oral habits part 1

by
Dr.Avaneethram
Department of pediatric and preventive
dentistry

Contents
Introduction
Definitions
Factors that make a habit pernicious
Classification
General Etiology
Sucking reflex
Sucking vs suckling
Description of reflexes of significance
Thumb sucking

Introduction
For many years oral habits have been the subject of intense discussion and study by the
dental profession.
Certain habits serve as stimuli to normal growth of the jaws, and abnormal habits which
interfere with the regular pattern of facial growth.
The abnormal habits bring about harmful unbalanced pressures to bear upon the immature
highly malleable alveolar ridges and potential changes in the positions of the teeth and
occlusion.

The data on the etiology, age of onset, self-correction and treatment modalities for the
various habits differ greatly.
Hence for a successful management of the habit, an understanding of the dental implications
and manifestations of the habit should be pursued.

Definition
According to Dorland:- Habit can be defined as a fixed or constant practice established by frequent repetition.
According to William James:- Habit is a new pathway of discharge formed in the brain by which certain
incoming current lead to escape.
According to Moyers:- Habits are learned patterns of muscle contraction, which are complex in nature.
Pediatric dentistry principles and practice - MS Muthu

According to Finn:- A habit is an act, which is socially unacceptable.
According to Stedman:- Habit is an act, behavioural response, practice
or custom established in one’s repertoire by frequent repetitions of the
same act.
According to Maslow:- A habit is a form 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.
According to Buttersworth:- Habit is a frequent or constant practice or acquired tendency,
which has been fixed by frequent repetitions.

Usefull
habits
Various authors have classified habits in different ways.
William James classified habits into:-
:- habits of normal function e.g. Correct
tongue posture, respiration and deglutition.
:- habits which exert pressure against teeth and
dental arches eg mouth breathing, lip biting and lip sucking.

:-
Based on the nature of the habits :-
(a) Functional oral habits:- e.g. Mouth breathing.
(b) Muscular habits:- Tongue thrusting, lip biting.
(c) Combined Muscular Habits:- Thumb and finger sucking
(d) Postural habits:-
1. Chin propping
2. Face leaning on hand.
3. Abnormal pillowing.

Earnest Klien:-
Classified habits into:-
: with a deep rooted
psychological disturbance.
: A meaningless habit which has no
need for support, they can be easily treated by reminder
appliance.

Finn and Sim:-
 Compulsive Oral Habits
 Compulsive Oral Habits: - An oral habit is compulsive when it has acquired a fixation in
the child to the extent that he retreats to the practice of this habit whenever his security is
threatened by events which occur in his world. These habits express deep-seated emotional
stress and attempts to correct them may cause increased anxiety.
 Non-compulsive Oral Habits
 Non-Compulsive Oral Habits: Are the ones that are easily added or dropped from the
child's behaviour pattern as he matures.
Compulsive
habits

:-
Graber included all habits under extrinsic factors of general causes of malocclusion. These
are:-
1. Thumb / Digit sucking.
2. Tongue thrusting.
3. Lip / Nail biting / bobby pin opening.
4. Mouth breathing.
5. Abnormal Swallowing.
6. Speech defects.
7. Postural defects.
8. Psychogenic habits bruxism.
9. Defective occlusal habits.

According to the cause of the habit:-
• Physiologic habits
* Those required for normal physiologic functioning. e.g. Nasal breathing,
suckling during infancy.
* Pathologic habits
Those that are pursued due to pathologic reasons. e.g. Mouth breathing due to
deviated nasal septum (DNS)/enlarged adenoids.

 Based on the origin of habit:-
 Retained Habits
Those that are carried over from childhood into adulthood.
 Cultivated Habits
Those that are cultivated during associative life of an individual.
Retained
habits

Based on the patient awareness to the habit:
Unconscious Habits:- are sustained by unconscious behaviour. Simple attenuation
of sensory feedback mechanism aids in cessation.
Conscious Habits: Involve choice or need, making treatment more difficult and
complex.

Sucking Habits
 sucking can be divided into two types
Non- nutrirtive
sucking

Thumb/Finger/Digit Sucking
Thumb sucking or digit sucking is defined as placement of thumb or one or
more fingers in varying depths into the mouth - Gellin 1970.

Factors that make a habit pernicious
Duration
Illuestrated Pediatric dentistry - PR Chokkalingom

Etiology
The origin and maintenance of non-nutritive sucking habits were addressed by
psychoanalytic and learning theories.
According to Freud, the persistence of sucking habits and the appearance of biting habits
have been associated with an arrest in the evolution (fixation) of the psychosexual oral
phase. He also regarded the sucking habits as a manifestation of infantile sexuality.

Etiological factors associated with thumb sucking
Socioeconomic status
Working mother
Number of siblings
Order of birth of the child
Social adjustments and stress
Age of the child
In the neonate

Occlusal interferences
Breathing obstruction
Irritations associated with tooth eruptions.

Theories and concepts of thumb sucking
Psychosexual/ psychoanalytical theory by Sigmund Freud
Oral drive theory by Sears and Wise 1960
Rooting reflex by Benjamin 1962
Sucking Reflex (Ergel—1962)
Learning theory by Davidson 1967

Psychoanalytical theory holds, that, original sucking response arises from an inherent
psychosexual drive. Freud considered non-nutritive sucking (NNS) as a pleasurable erotic
stimulation of the lips and mouth.
One of the concepts regarding thumb sucking according to the psychoanalytic theory is that
humans possess a biologic sucking drive. This is supported by the observation of
intrauterine sucking and by the neonatal reflex of rooting and placing by Benjamin. This
theory states that children tend to lose these habits by the age of 3 years.
 Children who persist with these habits are considered to have some underlying
psychological disturbance. This disturbance is viewed as an inability to cope with life’s
stresses and NNS represents a type of anxiety management.

The learning theory states that NNS is an adaptive response. For instance, an infant
associates sucking with such pleasurable feelings as hunger, satiety and being held. These
events will be recalled by transferring the sucking action to the most suitable object
available, namely, to the thumb or fingers.
This theory assumes no underlying psychologic cause to prolonged NNS. It views that the
response was continuously rewarded and eventually became a learned habit. It follows that
aggressive treatment of the habit would not place the patient at risk for symptom
substitution.

Sucking reflex
 The first coordinated muscular activity of the infant is the sucking reflex. The sucking reflex is
the active movements of the infant’s circumoral musculature which expresses milk from the
nipple. It is the sucking activity that occurs with the object making contact with the infant’s
mouth. This reflex lasts for approximately 12 months.
 In the newborn, the tongue is relatively large and positioned forward during normal sucking. The
tip of the tongue protrudes through the anterior gum pads and provides the anterior lip seal. This
type of swallowing is called visceral or infantile swallowing This early sucking reflex along with
the Moro reflex and grasp reflex which are seen at birth, help the infant to nurse and cling to the
mother.

• The suckling reflex involves a front to back movement of the
tongue. The tongue is deeply cupped and this allows the infant to
extract liquid from a breast or bottle. It is the same motion
children use when sucking on a pacifier. This reflex comes under
the baby’s control around 2-3 months and should disappear or
“integrate” between 6-12 months.
• The action of sucking is different. This action involves more of an
up and down movement. Sucking involves more active use of the
lips and elevation of the tongue than suckling. By 4 months, the
true suck is established, with the tongue sealing towards the first
one third of the mouth. (Bahr, 2010)
• The main difference between suckling and sucking is that
suckling is a primitive reflex and sucking is a more mature
pattern.
Sucking vs Suckling and Mouth Development by Brooke Andrews | Mar 18, 2017

Description of reflexes of significance
A number of primitive neonatal reflexes
can be elicited in a healthy term neonate.
These disappear as the child grows.

Classification of thumb sucking
According to Cook
1. The thumb pushes the palate in a vertical direction and displays only little
buccal wall contractions.
2. Beta group: Strong buccal wall contractions are seen and a negative pressure is created
resulting in posterior crossbite.
3. Gama group: Alternate positive and negative pressure is created.

Clinical aspects of thumb sucking
Moyers divided thumb sucking habit into 3 distinct
phases

Thumb sucking has 2 types:
1) : In this type, there is a heavy force by the muscles during the sucking and if this
habit continues for a long period, the position of permanent teeth and the shape of mandible
will be affected.
2) Passive: In this type, the child puts his/her finger in mouth, but because there is no force
on teeth and mandible, so this habit is not associated with skeletal changes.

Diagnosis of thumb sucking habit
History
Emotional status
Extraoral examination
Intraoral examination
Other features
Textbook of pedodontics - Shobha tandon

Effects of thumb sucking (dentofacial changes
associated with thumb sucking)
1. Maxilla
2. Mandible
3. Interarch relationship
4. Lip placement and function
5. Tongue placement and function
6. Other effects

Deformation of dentoalveolus and face is due to two important factors
Lever effects of hand and digit position - Pulp of thumb exert an outward force on
upper anteriors, root of thumb exert inward
force on lower anterior. This lever like action
proclines upper anteriors and retrocline lower
anteriors

Collapse of buccinator mechanism - Unequal pressure in the maxillary region the
neutral zone gets shifted to a more palatal position. This leads to a constricted
posterior maxillary segment and posterior crossbite.

Effects on Maxilla
• Proclination of maxillary incisors
• Increased arch length
• Increased SNA angle

Effects on mandible
Retroclination of mandibular incisors
Increased mandibular intermolar width
Mandible is more distally placed relative to the maxilla

Effects on interarch relationship
 Increased overjet
 Decreased overbite
 Posterior crossbite
 Anterior open bite
 Narrow nasal floor and high palatal
vault

Effect on lip placement and function
Lip incompetence
Hypotonic upper lip
Hyperactive lower lip

Effect on tongue placement and function
Tongue thrust
Lip to-tongue rest position
Lower tongue position

Other effects
Affects psychological health
Risk of malpositioning of the teeth and jaws
Deformation of digits
Speech defects (lisping)

Prevalence of adverse oral habits was 72.7% in children reporting for dental
treatment in Central Kerala, India.
Prevalence of thumb-sucking was more in younger children (4–8 years) -171 (17%)
in a total of 1034 children
Anila S, Dhanya RS, Thomas AA, Rejeesh TI, Cherry KJ. Prevalence of oral habits among 4–13-Year-Old children in Central Kerala, India. J
Nat Sc Biol Med 2018;9:207-10.

Counseling or age appropriate explanations to the child
Treatment consideration

Management
1. Councelling
2. Reminder therapy
3. Reward system
4. Adjunctive therapy
Pediatric dentistry Infancy through adolescences - pinkham

Interceptive treatments to stop a digit-sucking habit depend upon the patient’s age,
emotional and psychological state, cooperative motivation of the parents and
child, nature of occlusion changes, and associated functional adaptations.
Before Age 4 - If one accepts the premise that a digit habit will usually stop by
age 4 years and the effects on the occlusion are probably not permanent, then
direct intervention before this age has questionable merit. Additionally, the
understanding of the child complicates cooperation with any of the intervention
options.
Dentistry for the child and adolescent - McDonald

4- to 6-Year Age Group
Psychological plays and reward systems may help some children to cease digit-sucking
in this age group.
 A positive approach involves cooperation of the parents who are often over anxious
about the habit. This anxiety may result in nagging or punishment that often creates
greater tension and may even intensify the habit.
Negative reinforcers such as mittens, bandages, and bitter tasting medicaments applied
directly to the offending digit can occasionally affect a stoppage of the habit.
Dentistry for the child and adolescent - McDonald

: forced
purposeful repetition of a habit
eventually associates it with
unpleasant reactions and habit is
abandoned.

Psychological
approach
Six Steps in Cessation of Habit (Larson and Johnson)
Screening for psychological component.
Habit awareness.
Habit reversal with a competing response
Response attention.
Escalated DRO (differential reinforcement of other behaviors).
Escalated DRO with reprimands. (Consists of holding the child, establishing eye contact and
firmly admonishing the child to stop the habit.
Textbook of pediatric dentistry - Nikhil marwah and Textbook of pedodontics - Shobha tandon

Three alarm system (Norton and gellin 1968)
A chart is designed with the days of the week and blank spaces. During the hours the child usually engages in his
habit he is told to wrap whatever digit he sucks in coarse adhesive tape. When he feels this tape in his mouth this is a
‘first alarm’ and reminds him to stop. At the same time elbow of the arm with the offending thumb is firmly but not
tightly wrapped in a 2 inch elastic bandage obtainable in any drug store. Safety pins are placed in the proximal and
distal ends of the bandage, and one is placed lengthwise at the medial bend of the elbow. When he sucks again the
closed pin mildly jabbing indicates a ‘second alarm’ to stop sucking. If the child persists the elastic bandage will
tightened and his hand fall asleep as a ‘third and final alarm’.
Shetty RM, Shetty M,
Shetty NS, Deoghare
A. Three-Alarm
System: Revisited to
treat
Thumb_x0002_suckin
g Habit. Int J Clin
Pediatr Dent
2015;8(1):82-86

 Reminder therapy
Thermoplastic thumb post(Allen1991) : treatment time – 6 weeks
Illuestrated Pediatric dentistry - PR Chokkalingom and Pediatric dentistry Infancy through adolescences - pinkham

Reminder therapy :
Ace bandage approach : elastic bandage wrapped across elbow, worn during night time,
for nocturnal digit sucking

Reminder therapy :
Long – sleeve night gown

 Current strategies
Increased arm length of the night suit
Thumb horm concept
Textbook of pedodontics - Shobha tandon

Hand puppets Thumb sucking books
Dr. Dragon Antolos
Textbook of pediatric dentistry - Nikhil marwah

Chemical therapy
Hot, bitter tasting substance application on skin and nail of the offending digit
– Caster oil, pepper, quinine, asafetida, Femite (denatonium benzoate)
Illuestrated Pediatric dentistry - PR Chokkalingom and Textbook of pedodontics - Shobha tandon

Reward system
The reward must motivate the child.
Praise from the parent and dentist has a large role. The more involement by the
child, the more likely the project succeed.
Reward system is less successful if the child uses the habit to fall asleep.
Reward system and reminder therapy combined to improve the likelihood of
success.

Intraoral
appliances
Removable
appliances
Fixed
appliances

Oral screen

Hey rakes - Mack 1951
Palatal cribs

Blue grass appliance : Haskell (1991) – teflon roller slipped over stainless
steel wire that is soldered to molar bands.
Dentistry for the child and adolescent - McDonald and Illuestrated Pediatric dentistry - PR Chokkalingom
Modified blue grass -

Quad helix : prevents thumb sucking, as well as correction of malocclusion by
maxillary expansion.

Electronic Devices Used
ALARMING WRIST WATCH - Krishnappa et al published in
the year of 2020,They came up with anew device with an alarm that
was activated when the child placed the finger into the mouth. The
alarm was placed in a wristwatch, and making it attractive for the child
to accept and wear them. The child was followed for 5 months and
they found that there is decreased frequency of thumb sucking
followed bydiscontinuing the habit totally by 5 months.
Amudha S, Sowmiya P, Ponnudurai Arangannal JJ, Vijayakumar M. Thumb Sucking Habit And Management: Habit Breaking Appliances
With Electronic Devices. European Journal of Molecular & Clinical Medicine. 2020 Dec 13;7(2):6588-94.

Habit breaking appliance by using LED lights
 Normal upper hawleys appliance is made.
Acrylization is done in such a manner that the
whole assembly of this circuit gets embedded
within the acrylic baseplate except the LED bulb
and the on–off switch. While doing acrylization,
just behind the upper central incisorsthe LED bulb
is placed. The on–off switch is placed at a point,
which is most likely to be touched by the thumb/
digit/tongue of the patient while executing the
habit.
Amudha S, Sowmiya P, Ponnudurai Arangannal JJ, Vijayakumar M. Thumb Sucking Habit And
Management: Habit Breaking Appliances With Electronic Devices. European Journal of Molecular &
Clinical Medicine. 2020 Dec 13;7(2):6588-94.

JOURNALS AUTHORS CONCLUSION
Oral habits and their implications Aasim Farooq Shah Manu Batra
,Sudeep CB, Mudit Gupta,
Kadambariambildhok
,Rishikesh Kumar
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.
Thumb Sucking Habit And
Management: Habit Breaking
Appliances With Electronic
Devices
Sowmiya P. Ponnudurai Arangannal.
Jeevarathan J. Vijayakumar M.
AarthiJ . Amudha S
This makes the child not want to get
attention from the peer groups.
Hence the child will be conscious.
This helps in withdrawing the habit.
Three-Alarm System: Revisited to
treat Thumb-sucking Habit
Raghavendra M Shetty, Manoj
Shetty,
N Shridhar Shetty, Anushka
Deoghare
Revised ‘three-alarm’ system
incorporated in RURS’ elbow guard
can be an easy way to manage
thumb/digit sucking habit. It is an
alternative to intraoral habit breakers;

Prevalence of Oral Habits among 4–
13-Year-Old Children in Central
Kerala, India
S. Anila, R. S. Dhanya, Archana A.
Thomas, T. I. Rejeesh1, K. Jeffy
Cherry1
The prevalence of oral habits among
4–13–year-old children is very high
in Central Kerala, compared to
children in other Indian populations.
Since oral habits can be intercepted
and prevented, creating awareness
regarding the adverse outcomes of
oral habits is highlighted.
Non-nutritive Sucking Habits: A
Review
Sindhuri Gairuboyina, Prakash
Chandra, Latha Anandkrishna,
Punitha S Kamath, Ashmitha K
Shetty, M Ramya
NNSH may be considered normal till
certain stage of the child’s
development. These may or may not
be related to the emotional status of
the child. If the habit is causing a
malocclusion or other pathologic
process, it is privilege and
responsibility of the dentist to work
with the child and parents toward a
resolution of the problem.

Tongue thrusting
Mouth breathing
Bruxism
Lip biting
Nail biting
Cheek biting
Part 2

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