access cavities were prepared, and the canals of the teeth were filled with Meta-paste, consisting of calcium hydroxide, barium sulfate, and polypropylene glycol.

Following these procedures, both teeth were then splinted using composite [Figure 4].

Figure 4.

Mandibular occlusal view immediately after replantation of both mandibular central incisors, stabilized with a composite resin splint across the anterior segment.

Seven days later, both teeth were autoextracted, and a PA radiograph was ordered on December 19, 2022.

A periodontal examination conducted by a periodontist on the same day revealed excessive bone loss, making replantation not feasible. Following this, consultations were held with a child therapist and psychiatrist, leading to modifications in the prescribed medications. Regular follow-ups were conducted in preparation for definitive treatment, during which the left mandibular canine was auto-extracted. At the subsequent follow-up session on January 9, 2023, a grade III luxation was detected in the right mandibular canine. To address this, we disoccluded the right mandibular canine along with the left central and lateral mandibular incisors [Figure 5].

Figure 5.

Frontal intraoral view at follow-up, adjusting the anterior teeth to be out of occlusion.

Following the autoextraction, the mandibular canine underwent replantation and was subsequently splinted using a rigid composite. After the child’s mental stabilization, based on the consultation with the child’s psychiatrist, a lingual arch with teeth was designed to restore the site of the extracted teeth. This procedure was performed on July 15, 2023 [Figures 6 and 7].

Figure 6.

Frontal intraoral view at delivery of the mandibular lingual-arch appliance with acrylic replacement restoring the anterior edentulous space after autoextractions.

Figure 7.

Mandibular occlusal view of the cemented rigid lingual-arch space maintainer.

The patient returned for a follow-up after 6 months. During the intraoral assessment, it was noted that she had no cavities and was upholding appropriate oral hygiene practices. However, the cement on the lingual arch had washed away, so on December 17, 2023, we re-cemented the lingual arch.

DISCUSSION

This case presents the clinical and behavioral challenges involved in managing an 11-year-old pediatric patient with severe SIB, ADHD, and possible obsessive-compulsive features, leading to multiple episodes of intentional autoextraction of mandibular anterior teeth. Despite timely replantation and splinting, the child’s compulsive behaviors resulted in repeated removal of the replanted teeth, highlighting the limitations of conventional dental management in such high-risk behavioral contexts.

To contextualize this case, relevant literature was reviewed on the association between SIB and neurodevelopmental disorders such as ADHD, OCD, and ASD. Several reports have documented oral self-mutilation and autoextraction behaviors in children with these psychiatric conditions, emphasizing the complexity of diagnosis and management in such overlapping disorders.[4,16,25] This literature review supports the observed clinical pattern, as numerous studies have documented a strong and not uncommon correlation between ADHD and self-harming behaviors, particularly in children with overlapping psychiatric or behavioral disorders.[16,17,26]

In this case, the child was under pharmacologic management with aripiprazole, fluvoxamine, and atomoxetine, yet persistent SIB suggested either pharmacologic resistance or inadequacy of medical management alone. Current literature emphasizes that multidisciplinary intervention, beyond pharmacologic treatment, is often necessary for such complex behavioral presentations.[27,28]

Although ASD was initially considered, the absence of classic symptoms – such as pronounced social communication deficits or restricted repetitive behaviors – made ASD less likely. However, because ADHD and OCD may share overlapping behavioral features with ASD, neuropsychological testing remains important for diagnostic clarification and individualized treatment planning.

Given the degree of periodontal bone loss and previous failed replantations, further replantation attempts were deemed nonviable by the periodontist. Upon achieving improved behavioral stability, and based on psychiatric consultation, a fixed lingual arch with prosthetic teeth was fabricated. This appliance served to restore function and esthetics, prevent space loss, and potentially deter further self-injury. Literature supports the use of fixed prosthetic options in noncompliant or behaviorally complex pediatric patients, as removable appliances pose risks of repeated removal, aspiration, or ingestion.

Furthermore, research indicates that ADHD may be associated with delayed, rather than abnormal, brain maturation.[29,30,31] While this developmental delay may improve with age, during school-age years, children with ADHD are at a significantly elevated risk for behavioral disturbances, including antisocial tendencies, impulsivity, academic difficulties, and self-harm behaviors – risks shown to be 5–10 times higher than in the general population.[32,33]

This case underscores the importance of a comprehensive, interdisciplinary treatment model, involving pediatric dentistry, psychiatry, periodontology, and behavioral therapy. The decision to place a fixed lingual arch prosthesis was a rational, preventive, and patient-centered intervention, adapted to the child’s medical and behavioral status and supported by relevant literature. Continuous monitoring and a flexible treatment plan remain vital to ensuring both the child’s dental health and psychological well-being.

Children diagnosed with ADHD are at a greater risk of developing an increased number of dental cavities.[34,35] This higher prevalence of cavities can be attributed to insufficient oral hygiene practices, as children with ADHD may struggle to consistently remember to brush their teeth and face challenges in effectively maintaining their oral health.[36] In addition, kids with ADHD have a heightened susceptibility to dental injuries[6,19,37] and may also exhibit a higher occurrence of molar incisor hypoplasia.[38] Lalloo’s findings indicated that children with hyperactivity are at a twofold higher risk of sustaining facial and dental injuries compared to the control group.[39]

This heightened susceptibility is directly associated with their participation in violent behaviors stemming from conduct disorder.[40] Hyperactive children also demonstrate elevated plaque levels and reduced unstimulated saliva production.[41,42] Children with ADHD are at an increased risk of experiencing physical abuse from a caregiver in comparison to children who do not have ADHD.[43] Children with ADHD and their parents are at a higher risk of feeling heightened anxiety when visiting the dentist’s office.[34] Many parents are worried about how their child’s actions may affect others, including dental professionals.[44] This concern may lead to the avoidance of necessary dental treatment. As mentioned previously, there is a higher likelihood of self-harming actions in children with ADHD, which may include actions in the mouth resulting in luxation and autoextraction of teeth. Over the years, researchers have proposed various classifications for SIB. SIB can be divided into four groups: stereotypic, major, compulsive, and impulsive.[45]

Compulsive SIB includes actions such as pulling hair, picking at the skin, and biting nails.[46] Cannavale et al. emphasized a connection between OCD and difficulties in familial relationships or parental discord.[47] In the case we presented, the child’s parents divorced when she was 3 years old, leading to her residing with her mother and grandmother thereafter. This family dynamic might have served as a potential source of stress and anxiety for the child. The described autoextraction reportedly occurred rapidly during instances when the child was unsupervised, and the child exhibited a persistent inclination to engage in SIB whenever the opportunity arose. While we do not believe child abuse occurred, the emotional stress from parental divorce and the child’s family dynamics likely contributed to the behavioral manifestations observed. While literature has documented various instances of autoextraction, the majority involve adults. For instance, a 29-year-old individual with a diagnosis of a psychotic disorder removed their upper canine teeth and observed a reduction in stress levels and a pain-free procedure.[48] In a separate research investigation, a report detailed the case of a 27-year-old Caucasian male with psychosis who self-extracted several posterior teeth.[49] Another report documented the self-inflicted injury and self-removal of permanent incisors in a severely burned child.[50] In cases involving children, there have been documented instances of autoextraction linked to SIB affecting a primary canine tooth in a child diagnosed with ASD[49] and in six children diagnosed with familial dysautonomia, SIB often targeted the oral cavity as a common location.[51] A separate case study documented the autoextraction of 12 permanent teeth in a child with ASD.[52] Interestingly, there is a notable absence of literature on autoextraction in children diagnosed with ADHD or OCD. It has been suggested that self-injury, such as autoextraction, could potentially trigger the release of opiates, leading to a pleasurable or euphoric sensation that reinforces the behavior.[52] Healthcare providers caring for patients with ADHD need to be aware of the increased occurrence of self-harming actions in this group. If a patient with ADHD experiences unexplained dental pain that cannot be attributed to typical causes like cavities or infections, it is important to consider the potential for injuries caused by self-harm when evaluating the situation.

Ethical approval and consent to participate

Ethical approval was taken into account for the publication of this paper, and consent for participation, as well as written informed consent, were obtained from the patient and her parents for publication. A copy of the consent form is accessible to the Editor-in-Chief of this journal for reference.

Authors’ contribution

Matine Gharavi conducted the clinical procedures detailed in the case report, prepared the case report, discussion, and manuscript. Nahid Askarizadeh provided invaluable oversight of the clinical procedures and demonstrated expertise in reviewing and refining the article. Both authors collaborated closely, contributing their expertise and insights to shape and approve the final manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.

Funding Statement

Nil.