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Oral habits - pedodontics

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  • 1. 1 ORAL HABITS BY ELVIS CHIRAMEL DAVID 4th year (part A)
  • 2. 2 Any repetitive behaviour that utilizes the oral cavity.
  • 3. DEF OF HABIT DORLAND[1957] HABIT CAN BE DEFINED AS A FIXED OR CONSTANT PRACTICE ESTABLISHED BY FREQUENT REPETITION. BUTTERSWORTH[1961] DEFINED AS A FREQUENT OR CONSTANT PRACTICE OR ACQUIRED TENDENCY, WHICH HAS BEEN FIXED BY FREQUENT REPETITION. MATHEWSON[1982] ORAL HABITS ARE LEARNED PATTERNS OF MUSCULAR CONTRACTIONS. BOUCHER O.C A TENDENCY TOWARDS AN ACT OR AN ACT THAT HAS BECOME A REPEATED PERFORMANCE, RELATIVELY FIXED, CONSISTENT, EASY TO PERFORM AND ALMOST AUTOMATIC. 3
  • 4. 4 COMMON ORAL HABITS LIP BITING TONGUE THRUSTING BRUXISM NAIL BITING • Pencil chewing • Bobby pin opening • Bottle opening • Needle biting • Improper brushing • Wire Chewing ( Electricians) MOUTH BREATHING THUMB SUCKING Other ORALHABITS
  • 5. ETIOLOGY  FAMILY CONFLICTS  SCHOOL PRESSURE  JEALOUSY  PEER GROUP PRESSURE  STRESS  OCCLUSAL INTERFERANCE  BREATHING OBSTRUCTION  LIMITATIONS ASSOCIATED WITH TOOTH ERUPTION  POOR PHYSICAL HEALTH 5
  • 6. CLASSIFICATION By William James (1923):- • Useful habits (nasal breathing) • Harmful habits (eg:- Thumb sucking, Tongue thrusting) Useful habits:- The habits that considered essential for normal function such as proper positioning of tongue, respiration, normal deglutition. Harmful habits:- Habits that have deleterious effect on the teeth and their supporting structures. 6
  • 7. By Kingsley (1956):- • Functional oral habit (mouth breathing) • Muscular habits (tongue thrusting) • Combined muscular habits (thumb and finger sucking) • Postural habits (chin propping,abnormal pillowing) 7
  • 8. By morris and Bohana (1969):- • Pressure. (lip sucking, thumb sucking, tongue thrusting) • Non pressure (mouth breathing) • Biting habit (nail biting, pencil biting, lip biting) Pressure habit:- Habit that apply force on teeth & supporting structure. Non-pressure habit:- Habit that does not apply force on teeth & supporting structure. 8
  • 9. By Finn (1987):- • Compulsive • Non-compulsive Compulsive :- These are deep rooted habits that have acquired a fixation in child. The child tends to suffer increased anxiety when attempt made to correct Non-compulsive:- These are habits that easily learned and dropped as the child matures. 9
  • 10. By klein (1971):- • Empty/unintentional habits • Meaningful/intentional habits Empty habit:- They are habits that are not associated with deep rooted psychological pattern. Meaningful habits:- They are habits that have psychological bearings. 10
  • 11. 11 By Graber:- Graber included all habits under extrinsic factors of general causes of malocclusion. • 1. Thumb / digit sucking • 2. Tongue thrusting • 3. Lip/ nail biting • 4. Mouth breathing • 5. Abnormal Swallow • 6. Speech defects • 7. Postural defects • 8. Psychogenic habits – bruxism • 9. Defective occlusal habits
  • 12. 12 THUMB SUCKING Thumb and finger habits are seen in children from very small ages. Develops as a habit or due to sense of insecurity. It is defined as the placement of thumb or one or more fingers in varying depth into the mouth
  • 13. CLASSIFICATION OF NNS (NON NUTRITIVE SUCKING)  1. Level I (+/-) – boy or girl of any chronological age with a habit that occurs during sleep  2. Level II (+/-) – boy under the age of 8 years with a habit that occurs at one setting during waking hours.  3. Level III (+/-) – boy under the age of 8years with a habit that occurs across multiple setting during waking hours. 13
  • 14.  4. Level IV (+/-)-girl under the age of 8 years or a boy over the age of 8years with a habit that occurs at one setting during waking hours.  5. Level V (+/-)- girl under the age of 8 years or a boy over the age of 8 years with a habit that occurs cross multiple settings during waking hours.  6. Level VI (+5) – girl over the age of 8 years with a habit during waking hours. 14
  • 15. CLASSIFICATION OF THUMB SUCKING A. According to Subtelny (1973)   Group 1: Thumb placed into the mouth beyond the first joint and occupies a large portion of the vault of the hard palate, pressing against the palatal and alveolar mucosa 15
  • 16. Group 2: The thumb did not go completely into the vault area of the hard palate, however it usually entered into the mouth, upto and around the first joint or just anterior to it. 16
  • 17. Group 3: the thumb passed fully into the hard palate as in group one. 17
  • 18. Group 4: The thumb did not progress appreciably into the mouth. The lower incisors made contact at the approximate level of the thumbnail 18
  • 19. B. COOK (1958) DESCRIBED THREE DISTINCT PATTERN OF THUMB SUCKING.  Group I - pushes the palate in an vertical direction and displayed only little buccal wall contraction.  Group II- registered strong buccal wall contraction and a negative pressure in the oral cavity. This group showed posterior cross bite.  Group III- Altered positive and negative pressure and showed the least amount of malocclusion of any group. 19
  • 20. ETIOLOGY  FREUDIAN THEORY: This theory was proposed by Sigmund Freud. He suggested that a child passes through various distinct phases of psychological development of which the oral and the anal phases are seen in the first three-year of life. In the oral phase, the mouth is believed to be an oro-erotic zone. The child has the tendency to place his fingers or any other object into the oral cavity. Prevention of such an act is believed to result in emotional insecurity and poses the risk of the child indulging into other habits. 20
  • 21. ORAL DRIVE THEORY OF SEARS AND WISE:  proposed that prolonged sucking can lead to thumb sucking with no underlying cause or psychological bearing. BENJAMIN’S THEORY:  Benjamin has suggested that thumb sucking arises from the rooting reflex seen in all mammalian infants.Rooting reflex is the movement of the infant’s head and tongue towards an object touching his cheek. The object is usually the mother’s breast but may also be a finger or a pacifier. This rooting reflex disappears in normal infants around 7-8 months of age. 21
  • 22. LEARNING THEORY BY DAVIDSON:  According to this theory, habit stems from an adaptive response and assumes no underlying psychological cause and is acquired as a result of learning 22
  • 23. OTHER FACTORS  Parent’s occupation Can be related to socioeconomic status of the family  Working mother Children with working mother take onto sucking habit to obtain secure feeling  Number of siblings As the number increases the attention to the child gets divided  Social adjustment & stress can be due to peer pressure or scolding parents 23
  • 24. DIAGNOSIS OF THE DIGIT SUCKING HABITS HISTORY  Determine the psychological component involved  Questions regarding frequency, intensity & duration of the habit  Enquire the feeding pattern , parental care Presence of other habits should be evaluated The diagnosis can be obvious when the child is actively performing the habit .however during a dental appointment a child may seldom indulge in this habit 24
  • 25. 25 EXTRAORAL EXAMINATION  THE DIGITS Digits involved will appear redened, exceptionally clean & chapped  LIPS Position of the lips at rest whether they are held together or apart Position of lips during swallowing should also be seen  FACIAL FORM ANALYSIS Check for mandibular retrusion, maxillary protrusion, When swallowing, patient is observed for presence of a facial grimace or an excessive mentalis muscle contraction Facial profile is either convex or flat
  • 26. INTRAORAL EXAMINATION  TONGUE- examine for size & position of the tongue at rest Tongue action during swallowing  DENTOALVEOLAR STRUCTURES Digit apply an anterior force to the upper dentition & palate Flared & proclined maxillary anteriors with diastema Retroclined mandibular anteriors  Other intra oral symptoms- buccal crossbite Pronounced constriction of buccal musculature Tendency to narrow palates Measure overjet & overbite  GINGIVA Look for evidence of mouth breathing 26
  • 27. 27 WHAT HAPPENS TO YOUR CHILD’S TEETH & THUMB???
  • 28.  Maxillary anterior proclination &mandibular retroclination  Anterior open bite Occurs due to Interference with normal eruption of incisors due to interposed thumb Excessive eruption of posterior teeth due to separation of the jaws , 1mm of elongation posteriorly opens the bite by about 2mm anteriorly  Constriction of maxillary arch Failure of the maxillary arch to develop in width due to an alteration in the balance between cheek & tongue pressures  Posterior cross bite Occurs as a consequence of constriction of the maxillary arch 28
  • 29. PREVENTION  Motive based approach  Child engagement in various activities  Duration of breast feeding  Mother’s presence and attention during bottle feeding.  Use of a pacifier. 29
  • 30. 30 HOW DO I STOP THUMB SUCKING??? Palatal Crib THUMBCAP
  • 31. PSYCHOLOGICAL THERAPY  Screening of patients for underlying psychological disturbances.  Once determined—sent to psychologist for counseling.  Thumb sucking between 4-8 years, needs only reassurance, positive reinforcement, awareness can be achieved by emphasizing positive aspects of habit cessation.  Children and parents are informed about existing dento facial deformities and long term risk of the habit. 31
  • 32. 32 DUNLOP’s BETA hypothesis  If a subject is forced to concentrate on a habit at the time he practices it, he can learn to stop performing the habit  The child should be ask to sit in front of a mirror and ask to Suck his thumb; observe himself as he indulges in the habit.
  • 33. 33 REMINDER THERAPY  Extraoral approaches It employs hot tasting, bitter flavoured preparation or distasteful agents that are applied to finger and thumbs. For example, cayenne, pepper, asfoetida. Thermoplastic thumb post.  Intraoral approaches Various orthodontic appliances are employed to attenuate and eventually break the habit
  • 34. MECHANOTHERAPY  Removable appliances— palatal crib, rakes, lingual spurs, Hawley’s retainer with or without spurs 34
  • 35. FIXED APPLIANCES  Fixed intra oral anti thumb sucking appliance Most effective method is an intraoral appliance attached to the upper teeth by means of bands fitted to the primary 2nd molar or permanent 1st molar Hence preventing the patient from putting the digit in the mouth  Blue grass appliance  Quad helix Prevents the thumb from being inserted &also corrects the malocclusion by expanding the arch 35
  • 36. 36 MOUTH BREATHING Usually seen in people with nasal obstruction. May also occur as a habit.
  • 37.  Habitual respiration through the mouth instead of the nose CLASSIFICATION FINN(1987) Anatomic-short upper lip permits incomplete closure Obstructive-complete obstruction of the normal flow of air through nasal passages Habitual-continual breathing from mouth by force of habit although abnormal obstruction has been removed 37
  • 38. ETIOLOGY OBSTRUCTIVE/PATHOLOGICAL Complete or partial obstruction of nasal passage can result in mouth breathing. Some of the causes for obstruction are: • Deviated nasal septum • Nasal polyps • Chronic inflammation of nasal mucosa • Localized benign tumors • Congenital enlargement of nasal turbinate • Allergic reaction of nasal mucosa • Obstructive adenoids 38
  • 39. 39 WHAT CAN HAPPEN DUE TO THIS??? Forward placement of upper front teeth Gap between upper & lower front teeth Improperly placed teeth
  • 40. CLINICAL FEATURES General effects  Purification and humidification of inspired air does not take place  In oral respiration there is poor nasal resistance and pulmonary compliance giving an appearance of PIGEON CHEST.  Lubrication of esophagus donot take place as mouth breathers have a dry oropharynx and the mucous collected is often expectorated, may lead to mild ESOPHAGITIS.  Mouth breathers have 20% more CO2 and 20% less O2 in blood. 40
  • 41. Effects on the facial structures Facial form  Large face height  Large mandibular plane angle  Retrognathic mandible &maxilla Adenoid facies  Long narrow face with long narrow nose, nasal passage & flaccid lips  Nose tipped superiorly infront so an observer can look directly into the nares 41
  • 42. Gingiva  Inflamed &irritated gingival tissue in the anterior maxillary arch  Gingiva is hyperplastic due to continous exposure of the tissues to air  Gingiva exhibits classic rolled margin with an enlarged interdental papilla Lip  Short thick incompetent upper lip and a voluminous curled over lower lip  On smiling, patients reveal large amounts of gingiva producing a ‘gummy smile’ 42
  • 43. 43 Dental effects  Upper and lower incisors are retroclined  Posterior cross bite  Tendency towards an open bite  Constricted maxillary arch  Flaring of incisors Speech defects  Abnormalities of oral & nasal structures can compromise speech & so nasal tone in voice is seen Other Effects  Mouth breathing may lead to otitis media and loss of taste
  • 44. DIAGNOSIS  History Lip posture Tonsillitis &allergic rhinitis  Examination Mouth breathers when asked to inspire a deep breath,will not appreciably change size &shape of the external nares.  Clinical tests Mirror test Butterfly test Waterholding test Cephalometrics Rhinomanometry 44
  • 45. 45 HOW TO CONTROL MOUTH BREATHING??? Use of an appliance called ‘ORAL SCREEN’ Incase of nasal abnormalities, consult ENT surgeon
  • 46. TREATMENTTREATMENT Treatment of mouth breathing includes:  Elimination of the causeElimination of the cause  Interruption of the habitInterruption of the habit  Correction of malocclusionCorrection of malocclusion  Symptomatic treatmentSymptomatic treatment 46
  • 47. ORAL SCREENORAL SCREEN  This is the most effective way to reestablish nasal breathing, by preventing air from entering oral cavity.  It is curved corresponding to the curvature of the arch and is made of acrylic.  It works on the principle of both force application and force elimination  The appliance has to be worn for 2-3 hrs during the day and during the sleep at night. 47
  • 48. MODIFICATIONS:MODIFICATIONS:  If patient feels difficult to breathe, then multiple holes can be made that are closed one by one over a period of time.  Hotz Modification- A metallic ring is made and placed in the midline of the appliance which will help to hold the oral screen.  Double Oral Screen – an additional lingual screen for tongue thrusting habit. 48
  • 49. TONGUE THRUSTING Tongue thrust is the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition & in sounds of speech, so that the tongue lies inter-dental (Tulley1969) 49
  • 50. CLASSIFICATION  Physiologic Normal tongue thrust swallow of infancy  Habitual Tongue thrust present as a habit even after correction of the malocclusion  Functional When tongue thrust is an adaptive behavior Developed to achieve an oral seal  Anatomic Person having an enlarged tongue 50
  • 51. ETIOLOGY  Retained infantile swallow  Upper respiratory tract infection  Neurological disturbance  Functional adaptability to transient change in anatomy  Induced due to other oral habits  Tongue size  Hereditary  Feeding practices 51
  • 52. CLINICAL MANIFESTATIONS Extra oral findings  Lip posture- lip separation is greator in tongue thrust, both at rest and in function.  Mandibular movements- More erratic, no correlation between the movement of tongue and mandible.  Speech- speech disorders such as lisping, problems in articulation of s, n, t, d, l, z, and v sounds. Intra oral findings-  Tongue movements- swallowing movements are seen to be jerky and inconsistent.  Chin point is posterior as compare to normal position.  Tongue posture- tongue tip at rest is lower in tongue thrust group. 52
  • 53. 53 Malocclusion- Features pertaining to maxilla-  Proclination of maxillary anteriors resulting in an increase overjet  Generalized spacing  Maxillary constriction Features pertaining to mandible-  Retroclination or proclination of mandibular teeth depending on type of tongue thrust present Intermaxillary relationship-  Anterior or posterior open bite  Posterior teeth crossbite
  • 54. DIAGNOSIS History-  check for hereditary etiological factor.  Information regarding upper respiratory infection ,Sucking habits and neuromuscular problems Examination-  Study the posture of the tongue  Observe the tongue during various swallowing procedures  Observe role of tongue during mastication & speech  Intrinsic & extrinsic muscle action of tongue  Presence of grimace during swallowing 54
  • 55. TONGUE THRUST  Simple tongue thrust Anterior open bite Normal tooth contact posteriorly Contraction of lips, mentalis  Complex tongue thrust Generalised open bite Absence of contraction of lips, mentalis  Lateral tongue thrust Posterior open bite with tongue thrusting laterally 55
  • 56. 56 WHAT’S THE SOLUTION??? Tongue crib Oral Screen
  • 57. TREATMENT Tongue thrust often self corrects by 8 or 9years of age by the time the permanent anteriors completely erupts TRAINING OF CORRECT SWALLOW & POSTURE OF THE TONGUE:-  Myofunctional exercises 2S EXERCISES – Using the pressure point on the papilla the SPOT is shown .the tip is against this spot at rest position SQUEEZE is done by squeezing the tongue vigorously against this spot with the teeth closed , followed by relaxing. 4S EXERCISES SPOT ,SALIVATE,SQUEEZE & SWALLOW 57
  • 58. OTHER EXERCISES Child is asked to whistle Count from sixty to sixty nine  Using appliance as a guide in correct positioning of tongue Nance palatal arch appliance An acrylic button is used as a guide to place the tongue in correct position SPEECH THERAPY:- 1ST step should be training the correct positioning of the tongue .not indicated before 8 yrs. 58
  • 59. MECHANOTHERAPY:- Removable appliance therapy Modification of hawley’s appliance Advantages  Anchorage value gained from the acrylic covering the entire palate  Capability of using Hawley to close the anterior open bite through the use of the labial bow  The crib can serve as a reminder Fixed appliance  Crowns &bridges are given on the 1st permanent molar&0.04 inch stainless steel ‘U’ shaped lingual bar is adapted by one side extending to the canine anteriorly at the level of gingival margin 59
  • 60. Oral screen  For controlling abnormal muscle habits like the tongue thrusting &at the same time utilizing the musculature to effect a correction of the developing malocclusion Palatal expanders  Can be used both in cases of tongue thrusting & thumb sucking where development of the palate is hampered e.g. hyrax palatal expander, schwarz expander Correction of malocclusion Surgical treatment 60
  • 61. 61 BRUXISM Bruxism is the grinding or gnashing of teeth, usually occuring at night Causes RAMFFORD[1966] BRUXISM IS THE HABITUAL GRINDING OF TEETH WHEN THE INDIVIDUAL IS NOT CHEWING OR SWALLOWING.
  • 62. ETIOLOGY 1. PSYCHIC TENSION ASSOCIATED WITH ANY KIND OF STRESS. 2. OCCLUSAL INTERFERENCE SUCH AS DUE TO MALOCCLUSION. 3. INTESTINAL PARASITES. 4. SUBCLINICAL NUTRITIONAL DEFICIENCY 5. ALLERGY 6. ENDOCRINE DISTURBANCE. 62
  • 63. 63
  • 64. 64 TREATMENT Counseling Occlusal Splint Tranquillizers
  • 65. ADJUNCTIVE THERAPY:- • PSYCHOTHERAPY- COUNSELLING THE PATIENT TO REDUCE EMOTIONAL AND PSYCHIC TENSION • AUTO-SUGGESTION AND HYPNOSIS- PATIENT BECOMES CONCIOUS OF NERVOUS HABIT AND UNDERSTANDS THE POSSIBLE CONSEQUENCE • RELAXING EXERCISE AND PHYSIOTHERAPY • ELIMINATION OF ORAL PAIN AND DISCOMFORT 65
  • 66. OCCLUSAL THERAPY:- • OCCLUSAL ADJUSTMENTS- BITE RAISING CROWNS, SPLINTS AND ELIMINATION OF OCCLUSAL INTERFERENCE • BITE PLATES • OCCLUSAL RECONSTRUCTION AND PROSTHESIS • BITE GUARD 66
  • 67. HABITS THAT INVOLVE MANIPULATION OF THE LIPS AND PERIORAL STRUCTURES ARE TEERMED AS LIP HABITS 67 LIP HABIT
  • 68. ETIOLOGY  Malocclusion Deep bite malocclusion Large overjet &overbite child wants to produce normal lip seal during swallowing  Habits Can occur in conjunction with thumb sucking  Emotional stress 68
  • 69. 69 Mouth ulcers Spacing & flaring of upper front teeth Effects  Protrusion of maxillary incisors & retrusion of mandibular incisors.  Reddened irritated & chapped area below the vermillion border  Mentolabial sulcus becomes accentuated
  • 70. HOW DO I STOP???  Correction of malocclusion  Treating the primary habit Lip habit along with digit sucking can be corrected by hawley’s retainer with labial bow  Appliance therapy Oral screen Lip bumper It is positioned in the vestibule of the mandibular arch &serve to prohibit the lip from exerting excessive force on the mandibular incisors 70 Use of LIP BUMPER
  • 71. NAIL BITING BELOW 3 YEARS – ABSENT 4 TO 6 YEARS – INCIDENCE RISES SHARPLY 7 TO 10 YEARS – REMAINS CONSTANT REACHS ITS PEAK AT ADOLSCENCE 71
  • 72. ETIOLOGY  Insecurity  Psychosomatic successor of thumb sucking.  Nervous tension.  After the age of 15 the nail biting habit is replaced by pencil biting, hair twirling or gum chewing 72
  • 73. 73 EFFECTS Chapping of finger nails Fungal Infection of fingers Prevention Application of bitter substances onto finger nails Application of bitter substances onto finger nails
  • 74. 74 OTHERORALHABITS Bobby pin openingBobby pin opening Needle biting by tailors Pencil Chewing Wire chewing by electricians Bottle Opening
  • 75. 75 EFFECTS Chipping of tooth edge Notching of tooth edge Loss of tooth vitality
  • 76. 76 IMPROPER BRUSHING HABIT Effects
  • 77. REFERENCES  PRINCIPLES AND PRACTICE OF PEDODONTICS BY ARATHI RAO  DENTISTRY FOR ADOLESCENT AND CHILD BY DAVIDSON AND AVERY  TEXTBOOK OF PEDODONTICS BY SHOBHA TANDON  TEXTBOOK OF PEDIATRIC DENTISTRY BY DAMLE  PEDIATRIC DENTISTRY- PRINCIPLES & PRACTICE BY MS MUTHU AND SIVAKUMAR  ORTHODONTICS- ART AND SCIENCE BY SI BHALAJHI 77
  • 78. 78 THANK YOU