Oral habits - pedodontics

1. 1
ORAL HABITS
BY
ELVIS CHIRAMEL DAVID
4
th
year (part A)

2. 2
Any repetitive behaviour that
utilizes the oral cavity.

3. DEF OF HABIT
DORLAND[1957]
HABIT CAN BE DEFINED AS A FIXED OR CONSTANT
PRACTICE ESTABLISHED BY FREQUENT
REPETITION.
BUTTERSWORTH[1961]
DEFINED AS A FREQUENT OR CONSTANT PRACTICE
OR ACQUIRED TENDENCY, WHICH HAS BEEN FIXED
BY FREQUENT REPETITION.
MATHEWSON[1982]
ORAL HABITS ARE LEARNED PATTERNS OF
MUSCULAR CONTRACTIONS.
BOUCHER O.C
A TENDENCY TOWARDS AN ACT OR AN ACT THAT
HAS BECOME A REPEATED PERFORMANCE,
RELATIVELY FIXED, CONSISTENT, EASY TO
PERFORM AND ALMOST AUTOMATIC.
3

4. 4
COMMON ORAL HABITS
LIP BITING
TONGUE THRUSTING
BRUXISM
NAIL BITING
• Pencil chewing
• Bobby pin opening
• Bottle opening
• Needle biting
• Improper brushing
• Wire Chewing ( Electricians)
MOUTH BREATHING
THUMB SUCKING
O
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5. ETIOLOGY
FAMILY CONFLICTS
SCHOOL PRESSURE
JEALOUSY
PEER GROUP PRESSURE
STRESS
OCCLUSAL INTERFERANCE
BREATHING OBSTRUCTION
LIMITATIONS ASSOCIATED WITH TOOTH
ERUPTION
POOR PHYSICAL HEALTH
5

6. CLASSIFICATION
By William James (1923):-
•Useful habits (nasal breathing)
•Harmful habits (eg:- Thumb sucking, Tongue
thrusting)
Useful habits:- The habits that considered essential
for normal function such as proper positioning of
tongue, respiration, normal deglutition.
Harmful habits:- Habits that have deleterious effect
on the teeth and their supporting structures.

6

7. By Kingsley (1956):-
•Functional oral habit (mouth breathing)
•Muscular habits (tongue thrusting)
•Combined muscular habits (thumb and finger
sucking)
•Postural habits (chin propping,abnormal pillowing)

7

8. By morris and Bohana (1969):-
•Pressure. (lip sucking, thumb sucking, tongue
thrusting)
•Non pressure (mouth breathing)
•Biting habit (nail biting, pencil biting, lip biting)
Pressure habit:- Habit that apply force on teeth &
supporting structure.
Non-pressure habit:- Habit that does not apply force
on teeth & supporting structure.
8

9. By Finn (1987):-
•Compulsive
•Non-compulsive
Compulsive :- These are deep rooted habits that have
acquired a fixation in child. The child tends to
suffer increased anxiety when attempt made to
correct
Non-compulsive:- These are habits that easily learned
and dropped as the child matures.
9

10. By klein (1971):-
•Empty/unintentional habits
•Meaningful/intentional habits
Empty habit:- They are habits that are not associated
with deep rooted psychological pattern.
Meaningful habits:- They are habits that have
psychological bearings.
10

11. 11
By Graber:-
Graber included all habits under extrinsic factors
of general causes of malocclusion.
•1. Thumb / digit sucking
•2. Tongue thrusting
•3. Lip/ nail biting
•4. Mouth breathing
•5. Abnormal Swallow
•6. Speech defects
•7. Postural defects
•8. Psychogenic habits – bruxism
•9. Defective occlusal habits

12. 12
THUMB SUCKING
Thumb and finger habits are
seen in children from very
small ages.
Develops as a habit or due to sense of insecurity.
It is defined as the
placement of thumb or one
or more fingers in varying
depth into the mouth

13. CLASSIFICATION OF NNS (NON
NUTRITIVE SUCKING )
1. Level I (+/-) – boy or girl of any
chronological age with a habit that occurs
during sleep
2. Level II (+/-) – boy under the age of 8 years
with a habit that occurs at one setting
during waking hours.
3. Level III (+/-) – boy under the age of
8years with a habit that occurs across
multiple setting during waking hours.
13

14. 4. Level IV (+/-)-girl under the age of 8 years
or a boy over the age of 8years with a
habit that occurs at one setting during
waking hours.
5. Level V (+/-)- girl under the age of 8 years
or a boy over the age of 8 years with
a habit that occurs cross multiple
settings during waking hours.
6. Level VI (+5) – girl over the age of 8 years
with a habit during waking hours.
14

15. CLASSIFICATION OF THUMB
SUCKING
A. According to Subtelny (1973)
 Group 1: Thumb placed into the mouth
beyond the first joint and occupies a large portion
of the vault of the hard palate, pressing against
the palatal and alveolar mucosa
15

16. Group 2: The thumb did not go completely into
the vault area of the hard palate,
however it usually entered into the
mouth, upto and around the first joint or just
anterior to it.
16

17. Group 3: the thumb passed fully into the hard
palate as in group one.
17

18. Group 4: The thumb did not progress appreciably
into the mouth. The lower incisors made contact
at the approximate level of the thumbnail
18

19. B. COOK (1958) DESCRIBED THREE
DISTINCT PATTERN OF THUMB
SUCKING.
Group I - pushes the palate in an vertical
direction and displayed only little buccal wall
contraction.
Group II- registered strong buccal wall
contraction and a negative pressure in the oral
cavity. This group showed posterior cross bite.
Group III- Altered positive and negative pressure
and showed the least amount of
malocclusion of any group.
19

20. ETIOLOGY
FREUDIAN THEORY :
This theory was proposed by Sigmund Freud.
He suggested that a child passes through various
distinct phases of psychological development of
which the oral and the anal phases are seen in
the first three-year of life. In the oral phase, the
mouth is believed to be an oro-erotic zone. The
child has the tendency to place his fingers or any
other object into the oral cavity. Prevention of
such an act is believed to result in emotional
insecurity and poses the risk of the child
indulging into other habits.
20

21. ORAL DRIVE THEORY OF SEARS AND
WISE:
proposed that prolonged sucking can lead to thumb
sucking with no underlying cause or psychological
bearing.
BENJAMIN’S THEORY:
Benjamin has suggested that thumb sucking arises
from the rooting reflex seen in all mammalian
infants.Rooting reflex is the movement of the
infant’s head and tongue towards an object
touching his cheek. The object is usually the
mother’s breast but may also be a finger or a
pacifier. This rooting reflex disappears in normal
infants around 7-8 months of age.
21

22. LEARNING THEORY BY DAVIDSON :
According to this theory, habit stems from an
adaptive response and assumes no underlying
psychological cause and is acquired as a result of
learning
22

23. OTHER FACTORS
Parent’s occupation
Can be related to socioeconomic status of the
family
Working mother
Children with working mother take onto sucking
habit to obtain secure feeling
Number of siblings
As the number increases the attention to the child
gets divided
Social adjustment & stress
can be due to peer pressure or scolding parents
23

24. DIAGNOSIS OF THE DIGIT SUCKING
HABITS
HISTORY
Determine the psychological component involved
Questions regarding frequency, intensity &
duration of the habit
Enquire the feeding pattern , parental care
Presence of other habits should be evaluated
The diagnosis can be obvious when the child is
actively performing the habit .however during a
dental appointment a child may seldom indulge
in this habit
24

25. 25
EXTRAORAL EXAMINATION
THE DIGITS
Digits involved will appear redened,
exceptionally clean & chapped
LIPS
Position of the lips at rest whether they are
held together or apart
Position of lips during swallowing should also
be seen
FACIAL FORM ANALYSIS
Check for mandibular retrusion, maxillary
protrusion,
When swallowing, patient is observed for
presence of a facial grimace or an excessive
mentalis muscle contraction
Facial profile is either convex or flat

26. INTRAORAL EXAMINATION
TONGUE-
examine for size & position of the tongue at rest
Tongue action during swallowing
DENTOALVEOLAR STRUCTURES
Digit apply an anterior force to the upper dentition
& palate
Flared & proclined maxillary anteriors with
diastema
Retroclined mandibular anteriors
Other intra oral symptoms-
buccal crossbite
Pronounced constriction of buccal musculature
Tendency to narrow palates
Measure overjet & overbite
GINGIVA
Look for evidence of mouth breathing
26

27. 27
WHAT HAPPENS TO YOUR CHILD’S
TEETH & THUMB???

28. Maxillary anterior proclination &mandibular
retroclination
Anterior open bite
Occurs due to
Interference with normal eruption of incisors due
to interposed thumb
Excessive eruption of posterior teeth due to
separation of the jaws , 1mm of elongation
posteriorly opens the bite by about 2mm
anteriorly
Constriction of maxillary arch
Failure of the maxillary arch to develop in width
due to an alteration in the balance between cheek
& tongue pressures
Posterior cross bite
Occurs as a consequence of constriction of the
maxillary arch
28

29. PREVENTION
Motive based approach
Child engagement in various activities
Duration of breast feeding
Mother’s presence and attention during bottle
feeding.
Use of a pacifier.
29

30. 30
HOW DO I STOP THUMB
SUCKING???
Palatal Crib
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31. PSYCHOLOGICAL THERAPY
Screening of patients for underlying psychological
disturbances.
Once determined—sent to psychologist for
counseling.
Thumb sucking between 4-8 years, needs only
reassurance, positive reinforcement, awareness can
be achieved by emphasizing positive aspects of habit
cessation.
Children and parents are informed about existing
dento facial deformities and long term risk of the
habit.
31

32. 32
DUNLOP’s BETA hypothesis
If a subject is forced to concentrate on a habit at
the time he practices it, he can learn to stop
performing the habit
The child should be ask to sit in front of a mirror
and ask to
Suck his thumb; observe himself as he indulges
in the habit.

33. 33
REMINDER THERAPY
Extraoral approaches
It employs hot tasting, bitter flavoured
preparation or distasteful agents that are applied
to finger and thumbs.
For example, cayenne, pepper, asfoetida.
Thermoplastic thumb post.
Intraoral approaches
Various orthodontic appliances are employed to
attenuate and eventually break the habit

34. MECHANOTHERAPY
Removable appliances—
palatal crib, rakes, lingual spurs, Hawley’s
retainer with or without spurs
34

35. FIXED APPLIANCES
Fixed intra oral anti thumb sucking appliance
Most effective method is an intraoral appliance
attached to the upper teeth by means of bands
fitted to the primary 2nd molar or permanent 1st
molar
Hence preventing the patient from putting the
digit in the mouth
Blue grass appliance
Quad helix
Prevents the thumb from being inserted &also
corrects the malocclusion by expanding the arch

35

36. 36
MOUTH BREATHING
Usually seen in people
with nasal obstruction.
May also occur as a habit.

37. Habitual respiration through the mouth instead
of the nose
CLASSIFICATION
FINN(1987)
Anatomic-short upper lip permits incomplete
closure
Obstructive-complete obstruction of the normal
flow of air through nasal passages
Habitual-continual breathing from mouth by
force of habit although abnormal obstruction has
been removed
37

38. ETIOLOGY
OBSTRUCTIVE/PATHOLOGICAL
Complete or partial obstruction of nasal passage
can result in mouth breathing. Some of the
causes for obstruction are:
•Deviated nasal septum
•Nasal polyps
•Chronic inflammation of nasal mucosa
•Localized benign tumors
•Congenital enlargement of nasal turbinate
•Allergic reaction of nasal mucosa
•Obstructive adenoids
38

39. 39
WHAT CAN HAPPEN DUE TO THIS???
Forward placement of
upper front teeth
Gap between upper & lower
front teeth
Improperly placed teeth

40. CLINICAL FEATURES
General effects
 Purification and humidification of inspired air
does not take place
 In oral respiration there is poor nasal resistance
and pulmonary compliance giving an
appearance of PIGEON CHEST.
 Lubrication of esophagus donot take place as
mouth breathers have a dry oropharynx and the
mucous collected is often expectorated, may lead
to mild ESOPHAGITIS.
Mouth breathers have 20% more CO2 and 20%
less O2 in blood.
40

41. Effects on the facial structures
Facial form
Large face height
Large mandibular plane angle
Retrognathic mandible &maxilla
Adenoid facies
Long narrow face with long
narrow nose, nasal passage &
flaccid lips
Nose tipped superiorly infront so
an observer can look directly into
the nares
41

42. Gingiva
Inflamed &irritated gingival tissue in the
anterior maxillary arch
Gingiva is hyperplastic due to continous exposure
of the tissues to air
Gingiva exhibits classic rolled margin with an
enlarged interdental papilla
Lip
Short thick incompetent upper lip and a
voluminous curled over lower lip
On smiling, patients reveal large amounts of
gingiva producing a ‘gummy smile’
42

43. 43
Dental effects
Upper and lower incisors are retroclined
Posterior cross bite
Tendency towards an open bite
Constricted maxillary arch
Flaring of incisors
Speech defects
Abnormalities of oral & nasal structures can
compromise speech & so nasal tone in voice is
seen
Other Effects
Mouth breathing may lead to otitis media and
loss of taste

44. DIAGNOSIS
History
Lip posture
Tonsillitis &allergic rhinitis
Examination
Mouth breathers when asked to inspire a deep
breath,will not appreciably change size &shape of the
external nares.
Clinical tests
Mirror test
Butterfly test
Waterholding test
Cephalometrics
Rhinomanometry
44

45. 45
HOW TO CONTROL MOUTH
BREATHING???
Use of an appliance called
‘ORAL SCREEN’
Incase of nasal abnormalities, consult ENT surgeon

46. TREATMENT TREATMENT
Treatment of mouth breathing
includes:

Elimination of the causeElimination of the cause

Interruption of the habitInterruption of the habit

Correction of malocclusionCorrection of malocclusion

Symptomatic treatmentSymptomatic treatment
46

47. ORAL SCREENORAL SCREEN
This is the most effective way to reestablish
nasal breathing, by preventing air from entering
oral cavity.
It is curved corresponding to the curvature of the
arch and is made of acrylic.
It works on the principle of both force
application and force elimination
The appliance has to be worn for 2-3 hrs during
the day and during the sleep at night.
47

48. MODIFICATIONS:MODIFICATIONS:
If patient feels difficult to breathe, then
multiple holes can be made that are
closed one by one over a period of time.
Hotz Modification- A metallic ring is
made and placed in the midline of the
appliance which will help to hold the oral
screen.
Double Oral Screen – an additional
lingual screen for tongue thrusting habit.
48

49. TONGUE THRUSTING
Tongue thrust is the forward movement of the
tongue tip between the teeth to meet the lower
lip during deglutition & in sounds of speech, so
that the tongue lies inter-dental (Tulley1969)
49

50. CLASSIFICATION
Physiologic
Normal tongue thrust swallow of infancy
Habitual
Tongue thrust present as a habit even after
correction of the malocclusion
Functional
When tongue thrust is an adaptive behavior
Developed to achieve an oral seal
Anatomic
Person having an enlarged tongue
50

51. ETIOLOGY
Retained infantile swallow
Upper respiratory tract infection
Neurological disturbance
Functional adaptability to transient change in
anatomy
Induced due to other oral habits
Tongue size
Hereditary
Feeding practices
51

52. CLINICAL MANIFESTATIONS
Extra oral findings
Lip posture- lip separation is greator in tongue thrust,
both at rest and in function.
Mandibular movements- More erratic, no correlation
between the movement of tongue and mandible.
Speech- speech disorders such as lisping, problems in
articulation of s, n, t, d, l, z, and v sounds.
Intra oral findings-
Tongue movements- swallowing movements are seen to
be jerky and inconsistent.
 Chin point is posterior as compare to normal
position.
Tongue posture- tongue tip at rest is lower in tongue
thrust group.
52

53. 53
Malocclusion-
Features pertaining to maxilla-
Proclination of maxillary anteriors resulting in
an increase overjet
Generalized spacing
Maxillary constriction

Features pertaining to mandible-
Retroclination or proclination of mandibular
teeth depending on type of tongue thrust present
Intermaxillary relationship-
Anterior or posterior open bite
Posterior teeth crossbite

54. DIAGNOSIS
History-
check for hereditary etiological factor.
Information regarding upper respiratory infection
,Sucking habits and neuromuscular problems
Examination-
Study the posture of the tongue
Observe the tongue during various swallowing
procedures
 Observe role of tongue during mastication &
speech
Intrinsic & extrinsic muscle action of tongue
Presence of grimace during swallowing 54

55. TONGUE THRUST
Simple tongue thrust
Anterior open bite
Normal tooth contact posteriorly
Contraction of lips, mentalis
Complex tongue thrust
Generalised open bite
Absence of contraction of lips, mentalis
Lateral tongue thrust
Posterior open bite with tongue thrusting
laterally
55

56. 56
WHAT’S THE SOLUTION???
Tongue crib
Oral Screen

57. TREATMENT
Tongue thrust often self corrects by 8 or 9years of age
by the time the permanent anteriors completely
erupts
TRAINING OF CORRECT SWALLOW & POSTURE
OF THE TONGUE:-
Myofunctional exercises
2S EXERCISES –
Using the pressure point on the papilla the SPOT is
shown .the tip is against this spot at rest position
SQUEEZE is done by squeezing the tongue
vigorously against this spot with the teeth closed ,
followed by relaxing.
4S EXERCISES
SPOT ,SALIVATE,SQUEEZE & SWALLOW
57

58. OTHER EXERCISES
Child is asked to whistle
Count from sixty to sixty nine
 Using appliance as a guide in correct
positioning of tongue
Nance palatal arch appliance
An acrylic button is used as a guide to place
the tongue in correct position

SPEECH THERAPY:-
1ST step should be training the correct
positioning of the tongue .not indicated
before 8 yrs.
58

59. MECHANOTHERAPY:-
Removable appliance therapy
Modification of hawley’s appliance
Advantages
Anchorage value gained from the acrylic
covering the entire palate
Capability of using Hawley to close the
anterior open bite through the use of the
labial bow
The crib can serve as a reminder
Fixed appliance
Crowns &bridges are given on the 1st
permanent molar&0.04 inch stainless steel ‘U’
shaped lingual bar is adapted by one side
extending to the canine anteriorly at the level
of gingival margin
59

60. Oral screen
For controlling abnormal muscle
habits like the tongue thrusting &at
the same time utilizing the
musculature to effect a correction of
the developing malocclusion
Palatal expanders
Can be used both in cases of tongue
thrusting & thumb sucking where
development of the palate is
hampered
e.g. hyrax palatal expander, schwarz
expander
Correction of malocclusion
Surgical treatment
60

61. 61
BRUXISM
Bruxism is the grinding or gnashing
of teeth, usually occuring at night
Causes
RAMFFORD[1966]
BRUXISM IS THE HABITUAL
GRINDING OF TEETH WHEN THE
INDIVIDUAL IS
NOT CHEWING OR SWALLOWING.

62. ETIOLOGY
1.PSYCHIC TENSION ASSOCIATED WITH ANY
KIND OF STRESS.
2.OCCLUSAL INTERFERENCE SUCH AS DUE TO
MALOCCLUSION.
3.INTESTINAL PARASITES.
4.SUBCLINICAL NUTRITIONAL DEFICIENCY
5.ALLERGY
6.ENDOCRINE DISTURBANCE.
62

63. 63

64. 64
TREATMENT
Counseling Occlusal Splint
Tranquillizers

65. ADJUNCTIVE THERAPY:-
•PSYCHOTHERAPY- COUNSELLING THE PATIENT
TO REDUCE EMOTIONAL AND PSYCHIC TENSION
•AUTO-SUGGESTION AND HYPNOSIS- PATIENT
BECOMES CONCIOUS OF NERVOUS
HABIT AND UNDERSTANDS THE POSSIBLE
CONSEQUENCE
•RELAXING EXERCISE AND PHYSIOTHERAPY
•ELIMINATION OF ORAL PAIN AND DISCOMFORT
65

66. OCCLUSAL THERAPY:-
•OCCLUSAL ADJUSTMENTS- BITE RAISING
CROWNS, SPLINTS AND ELIMINATION OF
OCCLUSAL INTERFERENCE
•BITE PLATES
•OCCLUSAL RECONSTRUCTION AND
PROSTHESIS
•BITE GUARD
66

67. HABITS THAT INVOLVE MANIPULATION OF
THE LIPS AND PERIORAL STRUCTURES ARE
TEERMED AS LIP HABITS
67
LIP HABIT

68. ETIOLOGY
Malocclusion
Deep bite malocclusion
Large overjet &overbite child wants to
produce normal lip seal during swallowing
Habits
Can occur in conjunction with thumb
sucking
Emotional stress
68

69. 69
Mouth ulcers
Spacing & flaring of
upper front teeth
E
ffe
c ts
Protrusion of maxillary incisors & retrusion of
mandibular incisors.
Reddened irritated & chapped area below the
vermillion border
 Mentolabial sulcus becomes accentuated

70. HOW DO I STOP???
Correction of malocclusion
Treating the primary habit
Lip habit along with digit sucking
can be corrected by hawley’s retainer
with labial bow
Appliance therapy
Oral screen
Lip bumper
It is positioned in the vestibule of
the mandibular arch &serve to
prohibit the lip from exerting
excessive force on the mandibular
incisors 70
Use of LIP BUMPER

71. NAIL BITING
BELOW 3 YEARS – ABSENT
4 TO 6 YEARS – INCIDENCE RISES SHARPLY
7 TO 10 YEARS – REMAINS CONSTANT
REACHS ITS PEAK AT ADOLSCENCE
71

72. ETIOLOGY
Insecurity
Psychosomatic successor of thumb sucking.
Nervous tension.
After the age of 15 the nail biting habit is
replaced by pencil biting, hair twirling or gum
chewing
72

73. 73
EFFECTS
Chapping of finger nails
Fungal Infection of fingers
Preventiong&&-x/,Ex.2n.<n
qxEEy3n
10q1E,2/y1n
.2E.n<x24y3n
2,x-1
Application of
bitter
substances
onto finger
nails

74. 74
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Sd.qq>n&x2n.&y2x24
Bobby pin opening Needle biting by tailors
Pencil Chewing
Wire chewing
by electricians
Bottle Opening

75. 75
EFFECTS
Chipping of
tooth edge
Notching of
tooth edge
Loss of tooth
vitality

76. 76
IMPROPER BRUSHING HABIT
Effects

77. REFERENCES
PRINCIPLES AND PRACTICE OF PEDODONTICS
BY ARATHI RAO
DENTISTRY FOR ADOLESCENT AND CHILD
BY DAVIDSON AND AVERY
TEXTBOOK OF PEDODONTICS
BY SHOBHA TANDON
TEXTBOOK OF PEDIATRIC DENTISTRY
BY DAMLE
PEDIATRIC DENTISTRY- PRINCIPLES & PRACTICE
BY MS MUTHU AND SIVAKUMAR
 ORTHODONTICS- ART AND SCIENCE
BY SI BHALAJHI
77

78. 78
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