1

ORAL HABITS

BY

ELVIS CHIRAMEL DAVID

4th year (part A)

2

Any repetitive behaviour that utilizes the oral cavity.

DEF OF HABITDORLAND[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

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 BREATHINGTHUMB SUCKING

Oth

er

ORA

L HAB

ITS

ETIOLOGY

FAMILY CONFLICTS SCHOOL PRESSURE JEALOUSY PEER GROUP PRESSURE STRESS OCCLUSAL INTERFERANCE BREATHING OBSTRUCTION LIMITATIONS ASSOCIATED WITH TOOTH

ERUPTION POOR PHYSICAL HEALTH

5

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

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

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

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

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

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

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

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

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

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

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

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

17

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

18

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

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

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

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

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

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

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

INTRAORAL EXAMINATION TONGUE-examine for size & position of the tongue at restTongue action during swallowing DENTOALVEOLAR STRUCTURESDigit apply an anterior force to the upper dentition &

palateFlared & proclined maxillary anteriors with diastemaRetroclined mandibular anteriors Other intra oral symptoms-buccal crossbitePronounced constriction of buccal musculatureTendency to narrow palatesMeasure overjet & overbite GINGIVALook for evidence of mouth breathing

26

27

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

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

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

HOW DO I STOP THUMB SUCKING???

Palatal Crib

TH

UM

B C

AP

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

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

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

MECHANOTHERAPY

Removable appliances—

palatal crib, rakes, lingual spurs, Hawley’s retainer with or without spurs

34

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

MOUTH BREATHING

Usually seen in people with nasal obstruction.

May also occur as a habit.

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

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

WHAT CAN HAPPEN DUE TO THIS???

Forward placement of upper front teeth

Gap between upper & lower front teeth

Improperly placed teeth

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

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

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

Dental effects Upper and lower incisors are retroclined Posterior cross bite Tendency towards an open bite Constricted maxillary arch Flaring of incisorsSpeech 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

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

HOW TO CONTROL MOUTH BREATHING???

Use of an appliance called ‘ORAL SCREEN’

Incase of nasal abnormalities, consult ENT surgeon

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

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

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

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

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

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

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

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

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

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

laterally55

56

WHAT’S THE SOLUTION???

Tongue crib

Oral Screen

TREATMENTTongue 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

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

MECHANOTHERAPY:-Removable appliance therapy Modification of hawley’s applianceAdvantages 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

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 malocclusionSurgical treatment

60

61

BRUXISMBruxism 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.

ETIOLOGY1. 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

64

TREATMENT

Counseling Occlusal Splint

Tranquillizers

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

OCCLUSAL THERAPY:-

• OCCLUSAL ADJUSTMENTS- BITE RAISING CROWNS, SPLINTS AND ELIMINATION OF OCCLUSAL INTERFERENCE

• BITE PLATES

• OCCLUSAL RECONSTRUCTION AND PROSTHESIS

• BITE GUARD

66

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

67

LIP HABIT

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 stress68

69

Mouth ulcersSpacing & flaring of upper front teethEffect

s

Protrusion of maxillary incisors & retrusion of mandibular incisors.

Reddened irritated & chapped area below the vermillion border

Mentolabial sulcus becomes accentuated

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 therapyOral 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

NAIL BITINGBELOW 3 YEARS – ABSENT

4 TO 6 YEARS – INCIDENCE RISES SHARPLY7 TO 10 YEARS – REMAINS CONSTANTREACHS ITS PEAK AT ADOLSCENCE

71

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

EFFECTS

Chapping of finger nails

Fungal Infection of fingers

Prevention Application of bitter substances onto finger nails

Application of bitter substances onto finger nails

74

OTH

ER

OR

AL

HA

BIT

S

Bobby pin openingBobby pin opening Needle biting by tailors

Pencil Chewing

Wire chewing by electricians

Bottle Opening

75

EFFECTS

Chipping of tooth edge

Notching of tooth

edge

Loss of tooth vitality

76

IMPROPER BRUSHING HABIT

Effects

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

THANK YOU