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Good Morning

Success is the sum of small efforts,repeated day in and day out.

- Robert Collier

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Symposium on ORAL HABITS

Batch 2010-2013

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1) Normal oral musculature2) Historical background, beliefs,

definition, classification of habits

3) Etiology, theories, factors influencing the development of habits

4) Diagnosis, clinical features & its influences on occlusion

5) Treatment planning – behavioral therapy, mechanotherapy

6) Recent views & case reports.

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A habit is the result or is a sign of lack of harmony between the child and his/her environment

When the child cant adjust to a sudden change in the environment

INTRODUCTION

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Certain oral habits are considered normal in infancy, for eg.sucking

These are essential for survival of child and psychologic maturation

Believe that it is a normal sequence of maturation

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Schroeder et al.in 1983 quoted that

When the behavior continues longer than is typical

When the behavior becomes severe enough to cause physical damage

When it interferes with ongoing physical,social & cognitive development

Habit …..a problem..?

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Buccinator mechanism

Rationale behind …..

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Numerous biologic and environment factors

Acquired by imitation

Infuse a certain sense of security and comfort

How the habit develops….

Presented by

Dr.Dhanraj

Post graduate student

Etiology &Factors Influencing Development

Of Oral Habits

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The term pernicious means tending to a fatal issue

When the habits involving the oral cavity becomes fatal

Pernicious oral habit

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Degree to which they interfere with child’s physical, emotional or social functioning

Duration Intensity Frequency

Factors that make a habit pernicious

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Klein – Empty habits Meaningful

Morris &Bohanna:Pressure habitsNon pressure habitsBiting habits

Classification of oral habits

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According to Brash:Purely muscularCombined activity of the muscles of the

jaws,mouth and thumbMuscular action combined with

introduction of passive objectNo active part by muscles ,only extraneous

pressureFunctional disturbance

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Finn classificationNon compulsiveCompulsive

William JamesUseful Harmful habits

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In a prevalence study conducted in 1998 by Munshi et al.

Out of the selected population ,29.7% children had oral habits

Common oral habits

J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6.

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Age group of 3-6 years - Digit sucking, pencil biting and tongue thrust

Age group of 7-12years- Mouth breathing and bruxism

Age group of 13 -16 years- lip/cheek biting and nail biting

Age group and oral habits

J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6.

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Digit sucking, tongue thrust, mouth breathing and bruxism were more prevalent among the boys

Lip/cheek biting, nail biting and pencil biting were more prevalent among the girls

Sex and oral habits

J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6.

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A recent study conducted in 2003 reveals that

Thumb sucking was common in girls

Mouth breathing was more common in boys

Sex and oral habits

J Indian Soc Pedo Prev Dent September (2003) 21 (3) 120 - 124

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Thumb or digit sucking Tongue thrusting Mouth breathing Lip biting habits Nail biting Cheek biting Bruxism Masochistic habits

Most common oral habits …

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THUMB SUCKING

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Thumb sucking or digit sucking is defined as, “the placement of thumb or one or more fingers in varying depths into the mouth”

Other terms used are non-nutritive sucking and finger sucking habits

Most prevalent with a reported incidence that ranges from 13 to 100 % ,decrease with age

Thumb sucking

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PSYCHOLOGICAL FACTORS

SOCIAL OR ENVIRONMENTAL FACTORS

ETIOLOGY BEHIND ……

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First coordinated muscular activity of the infant

Active movements of infants circumoral musculature

Lasts for approx.12 months

SUCKLING REFLEX

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Tongue is relatively large and positioned forward

Tip protrudes through the gum pads

Visceral or infantile swallowing

In the newborn…

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In breast feeding,gums are apart and tongue is brought forward in a plunger like fashion

Mandible moves up and down and forward and backward

Buccinator also contracts and relaxes

Oral gratification

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Child feels the warmth of the breast not only in the area of contact but well away from the mouth

Enhances the feeling of euphoria

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When the object is liked by the infant ,it tries to take it inside her mouth which is called as introjection

When the object is not liked ,it rejects it

This reflex not only serves to relieve the hunger but also makes it to feel what is good and bad

Rejection and Introjection

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Using these past satisfying experiences,the child is able to provide some secondary gratification

The thumb here acts as a substitute for the mother

Implication ….

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Classical Freudian theory

Rooting reflex

Lack of function

Oral Drive theory by Sears and Wise

Learned behavior

Psychological factors

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Sigmond Freud - 1905 – five stages of psychosexual development

Each stage,there was a errogenous zone

According to him,oral cavity served as a errogenous zone in the first year of life

PSYCHOANALYICAL THORY

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Child derives sexual pleasure during the suckling reflex

If there is frustration or overindulgence of oral needs during infancy,it results as an oral habit.ie.prolongation of finger sucking

What happens…

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Peterson (1968) - lack of love and affection during breast feeding

Massler & Wood - parental rejection or pressure

Sheldon – emotionally disturbed children showed habit patterns

Kawata – parental displeasurement,admonition and punishment – emotional crisis

Supporting this theory…..

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Finger sucking of the neonates is the continuation of their neonate reflexes.i.e.rooting and placing

Innate activity of infants for the first three months

Rooting – sudden turning of the head towards the stimulus

Placing – subsequent contact of the mouth with the stimulus

Rooting reflex

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Improper or insufficient suckling in the infancy

Levy et al. believes – forced premature curtailing of suckling or effortless sucking from bottle

Sheldon – when more effort is expended ,there is less likelihood of developing habit

Rationale based on oral drive gratification

Lack of function

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This theory also agrees with Freudian concept

Based on learning theory

More a baby learns to associate sucking with the satisfaction of hunger,being held and other pleasures ,the more he will engage in non nutritive sucking habits later

Oral drive theory

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Based on the laws of conditioning

Sucking – Intake of food,attention from parents and release of aggression

Conditioning and stimulus generalization

Positively reinforced habit –Finger sucking

Finger Sucking –A learned Behaviour

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By Larsson and johnson (1997)

Digit sucking is a combination of psychoanalytical and learning theory

Recent view

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Keep in mind that there may be a psychological origin for its persistence

Be prepared for psychologcal damage from faulty intervention

Before treating….

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Still remains debatable

Klein – beyond 3.5 yrs –abnormal Massler – at 3.5 yrs –stopped Haryett et al. – problem over 4 years

Finger sucking beyond 4 years is abnormal & it should be treated

WHEN TO CONSIDER ABNORMAL AND TREAT..

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It refers to pacifier sucking habit

Pacifier use, which is the most common non-nutritive sucking habit, is usually introduced by parents to calm the child, not as an extra suction activity

Pacifier use alters occlusal development, depending on the intensity, frequency, and duration of the habit

DUMMY SUCKING

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Prevalence of 75% to 79% in industrialized western countries in recent decades

A study conducted by Larsson et al..clearly states the fact..

He compared prevalence of Swedish & African children

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Infant has a sucking urge in surplus amount

This can be satisfied by breast ,bottle and cup feeding

If the sucking urge is not satisfied,child finds satisfaction by non nutritive sucking ,thumb or dummy sucking

Reasons…

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Age Gender Race Pacifier Feeding methods Siblings Parental socioeconomic status

INFLUENTIAL FACTORS

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Many studies reported the prevalence of thumb sucking

Age and thunb sucking

Levin and Kaye et al.1964Singhal and Bhattia ,1988Garathini et al.1990

17% in 2-5years45% in 7yrs

Tandon et al.2006 Higher prevalence in 3-5 yrs and 6-8yr old

Traisman et al.1956 Low incidence in preschool children

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Author result

Levin & Kaye et al,1964 No correlation

Traisman A.S. and Traisman H.S,1958

Sucking habits are equivalent for males and females until the age of 1 year

Shoba Tandon et al.2006 More common in females, because males give up the habit earlier

Gender

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Higher incidence in the Western countries i.e.80-90 % of children

Low prevalence in Negroid race

Non-existent in Eskimos

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Race

Moore M.B. Digits, Dummies and Malocclusions. Dental Update 1998

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Author name Conclusions

Levy ,1928 Higher incidence in low duration breast fed children

Robert,1944 Longer feeding leads to habit

Yarrow et al.,1954 Related to amount of time spent in feeding

Tandon et al.2006 Low duration of breast feeding

Feeding methods

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No correlation between the level of habit and the number of siblings – Larsson et al,1971

Recent evidence shows that if the second child is female and the first sibling is a male,then there is a higher incidence (Tandon et al.2008)

Siblings

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Low socioeconomic groups – Higher incidence of dummy sucking

High socioeconomic groups – high incidence of digit sucking

Socioeconomic status

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Phase I – birth to 3 years Normal and subclinically significant Preventive measures can be applied

Phase II – extends from 3 to 6-7years Clinically significant sucking Habit correction is must

Phase III –Intractable sucking Serious problem Requires psychotherapy

Three distinct phases

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Agreement that if the habit continues beyond the age of 6-7 months,it is difficult to break until the child is 4-5 yrs of age

Should be viewed by a clinician as a behavioral pattern of multivariate in nature

Various thoughts….

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Suckling reflex

Digit sucking is a learned habit

Factors influencing digit sucking

Three phases

Points to ponder…..

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TONGUE THRUSTING

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Tongue thrust is defined as a condition in which the tongue makes contact with any teeth anterior to the molars during swallowing

Tulley(1969 )- states 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.”

Schneider et al.(1982) ,states that tongue thrust is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing

DEFINITION

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Physiologic Habitual

Functional

Anatomic

Classification of Tongue Thrust

Dent Clin NorthAm. 2000 Jul;44(3):659-69.

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Fletcher has proposed the following factors

Genetic

Learned Habit

Induction due to other habits

Psychogenic factors

Etiology of tongue thrusting

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There are complexity of factors Tendency towards allergies & upper

respiratory congestion Extremely high or narrow palatal arch Unusually large tongue Deviated nasal septum Hypertonicity of orofacial musculature Imbalance between the number of teeth

and size of oral cavity

Genetic factors

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Improper bottle feeding Prolonged thumb sucking Prolonged tonsillar and upper respiratory

tract infections Prolonged duration of tenderness of gum or

teeth can result in a change in swallowing pattern to avoid pressure on the tender zone

Tongue thrust ….a learned behavior

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Easy flow of milk through light sucking is ensured

In order to stop the abundant flow,infant is forced to hold the tongue forward against the hole in the nipple

Thus the perverted tongue thrust habit is initiated

Bottle feeding

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Antagonistic muscles to orbicularis oris are activated leading to everted lips

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Subtelny stated that there is no much significant difference in the pattern of feeding and tongue thrust

Weinberg et al.attained the same conclusions

Najera et al.(1963).stated that the breast fed babies had a lower incidence of tongue thrust

Several studies,,,,

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Results in an anterior open bite

Tongue thrusting occurs as a compensatory mechanism

Forms a lip tongue seal during swallowing act instead of lip lip seal

Prolonged thumb sucking

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Moyers stated that tongue thrust is a residuum of thumb sucking

He explains that since it open the bite it induces malfunction of tongue in deglutition

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Upper respiratory tract infections

Push the tongue forward due to pain and decrease in the amount of space which brings about a tongue thrust swallow.

It may also be present due to the physiological need

to maintain an adequate airway.

Prolonged respiratory infections

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Tongue thrust occurs when the incisors are missing.

Following the loss of deciduous teeth and prior to full eruption of the permanent incisors

The tip of the tongue may protrude into the open area during swallowing

Functional adaptation(Rogers)

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May disappear with the eruption of permanent centrals

May happen in the posterior region during transition

This is a form of adaptive tongue thrust

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Hansen and Cohen et al.found an increased incidence of tongue thrust in 6 yr old children after a follow up upto 12 yrs

They stated that it is due to exploratory excursion of the tongue

This type of transitional tongue thrust account for a considerable amount

Studies

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Induction due to other habits

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Retained infantile swallow

The infantile swallow changes to a mature swallow once the posterior deciduous teeth start erupting.

Poorest prognosis

Maturational problems

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Hypersensitive palate

Moderate motor disability

Poor sensory control and coordination of swallowing

Neurological disturbances

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Narrow maxillary arch

Macroglossia

Enlarged adenoids

Mechanical restrictions

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Sleeping patterns may be an etiologic factor

When patient sleeps on one side,the tongue rest in the mandibular arch and moves forward

Dewel in his study found that unilateral tongue thrust may result from sleeping patterns

Sleeping habits

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Because of the consistency of diet

Oral laxity is encouraged

Underdeveloped orofacial muscles

Because of disuse tongue,it spreads between the teeth

Soft diet

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Faulty prosthesis given by dentist

It has been found that there is a deviation in swallowing pattern leading to tongue thrust in those patients

Oral trauma

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Classification (Brauer & Holt)

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Genetic

Maturational

Induced due to other habits

Infections

Transitional

Points to ponder….

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MOUTH BREATHING

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A mouth breather is one who breathes orally even in relaxed and stressful situation

Defined as habitual breathing through mouth instead of nose

Mouth breathing

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Nasal breathing

Nasal airways help to filter and humidify the air while entering through the respiratory passage

Normal breathing

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Obstructive

Habitual

Anatomical

Classification

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Hypertrophy of nasal turbinates

Deviated nasal septum

Enlarged adenoids

Resistance to nasal breathing

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Anatomical and developmental abnormalities

Infection and inflammation

Localized benign tumors

Traumatic injuries to nasal cavity

Genetic Pattern

Thumb sucking

Etiology

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Jaw deformity

Compromised airway

Altered head, neck and body posture

Bad breath and gum disease

Consequences

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Low immune response

Obstructive sleep apnea

Poor oxygen saturation

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Systemic

Anatomic deformities

Induced

Points to ponder….

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LIP HABITS

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Defined as a habit that involves manipulation of lips and perioral structures

May involve either of the lips

Predominance of lower lip

Lip habits

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Lip wetting

Lip sucking /pulling

Classification

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Malocclusion

In conjunction with digit sucking and tongue thrusting

Emotional stress

Etiology

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The most common is the lower lip tucked behind the upper incisors

This places a inward force directly towards the tongue on the lower incisors. At the same time it creates an outward force on the upper incisors.

These forces cause the upper teeth to be pushed out and the lower teeth to be pushed inward.

This problem is most common in mixed dentition (baby and permanent teeth), and permanent teeth.

Clinically…..

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NAIL BITING

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Onychophagia, or nailbiting, is a common oral habit, observed in both children and adults

Onychophagy is classified as a nail disease caused by repeated injuries

Nail biting as autodestruction and onychophagy are its most aggressive forms

Onchyophagia

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The need to bite and even to eat fingernails is linked to a psycho emotional state of anxiety.

A child, by biting his or her nails, is exhibiting an evolutionary disturbance linked to the oral stage of psychological development

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Greater incidence is seen between the ages of 4 and 6

Stabilizes from 7 to 10and increases considerably during adolescence,

The incidence of nailbiting is relatively equal up to 10 years of age, but thereafter significantly fewer girls than boys are nailbiters

Incidence

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Anxiety

Psychic disorders

Transference of the thumb-sucking habit

Etiology

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Although nail biters have more anxiety than those without the habit, no significant difference was found when relating onychophagia to anxiety

Others explain it as a family trend, probably due to imitation

Anxiety

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Nail biting is common habit

Attention deficit hyperactivity disorder (74.6%),

oppositional defiant disorder (36%),

separation anxiety disorder (20.6%)

compulsive disorder (11.1%)

Psychic disorders

Child and Adolescent Psychiatry and Mental Health 2008, 2:13

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According to Massler and wood ,it is a continuation of thumb sucking habit after 3 years

Another form of oral gratification

Wechsler in 1931 ,also has stated that as the child discontinues thumb sucking ,it will be transferred as nail biting

Thumb sucking

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Is the most common habit in times of stress

After adolescence, onychophagia is usually replaced by the habit of lip “pinching,” chewing of pencils or other objects, nose scratching, or hair twirling.

In adults,smoking or gum chewing seems to be a more common substitute, because these are socially accepted methods of oral gratification

In adolescents…

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Malocclusion of the Incisors

Crowding, rotation, and attrition on the incisal edges of the mandibular incisors and protrusion of the maxillary incisors

Apical root resorption of the teeth

Nail bed infection

Consequences

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BRUXISM

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Defined as the clenching or grinding of teeth when not masticating or swallowing

Is a pathologic activity of stomatognathic system which involves grinding or clenching during parafunctional movemtns

Bruxomania – during day time

Bruxism or sleep bruxism

Bruxism

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Jaw is open during sleep and tooth contact can take place only during sleep arousal

CNS is mostly involved rather than the autonomic nervous systems

Mostly seen during REM sleep

Pathogenesis

Crit Rev Oral Biol Med 2003

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Related to growth and development of occlusion

Improper occlusion

Eruption

Tension ,anger

Pain due to ear ache or teething

In children….

Acta otorhinolaryngol Ital 2004

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Intestinal parasite infestations

Subclinical nutritional deficiency

Endocrine disturbances

Other etiologies

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Ranges from 7 to 15%

Males are more common than females

Prevalence

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MASOCHISTIC HABITS

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Term in German meaning pleasure in being abused or dominated : a taste for suffering

Termed as sado masochistic habits

Repetitive acts that result in physical damage to the individual

SELF MUTILATING HABITS

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Organic

Functional

Etiology

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Lesch Nyhan syndrome

DeLanges syndrome

Tourette syndrome

Organic syndromes

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In Lesch Nyhan syndrome, there is a deficiency of hypoxanthine-guanine phosphoribosyltransferase (HGPRT)

High concentrations of uric acid

Affects the inhibitory centres of basal ganglia

Lower pain threshold

What happens…

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Type A- Injuries superimposed on a pre-existing lesion

Type B –Injuries secondary to an established habit

Type C –unknown etiology

Functional

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A clinician should know about the oral habits & diagnose whether it is normal or abnormal

Knowledge of etiology plays an important role in the assessment

Proper treatment plan can be designed for an individual

To summarize…..

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Orthodontics –Principles & Practice –Graber -3rd edition Oral Myofunctional Disorders – Richard Barrett Pediatric Dentistry –Infancy through Adolecence – Pinkham -4th edition J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6. J Indian Soc Pedo Prev Dent September (2003) 21 (3) 120 – 124 Text book of Pedodontics –Shoba Tandon -2nd edition Annals & Essence of Dentistry 2009:1(3):14-23 Child and Adolescent Psychiatry and Mental Health 2008, 2:1-3 ASDC J Dent Child 1975 Aug :295-98 Am J orthod 1985:87(5):432-5 ASDC J Dent Child 1996 :321-8 Text book of pediatric dentistry – Nikhil Marwah Textbook of Pediatric Dentistry – MS Muthu Principles & practice of Pedodontics –Arathi Rao Pediatric Dentistry – 25:5, 2003:448-58 Am J Orthod Dentofacial Orthop 2008;134:305-8 West Indian Med J 2010; 59 (1): 92-95 www.google.co.in www.pubmed.gov.in www.en.wikipedia.org

References

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