A comprehensive yet more detailed presentation of Oral Habits

1. ORAL
HABITS
M. Nagendra Kumar
CRRI

2. CONTENTS
• Introduction
• Definitions
• Classification of Habits
• Thumb Sucking
• Tongue Thrusting
• Mouth Breathing
• Lip Biting
• Bruxism
• Nail Biting

3. 3
Introduction

4.  Repetitive behaviours are common during childhood.
 Numerous biological and environmental factors are responsible for causing and
maintaining these behaviours.
 Most of these repetitive behaviours are benign and self-limiting.
 One of the most common of these early behaviours is hand sucking which occurs in almost
100% of infants within the first year of life.
 Shroeder in 1983 quoted that these habits can become problems under the following
circumstances.
a. When the behaviour continues longer than typical.
b. When the behaviour becomes severe or chronic enough to cause physical damage.
c. When the behaviour is engaged in so frequently that it interferes with ongoing
physical, social or cognitive development.

5. 5
Definitions

6.  According to William James, habit is a new path of discharge formed in the brain by which
certain incoming currents lead to escape.
 According to Moyers, habits are learned patterns of muscle contraction, which are complex in
nature.
 Boucher defined habit as a tendency towards an act or an act that has become a repeated
performance, relatively fixed, constant, easy to perform and almost automatic.

7. 7
Classification of
Habits

8. ● Meaningful and Empty
Habits (Klein—1971)
o Meaningful habit: Habit
with a deep-rooted
psychological problem.
o Meaningless habit: Habit
that can be treated easily
by a dentist using
reminder therapy.
● Compulsive and
Noncompulsive Habits
(Finn—1987)
o Compulsive habits:
Acquired as a fixation in
the child to the extent that
he retreats to the practice
whenever his security is
threatened.
o Non-compulsive habits:
Children appear to
undergo continuing
behavior modification,
which permit them to
release certain undesirable
habit patterns and form
new ones which are
socially accepted.
● Useful & Harmful habits
(James-1923)
o Useful habits: include all
those habits of normal
function.
Ex: tongue position, proper
respiration and deglutition.
o Harmful habits: All those
that exert perverted stress
against the teeth and
dental arches.
Ex: mouth breathing, tongue
thrusting.
8

9. ● Retained and
Cultivated Habits:
o Retained Habit:
Those that are carried
over from childhood
into adulthood.
o Cultivated Habit:
Those cultivated
during the socio-
active life of an
individual.
● Physiologic and
Pathologic Habits:
o Physiologic habits:
Physiologic habits are
those that are required
for normal physiologic
fractioning.
E.g. nasal respiration, sucking
during infancy.
o Pathological Habits:
Habits that are pursued
due to pathological
reasons such as
adenoids and nasal
septal defects that may
lead to mouth breathing.
● Normal and Abnormal
Habits:
o Normal Habits: Those
habits that are deemed
normal by children of a
particular age group.
o Abnormal Habits: Those
habits that are pursued
after their physiological
period of cessation.
9

10. New Classification (Morris and Bohanna—1969)
10
HABIT EXAMPLE
Non-pressure habits Mouth Breathing
Pressure habits a. Sucking Habit
o Lip sucking
o Thumb and Digit sucking
b. Biting Habit
o Nail biting/Needle holding
o Pillow rest
o Chin rest
o Bruxism
Postural habits
Miscellaneous

11. ● Thumb sucking is defined as the
placement of thumb in varying depths
into the mouth
11
Thumb Sucking

12. 12
CLASSIFICATION OF THUMB SUCKING
Normal Thumb Sucking:
 considered normal during the first one and half years of life.
 usually seen to disappear as the child matures.
Abnormal Thumb Sucking:
 When thumb sucking habit persists beyond the pre school period then it could be
considered as an abnormal habit.
Psychological:
 may have a deep-rooted emotional factor involved and may be associated with neglect
and loneliness experienced by the child.
1. Habitual: does not have a psychological bearing.
2. Nutritive sucking habits: Breastfeeding, bottle feeding.
3. Non-nutritive sucking habit: Thumb or finger sucking, pacifier sucking.

13. 13
According to Subtelny (1973)
 Type A:
• Seen in 50% of the children
• Whole digit is placed inside the mouth with the pad of the
thumb pressing over the palate.
• At the same time maxillary and mandibular oral contact is
present.
 Type B:
• Seen in almost 13 to 24% of the children.
• Thumb is placed into the oral cavity.
• At the same time maxillary and mandibular contact is
maintained.

14. 14
 Type C:
• Seen in almost 18%of the children.
• Thumb is placed into the mouth just beyond the first
joint and contacts hard palate and the maxillary
incisors.
• There is no contact with mandibular anterior
incisors.
 Type D:
• Seen in almost 6% of the children
• Only a little portion of the thumb is placed into the
mouth.

15. 15
ETIOLOGICAL FACTORS ASSOCIATED WITH THUMB SUCKING:
 Socioeconomic status: In the low socioeconomic group mother is unable to provide
sufficient breast milk to the infants. Hence in the process the infant suckles intensively for
a long time.
 Working mother: Children are brought up in the hands of caretaker and develop
feelings of insecurity.
 Number of siblings: The development of the habit can be related to the number of
siblings because more the number increases the attention meted out by the parents to
the child gets divided.
 Order of Birth of the Child: Later the sibling ranks in the family, greater is the chance of
having an oral habit.
 Social Adjustment and Stress: Digit sucking has also been proposed as or emotionally
based behavior.
 Age of the Child: The time of appearance of digit sucking habit has significance.
o In the neonate: Insecurities are related to primitive demands as hunger
o During the first weeks of life: Related to feeding problems.
o During the eruption of the primary teeth: It may be used to relieve teething.

16. Emotional
Status
It is 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.
Extra Oral
Examination
Digits that are involved
in the habit will appear
reddened, exceptionally
clear, chapped and a
short fingernail, i.e. a
clean
dishpan thumb.
History
Once the positive history
of habit is determined
the question regarding
the frequency, intensity
and duration of the
habit
is determined.
Lips
A short, hypotonic upper
lip frequently
characterizes chronic
thumb suckers. Lower
lip is hyperactive and
this leads to
further proclination of
upper anterior teeth.
Intra oral
examination
The type of malocclusion produced
by digit sucking is dependent on a
number of variables like position of
the digit, associated orofacial
muscle contractions, mandibular
position during sucking, facial
skeletal pattern, intensity,
frequency and duration of habit.
Diagnosis of thumb sucking habit

17. Effects on
Maxilla
• Proclination of the
maxillary incisors
• Increased maxillary
arch length
• Increased clinical
crown length of
maxillary incisors.
• High palatal arch.
Effects on
Mandible
• Retroclination of
mandibular
incisors.
• Retrusion of
mandible.
Effects on
Interarch
relationship
• Increased overjet
• Decreased overbite
• Posterior crossbite
• Anterior Openbite
Effects on lip
placement and
function
• Development of
tongue thrust
• Lower tongue
position.
• Hypotonic upper lip
• Hyperactive lower lip

18. Calculus formation on nails Skin keratotic lesions Openbite
Proclination of incisors Deep palate

19. 19
MANAGEMENT:
 Preventive treatment (Hughes,1941):
 Feed the child whenever he is hungry and let him eat as much as he wants.
 Feed the child the natural way; importance of breastfeeding is primarily psychological and
secondarily nutritive.
 Never let the habit to be started, the practice must be discontinued at its inception.
 Psychological therapy:
 Nagging, scolding or frightening the child should be avoided.
 β-hypothesis or Dunlop’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 habit eventually associates with unpleasant reactions
and the habit is abandoned. The child should be asked to sit in front of the mirror and
asked to observe himself as he indulges in the habit.

20. Six steps in cessation of habit
(Larson and Johnson)
Step 2
Habit
awareness.
Step 3
Habit reversal
with a
competing
response.
Step 4
Response
attention.
Step 6
Escalated DRO
with reprimands.
(Consists of holding
the child,
establishing eye
contact and firmly
admonishing
the child to stop the
habit.)
Step 5
Escalated DRO
(differential
reinforcement
of other
behaviors).
Step 1
Screening for
psychological
component.

21. 21
 Chemical treatment:
 Least effective method.
 Bitter and sour chemicals have been used over the thumb to terminate the practice but
with very minimal success,
 e.g. quinine, asafetida, pepper, caster oil, etc.
 Mechanical Therapy or Reminder Therapy:
 Extraoral approach:
• Mechanical restraints applied to the hand and digits like splints, adhesive tapes.
• Thumb guard is most effective.

22. 22
 Intraoral approach:
• Optimal time for appliance placement is between the ages of 3 and 4½ years.
• Following appliances are recommended:
a) Removable or fixed palatal crib:
o It breaks the suction force of the digit on the anterior segment, reminds the patient
of his habit and makes the habit a nonpleasurable one.

23. 23
b) Oral Screen:
o It is a functional appliance introduced by Newell in 1912.
o It prevents the child from placing the thumb or finger
into the oral cavity during sleeping hours.
c) Blue grass appliance:
o Developed by Bruce S Haskell (1991).
o It is a fixed appliance using a Teflon roller, together with
positive reinforcement.
o Used to manage thumb sucking habit in children
between 7 and 13 years of age.

24. 24
d) Quad helix:
o The quad helix is fixed appliance used to expand the
constricted maxillary arch.
o The helixes of the appliance serve to remind the child
not to place the finger in the mouth.
e) Hay rakes:
o Mack (1951) advocated the use of dental appliance in
children over 3½ years of age who are persistent thumb
suckers.
o Series of fence like lines prevents sucking.

25. ● Tulley (1969) defined 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
lies interdentally
25
Tongue Thrusting

26. 26
Classification of Tongue Thrusting:
 Physiologic: This comprises of the normal tongue thrust swallow of infancy.
 Habitual: The tongue thrust swallow is present as a habit even after the correction of the
malocclusion.
 Functional: The tongue thrust mechanism is an adaptive behavior developed to achieve
oral seal.
 Anatomic: Persons having enlarged tongue can have an anterior tongue posture.

27. James S Brauer and Townsend V Holt classification of tongue thrusting
27
TYPE CLINICAL PRESENTATION
Type 1 Non deforming tongue thrust
Type 2 Deforming anterior tongue thrust
Subgroup 1: Anterior open bite
Subgroup 2: Associated procumbency of anterior teeth
Subgroup 3: Associated posterior crossbite
Type 3 Deforming lateral tongue thrust
Subgroup 1: Posterior open bite
Subgroup 2: Posterior crossbite
Subgroup 3: Deep overbite
Type 4 Deforming anterior and lateral tongue thrust
Subgroup 1: Anterior and posterior open bite
Subgroup 2: Associated procumbency of anterior teeth
Subgroup 3: Associated posterior crossbite

28. 28
Etiology of Tongue Thrusting:
 Genetic influence: There is a complexity of factors that might predispose a child towards
this habit like an extremely high narrow palatal arch, an imbalance between the
number and size of teeth and the size of the oral cavity.
 Thumb sucking: This act depresses the tongue and keeps the teeth apart.
 Mixed dentition: When a child loses deciduous teeth especially a canine or an incisor the
tongue frequently protrudes into the space at rest, during speech and swallowing
activity.
 Gap filling tendency: Any space around the dental arches not occupied by teeth will tend
to be filled by the tongue.
 Allergies: Allergies affecting the upper respiratory tract cause mouth breathing and
tongue thrusting.
 Macroglossia and macroglossia
 Soft diet
 Oral trauma
 Sleeping habits: Some patients who sleep on their back on a low pillow or with open
mouth, the tongue rests in the mandibular arch and moves forward against the teeth
during swallowing.

29. 29
Anterior tongue thrust:
Extraoral Features
o Dolichocephalic face
o Increased lower anterior
facial height
o Incompetent lips
o Expression less face as
the mandible is stabilized
by facial muscles instead of
masticatory muscles
during deglutition
o Speech problems like
sibilant distortions and
lisping, etc.
o Abnormal mentalis
muscle activity is seen.
Intraoral Features
o Proclined, spaced and
anteriors resulting in
increased overjet.
o Retroclined or proclined
lower anteriors
o anterior open bite.
o posterior crossbites.
o normal tooth contact
during the swallowing act.
o The tongue is thrust
forward during
swallowing to help
establish an anterior lip
seal.

30. 30
Anterior tongue thrust Lateral tongue thrust

31. Features:
 Proclination of anterior teeth.
 Bimaxillary protrusion
 Teeth apart swallow.
 The anterior open bite can be diffuse or absent.
 Absence of temporal muscle constriction during swallowing.
 The occlusion of teeth may be poor. Poor occlusal fit, no firm intercuspation.
 Posterior open bite in case of lateral tongue thrust.
 Posterior crossbite.
Complex tongue thrust:

32. Simple
tongue
thrusting
• Normal tooth cotact in
posterior region.
• Anterior openbite
• Contration of the lips,
mentalis muscle and
mandibular elevators.
Complex
tongue
thrusting
• Generalized
openbite.
• The absence of
contraction of lips
and oral muscles.
Lateral tongue
thrust
• Posterior openbite
with lateral tongue
thrust
Other features
• Proclination of
anterior teeth
• Anterior openbite.
• Midline diastema.
• Posterior crossbite.
Clinical Features:

33. 33
Treatment considerations:
A. Myofunctional Therapy:
 Garliader proposed this method.
 Patient is guided regarding the correct posture of the tongue during swallowing by
various exercises like asking the child to place the tip of the tongue in the rugae area for
5 minutes and then asking him to swallow.
B. Orthodontic Elastics:
 The tongue tip is held against the palate using orthodontic elastic of 5/16” and sugarless
fruit drop.
C. Lemon Candy Exercise:
 Instead of the elastic, a lemon candy is put on the tongue tip.
 Patient is asked to hold the candy against the palate by the tongue tip and then asking
the child to swallow.

34. 34
D. 4S Exercise:
 This includes 1. identifying the spot,
2. salivating,
3. squeezing the spot and
4. swallowing.
 Using the tongue the spot is identified, the tongue tip is pressed against this spot and the
child is asked to swallow keeping the tongue at the same spot.
E. Mechanotherapy:
 Both fixed and removable appliances can be fabricated.
 Some of the appliances that can be used to prevent tongue thrusting are:
• Preorthodontic trainer
• Modifications of Hawley’s appliance
• Tongue crib
• Oral screen Tongue crib

35. 35
1
1—tooth channels. 2—labial bows (impart a light force on misaligned anterior
teeth). Myofunctional training: 3—tongue tag (for the proprioceptive positioning of the tongue tip
as in myofunctional and speech therapies). 4—tongue guard (stops tongue thrusting when being
in place and forces child to breathe through the nose). 5—Lip bumpers (discourage overactive
mentalis muscle activity). Jaw positioning: 6—edge-to-edge class I jaw position (is produced
when in place (same as most functional appliances)
Pre-Orthodontic Trainer
Myofunctional training effects of the trainer are
o Correcting the incorrect tongue position and
function,
o Correcting tongue thrusting, and
o Correcting oral habits which are the cause of
many malocclusions.

36. ● Sassouni (1971) defined mouth
breathing as habitual respiration
through the mouth instead of nose.
36
Mouth Breathing

37. 37
Classification of Mouth Breathing:
Given by Finn in 1987.
 Obstructive: Increased resistance to or complete obstruc tion of normal airflow through
nasal passage.
 Habitual: As a matter of habit or persistence of the habit even after elimination of the
obstructive cause.
 Anatomical: Short upper lip leads to incompetence of lips and hence mouth breathing.
Etiology:
 Developmental & Morphological
anomalies. Eg: abnormal development
of nasal cavity, nasal turbinates, and
short upper lip.
 Partial obstruction due to deviated
nasal septum, localized benign tumors.
 Infection and inflammation of nasal
mucosa, chronic allergic stomatitis
 Traumatic injuries to the nasal cavity.
 Genetic pattern.

38. Mirror test
It is also called as Fog test.
Two-surfaced mirror is
placed on the patient’s
upper lip. If air condenses
on upper side of mirror
the patient is nasal
breather and if it does so
on the
opposite side then he is a
mouth breather.
Massler’s water
holding test:
Patient is asked to hold
the mouth full of water.
Mouth breathers cannot
retain the water for a
long aw3time.
Observe the
patient
 Mouth breathers:
Lips will be apart
 Nasal breather: Lips
will be touching
Jwemen’s
butterfly test
Take a few fibers of cotton
and place it just below the
nasal opening. On exhalation
if the fibers of the cotton
flutter downwards patient is
nasal breather and if fibers
flutter upward he is a mouth
breather.
Cephalometrics
It can be used to
calculate amount of
nasopharyngeal space.
Diagnosis of Mouth Breathing habit

39. General
Features
• Appearance of a
pegion chest.
• Presence of low grade
eosophagitis.
• Narrow maxillary sinus
and nasal cavity.
• Swollen turbinates.
• Sleep apnoea
syndrome.
Appearance
• Adenoid facies.
• Lips are held wide
apart.
• Lack of tone of oral
musculature.
• Short upper lip.
• Superiorly tipped
nose.
• Long narrow face.
• Expressionless face
• Flat nose bridge
• Pegion face
appearance
Blood Gas
Constituents
• Mouth breathers
have 20% more
CO2 and less O2
Dental &
Skeletal
• Low tongue position
• Narrow maxillary
area.
• Protrusion of
maxillary and
mandibular incisors.
• High palatal vault.
• Anterior openbite.
• Increased incedence
of caries.
Clinical Features:

40. 40
Tendency of cross-bite
Anterior Marginal Gingivitis

41. 41
Treatment:
The main aspect of management of a mouth-breathing patient is to treat and eliminate the
underlying cause or pathology that has created the habit. This should be followed by
symptomatic treatment.
Other procedures and appliances that can be used are:
 Deep breathing exercises.
 Lip exercises 15 to 30 min/day for 4 to 5 months.
 Oral screen.

42. ● Ramfjord in 1966 defined bruxism as the
habitual grinding of teeth when an
individual is not chewing or swallowing.
42
Bruxism

43. 43
Classification of Bruxism:
 Daytime: Diurnal bruxism/Bruxomania: It can be conscious or subconscious and may
occur along with para-functional habits.
 Night time bruxism: Nocturnal bruxism: Subconscious grinding of teeth characterized by
rhythmic patterns of masseter.
Etiology:
 Central nervous system: It could be a
manifestation of cortical lesions, e.g. in
children cerebral palsy.
 Psychological factors: A tendency to
gnash and grind the teeth has been
associated with feeling of anger and
aggression or be a manifestation of the
inability to express emotions such as
anxiety and hate.
 Occlusal discrepancies.
 Genetics
 Systemic factors: Magnesium deficiency,
chronic abdominal distress, intestinal
parasites.
 Occupational factors: An over
enthusiastic student and compulsive
overachievers may also develop the
habit.

44. Clinical Manifestations:
 Occlusal trauma: This include tooth ache, mobility mainly in morning.
 Tooth structure: Extreme sensitivity due to loss of enamel, atypical wear
facets, pulp may be exposed and many fractured teeth can also occur.
 Muscular: Tenderness of the jaw muscles on palpation, muscular fatigue
on waking up in the morning, hyper trophy of masseter.
 Temporomandibular Joint: Pain, crepitation, clicking in joint, restriction of
mandibular movements.
 Associated features: Headache.

45. 45
Attrited Teeth

46.  Occlusal adjustments of any premature contact.
 Occlusal splints/night guards.
 Restorative treatment.
 Relaxation training.
 Physiotherapy.
 Drugs: Local anesthetic injections, tranquilizers, muscle relaxants.
 Biofeedback.
 Electrical method: Electrogalvanic stimulation for muscle relaxation
 Acupuncture.
 Orthodontic correction.
Treatment
Night Guard

47. ● This is defined as a habit that involves
manipulation of lips and perioral
structures
47
Lip Biting

48. 48
Classification:
 Lip licking/Wetting of lips by the tongue.
 Lip sucking habit: Pulling the lips into the mouth between the teeth.
Etiology:
 Malocclusion.
 In conjunction with other habits.
 Emotional stress.
Clinical Manifestations:
 Protrusion of upper incisors.
 Retrusion of lower incisors.
 Lip trap.
 Muscular imbalance.
 Lower incisor collapse with lingual
crowding.
 Lip has reddened and chapped area
below the vermilion border.
 Mentolabial sulcus becomes
accentuated.

49. 49
Lip Trap

50. 50
Treatment:
• Lip habit is not self-correcting and may become more deleterious with age because of
the muscular force interacting child’s growth.
• Treatment of lip sucking should be directed initially towards the etiology followed by
appliance therapy like lip protector, oral screen and lip bumper.
Lip protector Lip bumper

51. ● Incidence as reported by Weschsher
(1931) is 43 percent in adolescents 25
percent in college students.
51
Nail Biting

52. 52
Etiology:
 Insecurity.
 Psychosomatic successor of thumb sucking.
 Nervous tension.
Effects:
 Crowding, rotation and alteration of
incisal edges of incisors.
 Inflammation of the nail bed.
Management:
 Patient is made aware of the problem
 Scolding, nagging and threats should
not be used.
 Treat the basic emotional factors
causing the act.
 Encouraging outdoor activities may
help in easing tension.
 Application of nail polish, light cotton
mittens as reminder.

53. 53

54. ● One of the most important factors in correcting an oral habit is the willingness of
the child. Whenever an appliance is planned to be used, the need for it should be
explained to the child and the child’s willingness should be obtained. It should be
reinforced to the child that the appliance simply serves as a reminder and not to
punish the child in any way.
● The role of the parents during the treatment cannot be underemphasized. The
parents are informed about the speech difficulties and inconveniences in the
initial days of appliance placement. They are encouraged to help and support
the child emotionally during this phase of the treatment.
● Regular recall visits until the child discontinues the habit are essential. The
positive reinforcement from the dentist about the child’s progress in the
treatment will be of great motivation for the child to continue and cope with the
treatment.
CONCLUSION
54

55. References:
 Pediatric dentistry: Principles and Practice by M.S. Muthu, N. Sivakumar
 Textbook of Pediatric dentistry by Nikhil Marwah

56. THANK YOU!