HABITS AND ITS MANAGEMENT www.indiandentalacademy.com
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Definitions:
William James: An acquired habit, from psychological point of view, is nothing but a new pathway of discharge formed in the brain, by which certain incoming currents ever after tend to escape. Moyers: Habits are learned pattern of muscle contraction, which are complex in nature. Finn: A habit is an act, which is socially unacceptable. www.indiandentalacademy.com
Classification of habits According to William James: Useful habits: These habits include the habits of normal function such as correct tongue posture, proper respiration etc. Harmful habits: These are the ones which exert stresses against the teeth and dental arches such as mouth breathing, lip sucking, thumb sucking. www.indiandentalacademy.com
According to Finn and Sim: • Compulsive habits: When the habit has acquired a fixation in the child to the extent that he retreats to the practice of this habit whenever his security is threatened.This is his safety valve when emotional pressures become too much to cope with. • Non-compulsive habits: Habits which are easily dropped or added from the child behaviour pattern as he matures. www.indiandentalacademy.com
Various habits are: • • • • • • • • • • •
Thumb sucking/finger sucking Tongue thrusting Mouth breathing Lip biting and lip sucking Postural habits Nail biting Masochistic habits Bobby pin opening Frenum thrusting Bruxism Cheek biting/sucking www.indiandentalacademy.com
Thumb sucking/finger sucking Gellin: Defines digit sucking as placement of thumb or one or more fingers in various depths into mouth. Moyers: Repeated and forceful sucking of thumb with associated strong buccal and lip contractions. www.indiandentalacademy.com
Psychology of thumb sucking • Freudian theory: He suggests that orality in the infants is related to pregenital organization and thus, the object of thumb sucking is nursing. He believes that abrupt interference in such basic mechanism will likely lead to substitution of such antisocial tendency such as stuttering.
• Oral drive theory (Sears and Wise): He suggests
that the strength of oral drive is in part a function of how long a child continuous to feed by sucking. Thus it is not the frustration of weaning but, rather oral drive which has been strengthened by the prolongation of nursing. www.indiandentalacademy.com
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Benjamins theory: He proposed two theories-
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Thumb sucking is an expression of a need to suck that arises because of association of sucking with primary reinforcing aspects of feeding. Thumb sucking arises from the rooting and placing reflexes common to all mammalian infants.
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A multidisciplinary research team at the university of Alberta support the theory that digital sucking habits in humans are simple learned response.
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Clinical aspects of digital sucking: Prenatal/ antenatal: Shortly before the child passes through the birth canal, the fetus shows increased muscular activity and the thumb may find its way into the mouth, thus initiating thumb sucking habit before birth. The fetus seeks a ‘position of comfort’ which occasionally interferes with post natal dentofacial development. www.indiandentalacademy.com
Postnatal: A: Finger sucking from birth to 4 yrs of age:
Infants generally start sucking habit in the first three months of life, which may be due to feeding problems, emotional stress with which they are unable to cope, insecurity and desire to attract attention. For the 1st 4yrs of life damage to occlusion is confined largely to the anterior segment. The damage is temporary, provided the child starts with normal occlusion. An exerciser or pacifier was developed which is hoped to greatly reduce the need and desire of the infant for thumb sucking between meals and at bed time. e.g Nuk sauger nipple. Edwall functional nursing nipple. www.indiandentalacademy.com
Nuk sauger nipple
Conventional nipple
B Active finger sucking after 4 yrs of age: The permanence of malocclusion increases if the habit persists beyond 4 yrs of life. Trident of habit factors: • DURATION • FREQUENCY • INTENSITY Duration: duration of sucking i.e hours per day of sucking, plays a major role in tooth displacement. Frequency: frequency of habit during day and night affects the end result. Intensity: more the intensity of sucking more the perioral muscles function and more is the damage. www.indiandentalacademy.com
Effect of thumb sucking • •
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The of effect of sucking habit depends on: Position of thumb in mouth Leverage effect the child gains against the other teeth and the alveolus. Apposition of sucking finger on the maxilla: In case the finger rests on the lower incisors as a fulcrum Promotes the development of class I, class II div I malocclusion. Anterior open bite. Protraction of maxillary anterior teeth. Labial tipping of mandibular www.indiandentalacademy.com anterior teeth.
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In case the finger rests on the lower anteriors then lingual displacement of lower anteriors will occur. Vertical equilibrium is altered on the posterior teeth leading to more eruption of posterior teeth causing open bite. Arch form is affected due to alteration in balance between cheek and tongue pressures i.e maxillary arch tends to become vshaped. Thumb sucking is associated with tongue thrust to maintain the anterior seal. www.indiandentalacademy.com
• Narrower nasal floor and high palatal vault • Maxillary lip hypotonic and mandibular lip hyperactive • Hyperactive mentalis muscle • In case the child bites on both its index fingers, it leads to protrusion and open bite corresponding with the side in which the finger is being held www.indiandentalacademy.com
• Bilateral posterior crossbite as the posterior teeth are forced palatally by the buccal musculature. Apposition of finger sucking on the mandible: • In case the fingers are pressed on the lingual side of the mandibular alveolar process and lower anterior teethlabial tipping of upper and lower incisors is due to forward and downward displacement of tongue.
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• Can lead to class III malocclusion in which mandible jaw is pulled forward by fingers • Facial asymmetry may be caused • Line of occlusion is changed • Callus formation and low virus infection on fingers which is continuously been sucked.
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Management • Most of the children discontinue their habit at the age of 4yrs or by 5 yrs • No treatment is recommended as the malocclusion,if present, corrects itself as the habit ceases • Adult approach: As the time of eruption of the permanent incisors approach, a straight forward discussion with a dentist is recommended • Reminder therapy: a simple method is to secure an adhesive bandage with waterproof tape on the finger that is being sucked. www.indiandentalacademy.com
• Reward system: if the reminder therapy fails then reward system is used in which small tangible reward daily for not engaging in the habit. • If this fails then elastic bandage loosely wrapped around the elbow prevents the arm from flexing and finger from being sucked. • If this fails then the reminder appliance is fitted to actively impede finger sucking. eg ,crib, maxillary lingual arch with crib etc.
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• Psychological approach: Dunlop theory (beta hypothesis)-This theory states that by practicing a bad habit with the intent to stop it, one learns not to perform the undesirable act. The child will not derive any satisfaction from purposeful repetition of the habit but will experience a painful reaction in its performance and will gradually abandon the habit. This is applicable to older children whose cooperation can be obtained. • Chemical approach: In this a hot flavored, bitter tasting or foul smelling preparations can be applied on the finger that is being sucked. e.g red pepper, quinine, asafetide. www.indiandentalacademy.com
Appliances used Removable appliances: • Tongue spikes • Tongue crib • Rake appliance • Vestibular screen Fixed appliances • Hay rake • Maxillary lingual arch with palatal crib www.indiandentalacademy.com
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A crib is a habit retraining appliance which utilizes a blunt wire ‘reminder’ which prevents the child from indulging into the habit. It serves the following functions: To break the suction and force on anterior segment. As a reminder. Make the habit non pleasurable. Forces the tongue backward, changing the shape during rest position from an elongated mass to a more wider position, nearly like a normal tongue. www.indiandentalacademy.com
A rake may be removable or fixed. It discourages not only thumb sucking but tongue thrusting and abnormal swallowing also. Another appliance by Haskell and Mink called the blue grass appliance was used to stop thumb sucking. In this a modified six sided roller machine from teflon was used. www.indiandentalacademy.com
Time of therapy • Check up appointments are made at 3-4 wk interval. • Appliance to be worn for 4-6 months. • A period of 3 months of total absence of finger sucking is good insurance for relapse. • The appliance is removed in parts i.e after 3 months of habit free interval the spurs are cut off,3 wks later posterior loop extension is cut and 3 wks later palatal bar and crown may be removed. www.indiandentalacademy.com
Tongue thrusting Definition: Placement of tongue tip forward
between incisors during swallowing. Tongue thrusting may be primary cause of malocclusion or it may be secondary adaptive factor as in case in skeletal open bite. It is generally associated with long term thumb sucking children. www.indiandentalacademy.com
Classifications of tongue thrust:
Primary Secondary
Anterior lateral, complex
Endogenous Habitual Adaptive (enlarged tonsils,pharyngitis)
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• Acc to Graber There are considerable amount of evidences that indicate that tongue thrust is the retention of the infantile suckling mechanism. Whatever may be the cause of tongue habit (size, posture, function) it serves as the effective cause of malocclusion.
• Acc to Proffit Whenever there is an open bite due to tongue sucking habit a compensatory muscle activity of the tongue develops which accentuates the deformity. Bringing the lips together and placing the tongue between anteriors is successful maneuver to make an anterior seal. After the sucking stops, the anterior open bite tends to close spontaneously otherwise an anterior seal by tongue tip remains necessary. www.indiandentalacademy.com
In modern view point: Tongue thrust swallow is seen in two circumstances, in younger children in normal occlusion in whom it represents a transitional stage in normal physiologic maturation and in individuals of any age in displaced anteriors. Therefore tongue thrust swallow should be considered the result of displaced incisors and not the cause.
Acc to equilibrium theory: The pressure generated is very less to effect the equilibrium but if there is forward resting posture of tongue the duration of pressure ,even if very light could effect tooth movement.
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Effects of tongue thrusting • Increase in overjet and overbite. • Tongue no longer lie on the lingual cusps of the buccal segment and posterior teeth erupt; thus eliminating interocclusal clearence. • May lead to bruxism. • Narrowing of maxillary arch as the tongue drops lower in the mouth. Clinically this may be seen as unilateral cross bite. • In horizontal growth pattern, tongue dysfunction leads to bimaxillary protusion. • In vertical growth pattern, tongue dysfunction leads to lingual inclination of lower incisors. • Diastemas may be present. • Deep bite in lateral tongue thrust. www.indiandentalacademy.com
Careful differentiation must be done among simple, complex tongue thrust and retained infantile swallowing pattern and faulty tongue posture. • Prognosis is good for simple tongue thrust. • Not very good for complex tongue thrust. • Poor for retained infantile swallowing pattern. Protracted tongue posture can be: • Endogenous- no certain treatment • Acquired- can be corrected www.indiandentalacademy.com
Normal tongue
Tongue thrust
Method of examination tongue dysfunction • Electronic recording. • Electromyographic examination. • Recording of pressure exerted by tongue intra orally. • Roentgenocephalometric analysis. • Cine-radiographic. • Paltographic. • Neurophysiologic examination.
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Management • Simple tongue thrust: it is the tongue thrust with teeth together swallow. If there is excessive labioversion of maxillary incisors,treatment of tongue thrust should be done after retraction of incisors. Patient should be taught swallowing exercises with sugar less mint and should be instructed to practice 40 times a day and maintain the record. On second appointment, patient should be able to swallow correctly at will. Sugar less drops may be used to reinforce the unconscious swallow. If the problem continues, soldered lingual arch wire having short and sharp spurs can be inserted. www.indiandentalacademy.com
To summarize; Conscious learning of new reflex.
Transferal of control of the new swallow Pattern to the subconscious level.
Reinforcement of the new reflex.
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Complex tongue thrust:
It is the tongue thrust with teeth apart swallow. Malocclusion present are: Poor occlusal fit. Generalized anterior open bite. Open bite may not be present if the tongue is seated evenly atop of all teeth.
Treatment: Treat occlusion first. When the treatment is in retentive phase- muscle training is begun. Maxillary lingual arch appliance is necessary for these patients. There may be chances of relapse and prognosis is not very good www.indiandentalacademy.com
• Retained infantile swallow: It is defined as the undue persistence of the infantile swallow well past the normal time for its departure. These patients occlude only on one molar in each segment. These patients do not have expressive faces. They have difficulty in breathing. Low gag threshold It is a problem of neuromuscular development. Appliance used is tongue crib with 3-4 vshaped projections which extend downward up to the cinguli of lower incisors when the casts are occluded. Prognosis is poor. www.indiandentalacademy.com
• Abnormal tongue posture: Endogenous tongue posture: it is an inherently abnormal
tongue posture and the tip of the tongue persists in lying between incisors. There is stability of incisor relationship even though a mild open bite is seen. Prognosis poor. Acquired tongue posture: it is due to chronic pharyngitis, tonsillitis, nasorespiratory disturbance. Refer the patient to otolaryngologist for the precipitating factors. Followed by lingual arch wire with sharp spurs. This is correctable after the precipitating factors are corrected. Adaptive tongue posture: This is due to narrow maxilla. When rapid palatal expansion is completed and posterior intercuspation is correct normal posture returns. www.indiandentalacademy.com
Mouth breathing Respiratory needs are the primary determinant of the posture of jaws and tongue. Therefore it is reasonable that an altered respiratory pattern, such as breathing through mouth rather than nose, could alter the equilibrium of pressure on jaws and teeth and affect both jaws growth and tooth position.
Finn classified mouth breathing into 3 different categories: • • •
OBSTRUCTIVE HABITUAL ANATOMIC
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• Obstructive mouth breathing: These are the children who have complete obstruction of normal air flow of air through the nasal passages. Due to difficulty in breathing through nose child is forced to breath through mouth.
• Habitual mouth breathing: This is a child who continuously breath through mouth by force of habit, even if abnormal obstruction is removed.
• Anatomic mouth breathing: They are the one whose short upper lip does not permit complete closure without undue effect. www.indiandentalacademy.com
Factors considered for mouth breathing • For an average individual, when ventilation exchange rate of 40-45l/min. is reached, there is a transition to partial oral breathing. • Heavy mental concentration could lead to increase air flow and a transition to partial mouth breathing. • If nose is partially obstructed, or there is a tortuous passage an individual shifts to mouth breathing. • Swelling of nasal mucosa accompanying common cold converts one into mouth breathing. • Chronic respiratory obstruction produced due to inflammation within the nasorespiratory system can lead to mouth breathing www.indiandentalacademy.com • Pharyngeal tonsils and adenoids can cause mouth breathing.
Clinical features • Associated with impeded maxillary growth. • Narrow jaw with high palate, dental crowding as well as retrognathism of maxilla. • Prognathism of mandible. • Tongue lies flat on th floor of mouth so it does not play its role in development of maxilla. • Hyperactivity of facial muscles especially buccinator, impedes the development of maxilla. • In class II malocclusion there is increase in overjet. • Bilateral cross bite. • Hyperplasia of gingiva. • Extra oral appearance of these patients is often conspicuous and is termed ‘adenoid facies’. www.indiandentalacademy.com
• There is downward and backward rotation of mandible to maintain postural changes leading to open bite anteriorly. • Two different tongue posture are possible: type I -in class III malocclusion tongue is flat and protruding. type II- in class II malocclusion tongue has a flat and retracted position.
Examination of breathing mode: Cotton pledget test: A cotton butterfly is placed below the nostrils and observed. The nasal breather will displace the cotton pledget on expiration where as the mouth breather will not. Mirror test: mirror is held in front of both the nostrils, in nasal breather the mirror will cloud with condensed moisture during expiration. Observation of nostrils: Alar muscles are inactive in mouth breathers i.e do not change their size on inhalation or expiration where as nasal breathers do. www.indiandentalacademy.com
Management • If mouth breathing is due to nasal obstruction, then operation by an E.N.T surgeon is indicated i.e in case of allergic rhinopathy. • If patient has habitual mouth breathing then pre-orthodontic therapy should be carried out by: breathing exercises, incorporation of oral or vestibular screen. In case in which vestibular screen is used holes can be slowly closed as the patient starts breathing through nose. • Myofunctional exercises like to hold a piece of card board to improve lip seal. www.indiandentalacademy.com
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Bruxism Definition : it is the habitual grinding of teeth, during sleep. this term is applied to clenching of teeth and also to repeated tapping of teeth.
Incidence: 5- 20 % Etiology (Nadler and Meklas): • • • •
Local Systemic Psychological occupational
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Local: These factors are associated when there is mild form of occlusal discomfort during transition from deciduous to permanent dentition.
Systemic:-gastrointestinal disturbances. - sub clinical nutritional deficiencies. - allergy or endocrine disturbances. - hereditary background.
Psychological factors: they are believed to be most common causes of bruxism. emotional tension such as fear, rage, rejection.
Occupations: athletes engaged in physical activities often develop bruxism. in which work has been more precise such as watch makers. voluntary bruxism in those who have habit of chewing gum, www.indiandentalacademy.com
Tobacco or objects such as pencil or tooth picks.
Clinical features (Glaros and Rao): divided into six • •
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categoriesEffect on dentition: severe wearing or attrition of teeth- both occlusal and interproximal. Effect on periodontium: loss of integrity of periodontal structures, resulting in loosening, drifting of teeth, gingival recession with bone loss. Effect on masticatory muscles: hypertrophy of masticatory muscles, particularly masseter muscle, cause trismus and alter opening and closing movements of jaw. TMJ disturbance may be seen. Head pain and facial pain. Psychological and behavior effects. www.indiandentalacademy.com
Management • If the underlying cause of the bruxism is an emotional one, the nervous factor must be corrected if the disease is to be cured. • Removable rubber splints can be worn at night to immobilize the jaws. • A vinyl plastic bite guard that covers the occlusal surfaces of all teeth plus 2mm of the buccal and lingual surfaces can be worn at night to prevent abrasion. www.indiandentalacademy.com
Lip sucking and lip biting Lip sucking is a compensatory activity which results from an excessive overjet and relative difficulty of closing the lips during deglutation. In most cases it is the mandibular lip that is involved in sucking, although biting habits of maxillary lip is also seen. The deformity reaches maximum when the discrepancy between the maxillary incisors and mandibular incisors becomes equal to the thickness of the lip. (B.J.Johnson). www.indiandentalacademy.com
Common features: • Labioversion of maxillary teeth and lingual displacement of mandibular teeth. • Vermillion border is hypertrophic and redundant during rest. • Flaccid lip due to lengthening. • Chronic herpes with areas of irritation and cracking of lips. • If a patient has lip sucking habit during sleep then telltale • Redness and irritation extending from mucosa to skin of lower lip is seen. • If patient is class II div1 malocclusion then the lip suking habit is only adaptive. www.indiandentalacademy.com
Management : If the patient is having class II div 1 malocclusion then the treatment should be done orthodontically. The lip sucking habit generally ceases after the treatment. If the habit continues then, the lip appliance i.e lip plumper is given. The appliance can be modified by adding acrylic between base wire and auxillary wire. Removal of appliance is done in parts i.e first the auxillary wire then the base wire is removed. A period of 8-9 months is required to cease the habit completely.
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Postural habits Poor postural position may also lead to malocclusion. A stoop shoulder child, with head hung so that, a chin rests on the chest, has been accused of creating his own mandibular retrusion. Child and adults do not lie in one position during sleep, they keep on changing which are induced by nervous reflexes. Before the sleeping position can produce any deleterious effect on jaw growth, the child would have to be suffering from some osteogenic deficiency. www.indiandentalacademy.com
Posture during the child’s waking hours is more important then position during sleep in the production of dental malocclusion. Deformity, flattening of the skull and facial asymmetry may occasionally develop during first year in infant who habitually lie in the supine position with head turned to right or left. Poor posture may accentuate an existing malocclusion, but this remains to be proved or disapproved conclusively. www.indiandentalacademy.com
Nail biting This habit is often mention as a cause of of tooth malpositions. High strung, nervous children most often display this habit. Nail biting is absent under 3yrs of age. There is rapid increase from 6yrs of age up to 12 yrs in girls and 14 yrs in boys, followed by rapid decline after the age of 16 yrs. It is more commonly seen in adolescence in boys than among girls. www.indiandentalacademy.com
Clinical features: • • •
may induce crowding rotations of incisors attrition of incisal edges these malocclusions are due to the untoward pressures introduced during nail biting.
Management: • It is important to study child’s physical, mental and social difficulties if the roots of the habit are to removed. • If the child continues after suggestions he may be in www.indiandentalacademy.com need of psychiatric consultation.
• He may be associated with toe nail biting. Kanner and Bakwin found toe nail biting only in girls. • Arousing a new interest such as nail polish has been found helpful in girls and boys may be given reward for sparing his nails. • Punishments, scolding and restraints are of no value. • Light cotton wittens may be worn at night to act as a reminder. • Nightsuits which encase the feet may be worn at night. • Rewards are sometimes of value. www.indiandentalacademy.com
Masochistic habits In this habit a child uses his finger nails to strip the gingival tissues from the labial surface of the lower cuspid. sometimes a child completely denudes the tooth of marginal gingiva and unattached gingival tissues, exposing the alveolar bone.
Management : Psychiatric assistance. Taping the finger. www.indiandentalacademy.com
Bobby-pin opening This is opening bobby pins with anterior incisors to place them in hair. Mostly seen in teen aged girls.
Clinical features: • Notched incisors • Teeth partially denuded of labial enamel may be observed.
Management: Calling attention to the harmful result is generally all that is necessary www.indiandentalacademy.com to stop the habit.
Frenum thrusting If a child has spaced incisors , the child may lock his labial frenum between these teeth and permit it to remain in this position for several hours. This habit is rarely seen. This develop into tooth displacing habit by keeping the central incisors apart.
Management: Orthodontic correction of incisors.
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Cheek sucking/biting This habit may persist as a substitute for thumb sucking or tongue thrusting.
Effects: • May lead to posterior open bite. • Wet like horizontal swelling may be formed as a result of constant irritation.
Management: Removable lateral crib may be used. Vestibular screen orwww.indiandentalacademy.com oral screen may be used.
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