NATIONAL DENTAL COLLEGE AND HOSPITAL

DERA BASSI

DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY

SEMINAR on Oral habits

SUBMITTED BY: PARVEEN BATHLA PG student

CONTENTS
Introduction Definition of habits Classification Thumb sucking Tongue thrusting Mouth breathing Bruxism Lip habits Nail biting Self injurious habits Cheek biting Bobby pin opening

References

Introduction Habits are acquired automatisms, represented by an altered pattern of muscle contraction with complex characteristics, which proceed unconsciously and in a regular basis. Some habits that occur in the oral region : harmful effects on health, promoting changes in dental, bone and muscle tissues, their development being determined by intensity, frequency and duration of inappropriate pressure. Habits can lead to the possibility of harmful unbalanced pressures which may be brought to bear upon the immature, highly malleable alveolar ridges, the potential changes in position of teeth, and occlusions which may become decidedly abnormal if habits are continued for long periods of time

Definitions Frequent or constant practice or acquired tendency which has been fixed by frequent repetition. Butterworth 1961 Habit may be defined as a fixed constant, settled practice or custom established by the frequent repetition of the same act. Markus 1928 An acquired habit is nothing but a new pathway of discharge formed in the beam, by which certain in covering currents tend to escape. William James 1923 Habit is defined as an act which is socially unacceptable. Finn 1972 Dorland defines habit as a fixed or constant practice established by frequent repetition. Habit is a response to a stimulus or stimuli either intrinsic or extrinsic, reinforced by the real positive rewards which may persist even after the stimulus is withdrawn. 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. Mathewson (1982) defined oral habits as learned pattern of muscular contractions.

Classification

William James 1923: Useful habits Include the habits or normal function such as, correct tongue position, proper respiration, deglutition and normal usage of lips in speaking. Harmful habits Include all that exert stresses against the teeth and dental arches such as tongue thrusting, thumb sucking, mouth breathing, nail biting, lip sucking etc.

Intraoral and extra oral habits (Barrette 1955) Intra oral habits Thumb sucking, mouth breathing, lip biting, nail biting, lip sucking. Extra oral habits Chin propping, face leaning on hand.

Pressure habits (Graber 1952) Intrinsic 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) Thumb sucking. Finger sucking. Tongue sucking. Lip sucking. Cheek sucking Blanket sucking. Nail biting. Lip biting. Tongue thrusting. Tongue biting. Incorrect swallowing. Mouth breathing.

Extrinsic 1) Chin propping. 2) Face leaning on hand.

3) Abnormal pillowing position. 4) Abnormal sleeping on the side,

Meaningful and empty habits (Klein et al 1971). Meaningful habits are due to psychological problems Empty habits can be treated by habit reminder appliance.

Compulsive habits and noncompulsive habits (Sim and Finn 1987). Non compulsive habits The habits which can be easily added or dropped from the child's behavior pattern as he matures are termed as non compulsive habits. children appear to undergo continuing behavior modification which permits them to release certain undesirable habit patterns and form new and more acceptable one.

Compulsive habits Is a habit that has acquired fixation in the child to the extent that he retreats to the practice of habits whenever his security is threatened These habits have deep seated emotional need

BRASH'S CLASSIFICATION A. Muscular Habit: 1. Individual habit : E.g. lip sucking.

2. Habits in which there is combined activity of the muscles of the mouth and jaws and of the thumb / finger inserted into the mouth. E.g. Thumb sucking. 3. Muscular action combined with the introduction of passive objects into the mouth. E.g. Pencil Biting. 4. Functional disturbance, E.g.: mouth breathing habit.

Habits in which muscles of the mouth and jaws take no active part, the effects on the position of dentition being extraneous pressures.

E.g. abnormal pillowing, face leaning on hand etc Kingsley Based on the nature of the habits, habits are classified into: (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. Acc. 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 THE HABIT Retained habits: Those that are carried over from childhood into adulthood. Cultivated Habits: Those that are cultivated during socio- active life of an individual. THUMB /DIGIT SUCKING Thumb and finger habits, or nonnutritive sucking habits: most prevalent of oral habits, incidence 13% to almost 100% at some time during infancy. The prevalence of digit habits decreases with age and most children give up this activity by 3 4 years of age.

THE SUCKING REFLEX Two essential reflexes present at birth and related to this drive.

 Sucking reflex (which remains until 12 months of age), and The rooting reflex (which remains until 7 months of age) - the movement of the infants head toward an object touching his/her cheek. A reflex occurring in the oral stage of development and is seen even at 29 weeks of intra uterine life. First coordinated muscular activity of the infant

There are two forms of sucking: The Nutritive form The Non-nutritive form

Non-nutritive form Children who receive restricted breast feeding and do not have an access to a pacifier may adopt non-nutritive sucking (NNS) in response to frustration and to satisfy their urge . Non-nutritive sucking ensures a feeling of well being, warmth and a sense of security. The attempt to take into his mouth a good object is termed as introjection. The rejection of a bad object is termed projection. This oral testing apparently not only serves to relieve the hunger tension inside the child but also is a means of testing by the senses available to him what is good and bad.

The types of changes in the dentition that an oral habit may cause vary, depending on the following factors: Intensity Duration Frequency of the habit Relationship of dental arches Childs state of health

THEORIES Classical Freudian Theory (1905) Freud considered thumb sucking to be a manifestation of infantile sexuality. thumb sucking is instinctive and therefore is normal for the infant and young child. It is a satisfying activity that gives the infant a feeling of well-being. humans possess a biologic sucking drive.

The learning theory Davidson (1967) Nonnutritive sucking stems from an adaptive response. The infant associates sucking with pleasurable feeling such as hunger. These feelings are recalled by sucking the suitable objects available mainly thumb or finger.

Oral drive theory Sears and Wise (1982): o Sears and Wise stated that prolonged unrestricted sucking strengthened the oral drive. o Thus, thumb sucking is the result of prolongation of nursing, and not the frustration of weaning. Rooting and placing drive Benjamin He suggested that thumb sucking arises from the rooting and placing reflexes common to all mammalian infants. Whenever an object touches a childs cheek, he tends to turn his face towards it and attempts to take it in his mouth. CAUSATIVE FACTORS Social adjustment and stress Working Mother Age of the child Number of Siblings Order of the birth of the child

Socioeconomic Status Feeding Practices

DIAGNOSIS History questions regarding the frequency, intensity and duration of the habit.

- feeding patterns and parental care of the child - presence of other habits Extra oral examination: Digits are reddened, exceptionally clean, chapped with a short fingernail and fibrous roughened callus present on the superior aspect of finger UPPER LIP: short, hypotonic & is passive or incompetent during swallowing. LOWER LIP : hyperactive and this leads to further increase in the proclination of upper anteriors. Facial form analysis mandibular retrusion, maxillary protrusion, high mandibular plane angle and profile. Facial profile is either straight or convex. Habitual mouth breathing and tongue thrust swallow may be present especially in children with anterior open bite.

Intraoral examination Tongue is checked for correct size and its position at rest and while swallowing. Individuals with severe finger or thumb sucking habits have flared and proclined maxillary anteriors with diastemas and retroclined mandibular anteriors.

CLINICAL MANIFESTATIONS The type and severity of malocclusion in digit suckers depends on the following variables: Digit being sucked. Direct pressure (position of the digit) Intensity of orofacial muscle contraction Position of the mandible during the sucking Alteration in pattern of resting of cheek and lip pressure.

Facial skeletal morphology (inherited type II class I malocclusion probably is more prone to changes than class III). Frequency of the habit (finger constantly in the mouth or child sleeps with thumb or finger between his teeth vs. sporadically sucking or just before sleep.) More than 4-6 hours devoted for sucking may affect dentofacial anatomy.

The classic symptoms Anterior open bite The digit impedes eruption of the anterior teeth, while the posterior teeth are free to erupt. Passive eruption of the molars will result in an anterior open bite. 1mm of elongation posteriorly opens the bite by about 2 mm.

Although to a lesser degree, anterior open bite can also be caused by intrusion of the incisors. Facial movement of the upper incisors and lingual movement of the lower incisors. Usually, the thumb is placed so that it exerts pressure on the lingual surfaces of the maxillary incisors and on the labial surfaces of the mandibular incisors. The result is increased overjet. Maxillary arch constriction When the thumb is placed in the mouth, the tongue is forced down and away from the palate. This decreases pressure by the tongue against the lingual surfaces of maxillary posterior teeth. Posterior crossbite

TREATMENT BEHAVIOR THERAPY Counseling Reassurance and positive reinforcements Adequate emotional support and concern should be provided

Reward system

A contract is agreed upon between the child and parent or between the child and dentist. The contract simply states that the child will discontinue the habit for a specified period of time and in return he/she will receive a reward if the requirements of the contract are met. Age Factor : 0-3 Years - No active intervention Between 3 to 7 years:- No active intervention. Give a detailed explanation to the child & Parents. 7 years and Older: - Orthodontic Intervention is needed. According to Pinkham Counseling Reminder Therapy Reward system Adjunctive Therapy Counseling best aimed at older children who can conceptually grasp the issue counseling with the patient on the basis of their maturity and responsibility Dunlops Theory Beta hypothesis REMINDER THERAPY Those who want to stop the habit but need some help to stop completely. Bitter tasting substances can be applied to thumb or finger e.g. pepper, quinine, asafoetida. Allen devised a thermoplastic thumb post in 1991 which was placed on the offending digit.

Norton and Gellin proposed a 3-alarm system for 3-7 yr old child

1. Offending digit is taped and when child feels the tape in the mouth it serves as the first alarm. 2. Bandage tied on the elbow of the arm with the offending digit, a safety pin is placed lengthwise. When child flexes the elbow the closed pin mildly jabs indicating a second alarm. 3. Bandage tightened if thumb sucking persists, serving as a third alarm. Reward system Praise from the parents and the dentist has a large role discontinue the habit within a specified period of time and in return will receive a reward Increasing the arm length of night suit Thumb sucking book

ADJUNCTIVE THERAPY APPLIANCE THERAPY: a. Removable 1.Easily misplaced or lost 2.Patient compliance is a major factor b. Fixed 1. Cemented in-place using a dental cement/adhesive 2. Does not rely on patient compliance

Removable Fixed Bluegrass Appliance / Kentucky appliance: Quad helix: Modified Hawley appliance Palatal Crib

Tongue thrusting habit Humans show two types of Swallow pattern: Normal Infantile (Visceral) Swallow- 32nd week of intrauterine life Normal Mature (Somatic) Swallow- by 4-5 years of age If the transition of infantile to mature swallow does not take place with the eruption of the teeth it leads to Tongue thrust Swallow.

The tongue is placed anteriorly in contact with the lower lip, so that milk is deposited on the tongue. This is infantile swallow which is characterized by active contractions of musculature of lips, tongue tip is brought contact with the lower lip and little activity of the posterior tongue or pharyngeal musculature. As semisolid and eventually solid foods are added to the diet, it is necessary for the child to use the tongue in a more complex way to gather up bolus, position it along the middle of the tongue and transport in posteriorly. The transitition from infantile to adult swallow occurs from the age of 2-4 years.

Definition Braurer (1965) a tongue thrust is said to be present if the tongue is observed thrusting between, and the teeth did not close in centric occlusion during deglutition. 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 becomes interdental Barber (1975) tongue thrust is an oral habit pattern related to the persistence of an infantile swallow pattern during childhood and adolescence and thereby produces an open bite and protrusion of the anterior tooth segments. Profit and Mason (1975) defined tongue thrusting as one or a combination of three conditions; (1) forward placement of the tongue during swallowing so that the tip of the tongue contacts the lower lip, (2) inappropriate placement of tongue between or against the anterior dentition during speech, and (3) forward positioning of the tongue at rest so that the tip is against or between the anterior teeth.

Schneider (1982) tongue thrust is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing Thrusting of the tongue between the anterior teeth especially in the initial stage of swallowing. It is often combined with a resting position also between the teeth, can exhibit normal eruption and so produce on open bite Boucher 1982

Etiology : no particular cause Fletcher has developed the following out line to indicate proposed etiologic factors for tongue thrusting syndrome:

Genetic causes Inherited variation in orofacial form that precipitate a tongue thrusting pattern. b) Genetically predetermined pattern of mouth behavior.

c) Inherited orbicularisis oris hypertony resulting from specific anatomic configuration and neuromuscular interplay and generating a tongue thrusting pattern.

Learned Behavior A Improper bottle feeding which results in abnormal functional patterns of lingual movement in the form of tongue thrusting. b) Protracted period of tenderness as soreness of gums and teeth, keeping the teeth apart during swallowing and there by changing the swallowing pattern. C d) e) Prolonged thumb sucking Tongue held in open spaces during mixed dentition Prolonged tonsillar and other upper respiratory tract infection

Maturational A Tongue thrust present as part of a normal childhood oral behavior pattern that is gradually modified as the lingual space and suspensory system change. b) c) Tongue thrust pattern as evidence of late maturation from infantile sucking swallow. Late maturation from retention of immature patterns of general oral behavior.

Mechanical restriction a) Constricted dental arches, which cause the tongue to function in a lower position than usual. b) Macroglossia Which, because of limited space in the oral cavity forces a forward thrust to manipulate bolus. c) Enlargement of the tonsils and adenoids, which reduces the space available for lingual movement. Neurological disorders Psychogenic factors CLASSIFICATION Moyers differentiated tongue thrust as being Simple tongue thrust with teeth together and commonly associated with digit sucking. Complex teeth remain apart. Retained infantile Positional

According to Braner and Holt Type I non deforming tongue thrust Type II deforming anterior tongue thrust Type III deforming lateral tongue thrust Type IV both anterior and lateral tongue thrust According to etiology 1. Physiological - in infancy 2. Habitual - present as a habit even after the correction of malocclusion 3. Functional - developed as an adaptive behavior to achieve an oral seal 4. Anatomic - due to large tongue

CLINICAL MANIFESTATIONS Simple tongue thrust : teeth-together swallow and the malocclusion associated with it is a well-circumscribed open bite in the anterior region. Complex tongue thrust : teeth-apart swallow. The malocclusion seen in these cases has two distinguishing features: A poor occlusal fit which prompts a slide into occlusion. Generalized anterior open bite. Speech disorders (lisping, sibilant distortions, defective articulation of s, n, t, d, l, z sounds. Aerophagia--the swallowing and gulping of air. The symptoms are similar to colic: Stomach pains after eating, feeling bloated or distended, or even diarrhea. Orofacial muscle strain and imbalance. Chronic headaches or orofacial muscle spasms or pain. Increased anterior facial height Tongue movements during swallowing are jerky and inconsistent. The movements are irregular from one swallow to another. At rest, the tongue tip position is lower in tongue thrust patients. Malocclusion

Findings in maxilla Proclination of maxillary anteriors resulting in increased overjet Generalized spacing between teeth Maxillary arch constriction

Findings in mandible Retroclination or proclination of mandibular teeth depending on type of tongue thrust present

Examination Tongue posture should be observed while the mandible is rest position. during various swallowing procedures tongue thrust should be determined by observing presence or absence of tooth contact, open bite and contraction of lips, mentalis and mandibular elevators.

Treatment For Simple Tongue Thrust According to Moyers the treatment of tongue thrust moves through three phases: 1. Conscious learning of new reflex. 2. Transfferal of control of the new swallow pattern to the subconscious level. 3. Reinforcement of the new reflex.

Exercises for Correction of Improper Tongue Position exercises such as whistling, reciting the count from sixty to sixty nine, gargling, yawning etc to tone the respective muscles. --One Elastic Swallow --Tongue Hold Exercise --Two Elastic Swallow --The Hold Pull Exercise

Pre orthodontic trainer appliance for aiding in correct positioning of tongue . Speech therapy Mechanotherapy Habit breaking appliance (crib) removable or fixed Oral screen (vestibular screen can also be incorporated

Mouth Breathing habit Sassouni (1971) defined mouth breathing as habitual respiration through the mouth instead of the nose. Checker FM: Defined mouth breathing as a prolonged or continued exposure of the tissues of anterior areas of mouth to the drying effects of inspired air.

ETIOLOGY I. Developmental and Morphologic Anomalies which Interferes with Nasal Breathing. a) Asymmetry of the face resulting is asymmetry of nasal passage due to intrauterine pressure during the period of embryonic development. b) Hereditary characteristics of facial form may be a factor in size of nasal passages and position of the septum. c) d) e) f) Abnormal development of nasal cavity. Abnormal development of nasal turbinates. Abnormally short upper lip, preventing proper lip seal. Under development or abnormal facial musculature.

II. Partial Obstruction Due To a) Deviated nasal septum : It can be a result of birth injuries / exogenous nasal trauma. It can cause bilateral blockage creating an S shaped deformity or more typically a unilateral one creating a C shaped obstruction. b) c) Localized benign tumors. Narrow nasal passage associated with narrow maxilla.

III. Infection and Inflammation: IV. Traumatic injuries to the nasal cavity. CLASSIFICATION Finn (1987) classified mouth breathing as

Anatomic - short upper lip does not permit complete closure without undue effort. Obstructive increased resistance or complete obstruction of normal flow of air through nasal passages. Habitual breathing through mouth as a force of habit, even after the removal of abnormal obstruction.

CLINICAL FEATURES Adenoid faces Long narrow face Narrow nose and nasal airway Flaccid lips with short upper lip Upturned nose exposing nares frontally V shaped and high palatal vault Collapsed buccal segments of maxilla Skeletal Open Bite or Long Face Syndrome Excessive eruption of posteriors Constricted maxillary arch Excessive overjet Anterior openbite Mandibular down/forward growth is poor Retroclined upper and lower incisors Posterior crossbite due to constriction of maxillary arch Incompetent lips, gummy smile

TREATMENT Elimination of cause Removal of nasal or pharyngeal obstruction

Respiratory allergies should be treated Interception of habit Physical exercises breathing exercises Lip exercises to improve the tonicity of lips and exert a retracting influence on maxillary incisors

Oral screen RAPID MAXILLARY EXPANSION BRUXISM Bruxism is one of parasomnias, taking the form of motor or autonomic phenomenon and associated with varying degrees of awakening. Typically, parasomnias are transient, but if frequent, they can impair sleep and thus daytime functioning. The prevalence of bruxism : 7% to 88% in children and from 5% to 15% in adults. Preliminary evidence suggests that juvenile bruxism is a self-limiting condition that does not progress to adult bruxism. Vanderas ( 1995) defined it as nonfunctional movement of the mandible with or without an audible sound occurring during the day or night. Diurnal bruxism / bruxomania Nocturnal bruxism

ETIOLOGY Local theory It suggests that bruxism is a reaction to an occlusal interference, high restoration or some irritating dental condition. Psychological theory It submits that bruxism is the manifestation of a personality disorder or emotional stress, anger, anxiety or aggression.

Systemic factors Intestinal parasites, subclinical nutritional deficiencies, allergies and endocrine disorders. Genetics Neurologic disabilities Cerebral palsy, mental retardation, epilepsy Morphologic factors Malocclusion, muscle recruitment

CLINICAL MANIFESTATIONS Occlusal trauma tooth mobility Damage to toth structure atypical wear facets, pulpal sensitivity Headache Muscular tenderness TMJ dysfunction dull pain, crepitation, Definitive Treatment a) b) Emotional stress therapy Occlusal therapy Occlusal interferences should be identified and equilibrated. Coronoplasty can be done if necessary. Systemic problems should be ruled out Occlusal splints can be fabricated using vulcanite.

Psychotherapy is indicated when psychological factors are suspected.

Clenching exercises: This technique called massed practice is accomplished by having the patient clench for 5 seconds, then relax and then repeat ten times. The sequence is performed six times each day Supportive Therapy Patient comfort and alleviation of pain analgesics for acute pain in the joints and musculature Use of muscles relaxants soft diet Lip Habits Lip habits can be defined as habits that involve manipulation of the lips and perioral structures. The lip habit may involve either of the lips with a higher predominance towards the lower lip. Lip Sucking Lip Wetting Lip Biting

A) B) C)

Etiology Malocclusion:- class II div I cases with incresed overjet and overbite. Habits:- in conjuction with other habits Emotional Stress

Treatment Lip over lip exercises. Playing bass instruments Correction of class II division I malocclusion Treating thumb sucking or any other involved habit

Oral Shield Lip Bumper

SELF MUTILATING HABITS (masochistic or sadomasochistic habits) elf-mutilation, repetitive acts that result in physical damage to the individual, is extremely rare in the healthy child. The incidence : in the mentally retarded population is between 10 and 20%. self-mutilation is a learned behavior.

ETIOLOGY I Organic Syndromes and syndrome like maladies such as Lesch Nyhan disease and De Langes syndrome have symptoms like repetitive lip, finger, tongue, knee and shoulder biting.

II. Functional Type A it includes the injuries superimposed on a preexisting lesion. Type B these are the injuries secondary to already established habit Type C injuries of unknown or complex etiology

TREATMENT Psychotherapy Emotional support and care Besides behavior modification, treatment for self mutilation includes use of restraints, protective padding and sedation. If use of restraints or protective padding is unsuccessful, extraction of selected teeth may be necessary.

REFERENCES Gavish, M. Halachmi, E. Winocur & E. Gazit: Oral Habits And Their Association With Signs And Symptoms Of Temporomandibular Disorders In Adolescent Girls. Journal of Oral Rehabilitation 2000 27; 2232 McDonald RE, Avery DR, Dean JA: Dentistry for the child and adolescent, Ed. 8th 2004, Mosby. O. Onyeaso: Oral Habits Among 7-10 Year-Old School Children In Ibadan, Nigeria: January 2004 East African Medical Journal OP Kharbanda, SS Sidhu, KR Sundaram, DK Shukla: Oral habits in school going children of Delhi: A prevalence study, ISPPD 2003; 21 (3): 120-124. Pinkham WR: Pediatric Dentistry- Infancy through Adolescence, Ed. 4th 2005, Saunders. Tandon S: Text book of Pedodontics, Ed Ist 2003, Paras Publications.