ORAL HABITS

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ORAL HABITS

• Dr. Jeff Johnson
• Division of Pediatric Dentistry
• Department of Oral Health Science
• UK College of Dentistry

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Outline

• Introduction
• Thumb/Finger Habits
• Pacifier Habits
• Lip Habits
• Tongue Thrust/and Mouthbreathing Habits
• Nail Biting
• Bruxism
• Self-Mutilation
• Appliance Therapy

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Oral Habits--Introduction--

• The presence of an oral habit in the 3 to 6 year
  old is an important finding in the clinical
  examination.
• An oral habit is no longer considered normal
  for children near the end of this age group.
• If the habit has resulted in movement of the
  primary incisors, some form of intervention is
  warranted prior to the eruption of the permanent
  incisors.
• The types of changes in the dentition that an
  oral habit may cause vary, depending on the
  intensity, duration, and frequency of the habit.

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Oral Habits--Introduction--

• Intensity
• Intensity is the amount of force that is applied
  to the teeth while performing the habit (i.e.
  Sucking).
• Duration
• Duration is defined as the amount of time spent
  sucking a digit.
• Frequency
• Frequency is the number of times the habit is
  practiced throughout the day.

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Oral Habits--Introduction--

• DURATION PLAYS THE MOST CRITICAL ROLE IN TOOTH
  MOVEMENT!!!

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Oral Habits--Introduction--

• Clinical and experimental evidence suggests that
  4 to 6 hours of force per day are necessary to
  cause tooth movement.
• The most important thing to remember about any
  intervention is that the child must want to
  discontinue the habit for treatment to be
  successful.

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Oral Habits--Introduction--

• Some Important Questions to Consider/Ask
• How long has the child had the habit?
• When does he/she indulge in the habit? Day?
  Night? Constantly?
• Does the child indulge in the habit at school?
• Does anyone ridicule the child in regards to the
  habit?
• Badgering the child about the habit tends to
  negatively reinforce the habit.

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Oral Habits--Introduction--

• Depending on the willingness of the child to stop
  the habit, three different approaches to
  treatment have been advocated.
• They are
• Reminder Therapy
• Reward Therapy
• Appliance Therapy

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Oral Habits--Introduction--
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Oral Habits--Introduction--

• Reminder Therapy
• Reminder therapy is appropriate for those who
  want to stop the habit but need some help to stop
  completely.
• An adhesive bandage taped to the offending finger
  can serve as a constant reminder not to place the
  finger/digit in the mouth. The reminder must
  be neutral and not perceived as any form of
  punishment

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Oral Habits--Introduction--

• Reward Therapy
• A contract is agreed upon between the child and
  parent or between the child and dentist.
• The contract simply states that the child will
  discontinue the habit for a specified period of
  time and in return he/she will receive a reward
  if the requirements of the contract are met.
• The reward does not need to be extravagant but
  special enough to motivate the child.
• The more involvement the child can take in the
  project, the more likely the project will succeed.

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Oral Habits--Introduction--

• Appliance Therapy
• Appliance therapy should only be used when
  reminder and reward therapy have failed.
• The dentist should explain to the patient and
  parent that the appliance is not a punishment but
  rather a permanent reminder.
• The parent and the child should be informed that
  certain side effects may temporarily appear after
  the delivery of an appliance. These include
• Eating difficulties.
• Speaking/speech problems.
• Disturbed sleeping patterns.
• Habit discouragement appliances should be left in
  the mouth for six months. Six months allows the
  habit to be completely extinguished.

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Oral Habits--Thumb and Finger Habits--

• Thumb and finger habits make up to majority of
  oral habits.
• The classic symptoms of an active habit are
  reported to be the following
• Anterior open bite.
• Facial movement of the upper incisors and lingual
  movement of the lower incisors.
• Maxillary constriction.

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Oral Habits--Thumb and Finger Habits--

• Anterior open bite, the lack of vertical overlap
  of the upper and lower incisors when the teeth
  are in occlusion, develops because the digit
  rests directly on the incisors. A slightly
  increased vertical opening is created.
• The digit impedes eruption of the anterior teeth,
  while the posterior teeth are free to erupt.
• Passive eruption of the molars will result in an
  anterior open bite.
• Although to a lesser degree, anterior open bite
  can also be caused by intrusion of the incisors.

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Oral Habits--Thumb and Finger Habits--

• Facio-lingual movement of the incisors depends on
  how the thumb or finger is placed in the mouth.
• Usually, the thumb is placed so that it exerts
  pressure on the lingual surfaces of the maxillary
  incisors and on the labial surfaces of the
  mandibular incisors. The result is increased
  overjet.

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Oral Habits--Thumb and Finger Habits--

• Maxillary arch constriction is due to the change
  in equilibrium balance between the oral
  musculature and the tongue.
• When the thumb is placed in the mouth, the tongue
  is forced down and away from the palate.
• The obicularis oris and buccinator muscles
  continue to exert a force on the buccal surfaces
  of the maxillary dentition.
• Without the tongues counterbalancing force on
  the lingual surfaces, the posterior maxillary
  arch collapses into crossbite.

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Oral Habits--Thumb and Finger Habits--

• Timing of treatment is critical.
• The child should be given every opportunity to
  stop the habit spontaneously before the eruption
  of the permanent teeth.
• Treatment is usually undertaken by age 6 years.

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Oral Habits--Pacifier Habits--

• Dental changes created by pacifier habits are
  similar to changes created by thumb habits.
• Anterior open bite and maxillary constriction are
  seen consistently in pacifier suckers.
• Labio-lingual movement of incisors may not be as
  pronounced as with a digit habit but is usually
  present nonetheless.
• Manufacturers have developed pacifiers that claim
  to be more like a mothers nipple and not as
  deleterious to the dentition as a thumb or
  conventional pacifier.
• Research has not substantiated these statements.

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Oral Habits--Pacifier Habits--

• Pacifier habits are theoretically easier to stop
  than digit habits.
• The pacifier can be discontinued gradually or at
  one point in time under the control of the
  parent.
• In a few cases, the child may subsequently start
  sucking a finger or thumb.

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Oral Habits--Lip Habits--

• Habits that involve manipulation of the lips and
  perioral structures are termed lip habits.
• Although most lip habits do not cause dental
  problems, lip sucking and lip biting certainly
  can maintain an existing malocclusion.
• The most common presentation of lip sucking is
  the lower lip tucked behind the maxillary
  incisors.
• A lingually directed force is placed on the
  mandibular teeth and a facial force on the
  maxillary teeth resulting in proclination of the
  maxillary incisors, a retroclination of the
  mandibular incisors, and an increased amount of
  overjet.
• The aforementioned problems are most common in
  the mixed and permanent dentitions.
• Treatment depends on the skeletal relationship of
  the child and on the presence or absence of space
  in the arch.

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Oral Habits--Tongue Thrust and Mouthbreathing
Habits--

• Epidemiological data indicate that there is not a
  simple cause-and-effect relationship between
  tongue thrusting and open bite.
• Further research suggests that tongue thrusting
  may be able to sustain an open bite but not
  create one.
• Tongue thrusting should be considered a finding
  and not a problem to be treated.

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Oral Habits--Tongue Thrust and Mouthbreathing
Habits--

• Often individuals appear to be mouthbreathers
  because of their mandibular posture or
  incompetent lips.
• It is normal for a 3 to 6 year old to be slightly
  lip incompetent.
• Despite the difficulties in identifying
  mouthbreathing individuals, there is an
  indication that a weak relationship may exist
  between mouthbreathing and malocclusions
  characterized by a long lower face and maxillary
  constriction.

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Oral Habits--Nail Biting--

• Nail biting is a habit rarely seen before 3 to
  six years of age.
• The number of people who bite their nails is
  reported to increase until adolescence.
• There is no evidence that nail biting can cause
  malocclusion or dental change.
• There is no recommended treatment.

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Oral Habits--Bruxism--

• Bruxism is a grinding or gnashing of the teeth
  and is usually reported to be nocturnal.
• Most children engage in some bruxism that results
  in moderate wear of the primary canines and
  molars.
• Rarely, with the exception of handicapped
  individuals, does the wear endanger the pulp by
  proceeding faster than secondary dentin is
  produced.

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Oral Habits--Bruxism--

• Treatment should begin with simple measures,
  including the elimination of occlusal
  interferences and occlusal equilibration if
  necessary.
• If occlusal interferences are not located or
  equilibration is not successful, referral to
  appropriate medical personnel should be
  considered to rule out any systemic problems
  (intestinal parasites, allergies, endocrine
  disorders, etc.).
• If neither of these two steps is successful, a
  mouth guard-like appliance can be constructed to
  protect the teeth and try to eliminate the
  grinding habit.

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Oral Habits--Self-Mutilation--

• Self-mutilation, repetitive acts that result in
  physical damage to the individual, is extremely
  rare in the healthy child.
• The incidence of self-mutilation in the mentally
  retarded population is between 10 and 20.
• Due to the fact that it always garners attention,
  it has been suggested that self-mutilation is a
  learned behavior.
• A frequent manifestation of self-mutilation is
  biting of the lips, tongue, and oral mucosa.
• Besides behavior modification, treatment for
  self-mutilation includes use of restraints,
  protective padding, and sedation. Also, the
  extraction of selected teeth may be necessary.

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Oral Habits--Appliance Therapy--

• There are two major categories of commonly used
  appliances
• Removable
• Fixed
• Removable
• Easily misplaced or lost
• Patient compliance is a major factor
• Fixed
• Cemented in-place using a dental
  cement/adhesive
• Does not rely on patient compliance

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Oral Habits--Appliance Therapy--

• Removable Appliance
• Example Modified Hawley

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Oral Habits--Appliance Therapy--

• Fixed Appliance
• Examples Hayrake Appliance
• Palatal Crib

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Oral Habits--Appliance Therapy--

• Fixed Appliance
• Examples (continued) Bluegrass Appliance

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Oral Habits--Appliance Therapy--

• Bluegrass Appliance
• Based on a concept from the horse industry
• Created and designed by Bruce S. Haskell, DMD,
  PhD and John R. Mink, DDS, MSD
• Indicated for thumb sucking habits
• Utilizes the principles of positive reinforcement

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Oral Habits--Appliance Therapy--

• Bluegrass Appliance (continued)
• Extremely well tolerated by patients and parents
• Indicated for children in the early or late mixed
  dentition who have a desire to stop their thumb
  sucking
• Works through a counter-conditioning response to
  the original conditioned stimulus for thumb
  sucking
• Extremely high success rate

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Oral Habits--Appliance Therapy--

• Construction of the Bluegrass Appliance
• Adapt bands on the maxillary first permanent
  molars or second primary molars
• Make a compound impression
• Place bands in the impression
• Pour a cast
• Use .045 wire

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Oral Habits--Appliance Therapy--

• Construction of the Bluegrass Appliance
  (continued)
• Place the beveled teflon roller just distal to
  the maxillary canines so that it interferes with
  the thumb
• Adapt wire to fit inside maxillary arch and
  terminate on the lingual surfaces of the molar
  bands
• Solder wire to molar bands

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Oral Habits--Appliance Therapy--

• A Little About the Teflon Roller
• Beveled on 3 sides
• 5/8 inch in length
• ¼ inch in diameter

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ORAL HABITS

• References
• Proffit, William R. Contemporary Orthodontics,
  2nd edition, Chapter 25, 1993.
• Haskell, Bruce S and Mink, John R. An Aid to
  Stop Thumb-Sucking The Bluegrass Appliance,
  Paediatric Dentsitry, Volume 13, Number 2.

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