Treatment of Cheek Biting
For patients with cheek biting habits, particularly those related to anxiety or stress, treatment should prioritize addressing underlying psychological factors with SSRIs or cognitive behavioral therapy while simultaneously implementing behavioral interventions and protective appliances to prevent tissue damage. 1, 2
Initial Assessment and Diagnosis
Before initiating treatment, confirm the pattern and severity of the behavior:
- Document the frequency, timing, and triggers of cheek biting episodes, particularly noting whether they occur during periods of stress, anxiety, or unconsciously 3
- Examine the buccal mucosa for characteristic findings including bilateral white keratotic lesions, ulcerations, or chronic mucosal trauma 3, 4
- Screen for underlying anxiety, depression, or other psychological stressors using validated tools, as cheek biting often represents a stereotypic movement disorder or impulse control disorder similar to other body-focused repetitive behaviors 1, 3
Treatment Algorithm
Step 1: Address Psychological Factors First
Treat comorbid anxiety or depression as the primary intervention, as these conditions drive the behavior and prevent successful habit cessation 1, 2:
- Initiate SSRI antidepressants (such as sertraline, fluoxetine, or escitalopram) as first-line pharmacotherapy for anxiety-related cheek biting 1, 2
- Consider low-dose amitriptyline as an alternative if SSRIs are contraindicated 1
- Refer to mental health professionals for cognitive behavioral therapy (CBT), which has the highest level of evidence for anxiety disorders and can address the underlying triggers 2
- Continue medications for 6-12 months after remission to prevent relapse 2
Step 2: Implement Behavioral Interventions Concurrently
Use distraction and redirection strategies to interrupt the automatic behavior pattern 1:
- Teach awareness techniques to help patients recognize when they are biting their cheeks, as the behavior is often unconscious 3, 4
- Implement stress-reduction techniques including mindfulness, relaxation exercises, and identification of specific triggers 1
- Reduce excessive musculoskeletal tension in the jaw, face, and neck muscles through relaxation exercises 1
Step 3: Provide Physical Barrier Protection
For moderate to severe cases with significant tissue damage, fabricate a protective intraoral appliance 4, 5:
- A removable "cheek plumper" or similar prosthesis creates a physical barrier between teeth and buccal mucosa, preventing further trauma while behavioral interventions take effect 4, 5
- Design the appliance considering injury severity and patient cooperation ability 4
- This is particularly important for patients with stress-induced habits who may continue biting during periods of heightened anxiety 4
Step 4: Multidisciplinary Follow-up
Establish ongoing psychiatric follow-up for medication management and psychotherapy when significant anxiety or psychological distress is present 1:
- Monitor for treatment response and adjust medications as needed 2
- Continue behavioral therapy to maintain gains and prevent relapse 1
- Reassess the buccal mucosa regularly to monitor healing and ensure the appliance is effective if used 4
Critical Pitfalls to Avoid
- Do not focus exclusively on the physical habit while ignoring psychological factors, as this leads to treatment failure and relapse 1
- Avoid delaying mental health referral when anxiety or depression is clearly present, as these conditions must be treated for successful habit cessation 1
- Do not assume absence of a clear psychological trigger excludes a functional diagnosis, as many patients with cheek biting have underlying anxiety that may not be immediately apparent 1, 3
- Recognize that cheek biting following dental anesthesia can lead to severe complications if the habit is not identified and managed appropriately 6
Special Considerations
For pediatric patients (adolescents), the same treatment principles apply but require additional attention to: