Sir, an 18-year-old female presented to the emergency department with extensive tissue loss from her lower lip. Questioning revealed that she had ingested 3,4-methylenedeoxymethamphetamine (MDMA, 'ecstasy') prior to the events that led to her presentation. An accompanying friend reported that, following consumption of MDMA, the patient exhibited involuntary chewing of her lower lip. Despite the pain, this persisted for several hours which led to gradual tissue loss.

Her medical history was unremarkable but she reported regular user of marijuana with monthly use of MDMA.

On examination, there was a 3 cm area of soft tissue loss to the left side of the lower lip. This extended from the midline to near the commissure and was well beyond the vermillion border and into the cutaneous zone. No oral seal was achievable (Fig. 1). Systemic examination, vitals, electrocardiogram and bloods were within normal limits.

Figure 1
figure 1

The 18-year-old patient with extensive tissue loss following MDMA ingestion

The patient was given 5 mg oral diazepam to help reduce the involuntary mastication and was taken to theatre the next day for wedge excision and primary closure. If destruction of the lower lip had been more extensive other complex reconstructive options would need to be employed.

As a department we are seeing an increasing number of cases attending presenting with oro-facial presentations following MDMA use. Despite recent national statistics showing no increase in consumption amongst young adults,1 a recent survey has reported that purity levels have increased over recent years.2,3 Whilst the case we present is an extreme example resulting in oral mutilation, bruxism, tooth-wear and oral ulceration remain the most common oral manifestations.4 Unexplained cases of the aforementioned should prompt a thorough recreational drug history.