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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2011  |  Volume : 29  |  Issue : 6  |  Page : 95-98

Self-injurious behavior and foreign body entrapment in the root canal of a mandibular lateral incisor

1 Department of Pedodontics, Thai Moogambigai Dental College and Hospital, Chennai, India
2 Department of Pedodontics, Rajah Muthiah Dental College and Hospital, Annamalai University, Tamil Nadu, India

Date of Web Publication12-Dec-2011

Correspondence Address:
B N Rangeeth
Department of Pedodontics, 987, TVS Colony, 50th Street, Anna Nagar West Extension, Chennai - 600 101, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.90754

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Self-injurious behavior is a deliberate alteration or damage without suicidal indent. Herein, we report a patient who had caused intentionally self-trauma to his left lower permanent canine and placed a long metallic foreign body into the root canal. History revealed a habit of placing metallic objects in the form of stapler pins into the mouth, but closer examination revealed the habit to be more as a method of self-injurious behavior. Following an episode of severe pain, the tooth was endodontically treated after removal of the foreign body that was corroding. Clinical significance of the case report is that the patient may just be put off as having a habit of inserting foreign objects into the mouth, but the behavior was more self-injurious in nature.

Keywords: Foreign body, habits, self-injurious behavior, self-mutilation

How to cite this article:
Rangeeth B N, Moses J, Reddy N V. Self-injurious behavior and foreign body entrapment in the root canal of a mandibular lateral incisor. J Indian Soc Pedod Prev Dent 2011;29, Suppl S1:95-8

How to cite this URL:
Rangeeth B N, Moses J, Reddy N V. Self-injurious behavior and foreign body entrapment in the root canal of a mandibular lateral incisor. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2023 Jan 29];29, Suppl S1:95-8. Available from: http://www.jisppd.com/text.asp?2011/29/6/95/90754

   Introduction Top

Children develop the habit of inserting foreign objects into the mouth, with some developing a persistent habit and when traumatized, they do not report it to the parents, fearing punishment. Deliberate self-harm is a traumatic experience with serious consequences at both individual and social levels. Providing care and support for people who self-harm poses a particular challenge to practitioners across a range of agencies. [1] The occurrence of foreign bodies in the form of screws, staple pins, darning needs, pencil leads and tooth pick have been reported in literature, [2],[3],[4],[5],[6] but rarely these have been associated with a self-injurious behavior (SIB).

SIB is the deliberate alteration or damage of one's own body or body part without suicidal intent. [7] The terms self-harm (SH) or deliberate self-harm (DSH) include self-injury (SI) and self-poisoning are used to describe intentional, direct injuring of body tissue without suicidal intent. These terms are used in the more recent literature in an attempt to reach a more neutral terminology. The older literature, especially which predates the "The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR)," almost exclusively refers to "self-mutilation." The term is synonymous with "self-injury." [7],[8],[9] Self-mutilation is a behavior commonly observed in patients with some psychiatric disorders, such as borderline personality disorder, depression, and schizophrenia, where patients violently inflict lesions to their own bodies with no intent to commit suicide. [10],[11]

Diagnosis of these cases is often made accidentally on radiographic examination or may be associated with pain, swelling and recurrent abscesses. Retrieval of foreign objects in root canals is a challenging part in pediatric practice. The objects can be easily retrieved if found in the root canal, but when encountering the objects in the root canal the retrieval may be complicated. Clinical and radiographic examinations are very important in the diagnosis of these cases, and our approach in obtaining a definitive case history led us to study a pattern of SIB.

   Case Report Top

An apparently healthy 13-year-old male child was brought to the out-patient department with the chief complaint of a painful fractured tooth in the left side of lower jaw for a little more than a week and with no history of any traumatic episodes [Figure 1]. Clinical examination revealed fractured crown of left mandibular lateral incisor, with a closer examination revealing a pattern that did not seem like that of a fracture line in the form of irregular margins, but was consistent with that of a pathologic wear pattern with the pulp chamber and root canal clinically visible. The parent was inquired once again, who reported that the patient used to intentionally injure the tooth with a metal piece, mostly a stapler pin or a stick. An intraoral digital radiograph [Figure 2] revealed the presence of two metallic objects in the root canal of the right mandibular lateral incisor, with one of the metallic objects passing slightly through the apical end into the surrounding tissues, and presence of slightly wide apical foramina. Same side lingual opposite side buccal rule was used to determine if the foreign object was in the canal or outside it. Closer examination revealed that the metallic object did not pass through the apex but was slightly above, indicating a perforation and periapical pathology. The patient confirmed the probable history that he used to forcefully injure himself and had placed a straightened stapler pin into the hole in the tooth (root canal). A tetanus vaccine booster dose was administered prior to initiating dental treatment. The primary aim of the treatment plan was to obtain a proper case history of the patient to ascertain about the SIB pattern and to provide counseling for the patient and parent. Secondly, conservative management of the lateral incisor was considered under antibiotic cover and removal of the foreign objects was done by tactile sensation using K-Files of size 10-25 with irrigation alternating between sodium hypochloride and hydrogen peroxide and the evacuation done using high vacuum suction [Figure 3]. The irrigants passed out of the canal with a blackish color revealing that the metallic objects were corroding. A few pieces of wood-based substance along with the metallic objects were obtained, which was not surprising as these are not radio-opaque [Figure 4]. Finally, the root canal was irrigated copiously with saline, then with chlorhexidine and sodium hypochloride, and the tooth was placed under observation for a period of time as there was bleeding from the canal with periapical pathology. Absence of foreign body in the root canal was later confirmed with a radiograph [Figure 5] and an intra-canal medicament containing calcium hydroxide (Metapex, Meta Biomed Co. Ltd., Korea) was administered to allow healing of the apical region following perforation by the foreign object, after drying the canal with sterile paper points [Figure 6]. The patient was advised routine endodontic procedure followed by dressing with calcium hydroxide. Obturation was advised on improvement of periapical symptoms. The patient was advised to see a psychologist for intervention of the SIB as the parents felt that the child was still continuing the practice of trying to injure the tooth.
Figure 1: Left mandibular lateral incisor showing signs of pathologic wear

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Figure 2: Intraoral radiograph revealing the presence two radio-opaque slender objects in the root canal, with one of them projecting into the periapical tissues

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Figure 3: Copious irrigation and careful instrumentation brings out one of the foreign bodies

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Figure 4: A few pieces of wood-based material (W) and corroding metal (M) removed from root canal

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Figure 5: Radiograph confirming the absence of foreign body in the root canal prior to placement of intra-canal medicament

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Figure 6: Calcium hydroxide placed as intra-canal medicament with improvement in the periapical pathology

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   Discussion Top

Toxic reactions can even be elicited by endodontic filling materials and may occur in any patient, provided the exposure exceeds a certain level. The threshold level is based on the fact that the human body has the ability to detoxify xenobiotics (compound foreign to the body), but when the exposure exceeds this ability, a toxic response occurs. A toxic reaction is also dose related in that the biological response increases with increasing dose. [12] When endodontic materials themselves can elicit toxic reactions, the present situation warranted urgent attention as the material was a corroding metal and corrosion increases the biological response, which can lead to mortality of the tooth involved.

The procedure primarily aimed at obtaining an access and use of irrigating solutions such as sodium hypochloride and hydrogen peroxide that would primarily remove the contamination in the root canal as a result of corrosion of the metal. The use of sodium hypochloride alternating with hydrogen peroxide produces effervescence that helps to dislodge the contamination from the root canal. [13] Following removal of the foreign body, it was of utmost importance to sterilize the canal. Root canal flora is dominated by obligate anaerobic bacteria; some facultative strains like Enterococcus faecalis, Staphylococcus aureus are involved in persistent infections, influencing the prognosis of the root canal treatment. [14] Routine endodontic procedure was followed to remove the foreign body as in a similar case report, [2] with the use of smaller files being more frequent while removing the foreign body.

The majority of bacteria found in the root canal microflora may be removed simply by the mechanical action of endodontic instruments. However, due to the mechanical complexities of many root canals, even after mechanical procedures, organic residues and bacteria located deep in the dentinal tubules cannot be reached. Therefore, various irrigating solutions have been used during and immediately after root canal preparation to remove debris and necrotic pulp tissue and to eliminate microorganisms that cannot be reached by mechanical instrumentation, [15] and the use of sodium hypochloride with chlorhexidine is more effective than using either one alone. [16]

The treatment of choice for necrotic teeth is apexification, which is induction of apical closure to produce more favorable conditions for conventional root canal filling. The most commonly advocated medicament is calcium hydroxide, although recently considerable interest has been expressed in the use of mineral trioxide aggregate. [17] The use of calcium hydroxide was considered as it is more cost effective. In addition to providing a good apical seal, there is a remote possibility of complimentary apical root development. [18]

   Conclusion Top

Children develop a variety of habits, but we must ensure that unwanted ones and sometimes dangerous ones in the form of SIB are eliminated. It could have been quite easy to dispose of this case as just another one with a habit of chewing pins, but the possibility of SIB was found to exist in this as the patient had undergone pain when the root canal got exposed. Though the parent said that the tooth was broken for little more than a week, careful questioning of the patient and parent revealed a more long-term episode of this form of behavior. Surely, if this was just another habit, it could have been stopped as there are initial signs of pain and continuation of injury could not have persisted beyond a point. The patient has also been advised psychological counseling to stop the habit.

   References Top

1.Kingdon A. Self-injurious behaviour and deliberate self-harm. In: Riding T, Swann C, Swann B, editors. The Handbook Of Forensic Learning Disabilities. 1 st ed. Lancaster, England: Radcliffe Medical PR; 2005. p. 97-120.  Back to cited text no. 1
2.Aduri R, Reddy RE, Kiran K. Foreign objects in teeth: Retrieval and management. J Indian Soc Pedod Prev Dent 2009;27:179-83.  Back to cited text no. 2
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3.Hall JB. Endodontics--patient performed. ASDC J Dent Child 1969;36:213-6.  Back to cited text no. 3
4.Prabhakar AR, Basappa N, Raju OS. Foreign body in a mandibular permanent molar: A case report. J Indian Soc Pedod Prev Dent 1998;16:120-1.  Back to cited text no. 4
5.Subbareddy VV, Mehta DS. Beads. Oral Surg Oral Med Oral Pathol 1990;69:769-70.  Back to cited text no. 5
6.McAuliffe N, Drage NA, Hunter B. Staple diet: A foreign body in a tooth. Int J Paediatr Dent 2005;15:468-71.  Back to cited text no. 6
7.Muehlenkamp JJ. Self-injurious behavior as a separate clinical syndrome. Am J Orthopsychiatry 2005;75:324-33.  Back to cited text no. 7
8.Laye-Gindhu A, Schonert-Reichl K. Nonsuicidal self-harm among community adolescents: Understanding the "Whats" and "Whys" of self-harm. J Youth Adolesc 2005;34:447-57.  Back to cited text no. 8
9.Klonsky ED. The functions of deliberate self-injury: A review of the evidence. Clin Psychol Rev 2007;27:226-39.  Back to cited text no. 9
10.Erdur B, Turkcuer I, Herken H. An unusual form of self-mutilation: Tongue amputation with local anesthesia. Am J Emerg Med 2006;24:625-8.  Back to cited text no. 10
11.Pradhan SC, Anand KS, Prasad A. Self-mutilation and behavioural disorder. Postgrad Med J 1998;74:759-60.  Back to cited text no. 11
12.Dahl JE. Toxicity of endodontic filling materials. Endod Topics 2005;12:39-43.  Back to cited text no. 12
13.Svec TA, Harrison JW. Chemomechanical removal of pulpal and dentinal debris with sodium hypochlorite and hydrogen peroxide vs normal saline solution. J Endod 1977;3:49-53.  Back to cited text no. 13
14.Siqueira JF, Machado AG, Silveira RM, Lopes HP, de Uzeda M. Evaluation of the effectiveness of sodium hypochlorite used with three irrigation methods in the elimination of Enterococcus faecalis from the root canal, in vitro. Int Endod J 1997;30:279-82.  Back to cited text no. 14
15.Ferraz CC, de Almeida Gomes BP, Zaia AA, Teixeira FB, de Souza-Filho FJ. In vitro Assessment of the antimicrobial action and the mechanical ability of chlorhexidine gel as an endodontic irrigant. J Endod 2001;27:452-5.  Back to cited text no. 15
16.Vijaykumar S, GunaShekhar M, Himagiri S. In vitro effectiveness of different endodontic irrigants on the reduction of Enterococcus faecalis in root canals. J Clin Exp Dent 2010;2:e169-72.  Back to cited text no. 16
17.Rafter M. Apexification: A review. Dent Traumat 2005;21:1-8.  Back to cited text no. 17
18.Kumar V, Hegde RS, Moogi P. Retention of calcium hydroxide at apical one third of root canal for apexification and continued root development - a clinical case repor. J Int Oral Health 2010;2:79-84.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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