Oral habits in pediatric patients: clinical aspects and management cover
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Definition

Boucher OC defined ‘oral habit’ as a tendency towards an act or an act that has become a repeated performance which is relatively fixed, consistent, easy to perform and almost automatic.

Oral habits in pediatric patients: clinical aspects and management, DentalReach - Leading Dental Magazine - Dentistry Journal, News & Events

Classification

1. USEFUL and HARMFUL HABITS (James 1923)

  • Useful Habits: Correct tongue posture, proper respiration and deglutition.
  • Harmful Habits : Mouth Breathing, Tongue Thrusting.

2. COMPULSIVE and NON COMPULSIVE HABITS (Finn 1987)

  • Compulsive Habit- Acquired as a fixation in the child to the extent that he retreats to the practice whenever his security is threatened.
  • Non Compulsive Habit- Children appear to undergo continuing behavior modification, which permit them to release certain undesirable habit patterns and form new ones which are socially accepted.

3. MEANINGFUL AND EMPTY HABITS (Klein—1971)

  • Meaningful Habit – Habit with a deep-rooted psychological problem.
  • Empty Habit – Meaningless habit that can be treated easily by a dentist using reminder therapy.

Digit/Thumb ucking

Digit sucking may be defined as placement of digit (thumb/finger) into various depths into the mouth.

Theories of various causative factors in thumb sucking

  • Classic Freudian theory. (Sigmund Freud, 1919)
  • Oral drive theory. (Sears and Wise 1982)
  • Learning theory. (Davidson 1967)
  • Rooting reflex. (Benjamin-1962)

Grades of digit/thumb sucking:

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

  • Type A: This type is seen in almost 50% of the children wherein whole digit is placed inside the mouth with the pad of the thumb pressing over the palate, while at the same time maxillary and mandibular oral contact is present.
  • Type B: This type is seen in almost 13 to 24% of the children wherein the thumb is placed into the oral cavity and at the same time maxillary and mandibular contact is maintained.
  • Type C: This type is seen in almost 18% of the children wherein the thumb is placed into the mouth just beyond the first joint and contacts hard palate and the maxillary incisors, but there is no contact with mandibular incisors.
  • Type D: This type is seen in almost 6% of the children wherein only a little portion of the thumb is placed into the mouth.

Possible etiologic factors:

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

Diagnosis: is based on history and examination.

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.
  • Emotional status determine if the habit is empty or meaningful.

Extra oral examination & clinical features:

1. Digit

  • Reddened, clean, chapped, short fingernail (dishpan thumb)
  • Chronic suckers – fibrous, roughened callus on superior aspect of finger
  • Deformation of finger

2. Lip

  • Position at rest or during swallowing should be observed.
  • Hypotonic upper lip
  • Hyperactive lower lips

3. Maxillary protrusion

4. Mandibular retrusion

  • Convex Profile
  • Mentalis muscle contraction

Intra Oral Examination & clinical features:

1. Dento alveolar structure

  • Flared , proclined maxillary anteriors with diastema
  • Retroclined mandibular anteriors
  • Deformed right or left sided maxillary arch

2. Effects on Maxilla

  • Increased maxillary arch length
  • Increased clinical crown length of incisors
  • Atypical root resorption in primary central incisor
  • Increased trauma to maxillary incisors
  • High palatal arch

3. Effects on Mandible

  • Retroclination of mandibular incisors
  • Retrusion of mandible

4. Effect on interarch relationship

  • Anterior open bite
  • Increased overjet
  • Decreased overbite
  • Posterior Cross Bite

Management

1. Preventive Treatment

  • Feed the child the natural way; importance of breastfeeding is primarily psychological and secondarily nutritive.
  • Never let the habit be started, the practice must be discontinued at its inception.

2. Psychological therapy

Nagging, scolding or frightening the child should be avoided since this could cause negativism and tend to make him resort to the habit.

β-hypothesis or Dunlop’s hypothesis: He believed that if a subject can be forced to concentrate on the performance of the act at the time he practices it, he could learn to stop performing the act. Forced purposeful repetition of habit eventually associates with unpleasant reactions and the habit is abandoned. The child should be asked to sit in front of the mirror and asked to observe himself as he indulges in the habit.

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3. Chemicals treatment: Bitter and sour chemicals have been used over the thumb to terminate the practice but with very minimal success, e.g. quinine, asafetida, pepper, castor oil, etc. Nowadays new antithumb sucking solutions like femite, thumbup, antithumb are also being marketed.

4. Mechanical Therapy

Extraoral approach:

  • Adhesive Tapes
  • Thumb guard or splints

Intraoral approach:

  • Removable or fixed palatal crib
  • Fixed intraoral anti thumb sucking appliance
  • Blue Grass appliance
  • Quad Helix

Tongue Thrusting

Definition

Tulley (1969) defined ‘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 lies interdentally.

Classification of tongue thrust:

Etiologic classification

  • Physiologic
  • Habitual
  • Functional
  • Anatomic

Clinical classification

(James S. Brauer & Holt) classified tongue thrust habit depending on deformity it caused-

  • Type 1: Non deforming tongue thrust
  • Type 2: Deforming anterior tongue thrust
  • Type 3: Deforming lateral tongue thrust
  • Type 4: Deforming anterior + lateral tongue thrust

Etiology of tongue thrust:

  • Retained infantile swallowing
  • Upper respiratory tract infection, allergies
  • Functional adaptability to transient change in anatomy
  • Induced due to other oral habits
  • Hereditary
  • Tongue size
  • Gap filling tendency
  • Oral trauma

Types of tongue thrust:

Simple tongue thrust

  • The simple tongue thrust is characterized by a normal tooth contact during the swallowing act. They exhibit good intercuspation of posterior teeth in contrast to complex tongue thrust.
  • The tongue is thrust forward during swallowing to help establish an anterior lip seal. At rest, the tongue tip lies at a lower level.
  • Proclined, spaced and sometimes flared upper anteriors resulting in increased overjet.
  • Retroclined or proclined lower anteriors
  • Anterior open bite
  • Posterior crossbite

Complex tongue thrust

  • Defined as tongue thrust with teeth apart swallow.
  • The occlusion of teeth may be poor. Poor occlusal fit, no firm intercuspation.
  • Posterior open bite in case of lateral tongue thrust.

Clinical features

  • Proclination and spacing of anterior teeth
  • Anterior open bite
  • Bimaxillary protrusion
  • Posterior open bite in lateral tongue thrust

Diagnosis is based on history and examination.

History should include following :

  • Information regarding any other oral habits eg. thumb sucking, mouth breathing, any infection of upper respiratory system, and inflamed tonsils for long duration.
  • Information regarding the swallowing pattern of sibling for possible hereditary etiologic factors.

Examination

  • Tongue and lip functions are synchronized in their activities. Thus it is possible to get an idea about abnormal tongue function from observed lip musculature. For example : in infantile swallow pattern with tongue thrust, lower lip also shows marked activity.
  • Tongue is examined for posture while mandible is at physiologic rest position.
  • One way is to trace this posture from cephalogram taken with mandible at rest position.
  • Clinically it is evaluated by asking patient to sit in upright position, & then tongue and lip relationship is examined gently.

Functional examination

Observe the tongue during swallows

  • conscious swallow
  • conscious swallow of saliva
  • conscious swallow of water
  • conscious swallow during mastication

Palpatory examination

Place the hand over temporalis muscle and ask to swallow –

  • Normal: Temporalis contracts and mandible is elevated
  • Tongue thrusting: No temporalis contraction

Treatment modalities

1. Myofunctional Therapy

  • Patient can be guided regarding the correct posture of the tongue during swallowing by various exercises like asking the child to place the tip of the tongue in the rugae area for 5 minutes and then asking him to swallow.
  • Orthodontic Elastics: The tongue tip is held against the palate using orthodontic elastic of 5/16” and sugarless fruit drop.
  • Lemon Candy Exercise: Instead of the elastic, a lemon candy is put on the tongue tip. Patient is asked to hold the candy against the palate by the tongue tip and then asking the child to swallow.

2. 4S Exercises

This includes identifying the spot, salivating, squeezing the spot and swallowing. Using the tongue, the spot is identified. The tongue tip is pressed against this spot and the child is asked to swallow keeping the tongue at the same spot.

3. Lip Exercises – Tug of war and button pull exercise:

A string is tied to two buttons, one of the buttons is placed between the lips of the patient while the other is held by the patient outside. The outer button is pulled outwards and at the same time the inside button is resisting the forces, thereby strengthening the lips on both aspects.

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4. Mechanotherapy

Both fixed and removable appliances can be used to restrain the various tongue movement.

  • Removable appliances Eg: tongue rake, tongue crib, tongue spikes
  • Fixed habit breaking appliance

Mouth Breathing

Definition

Sassouni (1971) defined ‘mouth breathing’ as habitual respiration through mouth instead of nose.

Classification: Finn (1987) classified mouth breathing into:

  • Anatomic
  • Obstructive
  • Habitual

Etiology

Mainly anatomically short upper lip.

Apart from anatomically short upper lip, the other cause for mouth breathing is nasal obstruction.

This airway obstruction may be due to-

  • Enlarged turbinates
  • Deviated nasal septum (DNS)
  • Allergic rhinitis, nasal polyps
  • Traumatic injury to nasal cavity

Clinical features

  • Long narrow face –classic adenoid facies
  • Narrow nose and nasal passage
  • Short & flaccid upper lip
  • Anterior marginal gingivitis
  • Possible anterior open bite

The classic adenoid facies consists of-

  • Long & narrow face
  • Narrow width dimensions
  • Protruding teeth
  • Lips separated at rest
  • Upper lip is short
  • Face is expression less
  • Bridge of the nose is flat

Diagnosis

History: Parents should be asked whether child had/has frequent occurrences of tonsillitis, allergic rhinitis etc; or if child frequently adopts lip apart posture.

Examination of mouth breathing: In normal relaxed individual, lips are touching lightly. But in a mouth breather, lips will be definitely apart at rest for passage of air. Lips will be dry, scaly because of continuous drying and this may predispose to lip wetting habit. Same drying effect predisposes for mouth breathing gingivitis and increased risk of dental caries.

Functional examination: Ask the patient to take a deep breath. A mouth breather when asked to close his / her lips and take deep breath, there will be no appreciable change in size and shape of external nares in contrast to normal nasal breather, who shows dilatation of nares during lips closed deep breathing because nasal breathers normally demonstrate good reflex control of alar muscle which control the size and shape of external nares.

Mirror Test: It is also called as ‘Fog test’. Two-surfaced mirror is placed on the patient’s upper lip. If air condenses on upper side of mirror the patient is nasal breather and if it does so on the opposite side, then he is a mouth breather.

Jwemen’s butterfly test: Take a few fibers of cotton and place it just below the nasal opening. On exhalation, if the fibers of the cotton flutter downwards patient is nasal breather and if fibers flutter upward, he is a mouth breather.

Massler’s water holding test: Patient is asked to hold the mouth full of water. Mouth breathers cannot retain the water for a long time.

Management:

1. E.N.T Consultation

Almost all the time cause of mouth breathing is nasal obstruction, so any E.N.T pathology should be ruled out before any habit correction attempt.

2. Interception of habit

Even after removal of causative factor if habit persists, following measures should be taken:

  • Deep breathing exercises
  • Lip exercises
  • Appliances for the correction of mouth breathing like oral/vestibular screen

Bruxism

Ramfjord in 1966 defined ‘bruxism’ as the habitual grinding of teeth when an individual is not chewing or swallowing.

Classification

  • Daytime: Diurnal bruxism/Bruxomania. It can be conscious or subconscious and may occur along with para-functional habits.
  • Night time bruxism: Nocturnal bruxism. Subconscious grinding of teeth characterized by rhythmic patterns of masseter.

Etiology

  • Occlusal discrepancies
  • Psychological factors
  • Genetics
  • Occupational factors

Diagnosis

History – Patient is asked about muscular tenderness in morning. Occasionally patient may not be aware of habit if only nocturnal bruxism in present. In those cases parents may provide information regarding habit.

Examination

Typical wear facets on occlusal table are evident. By using articulating paper, underlying occlusal disharmony may be found out.

Clinical manifestations

  • Occlusal trauma: Tooth ache, mobility mainly in morning.
  • Tooth structure: Extreme sensitivity due to loss of enamel, atypical wear facets, pulp may be exposed and many fractured teeth can also occur.
  • Muscular: Tenderness of the jaw muscles on palpation, muscular fatigue on waking up in the morning, hypertrophy of masseter.
  • Temporomandibular Joint: Pain, crepitating, clicking in joint, restriction of mandibular movements.
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Associated features:

  • Headache
  • Sounds- Grinding and tapping
  • Soft tissue trauma
  • Small ulceration or ridging on buccal mucosa opposite the molar teeth.

Treatment

  1. Occlusal splints and occlusal adjustments are usually sufficient to correct habit. Occlusal splints are indicated to reprogram the existing muscular pattern. Soft splints are advisable with flat occlusal surfaces so that mandibular movements will be free in all planes which breaks the reflex response of muscles established during habit.
  2. Restorative
  3. Severe abrasion – Pulp therapy followed by stainless steel crowns
  4. Psychotherapy – Counselling & tension relief
  5. Habit awareness -Increase voluntary control
  6. Drugs: Local anesthetic injections, tranquilizers, muscle relaxants
  7. Biofeedback
  8. Electrical method: Electrogalvanic stimulation for muscle relaxation
  9. Acupuncture
  10. Orthodontic correction

Lip Habits

Normal lip anatomy and function are important for speaking,eating and maintaining a balanced occlusion. Lip habit may involve either of lips but predominantly lower lip is involved.

Definition ‘Lip habit’ may be defined as those habits that involve manipulation of lip/ lips and perioral structures.

Types of lip habits

  • Lip licking/wetting of lips by the tongue
  • Lip sucking habit: Pulling the lips into the mouth between the teeth.

Etiology

  1. Malocclusion.
  2. Habits.
  3. Emotional stress.

Management

  • Lip Bumper – Lip bumper acts as both reminding device and habit interrupting appliance by making it difficult to draw the lip between anterior teeth.
  • Oral screen
  • Lip protector

NAIL BITING HABIT

This is the most common habit in adolescent and adults.

Nail biting is absent before age of 3, incidence rises from 4-6 years of age and remains stable between 7 and 10 year and rises to peak during adolescence.

Persistent nail biting may be indicative of emotional problem.

In teenage, nail biting habit may be substituted by pen /pencil biting etc.

Diagnosis – History and examination of finger nail will reveal the habit.

Clinical Features

1. Nail

  • Inflammation of nail beds and nail
  • Irregular nail margins

2. Dental effect

  • Crowding
  • Rotation
  • Attrition of incisal edges of incisors

Management:

  • Patient is made aware of the problem
  • Scolding, nagging and threats should not be used
  • Treat the basic emotional factors causing the act
  • Encouraging outdoor activities may help in easing tension
  • Application of nail polish, light cotton mittens as reminder.

SELF INJURIOUS HABIT

  • Also called as masochistic habits, sado-masochistic habits, self-mutilating habits
  • These are self injurious habits where patient enjoys inflicting damage to himself. It is rare in normal children and is commonly seen in children with special healthcare needs such as mental retardation.

Classification

Organic

  • Lesch- Nyhan syndrome
  • De Lagge’s syndrome- Repetitive lip, finger, tongue, knee, shoulder biting

Functional

  • Type A- Injuries superimposed upon a preexisting lesions
  • Type B- Secondary to another established habit
  • Type C- Unknown or complex etiology

Clinical Features

  • Biting of fingers, knees, shoulders
  • Frenum thrusting
  • Picking of gingiva
  • Insertion of sharp objects into the oral cavity

Treatment

  • Always with these habits, treatment should be initiated with psychotherapy because almost all these patient have strong emotional or psychopathic features.
  • Palliative Treatment: It is the adjunctive therapy eg: bandages for ulceration etc.
  • Mechanotherapy
  • Vestibular screen will prevent unconscious damaging act e.g. cheek biting while sleeping. Mechanotherapy may also include use of restraints and protective padding.

Conclusion

Oral habits are essentially certain abnormal muscular patterns acquired by the child at a conscious or subconscious level. Once a deleterious habit is identified, treatment should be carefully executed with full cooperation of child. At no stage child should be ignored in terms of his/her comfort and emotional feeling. Success of any habit breaking therapy ultimately depends on patient cooperation.

Oral habits in pediatric patients: clinical aspects and management, DentalReach - Leading Dental Magazine - Dentistry Journal, News & Events
Dr Mriganka Sekhar Ghose
Dr Mriganka Sekhar Ghose [BDS, Paed Dent Spclty Prog (Royal College Of Surgeons, Ireland] is a dental surgeon & independent medical researcher with multiple certifications from RCS Edinburgh, Ireland & Tehran Univ Of Medical Sciences, Iran and is Community Ambassador of Mohammad Rashid Bin Univ of Medicine & Health Sciences, UAE.

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    1. Thanks for the blog.Nice dental information.

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