A natural & normal reflex of infants use thumbs, fingers,
pacifiers and other objects to suck. This brings about a
feeling of security especially during difficult periods.
Most stop by age 2 and should be discouraged if not be age
Prolonged thumb-sucking can cause crowded crooked teeth,
or bite problems.
Breaking the Habit:
1. Wait till the time is right. (low stress)
2. Praise them when they are not
3. Focus on the cause (underlying anxiety)
4. Motivate your child
5. Use a reward system
6. Reminders (band-aid around the thumb)
-This is the majority of oral habits. Finger sucking is more than
-2/3 of these stop by age 5.
-The dental changes occur with digit sucking are based on:
• Duration (amount of time).
• Frequency (how often) .
• Position of thumb during sucking
• Associated muscles contraction
• State of child’s health.
• Associated hand pressure.
• Stage of osteogenic development.
4-6 hours of force /day necessary to cause tooth movement
Intermittent sucking with high intensity less harm than
continuous sucking more than 6 hour
Etiology of sucking habit:-
1. Physiological ( mouth used to investigate
2. Imitation of other children.
3. Feeding problems ( bottle feeding, deficient
feeding & transition from liquid to solid food).
4. Attract attention (when the presence of new
5. Emotional problems (child’s insecurity or
Effects on the jawbone
-Upper front teeth flare out and tip upward while lower
front teeth move inward.
- "open bite".
-If a child stops thumb sucking before loss of primary front
teeth & permanent front tooth eruption, most or all harmful
effects disappear within six months.
-If the habit persists through permanent front tooth
eruption lead to lasting damage: flared or protruded upper
teeth, delayed eruption of upper or lower front teeth, and
- Result in chewing difficulties, speech abnormalities, and
an unattractive smile.
Thumb sucking classified into: -
1.Phase I: - ( subclinical significant change)
form 3 months to 2 years. As the infant use
rubber pacifier & considered normal.
2.Phase II: - from 2 years- 4 years of age
cause temporary changes as decrease
overbite & increase over jet.
3.Phase III: -( active sucking habit)
persistence of the habit after 4 years &
-Dental changes are similar to the digit habit (maxillary incisor
flaring, constricted maxilla often associated with a post
cross-bite, lingualization of lower incisors, and an anterior
-Dental changes resolve with early discontinued usage.
-Most children discontinue the use of the pacifier on their own
by the age of 3-4 yrs.
-Pacifier use usually ends earlier than digit sucking, but it’s
uncommon that a child will stop using the pacifier and
replace it with a digit.
1. Manufacture pacifier similar to mother’s nipple.
2. Discontinued pacifier gradually under the control of parent.
1. Displacement of the child’s permanent teeth due to the
uneven forces placed on the teeth by the thumb.
2. The upper and lower front teeth may not approximate with
3. The upper front teeth may flare out.
4. The open bite or lack of approximation of upper and lower
front teeth may result in speech difficulties during
5. As a result of the flared out or protruding front teeth the
child may end up fracturing these teeth more often.
6. Protruding and uneven teeth change the facial appearance.
This can cause an inferiority complex in the young mind
1. Child above the age of 4 with protruding anterior teeth
affected by thumb sucking.
2. A detailed history about the habit.
3. The frequency and duration of this habit help in
evaluating the extent of the habit.
4. Presence of callous formation on the back of thumb or
finger & low grade of virus infection on the skin.
The thumb used by the child normally appears to be
very clean compared to the other finger.
Types of intervention:
Reminder therapy (like a bandage around
Distraction therapy (doodling when
Fixed or removable crib appliance with
Quad helix with a palatal crib (usually
worn for 6 months)
Guided the child consciously over a period. This is
possible only if the child is psychologically willing and
wants to stop the habit.
Children often combine thumb-sucking habit with other
secondary habits such as hair pulling or nose probing.
Frequently making the secondary habit impossible to
perform can break the primary habit.
It is very important not to criticize the child. The child
needs a lot of support and affection. He should be told
about the ill effects of sucking the thumb to reinforce
his determination to stop thumb sucking.
2.Substitute for sucking habit using chewing gum
3.Visual aids the effect of habits video tap, film poster
4. Reminder therapy: -
A . Extra oral method:
Painting the child’s thumb or finger with an
unpleasant tasting substance.
Tapping the thumb with plaster.
Glove can be taped to wrist.
Painting the girl’s finger or thumb by nail polish.
B. Reward therapy
C. Intra oral methods:
This is done by fabricating appliances, fixed or
Personalized calendar used to motivate the child to stop sucking
habit. By putting stick or stars on the days that child avoid
Home reminder treatment:-
- Placing gloves on child’s finger before
- Paint thumbs and fingers with various foul-
- Wrap bandages around the offending digits.
- One method which might help is to tie/roll a
used x ray film on the elbow of the child so that
child can not bend the hand after tape the
edges of the film to avoid sharp ends.
1. Child understanding
2. Parents’ cooperation
3. Maturity of child ( stage of teeth eruption).
4. Good orientation
5. Friendly rapport.
“Fixed palatal crib“
The crib consists of semicircular stainless steel wires connected to
supporting steel bands or rings. The half-circle of wires fits
behind the child's upper front teeth, barely visible in normal
view. The bands are fastened to the upper primary second
molars. Used for 4-6 months & check every 2-4 weeks
Crib construction , and cements the appliance. 8 to 10 millimeters
of open bite, can close within a few months.
- Crib wires prevent the thumb or finger from touching the gums
behind the front teeth and on the palate (roof of the mouth),
turning a pleasant experience into an unpleasant one. Deriving
no satisfaction from the activity, the child has no incentive to
- Instructions (avoiding gum chewing, hard and sticky candy,
popcorn, peanuts). Not pull on the crib with fingers. Thorough
tooth brushing after each meal.
-After crib placement, is checked in 2-4 weeks, and then seen
every 1-2 months until the appliance is removed.
-Improvement in front tooth position is typically noted within
two weeks after crib placement. It takes 4-6 months for the
open bit to close and the front teeth to straighten. However, is
left 9- 12 months to prevent relapse of the habit.
- The ideal time is when upper front primary teeth become
loose, just prior to eruption of permanent front teeth. This
usually occurs just before or after age six.
“Fixed palatal crib“
The appliance is used in early & late mixed
dentition in child who desire to stop the habit.
• A modified six sided roller from Teflon is
constructed to slip over stainless steel wire
which is soldered to molar orthodontic bands (
maxillary first permanent molar or second
• The roller is placed in the most superior aspect
of the palate to avoid eating or speech
• The child can turn the roller instead of sucking.
• The appliance used for 3-6 months
• Oral screen
• Active oral screen ( for anterior or posterior
• Passive oral screen
• Double oral screen
• Oral screen with anterior ring
• Oral screen with holes
In normal swallowing the tongue touch the
palate papillae of anterior teeth & dorm
surface of the tongue in contact with the
palate and lips are tightly closed together
While abnormal swallowing teeth are
separated, tongue thrust forward between
upper & lower anterior teeth, dorm
surface of the tongue away from the
palate and lips are separated.
Etiology of tongue thrust,
• Associated with sucking habit.
• Open mouth with protruded anterior teeth.
• Premature loss of deciduous anterior teeth.
• Respiratory obstruction due to large tonsile
• Macroglossia as in acromegaly.
• Prolonged artificial feeding.
• Muscular imbalance.
Tongue thrust classified into
• Simple tongue thrust (tongue thrust & teeth in
• Complex tongue thrust (tongue thrust & teeth apart).
• Retained infantile swallowing (abnormal swallowing
• Contraction of temporalis muscles during swallowing.
• Defect in the arch
-This a characteristic of the infantile and transitional
swallowing which are normal for neonates.
-Tongue thrust often sustains an open bite, but does
not cause one.
Protrusion of anerior teeth
Narowing of maxillary arch
1. Functional therapy: -
The child practice to swallow with the tip of tongue place against
incisor papillae. The holding sugarless mint against the incisor
papillae until it melt.
2. Appliance therapy: -
the use of mandibular lingual arch with horizontal crib or spurs for
4-9 months according to the severity of the case. Double oral
screen. Correction of protruded teeth by active oral screen or
extra oral force.
3. Speech therapy to correct speech disturbance.
-Due to mandibular posture/lip incompetence or nasal airway obstruction.
1. Obstructive mouth breathing
• In respiratory obstruction as atrophic rhinitis.
• Hypertrophy of turbinate caused by allergies.
• Deviated nasal septum.
• Narrow nasal passage.
• Enlarged tonsils.
• Chronic infection of mucous membrane of nasal passage.
2. Habitual mouth breathing
As a habit persist after removal of nasal obstructions
3. Anatomical mouth breathing
• Hypotonic upper lip
• Protruded anterior teeth.
• Associated with class II division I.
• Secondary to sucking habit.
Mouth breather has a typical appearance of
adenoid face have :-
• long narrow face
• protruded anterior teeth
• open & dry lips
• lower lip extend behind upper teeth
To differentiate between habitual & obstructive mouth
breather ask the child to breath with his eyes closed with a
cotton piece in front of the nostrils.
In nasal breather the mirror will could with
condensed moisture during expiration
In nasal breather the size of the external nares are
Oronasal breather the size of the external nares not
are changed & alar muscles inactive
1.Treatment of the cause before correction
2.Passive oral screen in habitual moth
3.Active oral screen to correct protruded
Myofunctional exercises Lip exercises with a
piece of cardboard held loosely in horizontal
position to improve lip seal
• Psychological disturbance
• Hypotonic lower lip
• Associated with thumb sucking
• Compensatory activity from excessive over
jet or open bite
• Abnormal relation between the upper
lower & jaws class II d I.
1. Abnormal mentalis muscles activity (puckering up of chin
2. Hyperactive vermillion border.
3. Accentuated labio-mental sulcus.
4. Chronic herpes with red inflamed & chapped lip.
1. Treat cause.
2. Lip exercise by extending upper lip over incisors & placing
the lower lip forcibly over the upper lip.
3. Oral screen .
4. Lip plumber to drawing the lower lip away
-Uncommon before age of 3 years
• release normal tension due to increase stress.
• gain attention of parents.
No malocclusion may be attrition in severe case. The
finger nail beds may be damage.
the use of nail protect materials.
It is unconscious and involuntary habit of clenching or
It is usually done on a subconscious, reflex-controlled level
with the patient unaware of doing it.
It can take place at night when asleep or during the day.
As it is related to stress.
It can affect the teeth, muscles, jaw joints
(Temporomandibular joints) & the appearance of the face.
The causes of bruxism
The etiology of bruxism is a combination of
psychic stress (overwork, worry, and
tension), as well as various irregularities in
the biting surfaces of the teeth, high
restoration or deep bite, malocclusion.
Emotional bases, nervous & irritable child.
Excessive tooth wear caused by bruxism is not the
same as normal tooth wear.
The symptoms of bruxism
1. Attrition of teeth (worn down, and become shorter).
Occlusal wear: The constant grinding of the teeth can
cause a significant loss of tooth structure from the
biting surfaces of the teeth.
2. The teeth will become flattened, and the
creamy/yellow dentine will be visible.
3. If bruxism is not treated, the teeth may be worn down
to the level of the gums.
4. Teeth have a tendency to chip as a result of the
5. Tenderness and pain may be felt in the muscles and
jaw joints on waking in the morning.
6. Eating become painful (restricted jaw movement).
7. Teeth become sensitive, painful & loose, as results of
worn down or cracked by grinding.
8. Extensive tooth wear cause the jaws to close down too
far, resulting in facial changes.
9. Unsightly creasing at the corners of the mouth.
10. Development of prominent jaw muscles. The jaw
muscles become painful due to their constant
11. The sound of grinding teeth can disturb other people.
12. Headache--is caused by a disturbance in the
circulation in the muscles.
13. TMJ pain.
The symptoms of bruxism
1.Relieve the causes of the stress (psychological
and medical) Behavior modification relaxation
2. The dental treatment directed to preventing further
damage to the teeth, and to the repair of the worn
down teeth. Occlusal adjustment of high filling or
3. The preventive treatment is to use a night guard.
4. The use of muscle relaxants.
5. Moist heat applied to the affected jaw muscles and
Night plastic mouth guard is constructed. to prevent
the teeth from grinding against each other.
Treatment of Bruxism
1.Impressions are taken of the upper and
2.Night guards are designed to cover the
biting and chewing surfaces of the teeth
usually the upper.
3.They made from a soft plastic or a hard
It is repetitive acts result in physical damage to the
child as pushing away gingival tissue from labial
surface of anterior teeth.
It is rare habit in normal child but in 20% of mentally
Emotional disturbance play a role in this habit.
Effect : -
Stripping of free & attached gingiva and bone may be
2.Use of restrain, protective padding & sedation.
3.Extraction of affect tooth.
It is holding upper labial frenum between permanent
Increase the diastma between interior teeth
2.Passive oral screen.
It is biting of cheek opposite to the occlusal plane of the
1.In nervous child.
Trauma to the cheek causing ulceration & pain
1.Remove the cause.
2.Vestibular oral screen.
In teenage girl
Notched upper incisor tooth or teeth.
Calling attention to harmful results.