CASE REPORT Nail-biting and foreign body embedment: a review and case report Eric D. Hodges, DDS Keith Alien, PhD Timothy Durham, DDS Introduction edges of the incisors, gingivitis,10 idiopathic tooth api- 15 16 Reports of foreign bodies in the oronasal complex cal root resorption, and orthodontic complications. have included bullets, impression materials, teeth, fish In addition, problematic variations have been noted bones, needles, plastics, pistachio nuts, earrings, and including biting the cuticles and the surrounding skin, the traumatic implantation of a toothbrush.1"1 These tearing at the nails, lip and cheek biting, and chronic foreign bodies have been found by palpation, direct thumb-sucking. This case describes damage to the peri- visualization, or as incidental findings on radiographs. odontal tissues as a result of inserting torn fingernails A thorough history may establish an etiology and time into the gingival sulcus. frame in which the foreign body was embedded in soft Case report tissue. A chronic oral habit can introduce foreign bodies A 6-year, 10-month-old white male was examined at into the oral cavity. Most pernicious oral habits such as the University of Nebraska Department of Pediatric dummy or digit sucking, lip and cheek biting, and Dentistry during a well patient visit. His medical his- tongue thrusting are associated with oral complica- tory included several ear infections, myringotomy, and tions, but do not involve foreign bodies. This unique tube placement. His past dental history included a habit case history describes the introduction of a foreign of biting and sucking on a mucocele and concomitant body in association with habitual fingernail biting. biting of the fingernails. A hard tissue examination revealed an early mixed dentition with buccal carious Literature review lesions in the mandibular first permanent molars. A Habitual nail-biting (onychophagia) is widespread soft tissue examination revealed an asymptomatic among children, beginning as early as 4 years and aphthous ulcer on the mandibular left buccal mucosa, a peaking typically between 10 and 18 years.5 Prevalence mucocele on the left mandibular lip mucosa, and erup- estimates are dated, but range from 30%6during child- tion gingivitis associated with the newly erupted max- hood to nearly 45% in adolescence.7 Onychophagia illary permanent central incisors. appears to be familial and occurs slightly more often in Following his initial examination, prophylaxis, and females.8 It is a repetitive, undesirable behavior often topical fluoride application, appointments were sched- assumed to be a sign of emotional tension or anxiety in uled for mucocele excision, sealants, and restorative children,9 a conclusion drawn from observations that care. An excisional biopsy was accomplished and the stress often precipitates specific occasions of nail-bit- clinical impression of mucocele confirmed by histo- ing.10 However, little evidence supports that children who bite their nails are generally more anxious than those who do not.1' While onychophagia has character- istics similar to those of obsessive-compulsive disor- der (OCD), it has never been considered a symptom or reported as co-occurring with OCD. Indeed, recent stud- ies suggest that even the most severe forms of nail- biting occur in the absence of major psychopathologi- cal disorders.12 Nail-biting is more likely a disorder of excessive grooming.13 This etiologic perspective sug- gests that the biological system mediates complex re- petitive behaviors like nail-biting that may at one time have had evolutionary adaptive significance. Most habitual nail-biting is considered trivial, but it can cause medical and dental problems. In addition to recurrent paronychia and chronic subungual infection, severe nail-biting has been associated with craniomandibular dysfunction,14 small fractures at the Fig 1. Pretreatment tissue condition. 236 Pediatric Dentistry: May/June 1994 - Volume 16, Number 3 logical study. The parent was counseled on minimizing the patient's nail-biting habit dur- ing the healing period to opti- mize wound healing. When the patient returned for dental treatment, his mother expressed concern re- garding a-localized swelling overlying the erupting maxil- lary right permanent central incisor without other soft tis- sue involvement or a history Fig 2. Post-treatment tissue condition. Fig 3. Fingernails removed from the maxillary of trauma (Fig 1). A radio- right permanent central incisor gingival sulcus. graphic examination of the af- fected area was unremarkable, but clinical examination Discussion showed a purulent exudate and a 10-mm periodontal Foreign bodies in the soft tissues of the oral cavity pocket in the buccal surface of the maxillary right per- have been reported previously, but this appears to be manent central incisor. The tooth was not significantly the first case of fingernail fragments embedded in the sensitive to percussion, but was tender to buccal prob- oral soft tissues' A habit such as nail-biting does not ing and palpation. The lingual surface of the tooth re- immediately predict the presence of oral soft tissue vealed normal probing depths. A foreign body was foreign bodies, but one that repeatedly introduces for- suspected as the etiology of the localized swelling and eign bodies into the oral cavity is a concern and makes periodontal defect. a careful history and examination important. The tooth and the soft tissues were anesthetized and The patient's nail-biting and embedding habit a curette was utilized to probe and remove any foreign seemed to intensify following removal of the mucocele, body or sulcular debris. After complete curette which had been habitually traumatized by a lip-biting debridement and irrigation of the sulcus with sterile habit. In retrospect, what had been initially diagnosed water, 15 fingernail fragments were found in the buccal as gingivitis associated with the eruption of the maxil- gingival sulcus (Figs 2 and 3). A gauze pressure pack lary right and left permanent central incisors was most was placed and the patient was dismissed to his mother likely the initial sign of trauma from the nail-biting with instructions to eliminate the nail-biting habit. Re- habit. ferral to the UNMC Department of Psychology was Typically, a thorough history and examination will suggested should further intervention be necessary. provide thenecessary information todiagnosea chronic The patient's operative dentistry was completed habit like nail-biting or lip-biting. The patient denied without complication and healing of the periodontal knowledge of placing fingernails into the gingival sul- pocket was uneventful (Fig 4). cus. Consequently, a complete history of oral habits should involve careful questioning of the parents to confirm a child's negative habit history. Nail-biting is a common, generally harmless child I behavior that is self limiting and typically does not requireintervention. Whether to treat nail-biting should be determined by risk potential, and the dentist can play an important role in identifying dental complica- tions and risk. One risk, described in this report, in- volves theembedding of tom fingernails into thegingi- val sulcus of a tooth. A complete history of oral habits should involvecareful questioning of the parents, since children are often unaware of their nail-biting or reluc- tant to admit to the habit. Dr. Hodges is assistant professor, University of Nebraska Medical Center College of Dentistry,Deparhnent ofPediatricDentistry,Meyer Rehabilitation Institute, Omaha. Dr. Allen is associate professor, UNMC College of Medicine, Deparhnent of Pediatric Psychology, Meyer Rehabilitation Institute, Omaha. Durham is assistant Fig 4. One month posl-treatment soft tissue condition. Dr. professor, UNMC Hospitals and Clinics, department of pathology, Pediatric Dentistry: Mayllvne 1994 -Volume 16, Number 3 237 diagnosis and radiology and director of the UNMCgeneral practice 8. BakwinH: Nail biting in twins. Dev MedChild Neuro113:304- residency program, Omaha. 7, 1971. 1. Hodges E, DurhamT, Stanley R: Managementof aspiration 9. Schneider PE, Peterson J: Oral habits: considerations in man- and swallowingincidents: a review of the literature and report agement. Ped Clin N Am29:523-41, 1982. of a case. ASDCJ Dent Child 59:413-19, 1992. 10. LeungA, RobsonW: Nailbiting. Clin Pediatr 29:690-92, 1990. 11. 2. O’BrienD, Fantasia J, Miller A: Unusualforeign body present- Deardorff PA, Finch AJ, Royall LR: Manifest anxiety and ing as a palatal tumor. Pediatr Dent10:226-27, 1988. nailbiting. J Clin Psychol30:378, 1974. 3. Kittle P, AaronG, Jones H, Duncan,N: Incidental finding of an 12. Leonard H, LenaneM, SwedoS, RettewD, RapoportJ: A double- intranasal foreign body discovered on routine dental examina- blind comparison of clomipramine and desipramine treatment tion: a case report. Pediatr Dent 13:49-51,1991. of severe onychophagia(nail biting). Arch GenPsychia 48:821- 4. MacLeodS: Traumatic implantation of a toothbrush: an un- 27, 1991. 13. usual hazard of oral hygiene. ASDCJ Dent Child 13:69-70, Demaret A: Onychophagia, trichotillomania and grooming. 1989. Anales Medico-Psychologiques1:235-42, 1970. 5. Ballinger B: The prevalence of nail biting in normaland abnor- 14. Westling L: Fingernail biting. Cranio 6:182-87, 1988. mal populations. Br J Psychia 117:445-46,1970. 15. Massler M, Malone AJ: Root resorption in humanpermanent 6. Birch LB: The incidence of nail-biting amongschool-children. teeth. AmJ Orthodom40:619-33, 1954. Br J Ecl Psychol25:123-28, 1955. 16. OdennckL, Brattstrom V: Nailbiting: frequency and associa- 7. WechslerD: Incidence and significance of fingernail biting in tion with root resorption during orthodontic treatment. Br J children. PsychoanalyRev 18:201-9, 1931. Orthodom12:78-81, 1985. Physicians’ euthanasia survey shows wide variation of opinions Almost 28% of physicians responding to a survey said they would be willing to perform euthanasia if it were legalized, according to an article in a recent issue of the AMA’sArchives of Internal Medicine. Robyn S. Shapiro, JD, and colleagues at the Medical College of Wisconsin, Milwaukee, conducted a survey that was returned by 740 physicians, a response rate of 33%.