oral habits

Presented by:
Dr Madiha Khan
Pg 1st Year
1

Content
• Introduction
• Classification of oral habits
• Etiology
• Prevelence
• Development of a habit
• Thumb sucking
• Tounge thrusting
• Mouth breathing
• Bruxism
• Lip ,Cheek & Nail Biting
• Masochistic habits
• Conclusion
2

Introduction
Dorland (1957)
• Habit can be defined as a fixed or constant practice established by
frequent repetition.
Buttersworth (1961)
• Habit is a frequent or constant practice or acquired tendency, which
has been fixed by frequent repetition.
Boucher(1963)
• Defined oral habit as a tendency towards an act or as act that has
become a repeated performance relatively fixed, consistent, easy to
perform and almost automatic”.
Mathewson (1982)
• Oral habits are learned patterns of muscular contractions.
Finn(1987)
• defined habit as • “an act, which is socially unacceptable”.
3

CLASSIFICATION
USEFUL AND HARMFUL HABITS (JAMES -1923)
Useful habits-
Include the habits of normal
function such as:
a)correct tongue position
b)proper respiration
c)proper deglutition and
d)normal usage of lips in
speaking.
Harmful habits-
• Those habits that exert
perverted stress against
teeth and dental arches.
5

ETIOLOGY OF HABIT DEVELOPMENT
1)Anatomical:
For ex: Posture of tongue. Infantile swallow occurs due to a large
tongue in a small oral cavity coupled with anterior open bite
2)Mechanical interferences
3) Pathological
4) Emotional
5) Imitation
6) Random behavior
15

PREVALENCE OF ORAL HABITS
Kharbanda et al 2003
• 5-13 yr old children, Delhi -25.5%
• Tongue thrusting – most common (18.1%) followed by mouth
breathing (6.6%)
• Thumb sucking (0.7%) and lip biting (0.04%)- relatively less common
• There was no significant difference between boys and girl
(Kharbanda O P et al. Oral habits in school going children of delhi: A prevalence study. Journal og Indian Scociety Of Pedodontics and Preventive
Dentistry2003;21(3):120-4.)
16

Shetty SR, Munshi AK (1998)
• Mangalore - 29.7% of children.
• Digit sucking(3.1%), Pencil biting-(9.8%) and Tongue thrust- (3.02%) Highly
prevalent among 3-6 yrs.
• Mouth breathing(4.6% )and bruxism (3.1%) - significant in 7- 12 yrs
• Lip/cheek biting(6%)and nail biting (12.7%) - more common in 13-16 yrs.
• Digit sucking, tongue thrust, mouth breathing and bruxism - more
prevalent among boys
• Lip/cheek biting, nail biting and pencil biting -more prevalent among girls.
(Shetty SR, Munshi AK. Oral habits in children- a prevalence study. J Indian Soc Pedod Prev Dent.1998; 16(2):61-6)
17

Development of a habit
• The newborn develops some instincts, which are composed of elementary
reflexes.
• Instinct : pattern and order are inherited,
• Habit: pattern and order are acquired,
if constantly repeated during the lifetime of an individual.
At the beginning,
• the infant makes an effort by frequent learning and practice,
• later on the muscles start responding more readily.
• At the onset it takes a long time for the impulses to pass along the efferent
nerves to muscle involved
18

It has been stated that unconscious mental pattern of childhood
develops from five sources namely
• Instinct,
• Insufficient or in correct outlet of energy,
• Pain or discomfort,
• Abnormal physical size of parts,
• Imitation of or imposition of others
19

Thumb/Finger sucking
Definition:
• Placement of the thumb or one or
more fingers in varying depths into the
mouth.
– Gellin- 1978
• Repeated and forceful sucking of
thumb with associated strong buccal
and lip contractions
- Moyers
22

• I.U Life
• First 2 yrs.
• Disappears with maturation.
• No: malocclusion
• Abnormal IF, persists
• IF not controlled at this age: May cause deleterious effects on
dentofacial structures.
23

CLASSIFICATION
• Based on clinical observation
1.Normal thumb sucking
2.Abnormal thumb sucking
25

A. Psychological
B. Habitual
26

O’BRIEN(1996)
A)Nutritive sucking habits: Provides essential nutrients
Ex- Breast feeding , Bottle feeding.
B)Non nutritive sucking habits: Ensures a feeling of well-being, warmth
and a sense of security.
Ex- Thumb/ finger sucking, Pacifier sucking
27

Substelny (1973)
Substelny has graded thumb sucking into four types
• In the first group: Almost 50% of the children place the whole digit
inside the mouth with the pad of the thumb pressing over the palate,
while at the same time maxillary and mandibular contact is present.
• In the second group (24%): The thumb is placed into the oral cavity
without touching the vault of the palate. While at the same time
maxillary and mandibular anterior contact is maintained.
28

• In the third group (18%): The thumb is placed into the mouth just
beyond the first joint and contacts the hard palate and only the
maxillary incisors, but there is no contact with the mandibular
incisors.
• In the fourth group (6%): The thumb is not fully inserted into the
mouth. The lower incisor makes contact at the approximate level of
the thumbnail
29

Classification of NNS habits Johnson and
Larson 1993
Level Description
Level I (+/-) Boys or Girls of any chronological age with a habit that occurs during sleep.
Level II (+/-) Boys below age 8 with a habit that occurs at one setting during waking hours.
Level III (+/-) Boys under age 8 years with a habit that occurs at multiple settings during waking hours.
Level I V (+/-) Girls below age 8 or a boy over 8 years with a habit that occurs at one setting during
waking hours.
Level V (+/-) Girls under age 8 years or a boy over age 8 years with a habit that occurs across multiple
settings during waking hours.
30

Sucking reflex- Engel 1962
• Seen even at 29 week of I.U. life
• First coordinated neuromuscular activity of infant
• Disappears during normal growth btw 1-3 ½ yrs
• Purpose:
Nutritional/Physiological gratification
Emotional gratification
Also experience pleasurable stimuli from lips, tongue and oral mucosa &
learn enjoyable sensations such as closeness of a parent.
Babies restricted from suckling due to disease or other factors become
restless and irritable.
This deprivation motivates the infant to suck the thumb or finger for
additional gratification
31

INFANTILE OR VISCERAL SWALLOW
Characteristic of the infantile or visceral swallow as listed by Moyer’s:
The jaws are apart, with the tongue between the gum pads.
The mandible is stabilized primarily by contraction of the muscles of
the VIIth cranial nerve and the interposed tongue.
The swallow is guided, and to a great extent controlled by sensory
interchange between the lips and the tounge.
33

MATURE SWALLOW
By 18 months of age the mature swallow characteristics listed by
Moyers are observable.
The teeth are together
The mandible is stabilized by contraction of the mandibular elevators,
which are primarily 5th cranial nerve muscles.
The tongue tip is held against the palate about and behind the
incisors and peripheral portions flow between opposing posterior
segments.
There are minimal contractions of the lips during the mature swallow.
34

Variables affecting malocclusion Sorokohit
and Nanda (1989)
1)Position of the digit
2)Associated orofacial muscle contraction
3)Mandibular position during sucking
4)Facial skeletal pattern
5)Intensity, frequency and duration of force applied.
36

THEORIES
• Psychology of Non Nutritive digit sucking Theories to explain the
cause of occurrence of this habit
• Freudian theory (1905)
• Learning theory (Davidson, 1967)
• Oral drive theory (Sears and Wise, 1982)
• Johnson and Larson (1993)
37

FREUDIAN THEORY(1905)
Distinct phases of psychological development
Oral and anal phases seen in first 3 years of life.
Oral phase- mouth believed to be Oro-erotic zone.
The child has tendency to place his finger or any object into the oral cavity.
Prevention of such an act : results in emotional insecurity and passes the risk of the child
diversifying into other habits.
Thumb sucking considered as manifestation of insecurity, maladjustment , internal
conflicts
38

The Learning Theory: Davidson 1967
• Non-nutritive sucking stems from adaptive response
• Infant associates sucking with hunger, satiety & being held.
• These events are recalled by finger or thumb.
• i.e habit stems from an adaptive response and assumes no underlying
psychological cause as a result of learning
39

BENJAMIN’S THEORY (1962):
Thumb sucking arises from “ROOTING REFLEX”, common to all
mammilian infants.
Rooting reflex is movement of the infants head and tounge towards
the object touching its cheek.
It is max’ during first 3months of life.
If it persists, may lead to abnormal habit.
40

ORAL DRIVE THEORY
• Sears and wise(1950)
• Acc to this, theory prolongation of nursing strengthens the oral drive.
• (i.e prolonged sucking can lead to thumb sucking)
41

The trident Factors affecting thumb sucking :
Graber and Swain (1985)
• Intensity: Implies how vigorously the habit is pursued. The digit may
rest passively in the mouth or may be sucked with much enthusiasm.
• Frequency: Indicates how often during the day the habit is Practiced.
• Duration: Indicates the number of years the habit is continued
42

Phases of Development of Thumb Sucking
(Moyers)
• Phase I
Normal and sub clinically significant.
It is seen during first three years of life.
The habit is considered normal during this phase and unusually terminates
at the end of phase one.
43

• Phase II
Clinically significant sucking:
The 2 phase extends between 3- 6 years of age.
The presence of sucking during this period is an indication that the child is under great
anxiety.
Treatment should be initiated during this phase.
44

• Phase III
Intractable sucking:
Any thumb sucking persisting beyond 4 and 5 year of life should alert
the dentist to the psychological aspect of approach
45

DIAGNOSIS
• History of the digit sucking activity
• Evaluation of the child’s emotional status
• Extra oral examinations
• Intra oral examinations
46

HISTORY
• Parents
• Feeding patterns
• Three major questions: (Graber 1972)
Frequency
Duration (most imp)
Intensity
Direction, type
47

EMOTIONAL STATUS
• Essential to determine meaningful or empty habit.
• Identify the child who wants to stop but just needs some help
48

CLINICAL FEATURES
– Digits
– Lips
– Facial form
– Dentofacial changes
– Other features
49

DIGITS
50
Reddened
Exceptionally clean and chapped
Short clean finger/ thumb nail (dish pan thumb)
Fibrous roughened callus on superior aspect of finger nail
Grooves on thumb

LIPS
Upper lip :
Short and hypotonic
Passive or incompetent during swallowing
Lower lip :
Hyperactive
51

FACIAL FORM ANALYSIS
Maxilla protrusion
Mandibular retrusion
High mandibular plane angle
Facial profile- straight / convex
Saddle nose (due to pressure of index finger)
52

Effects on Maxilla:
Proclined maxillary incisors
trauma to maxillary central incisors
Maxillary arch length
Clinical crown length of maxillary anteriors
palatal arch width ie High palatal arch
Increased atypical root resorption in primary
central incisors
53

Effects on Mandible
Retroclination / proclination of
mandibular incisors
Retroclination : direct apical & lingual
force from digit
Proclination: indirect force from tongue
beneath digit
Decreased clinical crown length of
mandibular anteriors
Increased mandibular inter molar
distance:Uncontained arch
Retrusion of mandible
54

Effects on Inter-arch relationship:
Anterior open bit
Decreased overbite
Increased overjet
Unilateral or bilateral Class II malocclusion.
Posterior cross bite
55

Effect on lip placement and function:
Lip incompetence
Lower lip function under the maxillary incisors
Effect on tongue placement and function:
Tongue thrust
Lip to tongue resting position (oral seal)
Lower & lateral tongue position
56

Other features
Other habits-
• habitual mouth breathing,
• tongue thrust swallow
• Middle ear infections
• Enlarged tonsils
• Speech defects (lisping)
57

TREATMENT CONSIDERATIONS: FINN
Psychological status of the child
Age factor
Motivation of child
Parental cooperation
Friendly rapport
Other factors (goal orientation for time limit)
58

TREATMENT MODALITIES
• The treatment considerations are psychological status, age factor, maturity
of the patient, and patient co-operation.
• The combinations of explanations with consideration of physical
appearance and social acceptance may be sufficient for the child to give up
the behavior.
• In addition to their own intention some children may require additional
help.
• Another tool that is helpful for this type of child is the use of positive
reinforcement.
• Rewards for progress in diminishing the habit should include praise and
something special that is agreeable to patient and parent.
59

Psychological Therapy :
A. Dunlop's hypothesis
• If a subject is forced to concentrate on the performance of the act
and the time he practices it, he could learn to stop performing the
act.
• Forced purposeful repetition of habit eventually associates with
unpleasant reactions and the habit is abandoned.
• The child should be asked to sit in front of the mirror and asked to
observe himself as he indulges in the habit
60

B. Six steps in cessation of habit (Larson &
Johnson)
• Step 1: Screening for psychological component.
• Step 2: Habit awareness.
• Step 3: Habit reversal with a competing response.
• Step 4: Response attention.
• Step 5: differential reinforcement of other behaviors
• Step 6: Consists of holding the child, establishing eye contact and
firmly admonishing the child to stop the habit
61

C. Three alarm system: (Norton & Gellin-
1968)
• A chart is designed with days of the week and blank spaces.
• When the child engage in his habit he is told to wrap the digit he
sucks with coarse adhesive tapes.
• The child feels the tape in his mouth it is the first alarm and this
reminds him to stop the habit.
• At the same time elbow of the arm with the offending thumb is
firmly but not tightly wrapped in a 2 inch elastic bandage obtainable
in any drug store. Safety pins are placed in the proximal and distal
ends of the bandage, and one is placed lengthwise at the medial
bend of the elbow. When he sucks again the closed pin mildly
jabbing indicates a ‘second alarm’ to stop sucking.
• If the child persists the elastic bandage will tightened and his hand
fall asleep as a ‘third and final alarm’.
62

Reward system
• Children should be encouraged and rewarded for not practicing the
habit. “contingency contracting” is a contract made between the child
and dentist or child and parent.
63

THUMB BUDDY TO LOVE
64
This is commercially available and is a positive teaching tool
and chemical free method.
It contains thumb puppet that is inserted into the child's
thumb and a calendar at the back of the book.
By having the thumb puppet, the child stays motivated to
stop the habit.

CHEMICAL TREATMENT
• Bitter and sour
• Very minimal success
• e.g. quinine, asafetida, pepper, caster oil etc.
• NEWER anti-thumb sucking solutions
• Femite
• Thumb-up
• Anti-thumb
65

REMAINDER THERAPY
• THUMB GUARD
• It is an appliance that is worn when the child is
tempted to suck.
• Once the guard is worn they cannot generate
vacuum and so sucking is not much satisfying.
• Another approach is long sleeve gown by
doubling the length of the sleeve.
• It makes difficulty for the child to suck.
• While providing remainder therapy the child
should be instructed that these are just to
remind them to take the thumb out and it is not
a punishment
66

PARENT COUNSELING
• A different approach that can be practiced when its known that the child,
wants to discontinue the habit, it requires the cooperation of the parent
and their consent to disregard the habit and not mention it to the child.
• In private conversation with the child, the problem and its effect must be
elicited.
• The parents' role in correction is very significant.
• Over anxiety and the resulting nagging approach or punishment often
creates greater tension and intensification of the habit.
• Thus a change in the home environment and routine help the child to
overcome the habit.
67

• Nagging, scolding or frightening the child should be avoided since this
could cause negativism and tend to make him resort to the habit.
• From a psychological point of view the child should make the decision
that he doesn't want to do it anymore.
• “Parents should not force the preschoolers to break the habit since
they only know the pleasure derived from the habit but they cannot
understand why the habit to be stopped”.
• Some children practice the habit while watching T.V especially when
there is no other person to take care of them during day time. So in
such case, parents should spend more time with children during day
time
68

INTRAORAL APPROACHES
• Palatal crib
• The palatal crib is vertically
disposed, extending from the palatal
region, completely encompassing
the anterior openbite, and resting
close to the gingival area lingual to
the lower incisors when the
posterior teeth are in occlusion.
• It serves as a complete mechanical
barrier to the thumb or fingers.
69

• Rakes
• A rake is constructed as is the crib, but
has blunt tines or spurs projecting from
the cross bars or acrylic retainer into the
palatal vault.
• The tines discourage thumb sucking.
• Disadvantage is that it acts more as a
punitive appliance rather than a
reminder.
70

INTRAORAL APPROACHES
• Mink and Haskell 1991 : Blue grass
appliance
• Pediatric clinics of University of
Kentucky and University of Louisville
• Six sided roller made of Telfon attached
with 0.045 stainless steel wire soldered
to molar orthodontic bands.
• Patient instructed to turn the roller
instead of sucking the digit. • Patient got
a new toy to play with tongue & got
distracted
• Time : 3- 6 months
71

• Location of roller: most superior aspect of palate
• Not in contact with palate
• No obstruction in eating or speech
72

Modified blue grass appliance
• Chris Baker 2000 : Modified blue grass appliance 4mm acrylic beads
• Advantage: reduced bulk Less obstruction, attractive for children
• Used in age group 1 ½ - 12 years
• Modification: Attachment with quad helix
• Removal time: 6 months after habit cessation
73

QUAD HELIX
• Maxillary expansion
• Posterior cross bite correction
• Alignment of maxillary and mandibular anteriors
• Reminder Therapy
74

TONGUE THRUSTING
DEFINITIONS
Tulley 1969 : Tongue thrust is the forward most placement of tongue tip
between teeth to meet the lower lip during deglutition and in sounds of
speech , so the tongue becomes interdental.
Profitt 1972: It is the placement of the tongue tip forward between incisors
during swallowing.
Norton & Gellin 1978: Tongue thrust is the condition in which the tongue
protrudes between anterior and posterior teeth during swallowing with or
without affecting tooth position
76

CLASSIFICATION
MOYERS [1955]
A)Simple : Normal tooth contact during the swallowing act.
• Anterior open bite.
• Good intercuspation of teeth.
• The tongue thrust forward to establish anterior lip seal.
• Abnormal mentalis muscle activity
77

B)Complex :Teeth apart during swallow.
• Diffuse or absent anterior open bite (Bimaxillary protrusion)
• Absence of temporal muscle constriction during swallowing.
• Contraction of the circum oral muscles during swallowing.
• Poor occlusion of teeth
78

Strub Classification (1961)
• Group 1 : Diastema between upper central incisors
• Group 2: Nonocclusion or open bite is seen not only between anterior
teeth but in posterior teeth as well, usually from first molar forward
(second molar in place)
• Group 3 : Side thrust : nonocclusion in the premolar and canine area
has been created by lateral displacement of tongue.
• Group 4 : Crossbite cases : most difficult to detect and correct. May
go undetected till ortho completes.
79

AMES BRAUER,TOWNSENDV. HOLT 1965
• Type I : Non deforming tongue thrust
• Type II : Deforming anterior tongue thrust
Subgroup 1: Anterior open bite
Subgroup 2: Anterior proclination
Subgroup 3: Posterior crossbite
80

• Type III: Deforming lateral tongue thrust
Subgroup 1:Posterior open bite
Subgroup 2:Posterior crossbite
Subgroup 3:Deep crossbite
81

• Type IV: Deforming anterior and lateral tongue thrust
Subgroup 1:Anterior and posterior open bite
Subgroup 2:Proclination of anterior teeth
Subgroup 3:Posterior crossbite
82

• Profitt 1990
▪ Physiologic
▪ Habitual
▪ Functional
▪ Anatomic
83

Etiology
• Retained infantile swallow
• Upper respiratory tract infection
• Neurological disturbances
• Feeding practices
• Hereditary
• Functional adaptability
• Other habits
84

History
• Determine swallow pattern of siblings & parents (hereditary etiology)
• Determine whether remedial speech therapy was provided.
• Information regarding :
• URTI
• sucking habits,
• neuromuscular problems
• Abilities and motivation of the patient
85

Clinical manifestations may include the
following
• EXTRAORAL
▪ Lip posture:
1.Lip separation at rest may be greater, with short and flaccid upper lip equal
consistent finding at both rest and function.
*Lack of compensatory lip activity during swallowing in these subjects
 Mandibular movements:
1.During swallowing may be more erratic
2. No correlations could be found between the movements of the tongue tip
and the mandible itself.
3. In the tongue thrust group , the average path of mandibular movements
was upward and backward with the tongue moving forward.
86

Speech disorders:
• Tongue thrust children are more likely to have various speech
disorders , such as : Sibilant distortions .
• Lisping problems in articulation of /s/, /n/, /t/, /d/, /l/, /th/, /z/, /v/
sounds.
• Facial form:
▪ Increase in anterior facial height.
87

INTRA ORAl
• Tongue movements: during swallowing may be jerky and inconsistent.
• Tongue posture: tongue tip at rest may be lower.
• Malocclusions associated with tongue thrust.
• Tongue posture
▪ At rest in normal individuals:
A.Tip : rests against lingual surface of mandibular incisors
B. Dorsum : touches hard palate
▪ Altered tongue posture
88

Altered tongue posture:
1. Retracted:
a. Tongue tip withdrawn from all anterior teeth, laterally spread tongue
b. Rare in children (10%). More common in edentulous patients
2.Protracted position:
a.Endogenous type: infantile postural pattern
b.Acquired type: enlarged tonsils
89

90
3. During Swallowing :
Tip: lies between incisal edge of mandibular & maxillary
incisors : oral seal

Malocclusions associated with tongue thrust:
A.Features pertaining to maxilla
1.Proclination of anteriors, and overjet.
2.Generalized spacing between teeth.
3.Maxillary constriction.
B. Features pertaining to mandible
1.Retro, or proclination of anteriors, depending on type of tongue thrust
C. Intermaxillary relationship
1.Anterior/posterior open bite depending on tongue thrust
2.Posterior crossbite
91

Clinical features
• Simple tongue thrust
a.Normal tooth contact in posterior region
b.Anterior open bite
c.Contraction of the lips, mentalis muscle and mandibular elevators
Complex tongue thrust
a.Generalized open bite
b. The absence of contraction of lip and oral muscles
92

93
Lateral tongue thrust
a. Posterior open bite with lateral tongue thrust
▪ Other features
a. Proclination of anterior teeth
b. Anterior open bite
c. Midline diastema
d. Posterior cross bite

Examination of Tongue
▪ Check for size, shape and movements
▪ Functional examination
▪ A) Observe for tongue position while the mandible is in rest position
▪ B) Observe the tongue during various swallows
1.Conscious swallow
2.2. Command swallow of water
3.3. Conscious swallow during mastication
94

Palpatory examination
1.Place water beneath the patients tongue tip and ask him to swallow
a.Normal: Mandible rises and teeth are brought together but no
contraction of lips or facial muscles
b. Tongue thrusting: Marked contraction of lips and facial muscles
2.Place hand over temporalis muscle and ask to swallow
a.Normal:Temporalis contracts & Mandible- elevated
b. Tongue thrusting: No temporalis contraction
3. Hold the lower lip withThumb
95

Treatment considerations
• Self correcting by 8-9 years: by the time permanent teeth erupt.
• If associated with other habits: Asstd habit should be treated first
96

RAINING OF CORRECT SWALLOW AND
POSTURE OF THE TONGUE
1)Myofunctional therapy Garliader
Patient can be guided regarding correct posture of tongue during
swallowing by various exercises like
•Asking the child to place the tip of the tongue in the rugae area for
5min and then asking him to swallow
2)Orthodontic elastics Tongue tip is held against the palate using
elastics of 5/16’’ and sugarless fruit drop.
97

3) Lemon candy Exercise
▪ Instead of elastic, a lemon candy is put on the tongue tip.
▪ Pt is asked to hold the candy against the palate by the tongue tip and then
asking the child to swallow.
4) 4S exercise
▪ Includes identifying the SPOT, SALIVATING, SQUEEZING the spot and
SWALLOWING.
▪ Using the tongue the spot is identified, the tongue tip is pressed against
this spot and the child is asked to swallow keeping the tongue at the same
spot
98

• Other exercises:
• Whistling
• Reciting count from 60-69
• Gargling
• Yawning
Peanuts exercise: patient chews peanuts
Chewed nuts placed in middle of tongue
Put peanuts on anterior part of palate and swallow
1960Andrews :Water holding exercise (infront of mirror)Repeat 20 times / day
99

Lip exercises
• Tug of war and Button pull exercise:
▪ A string is tied to two buttons, one of the buttons is
placed between the lips of the patient, while the other is
held by the patient outside.
▪ Outer button is pulled outwards, at the same time, the
inner button is resisting the forces thereby strengthening
the lips on both aspect
100

Sub concious therapy:
• Once voluntary swallowing pattern is acquired, the patient proceeds
to sub conscious therapy, i.e subliminal therapy where the patient is
asked to place a reminder sign or auto suggestion which requires the
patient to give self instructions like Repeat 6 times” I will swallow
correctly all night long” for 10nights
101

Pre orthodontic trainer for myofunctional
training
• It aids in correct positioning of the tongue with the help on tongue
tags. ▪
• The tongue guards prevent tongue thrusting when in place.
• Nance palatal arch appliance
Here, acrylic button can be used as a guide to place the tongue in
correct position
102

Speech therapy
1)To train the correct positioning of tongue, as this position is more
conducive to the articulation of speech and to normal alignment of
teeth.
The child is asked to repeat simple multiplication tables of sixes ,
pronounce words beginning with ‘S’ sounds
103

MECHANOTHERAPY
• 1) Fixed and removable appliances:
-Restrain anterior tongue movement
-form a more effective barrier -reduces anterior tongue positioning
(dorsum of tongue approximates palatal vault and the tip of the tongue
contacts the palatal rugae during deglutition)
2) Capability of using the Hawley to close the anterior openbite
through the use of the labial bow.
104

• Removable appliances:
▪ Hawley’s appliance
▪ Hawley’s appliance modifications:
• Acrylic cut in anterior hard palate region
• Cribs or rakes employed in anterior part
Advantages:
• Increased anchorage value
• The crib can serve as a reminder.
105

• Oral screen:
▪ Restriction of tongue thrusting habit
▪ Alignment of maxillary anterior teeth
▪ Correction of open bite
▪ Lip muscle exercises performed with
ring attached in anterior part of
appliance
106

MOUTH BREATHING
• DEFINITION
▪ Sassouni (1971) Habitual respiration through the mouth instead of the nose.
▪ Chacker (1961) Prolonged or continued exposure of the tissues of anterior areas
of mouth to the drying effects of inspired air.
▪ Merle (1980) : Used the term oro-nasal breathing instead of mouth breathing.
107

Finn (1987)
• 3 categories
• Anatomical
▪ Short upper lips which does not permit closure without undue effort.
• One must distinguish this type from the child who breathes through
his nose but keeps his lips apart because of a short upper lip.
• Habitual
▪ Continually breathe through the mouth by force of habit
108

• Obstructive
▪ Increased resistance to/ complete obstruction of normal flow of air
through nasal passages.
▪ Child is forced to breathe through mouth.
▪ Ectomorphic children.
▪ Because of this genetic type of tapering face and naso-pharynx, these
children are more prone to nasal obstruction
109

ETIOLOGY
• Airway obstruction may be due to:
1.Enlarged turbinates
2. Intranasal defects: (more likely to manifest in adulthood)
▪ Partial obstruction due to deviated nasal septum, localized benign
tumours.
▪ Thickness of sputum
▪ Bony spurs
110

3.Hypertrophy of pharyngeal lymphoid tissue.
4. Infection and inflamation of nasal mucosa, chronic allergic stomatitis, chronic
atropic rhintis, enlarged adenoids and tonsils, nasal polyps
5. Short upper lip
6. Obstruction in bronchial tree or larynx.
7. Obstructive sleep apnea syndrome.
8. Genetically predisposed ectomorphs.
9. Thumb sucking or similar oral habits leading to underdeveloped or abnormal
facial musculature.
10.Cleft lip & palate.
111

General features
▪ In order to breathe,
▪ the child bends the neck forward
straightening the Oro-naso- pharyngeal path
▪ This give the appearance of Pigeon chest
▪ In mouth breathers the oro-pharynx is dry
and can produce a low grade eosophagitis.
▪ Maxillary sinus and nasal cavity frequently
becomes narrowed.
112

Turbinates become swollen and engorged.
▪ Speech acquires a nasal tone
▪ Sleep apnea syndrome:
Due to loss of cleansing action of saliva there is generally an
enlargement of the lingual tonsil at the base of the tongue.
▪ This leads to partial or complete obstruction of the oro-pharynx
during sleep
113

• Blood Gas constituents
▪ Blood gas studies reveal that mouth breathers have 20% more
CO2 and less O2.
APPEARANCE
I. Adenoid faces is the characteristic feature of mouth breathers
ii. Lips are held wide apart
iii. There is lack of tone of oral musculature
iv. Upper lip: SHORT
v. Nose: tipped superiiorly ; Bridge: flat
vi. Long narrow face
vii. Face: expressionless
114

Dental and Skeletal
▪ Low tongue position
▪ Narrow maxillary arch
▪ Protrusion : maxillary and mandibular incisors
▪ Palatal vault: High
Mandible hangs in a slack manner
▪ Anterior open bite
▪ Increased : caries
▪ Mucus and plaque : more tenacious
Chronic keratinized marginal gingivits
115

History
▪ Parents can be questioned whether the child frequently adopts a lip
apart posture.
▪ Frequent occurrence of tonsillitis, allergic rhinitis, otitis media should
be questioned.
▪ Also whether the patient has restless sleep, snores wakes up feeling
thirsty.
116

DIAGNOSIS
1.Observe the patient
▪ Lips
2.Ask the patient to take deep breath through nose
▪ Shape/size: external nares
▪ good control of alar muscles
3.Mirror test: Fog test:
4.Massler’s water holding test:
117

5. Jwemen’s butterfly test:
6.Rhinometry(Inductive plethysmography): The total airflow through
nose and mouth can be quantified using inductive plethysmography
7.Cephalometrics: Can be used to calculate amount of naso-pharyngeal
space.
118

TREATMENT
▪ Main aspect: Treat and eliminate the underlying cause or pathology
that has created the habit.
▪ This should be followed by symptomatic treatment.
▪ Other procedures and appliances that can be used are:
1.Deep breathing exercises
2.Lip exercises 15-30in/day for 4-5months
3.Oral screen
119

• E.N.T examination
▪ An otolaryngologist examination may be advised : tonsils, adenoids or
nasal septum.
▪ In some children,it may be habitual.
▪ Correction should first aim at REMOVING any anatomic or functional
causes.
▪ To institute a treatment of actual cause, it is important to determine
the type and degree of mouth breathing, whether it is habitual or
obstructive, and whether total mouth breathing is present or it is
partial.
120

Correction Symptomatic treatment:
▪ The gingiva of the mouth breather should be restored to normal
health by
▪ Coating the gingival with petroleum jelly,
▪ Applying preventive dentistry methods and
▪ Clinically correcting periodontal defect that have occurred due to the
habit. ▪ *Mixed dent
121

Exercises
Deep breathing:
 Done in morning and night .
 Deep inhalation through nose with arms raised sideways and after a
short period arms are dropped to the side and the air is exhaled
through the mouth.
122

• Lip exercises:
• Child is instructed to extend the upper lip as far as
possible to cover the vermillion border under and behind
the maxillary incisors. This exercise is done for 15 to 30
mins per day for 4-5 months.
• In case of protruded maxillary incisors, lower lip can be
used to augment the upper lip exercise. The upper lip is
first extended into the previously described position. The
vermilion border of the lower lip is then placed against
the outside of the extended upper lip and pressed as
hard as possible against the upper lip.
• Celluloid strip or metal disk held between the lips.
123

To increase the tonicity of lips few myofunctional
excercises are recommended:
• Hold a sheet of paper between the lips.
• Button pull exercise-
a button is taken and a thread is passed. Patient is
asked to place the button behind the lips and pull
the thread while restricting it from being pulled out
by using lip pressure.
• Tug of war exercise-
involves two buttons, with one placed behind the
lips and other is pulled by the other person.
124

Maxillothorax myotherapy:
• This was advocated by Macaray in 1960.
• Used in conjunction with Macaray activator.
• The stable aluminum activator is incorporated at the angle of the mouth,
with horizontal hooks to which expanding rubber bands are attached.
• The mouth breather holds the activator in the mouth and at the same time
with the left and right arms alternately carries out 10 exercises thrice daily.
125

Oral screen
• Most effective way.
• Constructed with material compatible with oral tissues. The most
commonly utilized is synthetic resin.
• If the child has no difficulty breathing through his nose and the
mouth breathing is habitual, it should be corrected by the use of oral
screen.
• In the initial phase windows are made in the oral screen so as not to
completely block the airway passage.
• The appliance is worn 2-3 hours during the day and when sleeping at
night.
126

• It prevents lip biters from placing the lower lip lingual to the upper
incisors, tongue thrusters from forcing the tongue between the
incisors, mouth breathers from breathing through mouth and thumb
suckers from placing their fingers in the mouth.
• It, therefore, serves a multiplicity of purposes.
127

Correction of malocclusion
Mechanical appliances
▪ Children with class 1 skeletal and dental occlusion
and anterior spacing may fitted with clear plastic
oral shield appliance.
▪ Allows patient to breathe through the oral cavity
,and
▪ Through the increased tension of the perioral
musculature , it may close the anterior open bites.
▪ Generally worn at night but may be worn at day
time to correct the open bite more quickly.
128

Class II division 1 dentition without crowding,
and in age range 5-9 years
▪ Monobloc activator: Aids in both
correction of malocclusion and deterrence
of the habit.
▪ When worn will not allow the air to be
breathed through the mouth.
▪ Before any appliance is given, the
pediatrician and/ or otolaryngologist
should examine the child and determine
whether sufficient airway space is
available to allow nose breathing.
129

Class III malocclusion:
▪ Interceptive methods are recommended
as a chin cup.
▪ The child should be evaluated for a
sufficient airway before treatment.
▪ When the mouth breathing habit is
corrected, it is possible that a
malocclusion may be still present.
▪ The pediatric dentist and orthodontist
should re-examine the child for
orthodontic purposes
130

BRUXISM
• Rjamford et al (1966): Bruxism is the clenching or grinding of the teeth
when the individual is not chewing or swallowing.
• AAPD (2003): Habitual, nonfunctional, forceful contact between occlusal
tooth surfaces, which can occur while awake or asleep.
• McDonald, Avery & Dean: Nonfunctional grinding or gnashing of teeth.
131

Types
• Day time bruxism / Diurnal
• Conscious or subconscious grinding
• Along with parafunctional habits
• Silent
• Night time / Nocturnal
• Subconscious grinding in rhythmic pattern of masseter EMG activity
132

Etiology
• Local
• Reaction to an occlusal interference
• High restoration, improper interdigitation
• CNS
• Cortical lesions, cerebral palsy, mental retardation
• Systemic
• Intestinal parasites
• Nutritional deficiencies - Mg deficiency
• Allergies
• Other causes
• Genetics
• Occupational factors
133

Clinical manifestations
• Occlusal trauma
• mobility
• Tooth structure
• Nonfunctional occlusal wear
• Sensitivity
• Atypical shiny wear facet with sharp edges
• Pulpal exposure
• # crown, restoration
• Muscular tenderness, fatigue & hypertrophy
• TMJ disturbances
• Crepitation , clicking ,
• Pain – Dull , unilateral
134

Bruxism: Treatment
• Occlusal adjustment
• Coronoplasty
• High point correction
• Occlusal splints (Night guard)
• Vulcanite splint to cover occlusal surfaces
• Reduction of increased muscle tone
• TMJ appliance
• Prefabricated intra oral appliance for TMJ disorder
135

• Restorative
 Severe abrasion
-Pulp therapy
-Stainless steel crown
• Psychotherapy
-Counseling
-Tension relief
-Habit awareness -Increase voluntary control
• Relaxing training
-Hypnosis
-Behavior Conditioning etc..
136

LIP HABITS
• Definition
Habits that involve manipulation of the lips and peri oral structures.
• Classification
1.Lip biting.
2. Lip sucking.
3. Lip wetting.
137

Etiology
• Association with digit sucking
• Malocclusion: Class II Div-1
-Large overjet and overbite
• Emotional stress
-Increases the intensity and duration
138

Clinical features
• Lip
• Reddened , irritated, chapped
• Vermilion border
• Relocation outside the mouth due to constant wetting
• Hypertrophied
• Accentuated mento-labial sulcus
• Malocclusion
139

Treatment
• Not self- correcting
• Deleterious with age
• Treating primary habit
• Correction of digit sucking followed by habit reminder (Hawley’s appliance)
• Chemical reminder
• Correction of malocclusion
• Class II Div-1-
 Fixed or removable appliance
Activator
140

• Appliance therapy
Oral shield
 Class I malocclusion
 Lip exercise for improvement of lip tonus
Lip bumper
 Prohibits excessive force on mandibular incisors
 Reposition of lower lip away from upper incisors
141

CHEEK BITING
• Definition-
keeping or biting the cheek muscles in between the upper and lower
posterior teeth
• Clinical features
• Ulcers at the level of occlusal line
• Open bite
• Tooth malposition in buccal segment
• Treatment
• Vestibular screen
• Reminders
142

NAIL BITING
It is one of the most common habits in children and adults.
Etiology
• Insecurity.
• Nervous tension.
143

Clinical Features
• Nail
 Inflammation of nail beds and nail
 Irregular nail margins
• Dental effects
 Crowding
 Rotation
 Attrition of incisal edges of incisors
144

Management
• Avoidance of punitive methods
• Mild case- No treatment
• Care for emotional condition
• Encouragement of stress relieving activities
• Nail polish, light cotton mittens as reminder
• Bitter or sour chemical over the finger
E.g. : Foul smelling Quinine, Pepper etc..
145

Self- Injurious Habits(Masochistic,
Sadomasochistic, self-mutilating )
Definition-
Repetitive acts that result in physical damage to the individual
• Mentally retarded child (10- 20%)
• Etiology
Organic
• Lesch- Nyhan syndrome
• De Lagge’s syndrome- Repetitive lip, finger, tongue, knee, shoulder biting
146

• Functional
Type A Injuries superimposed upon a preexisting lesions
-Finger nail biting with skin lesion
Type B Secondary to another established habit
-Thumb sucker with rotating habit – Soft tissue injury
Type C Unknown or complex etiology
-Greater psychological component
-Multiplicity of symptoms with greater intensity
-Stress releasing outlet- Castration fear, Failure to resolve oedipal conflict
147

Management
• Avoidance of punitive , harassing approach by parents
• Correct diagnosis to omit physiological etiology
• Referral to Pediatrician, Psychiatrist
• Adjunctive therapy
• For oral ulcers
Oral bandage
• Oral screen
• Restraints & protective padding
148

Conclusion
• Oral habits can manifest themselves in a variety of ways. The
identification of an abnormal habit and assessment of a particular
habit and its immediate and long term effect on the craniofacial
complex and dentition should be made as early as possible.
• The assessment of these behavior must include a thorough evaluation
of the habit itself and the presence of, or the potential for oral health
repercussions.
• These judgements must be coupled with the sensitive assessment of
the physical and emotional status of the child and the relationship of
the parent or caregiver.
149

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