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Oral Habits in Children. Part II: Tongue thrusting,Mouth Breathing,Frenum thrusting,Cheek biting, Nail biting, Postural Habits,Bobby pin opening,Masochistic habits
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Oral Habits in Children. Part II: Tongue thrusting,Mouth Breathing,Frenum thrusting,Cheek biting, Nail biting, Postural Habits,Bobby pin opening,Masochistic habits


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The seminar has been prepared to the best of my knowledge, to cover in brief all other oral habits, except for the ones explained in part I.

The seminar has been prepared to the best of my knowledge, to cover in brief all other oral habits, except for the ones explained in part I.

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  • Barber 1975: Oral habit pattern related to the persistence of an infantile swallow pattern during childhood and adolescence and thereby produces open bite and protrusion of the anterior tooth segments.
  • DCNA 1978, Braham and Morris
  • Hanson M.L and Cohen M.S. Effects of form and function on swallowing on developing dentition. Am J Orthod. 1973; 64: 63Subtenly J D .oral habits- studies in form, function, and therapy. Angle Orthod 1973; 43: 349-383.
  • Straub WJ. Malfunction of the tongue. Am J Orthod 1960; 46: 404
  • DCNA 1978
  • TANDON 2001Physiologic Normal tongue thrust swallow of infancy. Habitual Tongue thrust swallow persists as a habit even after correction of malocclusion. Functional When tongue thrust mechanism is adaptive behaviour developed to achieve an oral seal. Anatomic Persons having enlarged tongue can have an anterior tongue posture
  • [Forrestor, Graber, Profitt, Moyers]
  • Tully W. J: Tongur trusting. Am J Orthod 1969; 55: 640
  • Tandon S, Text book of Pedodontics, 2nd edition. Paras publications. P: 427-28
  • David O, Michael W and Richard K. Oral Habits. In Pediatric Dental medicine by D. J.Forrester, M .L.Wagner. Lea and Febiger 1981 ed 1: 547-50
  • SPOT n SQUEEZE: 2S exercise. After learning this, Squeeze is taught.i.eby squeezing the tongue vigorously against the spot with the teeth closed, following by relaxing.
  • Gellin M E. Anterior open bite: serial observation of 37 young children. J Dent Child1966; 33: 266
  • frequently observed in ectomorphic who possess long, narrow faces and nasopharyngeal spacesGellin M E. Anterior open bite: serial observation of 37 young children. J Dent Child1966; 33: 266
  • Hab: These children continually breathe through the mouth by force of habit, although the abnormal obstruction has been removedAnat: These children have short upper lips which does not permit closure without undue effort. One must distinguish this type from the child who breathes through his nose but keeps his lips apart because of a short upper lip
  • Proffit WR. Contemporaey Orthodontics, ed 4. St Luise, 2007,Mosby publications: 534Gellin M E. Anterior open bite: serial observation of 37 young children. J Dent Child1966; 33: 266Tully W. J: Tongur trusting. Am J Orthod 1969; 55: 640
  • 3: Repeated infection resulting in overgrowth of lymphoid masses blocks the posterior nares, rendering mouth breathing necessary until 10-12 years (Atrophy of this tissue after puberty will cause them to drop mouth breathing) 7: (Child snores loudly, breathes heavily and may struggle for breath, and stops breathing for 30-45s while asleep. Due to upper airway obstruction by tonsils/adenoids).
  • Increased incidence of caries
  • Observe the patientMouth breathers: Lips will be apartNasal breather: Lips will be touching2.Ask the patient to take deep breath through noseMouth breathers: No change in shape or size of external naresNasal breathers: Demonstrates good control of alar muscles3.Mirror test: Fog test:4.Massler’s water holding test: Mouth breathers cannot hold water for a long timeTwo surfaced mirror is placed on the patient’s upper lip. If air condenses on upper side: Nasal, If on lower: mouth
  • Take a few fibres of the cotton and place below the nasal opening. On exhalation, if the fibres of the cotton flutter downwards patient is nasal breather and if fibres flutter upward he is a mouth breather.
  • Raymond L.B, Merle E.Morris. Oral Habits and their Management. In Text book of Pediatric Dentistry: ed 2: Waverly press. Inc.656
  • An otolaryngologist examination may be advised to determine whether conditions requiring treatment are present in tonsils, adenoids or nasal septum. David O, Michael W and Richard K. Oral Habits. In Pediatric Dental medicine by D. J.Forrester, M .L.Wagner. Lea and Febiger 1981 ed 1: 552-53In some children mouth breathing may continue even after correction of the pathological conditions, in which case it may be habitual.
  • Mouth breathing should be treated during mixed dentition period to prevent or correct its ill effects on occlusion.
  • reduction
  • If the habit continues even after removal of the obstruction then it should be corrected. Correction can be made by means of following:
  • Hypotonicityand flaccidity of upper lip are the most obvious characteristics. Martinot R.G. Rehabilitation of the mouth-breathing child . ActaOtorhinolaryngol Belg. 1993; 47:273-5.The child is instructed to extend the upper lip as far as possible to cover the vermillion border under and behind the maxillary incisors. This exercise should be done 15-30 mins/day period for 4-5 months when the child has short upper lip. If the maxillary incisors are protruded, the lower lip can be used to augment the upper lip exercise. The upper lip is first extended in to the previously described position. The vermillion border of the lower lip is then placed against the outside the lip and pressed as hard as possible against the upper lip. This type of exercise exerts strong retraction influence on the maxillary incisors, which increases the tonicity of both upper and lower lips.A celluloid strip or metal disk held between the lips not only necessitate their being closed, but also makes the child conscious of their opening if the object drops.The upper lip is first extended in to the previously described position. The vermillion border of the lower lip is then placed against the outside the lip and pressed as hard as possible against the upper lip. This type of exercise exerts strong retraction influence on the maxillary incisors, which increases the tonicity of both upper and lower lips.A celluloid strip or metal disk held between the lips not only necessitate their being closed, but also makes the child conscious of their opening if the object drops.
  • effective way to reestablish nasal breathing prevent air from entering the oral cavity. To do this either lips or the oral cavity must be closed. For this purpose an oral screen can be used.
  • NEWEL 1912
  • The cast is covered with this even layer of wax (24 gauge) to which a large sprue is attached, a layer of plaster is then boxed and then poured on the wax to form a mold. The wax is eliminated to with boiling water. To cast, a level is poured full of pure latex and is permitted to stand for 12 hours.
  • David O, Michael W and Richard K. Oral Habits. In Pediatric Dental medicine by D. J.Forrester, M .L.Wagner. Lea and Febiger 1981 ed 1: 552-53
  • Patrícia J, Irene Queiroz M, Luciana R, Emílio C, Leonardo H, Maria C. Speech-language pathology findings in patients with Mouth breathing: multidisciplinary diagnosis : According to etiology.International Journal of OrofacialMyology 2010;36:27-32 David O, Michael W and Richard K. Oral Habits. In Pediatric Dental medicine by D. J.Forrester, M .L.Wagner. Lea and Febiger 1981 ed 1: 552-53Bruxism usually refers to Nocturnal, subconscious grinding of the teeth but can occur during the day or night and may be performed consciously or subconsciously.
  • Shobha tendon, text book of Pedodontics, 2nd edition. Paras publications. P: 427ELECTROMYOGRAPHY
  • Massler. M and Zwemer. J D. Mouth Breathing. Diagnosis and Teatment. J Am Dent Assoc 1953; 446: 658
  • Ramfjord SP. Bruxism: A clinical and electromyographic study, j Am Dent Assoc 1961: 61; 21-44
  • Nadler SC. Bruxism: the classification. a critical review. J of Am Dent Assoc 1957; 54: 615
  • John R.C, Henry W.F. oral habits. In Peditric dentistry. Infancy through adolescence. Jimmy R. Pinkham. Ed 4. Elsevier publications.2005: 438
  • The most common presentation is the lower lip is positioned behind the upper incisors
  • This habitual pattern of muscle behaviour impedes the forward development of the anterior alveolar process in the mandible. The abnormal mentalis function often occurs together with lip sucking or lip thrust.
  • John R.C, Henry W.F. oral habits. In Peditric dentistry. Infancy through adolescence. Jimmy R. Pinkham. Ed 4. Elsevier publications.2005: 438Fisher GD: Growth and Development of the Child. J Dent Child 1958; 25: 69-83
  • Raymond L.B, Merle E.Morris. Oral Habits and their Management. In Text book of Pediatric Dentistry: ed 2: Waverly press. Inc.655NEXT SLIDEUsually accompanied by cheek sucking. There is placement interposition of the soft tissues buccal pad of fat between occlusal surfaces of maxillary and mandibular teeth. There may be lingual tipping of teeth in posterior region, and unilateral posterior open bite. Linea alba buccalis is seen as a white line along line of occlusion, there may even be an ulcer. It is more likely to be seen in children with buccoversion of molars, buccalnonocclusion flabby cheeks, atrophy of muscles seen in paralysis.
  • S. B.Finn, Clinical Pedoontics. 4th edition. 1987.W.B.Saunders Company, P: 317-18Willette J. Lip chewing: another treatment option. Special Care in Dentistry 1992; 12: 174–176.If the upper permanent incisors are spaced apart, the child may lock his labial fermium between these teeth and permit it to remain in this position for several hours. If probably starts as idle play but may develop into a tooth displacing habit by keeping the incisors apart, similar to an abnormal frenum.
  • Abnormal habit of keeping/biting the cheek muscles in between the upper and lower posterior teeth.
  • Frequently the child will go directly from thumb sucking stage to into nail biting stage.
  • habit which once was prevalent among teenage girls was the
  • Willette J. Lip chewing: another treatment option. Special Care in Dentistry 1992; 12: 174–176.Stewart, DJ and kernohan, D.C: Self inflicting gingival injuries, gingival artifacta, factitial gingivitis. Dent. Preac. Dent. Rec 1972; 22:418
  • Even though children have been found to have biochemical and enzymatic deficiencies, no direct correlation has been established between these deficiencies and behavior symptoms.Mallson , G., and Robertson, BM: Self enucleation and psychoses. Arch. Gen. Psychiatry 1976 ;33: 242Van Moffaert M. Localization of Self-inflicted dermatological lesions: what do thy tell the dermatologist?. ActaDermVenereologica 1991; 156: 23–27.
  • A. C. Medina, R. Sogbe, A. M. Gómez-Rey, M. Mata. Factitial oral lesions in an autistic paediatric patient. Inter. J of Paediatr Dent 2003; 2: 130–137,
  • David O, Michael W and Richard K. Oral Habits. In Pediatric Dental medicine by D. J.Forrester, M .L.Wagner. Lea and Febiger 1981 ed 1: 555-56
  • Transcript

    • 2. Contents ▪ Tongue thrusting ▪ Mouth Breathing ▪ Bruxism ▪ Lip Habits: Lip sucking : Mentalis habit ▪ Frenum thrusting ▪ Cheek biting ▪ Nail biting Postural Habits Bobby pin opening Masochistic habits References
    • 4. DEFINITIONS ▪ Tulley 1969 : Tongue thrust is the forward most placement of tongue tip between teeth to meet the lower lip during deglutition and in sounds of speech , so the tongue becomes interdental. ▪ Profitt 1972: It is the placement of the tongue tip forward between incisors during swallowing
    • 5. ▪ Norton & Gellin 1978: Tongue thrust is the condition in which the tongue protrudes between anterior and posterior teeth during swallowing with or without affecting tooth position
    • 6. Incidence:1,2,3 ▪ Milton 1978 : 97% newborns 80% 5-6yrs 3% 12 yrs ▪ Lewis & Connihan 1965: 97% new born children ▪ Fletcher 1961: 25-30% in children of 9 yrs age
    • 7. ▪ Hanson and Cohen found a similar incidence and age distribution of tongue protruding between the teeth during swallowing. ▪ Subtelny and Subtelny (1973) using cine radiography, observed that most thumb suckers exhibited tongue thrusting during swallowing (40%) . ▪ Anderson (1963) reported 15% of students having tongue thrusting habit, among which 54% had a history of digit sucking.
    • 8. ▪ Ardran et al (1958) observed that tongue thrusting habit during swallowing is almost universal in infancy. ▪ By adulthood the jaws grow sufficiently to permit the tongue to rest and function within the confines of the oral cavity. ▪ This could explain reduction in incidence of tongue thrusting habit with increasing age. ▪ Kelly et al (1973) indicated that % age of persons with infantile and transitional swallowing patterns is greater than % age of persons with open bite, so it is not a simple cause and effect relationship.
    • 10. MOYERS [1955] A) Simple : Normal tooth contact during the swallowing act. • Anterior open bite. • Good intercuspation of teeth. • The tongue thrust forward to establish anterior lip seal. • Abnormal mentalis muscle activity
    • 11. B)Complex :Teeth apart during swallow. • Diffuse or absent anterior open bite (Bimaxillary protrusion) • Absence of temporal muscle constriction during swallowing. • Contraction of the circum oral muscles during swallowing. • Poor occlusion of teeth
    • 12. 3) Strub Classification (1961)4 ▪ Group 1 : Diastema between upper central incisors ▪ Group 2: Nonocclusion or open bite is seen not only between anterior teeth but in posterior teeth as well, usually from first molar forward (second molar in place)
    • 13. ▪ Group 3 : Side thrust : nonocclusion in the premolar and canine area has been created by lateral displacement of tongue. ▪ Group 4 : Crossbite cases : most difficult to detect and correct. May go undetected till ortho completes.
    • 14. BACKLUND 1963 ▪ Anterior tongue thrust ▪ Forceful anterior thrust ▪ Posterior tongue thrust ▪ Lateral thrusting in case of missing teeth.
    • 15. JAMES BRAUER,TOWNSENDV. HOLT 1965 ▪ Type I : Non deforming tongue thrust ▪ Type II : Deforming anterior tongue thrust Subgroup 1: Anterior open bite Subgroup 2: Anterior proclination Subgroup 3: Posterior crossbite
    • 16. ▪ Type III: Deforming lateral tongue thrust Subgroup 1:Posterior open bite Subgroup 2:Posterior crossbite Subgroup 3:Deep crossbite ▪ Type IV: Deforming anterior and lateral tongue thrust Subgroup 1:Anterior and posterior open bite Subgroup 2:Proclination of anterior teeth Subgroup 3:Posterior crossbite
    • 17. TULLEY [1969] 1. As a habit 2. Innate or endogenous 3. Adaptive behaviour
    • 18. Fletcher [1975] A. Simple : associated with thumb sucking, open bite B. Complex : associated with tonsils, URTI
    • 19. Profitt 1990 ▪ Physiologic ▪ Habitual ▪ Functional ▪ Anatomic
    • 20. SWALLOW5,6 Characteristics of Infantile swallow: (Moyers)  Vigorous lip & cheek contractions  Swallow guided by sensory interchange between the lips and the tongue.  Jaws apart , with tongue between gum pads.  Mandible stabilized by facial muscles and interposed tongue.  The change to adult swallow pattern occurs in the “Transitional period”.
    • 21. Characteristics of mature swallow: (Moyers) ▪ Teeth are in occlusion ▪ Mandible stabilized by contractions of mandibular elevators ▪ Tongue tip held against the palate, above and behind maxillary incisors ▪ Minimal lip contractions
    • 22. Transition from infantile to mature swallow: Begins at 1st year of life: Complete development of mature swallow: 6-7years of life Growth of mandible & maxilla Developed jaw muscles to stabilize Eruption of primary teeth Introduction of semisolid foods
    • 23. If the transition of infantile to mature swallow does not take place with the eruption of teeth, then it leads to TONGUETHRUST SWALLOW
    • 24. Retained infantile swallow  It is defined as predominant persistence of the infantile swallowing reflex after the arrival of teeth.  The tongue thrust strongly between the teeth in front and on both sides.
    • 25.  Particularly noticeable are contractions of the buccinator muscle.  May have inexpressive faces , since the 7th cranial nerve muscles are being used for the massive effort of stabilizing the mandible during swallowing
    • 26. Normal mature swallowing pattern ▪ At rest: Tongue tip behind lingual surface of mandibular incisors ▪ Beginning of swallowing: Tongue tip in contact with palatal surface of maxillary incisors
    • 27. ▪ 1st phase: ▪ dorsum of tongue contacts anterior part of hard palate ▪ 2nd phase: ▪ Dorsum of tongue contacts posterior part of hard palate / soft palate
    • 28. ▪ 3rd phase: root of tongue contacts posterior pharyngeal wall.
    • 29. ETIOLOGY Retained infantile swallow Upper respiratory tract infections Neurological disturbances Feeding practices Functional adaptability to transient change in anatomy Other oral habits Hereditary Tonsils and adenoids Lingual frenum Brain injury Faulty surgical procedures
    • 30. Acc to FLETCHER(1975) 7 ▪ Genetic factors ▪ Learned behaviour (Habit) ▪ Maturation ▪ Mechanical restriction ▪ Neurological disturbances Psychogenic factors Craniofacial growth and maturation Open spaces during mixed dentition. Other factors
    • 31. History ▪ Information regarding : URTI : sucking habits, : neuromuscular problems. Determine swallow pattern of siblings & parents (hereditary etiology) Determine whether remedial speech therapy was provided. Abilities and motivation of the patient
    • 32. Clinical manifestations may include the following: 8 EXTRAORAL ▪ Lip posture: 1. Lip separation at rest may be greater, with short and flaccid upper lip = consistent finding at both rest and function. *Lack of compensatory lip activity during swallowing in these subjects  Mandibular movements: 1. During swallowing may be more erratic 2. No correlations could be found between the movements of the tongue tip and the mandible itself. 3. In the tongue thrust group , the average path of mandibular movements was upward and backward with the tongue moving forward.
    • 33. ▪ Tongue thrust children are more likely to have various speech disorders , such as : Sibilant distortions . ▪ Lisping problems in articulation of /s/, /n/, /t/, /d/, /l/, /th/, /z/, /v/ sounds. ▪ Facial form: ▪ Increase in anterior facial height. Speech disorders:
    • 34. INTRA ORAL9 ▪ Tongue movements: during swallowing may be jerky and inconsistent. ▪ Tongue posture: tongue tip at rest may be lower. ▪ Malocclusions associated with tongue thrust:
    • 35. Tongue posture ▪ At rest in normal individuals: A. Tip : rests against lingual surface of mandibular incisors B. Dorsum : touches hard palate ▪ Altered tongue posture:
    • 36. Altered tongue posture: 1. Retracted: a. Tongue tip withdrawn from all anterior teeth, laterally spread tongue b. Rare in children (10%). More common in edentulous patients 2.Protracted position: a. Endogenous type: infantile postural pattern b. Acquired type: enlarged tonsils
    • 37. 3. During Swallowing :  Tip: lies between incisal edge of mandibular & maxillary incisors : oral seal
    • 38. Malocclusions associated with tongue thrust: A. Features pertaining to maxilla 1. Proclination of anteriors, and overjet. 2. Generalized spacing between teeth. 3. Maxillary constriction. B. Features pertaining to mandible 1. Retro, or proclination of anteriors, depending on type of tongue thrust C. Intermaxillary relationship 1. Anterior/posterior open bite depending on tongue thrust 2. Posterior crossbite
    • 39. Clinical features Simple tongue thrust a. Normal tooth contact in posterior region b. Anterior open bite c. Contraction of the lips, mentalis muscle and mandibular elevators Complex tongue thrust a. Generalized open bite b. The absence of contraction of lip and oral muscles
    • 40. ▪ Lateral tongue thrust a. Posterior open bite with lateral tongue thrust ▪ Other features a. Proclination of anterior teeth b. Anterior open bite c. Midline diastema d. Posterior cross bite
    • 41. Diagnosis ▪ Careful differentiation must be made among a simple, complex and a retained infantile swallow. ▪ Prognosis is usually ▪ excellent simple tongue thrust ▪ Good complex ▪ Very poor Retained infantile swallow
    • 42. Examination ofTongue ▪ Check for size, shape and movements ▪ Functional examination ▪ A) Observe for tongue position while the mandible is in rest position ▪ B) Observe the tongue during various swallows 1. Conscious swallow 2. Command swallow of water 3. Conscious swallow during mastication
    • 43. Palpatory examination 1. Place water beneath the patients tongue tip and ask him to swallow a. Normal: Mandible rises and teeth are brought together but no contraction of lips or facial muscles b. Tongue thrusting: Marked contraction of lips and facial muscles 2.Place hand over temporalis muscle and ask to swallow a. Normal:Temporalis contracts & Mandible- elevated b. Tongue thrusting: No temporalis contraction 3. Hold the lower lip withThumb
    • 44. Treatment considerations ▪ Self correcting by 8-9 years: by the time permanent teeth erupt. ▪ If associated with other habits: Asstd habit should be treated first
    • 45. TRAINING OF CORRECT SWALLOW AND POSTURE OFTHETONGUE 1) Myofunctional therapy *Garliader Patient can be guided regarding correct posture of tongue during swallowing by various exercises like •Asking the child to place the tip of the tongue in the rugae area for 5min and then asking him to swallow 2)Orthodontic elastics Tongue tip is held against the palate using elastics of 5/16’’ and sugarless fruit drop.
    • 46. 3) Lemon candy Exercise ▪ Instead of elastic, a lemon candy is put on the tongue tip. ▪ Pt is asked to hold the candy against the palate by the tongue tip and then asking the child to swallow. 4) 4S exercise ▪ Includes identifying the SPOT, SALIVATING, SQUEEZING the spot and SWALLOWING. ▪ Using the tongue the spot is identified, the tongue tip is pressed against this spot and the child is asked to swallow keeping the tongue at the same spot
    • 47. ▪ Other exercises: • Whistling • Reciting count from 60-69 • Gargling • Yawning Peanuts exercise: patient chews peanuts  Chewed nuts placed in middle of tongue  Put peanuts on anterior part of palate and swallow  1960Andrews :Water holding exercise (infront of mirror)Repeat 20 times / day
    • 48. ▪ Lip exercises Tug of war and Button pull exercise: ▪ A string is tied to two buttons, one of the buttons is placed between the lips of the patient, while the other is held by the patient outside. ▪ Outer button is pulled outwards, at the same time, the inner button is resisting the forces thereby strengthening the lips on both aspect
    • 49. ▪ Sub concious therapy: ▪ Once voluntary swallowing pattern is acquired, the patient proceeds to sub conscious therapy, i.e subliminal therapy where the patient is asked to place a reminder sign or auto suggestion which requires the patient to give self instructions like ▪ Repeat 6 times” I will swallow correctly all night long” for 10nights
    • 50. Pre orthodontic trainer for myofunctional training ▪ It aids in correct positioning of the tongue with the help on tongue tags. ▪ The tongue guards prevent tongue thrusting when in place. Nance palatal arch appliance ▪ Here, acrylic button can be used as a guide to place the tongue in correct position.
    • 51. Speech therapy ▪ 1)To train the correct positioning of tongue, as this position is more conducive to the articulation of speech and to normal alignment of teeth. ▪ The child is asked to repeat simple multiplication tables of sixes , pronounce words beginning with ‘S’ sounds
    • 52. MECHANOTHERAPY1,10,11 1) Fixed and removable appliances: -Restrain anterior tongue movement -form a more effective barrier -reduces anterior tongue positioning (dorsum of tongue approximates palatal vault and the tip of the tongue contacts the palatal rugae during deglutition) 2) Capability of using the Hawley to close the anterior openbite through the use of the labial bow.
    • 53. Removable appliances: ▪ Hawley’s appliance ▪ Hawley’s appliance modifications: • Acrylic cut in anterior hard palate region • Cribs or rakes employed in anterior part Advantages: • Increased anchorage value • The crib can serve as a reminder.
    • 54. Oral screen: ▪ Restriction of tongue thrusting habit ▪ Alignment of maxillary anterior teeth ▪ Correction of open bite ▪ Lip muscle exercises performed with ring attached in anterior part of appliance
    • 55. Fixed Habit breaking appliance: • Crowns and bands on first perm. molar • 0.040inch stainless steel ‘U’-shaped lingual bar adapted at the level of gingival margin. • Crib formed (3-4 ‘V’ shaped projections) • Cut cribs as child weans the habit • Nance palatal arch (acrylic button)
    • 56. TREATMENTOF SIMPLETONGUETHRUST: ▪ Treatment of tongue thrust should not be begin until the incisors have been retracted. ▪ Steps: a. Acquaint the patient consciously to correct swallowing pattern b. Reinforce subconsciously
    • 57. TREATMENTOF COMPLEXTONGUETHRUST: Poor prognosis due to  Poor occlusal fit  Generalized open bite ▪ Neuromuscular problems  abnormal occlusal reflex ▪ abnormal swallow a. Treat the malocclusion first b. Muscle training similar to that for simple tongue thrust
    • 58. SURGERY Retained infantile swallow
    • 59. Weiss[1972] ▪ Phase 1: tongue positioning ▪ Phase 2: bite & swallow ▪ Phase 3: bite & swallow with lips apart ▪ Phase 4: reminder therapy
    • 60. Moyers [1973] ▪ 1st stage : Myotherapy in early phases ▪ 2nd stage : Lingual or palatal arch with spurs ▪ 3rd stage : 3 phases:  Phase 1: learn new swallow reflex at conscious level  Phase 2: exercises  Phase 3: reinforcement : lingual arch
    • 62. DEFINITION12 ▪ Chopra (1951) & Sassouni (1971) Habitual respiration through the mouth instead of the nose. ▪ Chacker (1961) Prolonged or continued exposure of the tissues of anterior areas of mouth to the drying effects of inspired air. ▪ Merle (1980) : Used the term oro-nasal breathing instead of mouth breathing.
    • 63. Finn (1987)12: 3 categories 1) Obstructive ▪ Increased resistance to/ complete obstruction of normal flow of air through nasal passages. ▪ Child is forced to breathe through mouth. ▪ Ectomorphic children. ▪ Because of this genetic type of tapering face and naso-pharynx, these children are more prone to nasal obstruction.
    • 64. ▪ Resistance to breathing through nose may be caused by : 1. hypertrophy of turbinates caused by allergies, chronic infection of mucosa lining nasal passage, atrophic rhinitis, hot and dry climatic conditions, polluted air. 2. Deviated nasal septum with blocking of nasal passage 3. Enlarged adenoids.
    • 65. 2.Habitual ▪ Continually breathe through the mouth by force of habit 3. Anatomical ▪ Short upper lips which does not permit closure without undue effort. * One must distinguish this type from the child who breathes through his nose but keeps his lips apart because of a short upper lip.
    • 66. ETIOLOGY7,9,12: Airway obstruction may be due to: 1. Enlarged turbinates 2. Intranasal defects: (more likely to manifest in adulthood) ▪ Partial obstruction due to deviated nasal septum, localized benign tumours. ▪ Thickness of sputum ▪ Bony spurs
    • 67. 3.Hypertrophy of pharyngeal lymphoid tissue. 4. Infection and inflamation of nasal mucosa, chronic allergic stomatitis, chronic atropic rhintis, enlarged adenoids and tonsils, nasal polyps 5. Short upper lip 6. Obstruction in bronchial tree or larynx. 7. Obstructive sleep apnea syndrome.* 8. Genetically predisposed ectomorphs. 9. Thumb sucking or similar oral habits leading to underdeveloped or abnormal facial musculature. 10.Cleft lip & palate.
    • 68. General features ▪ In order to breathe, ▪ the child bends the neck forward straightening the Oro-naso- pharyngeal path ▪ This give the appearance of Pigeon chest ▪ In mouth breathers the oro-pharynx is dry and can produce a low grade eosophagitis. ▪ Maxillary sinus and nasal cavity frequently becomes narrowed.
    • 69. ▪ Turbinates become swollen and engorged. ▪ Speech acquires a nasal tone ▪ Sleep apnea syndrome: Due to loss of cleansing action of saliva there is generally an enlargement of the lingual tonsil at the base of the tongue. ▪ This leads to partial or complete obstruction of the oro-pharynx during sleep
    • 70. Blood Gas constituents ▪ Blood gas studies reveal that mouth breathers have 20% more CO2 and less O2. APPEARANCE i. Adenoid faces is the characteristic feature of mouth breathers ii. Lips are held wide apart iii. There is lack of tone of oral musculature iv. Upper lip: SHORT v. Nose: tipped superiiorly ; Bridge: flat vi. Long narrow face vii. Face: expressionless
    • 71. Dental and Skeletal ▪ Low tongue position ▪ Narrow maxillary arch ▪ Protrusion : maxillary and mandibular incisors ▪ Palatal vault: High Mandible hangs in a slack manner ▪ Anterior open bite ▪ Increased : caries ▪ Mucus and plaque : more tenacious Chronic keratinized marginal gingivits
    • 72. History ▪ Parents can be questioned whether the child frequently adopts a lip apart posture. ▪ Frequent occurrence of tonsillitis, allergic rhinitis, otitis media should be questioned. ▪ Also whether the patient has restless sleep, snores wakes up feeling thirsty.
    • 73. DIAGNOSIS 1. Observe the patient ▪ Lips 2.Ask the patient to take deep breath through nose ▪ Shape/size: external nares ▪ good control of alar muscles 3.Mirror test: Fog test: 4.Massler’s water holding test:
    • 74. 5. Jwemen’s butterfly test: 6.Rhinometry(Inductive plethysmography): The total airflow through nose and mouth can be quantified using inductive plethysmography 7.Cephalometrics: Can be used to calculate amount of naso-pharyngeal space.
    • 75. TREATMENT ▪ Main aspect: Treat and eliminate the underlying cause or pathology that has created the habit. ▪ This should be followed by symptomatic treatment. ▪ Other procedures and appliances that can be used are: 1. Deep breathing exercises 2.Lip exercises 15-30in/day for 4-5months 3.Oral screen
    • 76. Treatment considerations 13 ▪ Age of the patient I. As with any other habit, correction of mouth breathing could be expected as the child matures. II. As the child grows, obstruction caused due to enlarged adenoids is relieved. III. Mouth breathing in many instances is self- correcting after puberty
    • 77. E.N.T examination ▪ An otolaryngologist examination may be advised : tonsils, adenoids or nasal septum. ▪ In some children,it may be habitual. ▪ Correction should first aim at REMOVING any anatomic or functional causes. ▪ To institute a treatment of actual cause, it is important to determine the type and degree of mouth breathing, whether it is habitual or obstructive, and whether total mouth breathing is present or it is partial.
    • 78. Correction Symptomatic treatment: ▪ The gingiva of the mouth breather should be restored to normal health by ▪ Coating the gingival with petroleum jelly, ▪ Applying preventive dentistry methods and ▪ Clinically correcting periodontal defect that have occurred due to the habit. ▪ *Mixed dent
    • 79. Treatment should be aimed at 1) Elimination of the cause ▪ If nasal or pharyngeal obstruction has been diagnosed : attempts should be made at treating the etiological factor first. ▪ Removal of nasal or pharyngeal obstruction by ▪ surgery or local medication should be sought. ▪ If a respiratory allergy is present, this should be brought under control. ▪ A marked in nasal airway resistance after a rapid maxillary expansion has been reported.
    • 80. Interception of the habit EXERCISES: If there is no physiological cause the patient should be instructed in breathing and lip exercise. A) Physical exercises ▪ Done in the morning and night. ▪ Deep breathing exercises are done with inhalation through the nose with arms raised sideways. ▪ After a short period, the arms are dropped to the sides and air is exhaled through the mouth.
    • 81. Lip exercises14 Hypotonicity and flaccidity of upper lip. ▪ Extend the upper lip as far as possible to cover the vermillion border under and behind the maxillary incisors. ▪ 15-30 mins/day period for 4-5 months when the child has short upper lip. ▪ If maxillary incisors are protruded, the lower lip can be used to augment the upper lip exercise.
    • 82. ▪ This type of exercise exerts strong retraction influence on the maxillary incisors, which increases the tonicity of both upper and lower lips. ▪ A celluloid strip or metal disk held between the lips not only necessitate their being closed, but also makes the child conscious of their opening if the object drops.
    • 83. Maxillothorax myotherapy 15 ▪ Macaray 1960. ▪ These expanding exercises are used in conjunction with Macaray activator. Macaray constructed an activator out of aluminium with which development of dental arches and dental base relationship could be corrected. ▪ This stable aluminium activator is incorporated at the angle of the mouth, with horizontal hooks to which expanding rubber bands are attached. ▪ The mouth breather holds the activator in the mouth, and the same time with left and right arms alternatively carries 10 exercises 3 times a day.
    • 84. ▪ Child stands with his back against the wall, raises and lowers on his toes in time to the expander exercises holding the lip tight together and carries out a lightly forced breathing technique in front of an open window. ▪ Myotherapeutic exercise is indicated for mouth breathers. ▪ They also help prevent a relapse. ▪ The additional myotherapeutic expander exercises during bimaxillary treatment help to establish physiological nasal breathing, as well as correcting maldevelopment of thorax.
    • 85. Oral screen15 ▪ Oral screen should be constructed with a biocompatible material. ▪ Reduction in anterior open bite is obtained after a treatment of 3-6 months. ▪ Effective device during sleeping hours, this rubber membrane/acrylic plate is either cut or cast to fit over the labial and buccal surfaces of the teeth and gums included in the vestibule of the mouth. ▪ During the initial phase, windows are placed on the oral screen so as not to completely block the airway passage.
    • 86. Construction of the membrane: ▪ Impression of the vestibule is taken with the teeth in occlusion. ▪ This should extend to the posterior limits and above and below the mucobuccal fold. ▪ Adapt a 22-guage rubber sheet over the plaster cast, remove and trim it to size.
    • 87. Construction of cast Another direct method: ▪ Warming Plexiglass to moulding stage and adapting to the cast. ▪ Painting pure latex over the cast surface. ▪ The latex is applied to an even thickness of 1/8 inch and cured for 10-20 minutes at 130- 140 F, and due to shrinkage of a half of its bulk a second coat is applied and cured giving a finished overall thickness of 1/8 inch.
    • 88. Correction of malocclusion10 Mechanical appliances ▪ Children with class 1 skeletal and dental occlusion and anterior spacing may fitted with clear plastic oral shield appliance. ▪ Allows patient to breathe through the oral cavity ,and ▪ Through the increased tension of the perioral musculature , it may close the anterior open bites. ▪ Generally worn at night but may be worn at day time to correct the open bite more quickly.
    • 89. Class II division 1 dentition without crowding, and in age range 5-9 years 16 ▪ Monobloc activator: Aids in both correction of malocclusion and deterrence of the habit. ▪ When worn will not allow the air to be breathed through the mouth. ▪ Before any appliance is given, the pediatrician and/ or otolaryngologist should examine the child and determine whether sufficient airway space is available to allow nose breathing.
    • 90. Class III malocclusion: ▪ Interceptive methods are recommended as a chin cup. ▪ The child should be evaluated for a sufficient airway before treatment. ▪ When the mouth breathing habit is corrected, it is possible that a malocclusion may be still present. ▪ The pediatric dentist and orthodontist should re-examine the child for orthodontic purposes.
    • 91. Depending on child’s age, severity of problem, and economics ▪ Dentist may continue the present orthodontic treatment, institute a new interceptive treatment, or refer the patient to orthodontist for more comprehensive care.
    • 92. BRUXISM
    • 93. BRUXISM17 ▪ Rjamford et al (1966): Bruxism is the clenching or grinding of the teeth when the individual is not chewing or swallowing. ▪ AAPD (2003): Habitual, nonfunctional, forceful contact between occlusal tooth surfaces, which can occur while awake or asleep. ▪ McDonald, Avery & Dean: Nonfunctional grinding or gnashing of teeth.
    • 94. Classification Olkimora (1972) divided bruxers into 2 categories. ▪ Those whose bruxism was associated with ▪ Stressful events. ▪ No such association *The non stress related group had more of hereditary influence.
    • 95. According to time of occurrence8: 1) Diurnal Bruxism: ▪ Conscious or subconscious grinding of teeth, usually during day, and ▪ Could include parafunctional activities such as chewing pencils, nails, cheeks and lips. It is usually silent except in patients with organic brain disease. 2) Nocturnal Bruxism: Subconscious grinding of teeth characterized by rhythmic patterns of masseter . ▪ EMG activity and audible sounds that are usually not reproducible during the conscious state. It is associated with Rapid Eye Movement Sleep.
    • 96. According to etiology18 ▪ 1) Primary (Idiopathic) : Include day time clenching and sleep bruxism in the absence of medical cause. ▪ 2) Secondary (iatrogenic) : Associated with either neurologic, psychiatric or sleep disorders or with administration or withdrawal of drugs.
    • 97. ETIOLOGY 19 ▪ Rjamford and Ash(1974) stated that there are 3 mechanisms that interact to trigger bruxism: ▪ emotional tensions, pain or discomfort, occlusal maladjustment. ▪ Based on contemporary information, nocturnal bruxism is considered to have a , rather than peripheral occlusal, origin.
    • 98. ▪ In fact, bruxism could not be elicited by experimental induction of occlusal disturbances (Rugh et al 1984). ▪ On the contrary, it is believed to have potential to cause occlusal disturbances (Laskin 1969). ▪ Also, occlusal adjustment was not seen to reverse bruxism (Kardachi et al 1978).
    • 99. Nadler (1957) gave the following causes of Bruxism20 . ▪ Local factors ▪ Systemic factors ▪ Psychological factors ▪ Occupational factors.
    • 100. Local Factors Within the stomatognathic system are prime factors of importance in development of bruxims. i. Faulty restorations. ii. Calculus and periodontitis. iii. Traumatic occlusal relationship: Occlusal interferences/ defective occlusal contacts are triggers that elicit bruxism. iv.Functionally incorrect occlusion.
    • 101. v. Malocclusions : ▪ It is unclear whether clinching and bruxism cause malocclusion or are the results of malocclusion. ▪ The cause and effect relationship is not clear. Malocclusion interferes with proper occlusion of teeth thus resulting in Bruxism. vi.Dentigerous cysts. vii. Faulty eruption of deciduous or permanent teeth.
    • 102. Systemic Factors ▪ Etiologically significant but difficult to evaluate. i. Nutritional deficiencies. ii. Calcium and vitamin deficiencies iii. Intestinal parasite infection iv. Gastrointestinal disturbances from food allergy. v. Enzymic imbalances in digestion causing chronic abdominal distress. vi. Persistent, recurrent urologic dysfunction. vii.Endocrine disorder, e.g., hyperthyroidism.
    • 103. viii. Hyperkinetic children. Nadler believed that histamine released during stress may act as an exciting agent in the irritation of Bruxism. ix.Pubertal growth spurt peak in boys and start of spurt in girls sees increase in bruxism. x. Hereditary factors : important to genesis and pattern of Bruxism (Lindquist).
    • 104. xi. Allergy: ▪ Nocturnal Bruxism may be initiated reflexly by increased negative pressures in the tympanic cavities from intermittent allergic edema of the mucosa of the Eustachian tubes. ▪ Chronic middle ear disturbances may promote reflex action to the jaws by stimulating the trigeminal nuclei in the brain. xii.CNS disturbances E.g. Cortical brain lesions, Disturbances in medulla and pons, epilepsy,Tuberculous meningitis.
    • 105. Psychological factors ▪ Most dominant factor. ▪ Nervous tension finds a most gratifying release in clenching and bruxism. ▪ Research studies show a positive relationship between tooth grinding and repressed aggression, unconscious and conscious anxiety, unconscious expression of oral gratification. ▪ Childhood bruxism may be related to other oral habits, such as, chronic biting and chewing of toys and pencils, digit sucking, tongue, thrusting and mouth breathing.
    • 106. Occupational factors ▪ Athletes, indulge in bruxism because of a great desire to excel. ▪ Over anxious students/ compulsive over achievers.
    • 107. Lip Habits21 ▪ Normal lip anatomy and function are important for speaking, eating and maintaining a balanced occlusion. ▪ Habits that involve manipulation of the lips and perioral structures are called lip habits. ▪ The basic types of lip habits include:
    • 108. Lip sucking: ▪ Most common presentation ▪ In many patients, this occurs in conjunction with hyperactivity of the mentalis muscle. ▪ This places a lingually directed force on mandibular teeth and facial force on maxillary teeth. ▪ The result is protrusion of upper incisors and impedes forward development of lower anterior alveolar process, and causes lingual inclination of incisors leading to increased overjet.
    • 109. ▪ This can be recognized by the reddened, irritated and chapped area below the vermilion border. ▪ In fact, the vermilion border may be relocated farther outside the mouth due to constant wetting of the lips. ▪ Although this may occur with either lip, it is more commonly associated with the lower lip.
    • 110. ▪ An important variation of lip sucking is the mentalis habit. ▪ The mentalis muscle originates on the labial surface of the mandible in the area of the apices of the mandibular incisors. ▪ Its fibers extend inferiorly, crossing over the midline and inserting into the soft tissue of the chin. ▪ Their function is to lift the lower lip. ▪ When this muscle is flexed, the skin of the chin will appear puckered
    • 111. Difference btw lipsucking and mentalis habit ▪ In lip sucking, the entire lip including the vermilion border is pulled into the mouth whereas, ▪ In the mentalis habit, ▪ Vermilion border of the lower lip is often everted, with the lingual aspect elevated into the mouth. ▪ Along with their lower lip eversion, a sub labial contracture line develops between lip and chin. ▪ Deep mentolabial sulcus is characteristics of a hyperactive mentalis muscle
    • 112. Management of mentalis habit ▪ Lip over Lip exercise ▪ Playing Bass instruments ▪ Lip bumper/shield ▪ Oral screen
    • 113. Other variants include: Schneider 1982 ▪ Lip wetting ▪ Here,the tongue constantly wets the lips due to dryness/irritation which later becomes a habit. ▪ Lip biting It may involve either of the lips, with cuts and abrasions, marks of incisors on lips and reddening of lips
    • 114. Etiology22,23 1. Malocclusion • A lip habit may occur in Class II division 1 malocclusion with large overjet. • The habit develops when the child wants to produce a normal lip seal during swallowing by placing lower lip posterior to maxillary incisors. 2. Habits • A digit habit may result in a large overjet and the child will attempt to create a lip seal as above.
    • 115. 3.Emotional stress • This may increase intensity, frequency and duration of lip sucking. • Occasionally ,may become a compulsive and gratificational activity during sleeping hours. 4.Cases of hyperactivity of mentalis muscle which occur in the same family are usually hereditary. • It may be due to initiation of the dysfunction.
    • 116. Clinical features ▪ Protrusion of maxillary incisors and retrusion of mandibular incisors ▪ With either of these habits in action is to wedge the lip betwn the upper and lower incisors. ▪ Thus, muscular imbalance is created ▪ If practiced with a sufficient intensity and frequency will cause ▪ maxillary incisors to move labially and upward with interdental spacing and lower incisors to collapse lingually with crowding
    • 117. Lip sucking: 1. Lip sucking can be recongnized by: Reddened, Irritated and happed area below the vermilion border. 2. The border may further be relocated farther outside the mouth due to constant wetting of the lips. 3. Most commonly seen with Lower lips 4. Vermilion border becomes Hypertrophic and redudant at rest. 5. In some cases, chronic herpes infection with areas of irritation and cracking of lip appears.
    • 118. Management24 ▪ Correction of the habit is not within the province of the dentist, but lies with child psychologist, psychiatrist, or family counselor if there are psychological issues concerned. ▪ The dentists responsibility is to bring the habit to the attention of the parent and make recommendations for therapeutic counseling.
    • 119. Frenum thrusting25,26 ▪ Rarely seen habit.
    • 120. Cheek Biting ▪ May injure the soft tissues and may cause an open bite or an individual tooth malposition in the affected area. CLINICAL FEATURES  Ulcer at the level of occlusion  Open bite  Tooth malposition in the buccal segment
    • 121. Treatment ▪ Removable crib ▪ Vestibular screen
    • 122. Nail biting
    • 123. Nail biting ▪ Nail biting is a habit that develops after the sucking age. ▪ Not a pernicious habit ▪ Does not assist in production of malocclusion since forces or stresses applied in nail biting are similar to those in chewing. ▪ Attrition of lower anterior teeth may rarely be seen. ▪ Nail biting is a normal tension release and although not socially acceptable. ▪ It is more likely to cause inflammation of nails beds
    • 124. Relationship with age: ▪ Not seen before 3 years of age. ▪ Incidence rises sharply from 4-6 years, constant btw 7-10 years and PEAK during adolescence. ▪ Persistent nail biting may be indicative of an emotional problem. ▪ As the child grows older, other objects are substituted for the fingers because every age has its own pacifiers. ▪ Ex include chewing gum, pencils, erasers, cheeks, tongue cigarettes, etc.
    • 125. Postural habits ▪ Postural habits leading to malocclusion are rare and must be diagnosed or treated orthodontically on an individual basis. ▪ Chin propping: Retraction of mandible ▪ Face leaning: Lingual movement of maxillary teeth ▪ Abnormal pillowing: Facial assymetry ▪ The Milwaukee brace as used for children with scoliosis is an example.
    • 126. Bobby pin opening ▪ Deleterious practice ▪ Opening bobby pins with incisors to place them in the hair. ▪ Notched incisors and teeth partially denuded of labial enamel have been observed in girls with this habit. ▪ At this age calling attention to the harmful results is generally all that is necessary to stop the habit.
    • 127. Masochistic habits27,28 (Sadomasochistic, self injurious, self-mutilating) Definition: ▪ Repetitive acts that result in physical damage to the person. ▪ Eg. picking at gingival with ginernails (gingival stripping); chewing inside of cheek, lip or on tongue.
    • 128. Incidence: ▪ Extremely rare in normal child. ▪ The between 10-20% in mentally retarded population ▪ Prevalence : higher in females. ▪ In the general population, prevalence is estimated at 750 in 100,000, ▪ Increasing in developmentally disabled individuals from 7·7% to 22·8%and reaching 40% in profoundly retarded individuals.
    • 129. Classification29,30: Ayer & Levin(1974) based on the etiology divided it into: 1) Organic : ▪ This consists of syndromes and syndrome- like maladies such as Lesch – Nyhan and de Lange’s which have been associated with self mutilation such as repetitive lip, tongue, finger, knee and shoulder biting.
    • 130. 2)Functional: This is subdivided by Stewart and Kernohan into: Type A behavior are injuries superimposed on a pre-existing lesion. Eg. a skin lesion perpetuated by a skin biting habit. E.g: 3½ year old child who has been treated for herpetic stomatitis. ▪ All but one of the numerous lesions responded well to treatment. ▪ This single ulceration was found to be perpetuated by a fingernail habit, which mainly occurred at night.
    • 131. Type B are injuries secondary to another established habit . Eg. Rotating the thumb during sucking process. ▪ Because of this rotational movement can cause ulcerations on the palatal gingiva. ▪ If the established habit is discontinued the lesions disappear.
    • 132. Type C : injuries of unknown or complex etiology. ▪ This has greater psychogenic component. ▪ There may be multiple symptoms of great intensity. ▪ These habits may serve as form of stress release. ▪ Mallson and Robertson31, have concluded that “castration fears, failures to resolve Oedipal conflicts, represented homosexual impulses, severe guilt and self punishment are ubiquitous phenomenon in type C behaviors
    • 133. Clinical features10: ▪ These may produce factitial injuries, 75% of which are located in the head and neck region. ▪ Oral structures such as gingiva, oral mucosa, tooth support structures, or teeth may be affected. ▪ They usually consists of putting fingernails or foreign objects in the gingival sulcus, digital pressure on oral structures or biting of tissue. ▪ Factitial oral lesions (FOL) include factitial gingivitis, factitial periodontitis, factitial ulcer, and self-extraction.
    • 134. ▪ The symptoms of both the functional and organic categories of self injurious behavior appear to be exacerbated during stressful situation. ▪ It has been observed that some children experience a feeling of neglect, abondanment, and loneliness, and through the use of self injurious behavior they attempt to solicit attention and love. ▪ Thus, some form of emotional stress, such as personal unhappiness, loss of security, or an unresolved pain producing dental condition is an important etiological factor.
    • 135. ▪ It has been suggested that self-mutilation is a learned behavior. ▪ This may be because attention is always gained, reinforcing the behavior. ▪ But any child who willingly inflicts pain to himself should be considered psychologically abnormal.
    • 136. TREATMENT ▪ Requires multidisciplinary approach. ▪ The role of pediatric dentist in treatment is to elicit a thorough social and medical history and correctly diagnose the condition so as to distinguish it from one of physiological etiology solely. ▪ After the diagnosis has been determined, referral to primary care physician usually pediatrician is done.
    • 137. ▪ Palliative treatment: Adjunctive therapy may be initiated by the dentist to aid in the healing of oral ulcerations. ▪ A Squibb oral bandage is beneficial to healing of oral tissues, as well as serving habit reminder.
    • 138. Mechanotherapy: ▪ In addition, an oral shield may be fabricated and inserted into the mouth at night. ▪ This appliance will deter the child from unconscious continuation of the habit. ▪ This therapy should not be instilled alone, but used as part of the multidisciplinary approach to the treatment of self injurious behavior.