ORAL HABITS

By Dr. Bomatuyibapre Ogoli

Outline

INTRODUCTION DEFINITION AETIOLOGY TYPES MANAGEMENT CONCLUSION REFERENCES

Introduction
 The process of oral habit in the 3 to 6 year

old is an important finding in the clinical examination.  A habit that has resulted in the movement of the primary teeth requires some form of intervention prior to the eruption of the permanent teeth.  Changes in the dentition brought about by oral habit vary and these may depend on the intensity, duration and frequency of the habit.

 Intensity

This is the amount of force applied to the teeth while performing the habit.  Duration Defined as the amount of time spent practicing a habit. Duration plays the most critical role in tooth movements  Frequency It is the number of times the habit is performed throughout the day.

Definition
 Habit is a tendency towards an act or an

act that has become repeated performances relatively fixed, consistent, easy to perform and almost automatic. (Boucher O.C)

 A relationship exists between the physiologic

development of the oral cavity and -The nature -The onset and -The duration of the oral habit  Arise from: -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen later in life  Generally, the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral cavity

Aetiology


Anatomical Factor: Abnormal Physical size of an organ can result in development of habits. For example, infantile swallow occurs due to a large tongue in a small oral cavity

Emotional Instability of the child: This can result in parafunctional habit for example digit sucking may give a feeling of security. Family conflicts, peer group pressure, lack of satisfaction through nourishment, stress all have a direct bearing on oral habits.

Mechanical Interferences: These lead to undesirable oral habits. For example, ectopic eruption of permanent incisors can make achieving a proper anterior oral seal difficult during swallowing. This can result in mouth breathing.

Pathological factor: Disease conditions of oral and perioral structures can result in oral habits E.g. Deviated nasal septum and hypertrophy of inferior nasal turbinate can cause nasal blockage. Also enlarged adenoids can cause obstruction of the upper air way. These factors result in mouth breathing.

Imitation: The child may imitate jaw position or speech disorders of parents, siblings, friends.

Types
Compulsive
 Fixated in a child s behavior

Non compulsive
 Naturally modified or

pattern.  Malocclusion frequently results due to persistent and intense habit.  Generally reflects a psychologic dependency on certain behavior.  Compelling reason for the behavior to continue -Insecurities -Fears -Lack of ego-defense mechanism development

eliminated through the maturation process.  Not so entrenched in the child s behavior that they cannot be not changed in response to the child s changing physiologic/ psychologic profile.  Resolve on their own and child grows out of!  No detrimental effects seen

 The oral habits of dental significance include

Digit Sucking (thumb or finger sucking) - Tongue Thrusting - Mouth breathing - Bruxism - Lip sucking - Lip biting

Digit Sucking (Thumb / Finger Sucking).

These make up majority of the oral habits. Sucking is the first coordinated muscular activity of the infant which enables bottles feeding. - Two forms of sucking are: - Nutritive sucking (bottle) - Non nutritive sucking (thumb, digit, pacifier etc)

    

Most commonly seen non-nutritive habit in children. Normal for newborns to engage in digit sucking. Commonly develop in the first year of life. Psychological factors contribute to the continuation of this habit past 67 months of age. Most habits abandoned prior to the eruption of the permanent incisors. No Tx needed if habit stopped by 6-7 years of age. Earlier Tx instituted if maxillary arch constricted or parent/child is concerned.

  

Sucking mechanism
 During infancy, it is the most well-developed

sensation -Helps with sustenance as well as deriving sensory pleasures. -Gives a feeling of security, warmth, and euphoria.  An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures.  This deprivation may motivate the infant to suck on the thumb or finger for additional gratification.

Malocclusion and digit sucking

 The type of malocclusion

1. 2. 3. 4. 5.

produced by the habit is dependant on the following variables Position of the digit/pacifier etc. Associated orofacial muscle contraction force Mandibular position during sucking Facial skeletal genetic pattern Amount, frequency, & duration of force applied

Digit sucking and age

 During the first 3 yrs, the

damage from the habit is mainly confined to the anterior segment, producing an anterior open bite.  Damage can be detrimental if the habit is continued beyond the age of 3.5 yrs.  After 4 years of age, the habit becomes strongly established. The damage seen is more significant.  After the eruption of the permanent incisors, the worst amount of damage seen.

Effects of digit sucking.

     

    

AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault. Decrease palatal width. Left/right side is usually affected. The deformation depends on whether the right or left thumb is sucked. Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping

Management


Diagnosing Digit Sucking Hx taking which is obtained from the parents p Frequency of Sucking p Duration p Intensity (Amount of force applied) Extra oral Examination p Cleaner digit p Redness / Wrinkling of digits due to regular sucking p Dishpan Thumb clean thumb with short finger nails p Short Upper lip p higher incidence of middle ear infections, enlarged tonsils and mouth breathing. Intra oral examination p Malocclusion

Treatment
 3 categories of treatment

- Behavioral modifications - Counseling - Reinforcement either positive or negative

Appliance therapy
 Removable appliance

-Goal post -Tongue spikes -Tongue guard  Fixed appliance -Fixed rake -Quad helix - hay rakes

Tongue spike

Tongue guard

Fixed rake appliance

Quad helix

Goal post appliance

 Goal post appliance is an upper removable

appliance used to dissuade the sucking habit. It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 0.9mm HSSW.  It functions by preventing the patient from attaining a comfortable position for the digit.  The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop.

Fixed rake appliance

 Fixed rake appliance is for a patient with both a

tongue thrusting habit and a digit sucking habit.  It consists of molar bands banded to the 1st or 2nd molars. The wire is made of 0.9mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region.  This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit. It is usually worn for a period of 6-10 months to prevent recurrence of the habit.

Tongue thrusting habit



Defined as the placement of the tongue tip forward between the incisors during swallowing

2 types of swallow patterns are the infantile and the adult swallow patterns

Infantile type: In the new born, the tip of the tongue rests between the gum pads anteriorly to form the anterior lip seal.

Mature / Adult Swallow pattern: placement of the tip of the tongue against the palate and behind the upper incisors. This usually happens when the incisors begins to erupt by age 6 months. 9

 Delayed transition between the infantile and adult swallowing pattern.  .. Transition usually begins to happen around the age of 2 years.  .. By the age of 6 years, 50% have completed the transition.  .. 10-15% estimated never to fully complete the transition.  .. Commonly associated with mouth breathing and anterior open bite.  .. Functional adaptation of malocclusion and not the etiology.  .. Can cause speech problems - lisping.  .. Most cases (80%) will self correct by 12 years of age.

Abnormally large tongue causing a tongue thrust.

Effects of tongue thrusting habit

1) Open bite Anterior / posterior (lateral) 2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced arches between incisors and canines. 4) High arched V Shaped palate resulting in posterior cross bite

Abnormal placement of the tongue

Management
 Hx taking which is obtained from the parents/ child.

p Frequency of tongue thrust p Duration p Intensity (Amount of force applied)



Extra oral Examination This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable), anterior facial height.

 Intra oral Examination of the tongue to assess the tongue

posture and its function. At rest, the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite.  Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids, or pharyngitis or macroglossia

Treatment
 Treatment involves interception of the habit first before   -

1)

2)

treating malocclusion. Treatment is based on age because tongue thrust decreases with age. Myofunctional Therapy The patient is trained to develop a new swallow pattern. There are different ways to achieve this. These include; Patient is advised to swallow 20 times before each meal. The child takes a sip of water, close the teeth into occlusion, place the tip of the tongue against incisive papilla and swallow. Using a sugar less mint, the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow.

Appliances Therapy  Tongue muscles function properly during swallowing once the child has been trained.  Mandibular lingual arch with a crib or rake can be worn by the patient.  Appliance serves as a reminder in positioning the tongue properly during swallowing.

Mouth breathing habit



Defined as habitual respiration through the mouth instead of the nose.  Mouth Breathing - can be caused by physiologic or anatomic conditions, such as enlarged adenoids, enlarged tonsils, deviated nasal septum etc, it can be transitional when exercise induced or due to a nasal obstruction.  True mouth breathing when the habit continues after the obstruction is removed.

Effect of mouth breathing



Adenoid Facies -Long narrow face -Narrow nose and nasal airway -Flaccid lips with short upper lip -Upturned nose exposing nares frontally

Skeletal Open Bite or Long Face Syndrome -Excessive eruption of posteriors -Constricted maxillary arch -Excessive overjet -Anterior openbite -Mandibular down/forward growth is poor

Hypertrophic gingivitis: Drying of the gingiva causes irritation as a result of increased plaque accumulation.

Constricted arches of mouth breathers.

Effect of mouth breathing on the gingiva and occlusion

Diagnosing mouth breathing habit

 A good history from parents and patients. History of nasal

stiffness, sore throats, repeated cold attacks, night thirst, Hoarseness of voice.
 Examination: Study patient s breathing unobserved. Mouth

breathers are likely to keep the lips parted during relaxed breathing. Ask patient to take a deep breathe. The nose does not change in size or shape in mouth breathers.

Investigation
 Cephalometry: assessment of naso-pharyngeal space, size

of adenoids and long face syndrome.  Water Test: patients is asked to hold water in the mouth for 4 minutes. A mouth breather will be unable to do so and will spit out the water as soon he s unable to breath.  Cotton Test: A butterfly shaped piece of cotton is placed over the upper lip below the nostrils. If the cotton flutters down, it indicates nasal breathing.  Mirror Test: Use of a double sided mirror which is held between the nose and mouth. Fogging on the nasal size indicates nasal breathing. Fogging on the oral side indicates mouth breathing.

Management
 Rule out airway impairment. ENT referral in

case of nasopharyngeal obstruction.  Myofunctional Therapy: A child is taught certain exercise which will gradually train him to breath through the nose. p During the day: Hold a pencil or a piece of paper between the lips. p Night Time: Tape the lips together with surgical tape. p Draw upper lip over the upper incisors and hold under tension for a count of 10

Appliance therapy
p Oral Screen: it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips p It is contraindicated in a case of nasopharyngeal obstruction.
 Breathing holes can be bored initially to allow

passage of some air in the mouth. As the child learns to breath through the nose, fill some holes with acrylic so that less air enters through the mouth and finally close all the holes. p Rapid maxillary expansion

Oral screen

Bruxism
 Defined as non functional contact of the

teeth which may include clenching, grinding and tapping of the teeth.  Bruxism is usually seen in nervous children, patients with psychogenic disturbances, and restlessness

Generalized attrition following Bruxism.

Effects of Bruxism  Occlusal trauma resulting tooth mobility  Occlusal wear which may result in dentine sensitivity and Pulpal exposures.  Can be seen in both primary and permanent teeth.  TMJ Pan Diagnosing  Detailed Hx and clinical examination  The two most reliable signs of active Bruxism are: - Scalloping of the lateral border of the tongue - Ridging of the buccal mucosa along the occlusal line  Both signs disappear when the parafunctional habit stops

Management
Determine the underlying cause and eliminate it E.g. - Occlusal adjustment is done to correct occlusal interferences - Stressful patients are counseled and reassured. Ant anxiety drugs p valium 5mg nocte can also be prescribed - Restoration of lost vertical dimension (onlays or an overlay denture help in achieving this) thus overcoming the problem of over closure. - Bite planes, occlusal splints, bite guards are used to cover the occlusal surface. They raise the bite therefore resulting in passive stretching of painful muscle fibers. They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism. - Muscle relaxation : Ethylchoride is sprayed over the TMJ area. : Local anesthesia for TMJ muscles

Occlusal guard

Lip sucking
 May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing.  Effects - proclined upper incisors - retroclined lower incisors -crowding of lower anterior segment

Lip biting
 Either of the lips may

be involved  Cuts, abrasions, marks of incisors are the major features seen in this habit.

Management
 Lip over lip exercise  Lip bumper  Oral screen

Prevention of oral habits.

 Usually starts with proper nursing

-on the part of the parent :Time :Patience :Holding the baby while nursing, :using a physiologically designed nursing nipple and pacifier to augment normal functional and deglutitional maturation.

Consideration for oral habit therapy

 Age of the patient    

-7 yrs Maturity of the patient -understands the problem, desires to correct it! Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presence/absence of other complexities

Treatment options
 Accurate assessment in context of the child s

physiologic and psychologic state of development for proper and effective management. -Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy

Dentist patient discussion

 Straight-forward discussion  Express concern and explain why the habit

should be dropped.  Encourage them to call the office and speak to you if the habit urge returns.  Parents can help monitor only.

Reminder therapy
 Tx principles of Aversive conditioning

-Association of unpleasant stimuli with a particular behavior.  Unpleasant and more difficult method  Reminder and not a punishment! -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps

Reward system
 Highly recommended as it is effective.  Consult parents to find out what are the

child s likes and what prizes are suitable and special to the child.  Above the age of 5 yrs, use self esteem rewards.  Formulate a contract between the child and parent for a short period of time (1-2 weeks).  Greater the involvement of the parent and child, the more successful the outcome.

Appliance therapy
 Intra-oral appliance 

Child must welcome continued assistance 

Permanent reminder

Summary
 Abnormal habits typically interfere with regular    

facial development. The longer a habit is practiced, the harder it is to break. Duration, frequency and intensity play important roles in the permanency of the damage seen. When considering treatment, make sure the child wants to break the habit. Placing fixed appliances should be the last resort for habit cessation.

Conclusion
 Oral habits have been known to have serious

long term effects on dentofacial structures. Hence; early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex.