Oral Myiasis: a Case Report

Oral Myiasis is a condition in which the soft tissues of different parts of oral cavity are invaded by the parasitic larvae of flies known as Maggots. This study presents a case of oral myiasis in 12 years old mentally retarded girl. Clinically, the patient had multiple perforations of the palatal mucosa at mid-hard palate and tunneling of the palatal gingivae from lateral incisor to the first molar on either side communicated to the palatal perforations. The patient was treated by mechanical removal of the maggots with simple curettage and irrigation with paraffin, povidone iodine and normal saline. After complete larvae removal, the wounds healed normally. Introduction The term myiasis (Greek: myi=fly) is used to refer the infestation of living tissues of humans and animals by eggs or larvae of house flies (diptera-two winged flies) 1 .Oral myiasis was first described by Laurance in 1909


Introduction
The term myiasis (Greek: myi=fly) is used to refer the infestation of living tissues of humans and animals by eggs or larvae of house flies (dipteratwo winged flies) 1 .Oral myiasis was first described by Laurance in 1909 2 .The most common anatomic sites for Myiasis are the nose, eye, lungs, ear, anus and vagina. 3The oral cavity is rarely affected by this infestation and is associated with poor oral hygiene, alcoholism, senility, suppurating lesions, severe halitosis and other conditions. 4Oral myiasis may present as an oral mucosal swelling, periodontal diseases, palatal swelling and ulceration.Secondary infestations may occur in cancrum oris, oral wounds such as extraction wound, jaw bone fractures, and oral leprosy lesion.
Depending on the conditions of the involved tissue, myiasis can be classified into 3 following categories: accidental myiasis; when larvae ingested along with food, semi-specific myiasis; where the larvaes are laid on necrotic tissue of the wound, and obligatory myiasis; in which larvae affects undamaged skin . 5Myiasis can be classified clinically as primary ; when larvae feed on the living tissue, secondary; when larvae feed on dead tissue. 6ggots produce irritation, sneezing, itching, headache and lacrimation.Patients are also seen with oozing bloody discharge from nostrils.Some time larvae come out crawling out from nose or oral cavity.They cause extensive damage to soft tissue, death may occur due to meningitis.
In our case report we presenting a rare case of Oral Myiasis in 12 years old mentally handicapped girl who visited to the department of Oral and Maxillofacial Surgery, Bangabandhu Sheikh Mujib Medical University and have received a subsequent management as described in detail.
A 12 years old girl, Kamrun Nahar visited to the department of Oral and Maxillofacial Surgery, BSMMU, on 16 october,2010.The patient was mentally retarded.She had a poor oral hygiene with multiple carious molars in all four quadrants.She was relatively well 5 days back.One day her parents noticed a live maggot exposing (crawling) from the palatal gingival sulcus.Her parents thus have removed 5-6 maggots then after.
On clinical examination, there was a perforation of the palatal mucosa at the mid-hard palate.The palatal gingivae was detached from the underlying alveolus from lateral incisor to the first molar on either side and was tunneled submucosally with the palatal perforation.The affected gingival and palatal mucoperiosteum was erythematous and edematous.The palatal perforation was about 2cm * 2cm in diameter.The oral hygiene was poor with multiple carious molar teeth on all four quadrants.The patient was a habitual mouth breather.The most frequently involved cases of oral myiasis are reported as being habitual mouth breathers, alcoholism, senility, mentally handicapped and cerebral palsy patients. 7ses of oral myiasis have also been reported in epileptic patients with lacerated lips, children with incompetent lips and thumb sucking habits, 8 patients with advanced periodontal disease 9 and infected extraction wound. 4Ng, et al. ( 2003) 11 reported a case of oral myiasis in a woman with a history of ischaemic heart disease, pulmonary tuberculosis and a stroke which has resulted her being bed-ridden and dependent on nasogastric tube feeding.
Low socioeconomic status, immunocompromised state, debilitated and unhygienic living conditions are the main contributing factors responsible for myiasis.The risk factors for oral myiasis include suppurative lesions, facial trauma, mouthbreathers, extraction wounds, fungating carcinomas and others conditions. 11There were several predisposing factors for the patient in this present study to be affected by this rare infestation.The patient was mentally handicapped, a habitual mouth breather and had a poor oral hygiene with the lack of self-care ability and communication capacity.
The traditional management of myiasis is the mechanical removal of the maggots. 4Topical application of several substances like gentian violet, 4 white head varnish 10 has been used to compel any maggots, if present to come out of the lesion.In addition, systemic treatment with Ivermectin, a semi-synthetic macrolide antibiotic, has been used for treatment of oral myiasis. 4However, in the present case the patient was managed by mechanical removal of maggots, proper irrigation of the wound with paraffin, povidine iodine solution and normal saline and systemic treatment with Cefixime.Such a treatment proved to be effective with complete healing occurring by the end of about 2 weeks.

Conclusion
Mental retardation is a predisposing factor for oral myiasis in our case.Oral Myiasis is a very rare infestation occurring in human which can be prevented by education and awareness regarding maintenance of oral hygiene and the predisposing factors for the occurrence of the infestation.Early management is possible and needed to avoid life threatening conditions.So special care should be taken for mentally retarded person as they are more susceptible to be infested by oral myiasis.______________

Figure 1A :
Figure 1A: Appearance of the patient at presentation

Figure 2A :
Figure 2A: Larvae removed from the wound

Figure 3A :
Figure 3A: Appearance of the wound on 6th visit