dentistry oral habit dentistry oral habit

2. Oral Habits – Thumb
Sucking Habit

3. 1. Introduction
2.Classification
3.Thumb sucking
4.Theories and concept of thumb sucking
5.Diagnosis of thumb sucking
6.Prevention of thumb sucking
7.Treatment considerations
8.Management of thumb sucking
9.Conclusion
10.References

5. What is an Oral
Habit?
Any
repetitive
behavior that
utilizes the
oral cavity.

6. “A tendency towards an act or an act that
has become a repeated performance
relatively fixed, consistent, easy to
perform and almost automatic.”
By Boucher (1963)
“An act, which is socially unacceptable.”
By Finn (1987)
“Oral habits are learned patterns of
muscular contractions, which are complex
in nature.”
By Moyers (1982)

7. Common Oral Habits
Mouth breathing
Thumb sucking
Tongue thrusting
Bruxism
Nail Biting Lip Biting

8. Etiology
• Anatomical
• Mechanical
interferences
• Pathological
• Emotional

10. Obsessed (deep rooted)
 Intentional / Meaningful
Habits
Eg. Nail biting, digit sucking, lip
biting
 Masochistic / Self inflicting
Habits
Eg. Gingival stripping

11. Non – Obsessed (easily learned
and dropped)
 Unintentional / Empty
Eg. Abnormal pillowing, chin
propping
 Functional
Eg. Mouth breathing, tongue
thrusting, Bruxism

12. By William James (1923) -
 Useful Habits
Eg. Correct tongue position
Proper respiration
Proper deglutition
 Harmful habits
Eg. That have deleterious effect on teeth and
supporting structures

13. By Kingsley (1958) -
 Functional oral habits
Eg. Mouth breathing
 Muscular habits
Eg. Tongue thrusting
 Combined muscular habits
Eg. Thumb and finger sucking
 Postural habits
Eg. Chin propping, Abnormal pillowing

14. By Morris and Bohana (1969) -
 Pressure Habits
Eg. Lip sucking
Thumb sucking
Tongue Thrusting
 Non – Pressure Habits
Eg. Mouth breathing
 Biting Habits
Eg. Nail biting
Pencil biting
Lip biting

15. By Finn (1987) -
 Compulsive Habits
These are deep rooted habits that have
acquired a fixation in child. The child tends to
suffer increased anxiety when attempts made
to correct the habit.
 Non – Compulsive Habits
These are habits that easily learned and
dropped as the child matures.

16. By Klein (1971) -
 Meaningful Habits
They are habits that have a psychological
bearing.
 Empty Habits
They are habits that are not associated
with deep rooted psychological pattern.

17.  Normal Habits
Those habits that are deemed normal by children
of a particular age group.
 Abnormal Habits
Those habits that are pursued after their
physiological period of cessation.
 Physiological Habits
Habits that are required for normal physiological
functioning.
Eg. Nasal respiration
Infantile suckling
 Pathological Habits
Habits pursued due to pathological reason like
adenoids and nasal septal defects that may lead to
mouth breathing.

18. Based on extrinsic or intrinsic factors (By Graber 1972) -
 Thumb / digit sucking
 Tongue thrusting
 Lip/ nail biting
 Mouth breathing
 Abnormal Swallow
 Speech defects
 Postural defects
 Psychogenic habits – bruxism
 Defective occlusal habits

19. Prevalence of oral habits -
 5-13 year old children
 Tongue thrusting- most
common (18.1%), Followed
by mouth breathing(6.6%)
 Thumb sucking(0.7%) and lip
biting(0.04%) are relatively less
common
 No significant difference
between boys and girls.

21.  Placement of thumb or one or more
fingers in various depths into the mouth
or oral cavity. (Gellin)
 Repeated and forceful suckling of thumbs
with associated strong buccal and lip
contractions. (Moyers)
 Finger sucking is perfectly normal at one
stage of development.
 Considered normal for the first year and a
half of life, and will disappear
spontaneously by the end of second year
with proper attention to nursing.

22. Classification -
Normal Thumb sucking
Abnormal Thumb sucking
Psychological – deep rooted
emotional factor
Habitual – performs the act
out of habit

23. Sucking habit classified as (O’ Brien 1996)–
 Nutritive sucking :
Breast feeding
Bottle feeding
 Non-nutritive sucking : (NNS)
Thumb sucking
Finger sucking
Pacifier sucking

24. Subtelny’s Grading -
Type A –
Seen in almost 50% of the children.
Whole digit is placed in the mouth with
pad of the thumb pressing over the
palate, while at the same time maxilla
and mandible anteriors contact is
present.
Type B –
Seen in 13-24% of children.
Thumb is placed in the oral cavity
without touching the vault of the
palate, while at the same time
maxillary and mandibular anteriors
contact is present.
Type C –
Seen in almost 18% of the children.
Thumb is placed in the mouth first,
contacts the hard palate and maxillary
incisors, but no contact with
mandibular incisors.
Type D –
Seen in almost 6% of
children.
Very little portion of thumb
is placed into the mouth.

25. Classification of NNS
Habit – (Johnson 1993)
Level Description
I (+/-) Boy or girl of any chronological age with a habit that occurs
during sleep.
II (+/-) Boys under the age of 8 years with a habit that occurs at one setting
during waking hours.
III (+/-) Boys under the age of 8 years with a habit that occurs at multiple settings
during waking hours.
IV (+/-) Girls below the age of 8 years or boys over 8 years with a habit that occurs
at one setting during waking hours.
V (+/-) Girls below the age of 8 years or boys over 8 years with a habit that occurs at
multiple settings during waking hours.
V (+/-) Girls over 8 years with a habit during waking hours.
(+/-) designates willingness of parents to participate in treatment.

26. Theories and
Concepts of
Thumb Sucking

27. 1. Classical Freudian Theory
 By Sigmund Freud in 1919
 The psychoanalytic theory has proposed that a child
goes through various distinct phases of psychological
development.
 In oral phase, it is believed that the mouth is
erogenous zone.
 During this phase child takes anything and everything
to the oral cavity. It is believed that any kind of
depression of this activity will cause an emotionally in
secure individual.

28. 2. Oral Drive Theory
 Given by Sears and Wise in 1982.
 They suggest the strength of oral drive is in
part of a function of how long a child
continues to feed by sucking.
 It is not the frustration of weaning that
produces the thumb sucking but in fact it is
the prolonged nursing that causes it.

29. 3. Rooting Reflex
 Given by Benjamin in 1962.
 The rooting reflex is movement of the
infant’s head and tongue towards an
object touching its cheek.
 He suggested that thumb sucking arises
from the rooting and placing reflexes
common to all mammalian infants
during the first month of life.

30. 4. Sucking Reflex
 Given by Ergel in 1952.
 The process of sucking is a reflex occurring in the oral
stage of development and is seen at 29weeks of
intrauterine life and may disappear during normal
growth between the age of 1- 31/2 years.
 It is the first coordinated muscular activity of the infant.
 Babies who are restricted from sucking due to disease or
other factors become restless and irritable. This
deprivation may motivate the infant to suck the thumb
and finger for additional gratification.

31. 5. Learning Theory
 Given by Davidson in 1967.
 This theory advocates that nun-nutritive
sucking stems from an adaptive response.
 The infant associates sucking with feelings
with pleasure and hunger and recalls these
events by sucking the suitable objects
available, mainly thumb or finger.

33. Socioeconomic status
Working mother
Number of siblings
Order of birth of the child
Social adjustment and
stress
Age of the child

35. Phase Clinical
Stage
Age of
child
inference
Phase I Normal or sub-
clinically significant
sucking
Pre-school infant This phase extends from childbirth to
about 3years of age depending on the
child’s social development. Most infants
display a certain amount of thumb
sucking during this period, particularly
at time of weaning.
Phase II Clinically significant
sucking
Grade school This phase extends from 3 years to 6
years. Continued, purposeful digit
sucking, deserves more serious
attention, indicates a clinically
significant anxiety, solving of dental
problems due to thumb sucking.
Phase III Intractable sucking Teenage child Persisting after the child’s 4th year.
Require psychological therapy and
integrated approach by dentist.
Clinical aspects of Thumb Sucking given by Moyers
in 1995

36. History
 Parental care
 Feeding patterns
 Remedies tried
 Questions regarding-
i. Frequency
ii. Intensity
iii.Duration

37. Emotional Status
 Essential to determine if the habit is
meaningful or empty.
 This requires an insight into the emotional
security and familial well being of the
child.

38. Extra oral
examination
 DIGITS :
Digits involved will appear reddened,
exceptionally clean and chapped.
Short fingernail i.e. dishpan thumb.
Fibrous roughened callus may be present on the
superior aspect of finger.
 LIPS :
Position of the lips at rest or swallowing should
be observed.
A short hypotonic upper lip frequently
characterizes chronic thumb suckers.
Lower lip is hyperactive and this leads to further
proclination of upper anterior teeth.

39.  FACIAL FORM ANALYSIS :
Maxillary protrusion
Mandibular retrusion
High mandibular plane angle
Facial profile – convex / straight
Saddle nose due to pressure of index
finger

40. INTRAORAL
EXAMINATION
 TONGUE :
Examine tongue position at rest,
tongue action during swallowing.
 GINGIVA :
Look for evidence of mouth breathing
– gum line etching, decay or excessive
staining on the labial surface of upper
central and lateral incisors.

41.  CLINICAL FINDINGS :
The type of malocclusion produced
by digit sucking is dependent on a
number of variables (NANDA 1989) –
Position of digit
Associated orofacial muscle
contraction
Mandible position during sucking
Facial skeletal pattern
Intensity, frequency and duration of
force applied

42. Dentofacial changes associated with thumb sucking
(Johnson and Larson 1993)
 Effect on Maxilla :
Increased proclination of maxillary anteriors with
diastema
Constricted maxillary arch
Increased crown length of maxillary incisors
Decreased palatal arch width
 Effect on Mandible :
Retroclined mandibular incisors
Increased mandibular intermolar distance

43.  Effects on the interarch relationship :
Anterior openbite
Increased overjet
Decreased overbite
Posterior crossbite
Increased unilateral and bilateral class II
occlusion
 Effect on Lip placement and function :
Increased lip incompetence
Increased lower lip function
 Effects on tongue placement and
function :
Tongue thrust
Increased lower tongue position

44.  Other Features :
Other habits – mouth breathing,
tongue thrusting
Middle ear infections
Enlarged tonsils
GI disturbances
Speech defects (lisping)

46.  MOTIVE BASED APPROACH :
The etiology of thumb sucking focuses on a predominant
psychological background.
Its prevention should be directed towards the motive
behind the habit.
History serves as an important tool for diagnosing an
etiology.
 CHILD’S ENGANGEMENT IN VARIOUS
ACTIVITIES :
Parents when questioned may reveal that the children
practice the habit when bored and left to himself, or it
could be just before he goes to sleep.
In such cases, the parents can be counseled on keeping the
child engaged in various activities.
This gives little chance for child to practice the habit.
 PARENTS INVOLVEMENT IN PREVENTION :
When parents are at home they should be advised to spend
ample time with the child so as to put away his feeling of
insecurity.

47.  DURATION OF BREAST FEEDING :
Care should be taken when feeding infants in that the
duration of feeding should be adequate so as to enable
the child to exhaust his sucking urge and feel completely
satisfied.
 MOTHER’S PRESENCE AND ATTENTION
DURING BOTTLE FEEDING :
Bottle fed babies should be held by the mother and
enough attention should be given in the process.
This will promote a close emotional union between the
mother and baby.
Similar to that in breast feeding.

48.  USE OF PHYSIOLOGICAL NIPPLE :
A physiological nipple should be used for bottle feeding and
size and number of holes should be standardized to
regulate a slow and steady flow of milk.
 USE OF DUMMY OR PACIFIER :
Acquiring a digit sucking habit can be prevented by
encouraging the baby to suck a dummy instead.
If the child already has thumb sucking habit, it will not be
easy to introduce a dummy.
It is necessary to offer a dummy to a child whose behavior
indicate an urgent desire to suck a digit or dummy.

49. Treatment Considerations

50. Psychological status of the child
Age factor
Motivation of child
Parent cooperation
Friendly rapport
Other factors
by Finn

52. PREVENTIVE
THERAPY
PYSCHOLOGICAL
THERAPY
REMINDER
THERAPY
APPLIANCE
THERAPY
According to Pinkham

53.  Firstly, feed the child whenever he/she is
hungry and let him eat as much as he/she
wants.
 Secondly, feed the child the natural way.
 Thirdly, never let the habit to be started, the
practice must be discontinued at its
inception.
Preventive Therapy
By Hughes 1941

54. ß HYPOTHESIS OR DUNLOPS’S HYPOTHESIS
 If a subject can be forced to concentrate on the
performance of the act at the time he practices it, he
could learn to stop performing the act.
 Forced purposeful repetition of the habit eventually
associates with unpleasant reaction 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.
Psychological Therapy

55. SIX STEPS IN CESSATION OF HABIT : (LARSON
AND JOHNSON)
 Step 1 – screening for psychological component
 Step 2 – habit awareness
 Step 3 – habit reversal with a competing response
 Step 4 – response attention
 Step 5 – escalated DRO (differential reinforcement of
other behavior)
 Step 6 – escalated DRO with reprimands
(consists of holding the child, establishing eye contact
and firmly admonishing the child to stop the habit.)

56. THUMB SUCKING BOOK
 “The little bear who sucked his
thumb” written and illustrated by Dr.
Dragon Antolos.
 It is a book that the child will relate to
the story and it will deliver a positive
message without pressure.

57. Reminder Therapy
1. Chemical Therapy 2. Mechanical Therapy
Extraoral Intraoral
Removable Fixed
1. CHEMICAL THERAPY :
 Recommends the use of hot flavored, bitter and sour
tasting or foul smelling preparations, placed on the
thumb or fingers that are sucked.
 chemicals used - Cayenne (red) pepper dissolved in a
volatile liquid medium, quinine and asafetida, castor
oil.
 A commercial product “Femite” (Denatonium
benzoate) is also used.

58. 2. MECHANICAL THERAPY
i. Thermoplastic Thumb Post –
 Was devised by Allen in 1991.
 A total of 6 weeks of treatment
time required for elimination of
habit.
ii. ACE bandage approach –
 It is an at home program to assist
children with nocturnal digit sucking
habit.
 It uses an elastic bandage which
wraps around the elbow.

59. iii. Three alarm system –
 Proposed by Nortan and Gellin in 1968
 Effective in children between 3-7 years
 First alarm : offending digit is taped, when child
feels the tape in the mouth.
 Second alarm : bandage tied n the elbow of the
arm of offending digit, with safety-pin placed
lengthwise. On flexion, the feeling of jabbing of
closed pin.
 Third alarm : Bandage tightening. Revisited three alarm system –
 First alarm : the child wearing the
elbow guard
 Second alarm : the
music/vibration/siren/recorded voice
played when tried to bend the elbow.
 Third alarm : the elbow guard
restricting thumb/ finger reaching the
mouth.

60. iv.Use of long sleeve
nightgown
v. Thumb-Home concept –
 Small bag is tied around the
wrist of the child during sleep.
 It is explained to the child that
just as the child sleeps in his
home, the thumb also sleeps in
his home.

61. vi. Use of hand-puppets
vii. My special shirt

62. Appliance Therapy
 Fixed Palatal Crib
 Oral Screen –
Introduced by Newell in 1912.
 Quad Helix –

63.  Hay Rakes appliance –
In children over 3 ½ years.
 Blue Grass Appliance –
Developed by Bruce S Haskell and
Mink in 1991.
 Modified blue grass appliance –

64. Chief complaint –
A 6-year-old and 8-month-old female patient, in
mixed dentition, presented a Class II division 1
malocclusion, overjet of 9.0 mm, and Anterior
Open Bite of 4.0 mm.
Constricted maxillary arch, slight diastema
between the maxillary incisors and between the
lower central incisors, and a slight midline
deviation to the left were also present
Case Report
Tanaka O, Oliveira W, Galarza M, Aoki V, Bertaiolli B. Breaking the Thumb
Sucking Habit: When Compliance Is Essential. Case Rep Dent. 2016:1-6.

65. Treatment –
A fixed Haas-type appliance for RPE was
planned and fixed in order to achieve
palatal expansion and serve as a
“reminder” to curb the habit and
indirectly promote the closure of the
anterior open bite.
Orthodontic treatment was started with
the fixation of the palatal device to the
first molars and bonding on the palatal
surfaces of the molars and deciduous
canines.
Post treatment response –

66. Case Report
Krishnappa S, Rani M S, Aariz S. New electronic habit reminder for the management of thumb-sucking
habit. J Indian Soc Pedod Prev Dent 2016;34:294-7
Chief complaint –
An 8-year-old male child along with his mother
reported to the department with the chief complaint
of thumb-sucking habit.
History of finger sucking regularly about 4–7 h/day
was noted, unconsciously in sleep or when the child
was idle since the primary dentition period.
On examination, a decrease in normal overbite/open-
bite was noted and the maxillary incisors were slightly
proclined, which confirmed the diagnosis of
nonnutritive sucking habit.

67. Treatment –
A non punitive reminder therapy was planned
using an extraoral appliance.
The appliance was a simple device, which gives
alarm when the child takes the finger into the
mouth as the appliance has to be worn on that
finger which is involved in sucking.
The alarm part was encased in an attractive
wristwatch so as to make the appliance attractive
to the child.
The appliance was custom fabricated by
measuring the length of the finger and by taking
the impression of the involved finger.
The appliance was delivered
Electronic habit reminder

68. Post management –
The child was followed for 15 months.
The frequency of the habit gradually came
down, and by the end of 5 months, the child
had discontinued the habit.
The child was instructed to continue to wear
the appliance for another 6 months so that
the habit does not relapse.

70. For successful management of a
habit, an understanding of dental
implications and manifestations
should be pursued.
Pedodontist is at an advantage as
he can see the child during the
period when habit is developing

72.  Principles and practice of Pedodontics by
Arathi Rao
 Dentistry for adolescent and child by
Davidson and Avery
 Textbook of Pedodontics by Shobha Tandon
 Textbook of Pediatric dentistry by Damle
 Pediatric dentistry- principles & practice by
Ms Muthu and Sivakumar
 Orthodontics- art and science by SI Bhalajhi