ORAL HABITS IN
CHILDREN
“We are what we repeatedly do.
Excellence, then, is not an act, but a
habit”
 Introduction
 Definitions
 Classifications
 Prevalence of oral
habits
 Thumb sucking
habit
 Tongue thrusting
habit
...
• Habit can be defined as a fixed or
constant practice established by
frequent repetition.
Dorland (1957):
• Habit is a fr...
• “ a tendency towards an act or as act
that has become a repeated
performance relatively fixed,
consistent, easy to perfo...
Oral Habits
• Frequent or constant practice or
acquired tendency, which has been fixed
by frequent repetition.
Butterswort...
CLASSIFICATIO
N
 Intentional/Meaningful
Eg:Nail biting, Digit
sucking,Lip biting
 Masochistic/Self
inflicting
Eg:Gingival stripping
 Un...
1.JAMES W. (1923)
Include the habits of
normal function such as:
a)correct tongue position,
b)proper respiration,
c)proper...
II.KINGSLEY(1958)
 Individual
habit:
FUNCTIONAL MUSCULAR
COMBINED
III MORRIS AND BOHANNA (1969)
A)Pressure habits
Eg: Thumb sucking
Tongue thrusting
 Non pressure habit
Eg: Mouth breathin...
IV KLEIN E(1971)
 Meaning habits :
 suggests the existence of a direct psychological
cause and effect relationship.
 Em...
Klein classified abnormal pressure habits
into intrinsic and extrinsic
a) Intrinsic pressure habits (within the mouth)
suc...
b) Extrinsic pressure habits (face)
C) Functional pressure
V. BARRETS (1978)
1. Intra oral habits
2)Extra oral habits
VII.FINN 1975
 Compulsive
 Non Compulsive
 Secondary habits
Compulsive habits
 Tends to suffer increased anxiety when attempts are made to
correct the habit.
 Easily dropped from the child’s behaviours pattern as
he matures.
 Naturally modified or eliminated through the
maturat...
GRABER
 Thumb and finger sucking
 Tongue thrust and tongue sucking
 Lip and nail biting
 Mouth breathing
 Abnormal sw...
PREVALENCE of Oral Habits
Kharbanda et al 2003
 5-13 yr old children, Delhi -25.5%
 Tongue thrusting – most common (18.1...
PREVALENCE of Oral Habits
Shetty SR, Munish AK
 Mangalore - 29.7% of children.
 Digit sucking(3.1%), Pencil biting-(9.8%...
DEVELOPMENT OF A HABIT
Development of a habit
 The newborn develops some instincts, which
are composed of elementary reflexes.
 Instinct : patt...
 At the beginning,
 the infant makes an effort by
frequent learning and
practice,
 later on the muscles start
respondin...
 It has been stated that unconscious mental pattern of
childhood develops from five sources namely
 Instinct,
 Insuffic...
1) Functional matrix- MELVIN MOSS
2) Psychoanalytical – SIGMOND FREUD
THEORIES
BUCCINATOR, SUPERIOR
CONSTRICTOR, PTERYG
PMANDIBULAR RAPHE
HARMONIOUS
PRESSURE
BALANCE
ORAL
HABIT
S
NORMAL
DENTOFACIAL AND...
Acc to Freud
 Personality develops through a series of
childhood stages during which the pleasure-
seeking energies of th...
 Stages successfully completed: Healthy
personality
 Unsuccessful @ appropriate age: Fixation
The Oral Stage:
 first ye...
Mouth: Vital for eating
the infant also develops a sense of trust and
comfort through this oral stimulation
the infant is ...
 Issues with dependency or
aggression.
 Oral fixation can result in habits
like:
 nail biting, thumb or finger
PRIMARY
...
THUMB/ DIGIT SUCKING
THUMB/DIGI
T SUCKING
Thumb/Finger sucking
Definition:
Placement of the thumb or
one or more fingers in
varying depths into the
mouth.
– Gellin-...
 I.U Life
 First 2 yrs.
 Disappears with maturation.
 No: malocclusion
 Abnormal IF, persists
 IF not controlled at ...
Significance: new born infant
FEELING OF
 euphoria,
 sense of security,
 warmth and being wanted.
CLASSIFICATION
Based on clinical observation
1. Normal thumb sucking
2. Abnormal thumb sucking
A. Psychological
B. Habitual*
O’BRIEN(1996)
A)Nutritive sucking habits:
Provides essential nutrients
Ex- Breast feeding , Bottle feeding.
B)Non nutritiv...
Classification of NNS habits
Johnson and Larson 1993 (JDC )
Level Description
Level 1 (+/-) Boys or girls of any chronolog...
Subtelny’s grading(1973)
1.Type A:- 50%
Subtelny’s grading(1973)
2.Type B :- 13-15%
Subtelny’s grading(1973)
3. Type C :- 18% 4. Type D :- 6%
Sucking reflex- Engel 1962
 Seen even at 29 week of I.U. life
 First coordinated neuromuscular activity of infant
 Disa...
 Babies restricted from suckling due to disease or other
factors become restless and irritable.
 This deprivation motiva...
SUCKLIN
G SUCKING
SEEN WITH BREAST
FEEDING
BREAST NIPPLE FORMS A
PERFECT ANTERIOR SEAL NO
NEED FOR ADDITIONAL NEGATIVE
PRE...
INFANTILE OR VISCERAL
SWALLOW
Characteristic of the infantile or
visceral swallow as listed by
Moyer’s:
 The jaws are apa...
MATURE SWALLOW
 By 18 months of age the mature swallow characteristics listed
by Moyers are observable.
 The teeth are t...
PHASES OF SUCKING
Buccinator mechanism
 OO: orbicularis oris
 LP: lower fibers of lip
 B: buccinator’s muscle
 PMR: pterigomandibular ra...
Buccinator mechanism
When the child places the thumb between teeth
Negative pressure is created within Mouth
and tongue ge...
Variables affecting malocclusion
Sorokohit and Nanda (1989)
 1) Position of the digit
 2) Associated orofacial muscle co...
THEORIES: Psychology of Non Nutritive digit
sucking
Theories to explain the cause of occurrence
of this habit
• Freudian t...
FREUDIAN THEORY(1905)
 Distinct phases of psychological
development
 Oral and anal phases seen in first 3
years of life....
 Prevention of such an act : results in emotional insecurity
and passes the risk of the child diversifying into other
hab...
The Learning Theory: Davidson 1967
• Non-nutritive sucking stems from adaptive response
• Infant associates sucking with h...
BENJAMIN’S THEORY (1962):
 Thumb sucking arises from “ROOTING
REFLEX”, common to all mammilian infants.
 It is max’ duri...
ORAL DRIVE THEORY
 Sears and wise(1950)
 Acc to this, theory prolongation of nursing strengthens
the oral drive.
 (i.e ...
PREVALENCE
 Birth to 2years of age: - 50-67%
 2 to 5 years of age:- 24-43%
 6 to 10 years of age:- 17%
 Above 10 years...
INCIDENCE:
Popovich and Thompson-1973, Kelley et al 1973:
• Higher incidence in girls than boys :11.7% girls and
8.3% boys...
ETIOLOGY
 Hanna 1958 : retained infantile
swallow
 Pearson 1948 : hereditary (JDC 1993)
 Cook 1944 : teething
 Kelston...
The trident Factors affecting thumb
sucking : Graber and Swain (1985)
 Intensity:
Implies how vigorously the habit is pur...
Phases of Development of Thumb Sucking
(Moyers)
 Phase I
 Normal and sub clinically significant.
 It is seen during fir...
Phase II
 Clinically significant sucking:
 The 2 phase extends between 3- 6 years of age. The
presence of sucking during...
Phase III
 Intractable sucking:
 Any thumb sucking persisting beyond 4 and 5 year of
life should alert the dentist to th...
VARIABLES INFLUENCING
 Age
 Sex
 RACE :negroids, eskimo :1969 Owen (MUNN)
 Pacifier : Ravn 1967 (Am J Ortho)
 Feeding...
DIAGNOSIS
• History of the digit sucking activity
• Evaluation of the child’s emotional status
• Extra oral examinations
•...
HISTORY: Mathewson, Forrestor
• Parents
• Feeding patterns
• Three major questions: (Graber 1972)
 Frequency
 Duration (...
EMOTIONAL STATUS
• Essential to determine meaningful or empty habit.
• Identify the child who wants to stop but just needs...
CLINICAL FEATURES
– Digits
– Lips
– Facial form
– Dentofacial changes
– Other features
DIGITS
 Reddened
 Exceptionally clean and chapped
 Short clean finger/ thumb nail (dish
pan thumb)
 Fibrous roughened ...
LIPS
Upper lip :
 Short and hypotonic
 Passive or incompetent during swallowing
Lower lip :
 Hyperactive
FACIAL FORM ANALYSIS
 Maxilla protrusion
 Mandibular retrusion
 High mandibular plane
angle
 Facial profile- straight
...
Dentofacial changes associated with prolonged non
nutritive sucking habits - Johnson and Larson 1993
Effects on Maxilla:
...
Effects on Mandible:
 Retroclination / proclination of mandibular
incisors
Retroclination : direct apical & lingual force...
Effects on Inter-arch relationship:
 Anterior open bit
 Decreased overbite
 Increased overjet
 Unilateral or bilateral
Class II malocclusion.
Posterior cross bite
 Lip incompetence
 Lower lip function under the maxillary
incisors
Effect on tongue placement and function:
 Tongue thr...
 Other features
 Other habits- habitual mouth breathing, tongue thrust
swallow
 Middle ear infections
 Enlarged tonsil...
TREATMENT CONSIDERATIONS:
FINN
 Psychological status of the child
 Age factor
 Motivation of child
 Parental cooperati...
TREATMENT
CONSIDERATIONS:FORRESTER
 Emotional significance
 Age of the patient
 Status of the child’s occlusion
Emotional significance
 Diagnosis and management of any psychological
problem should be planned before treatment of any
p...
 The events that precede the habit such as the use of a
security blanket, the dependency on a favorite
toy, problems with...
Age factor :1) Younger than 3 years
 No active intervention :general emotional immaturity.
 Most children will outgrow t...
 The parents should be advised generally to ignore the
active habit, and give the child as much attention as
possible whe...
3- to 7 year olds
 Caution : Depending on the type of the habit and
whether he is actively pulling his maxilla anteriorly...
Older then 7 years
 Anterior open bite that is usually not closed by itself
because of functional patterns that have been...
Motivation of the child to stop the habit:
 Important to assess : the maturity : in response to new
situations and to obs...
Parental concern regarding the habit:
 If the parent is unable to cope with the situation
positively then both the parent...
Other factors:
 Self-correction again depends on the severity of the
malocclusion, anatomic variation in the perioral sof...
Treatment (Pinkham)
 Counseling
 Reward system
 Reminder therapy
 Adjunctive therapy
TREATMENT
MODALITIES
Thumb sucking
TREATMENT MODALITIES
 Once the decision for treatment has been made, one
must next determine what intervention is appropr...
 In addition to their own intention some children may
require additional help.
 Another tool that is helpful for this ty...
Psychological Therapy :
A. Dunlop's hypothesis
 If a subject is forced to concentrate on the performance
of the act and t...
B. Six steps in cessation of habit (Larson &
Johnson)
Step 1: Screening for psychological component.
Step 2: Habit awarene...
Step 5: Escalated DRO (differential reinforcement of other
behaviors)
Step 6: Escalated DRO with reprimands.
(Consists of ...
C. Three alarm system: (Norton & Gellin-
1968)
 A chart is designed with days of the week and blank
spaces.
 When the ch...
D. Reward system
 Children should be encouraged and rewarded for not
practicing the habit. “contingency contracting” is a...
E. ACE BANDAGE APPROACH
 In this approach,
Bandage should be wrapped around
the finger and stars should be
entered into t...
F. THUMB BUDDY TO LOVE
 This is commercially available and is a positive teaching tool and
chemical free method.
 It con...
G. THUMB - HOME CONCEPT : Skinaz
2000
 This is the most recent concept.
 Eliminating chronic thumb sucking by preventing...
 Thus, make the child to suck all the ten finger the same
length of time so that it produce unpleasant reaction and
gradu...
H. CHEMICAL TREATMENT
 Bitter and sour
 Very minimal success e.g.
quinine, asafetida, pepper, caster oil etc.
 NEWER an...
I. REMAINDER THERAPY
 Painting something that tastes yucky on the thumbs can
make them less satisfying.
 Physical barrie...
J. THUMB GUARD
 It is an appliance that is worn when the child is tempted
to suck.
 Once the guard is worn they cannot g...
 It makes difficulty for the child to suck.
 While providing remainder therapy the child should be
instructed that these...
K. PARENT COUNSELING
 A different approach that can be practiced when its
known that the child, wants to discontinue the ...
 The parents' role in correction is very significant.
 Over anxiety and the resulting nagging approach or
punishment oft...
 Nagging, scolding or frightening the child should be
avoided since this could cause negativism and tend to
make him reso...
 “Parents should not force the preschoolers to break the
habit since they only know the pleasure derived from the
habit b...
Other Extra-oral approaches
a) Thermoplastic thumb (Allen 1992)
b) Alemaran2000 : Long sleeve gown (J Cons)
INTRAORAL APPROACHES :
• Mink and Haskell 1991 : Blue
grass appliance
• Pediatric clinics of University
of Kentucky and Un...
• Patient instructed to turn the roller instead of sucking the
digit.
• Patient got a new toy to play with tongue & got
di...
 Location of roller: most superior aspect of palate
 Not in contact with palate
 No obstruction in eating or speech
 N...
Chris Baker 2000 : Modified blue grass
appliance
4mm acrylic beads
Adv: reduced bulk
Less obstruction, attractive for chil...
QUAD HELIX
 Maxillary expansion
 Posterior cross bite correction
 Alignment of maxillary and mandibular anteriors
 Rem...
 Palatal Crib : Hayrett
1970
 Hayrakes : Korner and
Keider 1955 (Angle
Ortho)
 Spurs
 Triple Loop Activator
(TLA) : Vi...
Oral Habits in Children. Part 1: Thumb sucking and Mouth Breathing
Oral Habits in Children. Part 1: Thumb sucking and Mouth Breathing
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Oral Habits in Children. Part 1: Thumb sucking and Mouth Breathing

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“We are what we repeatedly do. Excellence, then, is not an act, but a habit”
The seminar is tailor made for students with an intent to help understand the subject, hope this makes up my little contribution in simplifying the topic.

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  • Oral habits are habits that frequently children acquire that may either temporarily or permanently be harmful to dental occlusion and to the supporting structures.When habit causes defect in orofacial structure, it is termed as pernicious oral habit.
  • Intentional/Meaningful. Eg:Nail biting, Digit sucking,Lip bitingMasochistic/Self inflicting. Eg:Gingival strippingUnintentional/Empty. Eg: Abnormal pillowing,chin proppingFunctional. Eg:Mouthbreathing,Tonguethrusting,Bruxism
  • Include the habits of normal function such as:correct tongue position, proper respiration, proper deglutition and normal usage of lips in speaking.Include all that exert perverted stresses against the teeth and dental arches such as:Tongue thrusting,Thumb-sucking, Mouth breathing, Lip biting, Nail biting, Lip sucking etc.
  • Comb’n activity of the muscles + jaws and of the thumb/finger inserted into the mouth.Eg. Thumb sucking.Muscular action combined with the introduction of passive objects into the mouth. Eg. Pencil bitingMuscles: No active role: Caused due to effects on the position of dentition being extraneous pressures. eg: abnormal pillowing, face leaning on hand, etc.
  • Am J Ortho 1978
  • A consultation with a pediatrician/psychologist may be necessary before any treatment.
  • Chin propping,Face leaning on hand,Abnormal pillowing positions,Leaning on forearm or handHabitually sleeping on the right side of the face may cause the nose to turn leftward or vice versa, a deviated septum may also result from this sleeping habit.
  • Malocclusion developed in musicians from pressure exerted on their teeth or face.
  • Thumb sucking , Mouth breathing ,Lip biting,Nail biting,Lip sucking,Tongue thrusting ,Bruxism
  • 1) Chin propping 2)Face leaning on hand 3)Abnormal pillowing position 4) Habitual sleeping on one side of the face.
  • Habit that has acquired fixation in the child to the extent that he reverts to the practice of this habit whenever his security is threatened by events, which occur around him. They have deep seated emotional need and is possibly the only safety value when emotional pressure become too much to cope with
  • Are those habits that are Children appear to undergo continuing behaviour modification, which permits them to release certain undesirable habit patterns and form new and more socially acceptable ones.
  • Many authors like Mitchell, Nelson, Swinehart, Mc Coy, Saltzman, Graber, Finn, Hogeboom and others have divided the harmful (deleterious) oral habits in various ways. But among them Graber gave a good and simple classification. He summed up extrinsic and intrinsic factors -
  • An instinct is one where the pattern and order are inherited, while in a habit the pattern and order are acquired if constantly repeated during the lifetime of an individual.
  • Until this conflict is resolved, the individual will remain "stuck" in this stage.During the oral stage, the infant's primary source of interaction occurs through the mouth, so the rooting and suckling reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral stimulation through gratifying activities such as tasting and suckling. Because
  • Caretakers(who are responsible for feeding the child)
  • Individual would have issues
  • The habit of thumb sucking is primarily a psychological principle. In efforts to discontinue the habit the responsibilities of the parent is no longer less than that of the doctor or the patient himself.
  • Am J Ortho
  • N: first 2 yrs of life.Disappears as child matures.Doesnt generate any malocclusionIF habit persts beyond preschool age,: then abnormal, IF ntcontrollddis age: May cause deletarious effects on dentofacial str.
  • Observed in intra uterine life
  • N: TS cons’ normal in first 2 yrs of life.Usualy disappears as child matures.Habit doesn generate any malocclusionIF habit perstsbeyong preschool age,: then abnormal, IF ntcontrolld @dis age: May cause deletarious effects on dentofacial str.
  • Has a deep rooted psycological bearingNone; Child performs act out of habit: CAUSE fr concern due to potential to develop malocc.
  • (+/-Depending Upon willingness of patient to participate in treatment levelIncreased level: Increased habit severity)
  • - 50% of the children - Whole digit is placed inside the mouth with the pad of the thumb pressing the palate. -Maxillary and mandibularanteriors contact is maintained.Ortho1973
  • - 13 – 15% of children -Thumb is placed into the oral cavity without touching the vault of the palate. -Max and mandanteriors contact is maintained
  • - 18 % of the children Thumb/fingers, placed into the mouth just behind the first joint and contacts hard palate and only maxillary incisors. - 6 % of the children - very little portion of the thumb is placed in the mouth
  • SUCKLING action is exerted by Masseter, Orbicularisoris, Mentalis, Buccinator, Sup Phary’ constr’, Ptymraphe
  • The development of various reflexES - INTRAUTERINE life By 14th week of intra uterine life- stimulation of lips causes the tongue to moveAt about the same time stimulation of upper lip causes mouth closure and even deglutitionGag reflex develops by about 18 ½ weeks Respiration by about 25 weeksSucking by 25 weeksSucking and swallowing by 32 weeks.
  • Nutritive Suction Physiology NS process includes three closely related phases: expression/suction (E/S),7,13-15 swallow (S) and breathing (B).
  • munn
  • JDC 1967
  • * Rooting reflex: Movement of an infant’s head and tongue towards a stimulus touching infant’s cheek
  • Forrestor 1981
  • Prader-Willi syndrome.
  • Anterior placement of apical base of maxilla
  • Increased retroclination
  • Most children will outgrow the habit by the time they are 5 years old\
  • Mainly characterized by:
  • Parents should become silent partners. Negative reinforcements in the form of threats
  • Counselling: Explain about habitsill effects• Show photographs, video• Dunlop hypothesis• Card to score• Discuss with parents
  • The elbow of the arm with offending thumb : firmly wrapped in two inch elastic bandage safety pins are placed at proximal & distal ends of bandage and one safety pin is placed lengthwise at the mesial end of the elbow and when the child sucks the thumb again, the closed pin on the medial end of elbow, mildly jabbing the elbow indicates second alarm. If the habit persist, the bandage is tightened this is the final or third alarm, which will definitely remind the child of the habit.
  • The contract simply states that the child should not suck their thumb for specific period of time. The child should be rewarded if the requirement of the contract is met.
  • Reminds the parents to wrap the bandage the previous day and also the child for not sucking their thumb. For every twenty stars entered in the calendar, the child should be rewarded.
  • In this a small bag is given to the child to tie around his wrist during sleep and it is explained to the child that just as the child sleeps in his home, the thumb will also sleep in its house and so the child is restrained from thumb sucking during night.
  • Chemicals have been used over the thumb causally to terminate the practice but withare also being marketed but they have also had a very moderate success
  • Ped Dent 1991
  • Oral Habits in Children. Part 1: Thumb sucking and Mouth Breathing

    1. 1. ORAL HABITS IN CHILDREN
    2. 2. “We are what we repeatedly do. Excellence, then, is not an act, but a habit”
    3. 3.  Introduction  Definitions  Classifications  Prevalence of oral habits  Thumb sucking habit  Tongue thrusting habit Contents Part I
    4. 4. • Habit can be defined as a fixed or constant practice established by frequent repetition. Dorland (1957): • Habit is a frequent or constant practice or acquired tendency, which has been fixed by frequent repetition. Buthersworth (1961):
    5. 5. • “ a tendency towards an act or as act that has become a repeated performance relatively fixed, consistent, easy to perform and almost automatic”. Boucher(1963) defined habit as • “an act, which is socially unacceptable”. Finn(1987)defined habit as
    6. 6. Oral Habits • Frequent or constant practice or acquired tendency, which has been fixed by frequent repetition. Buttersworth(1961) • Oral habits are learned patterns of muscular contractions, which are complex in nature Moyers( 1982)
    7. 7. CLASSIFICATIO N
    8. 8.  Intentional/Meaningful Eg:Nail biting, Digit sucking,Lip biting  Masochistic/Self inflicting Eg:Gingival stripping  Unintentional/Empty Eg: Abnormal pillowing,chin propping  Functional Eg:Mouth breathing,Tongue thrusting,Bruxism OBSESSED(deep rooted) NON OBSESSED (easily learned and dropped)
    9. 9. 1.JAMES W. (1923) Include the habits of normal function such as: a)correct tongue position, b)proper respiration, c)proper deglutition and d)normal usage of lips in speaking. USEFUL HARMFUL
    10. 10. II.KINGSLEY(1958)  Individual habit: FUNCTIONAL MUSCULAR COMBINED
    11. 11. III MORRIS AND BOHANNA (1969) A)Pressure habits Eg: Thumb sucking Tongue thrusting  Non pressure habit Eg: Mouth breathing B) Biting habits Eg: Pencil biting
    12. 12. IV KLEIN E(1971)  Meaning habits :  suggests the existence of a direct psychological cause and effect relationship.  Empty habits :  are simple habits without a detectable cause
    13. 13. Klein classified abnormal pressure habits into intrinsic and extrinsic a) Intrinsic pressure habits (within the mouth) sucking THUMB FINGER TONGUE LIP CHEEK biting NAIL TONGUE LIP MOUTH BREATHIN G MOUTH BREAT HING INCORRECT SWALLOWIN G TONGUE THRUSTIN G
    14. 14. b) Extrinsic pressure habits (face)
    15. 15. C) Functional pressure
    16. 16. V. BARRETS (1978) 1. Intra oral habits
    17. 17. 2)Extra oral habits
    18. 18. VII.FINN 1975  Compulsive  Non Compulsive  Secondary habits
    19. 19. Compulsive habits  Tends to suffer increased anxiety when attempts are made to correct the habit.
    20. 20.  Easily dropped from the child’s behaviours pattern as he matures.  Naturally modified or eliminated through the maturation process.  More consistent behaviour  Increased level of maturity and responsibility. Non compulsive oral acts –
    21. 21. GRABER  Thumb and finger sucking  Tongue thrust and tongue sucking  Lip and nail biting  Mouth breathing  Abnormal swallowing habit  Speech defects  Postural defects  Psychogenic Bruxism or Occlusal neurosis  Defective occlusal habits.
    22. 22. PREVALENCE of Oral Habits Kharbanda et al 2003  5-13 yr old children, Delhi -25.5%  Tongue thrusting – most common (18.1%) followed by mouth breathing (6.6%)  Thumb sucking (0.7%) and lip biting (0.04%)- relatively less common  There was no significant difference between boys and girls
    23. 23. PREVALENCE of Oral Habits Shetty SR, Munish AK  Mangalore - 29.7% of children.  Digit sucking(3.1%), Pencil biting-(9.8%) and Tongue thrust- (3.02%) Highly prevalent among 3-6 yrs.  Mouth breathing(4.6% )and bruxism (3.1%) - significant in 7- 12 yrs  Lip/cheek biting(6%)and nail biting (12.7%) - more common in 13-16 yrs.  Digit sucking, tongue thrust, mouth breathing and bruxism - more prevalent among boys  Lip/cheek biting, nail biting and pencil biting -more prevalent among girls.
    24. 24. DEVELOPMENT OF A HABIT
    25. 25. Development of a habit  The newborn develops some instincts, which are composed of elementary reflexes.  Instinct : pattern and order are inherited,  Habit: pattern and order are acquired, if constantly repeated during the lifetime of an individual.
    26. 26.  At the beginning,  the infant makes an effort by frequent learning and practice,  later on the muscles start responding more readily.  At the onset it takes a long time for the impulses to pass along the efferent nerves to muscle involved
    27. 27.  It has been stated that unconscious mental pattern of childhood develops from five sources namely  Instinct,  Insufficient or in correct outlet of energy,  Pain or discomfort,  Abnormal physical size of parts,  Imitation of or imposition of others
    28. 28. 1) Functional matrix- MELVIN MOSS 2) Psychoanalytical – SIGMOND FREUD THEORIES
    29. 29. BUCCINATOR, SUPERIOR CONSTRICTOR, PTERYG PMANDIBULAR RAPHE HARMONIOUS PRESSURE BALANCE ORAL HABIT S NORMAL DENTOFACIAL AND SKLETAL GROWTH TONGUE LIPS ABNORMAL SOFT TISSUE PRESSURE, ALTERED MUSCULAR CONTRACTION ALTERED DENTOFACIAL AND SKLETAL GROWTH
    30. 30. Acc to Freud  Personality develops through a series of childhood stages during which the pleasure- seeking energies of the id become focused on certain erogenous areas.  This psychosexual energy, or libido, was described as the driving force behind behavior.  Psychological development of child from birth to adolescence is divided into five stages
    31. 31.  Stages successfully completed: Healthy personality  Unsuccessful @ appropriate age: Fixation The Oral Stage:  first year of human life  erotic pleasure oral stimulation (Char’)  During the oral stage,  primary source of interaction : mouth,  Rooting and Suckling reflex is especially important.
    32. 32. Mouth: Vital for eating the infant also develops a sense of trust and comfort through this oral stimulation the infant is entirely dependent upon caretakers,. Infant derives pleasure from oral stimulation gratifying activities such as tasting and suckling.
    33. 33.  Issues with dependency or aggression.  Oral fixation can result in habits like:  nail biting, thumb or finger PRIMARY CONFLICT WEANING PROCESS IF, FIXATION OCCURS @ THIS STAGE,
    34. 34. THUMB/ DIGIT SUCKING THUMB/DIGI T SUCKING
    35. 35. Thumb/Finger sucking Definition: Placement of the thumb or one or more fingers in varying depths into the mouth. – Gellin- 1978 Repeated and forceful sucking of thumb with associated strong buccal and lip contractions - Moyers
    36. 36.  I.U Life  First 2 yrs.  Disappears with maturation.  No: malocclusion  Abnormal IF, persists  IF not controlled at this age: May cause deleterious effects on dentofacial structures.
    37. 37. Significance: new born infant FEELING OF  euphoria,  sense of security,  warmth and being wanted.
    38. 38. CLASSIFICATION Based on clinical observation 1. Normal thumb sucking 2. Abnormal thumb sucking
    39. 39. A. Psychological B. Habitual*
    40. 40. O’BRIEN(1996) A)Nutritive sucking habits: Provides essential nutrients Ex- Breast feeding , Bottle feeding. B)Non nutritive sucking habits: Ensures a feeling of well-being, warmth and a sense of security. Ex- Thumb/ finger sucking, Pacifier sucking
    41. 41. Classification of NNS habits Johnson and Larson 1993 (JDC ) Level Description Level 1 (+/-) Boys or girls of any chronological age with a habit that occurs during sleep. Level II (+/-) Boys below age 8yr with a habit that occurs at one setting during waking hours Level III (+/-) Boys below age 8yr with a habit that occurs at multiple sittings during waking hours Level IV (+/-) Girls below age 8yr or a boy over 8 yrs with a habit that occurs at one setting during waking hours Level V (+/-) Girls under age 8 yr or a boy over age 8 yrs with a habit that occurs at multiple sittings during waking hours Level VI (+/-) Girls over age 8 yrs with a habit during waking hours
    42. 42. Subtelny’s grading(1973) 1.Type A:- 50%
    43. 43. Subtelny’s grading(1973) 2.Type B :- 13-15%
    44. 44. Subtelny’s grading(1973) 3. Type C :- 18% 4. Type D :- 6%
    45. 45. Sucking reflex- Engel 1962  Seen even at 29 week of I.U. life  First coordinated neuromuscular activity of infant  Disappears during normal growth btw 1-3 ½ yrs Purpose:  Nutritional/Physiological gratification  Emotional gratification  Also experience pleasurable stimuli from lips, tongue and oral mucosa & learn assct’ enjoyable sensations such as closeness of a parent.
    46. 46.  Babies restricted from suckling due to disease or other factors become restless and irritable.  This deprivation motivates the infant to suck the thumb or finger for additional gratification
    47. 47. SUCKLIN G SUCKING SEEN WITH BREAST FEEDING BREAST NIPPLE FORMS A PERFECT ANTERIOR SEAL NO NEED FOR ADDITIONAL NEGATIVE PRESSURE HARMONIOUS, FEELING OF LOVE, WARMTH, AFFECTION AND BETTER NOURSMENT OF THE CHILD SEEN WITH BOTTLE FEEDING NEGATIVE PRESSURE CREATED IN THE ORAL CAVITY BY THE ACTION OF BUCCINATOR AND ORBICULARIS ORIS DELETERIOUS (FEELINGS OF DETACHMENT FROM MOTHER AND INADEQUATE NOURISHMENT)
    48. 48. INFANTILE OR VISCERAL SWALLOW Characteristic of the infantile or visceral swallow as listed by Moyer’s:  The jaws are apart, with the tongue between the gum pads.  The mandible is stabilized primarily by contraction of the muscles of the VIIth cranial nerve and the interposed tongue.  The swallow is guided, and to a great extent controlled by sensory interchange between the lips and the
    49. 49. MATURE SWALLOW  By 18 months of age the mature swallow characteristics listed by Moyers are observable.  The teeth are together  The mandible is stabilized by contraction of the mandibular elevators, which are primarily 5th cranial nerve muscles.  The tongue tip is held against the palate about and behind the incisors and peripheral portions flow between opposing posterior segments.  There are minimal contractions of the lips during the mature swallow.
    50. 50. PHASES OF SUCKING
    51. 51. Buccinator mechanism  OO: orbicularis oris  LP: lower fibers of lip  B: buccinator’s muscle  PMR: pterigomandibular raphe  SPC: superior constrictor muscle
    52. 52. Buccinator mechanism When the child places the thumb between teeth Negative pressure is created within Mouth and tongue gets lowered down Pressure against upper anteriors Cheek pressure against the upper posteriors Increased activity of Buccinator mechanism, and the absence of opposing tongue muscle force V shaped maxillary arch with high vault palate
    53. 53. Variables affecting malocclusion Sorokohit and Nanda (1989)  1) Position of the digit  2) Associated orofacial muscle contraction  3) Mandibular position during sucking  4) Facial skeletal pattern  5) Intensity, frequency and duration of force applied.
    54. 54. THEORIES: Psychology of Non Nutritive digit sucking Theories to explain the cause of occurrence of this habit • Freudian theory (1905) • Learning theory (Davidson, 1967) • Oral drive theory (Sears and Wise, 1982) • Johnson and Larson (1993)
    55. 55. FREUDIAN THEORY(1905)  Distinct phases of psychological development  Oral and anal phases seen in first 3 years of life.  Oral phase- mouth believed to be Oro-erotic zone.  The child has tendency to place his finger or any object into the oral cavity.
    56. 56.  Prevention of such an act : results in emotional insecurity and passes the risk of the child diversifying into other habits.  Thumb sucking considered as manifestation of insecurity, maladjustment , internal conflicts
    57. 57. The Learning Theory: Davidson 1967 • Non-nutritive sucking stems from adaptive response • Infant associates sucking with hunger, satiety & being held. • These events are recalled by finger or thumb. • i.e habit stems from an adaptive response and assumes no underlying psychological cause as a result of learning
    58. 58. BENJAMIN’S THEORY (1962):  Thumb sucking arises from “ROOTING REFLEX”, common to all mammilian infants.  It is max’ during first 3months of life.  If it persists, may lead to abnormal habit.
    59. 59. ORAL DRIVE THEORY  Sears and wise(1950)  Acc to this, theory prolongation of nursing strengthens the oral drive.  (i.e prolonged sucking can lead to thumb sucking)
    60. 60. PREVALENCE  Birth to 2years of age: - 50-67%  2 to 5 years of age:- 24-43%  6 to 10 years of age:- 17%  Above 10 years :- 10% Brahm and Morris
    61. 61. INCIDENCE: Popovich and Thompson-1973, Kelley et al 1973: • Higher incidence in girls than boys :11.7% girls and 8.3% boys. • Subtenly and Subtenly 1973: Equal distribution • Race: Low incidence in Negroid races. (Brenchley 1992)
    62. 62. ETIOLOGY  Hanna 1958 : retained infantile swallow  Pearson 1948 : hereditary (JDC 1993)  Cook 1944 : teething  Kelston 1949 : postnatal sucking reflex (JDC 1993)  Humphrey 1950 : subclinical hunger (BDJ 1950)  Mcdonalds, Graber 1958: insecurity attention  Levy 1928 : inadequate sucking during feeding  Cumley 1955 : revenge (JDC 1993)
    63. 63. The trident Factors affecting thumb sucking : Graber and Swain (1985)  Intensity: Implies how vigorously the habit is pursued. The digit may rest passively in the mouth or may be sucked with much enthusiasm.  Frequency: Indicates how often during the day the habit is Practiced.  Duration: Indicates the number of years the habit is continued
    64. 64. Phases of Development of Thumb Sucking (Moyers)  Phase I  Normal and sub clinically significant.  It is seen during first three years of life.  The habit is considered normal during this phase and unusually terminates at the end of phase one.
    65. 65. Phase II  Clinically significant sucking:  The 2 phase extends between 3- 6 years of age. The presence of sucking during this period is an indication that the child is under great anxiety.  Treatment should be initiated during this phase.
    66. 66. Phase III  Intractable sucking:  Any thumb sucking persisting beyond 4 and 5 year of life should alert the dentist to the psychological aspect of approach.
    67. 67. VARIABLES INFLUENCING  Age  Sex  RACE :negroids, eskimo :1969 Owen (MUNN)  Pacifier : Ravn 1967 (Am J Ortho)  Feeding methods : Levy 1928  Siblings : Larsson 1993 (JDC)  Parental status :Calisti 1960 (JDR)  Working mother
    68. 68. DIAGNOSIS • History of the digit sucking activity • Evaluation of the child’s emotional status • Extra oral examinations • Intra oral examinations
    69. 69. HISTORY: Mathewson, Forrestor • Parents • Feeding patterns • Three major questions: (Graber 1972)  Frequency  Duration (most imp)  Intensity  Direction, type
    70. 70. EMOTIONAL STATUS • Essential to determine meaningful or empty habit. • Identify the child who wants to stop but just needs some help
    71. 71. CLINICAL FEATURES – Digits – Lips – Facial form – Dentofacial changes – Other features
    72. 72. DIGITS  Reddened  Exceptionally clean and chapped  Short clean finger/ thumb nail (dish pan thumb)  Fibrous roughened callus on superior aspect of finger nail  Grooves on thumb
    73. 73. LIPS Upper lip :  Short and hypotonic  Passive or incompetent during swallowing Lower lip :  Hyperactive
    74. 74. FACIAL FORM ANALYSIS  Maxilla protrusion  Mandibular retrusion  High mandibular plane angle  Facial profile- straight / convex  Saddle nose (due to pressure of index finger)
    75. 75. Dentofacial changes associated with prolonged non nutritive sucking habits - Johnson and Larson 1993 Effects on Maxilla:  Proclined maxillary incisors  trauma to maxillary central incisors  Maxillary arch length  Clinical crown length of maxillary anteriors  palatal arch width ie High palatal arch  Increased atypical root resorption in primary central incisors
    76. 76. Effects on Mandible:  Retroclination / proclination of mandibular incisors Retroclination : direct apical & lingual force from digit Proclination: indirect force from tongue beneath digit  Decreased clinical crown length of mandibular anteriors  Increased mandibular inter molar distance:Uncontained arch  Retrusion of mandible
    77. 77. Effects on Inter-arch relationship:  Anterior open bit  Decreased overbite
    78. 78.  Increased overjet  Unilateral or bilateral Class II malocclusion.
    79. 79. Posterior cross bite
    80. 80.  Lip incompetence  Lower lip function under the maxillary incisors Effect on tongue placement and function:  Tongue thrust  Lip to tongue resting position (oral seal)  Lower & lateral tongue position Effect on lip placement and function:
    81. 81.  Other features  Other habits- habitual mouth breathing, tongue thrust swallow  Middle ear infections  Enlarged tonsils  GI disturbances  Speech defects (lisping)
    82. 82. TREATMENT CONSIDERATIONS: FINN  Psychological status of the child  Age factor  Motivation of child  Parental cooperation  Friendly rapport  Other factors (goal orientation for time limit)
    83. 83. TREATMENT CONSIDERATIONS:FORRESTER  Emotional significance  Age of the patient  Status of the child’s occlusion
    84. 84. Emotional significance  Diagnosis and management of any psychological problem should be planned before 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.
    85. 85.  The events that precede the habit such as the use of a security blanket, the dependency on a favorite toy, problems with sleep, nightmares, nervousness and anxiousness will yield information concerning the possible psychological stimuli of the habit.  If the oral habit is associated with an emotional problem this would suggest the need for psychological consultation.
    86. 86. Age factor :1) Younger than 3 years  No active intervention :general emotional immaturity.  Most children will outgrow the habit by 5  Most class 1 open bite malocclusion will be self correcting when the permanent incisors erupt if the habit doesn’t cease prior to their eruption.
    87. 87.  The parents should be advised generally to ignore the active habit, and give the child as much attention as possible when he is not thumb sucking.  They should also be advised,  For class II children: further orthodontic treatment will be necessary when the child is older.
    88. 88. 3- to 7 year olds  Caution : Depending on the type of the habit and whether he is actively pulling his maxilla anteriorly or just sucking his digit with buccal constriction.  Finger suckers : concern then thumb suckers because anterior orthopedic force vectors associated with finger sucking leverage.  It is advised counseling the child with good molar intercuspation with little anterior pull. i.e passive sucking child.
    89. 89. Older then 7 years  Anterior open bite that is usually not closed by itself because of functional patterns that have been established.  They will require active orthodontic treatment.  The appliances delivered should not be punitive,  Should be multipurpose  Should help the child to control his habits by giving him a reminder
    90. 90. Motivation of the child to stop the habit:  Important to assess : the maturity : 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.  The first ingredient needed to stop the habit is  the child’s desire to stop.
    91. 91. Parental concern regarding the habit:  If the parent is unable to cope with the situation positively then both the parent and the child should be dealt with during treatment.  Parents : silent partners.  Important : child should not be offered to deal with this difficult habit.  Negative reinforcements : threats, nagging and ridicule would only entrench the habit.
    92. 92. Other factors:  Self-correction again depends on the severity of the malocclusion, anatomic variation in the perioral soft tissue and the presence of other oral habits, such as  tongue thrusting,  mouth breathing and  lip biting habits.
    93. 93. Treatment (Pinkham)  Counseling  Reward system  Reminder therapy  Adjunctive therapy
    94. 94. TREATMENT MODALITIES Thumb sucking
    95. 95. TREATMENT MODALITIES  Once the decision for treatment has been made, one must next determine what intervention is appropriate.  The treatment considerations are  psychological status, age factor, maturity of the patient, and patient co-operation.  The combinations of explanations with consideration of physical appearance and social acceptance may be sufficient for the child to give up the behavior.
    96. 96.  In addition to their own intention some children may require additional help.  Another tool that is helpful for this type of child is the use of positive reinforcement.  Rewards for progress in diminishing the habit should include praise and something special that is agreeable to patient and parent.
    97. 97. Psychological Therapy : A. Dunlop's hypothesis  If a subject is forced to concentrate on the performance of the act and 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 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
    98. 98. B. Six steps in cessation of habit (Larson & Johnson) Step 1: Screening for psychological component. Step 2: Habit awareness. Step 3: Habit reversal with a competing response. Step 4: Response attention.
    99. 99. Step 5: Escalated DRO (differential reinforcement of other behaviors) Step 6: Escalated DRO with reprimands. (Consists of holding the child, establishing eye contact and firmly admonishing the child to stop the habit
    100. 100. C. Three alarm system: (Norton & Gellin- 1968)  A chart is designed with days of the week and blank spaces.  When the child engage in his habit he is told to wrap the digit he sucks with coarse adhesive tapes.  The child feels the tape in his mouth it is the first alarm and this reminds him to stop the habit.
    101. 101. D. Reward system  Children should be encouraged and rewarded for not practicing the habit. “contingency contracting” is a contract made between the child and dentist or child and parent.
    102. 102. E. ACE BANDAGE APPROACH  In this approach, Bandage should be wrapped around the finger and stars should be entered into the calendar.  Reminds the parent and child  Every 20 stars: REWARD
    103. 103. F. THUMB BUDDY TO LOVE  This is commercially available and is a positive teaching tool and chemical free method.  It contains thumb puppet that is inserted into the child's thumb and a calendar at the back of the book.  By having the thumb puppet, the child stays motivated to stop the habit.
    104. 104. G. THUMB - HOME CONCEPT : Skinaz 2000  This is the most recent concept.  Eliminating chronic thumb sucking by preventing a co- varying response: “The behavior is believed to lose its appeal by being reframed as a duty.
    105. 105.  Thus, make the child to suck all the ten finger the same length of time so that it produce unpleasant reaction and gradually it quits the habit”.  Forced repetition of the habit will eventually associate it with unpleasant reaction.
    106. 106. H. CHEMICAL TREATMENT  Bitter and sour  Very minimal success e.g. quinine, asafetida, pepper, caster oil etc.  NEWER anti-thumb sucking solutions  Femite  Thumb-up  Anti-thumb
    107. 107. I. REMAINDER THERAPY  Painting something that tastes yucky on the thumbs can make them less satisfying.  Physical barriers like band.  Aids, gloves etc can also be used.
    108. 108. J. THUMB GUARD  It is an appliance that is worn when the child is tempted to suck.  Once the guard is worn they cannot generate vacuum and so sucking is not much satisfying.  Another approach is long sleeve gown by doubling the length of the sleeve.
    109. 109.  It makes difficulty for the child to suck.  While providing remainder therapy the child should be instructed that these are just to remind them to take the thumb out and it is not a punishment.
    110. 110. K. PARENT COUNSELING  A different approach that can be practiced when its known that the child, wants to discontinue the habit, it requires the cooperation of the parent and their consent to disregard the habit and not mention it to the child.  In private conversation with the child, the problem and its effect must be elicited.
    111. 111.  The parents' role in correction is very significant.  Over anxiety and the resulting nagging approach or punishment often creates greater tension and intensification of the habit.  Thus a change in the home environment and routine help the child to overcome the habit.
    112. 112.  Nagging, scolding or frightening the child should be avoided since this could cause negativism and tend to make him resort to the habit.  From a psychological point of view the child should make the decision that he doesn't want to do it anymore.
    113. 113.  “Parents should not force the preschoolers to break the habit since they only know the pleasure derived from the habit but they cannot understand why the habit to be stopped”.  Some children practice the habit while watching T.V especially when there is no other person to take care of them during day time. So in such case, parents should spend more time with children during day time
    114. 114. Other Extra-oral approaches a) Thermoplastic thumb (Allen 1992) b) Alemaran2000 : Long sleeve gown (J Cons)
    115. 115. INTRAORAL APPROACHES : • Mink and Haskell 1991 : Blue grass appliance • Pediatric clinics of University of Kentucky and University of Louisville • Six sided roller made of Telfon attached with 0.045 stainless steel wire soldered to molar orthodontic bands.
    116. 116. • Patient instructed to turn the roller instead of sucking the digit. • Patient got a new toy to play with tongue & got distracted • Time : 3- 6 months
    117. 117.  Location of roller: most superior aspect of palate  Not in contact with palate  No obstruction in eating or speech  Not used in preschool children  7 – 13 yr age
    118. 118. Chris Baker 2000 : Modified blue grass appliance 4mm acrylic beads Adv: reduced bulk Less obstruction, attractive for children Used in age group 1 ½ - 12 years Modification: Attachment with quad helix Removal time: 6 months after habit cessation
    119. 119. QUAD HELIX  Maxillary expansion  Posterior cross bite correction  Alignment of maxillary and mandibular anteriors  Reminder Therapy
    120. 120.  Palatal Crib : Hayrett 1970  Hayrakes : Korner and Keider 1955 (Angle Ortho)  Spurs  Triple Loop Activator (TLA) : Viazis 1991 (Am J Ortho)  Tongue connector appliance (TCA) : Viazis 1993 (Am J Ortho)

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