**1. Introduction**

Self-mutilation is defined as a behavioral disturbance that consists of self-induced damage to body tissues, which might be associated in some cases with a conscious intent to commit suicide. Also called self-harm, it includes any intentional injury to one's own body [1–4]. Historically, the first institutions for abandoned children can be traced back in Europe since the Middle Ages; they came into prominence in the 19th century in Western Europe, today being common in di fferent parts of the world such as Asia, Central and South America, the Middle East or Africa. In the United States, orphanages were documented in the first half of the 20th century [5].

At present, worldwide there are between 8–10 million children living in di fferent types of institution [6] and there is much scientific evidence that their psychological development is impaired by these life

conditions [7]; furthermore, the trend of placing children in institutions appears to be growing [8,9]. According to data from literature, institutional care in Romania was associated with an impairment of the physical development [10] and also children who spent more than 6 months in an institution had higher rates of autism symptoms, inattention or disinhibited social engagemen<sup>t</sup> [11]. Due to the demands of taking care of a large number of children, the caregivers rarely interact with children in a warm manner, as their activity is frequently limited to routine care, such as feeding or toileting [12]. Therefore, most institutionalized children experience poor caregiver-child interaction and their physical, cognitive and social development is often delayed. Moreover, scientific data showed that these results are caused mainly by the quality of caregiver-child relationships, rather than by the quality of medical care and nutrition [13]. The inability to live with their parents predisposes institutionalized children to low self-esteem and impaired psychosocial development (attention problems or lower intelligence quotient) [7], which might represent confounding factors in the analysis of the correlation between self-harm and institutionalization.

In institutionalized children, the relief of emotional pain could be expressed by self-harm, as the physical wounds they create on themselves is a sign of their emotional su ffering [14]. The self-harm behavior has many causes, including stressful life events or mental disorders such as depression or anxiety [15]. Adolescents use deliberate self-harm methods such as cutting, poisoning or overdosing, while children usually scratch or bite themselves; this phenomenon may start during childhood and intensifies in adolescents and young adults, girls being considered more vulnerable to this behavior than boys [16]. Among the etiological factors of deliberate self-harm the following conditions were included: depression, low self-esteem and sense of persistent hopelessness, attempts to seek help from others, poverty, abuse, attempts to resist suicidal thoughts and family dysfunction. The early detection of non-suicidal self-injury (NSSI) allows immediate intervention which might help these children stop this behavior. Left undiagnosed for a long period of time, NSSI becomes more frequent, severe and versatile, with negative consequences on the quality of life and more di fficult recovery [17].

Oral self-harm (OSH) in institutionalized children occurs in connection with emotional, behavioral or even organic disorders. To date, most of the information comes from case series presentations and there are little scientific data regarding the frequency of OSH among abandoned children without mental disorders or retardation. Therefore, the aim of our paper was to conduct a cross-sectional study in order to assess the frequency and type of OSH among institutionalized children from three Romanian state centers. The null hypothesis to be tested was that there is no statistically significant di fference regarding the prevalence of oral self-inflicted lesions, according to gender and ethnicity in children at puberty.

### **2. Materials and Methods**

### *2.1. Study Design and Participants*

Our investigation was conducted between December 2019–February 2020 in the Clinic of Odontology and Oral Pathology from the George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mures, , where there is a special program dedicated to dental medical care for institutionalized children, belonging to three state centers. The investigation was carried out after the approval obtained from the Ethics Committee of our university (No. 520/21.11.2019), accompanied by a written consent for the use of personal data signed in each case by the legal representative of the child (institution manager or legal guardian). Prior to enrolment in the study, children were also asked if they agreed to participate. We are located in the historical province of Transylvania, characterized by a multicultural and multiethnic population, represented mainly by Romanians, Hungarians and regional Roma. In order to address a source of bias related to the number of participants from each ethnicity, we decided to include close numbers in each group, according to age and gender. Moreover, all clinical

examinations were carried out by one experienced dentist and data were recorded by one dental specialist. In our study we included 116 children aged between 10–14 years old, selected from a total of 167 children, based on application of inclusion criteria (status of institutionalized child for more than 5 years, age 10–14 years) and exclusion criteria (history of psychological counseling or psychiatric treatment, recordings of drugs or alcohol abuse, children with diagnosed neurologic or psychiatric disorders, known to be etiological factors of self-harm behavior, such as epilepsy, depression, anxiety or autism spectrum disorder) (Figure 1).

**Figure 1.** Flow diagram illustrating selection of participants to the study.

### *2.2. Clinical and Histopathological Examination*

Ordinary dental examinations, with an emphasis on the health status of the lips, buccal mucosa and tongue (ulcerations, color change, surface aspect), were performed. In order to detect any changes from normal texture, the area between oral commissures was carefully evaluated by palpation. Cases in which a chronic evolution was suspected, resembling premalignant lesions, were further investigated by exfoliative cytology, using Papanicolau stain. All children who presented OSH were further referred to interdisciplinary evaluation by a psychologist and dental specialist.
