How should lip picking behavior be managed in a patient to prevent complications like infection, scarring, and dental problems?

Management of Lip Picking Behavior

Lip picking should be managed through a combined approach of behavioral modification, meticulous lip care with regular emollient application, elimination of dental trauma sources, and strict oral hygiene protocols to prevent infection, scarring, and dental complications.

Immediate Protective Measures

Lip Lubrication and Barrier Protection

• Apply white soft paraffin ointment or lip balm to the lips immediately and then every 2 hours to create a protective barrier and prevent further trauma 1
• Avoid chronic use of petroleum-based products as they promote mucosal cell dehydration and increase risk of secondary infection 1
• Maintain adequate hydration by drinking ample fluids to keep the mouth moist 1

Daily Inspection and Monitoring

• Inspect the oral mucosa and lips daily for signs of infection, tissue breakdown, or worsening trauma 1, 2
• Monitor for warning signs including increasing swelling, difficulty breathing or swallowing, or signs of spreading infection 2

Elimination of Contributing Factors

Dental Assessment and Correction

• Have a dental team eliminate all sources of trauma including ill-fitting prostheses and fractured teeth 1, 2
• This is critical as dental irregularities can perpetuate the picking behavior and create additional trauma sites 3, 4

Behavioral Modification

• Implement tracking (self-recording) of the picking behavior to increase patient awareness 5
• Consider aversive response substitution techniques where the patient substitutes the picking behavior with a less harmful action 5
• Relaxation techniques may help reduce anxiety-driven picking behaviors 5
• Behavioral therapy has demonstrated immediate and long-lasting tissue repair in compulsive lip-biting cases 5

Infection Prevention Protocol

Oral Hygiene Regimen

• Use a soft toothbrush after meals and before sleep, replacing it monthly 1
• Brush teeth twice daily with mild fluoride-containing, non-foaming toothpaste 1, 2
• Clean the mouth daily with warm saline mouthwashes 1, 2

Antimicrobial Mouth Rinses

• Rinse with alcohol-free mouthwash (such as 0.2% chlorhexidine) at least four times daily for approximately 1 minute 1, 2
• Alternative options include 1.5% hydrogen peroxide mouthwash twice daily 1
• Avoid eating or drinking for 30 minutes after rinsing 1

Topical Antiseptics and Anti-inflammatory Agents

• Apply mucoprotectant mouthwash three times daily to protect ulcerated surfaces 1
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, for pain control 1
• For inadequate pain control, consider viscous lidocaine 2% (15 mL per application) 1

Management of Complications

If Infection Develops

• Take oral and lip swabs if bacterial or candidal secondary infection is suspected 1
• Treat candidal infection with nystatin oral suspension 100,000 units four times daily for 1 week or miconazole oral gel 5-10 mL four times daily 1
• For dental infections with systemic involvement, prescribe amoxicillin 500 mg three times daily for 5 days after appropriate surgical drainage 6
• Use clindamycin for penicillin-allergic patients 6

If Severe Tissue Damage Occurs

• Surgical intervention may be required for severe self-mutilation with tissue loss 7
• In extreme cases, orthognathic surgery to create an anterior open bite has been successful in preventing continued self-mutilation 7

Avoidance of Irritants

Dietary and Environmental Modifications

• Avoid smoking, alcohol, tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods 1, 2
• These substances cause additional pain and trauma to already damaged lip tissue 1

Long-term Management Strategy

Orthodontic Considerations

• If lip picking is secondary to dental spacing or malocclusion, orthodontic treatment to align and level the dental arch may eliminate the trigger for the habit 4
• Morphological correction assists patients in breaking the habit and prevents recurrence 4
• A 10-year follow-up study demonstrated no recurrence when dental spaces were closed and the habit was addressed 4

Psychiatric Evaluation

• Consider psychiatric evaluation if the behavior persists despite conservative measures, as personality disturbances are commonly associated with factitious lip trauma 8
• The presence of bizarre hemorrhagic or keratotic crusts should alert clinicians to possible factitious origin 8

Critical Pitfalls to Avoid

• Never prescribe antibiotics without addressing the underlying trauma source and implementing behavioral modification 6
• Do not ignore potential airway compromise if severe facial swelling develops 2
• Avoid chronic petroleum jelly use on lips due to infection risk 1
• Do not start interdental cleaning if the patient is not already accustomed to it, as this can break the epithelial barrier 1