Silent Behaviors, Loud Truths: The Role of the Dentist in Münchausen Syndrome by Proxy

Factitious Disorder Imposed on Another (FDIA)—formerly known as Münchausen Syndrome by Proxy—is a form of abuse in which a caregiver deliberately induces, falsifies, or exaggerates illness in a dependent to satisfy an internal psychological need. Prolonged exposure to this behavior can lead the victim to adopt the “sick role” themselves, eventually developing Factitious Disorder Imposed on Self (FDIS). While children are the most common victims, documented cases have included adults, the elderly, and even household pets【1】.

Despite the severity of this condition, the scientific literature within the dental field remains limited【2】.

Understanding FDIA: Definitions and Diagnosis

The World Health Organization defines FDIA as “the feigning, falsification, or induction of medical, psychological, or behavioral signs and symptoms—or actual injury—in another person, most often a dependent child.” Crucially, deception must be demonstrated for an FDIA diagnosis【1】. It is a diagnosis of exclusion【3】.

Polish authors have proposed three clinical grades of FDIA【4】:

• Mild: Symptoms are fabricated or invented.
• Moderate: Symptoms are induced but not life-threatening.
• Severe: Abuse causes life-threatening conditions.

Modern technology has expanded the methods of abuse, allowing perpetrators to manipulate symptoms remotely—via phone or telehealth consultations.

Red Flags for Dental Professionals

Several warning signs may alert clinicians to the possibility of FDIA【1】:

• A clinical story that does not match direct observation.
• Patient deterioration following contact with the caregiver.
• Repeated, extensive investigations that fail to yield a plausible diagnosis.
• Laboratory findings that defy clinical logic (e.g., unexplained chemicals or drugs).
• Illness that appears to “jump” from one child to another or affects family pets.
• The caregiver’s assertion that the other parent is absent or uninvolved.
• Unusual eagerness to consent to invasive procedures.

The differential diagnosis should include anxious parenting, custody conflicts, frequent provider switching, or caregiver delusional disorder.

Typically—but not exclusively—the perpetrator is a young married woman with a history of somatoform or factitious disorders, often coupled with borderline personality traits, substance abuse, or a history of sexual trauma【1,4】. The ability to deceive healthcare providers is common. Tragically, mortality or permanent disability occurs in approximately 9–10% of documented cases【4】.

Oral Manifestations of Abuse

Though underreported, several oral signs of FDIA have been documented:

• Ulcers on lips or mucosa caused by sodium hydroxide or detergents【5】.
• Tooth loss, fractured teeth, and bloody secretions from chemical or mechanical trauma【4,6,7】.
• Oral bleeding induced with sharp objects like lapel pins【8】.
• Gingivitis, erosions, tongue ulcers, and mucosal damage from corrosive household cleaners【9】.
• Pharyngeal or esophageal lesions from ingestion of caustic substances【9,10】.

The Dentist’s Role in Detection

The oral cavity is often the first site where signs of FDIA manifest, giving dentists a unique opportunity for early intervention.

Recommended steps:

• Document meticulously in the Electronic Dental Record (EDR).
• Consult discreetly with colleagues, specialists, or forensic experts.
• Arrange close follow-up, especially if suspicions arise.
• Refer to psychiatry and involve a multidisciplinary care team if the patient is not in immediate danger.
• Take urgent action if a patient’s safety is at risk.

Reviewing the patient’s broader Electronic Medical Record (EMR) may also reveal a history of excessive appointments and erratic findings【1,4】.

Unfortunately, oral manifestations of FDIA remain largely underreported, underscoring the need for greater awarenessamong dental professionals. Dentists must recognize their role as sentinels of oral-systemic health and be prepared to advocate for vulnerable patients when subtle patterns of abuse emerge.

References

1. Yee R, Sim SY, Chow WH, Rajasegaran K, Hong CHL. Munchausen syndrome by proxy: A narrative review and update for the dentist and other healthcare professionals. Dent Traumatol. 2024 Mar;40 Suppl 2:23-32.
2. Hassona Y. Self-provoked oral illness: When the mouth mirrors the soul. Spec Care Dentist. 2024 May-Jun;44(3):756-760.
3. Khawaja SN, Sultan AS. Munchausen syndrome: report of a case and implications for dentists. Gen Dent. 2021 Mar-Apr;69(2):56-59.
4. Olczak-Kowalczyk D, Wolska-Kusnierz B, Bernatowska E. Fabricated or induced illness in the oral cavity in children. Cent Eur J Immunol. 2015;40(1):109-14.
5. Al-Jumaah S et al. Munchausen syndrome by proxy in a Saudi child. Ann Saudi Med. 1993;13(5):469–71.
6. Porter GE, Heitsch GM, Miller MM. Munchausen syndrome by proxy. Med J Aust. 1993;158(10):720.
7. Walters IC et al. Factitious disorder imposed on another and malingering by proxy. Paediatr Child Health. 2020;25(6):345–8.
8. Milroy CM. Munchausen syndrome by proxy and intra-alveolar haemosiderin. Int J Legal Med. 1999;112(5):309–12.
9. Tamay Z et al. Corrosive poisoning mimicking cicatricial pemphigoid: Munchausen by proxy. Child Care Health Dev. 2007;33(4):496–9.
10. Clin B et al. Recurrent caustic esophagitis: a clinical form of Münchausen syndrome by proxy. Child Abuse Negl. 2009;33(5):293–5.