ORAL HABITSPRESENTED BY: ROSHNI MAURYA

DEPT. OF PEDODONTICS AND PREVENTIVE

DENTISTRY, GNIDSR

INDEX Introduction

Definition

Classification

Development of a habit

Etiological agents in development of a habit

Oral habit therapy

HABIT make or break

INTRODUCTION

• HABIT is a way of acting through fixed repetition. • The word HABIT is such that when the letter “H” is removed, “A

BIT” remains;• When the letter “A” is removed, “BIT” remains; • When the letter “B” is removed, “IT” still remains. • This implies the persistence of act and interference with regular

pattern of facial growth.

• As the mouth is the primary and permanent location for expression of emotions and even is a source of relief in passion and anxiety in both children and adults, stimulation of this region with tongue, finger, nail or cigarette can be a palliative action (BEAR AND LESTOR, 1987).

Though it is difficult to delineate it, but it is important to have differentiation of abnormal from normal because, if normal development get disturbed unknowingly and at the same time, if abnormal growth or underlying psychological cause let continue without interfering at proper time/age it will lead to long lasting effect on growth & development and

psychological development of child.

ORAL HABIT

PedodontistOrthodontist

PediatricianPsychologist

Speech Pathologist

Parents

• The form- function interaction includes both the effects of active movement and subtle but long-lasting effects of the soft tissues on the developing skeletal and dental structures.

• For dentofacial development, the influences of the soft tissues at rest (postural activity) are more important than the effects of muscle contraction and jaw movements.

• In other words, how one posture their lips, tongue, and jaw is a more important influence on the pattern of growth than how one move them.

DEFINITION:

It is a tendency towards an act which has become a repeated

performance relatively consistent , fixed and easy to perform by an

individual.( boucher oc)

According to, Dorland(1957):Habit can be defined as a fixed or constant practice established by frequent repetition.

Butterswort(1961):efined a habit 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.

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.

ORAL HABIT

OBSESSIVE ( DEEP ROOTED)

NON-OBSESSIVE(EASILY LEARNED AND DROPPED)

INTENTIONALOR

MEANINGFUL

MASOCHISTIC ORSELF-INFLICTING

UNINTENTIONALOR

EMPTY

FUNCTIONALHABIT

Nail bitingDigit suckingLip biting

Gingivalstripping

Abnormal pillowingChin propping

Mouth breathingTongue thrustingBruxism

CLASSIFICATION (CONT’D)ACCORDING TO,

Non pressure habit Pressure habitMORIS & BOHANNA(1969) Biting habit

Intentional habits (meaningful)Klein classification(1971)

Non intentional habits(empty habits)

Finn (1987) a) Compulsive habits Non compulsive habits

b)Primary habitsSecondary habits

william James(1932)

Useful habitsHarmful habits

Kingsley(1958)

Functional oral habitsMuscular habitsCombined ones.

Classification (cont’d)

General considerations when deal with oral habits

1. Can the habit considered normal for particular age?

2. Why child has acquired the habit?

3. Psychological implications of allowing habit to continue?

4. Is the habit harmful/potentially harmful?

5. Does harmful effects subside or persist after habit

discontinuation?

6. Reasonable time to break the habit?

7. How to break the habit?

UNDESIRABLE ORAL HABITS IN CHILDREN

• DIGIT SUCKING• PACIFIER SUCKING• TONGUE THRUSTING• LIP HABITS• MOUTH BREATHING• CHEEK BITING• FRENUM BITING• BRUXISM• NAIL BITING• POSTURAL HABITS• MASOCHISTIC HABITS• TONGUE SUCKING• CLENCHING• OCCUPATIONAL HABITS

COMMON HABITS SEEN ON CHILDREN

1. Thumb sucking

2. Tongue thrusting

3. Mouth breathing

5. Bruxism

6. Lip biting

7. Nail biting

DEVELOPMENT OF HABIT:

• Development of habit should not be confused with one normal developmental phenomenon instinct.

• Newborn infant develops some instincts composed of elementary reflexes. An instinct is one where the pattern and order are inherited while in habit, pattern and order are acquired.

• If these acquired pattern and order are repeated over a long period of time, it becomes habit.

THE DEVELOPMENT OF VARIOUS REFLEXES -INTRAUTERINE LIFE

• By 14th week of intra uterine life- stimulation of lips causes the tongue to move

• At about the same time stimulation of upper lip causes mouth closure and even deglutition

• Gag reflex develops by about 18 ½ weeks• Respiration by about 25 weeks• Sucking by 29 weeks• Sucking and swallowing by 32 weeks.

Sensory guidance for all activities including jaw movements covers a large area and includes multiple contacts for sensory inputs (tongue, lips, soft palate, posterior pharyngeal wall and TMJ.

A brief review of the forces acting on the bony structures to shape them during the developmental stages helps us in understanding the changes that pernicious oral habits can bring about in the oral architecture.

SOME ANTAGONISTIC FORCES ACTING ON THEMASTICATORY APPARATUS

• Lip – tongue• Cheeks – tongue• Eruption of teeth – masticatory muscles masseter, temporalis

and medial pterygoid)

• Air pressure of the skin - tongue (in closed mouth)• Air pressure in nasal cavity –tongue (open mouth)

• Masseter – elasticity of periodontal ligament (particularly of molars and suprahyoid muscles).

• Internal pterygoid – same as masseter in vertical movement.

• External pterygoid in anterior movement –posterior one third of temporalis, suprahyoid group, digastric and muscles of neck.

• External pterygoid in lateral movement –external pterygoid of opposite side

• In 1942, BREITNER stated that 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. He called this as functional equilibrium.

BUCCINATOR MECHANISM

• Muscles are a potent force, whether they are in active function or at rest. A resting muscle still is performing a function that of maintaining posture and a relationship of contiguous parts. The teeth and supporting structures are constantly under the influence of the contiguous musculature. Aberrations of muscle function can and do produce marked malocclusions. The restrictive, guiding role of the buccinators mechanism must be emphasized.

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.

At this point it intermingles with fibers of the superior constrictor muscle and continues posteriorly and medially to anchor at the origin of the superior constrictor muscles, the

pharyngeal tubercle of the occipital bone. Opposing the buccinator mechanism is a very powerful muscle the tongue. Balance between these muscle forces is very important. Any

deviation in these reflexes or mechanism leads to malocclusion.

GENERAL ETIOLOGY OF ORAL HABITS.

• According to Freud, the persistence of sucking habits and the appearance of biting habits have been associated with an arrest in evolution(fixation) of psychosexual oral phase.

• Orofacial neuromuscular components in a newborn primarily function for fulfillment of the most basic needs of feeding, maintenance of the airway and gratification of oral needs.

• In a newborn, the sucking reflex is very well developed which take care of his/her feeding and emotional needs.

ORAL HABIT THERAPY• When need for active intervention ,particularly appliance

therapy is considered , a number o factors are involved:• Age of patient• Maturity of patient• Parent cooperation• Timely deliberation• Assessment of deformity

Thumb sucking

THUMB SUCKING

• Thumb sucking is defined as placement of the thumb or one or more fingers in varying depths into the mouth.

• Thumb and digit sucking is one of the commonly seen habits that most children indulge in.

• Recent studies have shown that thumb sucking may be practiced even during intra uterine life.

• The presence of this habit is considered quite normal till the age of 3-4 years. Persistence of the habit beyond this age can lead to various malocclusions

CLASSIFICATIONNormal thumb sucking• It is considered normal during 1st & 2nd year of life.• It disappears as the child mature.• The habit at this age does not generate any malocclusion.• Abnormal thumb sucking• It is considered abnormal when thumb sucking habit persist beyond the preschool period.• If the habit is not controlled or treated during this age it may cause deleterious effect to the

dento facial structure.

This again classified as:-a) Psychological The habit may have a deep rooted emotional factor.b) Habitual The habit does not have a psychological bearing.

SUCKING HABITS

Nutritive Sucking• Breast feeding• Bottle feeding

Nonnutritive Sucking

• Thumb sucking• Pacifier sucking• Others (blanket)

36

SUCKING REFLEX

37

• Stimulates muscles around the mouth and tongue activity for normal growth.

• Allows milk flow on demand

• Allows gravity working correctly on muscles involved.

• Muscles don’t work hard, normal growth affected.

• Milk flows in continuous flow, muscles don't work

• Keeps tongue in unnatural forward position.

GRADES OF DIGIT SUCKING:

• Subtelny (1973) has graded thumb sucking into 4 types:

• Type A• Type B• Type C• Type D

39

• According to Crook:• Alpha group – the thumb pushes the palate in a

vertical direction and displays little buccal wall contractions

• Beta group- Strong buccal wall contractions are seen and a negative pressure is created resulting in posterior cross bite

• Gamma group – alternate negative and positive pressure is created.

level DescriptionClassification of NNS habits by Johnson 1993

Level I (+/-)

Level II (+/-)

Level III (+/-)

Level IV (+/-)

Level V (+/-)

Level VI (+/-)

Boys and girls of any chronological age with a habit that occurs during sleep.

Boys below the age of 8 with a habit that occurs at one setting during waking hours.

Boys under the age of 8 with the habit that occurs at multiple settings during the waking hours

Girls below the age of 8 or boys above the age of 8 with a habit that occurs at one setting during waking hours.

Girls below age of 8 or boys above the age of 8 with a habit that occurs across multiple settings during waking hours.

Girls over the age 8 with a habit during the waking hours.

PHASES OF DEVELOPMENT• Phase I: (Normal and Sub-clinically significant). The first phase is

seen during the first three years of life. The presence of thumb sucking during this phase is considered quite normal and usually terminates at the end of phase one.

• Phase II: (Clinically Significant Sucking): The second phase extends between 3-6 years of age. The presence of thumb sucking during this period is an indication that the child is under great anxiety. Treatment to solve the dental problems should be initiated during this Phase.

• Phase III: (Intractable Sucking) : Any thumb sucking persisting beyond the fourth or fifth year of life should alert the dentist to the underlying psychological aspects of the habit. A psychologist might have to be consulted during this phase.

ETIOLOGY

• A number of theories have been put forward to explain why thumb sucking occurs. The following are some of the more accepted ones:

1. Classic Freudian theory. (Sigmund Freud, 1905) 2. Learning theory. (Davidson 1967)3. Oral derive theory. (Sears and Wise 1982) 4. Rooting and placing reflex theory. (Johnson and Larson1993)

MATURATION OF ORAL FUNCTION

• With the eruption of the lower incisors the tongue starts retracting and muscular activity shifts from the anterior perioral region to the posterior region, of the tongue, pharynx and masticatory muscles, with the eruption of posterior teeth the tongue starts retracting laterally between the gum pads

MAINTENANCE OF THE HABIT

• Most children would stop digit sucking by the age of three to four years.

• But an acute increase in child’s level of stress and anxiety due to some underlying psychological or emotional disturbances can account for continuation of digit sucking habit, with conversion of an empty habit into a meaningful stress reducing response.

AGE OF CHILD & CO-RELATION

• In the neonates – insecurities are related primitive demand as hunger.

• During 1st few weeks of birth – related to feeding problem

• During eruption of primary teeth – it may be used to relieve teething.

• Possible etiologic factors:

• Parent’s occupation• Working mother• Number of siblings• Order of birth of child• Social adjustments• Feeding practices• Age of the child

47

DAMAGE TO PRIMARY DENTITION RESULTING FROM THUMB AND FINGER(DIGIT) SUCKING BY OSAMU FUKUTA NOV.1996

• The study was to investigate relationship between thumb or finger sucking in malocclusion, 930 subjects meet the following inclusion criteria were selected from the original 2180 children

• Those who only indulge in digit sucking,

• Those with no oral habits

• Subjects with complete primary dentition and no permanent teeth erupting.

• This study investigated the effect of thumb and finger sucking on the antero posterior regions of the primary dentition of children 3-5 years of age. Around 19.8% of children were found to suck finger or thumb.

• At all ages the frequency of open bite and maxillary protrusion for the thumb sucking groups were higher than non oral habit group.

• In the five year old children the mesial step terminal plane type of thumb sucking group demonstrated significantly lower malocclusion frequencies and the distal step terminal plane type significantly higher frequencies than those of the non oral habit group. There was an increased tendency to a permanent malocclusion in distal step type in children who continued after 4 years of age.

• The results of this studies suggest that thumb and finger sucking should be eliminated before damage is done to the terminal plane. It would appear to be between 3-4 years of age.

NON-NUTRITIVE SUCKLING HABITS IN BRAZILIAN CHILDREN: EFFECTS ON DECIDUOUS DENTITION AND RELATIONSHIP WITH FACIAL

MORPHOLOGY BY CINTIA REGINA AJO 2004

• The study was to assess the relationship between non nutritive suckling habits, facial morphology and malocclusion in all three planes of space, in four year old children attending state school.

• Conclusions drawn from these studies are prevalence of malocclusion the sample was high 49.7% and 28.5% of the children had association of 2-3 malocclusion factors(posterior crossbite, anterior open bite increased overjet).

• The assessed malocclusions were strongly associated with nonnutritive suckling habits.

• The results drawn attention to the magnitude of the problem of malocclusion in childhood and emphasize the need of longitudinal studies to provide scientific evidence.

CHANGES ASSOCIATED WITH THUMB SUCKING

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

DIAGNOSIS OF DIGITAL HABITS:

1) History 2) Extra oral examination a) The digits b) Lips c) Facial form d) Other features3) Intra oral examination a) Tongue b) Dent alveolar structures c) Gingiva

DIAGNOSIS:

1. History:

• Enquire the feeding pattern and parental care.• Questions regarding the frequency, intensity

and duration of habit.• Presence of other related habits e.g. tongue

thrust etc should be evaluated.53

EXTRA ORAL EXAMINATION

• Digit• Reddened, clean, chapped, short fingernail (dishpan thumb)

• Chronic suckers - fibrous, roughened callus on superior

aspect of finger• Deformation of finger

• Lip• Position at rest, During swallowing• Hypotonic upper lip• Hyperactive lower lips

FACIAL FORM ANALYSIS

• Maxillary protrusion

• Mandibular retrusion

• High mandibular plane angle

• Profile

• Mentalis muscle contraction

INTRAORAL EXAMINATION

• Tongue • Position at rest , during

swallowing

• Gingiva• Evidence of mouth breathing

• Etching of gumline• Staining on max. labial surface

DENTO ALVEOLAR STRUCTURE

• Flared , proclined maxillary anteriors with diastema

• Retroclined mandibular anteriors

• Deformed right or left sided max. arch

SUCKING HABITS AND FACIAL HYPERDIVERGENCY AS RISK FACTORS FOR ANTERIOR OPEN BITE IN THE MIXED DENTITION AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS OCTOBER 2005COZZA ET AL

The aim of this study was to evaluate sucking habits and hyperdivergency as risk factors for anterior open bite in mixed-dentition subjects. Pretreatment cephalometric records of 1710 mixed-dentition subjects were assessed for sucking habits, dental open bite, and facial hyperdivergency.

Multiple logistic regression showed that both prolonged sucking habits and hyperdivergent vertical relationships significantly increased the probability of an anterior dentoalveolar open bite, with a prevalence rate of 36.3%. Conclusions: Prolonged sucking habits and hyperdivergent facial characteristics are significant risk factors for anterior open bite in the mixed dentition.

58

DENTOFACIAL CHANGES ASSOCIATED WITH PROLONGED SUCKING HABIT

• Effects on maxilla• Maxillary arch length• Clinical crown length of incisors• Counterclockwise rotation of occlusal plane• Atypical root resorption• Trauma to incisors

• Palatal arch width

• Increased SNASN

A

EFFECT ON MANDIBLE

• Proclination of incisors (Finger sucking)

• Increased Distal position of B point

EFFECT ON INTERARCH RELATIONSHIP

• Anterior open bite

• Increased over jet

Increased unilateral and bilateral Cl II malocclusion

Decreased U/ L incisal angle

• Decreased overbite

• Increased posterior cross bite

SEQUELAE OF THUMB SUCKING• Anterior openbite – interference with occlusal movement of the incisors. This

openbite can lead to tongue thrusting problems and speech difficulties.• 2. Proclination and spacing of the maxillary anterior teeth if thumb is held

upward against the palate. Prominences of this labially posed incisor make them particularly vulnerable to accidental fractures.

• 3. Increased overjet.• 4. Mandibular postural retraction may develop if the weight of the hand or

arm continuously forces the mandible to assume a retruded position in order to practice the habit. Pressure in the lingual direction causes lingual tipping of mandibular incisors.

• 5. When maxillary incisors have been tipped labially and an openbite has developed it becomes necessary for the tongue to thrust forward during swallowing in order to effect an anterior oral seal - “compensatory tongue thrusting”.

• 6. During thumb sucking, buccal wall contractions produce, a negative pressure within the month, with resultant narrowing of the maxillary arch – bilateral posterior cross bite may be produced.

• 7. With these changes in the force system in and around the maxillary complex it is often impossible for the nasal floor to drop vertically to its expected position during growth.Therefore thumb suckers have a narrow nasal floor and high palatal vault.

• 8. Upper lip becomes hypotonic and lower lip becomes hyperactive. These abnormal muscle contractions during sucking and swallowing stabilize deformation.

• 9. Compensatory tongue thrust, retained infantile swallowing pattern, abnormal perioral muscle function will assist the thumb sucking in producing the malocclusion

(DELETERIOUS EFFECTS OF ORAL HABITS. Indian Journal of Dental Sciences; Vol. 1 Issue 2 November 2009)

MUSCULATURE EFFECTED DURING THUMB SUCKING

• In an article named “An Electromyographic Analysis of the Temporalis Muscles and Certain Facial Muscles in Thumb and Finger-sucking Patients” in 1960, the authors Claude Baril And Robert E. Moyers discussed effect of thumb sucking on temporalis, buccinator, mentalis and orbicularis oris muscle using EMG.

• According to Carlso, Jarabak, Moyers, Perry, and others, the temporalis muscles usually show action potentials during the elevation of the mandible. This study states that none of the subject were biting on the thumb during sucking, so abormal force on temporalis muscle was not seen.

• Moyers and Schlossberg have found that in Class II subjects the mentalis muscles were more active than in Class I subjects. This study suggested that sample with class I and thumb sucking tend to show class II mentalis activity thus showing hyperactive mentalis muscle action with thumb sucking.

• The article concluded itself as 1. Orofacial neuromuscular behavior is highly individualistic.

One cannot assign a cause-effect relationship between the thumb habit and muscle pattern.

2. The neuromuscular behavior could not be related to the skeletal or dental aspect of the malocclusions.

3. The callus often seen on fingers of sucking subjects does not seem to be caused by mandibular elevation but by the pressure of the digit against the teeth.

4. There was no observable relationship between the retained visceral swallow and thumb-sucking.

5. There seemed to be no relationship between the pressure applied by the thumb and the neuromuscular behavior.

6. The abnormal mentalis contraction found in 19 subjects suggests that special early attention should be given to children displaying such contraction in conjunction with a sucking habit.

EFFECT OF DURATION OF THUMB SUCKING

• If there is a great deal of thumb/finger sucking daily and/or nightly, with a very strong sucking action, and this pattern continues for an extended length of time, changes to the dentition and disruption of dental equilibrium (i.e. causing instability of tooth position) and interference with the normal rest position of the mandible (the freeway space) will occur. The change in the rest posture of the mandible by opening the freeway space triggers continued eruption of posterior maxillary teeth while the anterior teeth are inhibited from erupting, or the incisors may become flared facially due to the continual presence of a thumb or finger.

• The constant sucking behavior with the tongue remaining low and forward and the freeway space remaining opened for hours per day with a disruption of the dental equilibrium leads to many possible changes involving the orofacial structure, malocclusions, speech problems, and abnormal tongue patterns.

PRESSURE SEEN DURING THUMB SUCKING

• Mishiro et al. studied 60 female children aged 7-12 years using a pressure sensor similar to ours on the anterior region of the palate. They reported a maximum tongue pressure of 1.57 kgw in the normal palate group, 1.65 kgw in the maxillary protraction group, and 1.80 kgw in the mandibular protraction group.

• During thumb-sucking, pressure on the dentition is believed to have been increased by forces of direct compression by the thumb and biting and negative pressure due to sucking, as well as intrinsic maximum tongue pressure. Thumb-sucking pressure measured in this study far exceeded tongue pressure, causing malocclusion and potential dental migration.

EFFECT ON SPEECH DUE TO THUMB SUCKING

• The facial muscles utilized in chewing, swallowing, and speech constitute an important part of the foundation upon which speech is constructed. When the thumb anchors the tongue down and forward and serves to reinforce an incorrect rest posture of the tongue, an inaccurate and inappropriate spring-off point for speech sound production occurs.

• Some sounds may be produced incorrectly. When the tongue is resting low and forward, the production of a frontal /t/d/n/l/, or interdental /s/ lisp may occur.

FEW JOURNAL REVIEW REGARDING EFFECT OF THUMB SUCKING ON OROFACIAL STRUCTURE

• Tewari conducted a study on the relationship of abnormal oral habits with malocclusion and their influence on anterior teeth in a sample of 2,124 school children in the age range of 6-12 years. She reported that protrusion was observed in 306 children, out of these 213 (69.61%) had the habit of thumb sucking. Open bite was found in 105 children, out of which 84 (80%) had the habit of thumb sucking.

• The role of thumb and finger sucking and its relation to malocclusion was investigated by Popovich and Thompson in 1,258 children between 3 to 12 years of age. They found that 462 (36.72%) children had sucking habit. With increase of age the percentage of Class II malocclusion increased from 21.5 to 41.9% in children with sucking habit.

• Melson et al. studied the relationship between sucking habit, swallowing pattern and the prevalence of different types of malocclusion in 723 children between 10 to 11 years of age. The abnormal swallowing pattern tendency was reported to increase in children with finger and thumb sucking, who exhibited high frequency of tongue thrust leading to higher frequency of open bite, which also led to development of unilateral or bilateral disto-occlusion and extreme maxillary overjet.

• Linder and Modeer studied the relationship between sucking habit and dental characteristics in pre-school children with unilateral cross bite in 68 children with a mean age of 51 months. They reported that unilateral cross bite on the right side was in 58% and on left side was in 42% children. In 85% of children three or more pairs of teeth were involved in malocclusion.

• The damage which may be caused by thumb sucking includes: anterior open bite, posterior cross bite, exaggerated overjet, temporo-mandibular joint problems, diastema, and retrusive position of the mandible. Houston and Melsen et al. also reported a positive correlation between the distal occlusion and cross bite due to finger sucking habit. Larsson reported in his studies anteriorly placed maxilla and protrusion of upper anteriors.

• Bowden conducted a study on longitudinal study of the effects of digit and dummy sucking in 116 children between the ages of 2 and 8 years and reported that children in whom digit sucking persisted, revealed a statistically significant increase of skeletal Class II dental base relationship, tongue thrust and open bite tendencies.

• Parents usually start to worry too early, about how to stop thumb sucking habit of their children. It is advised that parents do not try to make a child to stop thumb sucking before the age of four (unless you notice a problem to teeth due to vigorous thumbsucking) because it might have the opposite results.

• Usually children stop the habit on their own, by that age. If they don't, here are some easy ways to get kids to stop thumbsucking :

HOW TO STOP THUMB SUCKING

EASY WAYS TO GET KIDS TO STOP SUCKING THEIR THUMB

• Keep the child's hands occupied with a toy, puzzle or other activity.

• Carefully remove your child's thumb from his or her mouth during sleep

• Give the example of his friends that have managed to stop thumbsucking.

• Don't put the child in a state of anxiety or fear. If the child has any emotional problems, or is under stress and needs comforting, one may need to resolve those issues first before their child can succesfully stop thumb-sucking.

• Talk about the 'bad' germs that are on our hands and how the child puts them in his or her mouth while thumb sucking.

• Avoid punishing or shaming the child.

• Reward the child for not thumbsucking for a progressively increasing time period.

• Ask the advice of a pediatric dentist. They will explain to kid what will happen to the teeth if the child does not stop sucking their thumb.

• Use a thumb sucking guard. - In difficult cases, thumb guard ( a device with a plastic cover of the thumb )is attached to a child's wrist. The thumb sucking guard interrupts the process by breaking the vacuum created by sucking, thus removing the child's pleasure. Treatment with thumb guards usually lasts four weeks and helps children to stop thumb sucking succesfully.

PREVENTION:

• Providing guidance to patients• As a guide for addressing sucking habits seen by a dental practitioner and to provide

patients with knowledge and guidance, the following questions can be posed:• Does this child need to stop thumb/finger sucking?• Is there a developing malocclusion – open bite, excessive overjet, or crossbite present?• Does this individual demonstrate a low forward rest posture of the tongue?• Is there an open mouth rest posture of the lips?• Are there evident speech problems (i.e., interdental /s/ lisp, /t/, /d/, /n/, and /l/

misarticulation)?• Is there difficulty in carryover of speech patterns to the patient's conversational speech?• Is there a narrow, high arched palate present?

• Is the thumb/finger sucking strong enough to cause calluses on the sucking digit?

• Is the child's sucking habit resulting in ridicule, harassment, or embarrassment in school?

• Is the child's thumb sucking in school affecting class participation or attention span?

• Has the child expressed interest in eliminating his/her thumb sucking habit?

• If the answer to all, some, or a few questions is yes, then it is time for action. Discussing the complications with the parent and child and then providing them with information regarding treatment can be an important role for the dental practitioner to assume where the cessation of a sucking habit is indicated.

PREVENTION

• Motive based approach

• Child’s engagement in various activities

• Parents involvement in prevention

• Adequate duration of breast feeding

• Mothers presence and attention during bottle feeding

• Use psychological nipple

• Use of dummy or pacifier

• Motive based approach:The etiology of thumb sucking focuses on a predominant psychological background. It’s prevention should be directed towards the motive behind the habit. History serves as an important tool for diagnosing the etiology, whether the habit is meaningful or empty.

• Child’s engagement in various activities:Parents when questioned may reveal that the child practices the habit when bored and left to himself, or it could be just before he goes to sleep. In such cases, the parents can be counseled on keeping the child engaged in various activities. This gives little chance for the child to practice the habit. The child can be encouraged to follow his hobbies of interest such as painting or engaging in outdoor activities with his fellow mates. These measures can be followed when the parents are working.

• Parent’s involvement in prevention:When the parents are at home they should be advised to spend ample time with the child so as to put away his feeling of insecurity. At night this can again be reinforced by playing soothing music or by telling good bedtime stories till the child falls asleep.

• Duration of breast feeding:Care should be taken when feeding infants in that the duration of feeding should be adequate so as to enable the child to exhaust his sucking urge and feel completely satisfied.

• Mother’s presence and attention during bottle feeding:Bottle-fed babies should be held by the mother and enough attention should be given in the process. This will promote a close emotional union between the mother and the baby similar to that seen in breast feeding.

• Use of a physiological nipple:A physiological nipple should be used for bottle feeding and the size and number of the hole should be standardized to regulate a slow and steady flow of the milk.

• Use of a dummy or pacifier:Acquiring a digit sucking habit can be prevented by encouraging the baby to suck a dummy instead. If the child has already found his thumb or fingers, it will not be easy to introduce the dummy. Because not all babies start to suck their thumbs, it is only necessary to offer a dummy to a child whose behaviour indicates an urgent desire to suck a digit or dummy. Dummies are easier to dispense with at an earlier age than is digit sucking.

http://www.aap.org/oralhealth/pact

PACIFIERS AND SIDS

• The use of pacifiers has been shown to decrease the incidence of SuddenInfant Death Syndrome (SIDS).

•In 2005, the American Academy of Pediatrics (AAP) Task Force on SuddenInfant Death Syndrome published recommendations on pacifier use.

http://www.aap.org/oralhealth/pact

CONT….....

•Consider offering a pacifier at nap time and bedtime.

•Although the mechanism is not known, the reduced risk of SIDS associated with pacifier use during sleep is compelling.

. The development of latex allergy, tooth decay, oral ulcers and sleep disorders are other problems encountered with pacifier use.

http://www.aap.org/oralhealth/pact

PACIFIER RECOMMENDATIONS

•The task force recommends use of a pacifier throughout the first year of life,according to the following procedures:   The pacifier should be used when placing the infant down for sleep and not be reinserted once the infant falls asleep.    Pacifiers should not be coated in any sweet solution.   Pacifiers should be cleaned often and replaced regularly.   For breastfed infants, delay pacifier introduction until 1 month of age to ensure that breastfeeding is firmly established.

http://www.aap.org/oralhealth/pact

PACIFIER RECOMMENDATIONS, CONTINUED

Pacifiers should never be used to replace or delay meals and should be offered when the caregiver is certain the child is not hungry.

Pacifiers should have ventilation holes and a shield wider than the child’s mouth (at least 1¼ inches in diameter).

• Pacifiers should be one piece and made of a durable material, replaced when worn, and never tied by a string to the crib or around a child’s neck or hand.

EFFECTS OF DIFFERENT PACIFIERS ON THE PRIMARY DENTITIONAND ORAL MYOFUNCTIONAL STRUCTURES OF PRESCHOOL CHILDREN

ZARDETTO ET AL. EFFECTS OF PACIFIERS PEDIATRIC DENTISTRY – 24:6, 2002

The aim of this study was to evaluate the characteristics of the dental arches and some oral myofunctional structures in 36- to 60-month-old children who sucked a pacifier or did not have this habit.

Methods: Sixty-one children were divided into 3 groups: (1) those who never sucked a pacifier, (2) those who exclusively sucked a physiological pacifier, and (3) those who exclusively sucked a conventional one. A clinical examination was performed on the children to observe the relationship between the arches and their width, as well as the following oral myofunctional structures: lips, tongue, cheeks, and hard palate.

93

Conclusions: Children who sucked pacifiers, both conventional and physiological ones, showed higher prevalence of alterations in the relationship of the dental arches and oral myofunctional structures, when compared to those who never sucked a pacifier.

94

PACIFIERS AND THUMB SUCKINGBY CATHY HESTER SECKMAN, RDH

• Use of pacifiers after six months of age is implicated in acute otitis media (AOM). When babies suck too hard or too often on a pacifier, it can alter their nasopharyngeal function.

• Unsanitary pacifiers and fingers can be a vector of infection, leading to more illness in general. If a baby also has reduced antibody protection because of decreased duration of breastfeeding, one can see the problem. Non-nutritive sucking that continues beyond age 6, of course, is implicated in orthodontic complications.

• The bottom line is that moderate pacifier use during sleep is beneficial and should not be discouraged in the first six months of life, with care taken that it is not frequent enough to interfere with breastfeeding establishment. Experts also say children should be weaned from pacifiers in the second six months of life because of the problems listed above.

• New information about pacifier use and thumb sucking came out in 2012. Studies conducted at five different universities and published last year by Niedenthal et al in Basic and Applied Social Psychology looked at negative emotional consequences of non-nutritive sucking. Do pacifiers, asked the researchers, disrupt facial mimicry in the user, and are they therefore associated with compromised emotional development?

• The researchers in the Niedenthal study wanted to investigate whether a pacifier, in monopolizing the muscles around the mouth, would interrupt the baby's ability to copy its caregivers' facial expressions. Because the processing of facial expression is important to emotional development, they theorized, use of a pacifier could have long-term negative consequences.

• They also looked at thumb sucking, but did not expect the results to be the same, since thumb sucking is seen as a more negative behavior and more likely to be done when the child is alone; also because thumb sucking is controlled by the child, and pacifier use by the adult. They expected the findings would be different between boys and girls, since girls have been shown to develop emotional competence more quickly than boys.

• During the first study, 106 children with an average age of seven years, three months, were shown movies in which facial expressions changed gradually from smiles to frowns, or vice versa. The second study involved 167 university students, 92% of whom had used a pacifier in childhood for nearly two years. They filled out questionnaires that assessed their ability to see events from the viewpoint of other people. In the third study, 428 university students filled out the same questionnaires, but in addition they were administered the Adolescent Short Form of Trait Emotional Intelligence Questionnaire. (Higher scores on this test indicate greater emotional intelligence.)

• Niedenthal and colleagues were able to confirm most of their hypotheses. Their findings showed that since the babies were hampered in facial mimicry because their mouths were hidden and occupied by a pacifier, their emotional growth and eventual competence were compromised.

• Interestingly, thumb sucking did not show the same effect. In the first study, of young children, thumb sucking was shown to be positively associated with facial mimicry. In the second and third studies, no long-term effects on emotional competence were found because of thumb sucking.

• The researchers concluded (as they usually do) that more research is needed on the subject. "We see this set of studies," they said, "as a first attempt to address the negative consequences of such inhibition early in development when emotional skills are being set in place."

UNUSUAL METHOD OF THUMB-SUCKING PREVENTION LEADS TO BILATERAL G ANG RENOUS THUMBSHISHAM ABD ALKAREM ALKATTAN, DEPARTMENT OF SURGERY. MOSUL, IRAQ

This is a case report of a toddler whose mother, out of concern for her child and to aid him to stop sucking his thumbs, used a nylon cover secured by a thin elastic band on both thumbs. Ultimately, gangrene resulted, and both thumbs were amputated at the metacarpophalengeal joints. This was an unusual course of management, and a similar case has not been reported previously.

Parents’ attempts to stop thumb sucking by wrapping the thumbs with a piece of nylon firmly secured with an elastic ring reflects a lack of awareness and education in the management of this common problem of infancy and early childhood

JIMA: Volume 40, 200899

TREATMENT CONSIDERATIONS:• Psychological status of the child : 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 was associated with an emotional problem this would suggest the need for psychological consultation.

• Age factor : If the child desists with the finger sucking habit within the first three years of life, the damage incurred such as open bite, is temporary provided the child’s occlusion is normal. No treatment is provided in this age group. If a malocclusion is caused by digit sucking and the habit is discontinued between the age of 4 and 5 years, self correction of the habit can be expected. When digit sucking continues after 6 years or into mixed dentition, the malocclusion will not self correct.

• Motivation of the child to stop the habit:• It is also important to assess the maturity of the child 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. The parents should become silent partners. • 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

The treatment plan can be divided into

1. Psychological therapy

2. Reminder therapy

3. Mechanotherapy

MANAGEMENT

(1) PSYCOLOGICAL THERAPY:- Screen the patient for underlying psychological disturbance that

sustain thumb sucking habit. Once the psychological dependence is suspected child referred for counseling.

Thumb sucking children between the age of 4 to 8 year need only reassurance, positive reinforcements and friendly reminders.

Various aid are employed to bring the habit under the notice of child such as study model, mirror’s etc.

Dunlop hypothesis:-• He belives that if a subject can be forced to concentrate on the

performance of the act at the time he practices it, he can learn to stop performing the act. The child should be ask to sit in front of the mirror and asked to suck his thumb, observing himself as a indulges in the habit.

• this will make him realize how awkward he looks and want to stop sucking his thumb.

Patient should presented with positive mental and visual images of dentofacial ideals expected from habit cessation.

During treatment adequate emotional support & concern should be provided to child by parents.

When habit is discontinued the child can be reward with a favorite new toys.

(2) REMINDER THERAPY:-,(A) Extra oral approach:- Employed bitter flavored preparations or distasteful agent that applied to finger or thumb

eg. Cayenne, pepper, quinine, asafetida.

A commercially available product femite can also be used. It should be applied on skin and nails allowed to dry for 10 min. A new coat should be

applied in mornings n evening till habit is broken. (B) Ace bandage approach:- Ace bandage approach involve nightly use of an elastic

bandage wrapped across the elbow pressure exerted by the bandage remove the digit from the mouth as child tries and falls asleep.

(C) Use of long sleeve night gown. It has been found that long sleeve night gown prevent the child from practicing thumb sucking because it interfere with contact of the thumb and oral cavity.

(2) Intra oral approaches:- Various orthodontic appliances are employed to break the habit. Removable appliance palatal crib, rakes, palatal and lingual spur. Fixed appliances such as oral screen is more effective. (3) MECHANO THERAPY:-

(A) Fixed intra oral anti thumb sucking appliances- An intraoral appliance attached to the upper teeth by means bands fitted to the primary second molar or first permanent molar.

(B) Blue grass appliances - Consist of modified six sided roller machined from Teflon to permit purchase of the tongue.

(C) Quad helix – prevents the thumb from being inserted and also corrects the malocclusion by expanding the arch.

ANALYSIS AND TREATMENT OFFINGER SUCKING

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2000, 33, 41–52

They analyzed and treated the finger sucking of 2 developmentally typical children aged 7 and 10 years. The functional analysis revealed that the finger sucking of both children was exhibited primarily during alone conditions. An extended analysis provided support for this hypothesis and demonstrated that attenuation of stimulation produced by the finger sucking resulted in behavior reductions for both children. Treatment consisted of having each child wear a glove on the relevant hand during periods when he or she was alone. Use of the glove produced zero levels of finger sucking for 1 participant, whereas only moderate reductions were obtained for the other. Subsequently, an awareness enhancement device was used that produced an immediate reduction in finger sucking.106

• An article on “Suffer The Little Children: Fixed Intraoral Habit Appliances For Treating Childhood Thumbsucking Habits: A Critical Review Of The Literature.” by Nicholas L. Moore in IJOM 2002, (V28, pp 6-38) discusses that obstructive intra-oral devices can be stated as -

1) Vertical Appliances• These provide a vertical barrier or "wall" preventing the child

from inserting a digit. They may be further subdivided into: a). The Rake ("Hayrake")(Mack 1951)(i). Sharp Rake This appliance has a series of sharp points that

cause the child to pierce its digit when attempting to insert it, providing painful feedback. It also pierces the tongue and is therefore popular for treating tongue thrust.

The Rake ("Hayrake")

(ii). Blunt Rake : This appliance is similar to the Sharp Rake but has blunt or "balled“ points and does not pierce the digit. One variation can also feature wire loops. Another can comprise a Palatal Bar with short, blunt protuberances, forming a hybrid between a Blunt Rake and a Palatal Bar.

(iii) Lingual Spurs: This appliance has sharp/blunt spikes and functions in the same way as the Rake (Sharp/Blunt) but is anchored to the incisors rather than the molars.

b). The Vertical Crib • This appliance takes the form of a semicircular wire "gate" which does not pierce

the digit but simply forms a barrier to its entry. One variation can incorporate small spurs ("crib with spurs") along the bottom edge of the crib body.

.

Lingual spurs

2). Horizontal Appliances• These do not form a barrier to the digit's entry but lie horizontally in

such a way as to partially cover the palate. This prevents the digit from making pleasurable contact with the palatal tissue and prevents the formation of a seal to enable suction to take place. It is also claimed that they act as "reminders" to the child rather than physical preventive measures.

a). The Palatal Bar This is the simplest appliance and takes the form of a single, double or looped wire fitted across the arch wire. Its barrier properties are minimal and acts more as a reminder to the child.

b). The Horizontal Crib This appliance takes a physical form similar to the vertical crib, with a

semicircular "gate", but turned through 90 degrees so that it partially covers the palate.

3). Combination and Special Appliances There are two special habit appliances: the Graber Appliance; and the Bluegrass

Appliance. a). The Graber Appliance This combines the Blunt Rake, the Palatal Bar and the Horizontal Crib into a

single appliance, allowing adjustment of the treatment by the practitioner. It was invented by Graber.

NOTE : THIS ALL APPLIANCES ARE MADE OF 0.9MM WIRE OR 0.036 INCH WIRE

THE GRABER APPLIANCE

b). The Bluegrass Appliance (BRUCE S HASKELL,1991)This is a totally unique type of habit appliance in that it uses a

Teflon roller or several beads that are free to rotate on a Palatal Bar. The child is encouraged to treat it as a "toy" and so the underlying philosophy of the appliance is totally different from the other fixed intraoral habit appliances.

• The child is encouraged to treat the appliance as a toy and to use its tongue to spin the rollers/beads and move them from side to side along the wire whenever the thumbsucking urge occurs leading to a "fascination response which is quickly imprinted due to the intense sensitivity and neuromuscular nature of the tongue and a new, non-destructive habit of playing with the roller”

The modified bluegrass appliance

• J Indian Soc Pedod Prev Dent. 2010 Jul-Sep;28(3):212-8• In an article “RURS’ elbow guard: An :innovative treatment of the thumb-

sucking habit in a child with Hurler’s syndrome” by Shetty RM, Dixit U et al the step in fabrication of an RUR’s elbow guard is stated as

• Step 1: Child was prepared for impression making. Elbow was kept at 45–60 degree angulation and the impression of the elbow was made using vinyl polysiloxane putty impression material .

• Step 2: Impression was poured with dental stone and the cast was obtained • Step 3: Two layers of modelling wax were adapted over the cast, which acted

as a spacer• Step 4: Acrylization was performed using self-cure acrylic. The spacer was

removed and the acrylic elbow guard was trimmed for any sharp edges

• Step 5: The spacer was replaced by a layer of sponge for cushioning and to allow limited movements of the elbow

• Step 6: A cover with velcro strap was stitched over the acrylic elbow guard

• Step 7: RURS’ elbow guard was tried on the cast.• Step 8: RURS’ elbow guard was removed from the cast and

delivered to the patient • RURS’ elbow guard allowed some movement of the elbow but it

did not allow the thumb to reach the mouth. The patient was comfortable with the RURS’ elbow guard

CURRENT STRATEGIES.

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

A NEW SOLUTION FOR PARENT AND CHILD: THE PROBLEM OF DIGIT-THUMB SUCKING

• This aid (book and glove) called "My Thumb and I" was developed by Carol A. Mayer, a certified Speech pathologist and Certified Orofacial Myologist and Barbara E. Brown.

• "My Thumb and I" is a ten step behavior modification program designed to stop the habit of digit sucking. It is for children 6-10 years old who have been unable to stop thumb or finger sucking on their own. Each step is abundantly illustrated and includes motivational activities which reinforce the concepts stated.

• "My Thumb and I" will increase the emotional as well as the dental health of the child.

• My Thumb and I is..• Effective-- Teaches and motivates through behavior modification and rewards children to

stop digit sucking.• Healthful-- Promotes proper development of mouth, teeth, face, and speech.• Positive-- Builds self-esteem, confidence, and gives a sense of accomplishment.• Wholesome-- Encourages communication and understanding between parent and child as

they work together.• Fun-- Fascinates and involves children in entertaining activities.• Relaxed-- Helps children progress at a personally meaningful pace.• Appealing-- Easy to read large type, spiral bound, for easy use.• Complete-- Includes a glove, progress charts, and a parent's guide.

OROFACIAL MYOLOGIST.• As we know, there is an expert for every part of the body. Why

should the thumb be any different? Dental and orthodontic professionals specialize in maintaining oral health, and pediatricians specialize in the care and development of children and the prevention and treatment of children's diseases. However, most people have not heard about a professional who specializes in the treatment of thumb/finger sucking problems. This professional is called an orofacial myologist.

• An orofacial myologist is a trained professional who diagnoses and provides treatment for orofacial myofunctional disorders (OMDs) such as abnormal tongue patterns, open mouth rest posture of the lips, low forward rest posture of the tongue, and sucking habits. The therapy is referred to as orofacial rest posture therapy. Before an orofacial myologist can begin treating any of these other OMDs, the thumb/finger sucking pattern has to first be eliminated or other therapy protocols will not be successful.

• The IAOM (International Association of Orofacial Myology) is a professional organization devoted to educating, training, and verifying qualified orofacial myologists. Many dentists are members of the IAOM and have achieved certification as orofacial myologists.