Oral Habits In Children(Thumb Sucking,Tongue Thrusting, Mouth Breathing,Bruxism)

Oral habits
Presented by: Anukrati Doneria

 Introduction
 Definitions
 Classifications
 Sucking Habits
 Tongue Thrusting
 Mouth Breathing
 Bruxism
 Lip biting
 Nail biting
 Self inflicting habits
 Conclusion
 References

Introduction
● The presence of an oral habit is an important finding, especially in the 3–6-year-old
child.
● It can either be seen associated with psychological disturbances or as a part of
abnormal facial growth.
● Oral habits can have detrimental unbalanced force on malleable dental arches which
leads to:
1. Possible alterations in teeth position
2. Alterations in overall occlusion
• If not diagnosed at early stages, then it can be complex procedure to correct the
problem in advanced stages.
• In this presentation we are going to consider the various oral habits that may be
associated with either malocclusion or oral health.

Definitions
1. William James (1923):
A new pathway of discharge formed in the brain, by which certain incoming currents tend to
escape (Psychological view-point).
2. Maslow (1949)
A formed reaction that is resistant to change, whether useful or harmful, depending on the
degree to which it interferes with the child’s physical emotional and social functions.
3. Dorland (1957)
A fixed or constant practice established by frequent repetition

Definitions
4. Moyers (1958)
Learned patterns of muscle contraction of a very complex nature.
5. Buttersworth (1961)
Frequent or constant practice or acquired tendency, which has been fixed by frequent
repetition.
6. Finn (1972): An act which is socially unacceptable.
7. Mathewson (1982): Learned patterns of muscular contractions.

Definitions
8. Stedman (1999) 27th ed.
An act, behavioral response practice or custom established in one’s repertoire by frequent
repetitions of the same act.
9. Tandon (2001)
A settled tendency in response to a specific cause resulting from repeated learning.
10. Rao (2005)
an automatic response to a specific situation acquired normally as the result of repetition and
learning. At each repetition the act becomes less conscious and if repeated often enough,
may enter the realm of unconscious habit”.

WILLIAM JAMES (1923)
Eg. nasal
breathing,
deglutition,
correct tongue
posture.
E.g. mouth
breathing, lip
biting, thumb
sucking
ORAL HABITS
Useful habits
Non-useful /
harmful
CLASSIFICATION:

2. Brash (1956)
a. Purely muscular
Eg. tongue thrusting, lip sucking.
b. combined activity of muscle of jaw, mouth and thumb
eg. thumb – sucking.
c. Muscular action combined with introduction of passive object into the mouth
Eg. pencil chewing.
d. . Habits in which muscles of the mouth and jaw take no active part, the effect on the
position of the teeth are produced by extraneous pressure.
eg. abnormal pillowing.
e. Functional disturbance
eg. mouth breathing.

3. Kingsely (1956): Based on nature of habit
A. Functional – eg. mouth breathing.
B. Muscular – eg. tongue thrusting, cheek / lip biting
C. Combined muscular habits – eg. thumb & finger sucking
D. Postural habits – eg. chin propping, face leaving on hand, abnormal pillowing.
4. Morris & Bohana (1969)
A. Pressure habits: e.g. Thumb sucking, tongue thrusting
B. Non-pressure habits: e.g. Mouth breathing
C. Biting habits: e.g. Pencil biting

8. Bayardo et al (1996)
a. Sucking habits:
digital, nursing bottle, lips, cheeks, objects
b. Biting habits:
oxychophagia (habitual nail biting), bruxism,
biting body parts, biting objects.
5. Earnest Klein (1971)
A. International (meaningful)
B. Unintentional (empty)
6. Finn and Sim(1975)
a. Compulsive habits
b. Non compulsive habits
7. Finn(1987)
a. Primary habits
b. Secondary habits

9. TANDON (2001)
ORAL HABITS
Obsessive (deep-
rooted)
Intentional OR
meaningful
Masochistic or
Self- inflicting
injurious habit
Non-obsessive
(easily learned &
dropped)
Empty or
Unintentional
Functional

10. Gurkeerath singh(2010)
1. According to patient’s
awareness of habit
2. According to origin
of habit
3. According to cause
of habit
a. Conscious habit a. Physiologic habit
a. Retained habit
b. Unconscious habit b. Cultivated habit b. Pathologic habit

Etiology of oral Habits
• According to Freud(1973) persistence of any habit have been associated with
an arrest in evolution of psychosexual oral phase.
• In the initial stages, oral habits is developed as a solution to displeasure.
• Some of the etiological factors considered responsible for oral habits
includes:
family conflicts, jealousy, school pressure, moving to other city or school, lack of
satisfaction through nourishment, initiation of media activities, irritation
associated with tooth eruption, occlusal interference and breathing obstructions.
(Massler, 1963)

SUCKING HABIT
Nutritive sucking
habits
Breast-feeding
Bottle feeding
Non- nutritive sucking
habits (O’Brien 1996)
Thumb sucking, Finger
sucking, Pacifier sucking

NUTRITIVE SUCKING HABITS
1. Breast feeding:
• Present in the new born child.
• The rhythmic pumping action which makes an infant able to feed from the
breast is called as suckling.
• In suckling, the intra-oral negative pressure is created in 2 stages:
1. By depression of mandible at one stage of the cycle,
2. By pumping and squeezing action, which is typical of ‘milking’.

MOA of suckling
• The nipple is grasped between the
upper gum pad and dorsum of
tongue.
• The lips form a seal and the jaw is
lowered.
• The central portion of the tongue
is deeply grooved antero-
posteriorly and its edges are
averted.

MOA of suckling
• The nipple is extended and taken well back into mouth, the
squeezing action is completed by contraction of the floor of the
mouth.
• The infant stimulates the smooth muscle to contract and squirt milk
into his mouth. So, suckling consists of small, nibbling movements of
the lips, a reflex action in infants.
• The tongue is grooved allowing the milk to flow posteriorly into the
pharynx and esophagus.

Bottle feeding:
• Effects of bottle feeding on dentoalveolar structures vary based on
various factors:
1. Type of nipple used, which are available in various sizes and shapes.
2. Length and form of nipple
3. Location of hole
4. Flexibility
• It is important to simulate the sucking movement similar to
breastfeeding

Bottle feeding:
• When a nonphysiologically designed nipple is used, the end of the nipple is almost
against the pharyngeal wall.
• The liquid is then released directly into the digestive tract and the flow may be too
rapid.
• Consequently, the infant will either force the nipple out of his mouth, or stop the
flow with the tip of his tongue.
• Thus, certain muscles are either immobilized (orbicularis oris, masseter) overactive
(chin muscle) or malpositioned (tongue pushed backward) and may product
abnormal dentofacial development in the child (Labbok and Hendershot, 1987).

Bottle feeding:
• With the physiologically designed nipple, there is forward movement of the tongue
under the flat surface of the nipple that draws it backward and upward against the
hard palate of the infant.
• Consequently, the child has to exercise the lower jaw.
• The posterior part of the tongue then awaits the milk and pushes it down into the
esophageal area, instead of the milk being squirted into the throat. It also improves
the labial seal.
• So these nipples seem better adapted to the anatomy and physiology of sucking
(Geovic & Ostric, 1991).

NON NUTRITIVE HABITS
• Provides a feeling of well being, warmth and security.
• This is probably the earliest sucking habit adopted by
infants in response to frustration and to satisfy their urge
and need for contact.

● Thumb sucking habits are often considered within a broad category of habits
that include finger sucking. Hence these 2 habits are more generally termed
‘digit sucking’ habits.
● Moyers (1958) : Repeated forceful sucking of the thumb with associated strong
buccal and lip contractions.
● Gellin (1978) : The placement of the thumb or one or more fingers in varying
depths into the mouth.
1. Thumb Sucking

CLASSIFICATION
Thumb sucking
Normal thumb sucking
•1st & 2nd years
Disappear as child
matures
Does not generate
malocclusion
Abnormal thumb sucking
Psychological
Deep-rooted emotional
factor – insecurities,
neglect or loneliness
Habitual
potential
malocclusion

Cook, 1958
a.  Group : Thumb pushes palate in
vertical direction and only little
buccal wall contractions are
displayed.
b.  group : Strong buccal wall
contractions are seen and a negative
pressure is created resulting in
posterior cross bite.
c.  group: Alternate positive and
negative pressure is created, this has
least effect on anterior occlusion.
Klein, 1971
a. Meaningful habits:
when the child is under emotional
stress and seeks security by
sucking his thumb
b. Meaningless habits:
done when the child is not under
any psychological problem or
stress.

● Observed prenatally and stimulated in 29-week-old fetus.
● Sucking and rooting incidences are present at birth.
● Necessary function for newborn’s survival.
● Early postnatal reflex: nonspecific, may be activated by number of stimuli like smell, taste,
temperature variations.
● During first few weeks after birth: the reflex becomes specific to stimuli of cheek, lips and
tongue.
The sucking Reflex
DIGIT SUCKING(incidence of digit sucking)

• Associated with oral gratification and nourishment.
• Engel emphasized that on direct observation of
infants during their first year of life it has been
revealed that their neural organization is
predominantly an oral and dining type.
• Disappears- during normal growth between 1-3 ½
years.
• If it continues beyond that, malocclusion might
result. First coordinated muscular activity of the
infant.
The sucking Reflex
MUSCLES INVOLVED

● Early neural organization allows the infant to cling to the mother and nurse as
evidenced by grasping and sucking reflexes.
● With hearing and vision development the baby tries to reach and transport to its
mouth what it has seen and heard.
• This persists until all possible objects are carried into his mouth, and examined by
oral sensations.
• If the object feels good, he may attempt to eat it. The attempt to take into his mouth
a “good” object is termed introjection.
Initiation of digit sucking(infantile)

● If the object feels bad, he spits it out and signifies his disgust by making a wry face and
turning his head away. This rejection of a “bad” object is termed projection.
● Now child is able to provide himself with some secondary gratification to relive frustration
of hunger or other discomfort by putting his finger/thumb into his mouth.
● This satisfies both the sucking reflex and cling needs, so it considered by some to be one of
the earliest signs of developing independence from the mother.
Initiation of digit sucking(infantile)

● Why do some children retain thumb sucking past puberty also, why do some children
develop into retained thumb sucking?
● Many psychologists have different theories and approaches regarding this.
● One class of psychologists are Freudians and Neofreudians who claims that “digit
sucking is a symptom of lack of oral gratification and a deep psychologic significance.
● The other class of psychologists- the behaviorists claims that thumb sucking is just a
simple retained infantile swallow without any deep emotional significance.
Retained digit sucking: etiology and theories

1. The Psychoanalytic Theory (Psychosexual)
● According to “Freud”: digit sucking is symptom of lack of oral gratification because
according to his theory the thumb sucking habit evolves from an inherent psychosexual
drive. He suggested that NNS is a pleasurable stimulation of the lips and mouth. and
furthermore, retained digit sucking is a symptom of deep psychologic significance.
● Evidences in support of Freudian theory states that close contact with mother during first 6
months of life is important, any separation from mother may result in severe emotional
problems along with thumb sucking even though there is adequate nourishment in form of
bottles.

• Harlow has conducted an experiment in which:
He has separated newborn rhesus monkeys from their mothers, and they are given a
choice of two different type of mother monkeys- one was wire surrogate mother with
attached nipples and bottles and the 2nd group is surrogate monkey covered with soft
cloth but without any nourishment.
This was done to test the dominance of oral gratification drive. It was noted that the
baby monkeys ran towards the soft cloth covered monkey rather than milk producing
monkey except when they needed milk for nourishment.

2. Oral Drive Theory: Sears & Wise (1950)
● According to this theory, strength of oral drive is an outcome of how long child
continues to feed by sucking, prolongation of nursing strengthens the oral drive
and the child begins thumb sucking. Thus it is not the frustration of weaning that
produces thumb sucking.
3. The observations of sucking in IU life brings us to Benjamin’s theory(1962):
● According to this theory thumb sucking arises from the rooting and placing
reflexes common to all mammalian infants.

4. Palermo (1956) Behavioral/learning theory:
Claims that sucking has no deep emotional significance but it is simply learned retained habit.
Davidson et al, (1967) when the habit is extinguished, the child is not expected to experience
emotional or psychologic problems or to substitute another more objectionable habit.
Again, in Harlow’s work it was seen that all the monkey’s separated from their mothers
became thumb suckers, but an instant recovery was seen as soon as the mother returns. Which
suggests that presence of mother and amount of close contact with mother is an strong
variable in incidence of thumb sucking.

5. The learning theory Davidson (1967) advocates that NNS stems from an adaptive response.
● An infant associates sucking with pleasurable feelings as hunger.
● These events are recalled by transferring the sucking action to the most suitable object
available (thumb/finger).
6. Johnson & Larson, (1993): combination of psychoanalytic and learning theories
● All developmentally normal children possess an inherent biologic drive for sucking.
● Rooting and placing reflexes are merely expressions of this drive. Environmental factors
contribute to the transfer of this sucking drive to Nonnutritive sources (thumb/finger).

● Hanna (1967) Traisman & Traisman (1958) Backlund (1963):
Found no correlation between thumb sucking and mode of feeding (breast vs
bottle).
● Traisman (1958) observed that infants who had 30-60 min periods of
feeding were more likely to form thumb sucking habit than those with
average feeding time of 10-25 min.
● The time of appearance of digital sucking habits has significance. Those that
appear during the very first few weeks of life are typically related to feeding
problems.
● Some children do not begin to suck a thumb or finger until it is used as a
teething device during the difficult eruption of a primary molar.
Thumb sucking related to feeding

Phases of development of Thumb sucking Moyers (1958)
1. Phase I: Normal and sub clinically significant
• from birth to 3 years, depending on child’s social development.
• Most infants exhibit digit sucking, esp. during weaning.
• Usually resolved towards end of phase I
• If vigorous sucking persists at end of Phase I, definite prophylactic approach is
to be taken due to possible occlusal harm.
2. Phase II: Clinically significant sucking
• from 3 – 6 or 7 years.
• Best time to solve dental problem related to sucking.
• firm and definite corrective program indicated.

Phases of development of thumb sucking Moyers (1958)
3. Phase III: Intractable sucking
• persistence of thumb sucking to this phase is a symptom of significant problem and
may require psychotherapy besides treatment of malocclusion.
•
• Children who stop thumb sucking and begin again later in childhood often have
underlying social or psychological problems.
•
• With some children sucking may serve as an attention grabbing method (Graber).

Causative/contributing factors
1. Parent’s occupation
Socioeconomic status
2. Working mother
Absence – insecurity
3. No. of siblings
Compensation for neglect
4. Order of birth of child
5. Social adjustment and stress
Peer pressure, scolding parents
6. Feeding practices
7. Age
In neonates
During eruption of primary molar-
Teething
Still later (Active after 4 year)

Diagnosis
• Determine
psychological
component.
• Question frequency,
intensity and duration
and habit.
• feeding pattern,
parental care of child.
• Presence of other
habits.
1. Digits
2. Lips
3. Mouth breathing
4. Tongue thrust
swallow(specially if anterior
open bite is present).
5. Middle ear infections.
6. Enlarged tonsils.
History Taking Extraoral examination

Facial form analysis:
• Mandibular retrusion
• Maxillary protrusion
• High mandibular plane angle
• Mentalis muscle contraction

1. Tongue
● Increased tongue thrust,
● Increased lower tongue position.
3. Gingiva:
● Gum line etching
● Staining on labial surface of upper
central and lateral incisors.
4. Symmetry of position of upper lateral
and central incisors
Diagnosis: Intraoral examination
2. Malocclusion:
 depends on a TRIDENT of factors:
• Duration
• Frequency
• Intensity

Clinical findings
1. Anterior open bite :
• Arises due to a combination of factors:
a. Interferences with normal eruption incisors due to an
interposed thumb.
b. Excessive eruption of posterior teeth due to
separation of the jaws, which alters the vertical
equilibrium on the posterior teeth, 1mm of
elongation posteriorly open the bite by about 2mm
anteriorly.

Clinical findings
2. Posterior Cross Bite
3. Constriction of maxillary arch:
failure of the maxillary arch to develop
in width due to an alteration in the
balance between cheek and tongue
pressures.

Clinical findings: Dentofacial changes
a. Maxilla:
 Increased proclination
 Increased maxillary arch length
 Increased clinical crown length of maxillary
incisors
 Decreased palatal arch width
 Increased atypical root resorption in primary
central incisors .
 Increased trauma to maxillary central incisors.
b. Mandible:
• Retrusion
• Point B

Clinical findings: Dentofacial changes
c. Inter-arch relationship
– decreased maxillary &
mandibular incisal angle
- increased overjet, decreased
overbite
d. Effects on lip placement and
function:
- Increased lower lip function
under the maxillary incisors

Prevention
1. Motive base approach:
• Predominant psychological background.
• Motive behind habit
• History is important
2. Engage child in other activities:
• Child practices the habit when
a. Bored
b. Left to himself
c. Before sleep
• Engage child in hobbies like painting/ indoor and
outdoor activities

Prevention
3. parent’s involvement:
• Spend ample time with children
• Bed-time stories
• Soothing and calming music
4. Duration of breast feeding:
• Adequate time for feeding
5. Mother’s presence and attention:
• Hold the bottle-fed babies while feeding.
• Promote the emotional union between mother and the baby.

Prevention
6. Use of physiological/orthodontic nipple:
• For bottle fed babies
• Size of nipple and no. of holes should be
standardized
7. Use dummy or pacifier:
• Encourage the child to suck a pacifier
8. Well timed weaning and beginning of solid foods.

Treatment considerations
1. emotional significance of child/psychology of child:
• Events like use of a security blanket, dependency on a favorite toy, problems with
sleep, nightmares, nervousness and anxiety will provide information about possible
psychological stimuli of the habit.
2. age of child: In child younger than 3 years:
• The habit will suppress in most of the children by the time they are 6 years old, by
the time of eruption of central incisors.
• For class-II children, future orthodontic treatment is necessary.

In 3 to 7 years:
• Outcome depends on whether the child is actively pulling his maxilla anteriorly or just sucking
his digits with buccal constriction.
• Class-I with little anterior pulling force- watching, counselling the child, and contingent
behavior management.
• Normal occlusion but anterior open bite- approaching 6 years of age, active intervention is
required.
Older than 7 years:
• Functional patterns that have already been established.
• These children will require some form of active orthodontic treatment.
3. Status of child’s occlusion:
Self-correction depends on the severity of the malocclusion, anatomic variation in perioral soft
tissues and presence of other oral habits.

Treatment
Treatment plan can be broadly divided into the following:
a. Psychological treatment-
• Refer to the professionals for counselling.
• Between 3-8 years of age: reassurance, positive reinforcement,
and friendly reminders.
• Inform the children and the parents about the possible
dentofacial deformities as the consequence of long-term
persistence of habit.
• Reward therapy

Dunlop’s hypothesis:
• Dunlop believed that if a subject can be forced to
concentrate on the performance of act while practicing it, he
can learn to stop performing the act.
Parental concern regarding the habit:
• If parents are unable to cope positively with the situation,
then parents should become silent partners.
• Do not embarrass or criticize the child or any kind of
negative reinforcement should be avoided.

b. Reminder therapy: Extraoral approaches:
• Applying hot/bitter/distasteful agents like pepper,
quinine, asafetida to fingers and thumb.
• Femite:
 bitter compound containing denatonium benzoate
• Thermoplastic thumb post:
 Made by Allen in 1991.
 A thermoplastic material placed on thumb.
 total 6 weeks of treatment is required for the
elimination of the habit.

• Ace bandage approach:
 Children who doesn’t have any psychological
problems.
 who are willing to discontinue their habits
 An elastic bandage is wrapped across the
elbow every night, the pressure exerted by
the elastic will remove the hand of the child
away from the mouth when he is asleep.
• Long sleeve night gown:
 Interfere between the thumb and oral cavity
and thus, reminding the child.

ORTHODONTIC
APPLIANCES/MECHANOTHERAPY
• The final stage in treatment is the use of orthodontic appliance whether fixed or
removable, which can play the role of reminder and can reduce the willing of finger
sucking.
• For long-term habits or unwilling patient, the fixed intra oral appliance is the most
effective inhibitor.
• After active phase of treatment, the appliance should remain in place for more 3 to
6 month to minimize the relapse potential.

Mechanotherapy
a. palatal cribs:
• Breaks the suction and force on anterior segment
• Makes the habit non pleasurable
b. Hay rakes:
• Not much helpful
• Symptoms of irritability, night tremor, day wetting
c. Oral screen:
• Redirection of muscular and soft tissue pressure
• Prevention of placement of thumb in mouth

Case report
• Acute naso labial angle
• Convex facial profile
• Angles class-I molar relation
• Age- 7 years
• Treatment: A tongue crib was constructed of 0.7 mm
stainless steel wire and welded to bands on the
second primary molars.
• The thumb-sucking habit ceased after four weeks.
The patient's anterior open bite had spontaneously
corrected after four months. The appliance was
removed after six months.

d. Quad helix:
• Expansion of constricted maxillary arch
• Helixes as a reminder
• Posterior cross bite correction
e. Blue grass appliance:
• Bruce Haskell (1991)
• Between 7 – 13 yr
• Teflon roller appliance
• 3 – 6 month placement time
F. Hybrid Habit Correcting Appliance
(HHCA)
• Tongue bead, a palatal crib and a U-
loop attached to the molar bands on
either sides.
 Abraham R, Kamath G et al. Habit Breaking
Appliance for Multiple Corrections

Forester: (If child is under 6 years)
• Class-I: Behavior conditioning, motivation,
reward therapy. Weiss and Eiser (1993)
• Class II malocclusion with the chronic anterior
pull: more dangerous.
• The longer he will apply the force, the more will
be the chances for malocclusion which will not
be self-correcting also.
• In 3-7 years old, if there is presence of spacing in
primary dentition, and there is a mild
overlapping of permanent lower incisors,
activator could be an appliance of choice as the
eruption of permanent maxillary central incisors
approaches (7-8 years).

• In high mandibular angle with marked
anterior open bite- high pull headgear.
• Class-III:
Pressure applied during thumb sucking can
have advantageous effects on maxilla and
anterior teeth, so encourage the child with
class-III malocclusion to continue their
habit.
-Forester

If child is older than 7 years
In class-I molar relation:
a. class-I + anterior open bite(with sufficient
spacing): MODIFIED HAWLEYS APPLIANCE
b. Class-I +non crowded dentition + buccal
crossbite: Fixed or removable palatal
expansion appliances
Class-II molar relation:
a. class-II div I + non crowded + lower
mandibular plane angle: activator and
headgear

Pacifier/soothers/dummies/artificial teets
• Children who do not have access to exclusive breast feeding or who are bottle
fed may satisfy instinctive sucking urge with a pacifier.
 Changes seen with pacifier usage:
1. Posterior cross bite
2. Increased mandibular arch width
3. Decreased max. arch width
4. Anterior open bite
5. Increased overjet
6. Decrease muscular tonicity of tongue and lip
7. Lip entrapment
8. Lip incompetence
9. Narrow hard palate

Pacifier sucking
• There are many sizes and shapes available.
• orthodontic pacifier offers many advantages (according to
manufacturer):
a) it confirms to the baby’s lips
b) smooth and adapted contour promotes nasal breathing.
c) Flat nipple simulates shape of mother’s beast allowing tongue
to touch palate in more natural sucking position and improving
lip seal.
• some minor differences between occlusions of 95 children who
used orthodontic or conventional pacifiers.
Adair et al (1992)

Pacifier sucking
 Recommendations:
1. Should not use before breast feeding established( Kramer et al )
2. No sugar coating
3. Cleaned
4. Avoidance of sharing among siblings
5. Use should be curtailed before 2 year
6. discontinued by 4 years

Introduction
• Considered to be an outcome of retained infantile swallow.
• All the newborns have a characteristic swallow pattern associated with nursing
and sucking reflex.
• The type of swallow that is a part of sucking reflex is termed as visceral or infantile
swallow.
• As the child matures, along with the development of musculature and jaws, the
swallow is more of an adult or somatic or mature swallow.
• Failure in transition of swallow from infantile to adult swallow is considered as
tongue thrusting.

Definitions
• Brauer(1965)- tongue thrust is said to be present if a tongue is observed thrusting
between the teeth, and the teeth do not close in the centric occlusion during
deglutition.
• Tulley(1969) - states tongue thrust as the forward movement of the tongue tip
between the teeth to meet the lower lip during deglutition and in sounds of speech,
so that the tongue becomes interdental.
• Barber(1975)- tongue thrust is a oral habit pattern related to the persistence of
infantile swallow pattern during childhood and adolescence and thereby produces
an open bite and protrusion of anterior tooth segment.

Classification
BY TONDON 2001
1. Physiologic:
This comprises of the normal tongue thrust swallow of infancy
2. Habitual :
The tongue thrust swallow is present as a habit even after the correction of the
malocclusion.
3. Functional :
When the tongue thrust develops as an adaptive behavior to achieve an oral seal, it
can be grouped as functional.
4. Anatomic
Persons having enlarged tongue can have an anterior tongue posture.

BY MOYERS (1955)
1. Simple (Teeth together swallow)
2. Complex (Teeth apart swallow) (deranged buccal occlusion)
3. Retained Infantile swallow (even after permanent teeth appear)
INCIDENCE
• Fletcher (1961) reported 25-30% of children within 9 years age.
• Higher incidence in children with malocclusion.
• Anderson (1963) reported 15% of students having TT, among which 54% had a
history of digit sucking.

The infantile swallowing/visceral swallow:
1. The jaws are apart, with tongue between gum pads.
2. Tongue tip is more active.
3. Posterior part/pharyngeal part – less active
4. The mandible is stabilized primarily by contraction of
muscles of VII the cranial nerve and interposed tongue.
5. The swallow is guided and to great extent controlled by
lips and tongue.
6. Infantile swallow begin to disappear during first year of
life.

Juvenile swallowing pattern:
• This is the transitional phase during 6-12 months of life.
• As the infant matures, there is increased activation of
elevator muscles of mandible as the child swallows.
• The tongue no longer is forced into the space between gum
pads or incisal surfaces.
• As semi solid and solid foods are introduced, it is necessary
for the child to use the tongue in a more complex way to
gather up a bolus, position it along the middle of the
tongue and transport it posteriorly.

Juvenile swallowing pattern:
• The chewing movements of a young child typically involve moving the
mandible laterally as it opens, then bringing it back toward the
midline and closing to bring the teeth into contact with the food. By
the time the primary molars begin to erupt, this juvenile chewing
pattern is established.

Mature swallow
• Characterized by a gradient from anterior to posterior.
• At birth lips are capable of vigorous suckling activity, whereas more posterior structures
are quite immature.
• As time passes, greater activity by posterior parts of tongue and more complex motions of
pharyngeal structures are requires.
• When sucking activity stops, a transition in swallow pattern leads to acquisition of adult
pattern.
• There will be cessation of lip activity (lips relaxed, placement of tongue tip against
alveolar process behind upper incisors and posterior teeth brought into occlusion during
swallowing).
• Most patients complete the transition between the ages of 2 & 12

Mature swallow
• Moyer(1971) listed following characteristics:
1. Teeth are together.
2. Mandible is stabilized by contractions of mandibular
elevators.
3. Tongue tip is held against palate, above and behind
incisors.
4. There are minimal contractions of the lips during
swallow.
• As long as, sucking habits persist there will not be total
transition to adult swallow. After sucking habits are
extinguished a complete transition to the adult swallow
may require some months.

ETIOLOGY: FLETCHER
1. Genetic or heredity factor :
Specific anatomic or neuromuscular variations in the orofacial
region that can precipitate tongue thrust. E.g. hypertonic
orbicularis oris activity.
2. Learned behavior ( habit ) : some of the predisposing factors
are:
• Improper bottle feeding
• Prolonged thumb sucking
• Prolonged tonsillar and upper respiratory tract infections
• Prolonged duration of tenderness of gum or teeth
• Upper respiratory tract infections in mouth breathing, chronic
tonsillitis, allergies.
• Due to the physiological need to maintain an adequate
airway

ETIOLOGY: FLETCHER
3. Maturational factors:
• Late maturation from infantile swallowing
pattern.
4. Mechanical restrictions:
5. Neurological differences:
• Disruption in tactile sensory control and
coordination of swallowing.
• Moderate motor disability and loss of precision
in oral function. In cerebral palsy, there may
even be disruption of pharyngeal stage of
swallow.

Effects & clinical features
EXTRA ORAL
1. Lip posture
2. Mandibular movements : during swallowing
may be more erratic
3. Speech disorders- S/n/t/d/l/th/z/v
4. Facial form
INTRA ORAL
1. Tongue movements: during swallowing may
be jerky and inconsistent.
2. Tongue posture: tongue tip at rest is lower.

3. Malocclusions related to tongue
thrust, effects are seen in both
maxilla and mandible.
Intermaxillary relationship
 anterior/posterior open bite
depending on TT
 posterior crossbite

MISCELLANEOUS:
 Strong contractions of lips and facial muscles,
especially, buccinator.
 Massive grimace
 H/O. Difficulty in mastication
 Low gag threshold.

Diagnosis
1. History: related to habit details-
• hereditary etiological factors
• whether remedial speech therapy was provided.
• Information regarding URTI, sucking habits, neuromuscular problems.
• Abilities, interests and motivation of patient.
2. Examination:
• Observe the tongue during various swallow procedures like: the unconscious swallow, the
command swallow of saliva, the command swallow of water, unconscious swallow
during chewing.
• Also observe the complexity of tongue thrust.
• Check for following features in different swallow patterns:

1. Simple tongue thrust:
• Teeth together swallow
• normal tooth contact during the swallowing act.
• Good intercuspation of posterior teeth in contrast to complex
tongue thrust.
• The tongue is thrust forward during swallowing to help establish
an anterior lip seal.
• At rest the tongue tip lies at a lower level

2. COMPLEX TONGUE THRUST (ANTERIOR AND POSTERIOR TONGUE THRUST):
• It is defined as tongue thrust with a teeth apart swallow.
• Usually associated with chronic naso-respiratory distress, mouth breathing, tonsillitis,
and pharyngitis.
• The following features are seen :
 Proclination of anterior teeth
 Bimaxillary protrusion
 Characterized by a teeth apart swallow.
 The anterior open bite can be diffuse.
 Absence of temporal muscle constriction during swallowing.

 Combine contractions of the lip, facial and mentalis muscle.
 The occlusion of teeth may be poor, no firm intercuspation.
 Posterior open bite
 Posterior crossbite
3. Lateral tongue thrust (posterior tongue thrust):
 Clinically lateral/posterior open bite.
 It may be unilateral or bilateral and depends upon
the type of tongue thrust.
 Presence of grimace during swallowing.

Methods of examination
1. Examination of unconscious swallow: lip contraction
2. COMMAND SWALLOW OF WATER
• small amount of tepid water beneath the patient’s tongue tip
• mandibular movements.
• In the normal mature swallow, the mandible rises, the facial muscles ordinarily do not
show marked contractions .
3. TEMPORALIS TEST
4. Place a tongue depressor or mouth mirror or hold the lower lip & patient to swallow.
Those with teeth apart swallow will have their swallow inhibited by depression of lip,
since strong mentalis and lip contractions are needed for mandibular stabilization in the
teeth apart swallow.

1. Age:
self corrects often by 8-9 years.
2. Presence/absence of associated manifestations:
Treatment is not generally considered if tongue thrust is present without malocclusions or a
speech problem.
3. Malocclusion without speech defects:
Correction of malocclusion will usually eliminate the tongue thrust.
4. Speech defects:
Speech therapy during the elementary school years.
 Tongue thrust + speech defect + malocclusion= speech therapy+ orthodontic treatment.

Treatment
Treatment is divided into several steps:
a. Training of correct swallow and tongue postures by:
- Myofunctional exercises
- Appliances to guide the correct posture of tongue
b. Speech therapy
c. Mechanotherapy
- Fixed appliance therapy
- Removable appliance therapy
d. Correction of malocclusion by myofunctional appliance

Treatment
1. Training of correct swallow and tongue
postures:
a. MYOFUNCTIONAL ECERCISES-
- place the tip of tongue on rugae area for 5 min
& swallow.
- Put orthodontic elastics or sugarless fruit drops
at tip of tongue.
- 4s exercises: spot, squeeze, salivate, swallow
- Other exercises: whistling, reciting the counting
from 60-69, gargling etc.

● To improve tongue tip
elevation.
● Moisten it & place it over the
tip.
● Make tongue tip reach & place
it over the roof of mouth with
the help of tongue.
Cheerios

Treatment
b. APPLIANCES TO GUIDE THE CORRECT POSTURE-
• Once the patient is familiar with the correct position, an
appliance is given to train the correct tongue position.
a. Pre orthodontic trainer for myofunctional training: T4K appliance:
 Resembles mouthguard
 Tongue tags, tongue guards
 Also helps in training the correct lip seal, correct swallow, nose
breathing.
 Promotes arch development, tooth alignment and bite
correction.
 Prevents and corrects developing malocclusions by retraining
the perioral muscles.
 Wear it for 1-2 hour every day for 2 weeks and then whole
night.

Treatment
B. Nance palatal arch appliance:
• Acrylic button- guides
tongue tip
• Repeat multiplication table
of 6
• Tongue posture after
wearing.
• Nance palatal arch is more
conductive towards the
speech correction along
with guiding the tongue.

Treatment
2. Speech therapy:
• Training of correct position of tongue
• Articulation of speech and normal alignment of the teeth
• Repetition of words with ‘S’ sound – multiplication of 6 tables
• Not indicated before 8 years
3. mechanotherapy:
Purpose:
i. Re-education of tongue position
ii. Maintaining tongue in the confines of dentition
iii. Prevention of over eruption and narrowing of maxillary buccal segment

Treatment
Removable appliance
 Modifications of Hawley’s appliance
1. Active labial bow
2. Addition of palatal crib
Advantages :-
1. Anchorage– acrylic covers entire palatal area and contacts entire
maxillary dentition on the lingual surface
2. Capability of Hawley’s to close ant open bite
3. Crib – reminder
Note :-
remove acrylic on the gingival margin on the lingual side
Loops of tongue crib removed one by one – weaning – 6 months period

Treatment
Removable appliance
 Oral screen and vestibular screen
• redirects muscle forces
• Double oral screen (acrylic or wire loop is constructed to prevent
tongue thrusting)
• Wear appliance at nighttime and at least 2 hours at daytime.

Treatment
Fixed habit breaking appliances:
• Fixed tongue crib- 4-9 months.
• Modified palatal crib to eliminate lateral tongue thrust.
4. Correction of malocclusion:
Treatment with myofunctional bead appliance
a. Promote lip closure
b. Enlarge oral cavity
c. Move incisors
d. Improve relation among jaws, tongue, Dentition and soft
tissue
e. E. g: activator, bionator

Definitions
• Chopra (1951) & Sassouni (1971): It is the habitual respiration through the mouth
instead of the nose.
• Merle (1980): Suggested the term oro-nasal breathing instead of mouth
breathing.
• 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 oronasal breathing instead of mouth breathing.

Classifications
• Obstructive mouth breathing:
- frequently observed in ectomorphic children
- Children who have increased resistance to, or
complete obstruction of, normal flow of air
through nasal passages.
• Habitual mouth breathing:
- Even though the abnormal obstruction is
removed.
- Child continuously breathes through his mouth
by the force of habit.
• Anatomical mouth breathing:
- Anatomic defects/deficiencies
- Short upper lip
Finn (1987)

Etiology
1. Allergic Rhintis.
2. Obstruction in bronchial tree or larynx.
3. Obstructive sleep apnea syndrome.
4. Genetically ectomorphs

Clinical features
1. GENERAL EFFECTS:
• Purification & humidification of inspired air is affected.
• Pigeon chest:
Normal airway- proper nasal resistance
Diaphragm & intercostal muscles create negative pressure to
promote airflow into the lungs.
• Presence of low grade eosophagitis
• Changes in blood gas constitution: mouth breathers have
20% more carbon dioxide and 20% less oxygen in the
blood.

Clinical features
2. EFFECTS ON DENTOFACIAL STRUCTURES
Facial form:
• In hypertrophied lymphoid tissue mouth
breathers- vertical growth pattern
• Cephalometric analysis shows-
 Increase in facial height
 Increased mandibular plane angle
 Retrognathic maxilla and mandible
• In allergic mouth breathers- Increased anterior
face height.

Clinical features
Adenoid facies:
• Long, narrow face
• narrow nose and nasal passage
• Dolicofacial skeletal pattern
• Short flaccid lips
• Superiorly tipped nose in front
• Expressionless face
• “V” shaped and high palatal vault

Clinical features
Dental effects:
• Retroclined maxillary & mandi.
Incisors
• Posterior crossbites with tendency
towards open bite
• Narrow palatal width/constricted
maxillary arch
• Low set position of tongue
• Flaring of incisors
• Decrease in vertical overlap of anterior
teeth.

Clinical features
Speech defects:
• nasal tone
Lips:
• Lips apart posture
• Gummy smile
• Long face syndrome
• Short, thick upper lip
• Voluminous curled lower lip

Clinical features
External nares:
• Atrophied nasal mucosa
• Slit like external nares with narrow nose
• Nasal collapse on inspiration.
Gingiva:
• Inflamed & irritated gingival tissues
• Heavy deposits of plaque
• Classic rolled margin
• Enlarged interdental papilla
• Periodontal diseases with proximal bone loss

Diagnosis
1. HISTORY
Questions to be asked from parents:
a. whether the child frequently adopts a lip apart posture.
b. Frequent occurrence of tonsillitis, allergic rhinitis, otitis media
c. restless sleep, snores wakes up feeling thirsty.
2. EXAMINATION
a. Study the patients’ breathing unobserved. (lips touch usually in nasal breathers during
relaxed breathing)
b. Ask the patient to take a deep breath:
In a mouth breather there will be no change in the size and shape of the external nares and
occasionally contracts the nasal orifices while inspiring.
Whereas a normal nasal breather will usually dilate the nostrils when breathing deeply.

Diagnosis
CLINICAL TESTS:
1. Mirror test (Fog test)
2. Massler and Zwemer Butterfly test.
3. Massler Water holding test .
4. Inductive plethysmography (rhinometry)
The total airflow through the nose and
mouth can be quantified using inductive
plethysmography, the only reliable way. This
allows the percentage of nasal and oral
respiration to be calculated.

Diagnosis
5. Cephalometrics:
• Can establish the amount of nasopharyngeal
space, size of adenoids and the skeletal
patterns of the patient.
• Upper pharyngeal width can be measured on
lateral cephalogram. Airway obstruction is
indicated if measurement is 5mm or less.
6. Rashmdeep method:
• An innovative method suggested by deepesh
and Rashmi(2013) to confirm the type of
breathing performed by children.
• Can also be used to diagnose any unilateral
nasal blockage

Diagnosis
 When patient breathes the expired air from nostrils, it can be felt on the thumb of
clinician.
 To test unilateral nasal obstruction: block one of the nostril with index finger of right
hand..
 Caution:
1. Asthmatic patients
2. Acute upper respiratory tract infections
3. Running nose
4. Carrying any communicable disease.
 Most important aspect of diagnosis is to first figure out which category the habit of child
belongs to(habitual/obstructive/anatomic)

Treatment considerations:
• Age ; maturity of the child
• E.N.T. examination; tonsils, adenoids or nasal septum.
• Aim of correction: removing anatomic/functional obstructions
• Correction time: Mix dentition- prevents ill effects on occlusion
Treatment:
1. Symptomatic relief:
• Gingival coating
• Periodontal consideration: Prophylaxis

2. Elimination of cause:
• Removal of nasal or pharyngeal obstruction(surgical/local
medication)
• Rapid maxillary expansion: marked reduction in nasal airway
resistance.
3. Interception of habit
• Physical – deep inhalation exercise
• Playing wind-pipe
• Disc holding exercise
• Patients with short hypotonic upper lip

Exercises:
• During day timehold pencil between the
lips.
• During night timetape the lips together
with surgical tape in habitual mouth
breathing.
• Hold a sheet of paper between the lips. •
Piece of card 1 1½" held between the
lips.
• Button pull exercise
• Tug of war exercise

Mechanotherapy
 Rapid maxillary expansion (RME)
 Correction of malocclusion
Class-I: Oral screen
Class-II Div-1: Noncrowded dentition (5-9 yr) – Monobloc
activator.
Class-III malocclusion: interceptive chin cap

Bruxism
Marie Pietkiewicz in 1907.

Bruxism can occur as brief rhythmic strong contractions of the jaw muscles during eccentric
lateral jaw movements, or in maximum intercuspation, which is called Clenching
-Clark,1993
1. American Sleep Disorders Association (1990):
Tooth grinding or clenching during sleep plus one of the following: tooth wear, sounds or jaw
muscle discomfort in the absence of medical disorder.
2. American Academy of Orofacial Pain (1996) :
Diurnal or nocturnal parafunctinal activity including clenching, bracing, gnashing and grinding of
teeth.
3. AAPD (2003) :
Habitual, nonfunctional, forceful contact between occlusal tooth surfaces, which can occur while
awake or asleep.
Introduction & Definitions

CLASSIFICATION
1. Day time/diurnal bruxism/bruxomania:
• conscious/ subconscious grinding.
• During day time.
• Associated with other parafunctional habits.
• Usually silent, except in patients with brain related disorders.
2. nocturnal/night time:
• Subconscious grinding of teeth.
• Characterized by rhythmic patterns of masseter.

Types
I- Olkimora (1972) divided bruxers into 2 categories:
1. Those whose bruxism was associated with stressful events.
2. No such association
II- Primary (Idiopathic) : Include daytime clenching and sleep bruxism in the absence of
medical cause.
Secondary (iatrogenic) : Associated with either neurologic, psychiatric or sleep disorders
or with administration or withdrawal of drugs.

Etiology: Nadler(1957)
1. Local factors-
- Faulty restorations.
- Traumatic occlusal relationship: Occlusal interferences/
defective occlusal contacts are triggers that elicit bruxism
- Functionally incorrect occlusion.
- Faulty eruption of deciduous or permanent teeth.
- kids may grind because the top and bottom teeth aren't
aligned properly.
- Some do it as a response to pain, such as from an earache or
teething.

2. Systemic Factors:
- Nutritional deficiencies.
- Calcium and vitamin deficiencies
- Intestinal parasite infection
- Gastrointestinal disturbances from food allergy.
- Enzymic imbalances in digestion.
- Endocrine disorder, e.g., hyperthyroidism.
- Hyperkinetic children.
- Pubertal growth spurt peak in boys and start of spurt in girls sees increase in bruxism.
- CNS disturbances e.g. Cortical brain lesions, Disturbances in medulla and pons, epilepsy.
Etiology

Etiology
3. Psychological Factors
Most dominant factor.
Nervous tension finds a most gratifying release in clenching and bruxism.
4. Occupation Factors
Athletes, indulge in bruxism because of a great desire to excel.
Overanxious students/ compulsive over achievers.

Occurrence
1. In infants with eruption of permanent teeth.
2. Increases in mixed dentition stage and decreases with age.
3. Commonly occurs during sleep.
Clinical manifestations
Depends on:
1. frequency
2. Intensity
3. Age of patient.
Bruxism forces transmitted to masticatory apparatus some amount of
force gets absorbed, some gets transferred to other structures.

Clinical features
1. Occlusal trauma: leading to:
- tooth mobility
- gingivitis spread into deep
periodontal structures and alveolar
bone loss
2. tooth structures:
- nonfunctional patterns of occlusal
wear
- increased tooth sensitivity
- atypical wear facets
- pulpal sensitivity to cold

3. Muscular tenderness:
- tenderness in jaw muscles
- muscular fatigue on waking up
- bilateral/unilateral hypertrophy of masseter
4. TMJ disorders:
- dull and unilateral pain in TMJ
- crepitation, palpitation and clicking within the joints.
- Restricted mandibular movements & jaw deviations.
- Deviated chin during mandibular movements.

5. Chronic Headaches due to muscular contraction most often.
6. Other signs & symptoms:
- grinding & tapping sounds
- soft tissue trauma
- small ulcerations on buccal mucosa opposite the molars.

- Check wear patterns on the opposing teeth.
- These wear facets are frequently seen in lateral positions of mandible
relative to maxilla.
- If opposing wear facets are brought into firm or bruxistic contact and
maintained for extended periods, pain patterns will be observed.
Diagnosis

Treatment
1. Occlusal adjustments
• Results in immediate disappearance of habitual grinding.
• Coronoplasty
2. Occlusal splints & night guards:
• Vulcanite splints reduces the increased muscle tone
• Use soft splints in young children
• A custom fabricated acrylic appliance, covering maxillary
or mandibular teeth, leaving 2 mm thickness on
permanent molars can be Worn at night.
3. Restorative treatment
• Severe cases: pulp therapy with ssc crowns

Treatment
4. Psychotherapy
• Psychological counselling of patient reduces the
build up tension and also creates the awareness
about the habit.
5. Relaxation training:
• Create tension in muscles and relax
• Training muscles to relax voluntarily
6. drugs:
• Ethyl chloride for pain relief in TMJ area.
• LA injections directly into TMJ or muscles.
• Tranquilizers, sedatives & muscle relaxants.
7. Biofeedback:
• Patient is allowed to view EMG monitor while patient
learn tension reduction.

Lip habits
1. Habits that involved manipulation of lips, & perioral structures.
2. Can be recognized by the reddened, irritated and chapped area below
the vermilion border (Massler and Chopra, 1950).
3. The vermilion border may be relocated farther outside the mouth due
to constant wetting of the lips (Barber, 1978).
4. Although this may occur with either lip, it is more commonly associated
with the lower lip (Sheppard, 1960).
5. Classification: (schneider, 1982)
a. Wetting of lips with the tongue
b. Pulling the lips into the mouth between the teeth

Aetiology
1. Malocclusion:
- Angles class II division I with a large overbite &
overjet.
2. In conjunction with other Habits:
3. Emotional stress
- This may increase intensity, frequency and duration
of lip sucking.
- Occasionally the habit may become a compulsive
and gratification activity during sleeping hours.
4. Hyperactivity of mentalis muscle

1. Proclination of maxillary incisors.
2. Retroclination of mandibular anteriors.
3. Increased overjet
4. Dry & chapped lips.
5. Inflammation of affected lips.
6. Discoloration of lips.
7. Accentuated mentolabial sulcus.
8. Increased overjet & overbite

Treatment
• Non self correcting.
• Becomes more deleterious with age
• Treatment depends upon etiology(if it is associated with
digit sucking or due to malocclusions)
• Emotional security of the child should be considered if it
is associated with thumb sucking habit.
• Appliances: repositioning of incisors and their proper
alignment:
1. Hawley’s retainer

Treatment
2. Oral screen: prevents the habit as well as corrects the
teeth alignment.
3. Pre-orthodontic trainers
4. Angles class II malocclusion with large overjet and deep
bite due to lip sucking habit in permanent dentition:
orthodontic corrections.
5. In early mixed dentition stage: Activator to reposition
the maxilla & mandible in more favorable position.

6. Lip bumper: Helps to reposition the
maxillary incisors distally resulting in
decreased overjet & overbite.
• Can be fixed/removable/combines type.
• Either the 2nd deciduous molar or 1st
permanent molars are banded, buccal
tubes are soldered to them.
• Labial screen can be either soldered to
band/crown or slipped into the buccal
tubes.

Introduction
• Abnormal habit of keeping cheeks or biting cheek
muscles between upper & lower posterior teeth.
Clinical features:
• Ulcers at the level of occlusion
• Open bite
• Tooth malposition in buccal segment
Treatment:
• Removable crib as habit breaking appliance.
• Vestibular screen
• Oral lubricants

• Onychophagia/nail biting- putting nails into mouth in such a manner that
contact occurs between finger-nail with one or more teeth.
• Nail biting is a normal habit that develops after the sucking age.
• About 80% of all individuals have been or are nail biters (Finn).
• This is not a pernicious habit and does not assist in production of
malocclusion since forces are similar to those in chewing.

1. CLASSIFICATION:
A. Mild form: involves tearing of nails without injuring the nail bed.
B. Severe form: leads to damage to nail bed and cuticles.
C. Pathological: exhibits increased frequency, intensity and duration.
D. Non pathological: temporary habit, in healthy children
• 23% in school children, 33% in children between 7-10 years,
45% in adolscents

Etiology:
• In normal, healthy children: response to stress, anxiety or
nervousness.
• Fixation of an individual to the oral stage(psychosexual theory
by Freud)
• Acquired learned habit without any underlying emotional
disturbances.
• Association with other disorders:
Attention deficit hyperactivity disorder, oppositional defiant
disorder, separation anxiety disorder, tic disorder, obsessive
compulsive disorder, pervasive developmental disorder, mental
retardation.

Manifestations:
• Fracture of incisal edges
• Attrition, proclination of teeth
• Damage to periodontium & surrounding alveolar bone
• Transmission of bacterial infection from nails to oral cavity.
• Transmission of infections like herpes simplex.
• Social ridicule.
• Low self esteem.

Dental Manifestations:
• Crowding and rotation
• attrition of incisal edges of mandibular incisors is usually
seen.
• Inflammation of nail bed & nails.
Age of Occurrence:
• Not seen before 3 years.
• Incidence rises sharply from 4-6 years, remains constant
between 7-10 years.
• Peak rise again during adolescence.

Management
1. Habit reversal treatment:
a. Awareness training:
• understanding the details of child’s habit
• understanding and recognizing the precursors signs when child engages in habit.
• followed by simulation of habit by child in front of clinician or therapist.
b. Educating parents & siblings:
• educating the children as well as their parents, siblings and teachers.
• They should be taught about what to do and what not to do about it.
• For example, they should know that punishment, threat or laugh at the children with NB
can increase this behavior.

2. Mild aversive therapy:
• A bitter solution is painted on fingernails which increases the awareness of habit
& decreases the behavior because of unpleasant association.
• Apply paint 2-3 times a day around the time child usually engages in the habit.
3. Self Control Intervention:
• Teaching child some specific self control skills like self talk or self reward to
change the detrimental habit.
4. Pharmacotherapy:
• If it comes as OCD, drugs like clomipramine can be used.

DEFINITIONS:
• Christensen et al (1999): Repetitive acts that result in physical damage to the person.
• Masochistic behavior has been defined as the deliberate destruction or alteration of body
tissue without conscious suicidal intent and occurs in conjunction with a variety of
psychotic disorders as well as various developmental anomalies and some syndromes
INCIDENCE:
• Extremely rare in normal child, between 10-20% in mentally retarded population
(DenBesten & McIver, 1984).
• It is a self destructive habit in which the sufferer derives pleasure from his own pain.

Classification
Ayer & Levin (1974) based on the etiology divided it into :
1) Organic: unknowingly, unintentionally, compulsively .
Syndromes such as Lesch – Nyhan and dehange’s, Tourette’s syndrome, schizophrenia,
borderline personality disorder, stereotypic movement disorder.
2) Functional:
Type A injuries are superimposed on a pre-existing condition, such as herpetic lesions or
localized gingival infection.
Type B are injuries secondary to another established habit eg. rotating the thumb during
sucking, which can hurt soft tissues.
Type C are injuries of unknown or complex etiology. Due to psychological problems. There
may be multiple symptoms of great intensity. These habits may serve as form of stress
release.

Features
• Presence of ulcers on lips due to lip biting
• Attrition of teeth.
• Skin peeling
• Common sado-masochistic behavior includes skin picking, scratching, head banging, nail
biting, falling.
• careful history taking and examination of the patient.
A Report of Sado-Masochistic Behavior in a 7-year-old Child- R.Neeraja

Frenum thrusting
• Rare habit
• Seen in children who has their anterior teeth apart.
• On constant repetition, tooth displacement can occur.
TREATMENT:
• Psychotherapy
• Palliative treatment: in form of bandages for any oral
ulcerations.
• Mechanotherapy: oral shield.

Bobby pin opening
• In teen girls
• Notched incisors & denuded labial incisors
• In upper anteriors

Conclusion
• In order to replace the adverse oral habits by good habits, a holistic approach is
indicated, which includes patient-parent counselling, behavior modification techniques,
use of habit breaking appliances, physical exercise, followed by recall visits and
reinforcement.
• Prevention and interception of these deleterious oral habits at an early stage is utmost
important for the good oral health of the children.
• Techniques to eliminate the undesirable oral habit should be introduced when a program
plan, which will outline the replacement behaviors, is established and when family and
caregiver support is in place.

● Textbook of pedodontics: Shobha Tondon
● Textbook of pedodontics: S.G Damle
● Textbook of Orthodontics: Gurkeerat Singh
● Dentistry for the Child and Adolescent: McDonald, Avery, Dean

Oral Habits In Children(Thumb Sucking,Tongue Thrusting, Mouth Breathing,Bruxism)

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