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  3. 3. Oral habits in children are prime concern for the dentist, be it an orthodontist , pedodontist or a general practitioner. Finn says that habits cause concern because they cause Oral structure changes Behavioral problems Socially unacceptable act DEFINITIONS OF HABITS 1. DORLAND (1963): Fixed or Constant practice establishment by frequent repetition. 2. WILLIAM JAMES: A new pathway of discharge formed in the brain by which certain in coming currents lead to escape. 3. MASLOW (1949): A habit is a formed reaction that is resistant to change, whether useful or harmful, depending on the degree to which it interferes with the child’s physical , emotional and social functions. 4. MOYERS: Habits are learned patterns of muscle contraction, which are complex in nature. Habit is an automatic response to a situation acquired normally as the result of repetition and learning, strictly applicable only to motor responses. At each repetition the act becomes less conscious and can lead on to an unconscious habit. CLASSIFICATION OF HABITS: USEFUL AND HARMFUL HABITS(JAMES IN 1923) 1. USEFUL HABITS These include habits that are considered essential for normal function such as proper positioning of the tongue, respiration and normal deglutition. 2. HARMFUL HABITS These include habits that have a deleterious effect on the teeth and their supporting structures such as thumb sucking, tongue thrusting etc
  4. 4. MEANINGFUL AND EMPTY HABITS(KLEIN 1971) 1. MEANINGFUL HABITS They are habits that have a psychological bearing . 2. EMPTY HABITS They are simple habits without a detectable cause. PRESSURE, NON-PRESSURE AND BITING HABITS(MORRIS AND BOHANA 1969) 1. PRESSURE HABITS These include sucking habits such as thumb sucking, lip sucking, finger sucking and also tongue thrusting. 2. NON-PRESSURE HABITS Habits which do not apply a direct force on the teeth or supporting structures are termed non-pressure habits. Example: mouth breathing. 3 .BITING HABITS These include habits such as nail biting, pencil biting and lip biting. FUNCTIONAL ORAL HABITS AND MUSCULAR HABITS(KINGSLEY 1958) 1 .FUNCTIONAL ORAL HABITS Eg :Mouth breathing 2 .MUSCULAR HABITS Individual habit eg.lip sucking Habits in which there is combined activity of the muscles of the mouth and jaws of the thumb/finger inserted into the mouth .eg:.thumb sucking. 3. COMBINED HABITS COMPULSIVE AND NON-COMPULSIVE HABITS(FINN 1987) 1. COMPULSIVE HABITS These are deep rooted habits that have acquired a fixation in the child to the extend that the child retreats to the habit whenever his security is threatened by events which occur around him.The child tends to suffer increased anxiety when attempts are made to correct the habits.
  5. 5. 2 .NON-COMPULSIVE HABITS Children appear to undergo continuing behavior modification, which permit them to release certain undesirable habit patterns and form new ones which are socially accepted. NORMAL AND ABNORMAL HABITS 1. NORMAL HABITS Those habits that are deemed normal by children of a particular age group. 2. ABNORMAL HABITS Those habits that are pursed after their physiological period of cessation. PHYSIOLOGICAL AND PATHOLOGICAL HABITS 1. PHYSIOLOGICAL HABITS Physiological habits are those that are required for normal physiologic fractioning eg:Nasal respiration, sucking during sucking. 2 .PATHOLOGICAL HABITS Habits that are pursued due to pathological reasons such as adenoids and nasal septal defects that may lead to mouth breathing. BASED ON THE EXTRINSIC OR INTRINSIC FACTORS(GRABER 1972) 1 .Thumb or finger sucking 2. Tongue thrusting or sucking 3. Lip or nail biting 4. Speech defects 5 .Mouth breathing 6. Bruxism 7 .Postural defects 8. Defective occlusal habits RETAINED AND CULTIVATED HABITS 1. RETAINED HABITS Those habits that carried overhood from childhood into adult. 2. CULTIVATED HABITS Those cultivated during the socio-active life of an individual.
  6. 6. DEVELOPMENT OF HABIT A new born instinctively develops certain habits essential for his survival in the state of neuromuscular immaturity. There are five sources of conscious mental patterns in childhood which lead to the development of habit: Instinct Insufficient outlet for surgery Pain /discomfort or insecurity Abnormal physical size of parts Limitations /imposition by parents or others ETIOLOGICAL AGENTS IN THE DEVELOPMENT OF ORAL HABIT 1. ANATOMICAL For example posture of tongue. Infantile swallow occurs due to the large tongue in a small oral cavity coupled with anterior open bites of gum pads. 2. MECHANICAL INFERENCES Mechanical inferences lead to undesirable oral habits, example in a child with normal breathing and swallowing, if permanent incisors erupt ectopically, then to achieve a proper anterior seal/vacuum when swallowing, the child must thrust the tongue and resultant mouth breathing occurs due to loss of lip seal. Again if the succedaneous teeth are missing, an abnormal habit can develop. 3. PATHOLOGICAL Certain conditions of oral and perioral structures can cause an undesirable oral habit, example tonsillitis, DNS, hypertrophy of inferior nasal turbinates (can cause mouth breathing). 4. EMOTIONAL Upset children regress towards infancy, assume infantile postures, example digit sucking which gives the child a feeling of security 5. IMITATION Young children are extremely observant and sensitive to environment and highly affected by parents and siblings.The child may imitate jaw positions/speech disorders of parents.
  7. 7. THUMB SUCKING (DIGIT SUCKING(FINGER SUCKING) HABIT DEFINITION:  Placement of thumb or one or more fingers in various depths into the mouth or oral cavity (Gellin).  Repeated and forceful sucking of thumb with associated strong buccal and lip contractions(Moyers) (Gessell and Lig)  Finger sucking is perfectly normal at one stage of development.  Finger sucking may be considered normal for the first year and a half of life and will disappear spontaneously by the end of the second year with proper attention to nursing. CLASSIFICATION:   NORMAL THUMB SUCKING ABNORMAL THUMB SUCKING -Psychological –deep rooted emotional factor -Habitual –performs the act out of habit. Sucking habits classified as Nutritive - Breast feeding, bottle feeding Non-nutritive sucking habits(NNS) -Thumb or finger sucking, pacifier sucking.
  8. 8. Subtelny (1973): graded thumb sucking into 4 types TYPE A Seen in almost 50% of children, where in the whole digit is placed inside the mouth, with the pad of thumb pressing over the palate, while at the same time maxilla and mandible anteriors contact is present. TYPE B Seen in almost 13-24% of children where in the thumb is placed in oral cavity without touching the vault of the palate, while at the same maxillary and mandibular anteriors contact is maintained. TYPE C Seen in almost 18% of children where, the thumb is placed in the mouth first,and contacts the hard palate and maxillary incisors but there is no contact with mandibular incisors. TYPE D Seen in almost 6%of children where very little portion of thumb is placed into the mouth. Cook (1958) 3 Patterns of thumb sucking. Pushed palate in a vertical direction and displayed only little buccal wall contractions. Registered strong buccal wall contractions and a negative pressure in the oral cavity show posterior cross bite. Alternate positive and negative pressure, least effect on anterior occlusion .
  9. 9. CLASIFICATION OF NNS HABITS (JOHNSON 1993) LEVEL I(+/-) II(+/-) DESCRIPTION Boys or girls of any chronological age with a habit that occurs during sleep Boys below age 8years with a habit that occurs at one setting during waking hours III(+/-) Boys under age of 8 with a habit that occurs at multiple settings during waking hours IV(+/-) Girls below age of 8 years or boy over 8 years with a habit that occur at one setting during waking hours V(+/-) Girls below age of 8 years or boy over 8 years with a habit that occur multiple setting during waking hours VI(+/-) Girls over 8 years with a habit during waking hours (+/-) designates willingness of parents to participate in treatment
  10. 10. THEORIES AND CONCEPTS OF THUMB SUCKING 1.CLASSICAL FREUDIAN THEORY (SIGMUND FREUD-1919) The psychoanalytic theory has proposed that a child goes through various distinct phases of psychological development. In oral phase, it is believed that the mouth is erogenous zone. During this phase child takes anything and everything to the oral cavity. It is believed that any kind of deprivation of this activity will cause an emotionally insecure individual 2.ORAL DRIVE THEORY(SEARS AND WISE-1982) They suggest the strength of oral drive is in part of a function of how long a child continues to feed by sucking. It is not the frustration of weaning that produces the thumb sucking but in fact it is the prolonged nursing that causes it. 3.ROOTING REFLEX (BENJAMIN-1962) The rooting reflex is movement of the infant’s head and tongue towards an object touching its cheeks. He suggested that the thumb sucking arises from the rooting and placing reflexes common to all mammalian infants during the first 3 months of life. 4.SUCKING REFLEX(ERGEL-1962) The process of sucking is a reflex occurring in the oral stage of development and is seen even at 29 weeks of intrauterine life and may disappear during normal growth between the ages of 1-3and half years. It is the first coordinated muscular activity of the infant. Babies who restricted from sucking due to disease or other factor become restless and irritable. This deprivation may motivate the infant to suck the thumb and finger for additional gratification. 5 .LEARNING THEORY(DAVIDSON-1967) This theory advocates that non-nutritive sucking stems from an adaptive response. The infant associates sucking with feelings like pleasure and hunger and recalls these events by sucking the suitable objects available, which is mainly thumb or finger.
  11. 11. ETIOLOGICAL FACTORS ASSOCIATED WITH THUMB SUCKING SOCIO-ECONOMIC STATUS In high socio-economic status the mother is in a better position to feed the baby and in a short time the baby’s hunger is satisfied. Whereas in the low socio-economic group mother is unable to provide sufficient breast milk to infants, hence in the process the infants suckles intensively for a long time thereby exhausting the sucking urge. This theory explains the increased incidence of thumb sucking in industrialized areas when compared to rural areas. WORKING MOTHER The sucking habits is commonly observed to be present in children with working parents because such children are brought up in hands of caretaker and develop feeling of insecurity. NUMBER OF SIBLINGS The development of habit can be related to the number of siblings because more the number increases the attention meted out by the parents to the child gets divided. A child who feels neglected by the parents may attempt to compensate his feelings of insecurity by means of this habit. ORDER OF BIRTH OF THE CHILD Later the sibling ranks in the family, greater is the chance of having an oral habit. FEEDING HABITS Thumb sucking is seen to be more frequent in among breast –fed children. Yet abrupt weaning from the bottle or breast has also been hypothesized to contribute to acquiring an oral habit. A negative relation is also seen between breast feeding and the development of dummy or finger sucking.
  12. 12. SOCIAL ADJUSTMENT AND STRESS Digit sucking has also been proposed as or emotionally based behavior. AGE OF THE CHILD The time of appearance of digit sucking habit has significance.  In the neonates: Insecurities are related to primitive demands as hunger.  During the first few weeks of life: Related to feeding problems.  During eruption of primary teeth: It may be used to relieve teething.  Still later: Children use the habit for the releases of emotional tensions with they are unable to cope, taking refuge in regressing to an infantile behavior pattern  DIAGNOSIS OF THUMB SUCKING HABIT Clinical aspects of thumb sucking given by Moyers in 1995 PHASE PHASE I PHASE II CLINICAL STAGE Normal or sub clinically significant sucking AGE OF CHILD Pre-school infant Clinically significant sucking Grade school PHASE III Intractable sucking Teenage child INFERENCE This phase extends from childbirth to about 3yrs of age depending on the child’s social development. Most infants display a certain amount of thumb sucking during this period, particularly at time of weaning. This phase extends from 3 to 6years.Continued, purposeful digit sucking during this time deserves more serious attention because the possibility indicates a clinically significant anxiety and it is the time to solve dental problems related to digit sucking. Any thumb sucking persisting after the child’s fourth year presents the dentists with a problem. A thumb sucking habit seen during this phase may require psychological therapy and an integrated approach by the dentist.
  13. 13. HISTORY Once the positive history of habit is determined the question regarding the frequency, intensity and duration of the habit is determined. The remedies that have been tried at the home, the feeding patterns, parental care of the child is also ascertained. EMOTIONAL STATUS It is essential to determine if the habit is meaningful or empty. This requires an insight into the emotional security and familial well being of the child. EXTRA ORAL EXAMINATION Digits that are involved in the habit will appear reddened, exceptionally clear, chapped and a short fingernail i.e. a clean dishpan thumb. Fibrous roughened callus may be present on the superior aspect finger Lips:The position of the lips at rest or during swallowing should be observed. A short, hypotonic upper lip frequently characterizes chronic thumb suckers. Lower lip is hyperactive and this leads to further proclination of upper anterior teeth.
  14. 14. Facial form analysis: Check for mandibular retrusion, maxillary protrusion, high mandibular plane angle and profile. When swallowing, the patient is observed for presence of a facial grimace or an excessive mentalis muscle contraction, a normal placement of the tongue against the teeth and palate and whether the pattern of speech of the child is essentially normal. Facial profile is either straight or convex. Other features include Associated symptoms hat should be watched for during the initial examination are habitual mouth breathers and tongue thrust swallow, particularly in children with anterior open bite. Active thumb suckers also have a higher incidence of middle ear infection and frequently have enlarged tonsils accompanied by mouth breathing. INTRAORAL EXAMINATION- TONGUE- Examine for tongue position at rest, tongue action during swallowing. GINGIVA- Look for evidence of mouth breathing; gum line etching, decay or excessive staining on the labial surface of upper central and lateral incisors.
  15. 15. CLINICAL FINDINGS The type of malocclusion produced by digit sucking is dependent on a number of variables (NANDA 1989)  Position of digit  Associated orofacial muscle contraction  Mandibular position during sucking  Facial skeletal pattern  Intensity, frequency and duration of force applied DENTOFACIAL CHANGES ASSOCIATED WITH THUMB SUCKING (JOHNSON & LARSON 1993)
  16. 16. EFFECTS ON MAXILLA EFFECTS ON THE MANDIBLE •Increased proclination of maxillary anteriors with diastema •Increased maxillary arch length •Increased anterior placement of apical base of maxilla •increased SNA •increased clinical crown length of maxillary incisors •increased counterclockwise rotation of the occlusal plane. •Decreased SN to ANS-PNS angle. •Decreased palatal arch width. •Increased atypical root resorption in primary central incisors. •Increased trauma to maxillary central incisors •Increased proclination of mandibular incisors •Increased mandibular intermolar distance •Increased distal position of B point •Decreased maxillary and mandibular incisal angle •Increased overjet •Decreased oerbite •Increased posterior crossbite • Increased unilateral and bilateral Class II occlusion EFFECTS ON THE INTERARCH RELATIONSHIP EFFECTS ON LIP PLACEMENT AND FUNCTION •Increased lip incompetence •Increased lower-lip function under hte maxillary incisors EFFECTS ON TONGUE PLACEMENT & FUNCTION •Increased tongue thrust •Increased lip to tongue resting postion •Increased lower tongue position •Risk to psycologic health OTHER EFFECTS •Increased risk of poisoning •Increased deformation of digits •Increased risk of speech defects,especially lisping
  17. 17. PREVENTION OF THUMB SUCKING 1) Motive based approach The etiology of thumb sucking focuses on a predominant psychological background. Its prevention should be directed towards the motive behind the habit. History serves as an important tool for diagnosing the etiology. 2) Child’s engagement in various activities Parents when questioned may reveal that the child practices the habit when bored and left to himself, or it could be just before he goes to sleep. In such cases, the parents can be counseled on keeping the child engaged in various activities. This gives little chance for child to practice the habit. 3) Parents involved in prevention When parents are at home they should be advised to spend ample time with the child so as to put away his feeling of insecurity. 4) Duration of breast feeding Care should be taken when feeding infants in that the duration of feeding should adequate so as to enable the child to exhaust his sucking urge and feel completely satisfied. 5) Mother’s presence and attention during bottle feeding Bottle fed babies should be held by the mother and enough attention should be given in the process. This will promote a close emotional union between the mother and baby similar to that in breast feeding. 6) Use of physiological nipple A physiological nipple should be used for bottle feeding and size and number of holes should be standardized to regulate a slow and steady flow of milk.
  18. 18. 7) Use of dummy or pacifier Acquiring a digit sucking habit can be prevented by encouraging the baby to suck a dummy instead. If the child already has thumb sucking habit, it will not be easy to introduce a dummy. It is necessary to offer a dummy to a child whose behavior indicates an urgent desire to suck a digit or dummy. TREATMENT CONSIDERATIONS  Psychological status of the child Diagnosis and management of any psychological problem should be planned before the treatment of any potential or present dental problem. The frequency, duration and intensity of the oral habit are important in evaluating the psychological status of the child. If the oral habit was associated with an emotional problem this would suggest the need for psychological consultation.  Age factor If the child desists with finger sucking habit within the first three years of life, the damage incurred such as open bite, is temporary provided the child’s occlusion is normal. No treatment is provided in this age group. If a malocclusion is caused by digit sucking and the habit is discontinued between the age of 4-5 years, self correction of habit can be exempted. When digit sucking continues after 6 years or into mixed dentition, the malocclusion will not be self corrected.  Motivation of the child to stop the habit It is also important to assess the maturity of the child in response to new situations and to observe the child’s reactions to any suggestion. The treatment approach for the digit sucking habit should deal directly with the child.
  19. 19.  Parental concern regarding the habit If the parent is unable to cope with the situation positively then both the parents and the child should be dealt with during the treatment. It is important that the child should not be embarrassed or criticized, rather help should be offered to deal with this difficult habit.  Other factors Self –correction again depends on the severity of the malocclusion, anatomic variation in the peri oral soft tissue, and the presence of other oral habits such as tongue thrusting, mouth breathing and lip biting. MANAGEMENT OF THUMB SUCKING The treatment can be broadly divided into the following (according to PINKHAM) i. ii. iii. iv. i. PREVENTIVE THERAPY PSYCHOLOGICAL THERAPY REMINDER THERAPY- a) chemical APPLIANCE THERAPY b) mechanical PREVENTIVE THERAPY (Hughes 1941) Firstly, feed the child whenever he is hungry and let him eat as much as he wants. Secondly feed the child the natural way. Thirdly never let the habit to be started the practice must be discontinued at its inception. ii. PSYCOLOGICAL THERAPY Screen the patient for underlying psychological disturbances that sustain a thumb sucking habit. Once psychological dependence is suspected, the child referred to professionals for counseling. β-HYPOTHESIS OR DUNLOP’S HYPOTHESIS. He believed that if a subject can be forced to concentrate on the performance of the act at the time he practices it, he could learn to stop performing the act. Forced purposeful repetition of habit eventually associates with unpleasant reactions and the
  20. 20. habit is abandoned. The child should be asked to sit in front of the mirror and asked to observe himself as he indulges in the habit. THUMB SUCKING BOOK-“The Little Bear who Sucked His Thumb” is a book directed at children, for children. The book has been written and illustrated by DR.Dragan Antolos, an experienced dentist with a special interest in thumb sucking habits in children. The book and chart are a non-invasive and effective strategy for stopping thumb sucking, and have received positive support from psychiatrists, speech pathologists and pedodontic societies. DR.Dragan Antolos,”It is important to balance the psychological benefits of thumb sucking with the negative impact it has on developing, permanent teeth.”The Little Bear who Sucked His Thumb” is a book that the child will relate to the story and it will deliver a positive message without pressure.
  21. 21. iii. REMINDER THERAPY CHEMICAL THERAPY Recommends the use of hot flavoured,bitter and sour tasting or foul smelling preparations, placed on the thumb or fingers that are sucked. The chemical therapy uses Cayenne (red) pepper dissolved in a volatile liquid medium. Quinine and Asafoetida, castor oil which have bitter taste and an offensive odor respectively, also may be used. This should be done only when the patient has a positive attitude and wants treatment to break the habit.A commercially available product FEMITE (Denatonium benzoate) is also used for prevention of digit sucking. MECHANICAL THERAPY Mechanical restraints applied to the hand and digits like splints, adhesives tapes. Thumb guard is the most effective extra oral appliance for control of the habit.
  22. 22. a. THERMOPLASTIC THUMB POST was devised by Allen in 1991 where a thermoplastic material was placed on the offending digit. A total of 6 weeks of treatment time was required for elimination of habit. b. ACE BANDAGE APPROACH: other approach include the use of ace bandage which is an at home program to assist children with nocturnal digit sucking habits. The program involves nightly use of an elastic bandage wrapped across the elbow. Pressure exerted by the bandage removes the digit from the mouth as the child tires and fall asleep. c. NORTAN AND GELLIN(1968)- proposed a 3 alarm system often effective in children between 3-7 years  Offending digit is taped and when the child feels the tape in te mouth it serves as the first alarm.  Bandage tied on the elbow of the arm with the offending digit, a safety pin is placed lengthwise. When the child flexes the elbow, the closed pin mildly jabs indicating a second alarm
  23. 23.  Bandage tightens if the child persists serving as a third alarm d. USE OF LONG SLEEVE NIGHTGOWN-This is useful in children who sincerely want to discontinue the habit and only perform during their sleep. The arms of their night suit are lengthened so that they cannot reach their thumb during night. e. THUMB-HOME CONCEPT-This is the most recent concept. In this method a small bag is tied around the wrist of the child during sleep. It is explained to the child that just as the child sleeps in his home, the thumb also sleeps in its house. Thus the child is restrained from thumb sucking during night.
  24. 24. f. USE OF HAND PUPPETS-Currently the use of hand puppets is gaining popularity. These help in eliminating thumb sucking. g. MY SPECIAL SHIRT-This helps in minimizing the damage of the finger sucking by providing a number of tools to address the habit in a phased manner.
  25. 25. iv. APPLIANCE THERAPY Various orthodontic appliances are employed to attenuate and eventually break the habit. Removable appliances used may be palatal crib, rakes, palatal arch, lingual spurs, and Hawley’s retainer with and without spurs. Fixed appliances such as upper lingual tongue screens appear to be more effective in breaking these habits. Removable or fixed palatal crib-It breaks the suction force of the digit on the anterior segment, reminds the patient of his habit and makes the habit a non-pleasurable one. Oral Screen-Oral screen is a functional appliance introduced by Newell in 1912.It produces its effects by redirecting the pressure of the muscular and soft tissue curtain of the cheeks and lips. It prevents the from placing the thumb or finger into the oral cavity during sleeping hours.
  26. 26. Hay Rakes-Mack (1951) advocated the use of dental appliance in children over 3 1/2 years of age who persistent thumb suckers. The device was called hay rake as it was designed with a series of fence like lines that prevented sucking. Blue Grass appliance-Developed by Bruce S Haskell (1991).It is a fixed appliance using a Teflon roller, together with positive reinforcement. Used to manage thumb sucking habit in children between 7 and 13 years of age. The patient believes that he has acquired a new toy to play with. Instructions are given to them to roller instead of sucking the digit. Quad helix-The quad helix is fixed appliance used to expand the constricted maxillary arch. The helixes of the appliance serve to remind the child not to place the finger in the mouth.
  27. 27. Modified Blue Grass appliance-This is a modification of the original appliance with the difference being that this has two rollers of different colors and material instead of one. If the patient tries to suck on his thumb the suction will not be created and his thumb will slip from the rollers thus breaking the act. GRABER explained the working of these appliances  Render finger habit meaningless by breaking suction  Prevents finger pressure from displacing maxillary central incisors thus avoids/labially from creating worse a malocclusion.  Forces the tongue backwards changing its postural rest position, thus exerting more lateral pressures