4. 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.
5. • 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).
6. 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.
8. • 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.
9. 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)
10. 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.
11.
12. 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.
13. ORAL HABIT
OBSESSIVE
( DEEP ROOTED)
NON-OBSESSIVE
(EASILY LEARNED AND DROPPED)
INTENTIONAL
OR
MEANINGFUL
MASOCHISTIC
OR
SELF-INFLICTING
UNINTENTIONAL
OR
EMPTY
FUNCTIONAL
HABIT
Nail biting
Digit sucking
Lip biting
Gingival
stripping
Abnormal
pillowing
Chin propping
Mouth breathing
Tongue thrusting
Bruxism
14. CLASSIFICATION (CONT’D)ACCORDING TO,
Non pressure habit
Pressure habit
MORIS & BOHANNA(1969) Biting habit
Intentional habits (meaningful)
Klein classification(1971)
Non intentional habits
(empty habits)
Finn (1987) a) Compulsive habits
Non compulsive habits
16. 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?
20. 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.
21. 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.
22. 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.
23. SOME ANTAGONISTIC FORCES ACTING ON THE
MASTICATORY 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)
24. • 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
25. • 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.
26. 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.
27. 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.
28. 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.
30. • 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.
31. • 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.
32. 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
34. 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
35. CLASSIFICATION
Normal 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.
38. • 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.
39. GRADES OF DIGIT SUCKING:
• Subtelny (1973) has graded thumb sucking into 4 types:
• Type A
• Type B
• Type C
• Type D
39
40. • 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.
41. level Description
Classification 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.
42. 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.
43. 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)
44. 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
45. 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.
46. 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.
47. • 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
48. 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.
49. • 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.
50. 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.
51. 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.
52. DIAGNOSIS OF DIGITAL HABITS:
1) History
2) Extra oral examination
a) The digits
b) Lips
c) Facial form
d) Other features
3) Intra oral examination
a) Tongue
b) Dent alveolar structures
c) Gingiva
53. 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
54. 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
56. INTRAORAL EXAMINATION
• Tongue
• Position at rest , during
swallowing
• Gingiva
• Evidence of mouth breathing
• Etching of gumline
• Staining on max. labial surface
57. DENTO ALVEOLAR STRUCTURE
• Flared , proclined maxillary
anteriors with diastema
• Retroclined mandibular
anteriors
• Deformed right or left sided
max. arch
58. SUCKING HABITS AND FACIAL HYPERDIVERGENCY
AS RISK FACTORS FOR ANTERIOR OPEN BITE IN THE
MIXED DENTITION
AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL
ORTHOPEDICS OCTOBER 2005
COZZA 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
59. 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
65. 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.
66. • 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.
67. • 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)
68. 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.
69. • 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.
70. 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.
71. 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.
72. 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.
73. 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.
74. • 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.
75. • 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.
76. • 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
77. • 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.
78. • 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.
79. • 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.
80. • 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.
81. 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?
82. • 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.
83. 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
84. • 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.
85. • 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.
86. • 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.
87. • 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.
88. • 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.
89. http://www.aap.org/oralhealth/pact
PACIFIERS AND SIDS
• The use of pacifiers has been shown to
decrease the incidence of Sudden
Infant Death Syndrome (SIDS).
•In 2005, the American Academy of
Pediatrics (AAP) Task Force on Sudden
Infant Death Syndrome published
recommendations on pacifier use.
90. 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.
91. 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.
92. 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.
93. EFFECTS OF DIFFERENT PACIFIERS ON THE PRIMARY DENTITION
AND 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
94. 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
95. PACIFIERS AND THUMB SUCKING
BY 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.
96. • 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.
97. • 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.)
98. • 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."
99. UNUSUAL METHOD OF THUMB-SUCKING
PREVENTION LEADS TO BILATERAL GANGRENOUS
THUMBS
HISHAM 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, 2008
99
100. 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.
101. • 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.
102. TREATMENT
The treatment plan can be divided into
1. Psychological therapy
2. Reminder therapy
3. Mechanotherapy
103. 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.
104. 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.
105. (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.
(A) Quad helix – prevents the thumb from being inserted and also corrects
the malocclusion by expanding the arch.
106. ANALYSIS AND TREATMENT OF
FINGER 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
107. • 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.
109. (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.
.
111. 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.
112.
113. 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.
114. NOTE : THIS ALL APPLIANCES ARE MADE OF 0.9MM WIRE OR 0.036
INCH WIRE
THE GRABER APPLIANCE
115. 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.
116. • 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
117. • 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
118.
119.
120. • 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
121.
122. 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
123. 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.
124. • 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.
125. 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.
126. • 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.
