ORAL HABITS - DEFINITION, CLASSIFICATIONS, CLINICAL FEATURES AND MANAGEMENT

This seminar consists of description of various oral habit along with definitions, classifications, clinical features and management of oral habits like thumb sucking,tongue thrusting,mouth breathing and other secondary habits

1. ORAL HABITS – Definition, Etiology and Classification,Clinical features part - i Karishma.S III MDS

2. Contents: Introduction Classification Thumb sucking Mouth breathing Tongue thrusting Lip biting Cheek biting Nail biting Self injurious habits.

3. INTRODUCTION: 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. 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.

4. DEFINITIONS: According to Boucher DC(1974): “Habit is a tendency towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic.” Acc. to Moyers: “ Habits are learned patterns of muscle contraction, which are complex in nature.” Acc. to Finn(1972): “Habit is an act, which is socially unacceptable.” According to Mathewson(1982): “Oral habits are learned patterns of muscle contractions”

5. CLASSIFICATION OF ORAL HABITS :

6. Classification: BY WILLIAM JAMES(1923) a. Useful habits- e.g. nasal breathing b. Harmful habits- e.g. mouth breathing BY MORRIS AND BOHANA(1969) Pressure habits- Eg . Lip sucking, thumb and digit sucking. Non-pressure habits- eg.mouth breathing. Biting habit- Eg . Nail biting

7. BY KINGSLEY (1958) a) Functional oral habits- eg . Mouth breathing b) Muscular habit- eg . tongue thrusting c) Combined muscular habits- eg . Thumb and finger sucking. d) Postural habits- eg chin propping, face leaning on hand, abnormal pillowing. BY EARNEST KLEIN(1971) Intentional habits (meaningful habits)- has a definite underlying psychological disturbances. Unintentional habits (empty habits)- a meaningless habit that has no need for support, they can be easily treated by reminder appliance.

8. BY SYDNEY FINN(1987) Non-compulsive habit: Habits which are easily added or dropped from the child’s behavior pattern as he/she matures. Compulsive habit: 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 and express a deep seated emotional need.

9. GENERAL CONSIDERATIONS Factors influencing dento -alveolar skeletal deformation: 1. Frequency: more the child indulges his habit each day, more the deformation. 2. Duration: longer the child performs the habit, greater the deformation. 3. Intensity: more the force applied, more the deformity. 4. Direction and type: deformity results due to the force vector applied to the bone.

10. BUCCINATOR MECHANISM Starting with the decussating fibers of the orbicularis oris muscle, joining right and left fibers in the lips, the buccinator mechanism runs laterally and posteriorly around the corner of the mouth, joining other fibers of the buccinators muscle which insert into the pterygomandibular raphe just behind the dentition. Opposing the buccinator mechanism is a very powerful muscle the tongue.

11. FUNCTIONAL EQUILIBRIUM • There should be a balance between the forces of the tongue from within the dental arches and compensating action of the lips and cheek musculature. • Balance between these muscle forces is very important. Any deviation in these reflexes or mechanism leads to malocclusion.

12. SUCKING HABITS There are essentially two forms of sucking (O’Brien et al, 1996): – Nutritive form. – Non-nutritive form. • Non-nutritive sucking is considered normal for children during infancy. • The most common form is thumb or digit sucking. Since mouth is the source of communication with outer environment, this gives the infant a feeling of warmth, a glow, a sense of satisfaction or euphoria.

13. The non-nutritive sucking habits spontaneously disappear sometimes between the 6th and 18th months of life. In some children these habits may be normal for at least another year or so. The oral habits detected at age of 3-6 years old are an important issue because after this age the oral habits are considered as abnormal.

14. Thumb Sucking DEFINITION • “Thumb sucking is the placement of thumb in varying depths into the mouth.” • Thumb sucking and finger sucking can more generally be termed as digit sucking.

15. THE SUCKING REFLEX • The process of sucking is a reflex occurring in the oral stage of development and is seen even at 29 weeks of IUL, and may disappear during neonatal growth between the ages of 1 and 3.5 years. • It is the first coordinated activity of the infant. • It is important for meeting both psychological and nutritive needs during feeding.

16. 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 infant’s head toward an object touching his/her cheek. • Babies who are restricted from sucking due to a disease or other factors become restless and irritable. • This deprivation may motivate the infant to suck the thumb or finger for additional gratification. • If it continues beyond 3 years, malocclusion will result

17. THEORIES CLASSICAL FREUDIAN THEORY (1905 ) • It holds that this original response arises from an inherent psychosexual drive suggesting that digit sucking is a pleasurable stimulation of lips and mouth. • That humans possess a biologic sucking drive. • A satisfying activity that gives the infant a feeling of well-being. • An infant associates sucking with pleasurable feelings such as hunger, satiety and being held. • These events will be replaced in later life by transferring the sucking action to the most suitable object available, namely thumb and finger. • If sucking continues beyond the oral phase, it becomes fixation. • Finger sucking at a later stage is usually considered a sign of regression. • Both fixation and regression are the signs of emotional disturbances.

18. THE LEARNING THEORY – DAVIDSON (1967 ) • Nonnutritive sucking stems from an adaptive response. • The infant associates sucking with such pleasurable feeling as hunger. • These feelings are recalled by sucking the suitable objects available mainly thumb or finger. • This theory suggests that sucking is an outlet for an excess sucking urge because of efficient feeding either breast feeding by a nutritionally component mother or bottle feeding. • When feeding is quickly and efficiently satisfied, the excess sucking urge expressed as non-nutritive sucking.

19. ORAL DRIVE THEORY – SEARS AND WISE (1982 ) • They suggested that the strength of oral drive is in part a function of how long a child continues to feed by sucking. • Thus, thumb sucking is the result of prolongation of nursing, and not the frustration of weaning. • This theory agrees with Freud’s theory that the sucking increases the erotogenesis of the mouth.

20. COMBINATION OF PSYCHOANALYTIC AND LEARNING THEORY By Eric Johnson and Brent Larson (1993 ) • According to them all children possess an inherent biologic drive for sucking. • The rooting and placing reflexes are merely a means of expression of this drive. • Environmental factors may also contribute to this sucking drive to non nutritive sucking such as thumb or fingers.

21. BENJAMIN THEORY • He supported the psychoanalytic theory by the observation of intrauterine sucking and by the neonatal reflex of rooting and placing. • Rooting reflex consists of tilting the head towards the stimulus and opening the mouth. • Placing is a subsequent contact between the mouth and the stimulus object.

22. CLASSIFICATION OF THUMB SUCKING BASED ON CLINICAL OBSERVATION: • Normal Thumb Sucking:- during the first and second year of life.. • Abnormal Thumb Sucking:- habit persists beyond the preschool period This can again be divided into: (a) Psychological: The habit may have a deep-rooted emotional factor involved and may be associated with insecurities, neglect or loneliness experienced by the child. (b) Habitual : The habit does not have a psychological factor involved; however the child performs the act out of habit.

23. GRADING OF THUMB SUCKING BY SUBTELNY (1973) TYPE A – (50%) whole digit is placed inside the mouth with the pad of the thumb pressing over the palate maxillary and mandibular anteriors contact is present. TYPE B – (13-24% ) thumb is placed into the oral cavity without touching the vault of the palate maxillary and mandibular anteriors in contact.

24. TYPE C – (18% ) Thumb is placed into the mouth just beyond the first joint and contacts the hard palate and only the maxillary incisors No contact with mandibular incisors. TYPE D – (6%) Very little portion of thumb is placed into mouth.

25. PHASES OF DEVELOPMENT OF THUMB SUCKING HABIT BY MOYERS PHASE-I: NORMAL AND SUBCLINICALLY SIGNIFICANT SUCKING :- • Extends from birth to 3 years. • This period is considered normal and does not require any intervention. • It should be kept in mind that at the end of this stage any vigorous thumb sucking may be carried into the next phase which then becomes abnormal. So preventive measures can be instituted.

26. PHASE-II: CLINICALLY SIGNIFICANT SUCKING – • Extends from 3 to 6-7 years. • It is associated with clinically significant sucking. • The habit may be meaningful or empty. • It is necessary to manage or correct the habit at this stage . PHASE-III: INTRACTABLE SUCKING- • Thumb sucking habit persisting till phase-III. • May be a symptom more significant than associated malocclusion.

27. DIAGNOSIS: 1. HISTORY. 2. EMOTIONAL STATUS. 3. EXTRAORAL EXAMINATION. 4. INTRAORAL EXAMINATION.

28. HISTORY • History regarding the frequency, intensity and duration of the habit. • Remedies tried at home. • Feeding patterns. • Parental care of the child. • Presence of other habits.

29. EXTRAORAL EXAMINAT ION DIGITS • Digits appear reddened, exceptionally clean, chapped, with a short finger nail i.e. a clean 'dish pan thumb'. • A chronic thumb sucker frequently has a fibrous, roughened callus on the superior aspect of the thumb. • The habit is also known to cause deformation of the finger.

30. LIPS • Chronic thumb sucking are frequently characterized by a short,hypotonic upper lip and hyperactive lower lip. • Upper lip is passive or incompetent during swallowing.

31. FACIAL FORM ANALYSIS • Checked for mandibular retrusion , maxillary protrusion, high mandibular plane angle and facial profile. – A straight profile indicates a favourable growth pattern and the effects of the habit are self correcting when it ceases. – Convex profile is a class II growth pattern and the over jet will remain inspite of removal of the habit.

32. INTRAORAL EXAMINATION COMMONLY OBSERVED CLINICAL PROBLEMS- Maxillary anterior proclination and mandibular retroclination . • It is because when a child places a thumb between the teeth, it is usually placed at an angle so that it presses lingually against the lower incisor and labially against the upper incisors. Anterior open bite. • The digit impedes eruption of the anterior teeth, while the posterior teeth are free to erupt. • 1mm of elongation posteriorly opens the bite by about 2 mm.

33. Constriction of maxillary arch. • Failure of maxillary arch to develop due to an alteration in the balance between cheek and tongue pressures as tongue position is lowered when thumb is placed between the teeth. • Cheek pressure increases against the teeth as the buccinator muscle contracts while sucking. Posterior crossbite . • Occurs as a consequence of constriction of the maxillary arch.

34. EFFECTS ON DENTOFACIAL STRUCTURES • Effects on maxilla – Increased proclination of maxillary incisors. – Increased maxillary arch length. – Increased clinical crown length of the maxillary incisors. – Increased counter clockwise rotation of the occlusal plane. – Decreased palatal arch width. – Increased atypical root resorption in primary central incisors. – Increased trauma to maxillary central incisors.

35. • Effects on the mandible – Increased retroclination of mandibular incisors. – Increased mandibular intermolar distance. • Effects on the Interarch Relationship – Decreased maxillary and mandibular incisor angle. – Increased overjet . – Decreased overbite. – Increased posterior crossbite . – Increased unilateral and bilateral class II occlusion.

36. Effect on lip placement and function – Increased lip incompetence. – Increased lower lip function under maxillary incisors. • Effects on tongue placement and function – Increased tongue thrust. – Increased lip to tongue resting position. – Increased lower tongue position. • Other Effects – Increased deformation of digits – Increased risk of speech defects, especially lisping.

37. MOUTH BREATHING Nasal breathing is the primary mode of air intake for the humans, and it is essential for supply of properly cleansed, moistened and warmed air. The mouth is only a secondary emergency orifice for assuring an uninterrupted supply of air, and using it on regular basis can cause many problems. The term “nasal breather” is used to mean a person who breathes mostly through the nose except during exertion. Mouth breathers are those who breathe orally even in relaxed and restful situations. For normal dentofacial growth to occur there should be normal breathing. Mouth breathing can alter the equilibrium of pressures on the jaws and teeth and affect both jaw growth and tooth position.

38. DEFINTION Sassouni (1971) : Mouth breathing can be defined as habitual breathing through mouth instead of the nose. Merle(1980): Suggested the term oronasal breathing instead of mouth breathing . Chacker F M (1961): Defined mouth breathing as the prolonged or continued exposure of the tissues of the anterior area of the mouth to the drying effects of the inspired air.

39. CLASSIFICATION Finn, 1987 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.

40. ETIOLOGY Increased resistance to the flow of air through the nasal passage may be considered the primary cause of mouth breathing. Allergies, physical obstruction and chronic infections. Airway obstructions may be due to: Enlarged turbinates Deviated nasal septum Allergic rhinitis, nasal polyps Enlarged adenoids or tonsils Abnormally short upper lip preventing proper lip seal Obstructive sleep apnea syndrome Genetic predisposition Thumb sucking or similar oral habits may be instigating agents.

41. CLINICAL FEATURES GENERAL EFFECTS – Appearance of pigeon chest. – Low grade esophagitis . – Blood gas constituents : Mouth breathers have 20% more carbon dioxide and 20% less oxygen. • EFFECTS ON DENTOFACIAL STRUCTURES Facial form: Tendency towards more vertical growth pattern. Increased facial height. Increased mandibular plane angle.

42. Adenoid facies Long narrow face. Narrow nose and nasal airway. laccid lips with short upper lip. Upturned nose exposing nares frontally. ‘V’ shaped and high palatal vault. Collapsed buccal segments of maxilla.

43. Dental effects Proclined upper and lower incisors. Posterior cross bite. Tendency toward an open bite. Narrow palatal and cranial width(low set position of tongue). Constricted maxillary arch(imbalance of forces exerted by tongue and facial musculature).

44. Speech defects: Nasal tone in voice. Lip Lip apart posture. Excessive appearance of maxillary anteriors - long face syndrome. Gummy smile. Short thick incompetent upper lip. Voluminous curled over lower lip. External nares Disuse atrophy of the lateral nasal cartilage leading to slit like external nares with narrow nose. Nasal mucosa becomes atrophied due to a disturbed ciliary action.

45. Gingiva Inflamed and irritating gingival tissue in the anterior maxillary arch. Hyperplastic gingiva due to continuous exposure to air drying. Heavy deposits of plaque due to decreases salivary cleansing action. Classic rolled margin and an enlarged inter dental papilla. Interproximal bone loss with presence of deep pockets. Chronic gingival condition and periodontal disease. Other effects Otitis media. Sense of smell and taste is decreased.

46. DIAGNOSIS HISTORY • Parents should be questioned about the Frequent lip apart posture. Frequent occurrence of tonsillitis, allergic rhinitis or otitis media. EXAMINATION Patient’s breathing should be observed. Nasal breathers - lips touching lightly during relaxed breathing whereas mouth breathers keep their lips apart. A mouth breather when asked to close his lips and take a forced deep breath will not appreciably change the size and shape of the external nares and occasionally contracts the nasal orifices while inspiring.

47. CLINICAL TESTS 1. Mirror test- Two-surfaced mirror is placed on the patient’s upper lip. If air condenses on upper side, the patient is a nasal breather and if it condenses on lower side, the patient is mouth breather. 2. Butterfly test/cotton test- Take a few fibers of cotton (in butterfly shape) and place it just below the nasal opening. On exhalation if the fibers of cotton flutter downwards, the patient is nasal breather; otherwise the patient is mouth breather. This can also be used to determine unilateral nasal blockage.

48. 3. Water holding test- Patient is asked to hold water in mouth for 2-3 minutes. A mouth breather cannot hold water for that time.

49. Cephalometrics - To establish Amount of nasopharyngeal space Size of adenoid Skeletal pattern of the patient Inductive plethysmographry ( Rhinomonometry ) - To establish total air flow through nose and mouth respectively. Blood gas constituents- Mouth breathers have 20% more CO2 and 20% less oxygen.

50. TONGUE THRUSTING In embryonic life, the developing tongue is considered disproportionately large in comparison to the developing mandible and it fills the embryonic oral cavity. In neonates the tongue is relatively large and located in the forward suckling position for nursing. The tip inserts through the anterior gum pads and assists in the anterior lip seal. This tongue position and coincident swallowing termed as infantile or visceral.

51. With eruption of the incisors at about 6 months, the tongue position starts to retract. Over a period of 12 to 18 months as proprioception causes tongue postural and functional changes, a transitional period ensues. Between 2 and 4 years the functionally balanced, or mature, somatic swallow is in normal developmental patterns . Visceral swallow can persist well after the 4 th year of life, however, it is considered dysfunctional or abnormal because of certain malocclusive characteristics. If the transition of infantile to mature swallow does not take place with the eruption of teeth, then it leads to what is known as the tongue thrust swallow.

52. In normal swallower, the tip of the tongue contacts the palatal rugae area posterior to the maxillary anterior teeth; its midportion contacts the hard palate; its posterior aspect assumes a 45⁰ angulation against the pharyngeal wall to permit the bolus of food to move on into the digestive tract. Abnormal swallower is described as person who positions the tip of the tongue against or between the teeth during swallowing . Then the posterior aspect of the tongue contacts the posterior area of the hard palate and does not assume a 45⁰ angulation relative to the posterior pharyngeal wall. Masseter muscle activity is prevented and there is no molar contact during deglutition. Mentalis muscle is hyperactive.

53. MATURATION OF DEGLUTITION The normal infantile swallow is seen in neonates and gradually disappears with the eruption of the buccal teeth in primary dentition. The cessation of the infantile swallow and appearance of mature swallow are not a simple on-and-off phenomenon but elements of both intermix during the primary dentition and sometimes even into the early mixed dentition. The normal appearance of features of both the infantile and mature swallow is termed as “transitional swallow”.

54. Diminishing of buccinators activity is part of the transitional period but the most characteristic feature of the start of cessation of infantile swallow is the appearance of contractions of the mandibular elevators during the swallow as they stabilize the teeth in occlusion . The arrival of the incisors leads to more precise opening and closing movements of the mandible,a more retracted tongue posture, and initiates the learning of mastication.

55. NORMAL INFANTILE SWALLOW The jaws are apart, with the tongue between the gum pads. The mandible is stabilized primarily by the contraction of the muscles of the VIIth cranial nerve and the interposed tongue. The swallow is guided, and to a great extent controlled by sensory interchange between the lips and the tongue.

56. NORMAL MATURE SWALLOW The teeth are together. The mandible is stabilized by the contractions of the mandibular elevators, which are primarily 5th cranial nerve muscles. The tongue tip is held against the palate, above and behind the incisors. There is very little lip and cheek activity. The amount of lip activity during the normal mature swallow depends on the ability of the tongue to effect a complete valve seal against the teeth and alveolar process. During the mixed dentition, when some teeth are missing and there is normal interdental spacing, the lips may contract a bit to secure the seal

57. SIMPLE TONGUE THRUST SWALLOW It typically displays the contraction of lips, mentalis muscle and mandibular elevaters and the teeth are in occlusion as the tongue protrudes into an open bite There is a normal teeth together swallow,but a tongue thrust is present to seal the open bite The so called tongue thrust is simply an adaptive mechanism to maintain an open bite created by something else, usually thumb sucking. The open bite is well circumscribed When one fits together the dental cast of the patient they have a precise and secure intercuspation because the occlusal position is continuously reinforced by the teeh together swallow

58. COMPLEX TONGUE THRUST SWALLOW It is tongue thrust with teeth apart swallow The patient combines contraction of lip, facial and mentalis muscles, lack of contraction of mandibular elevators, a tongue thrust between the teeth and teeth apart swallow Examination of dental cast typically reveals a poor occlusal fit and instability of intercuspation because the intercuspal position is not repeatedly reinforced during the swallow. Persistant teeth apart swallows don’t stabilize the occlusion They are far more likely to be the mouth breathers and to have incidence of complex tongue thrusting This type of tongue thrust doesn’t diminish as much with age as does the simple tongue thrust

59. RETAINED INFANTILE SWALLOW IN BEHAVIOUR True retained infantile swallowing behavior is rare. It is defined as predominant persistent of the infantile swallowing reflex after the arrival of permanent teeth The patient demonstrate very strong contraction of the lips and facial musculature They present massive grimacing. The tongue thrusts strongly between the teeth in front and on both sides Particularly noticeable are contraction of buccinators muslces Such patients may have inexpressive faces since the 7 th cranial nerve, muscles are not being used for the delicated purpose of facial expression but rather for the massive effort of stabilizing the mandible swallowing.

60. Definition- 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 teeth segments. Schneider(1982): Tongue thrust is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing.

61. Tulley (1969): Tongue thrust is a 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 . Brauer (1965 ) : A tongue thrust is said to be present if the tongue is observed thrusting between and the teeth don’t close in centric occlusion during deglutition Profitt : Defined it as placement of the tongue tip forward between the incisors during swallowing.

62. Classification: 1. Physiologic- normal tongue thrust swallow of infancy. 2. Habitual- present as a habit even after correction of the malocclusion. 3. Functional- adaptive behavior to achieve an oral seal. 4. Anatomic- enlarged tongue.

63. Etiology: Retained infantile swallow. Upper respiratory tract infections. Mouth breathing, chronic tonsilitis , allergies. Neurological disturbance- Hyposensitive palate, moderate motor disability, disruption of sensory control and coordination of swallowing. Functional adaptability to transient change in anatomy-Missing incisors. Feeding practices and tongue thrusting- Bottle feeding. Induced due to other oral habit. Hereditary. Tongue size.

64. Clinical manifestations- Extra oral findings- 1. Lip posture- lip separation is greater 2. Mandibular movements- average path of mandibular movement is upward and backward with the tongue moving forward. 3. Speech- Problems in articulations of /s/,/n/, /t/, /d/, /l/,/ th /,/z/, /v/ sounds 4. Facial form- Increase in anterior facial height

65. Intraoral findings- 1. Tongue movements- swallowing sequences are jerky and inconsistent. 2. Tongue posture- The tongue tip at rest is lower. 3. Malocclusion- – Features pertaining to maxilla - Proclination of maxillary anteriors resulting in an increased overjet - Generalized spacing between the teeth - Maxillary constrictions – Features pertaining to mandible - Retroclination or proclination of mandible depending on type of tongue thrust – Intermaxillary relationships - Anterior or posterior open bite based on posture of the tongue - Posterior cross bite

66. Diagnosis- History: Questions pertaining to – Swallow pattern of siblings and parents. – Where or not remedial speech was ever provided. – Upper respiratory infections, sucking habits and neuromuscular problems. – Past and present information regarding the overall abilities, interests and motivation of the patient

67. Examination: Study the posture of tongue while mandible is in postural position. Observe the tongue during various swallowing procedures, the unconscious swallow, the command swallow of saliva and the command swallow of water, unconscious swallow during chewing.

68. Simple tongue thrust Normal tooth contact in posterior region Anterior open bite Contraction of lips, mentalis muscles and mandibular elevators Lateral tongue thrust: Posterior open bite with tongue thrusting laterally.

69. Complex tongue thrust: Generalized open bite with the absence of contraction of lip and muscle and teeth contact in occlusion.

70. Bruxism Definition- Ramjford (1966)- Bruxism is the habitual grinding of teeth when the individual is not chewing or swallowing. Vanderas (1995) - Nonfunctional movement of the mandible with or without an audible sound occurring during the day or night.

71. Types- 1. Daytime bruxism /Diurnal bruxism / Bruxomania . 2. Night time bruxism /Nocturnal bruxism / Bruxism .

72. Etiology- Local factors Mild occlusal trauma or minor anatomic defects, traumatic occlusion. Systemic factors Intestinal parasites, subclinical nutritional deficiencies, allergies and endocrine disorders. Psychological factor Emotional stress, anger, anxiety or aggression. Occupational factor Athletes , watch makers, die-makers, diamond cleaners

73. Clinical manifestation- Occlusal trauma. Tooth mobility. Atypical shiny wear facets with sharp edges. Pulpal sensitivity to cold. Pulp exposures. Muscular tenderness, especially lateral pterygoid and masseter muscles. Muscular fatigue on waking. Muscular hypertrophy. TMJ disorders. Headache. Grinding and tapping sound. Soft tissue trauma.

74. Lip habit Definition- Habits that involve manipulation of the lips and peri oral structures. Classification- 1. Lip biting. 2. Lip sucking. 3. Lip wetting.

75. Etiology- 1. Malocclusion- Class II div 1 with large overbite and overjet . Child wants to produce a normal lip seal during swallowing by placing the lower lip posterior to upper incisors. 2. Habits- In conjunction with thumb sucking habit which may result in large overjet and overbite. 3. Emotional stress.

76. Clinical manifestations- • Protrusion of maxillary incisors and retrusion of mandibular incisors. • Reddened, irritated, chapped lips with vermillion border relocated farther outside the mouth, especially with lower lip. • Mentolabial sulcus becomes accentuated.

77. Cheek biting • It is an abnormal habit of biting or keeping the cheek muscles in between upper and lower posterior teeth . Clinical features- Ulcer at the level of occlusion. Open bite. Tooth malposition in buccal segment.

78. Nail biting It is one of the most common habits in children and adults. Etiology- Insecurity. Nervous tension. Effects- Crowding, rotation and alteration of incisal edges of incisors. Inflammation of nail beds.

79. Self injurious habits (Masochistic habits/Sadomasochistic habits/Self-mutilating habits) Definition- Repetitive acts that result in physical damage to the individual. Etiology- 1. Organic- Lesch-Nyhan disease, De Lange’s syndrome. 2. Functional- Type A- these are injury superimposed on a preexisting lesion. Type B- injuries secondary to another established habit. Type C- injuries of unknown or complex etiology.

80. Frenum thrusting- If the upper incisors are slightly spaces apart, the child may lock his labial frenum between these teeth and permit it to remain in this position for hours.

81. MANAGEMENT OF ORAL HABITS IN CHILDREN part - ii Karishma.S III MDS

82. CONTENTS General treatment considerations Management of Thumg sucking Tongue thrusting Mouth breathing Bruxism Lip habits Cheek and Nail biting Masochistic habits

83. General treatment considerations

84. TREATMENT CONSIDERATIONS: FINN Psychological status of the child Age factor Motivation of child Parental cooperation Friendly rapport Other factors (goal orientation for time limit) TREATMENT CONSIDERATIONS:FORRESTER Emotional significance Age of the patient Status of the child’s occlusion

85. EMOTIONAL SIGNIFICANCE : Diagnosis and management of any psychological problem should be planned before treatment of any potential or present dental problem. The frequency, duration and intensity of the oral habit are important in evaluating the psychological status of the child . The events that precede the habit such as the use of a security blanket, the dependency on a favorite toy, problems with sleep, nightmares, nervousness and anxiousness will yield information concerning the possible psychological stimuli of the habit. If the oral habit is associated with an emotional problem this would suggest the need for psychological consultation.

86. AGE FACTOR : ( Younger than 3 years) No active intervention : General emotional immaturity, Most children will outgrow the habit by 5. Most class 1 open bite malocclusion will be self correcting when the permanent incisors erupt if the habit doesn’t cease prior to their eruption. The parents should be advised generally to ignore the active habit, and give the child as much attention as possible when he is not thumb sucking. For class II children: further orthodontic treatment will be necessary when the child is older.

87. 3- TO 7 YEAR OLDS : Caution : Depending on the type of the habit and whether he is actively pulling his maxilla anteriorly or just sucking his digit with buccal constriction. Finger suckers : inc. concern i n thumb suckers because anterior orthopedic force vectors are associated with finger sucking leverage. It is advised to counsel the child with good molar intercuspation with little anterior pull. i.e passive sucking child.

88. Older than 7 years : Anterior open bite that is usually not closed by itself because of functional patterns that have been established. They will require active orthodontic treatment. The appliances delivered should not be punitive, Should be multipurpose Should help the child to control his habits by giving him a reminder

89. Motivation of the child to stop the habit: Important to assess : the maturity : in response to new situations and to observe the child’s reactions to any suggestion . The treatment approach for the digit sucking habit should deal directly with the child. The first ingredient needed to stop the habit is the child’s desire to stop . Parental concern regarding the habit: If the parent is unable to cope with the situation positively then both the parent and the child should be dealt with during treatment. Parents : silent partners. Important : child should not be offered to deal with this difficult habit . Negative reinforcements : threats, nagging and ridicule would only entrench the habit.

90. Other factors: Self-correction again depends on the severity of the malocclusion, anatomic variation in the perioral soft tissue and the presence of other oral habits, such as tongue thrusting, mouth breathing and lip biting habits. Treatment (Pinkham) : Counseling Reward system Reminder therapy Adjunctive therapy

91. TREATMENT - THUMB SUCKING

92. TREATMENT MODALITIES - Thumb sucking Once the decision for treatment has been made, one must next determine what intervention is appropriate. The treatment considerations are P sychological status, age factor, maturity of the patient, and patient co-operation. The combinations of explanations with consideration of physical appearance and social acceptance may be sufficient for the child to give up the behavior. In addition to their own intention some children may require additional help. Another tool that is helpful for this type of child is the use of positive reinforcement. Rewards for progress in diminishing the habit should include praise and something special that is agreeable to patient and parent.

93. Psychological Therapy : ( A) Dunlop's beta hypothesis If a subject is forced to concentrate on the performance of the act and 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

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

95. (C). Three alarm system: (Norton & Gellin - 1968) : A chart is designed with days of the week and blank spaces. When the child engage in his habit he is told to wrap the digit he sucks with coarse adhesive tapes. (D). ACE BANDAGE APPROACH

96. Three-Alarm System: Revisited to treat Thumb-sucking Habit Raghavendra M Shetty , Manoj Shetty ,  N Shridhar Shetty , and  Anushka Deoghare

97. (E). Reward system : Children should be encouraged and rewarded for not practicing the habit. “contingency contracting” is a contract made between the child and dentist or child and parent . In this approach, Bandage should be wrapped around the finger and stars should be entered into the calendar. (F). THUMB BUDDY TO LOVE This is commercially available and is a positive teaching tool and chemical free method . By having the thumb puppet, the child stays motivated to stop the habit.

98. (G). THUMB - HOME CONCEPT : Skinaz 2000

99. (H). CHEMICAL TREATMENT Bitter and sour Very minimal success e.g. quinine, asafetida, pepper, caster oil etc. NEWER anti-thumb sucking solutions Femite Thumb-up Anti-thumb

100. (I). THUMB GUARD: It is an appliance that is worn when the child is tempted to suck. Once the guard is worn they cannot generate vacuum and so sucking is not much satisfying. Another approach is long sleeve gown by doubling the length of the sleeve. It makes difficulty for the child to suck. While providing reminder therapy the child should be instructed that these are just to remind them to take the thumb out and it is not a punishment.

101. (J). PARENT COUNSELING : In private conversation with the child, the problem and its effect must be elicited . The parents' role in correction is very significant. Over anxiety and the resulting nagging approach or punishment often creates greater tension and intensification of the habit .(NEGATIVISM) Thus a change in the home environment and routine help the child to overcome the habit.

102. From a psychological point of view the child should make the decision that he doesn't want to do it anymore . “ Parents should not force the preschoolers to break the habit since they only know the pleasure derived from the habit but they cannot understand why the habit to be stopped”. Some children practice the habit while watching T.V especially when there is no other person to take care of them during day time. So in such case, parents should spend more time with children during day time

103. Other Extra-oral approaches : Thermoplastic thumb (Allen 1992) Alemaran2000 : Long sleeve gown (J Cons ) INTRAORAL APPROACHES : • Mink and Haskell 1991 : Blue grass appliance • Six sided roller made of Telfon attached with 0.045 stainless steel wire soldered to molar orthodontic bands. • Patient instructed to turn the roller instead of sucking the digit. • Patient got a new toy to play with tongue & got distracted • Time : 3- 6 months

104. Location of roller : M ost superior aspect of palate Not in contact with palate No obstruction in eating or speech Not used in preschool children 7 – 13 yr age Chris Baker 2000 : Modified blue grass appliance : 4mm acrylic beads Adv : reduced bulk, Less obstruction, attractive for children, Used in age group 1 ½ - 12 years Modification : Attachment with quad helix Removal time : 6 months after habit cessation

105. QUAD HELIX : Maxillary expansion Posterior cross bite correction Palatal Crib : Hayrett 1970 Hayrakes : Korner and Keider 1955 (Angle Ortho) Triple Loop Activator (TLA) : Viazis 1991 (Am J Ortho) Tongue connector appliance (TCA) : Viazis 1993 (Am J Ortho)

106. TONGUE THRUSTING

107. TREATMENT CONSIDERATIONS: Self correcting by 8-9 years: by the time permanent teeth erupt. If associated with other habits: Associated habit should be treated first

108. TRAINING OF CORRECT SWALLOW AND POSTURE OF THE TONGUE : Myofunctional therapy * Garliader Patient can be guided regarding correct posture of tongue during swallowing by various exercises like Asking the child to place the tip of the tongue in the rugae area for 5min and then asking him to swallow 2) Orthodontic elastics Tongue tip is held against the palate using elastics of 5/16’’ and sugarless fruit drop .

109. 3) Lemon candy Exercise: ▪ Instead of elastic, a lemon candy is put on the tongue tip. ▪ Pt is asked to hold the candy against the palate by the tongue tip and then asking the child to swallow. 4 ) 4S exercise : ▪ Includes identifying the SPOT, SALIVATING, SQUEEZING the spot and 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

110. Other exercises : • Whistling • Reciting count from 60-69 • Gargling • Yawning Peanuts exercise : patient chews peanuts Chewed nuts placed in middle of tongue Put peanuts on anterior part of palate and swallow 1960Andrews :Water holding exercise ( infront of mirror)Repeat 20 times / day

111. Lip exercises Tug of war and Button pull exercise: ▪ A string is tied to two buttons, one of the buttons is placed between the lips of the patient, while the other is held by the patient outside. ▪ Outer button is pulled outwards, at the same time, the inner button is resisting the forces thereby strengthening the lips on both aspect. Pre orthodontic trainer for myofunctional training : ▪ It aids in correct positioning of the tongue with the help on tongue tags. ▪ The tongue guards prevent tongue thrusting when in place.

112. Sub concious therapy : Once voluntary swallowing pattern is acquired, the patient proceeds to sub conscious therapy, i.e subliminal therapy where the patient is asked to place a reminder sign or auto suggestion which requires the patient to give self instructions like Repeat 6 times” I will swallow correctly all night long” for 10nights. Nance palatal arch appliance : ▪ Here, acrylic button can be used as a guide to place the tongue in correct position .

113. Speech therapy To train the correct positioning of tongue, as this position is more conducive to the articulation of speech and to normal alignment of teeth. The child is asked to repeat simple multiplication tables of sixes , pronounce words beginning with ‘S’ sounds

114. MECHANOTHERAPY : Fixed and removable appliances: -Restrain anterior tongue movement -form a more effective barrier -reduces anterior tongue positioning (dorsum of tongue approximates palatal vault and the tip of the tongue contacts the palatal rugae during deglutition) Capability of using the Hawley to close the anterior openbite through the use of the labial bow.

115. Removable appliances : ▪ Hawley’s appliance ▪ Hawley’s appliance modifications: • Acrylic cut in anterior hard palate region • Cribs or rakes employed in anterior part Advantages: • Increased anchorage value • The crib can serve as a reminder.

116. Oral screen : ▪ Restriction of tongue thrusting habit ▪ Alignment of maxillary anterior teeth ▪ Correction of open bite ▪ Lip muscle exercises performed with ring attached in anterior part of appliance Fixed Habit breaking appliance: Crowns and bands on first perm. molar 0.040inch stainless steel ‘U’-shaped lingual bar adapted at the level of gingival margin. Crib formed (3-4 ‘V’ shaped projections) Cut cribs as child weans the habit Nance palatal arch (acrylic button)

117. TREATMENTOF SIMPLE TONGUE THRUST : ▪ Treatment of tongue thrust should not be begin until the incisors have been retracted. ▪ Steps : Acquaint the patient consciously to correct swallowing pattern Reinforce subconsciously

118. TREATMENTOF COMPLEX TONGUE THRUST : Poor prognosis due to Poor occlusal fit Generalized open bite Neuromuscular problems abnormal occlusal reflex abnormal swallow Treat the malocclusion first Muscle training similar to that for simple tongue thrust SURGERY - Retained infantile swallow

119. Weiss[1972] : ▪ Phase 1: tongue positioning ▪ Phase 2: bite & swallow ▪ Phase 3: bite & swallow with lips apart ▪ Phase 4: reminder therapy Moyers [1973] : ▪ 1st stage : Myotherapy in early phases ▪ 2nd stage : Lingual or palatal arch with spurs ▪ 3rd stage : 3 phases: Phase 1: learn new swallow reflex at conscious level Phase 2: exercises Phase 3: reinforcement : lingual arch

120. MOUTH BREATHING

121. TREATMENT: ▪ Main aspect: 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 15-30in/day for 4-5months Oral screen

122. Treatment considerations : Age of the patient As with any other habit, correction of mouth breathing could be expected as the child matures. As the child grows, obstruction caused due to enlarged adenoids is relieved. Mouth breathing in many instances is self- correcting after puberty

123. E.N.T examination: ▪ An otolaryngologist examination may be advised : tonsils, adenoids or nasal septum. ▪ In some children , it may be habitual. ▪ Correction should first aim at REMOVING any anatomic or functional causes. ▪ To institute a treatment of actual cause, it is important to determine the type and degree of mouth breathing , whether it is habitual or obstructive , and whether total mouth breathing is present or it is partial.

124. Correction Symptomatic treatment : ▪ The gingiva of the mouth breather should be restored to normal health by Coating the gingival with petroleum jelly, ▪ Applying preventive dentistry methods and ▪ Clinically correcting periodontal defect that have occurred due to the habit.

125. Interception of the habit EXERCISES : If there is no physiological cause the patient should be instructed in breathing and lip exercise. Physical exercises ▪ Done in the morning and night. ▪ Deep breathing exercises are done with inhalation through the nose with arms raised sideways. ▪ After a short period, the arms are dropped to the sides and air is exhaled through the mouth .

126. Lip exercises Hypotonicity and flaccidity of upper lip. ▪ Extend the upper lip as far as possible to cover the vermillion border under and behind the maxillary incisors. ▪ 15-30 mins /day period for 4-5 months when the child has short upper lip. ▪ If maxillary incisors are protruded, the lower lip can be used to augment the upper lip exercise. ▪ This type of exercise exerts strong retraction influence on the maxillary incisors, which increases the tonicity of both upper and lower lips. ▪ A celluloid strip or metal disk held between the lips not only necessitate their being closed, but also makes the child conscious of their opening if the object drops.

127. Maxillothorax myotherapy : ▪ Macaray 1960. ▪ These expanding exercises are used in conjunction with Macaray activator. Macaray constructed an activator out of aluminium with which development of dental arches and dental base relationship could be corrected. ▪ This stable aluminium activator is incorporated at the angle of the mouth, with horizontal hooks to which expanding rubber bands are attached. ▪ The mouth breather holds the activator in the mouth, and the same time with left and right arms alternatively carries 10 exercises 3 times a day.

128. Child stands with his back against the wall, raises and lowers on his toes in time to the expander exercises holding the lip tight together and carries out a lightly forced breathing technique in front of an open window. Myotherapeutic exercise is indicated for mouth breathers. They also help prevent a relapse. The additional myotherapeutic expander exercises during bimaxillary treatment help to establish physiological nasal breathing, as well as correcting maldevelopment of thorax .

129. Oral screen: ▪ Oral screen should be constructed with a biocompatible material. ▪ Reduction in anterior open bite is obtained after a treatment of 3-6 months. ▪ Effective device during sleeping hours, this rubber membrane/acrylic plate is either cut or cast to fit over the labial and buccal surfaces of the teeth and gums included in the vestibule of the mouth. ▪ During the initial phase, windows are placed on the oral screen so as not to completely block the airway passage .

130. Correction of malocclusion: Mechanical applianc es Children with class I skeletal and dental occlusion and anterior spacing- Oral shield appliance . Class II division I dentition without crowding, age 5-9 years, Monobloc activator to aid both in the correction of malocclusion and deterrence of the habit. This appliance when worn will not allow the air to be breathed through the mouth . Class III malocclusion interceptive methods are recommended as a chin cap. The child should be evaluated for a sufficient airway before treatment .

131. BRUXISM

132. TREATMENT 1. Occlussal adjustments : This would result in immediate disappearance of habitual grinding of teeth. Any prematurities or occlusal interferences in restorations should be corrected. Coronoplasty plays an important role in occlusal treatment. However, extensive occlusal adjustments are contraindicated. Before any occlusal adjustments are done the muscles should be brought back to a relaxed position to allow the jaw to resume its normal physiologic movements.

133. 2. Occlussal splints: Vulcanite splints have been recommended to cover the occlusal surfaces of all the teeth as treat ment for bruxism. A reduction in the increased muscle tone is observed with its use. In the case of children the use of a soft splint is advisable. The splint is made on the mandibular models using Scher Dental Bioplast material. Little adjustment is required in children where intercuspation is less.

134. The TMJ appliance: It is a prefabricated intra oral appliance designed mainly for the treatment of TMJ disorders. Habits such as bruxism are prevented by the patented aerofoil shaped base and a double mouth guard design. 3.Restorative treatment: If the abrasion is so severe that penetration into the pulp chamber is imminent, pulpal therapy with fiill coverage stainless steel crowns is indicated .

135. 4. Psychotherapy: Counselling the patient can lead to a decrease in tension and also create a habit awareness. This may result in an increase in voluntary control that can lead to reduced tooth parafunctions. Behavioural modality is initiated by the dentist through explanation and arousal of the patient’s awareness of the habit. 5. Relaxation training: In this technique, the patient is instructed to tense the muscle group in consideration and relax thereby training the patient to relax the muscle group voluntarily. Hypnosis , conditioning, etc , are also indicated for subjects in whom bruxism is due to a central cause.

136. 6 .Drugs: Vapo coolants such as ethyl chloride for pain within the TMJ area, local anesthetic injections directly into the TMJ or into the muscles, tranquilizers and sedatives and muscle relaxants are used. Placebos may be used to rule out psychological etiology . Medications may be prescribed for a few days to alter the sleep arousal and anxiety level, eg . diazepam. Low doses of tricyclic antidepressants may be used to inhibit the amount of Rapid Eye Movement sleep .

137. 7 .Bio feedback : This is a technique that utilizes positive feedback to enable the patient to learn tension reduction. It is accomplished by allowing the patient to view an EMG monitor, while the mandible is postured with a minimum of activity. 8 .Electrical method: Electrogalvanic stimulation for muscle relaxation is currently being utilized for treatment of bruxism. Acupuncture techniques for muscle relaxation are also under evaluation.

138. 9.Physical therapy: If musculoskeletal pain and stiffness are associated with bruxism, a brief course of physical therapy is appropriate 10. Orthodontic correction: Malocclusions such as Class II and Class III occlusions frontal open bite and crossbites when associated with functional malocclusion may create a predisposition to bruxism

139. LIP HABIT management

140. The lip habit is not self-correcting and may become more deleterious with age, because of muscular forces interacting with the child’s growth. Treatment of a lip sucking habit should be directed initially towards the etiology of the habit. 1.Correction of malocclusion: If there is a Class II division I malocclusion or an excessive overjet problem , the abnormal lip activity may be adaptive to the dento alveolar morphology . In such cases, it is deemed wise to correct the malocclusion before going on to break the habit

141. Class I Malocclusion with increased overjet , fixed or removable appliance to tip the teeth back Class II - Growth modification procedures to treat the malocclusion. If the child has an uncrowded early mixed dentition , an activator may be placed in an attempt to reposition the maxilla to the mandible in a favourable position and allow the child to achieve a more normal lip seal.

142. 2. Treating the primary habit: The lip habit along with digit sucking can be corrected by aligning the dental arch using Hawley retainer with a labial bow; which can be used to retract the maxillary incisors and an acrylic plate can be used as a habit reminder. 3. Appliance therapy: Oral shield is also a useful appliance in Class I malocclusion . It helps to stop the habit and also in incisal alignment. The addition of a small loop to the labial oral shield improves the lip tonus by helping in lip exercises. Performed for 10 minutes -3 times a day.

143. Lip bumper: A lip bumper may be used as an adjunctive therapy in both comprehensive and interceptive treatment regimens . The lip bumper is positioned in the vestibule of the mandibular arch and serves to prohibit the lip from exerting excessive force on the mandibular incisors and to reposition the lip away from the lingual aspect of the maxillary incisors . This enables the distal repositioning of the maxillary incisors resulting in a decreased over-jet and overbite.

144. The lip bumper can be a combined , fixed and removable appliance. Either the second deciduous molars or the first permanent molars are banded and the buccal tubes are soldered to them. The labial screen assembly may either be soldered to the band or crowns or slipped into the buccal tubes. The labial shield keeps the wire away from the lower incisors, preventing it from cushioning to the lingual of the maxillary incisors during posture and function. With no labial restraining lip habit, the tongue will then stimulate the lower incisors to move labially , which increases the arch length, reduces crowding and excessive overjet.

145. CHEEK BITING and nail biting

146. Management (cheek biting): A removable crib or a vestibular screen may be used to break the habit Management (Nail biting) M ild cases no treatment is indicated. Avoid punitive methods, such as scolding, nagging and threats Treat the basic emotional factors causing the act. Encourage outdoor activities which may help in easing tension Application of nail polish , light cotton mittens as a reminder.

147. SELF INJURIOUS HABITS (masochistic habits, sadomasochistic habits, self-mutilating habits)

148. Treatment: Treatment should first be initiated towards psychotherapy. Some children experience a feeling of neglect, abandonment and loneliness and through the use of self-injurious behaviour attempt to solicit attention and love. Treatment of self-injurious behavior generally requires a multidisciplinary approach . Care should be taken in dealing with this form of behaviour because of the underlying emotional component. Continued concern for the habit may support or reinforce the habit.

149. Palliative treatment: Adjunctive therapy in the form of bandages for any oral ulcerations will help in healing of the wounds as well as serve as a habit reminder Mechano therapy: An oral shield will also deter the child from the unconscious continuation of the habit. Treatment for self-mutilation may also include use of restraints and protective padding

150. conclusion

151. references Stephen H. Y. Wei. Pediatric Dentistry: Total Patient Care . Sidney B. Finn. Textbook of Clinical Pedodontics . 4 th ed Ray E. Stewart, Thomas K. Barber, Kenneth C. Troutman and Stephen H . Y Wei. Pediatric Dentistry: Scientific foundations and clinical practice. Ralph E. McDonald, David R. Avery & Jeffrey A. Dean. Dentistry for the Child and Adolescent. 8 th ed Shobha Tandon . Textbook of Pedodontics . 2 nd ed.