thumb sucking pacifier habit

1. Oral Habits
By -
Sudeep Madhusudan Chaudhari
MDS 2nd Year
Dept of Paedodontics & Preventive Dentistry

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Contents●Introduction
●Definitions
●Classification
●Prevalence of habit
1) Thumb sucking
2) Pacifier habit
3) Tongue thrusting
4) Mouth breathing
5) Bruxism
6) Lip habit
7) Frenum thrusting
8) Cheek biting
9) Nail biting
10) Postural habit
11) Masochistic habit
●Conclusion
●References

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Introduction
Repetitive behaviours are common during childhood. Most of them are
benign and self-limiting. These responses are very essential for
survival of an infant and to explore the world around him/her.
Oral habits may be a part of normal development, a symptom of deep
rooted psychological basis or may be the result of abnormal facial
growth.

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Digit sucking, mouth breathing, tongue thrusting, lip and nail biting,
bruxism, etc may be considered as some of the common oral habits seen
in children.
These habits bring about harmful unbalanced pressures to bear upon the
immature, highly malleable alveolar ridges, the potential changes in
positions of teeth and occlusion.
One of the most valuable services that can be rendered as part of the
interceptive orthodontic procedures is elimination of the abnormal
habits before they can cause any damage to the developing dentition.

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Definition
It is a tendency towards an act which has become a repeated
performance relatively consistent, fixed and easy to perform by an
individual.
-Boucher OC (1963)
Habit can be defined as a fixed or constant practice established by
frequent repetition.
-Dorland(1957)

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The frequent or constant practice or acquired tendency, which has
been fixed by frequent repetition.
-Butterswort(1961)
An act, which is socially unacceptable.
-Finn(1987)
Oral habits are learned patterns of muscular contractions which are
complex in nature.
-Moyers(1982)

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Classifications
Obsessed (deep rooted)
➔Intentional / meaningful
➔eg. digit sucking, nail biting, lip
biting
➔Masochistic / self inflicting
➔eg. gingival stripping
Non obsessed (easily learned
and dropped)
➔ Unintentional / empty
➔ eg. chin propping, abnormal
pillowing
➔ Functional
➔ eg. mouth breathing, tongue
thrusting, bruxism

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According to James (1923) -
Useful habits
Include all those habits of normal
function such as correct tongue
position, proper respiration and
deglutition.
Harmful habits
All those that exerts perverted
stress against the dental archs
and teeth
eg. thumb sucking, mouth
breathing, tongue thrusting

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According to Finn (1987) -
Compulsive habits
Acquired as a fixation in the child
to the extent that he retreats to
the practice whenever his
security is threatened
Noncompulsive habits
Children appears to undergo
continuing behaviour
modification, which permit
them to release certain
undesirable habit patterns and
form new ones which are
socially accepted.

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According to Morris and Bohanna (1969) -

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Prevalence of habit
● Kharbanda et al (2003): 5-13 years old children, tongue thrusting is most common
(18.1%) followed by mouth breathing (6.6%). Thumb sucking (0.7%) and lip biting
(0.04%) are relatively less common.
● Shetty, Munishi (1998): digit sucking (3.1%), pencil biting (9.8%) and tongue thrust
(3.02%) highly prevalent among 3-6 years.
● Mouth breathing (4.6%) and bruxism (3.1%) - significant in 7- 12 years, lip/cheek
biting (6%) and nail biting (12.7%) - more common in 13-16 years.
● Digit sucking, tongue thrust, mouth breathing and bruxism - more prevalent among
boys. Lip/cheek biting, nail biting and pencil biting - more prevalent among girls.
Khan I, Mandava P, Singaraju GS. Deleterious oral habits: a review. Annals and Essences of Dentistry. 2015;7(1).

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1.Thumb and Digit Sucking
●Is defined as placement of the thumb or one or more fingers in varying
depths into the mouth.
– Gellin (1978)
●Repeated and forceful sucking of
thumb with associated strong
buccal and lip contractions.
●– Moyer

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Classification of thumb sucking a) Psycological
-The habit may have a deep-
rooted emotional factor
involved.
-May be associated with neglect
and loneliness.
b) Habitual
-The habit does not have a
psycological bearing, however
the child performs the act.
Normal thumb sucking
●The thumb sucking habit is
considered normal during the
first 2 years of age.
●Such a habit is usually seen
to disappear as the child
matures.
●The habit at this age does not
generate any malocclusion.
Abnormal thumb sucking
●It is considered abnormal
when thumb sucking habit
persist beyond the
preschool period.
●If the habit is not controlled
or treated during this age it
may cause deleterious effect
to the dento facial structure.

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● According to Crook (1958)
Alpha group – the thumb pushes the palate in a vertical direction and displays little
buccal wall contractions
Beta group – Strong buccal wall contractions are seen and a negative pressure is created
resulting in posterior cross bite
Gamma group – alternate negative and positive pressure is created.

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● According to Subtelny (1973)
Type A : Almost 50% of the children place the whole digit inside the mouth with the pad of
the thumb pressing over the palate, while at the same time maxillary and mandibular
contact is present.

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Type B (24%): The thumb is placed into the oral cavity without touching the vault of the
palate. While at the same time maxillary and mandibular anterior contact is maintained.

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Type C (18%): The thumb is placed into the mouth just beyond the first joint and contacts the
hard palate and only the maxillary incisors, but there is no contact with the mandibular
incisors.

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Type D (6%): The thumb is not fully inserted into the mouth. The lower incisor makes
contact at the approximate level of the thumbnail.

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●According to Johnson and Larson (1993)

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Theories & concepts of thumb sucking
a) Classical Freudian Theory (Sigman Freud, 1919) :-
➢The psycoanalytic theory has proposed that a child goes through
various distinct phases of psycological development.
➢In oral phase, it is believed that the mouth is the erogenous zone.
During this phase the child takes everything in his mouth.
➢It is believed that any kind of the deprivation of this activity will
probably cause an emotionally insecure indivudial.

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b) Oral drive theory (Sears and Wise, 1982) :-
➢ The strength of the oral drive is in part a function of how long a
child continues to feed by sucking.
➢ It is not the frustration of weaning that produces thumb sucking
but in fact it is the prolonged nursing that causes it.

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c) Rooting reflex (Benjamin, 1962) :-
➢ The rooting reflex is movement of the infant’s head and tongue
towards an object touching its cheek.
➢ He suggested that thumb sucking arises from the rooting and
placing reflexes common to all mammalian infants during the
first 3 months of life.

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d) Sucking reflex (Ergel, 1962) :-
➢ The process of sucking is a reflex occuring in the oral stage of
development and is seen at 29 weeks of intrauterine life and may
disappear during normal growth between the ages of 1 to 3 1/2
years.
➢ It is the first coordinated muscular activity of infants.
➢ Babies who are restricted from sucking due to disease or other
factors become restless and irritable. This deprivation may
motivate the infant to suck the thumb and finger for additional
gratification.

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e) Learning theory (Davidson, 1967) :-
➢ According to this theory, habit stems from an adaptive response
and assumes no underlying psychological cause and is acquired
as a result of learning.

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Etiological factors associated with thumb sucking
High
Mother is in better position to feed
the baby & in short time baby’s
hunger is satisfied.
Low
Mother unable to provide
sufficient breast milk, hence in
the process the infant suckles
intensively for a long time
thereby exhausting the sucking
urges.
a) Socioeconomic status :-
➢This theory explains the increased incidence of thumb sucking in industrializ

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b) Working mother :-
➢ Thumb sucking habit is commonly observed to be present in
children with working parents because such children are brought
up in the hands of caretaker and develop feelings of insecurity
c) Number of siblings :-
➢ More the number increases the attention meted out by the parents
to the child gets divided.
➢ The child who feels neglected by the parents may attempt to
compensate his feelings of insecurity by means of thumb
sucking.

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Phases of development
Phase I: (Normal and Sub-clinically significant)
Many children suck their thumbs or fingers for
short periods during infancy or early childhood
with the habit considered normal during the
first 2 years of life.
If present at such an early age, parents should
be advised to periodically observe the nature &
intensity of the habit.

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If the child demonstrates gradually diminishing activity, it is probable the
habit will cease without intervention.
The average age at which digit sucking stopped was 3.8 years.
The effect digit sucking on the occlusion are not probably permanent if
the habit is discontinued by age of 3 to 4 years.

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Phase II: (Clinically Significant Sucking):
The second phase extends between 3-6 years of
age. Continued, purposeful digit sucking during
this time deserves more serious attention
because the possibility indicates a clinically
significant anxiety and it is the time to solve
dental problems related to digit sucking.

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Phase III: (Intractable Sucking) :
Any thumb sucking persisting beyond the fourth or
fifth year of life should alert the dentist to the
underlying psychological aspects of the habit.
A thumb sucking habit seen during this phase may
require psychological therapy and an integrated
approach by the dentist.

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The trident factors affecting thumb sucking (Graber & Swin,
1985)
Intensity : implies how vigorously the habit is pursued. The digit
may rest passively in the mouth or may be sucked with
enthusiasm.
Duration : indicates the number of years the habit is continued.
Frequency : indicates how often during the day
the habit is practiced.

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Apart from these conditioning factors, the type of malocclusion
produced also depends on a number of variables as suggested by
Nanda(1989) :
1) Position of digit in the mouth
2) Associated orofacial muscle contractions
3) Mandibular position during sucking.
4) Facial skeletal pattern

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Changes associated with thumb sucking -
When the formula frequency + intensity + duration = negative dental
and oral changes is applied to the concept of thumb sucking and if
there is a great deal of thumb sucking daily and/or nightly, with a
very strong sucking action and this pattern continues for an extended
length of time, changes to the dentition and disruption of dental
equilibrium (i.e. causing instability of tooth position) and
interference with the normal rest position of the mandible (the
freeway space) will occur. The change in the rest posture of the
mandible triggers continued eruption of posterior maxillary teeth
while the anterior teeth are inhibited from erupting or the incisors
may become flared facially due to the continual presence of a thumb
or finger.

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Diagnosis of thumb sucking -
A) History
B)Emotional status
C) Extra oral examination
1)The digits
2)Lips
3)Facial form
4)Other feature
D) Intra oral examination
1)Tongue
2)Dento-alveolar structures
3)Gingiva

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A)History :
Once the positive history of habit is determined the question regarding
the frequency, intensity and duration of the habit is determined. The
remedies that have been tried at the home, the feeding patterns,
parental care of the child is also ascertained.

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B)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.

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C)Extraoral examination :
● Digits:
●that are involved in the habit will appear
reddened, exceptionally clear, chapped
and a short fingernail i.e. a clean dishpan
thumb. Fibrous roughened callus may be
present on the superior aspect finger.

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● Lips:
●The position of the lips at rest or during
swallowing should be observed. A short,
hypotonic upper lip frequently characterizes
chronic thumb suckers. Lower lip is
hyperactive and this leads to further
proclination of upper anterior teeth.

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● Facial form analysis:
●Check for mandibular retrusion,
maxillary protrusion, high mandibular
plane angle and profile.
●Facial profile is either straight or
convex.

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● When swallowing, the patient is observed for presence of a facial
grimace or an excessive mentalis muscle contraction, a normal
placement of the tongue against the teeth and palate and whether the
pattern of speech of the child is essentially normal.

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● Other features include associated symptoms that should be watched
for during the initial examination are habitual mouth breathers and
tongue thrust swallow, particularly in children with anterior open
bite. Active thumb suckers also have a higher incidence of middle ear
infection and frequently have enlarged tonsils accompanied by mouth
breathing.

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D)Intraoral examination :
● Tongue : Position at rest , during swallowing.
● Gingiva :
– Evidence of mouth breathing
– Etching of gumline
– Staining on maxillary labial surface

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● Dento alveolar structure :-
– Flared , proclined maxillary anteriors with diastema
– Retroclined mandibular anteriors
–Deformed right or left sided maxillary arch

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● Effects on maxilla
– Increased maxillary arch length
– Increased clinical crown length of incisors
– Counterclockwise rotation of occlusal plane
– Atypical root resorption
– Trauma to incisors
– Decreased palatal arch width

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– Increased SNA angle

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● Effect on mandible -
– Retroclination / proclination of mandibular incisors
● Retroclination due to direct apical & lingual force from digit
● Proclination due to indirect force from tongue beneath digit

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– Decreased clinical crown length of mandibular anteriors
– Increased mandibular inter-molar distance

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– Retrusion of mandible

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● Effect on inter-arch relationship -
– Anterior open bite
– Decreased overbite

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– Increased overjet
– Unilateral / bilateral class II malocclusion

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– Posterior cross bite

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Sucking habits and facial hyperdivergency as risk factors for anterior open
bite in the mixed dentition
Paola Cozza, Tiziano Baccetti, Lorenzo Franchi, Manuela Mucedero and
Antonella Polimenie
American Journal Of Orthodontics And Dentofacial Orthopedics.
2005;128:517-9
The aim of this study was to evaluate sucking habits and hyperdivergency as
risk factors for anterior open bite in mixed-dentition subjects. Pretreatment
cephalometric records of 1710 mixed-dentition subjects were assessed for
sucking habits, dental open bite, and facial hyperdivergency. Multiple
logistic regression showed that both prolonged sucking habits and
hyperdivergent vertical relationships significantly increased the probability
of an anterior dentoalveolar open bite, with a prevalence rate of 36.3%.
Conclusions: Prolonged sucking habits and hyperdivergent facial characteristics
are significant risk factors for anterior open bite in the mixed dentition.
Cozza P, Baccetti T, Franchi L, Mucedero M, Polimeni A. Sucking habits and facial hyperdivergency as risk factors for anterior open bite in the mixed dentition.
American journal of orthodontics and dentofacial orthopedics. 2005 Oct 1;128(4):517-9.

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Sequelae of thumb sucking
1) Anterior openbite – interference with occlusal movement of the
incisors. This openbite can lead to tongue thrusting problems and
speech difficulties.
2) Proclination and spacing of the maxillary anterior teeth if thumb is
held upward against the palate. Prominences of this labially posed
incisor make them particularly vulnerable to accidental fractures.
3) Mandibular postural retraction may develop if the weight of the hand
or arm continuously forces the mandible to assume a retruded
position in order to practice the habit. Pressure in the lingual
direction causes lingual tipping of mandibular incisors.

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4)When maxillary incisors have been tipped labially and an openbite has
developed it becomes necessary for the tongue to thrust forward during
swallowing in order to effect an anterior oral seal - “compensatory
tongue thrusting”.
5)During thumb sucking, buccal wall contractions produce, a negative
pressure within the month, with resultant narrowing of the maxillary arch
– bilateral posterior cross bite may be produced.
6)With these changes in the force system in and around the maxillary
complex it is often impossible for the nasal floor to drop vertically to its
expected position during growth.Therefore thumb suckers have a narrow
nasal floor and high palatal vault.

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7)Upper lip becomes hypotonic and lower lip becomes hyperactive.
These abnormal muscle contractions during sucking and swallowing
stabilize deformation.
8) Compensatory tongue thrust, retained infantile swallowing pattern,
abnormal perioral muscle function will assist the thumb sucking in
producing the malocclusion.

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Effect on speech due to thumb sucking -
● The facial muscles utilized in chewing, swallowing, and speech
constitute an important part of the foundation upon which speech is
constructed. When the thumb anchors the tongue down and forward
and serves to reinforce an incorrect rest posture of the tongue, an
inaccurate and inappropriate spring-off point for speech sound
production occurs.
● Some sounds may be produced incorrectly. When the tongue is
resting low and forward, the production of a frontal /t/d/n/l/, or
interdental /s/ lisp may occur.

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Management of thumb sucking :-
According to Forrestor (1981), three main areas should be assessed in
constructing a treatment plan.
1. Emotional significance of the habit
2. The age of the patient
3. The status of the child’s occlusion.

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1. Emotional significance of the habit
Before initiating corrective procedures, it is important to determine
whether the thumb- sucking is a meaningful or an “empty” habit.
One should treat the meaningful habit with the psychological
approach and the empty habit with the dental approach. Consultation
with a psychiatrist is considered if the sucking habit is a symptom of
an abnormal behavior problem.

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2.The age of the patient
Treatment of an infant (birth to 2 years)
Thumb sucking during infancy is of no concern to the dentist or the
parent if no physical effect is produced on the teeth. When sucking is
abnormally vigorous enough to displace the teeth, the problem is of
concern and also could act as a symptom of:
1. Insufficient feeding
2. Inadequate love
3. Bored, unhappy or over the fatigued child.

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No attempt should be made to cure the habit in a malnourished or sick
infant who may obtain significant emotional gratification from it.
Frequently, the only treatment necessary may be a little more
cuddling and playing with the child and simple instruction to the
mother in the technique of feeding the infant.

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Treatment in a preschool child (21⁄2 - 3 years) -
● At these years, child begins to assert his/her independence from the
mother and inevitably tensions and frustrations may occur causing an
occasional short-lived sucking episode. In the preschool child, thumb
sucking which is practiced only before going to bed may be
disregarded being a benign activity, and correction may prove
harmful. However, if it is frequently indulged during the waking
hours, the child is over fatigued bored or unhappy, then suitable
factors in the environment should be corrected. A child should have
ample play facilities and an adequate amount of self-expression.

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Treatment in 3-7 years old -
● This age group child may be more of a concern depending on the
type of habit and whether the child is pulling the maxilla anteriorly or
just sucking his digit with buccal constriction. The child with good
molar intercuspation and little anterior pull, i.e., the passive sucking
child should be counseled, and the dentist should work along with the
parent with contingent behavior modifications.

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Treatment in children older than 7 years -
● These children are mainly characterized by anterior open bite that
will usually not close by itself due to functional patterns that have
been established. These children will all require some form of active
orthodontic treatment.

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Techniques for habit cessation
● Habit awareness -
● Habit reversal therapy is commonly used in repetitive, body focused
behavior disorders that cause significant functional impairment. It
involves training the individual to recognize the behaviors preceding
digit sucking, together with situations where it occurs. It also aids in
teaching the individual about alternative responses to the habit
behavior.

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● Covert sensitization -
● Covert sensitization is a procedure in which a cognitive-induced
aversive response is paired with the habit. An imaginary picture of
the activity to be eliminated is evoked and then accompanied by a
mental image of an aversive response like nausea.

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● Contingency contracting -
● Punishment using the time out from positive reinforcement
● A contract of reward or punishment is made contingent on habit
cessation or the lack of habit cessation, reward, respectively.
Contingent reading has also been used to treat night-time thumb
sucking.

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● Sensory attenuation procedure -
● Many procedures are designed to interrupt the sensory feedback
experienced with NNS. These procedures are divided into -
(a)Psychological therapy
(b)Reminder therapy
(c)Mechanotherapy

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(a)Psychological therapy -
● Screen the patient for underlying psychological disturbance that
sustain thumb sucking habit. Once the psychological dependence is
suspected child referred for counseling.
● Thumb sucking children between the age of 4 to 8 year need only
reassurance, positive reinforcements and friendly reminders.
● Various aids are employed to bring the habit under the notice of child
such as study model, mirrors etc.

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i. Dunlop hypothesis:-
He belives that if a subject can be forced to concentrate on the
performance of the act at the time he practices it, he can learn to stop
performing the act. The child should be ask to sit in front of the
mirror and asked to suck his thumb, observing himself as a indulges
in the habit.
This will make him realize how awkward he looks and want to stop
sucking his thumb.

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● Patient should presented with positive mental and visual images of
dentofacial ideals expected from habit cessation.
● During treatment adequate emotional support & concern should be
provided to child by parents.
● When habit is discontinued the child can be reward with a favorite
new toys.

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(b) Reminder therapy -
● Reminder therapy is appropriate for those who desire to stop the
habit but need some assistance. The purpose of these reminders
should be thoroughly explained to the child. These are reminders for
child to make the habit unpleasant and difficult to practice.
● Finn (1972): Habit reminders can be basically divided into two extra
oral reminders and intraoral reminders.

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i. Extra oral reminders
● Chemical and Mechanical therapy involves the use of bitter and
unpleasant tasting preparations which are painted on the nails to
serve as a deterrent to placing the fingers or thumb in the mouth.
These preparations are effective only if the habit is new and are less
effective in countering a long-standing habit. Simple devices for
controlling thumb are the application of adhesive tape to the thumb
or finger and bending the elbow.

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ii. Intra oral appliance -
➔ Palatal bar :-
➔ The palatal bar is one of the principal habit
reminders. It consists of a 0.030 inch round lingual
arch wire attached to the upper first molar bands with
an anterior platform, which clears the palate by about
1/8 inch. This keeps the thumb or finger from
exerting pressure on the soft tissue of the palate. The
seal is broken, there is no suction, and the pleasure of
thumb-sucking is destroyed. An occlusal rest on the
occlusal surface of the upper first premolars prevents
the palatal bar from settling into the soft tissue. The
bar must be so designed that it will not prevent the
teeth from closing normally.

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➔ Palatal arch -
Bands are placed on either the maxillary second deciduous molars or the
first permanent molars. The palatal arch is made from 0.040-inch
stainless steel wire and is similar in design to the palatal crib, except
that it does not have a vertical fence like portion.

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➔ Palatal crib -
Habit retraining appliance, which
utilizes a blunt wire “reminder”
which may prevent the child from
indulging in the habit. The crib
consists of a wire embedded in
removable acrylic appliance
similar to a Hawley retainer, or it
may be a “fence” added to an
upper palatal arch and used as
fixed appliance.

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➔ Hay-rake -
Mack (1951) introduced a dental appliance for children over 31⁄2 years
of age who are persistent thumb suckers. A rake may be a fixed or
removable appliance, just as the crib. As implied by the term, this
appliance more nearly punishes than reminds the child. It is
constructed as is the crib, but has blunt tines or spurs projecting from
the crossbars or acrylic retainer into the palatal vault. The tine
discourages not only thumb sucking but also tongue thrusting and
improper swallowing habits as well.

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➔ Blue grass -
Appliance consists of a roller made of Teflon which is constructed over
a 0.045 stainless steel wire which is soldered to bands placed on
either the maxillary first molars or on the primary second molars.
The roller is placed in the most superior aspect of the palate and must
not be in contact with the palatal tissue so that patients can roll them
with their tongues. This device works through a counter-conditioning
response to the original conditioned stimulus for thumb sucking. This
appliance is placed for 3-6 months and in early or mixed dentition
period it is indicated.

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Baker modified blue grass appliance with 4 mm acrylic beads, multiple
rollers and thus expanding its use from primary to permanent
dentition. The advantage of the new design is that it encourages
maximum neuromuscular stimulation by using two or more beads,
according to the principles of Castillo-Morales. One to four beads are
placed on the cross palatal wire, depending on the amount of space
available.
Haskell and Mink recommended to leave the bluegrass in the mouth for
6 months after the habit has stopped. Earlier removal has resulted in
the reappearance of the habit.

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➔ Quad helix -
➔The quad helix is a fixed appliance used to
expand the constricted maxillary arch. The
helixes of the appliance serve as a reminder to
the child not to place the finger in the mouth.
May be modified to incorporate a roller
simulating blue grass appliance.
➔ The disadvantages of intraoral appliances include a period of
emotional upset until they get used to the appliance, speech being
affected temporarily and difficulty in eating. With the use of fixed
orthodontic habit breakers increased tendency for caries and
decalcification of enamel surfaces, gingival inflammation may occur.

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● Current strategies -
➔ Increasing the arm length of the night suit.
➔ Thumb- home concept
➔ Currently the use of hand puppets is gaining popularity
➔ Thumb sucking book
➔ My special shirt

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➔ Increasing the arm length of the night suit :-
This is usuful in children who sincerely want to dincontinue the habit
and only perform during their sleep. The arm of their night suit are
lengthened so thet they cannot reach the thumb during night.

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➔Thumb- home concept :-
This is the most recent concept. In this a small bag is given to the child to
tie around his wrist during sleep and it id explained to the child that just
as the child sleeps in his home, the thumb will also sleep in its house and
so the child is restrained from thumb sucking during night.

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➔ Thumb sucking book :-
“The Little Bear who Sucked His Thumb” is a
book directed at children, for children. The
book has been written and illustrated by
Dr.Dragan Antolos, an experienced dentist with
a special interest in thumb sucking habits in
children. The book and chart are a non-invasive
and effective strategy for stopping thumb
sucking, and have received positive support
from psychiatrists, speech pathologists and
pedodontic societies.
It is important to balance the psychological
benefits of thumb sucking with the negative
impact it has on developing, permanent teeth.

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➔ My special shirt :-
This helps in minimizing the damage of finger
sucking by providing a number of tools to address
the habit in a phased manner. This shirt keeps the
child busy thereby avoiding the habit. By working
as a team, the child will gain confidence, balance
emotion and stop their depedence on need to suck.

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2. Pacifier habit
●Pacifiers have been used by mankind for more
than thousands of years. They have been
identified to help children in transitioning to
sleep, to soothe infants, to provide comfort while
teething.
● The effect of pacifier sucking as the same as non nutritive sucking or
thumb sucking but some other associated risk are as follows -

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● Effict of pacifier use on breastfeeding -
➔ Newman hypothesized that the use of pacifier causes ‘nipple
confusion’ in the infant and a faulty technique of breastfeeding which
eventually leads to early weaning.
➔ This was also supported by Mitchell who found out that infants given
pacifiers in hospitals are less likely to breastfeed mothers on
discharge as compared to those who were not given pacifiers.

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● Pacifier and caries -
➔ Prolonged use of pacifiers in children and specially those used with
sugar syrups or sweetened liquids have a positive relation with caries.

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Effects of different pacifiers on the primary dentition and oral myofunctional
structures of preschool children
Zardetto et al.
Pediatric Dentistry – 2002;24:6.
The aim of this study was to evaluate the characteristics of the dental arches and some
oral myofunctional structures in 36- to 60-month-old children who sucked a pacifier
or did not have this habit.
Methods: Sixty-one children were divided into 3 groups: (1) those who never sucked a
pacifier, (2) those who exclusively sucked a physiological pacifier, and (3) those
who exclusively sucked a conventional one. A clinical examination was performed
on the children to observe the relationship between the arches and their width, as
well as the following oral myofunctional structures: lips, tongue, cheeks, and hard
palate.
Conclusions: Children who sucked pacifiers, both conventional and physiological ones,
showed higher prevalence of alterations in the relationship of the dental arches and
oral myofunctional structures, when compared to those who never sucked a pacifier.

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● Pacifier recommendations-
➔ The pacifier should be used when placing the infant down for sleep
and not be reinserted once the infant falls asleep.
➔ Pacifiers should not be coated in any sweet solution.
➔ Pacifiers should be cleaned often and replaced regularly.
➔ For breastfed infants, delay pacifier introduction until 1 month of age
to ensure that breastfeeding is firmly established.

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➔ Pacifiers should never be used to replace or delay meals and should
be offered when the caregiver is certain the child is not hungry.
➔ Pacifiers should have ventilation holes and a shield wider than the
child’s mouth (at least 11⁄4 inches in diameter).
➔ Pacifiers should be one piece and made of a durable material,
replaced when worn, and never tied by a string to the crib or around a
child’s neck or hand.

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➔ Infants and children with chronic or recurrent otitis media should be
restricted in their use of a pacifier.
➔ Pacifiers should not be routinely discouraged as the current evidence
suggests a decreased risk of sudden infant death syndrome associated
with their use.