Oral Habits Dr.Issam Aljorani (BDS, MSc. Ortho.) Bad Habit is defined as the action which by repetition had become rhythmic and spontaneous. Fixed or constant practice established by frequent repetition, its formed reaction that is resistant to change, whether useful or harmful depending on the degree to which it interferes with the child s physical, emotional and social function. These habits decrease with increase in age and have no gender differences during infancy but later on it is more demonstrated in females, it is less with bottle feeding than glass feeding and decreases as the feeding time increases A bad habit for the children between the age of six mounts until 5.5 years of age has little effect if no any effect on the occlusion but if it continues after 5.5years of age then its treatment is recommended. The number of children involves with bad habits seems to be reduced as the child grow, at 2.5 years of age about 65% of children sucks thumb or finger or artificial comforter but at 6 years of age only 55% of the children do the habit. and this percentage reduced to 16.6% at 11 year of age and its rarely to get a person who sucked the thumb or a finger at 15 year of age unless the is a psychological background. The effect of each habit on the occlusion is really cumulative in nature depending on: Intensity is the amount of force applied to the teeth and supporting bone during sucking. Duration is the total time children spend sucking. Frequency refers to the number of times children practice the habit during the day. Sucking Habits Thumb or finger sucking is one of the most common types of non-nutritive oral habit present in children. Reports indicate that sucking habits are reflexes whose precursors appear during intrauterine life. Ultrasound pictures of intrauterine life have shown fetuses sucking their thumb. Thumb sucking appears to be a natural habit of children in all parts of the world, and it seems that putting objects in their mouths and sucking on them is a way for children to explore their world. Nutritive factor: some fetuses have been reported to suck their thumbs in utero and the vast majority of infants do so during the period of 6 months to 2 years or later. Non-nutritive sucking habits: Prolonged thumb sucking after the age of 4 years is usually a symptom that the child suffers from emotional starvation and used the thumb or finger sucking for comfort and compensation 1
Effects on occlusion Increased overjet due to incisor flaring Anterior open bite Interdental spacing Posterior crossbite Mandibular incisor crowding Lingual tipping of mandibular incisors Under eruption of maxillary incisors Overeruption of posterior teeth Class II molar relationships Narrow (V-shaped) anterior maxillary arch Clinical examination When the history of a child s habit is assessed, parents are usually the best source of information. However, indirect questions to the child might also be helpful, for example: When do you suck your finger? Which finger do you use while sucking? Extra oral examination The offending digit may be red, wrinkled, calloused or unusually clean. The profile is usually convex because of dentoalveolar protrusion, and the lips are usually apart. Intraoral examination The positions of the individual teeth and occlusion should be noted, based on the signs noted during the extraoral examination. Cephalometric analysis is very useful in assessing dentoskeletal changes. Age of intervention Sucking habits during the primary dentition years usually have little if any long-term effect and usually stop around 4 to 5 years of age. Intervention is recommended after 4 or 5 years of age but should be considered earlier if a high-intensity and long duration are involved and there is severe damage to occlusion or to the jaw Treatment Approaches Depending on the cooperation of the child and his or her willingness to stop the habit, different approaches to treatment have been advocated. These approaches include reminder therapy, reward therapy, and appliance therapy Reminder therapy Reminder therapy is applied with children who want to stop the habit and need some kind of reminder until termination of the habit. An adhesive bandage can be attached to the involved finger for this purpose. Any type of reminder must be applied with the child s awareness and willingness, not as a punishment. Another device that has been used as a reminder is a thumb device that covers the thumb and is held on the wrist by straps. 2
Reward therapy In this approach, a type of contract is established between the child and parents or between the child and dentist. The contract simply states that the child agrees to stop the habit for a specified period of time and in return he or she will receive a reward if the requirements of the contract are met. Use of orthodontic appliances Habit-discouraging appliances usually have positive effects within 2 to 3 months, but they should be left in place for at least 6 months to make sure the habit is completely controlled. Depending on the patient s cooperation, the kind of habit, and the type of deformity, several kinds of removable and fixed, appliances can be used Removable habit breakers A removable habit breaker is a simple Hawley appliance with a piece of wire embedded in the acrylic resin portion behind the incisors; it can be a useful reminder device and has the advantage of allowing the patient to remove it for eating and maintaining good hygiene. The disadvantages of this type of appliance are that patient compliance is a major factor and the appliance can be easily misplaced or lost. Fixed habit breakers Fixed habit breakers are advantageous because they do not rely on patient compliance. A fixed device is an intraoral appliance attached to the maxillary teeth by means of two bands fitted to the primary second molars or the permanent first molars. Bluegrass appliance. This appliance was introduced by Haskell and Mink in 1991 and can be used during the primary or mixed dentition. It is very well tolerated by patients and parents. The Bluegrass consists of a six-sided roller that is slipped over a stainless steel wire soldered to molar bands. The child is instructed to turn the roller with his or her tongue instead of sucking the digit. The substitution of tongue movement for digit sucking seems to be very effective and encourages the child to stop the habit Palatal bar. The palatal bar is constructed of two molar bands and a stainless steel wire to serve as the base of the appliance. A shield or crib made of 0.030-inch wire is adapted to the deepest anterior part of the palate, separating the thumb or finger from the soft tissue. A short vertical extension in the front serves as a reminder. Mouth breather Nasal respiration and its capsular matrix, the nasomaxillary complex, have an important role in and effect on normal maxillofacial morphology and growth and therefore on occlusion. Normal respiration requires adequate airway space through the nasal and nasopharyngeal areas. If the structures within this passage, such as the adenoids, tonsils, or nasal turbinate, are enlarged pathologically or anatomically, nasal respiration is precluded; the result can be an adaptation to oral respiration. Oral respiration and nasal obstruction are common findings 3
among orthodontic patients. The adenoid facial type is characterized as a long, narrow face with anterior open bite, dental protrusion, incompetent lip, narrow maxillary arch, and deep palate; this facial morphology was considered to be caused by mouth breathing for many years. Etiology Anything that blocks the nasal airway can reduce or prevent nasal breathing. One of the most common causes of mouth breathing is allergies. Inflammation and enlargement of tonsils and adenoids are other factors that block the airway and promote mouth breathing. Congenital malformations that cause structural deformities can also block nasal airways. These include deviated or enlarged conchae and deviated septum. trauma such as a broken nose can distort the anatomy of the nose and cause blockage. In some children, mouth breathing is considered a habit. This habit is believed to be sustained abnormal breathing following thumb sucking and long pacifier habits. Clinical signs The child can be examined for signs of mouth breathing in two areas: (1) general body growth and posture of the child and (2) dentofacial characteristics such as orofacial morphology, soft tissue characteristics, and dental occlusion. General body growth and posture Children suffering from chronic mouth breathing usually have problems getting enough oxygen into their blood during sleep. Thus, the sleep cycle is disrupted, growth hormone production is interfered with, and general body growth (size and weight) and even school performance are affected. Bedwetting, poor-quality sleep, and obesity are other effects on these children. These children are usually tired during the day, and their performance in school is poor; they often exhibit anger and frustration. Sometimes they can be misdiagnosed with attention deficit hyperactivity disorder. Dentofacial characteristics Dental and soft tissue changes Anterior crowding Maxillary incisor proclination Anterior open bite Narrow anterior maxilla Narrow maxillary arch and bilateral posterior crossbite Skeletal changes Clockwise rotation of the growing mandible Increased anterior facial height Increased lower anterior vertical face height Long, narrow face 4
Overeruption of molars Dry lips Bad breath and periodontal disease, caused by the shift in the bacterial flora in the mouth Dark circles under the eyes Retrognathia of the mandible Antegonial notching Increased mandibular steepness Maxillary constriction, deep palate, and posterior crossbite Downward rotation of the posterior palate Maxillary deficiency Narrowed nasal airway passage and decreased internasal capacity Orthodontic management Otolaryngologists have the ability to assess upper airway conditions and decide on any medical or surgical treatment of respiratory dysfunction, in patients with maxillary constriction, the orthodontic treatment technique of rapid palatal expansion results in significant changes in children s breathing patterns. This type of treatment corrects transverse occlusal disharmony and functional problems and provides more space for teeth. It also increases nasal airway capacity as an immediate result of rapid skeletal expansion. Expansion also provides room for the tongue to rest and function normally in the palate. Even after medication, anatomical correction of problems, and orthodontic treatment, the child may continue the mouth breathing habit. Suggestions for breaking this habit include use of a piece of surgical tape to keep the mouth closed, use of an oral screen with a thin piece of rubber behind and between the lips to block airflow Tongue Thrust Clinically, tongue thrust is defined as a forward placement of the tip of tongue between the anterior teeth during swallowing. This myofunctional disorder of the tongue in the oral cavity has been referred to a s deviate swallow, infantile swallow, abnormal swallow, reverse swallow, and immature swallow. The terms most commonly used are tongue thrust and tongue thrusting. Classification Moyers divided abnormal swallowing into three types; Simple tongue thrust Simple tongue thrust is usually associated with a history of digit sucking that has led to open bite. According to Moyers, in simple tongue thrust the teeth are in occlusion during 5
swallowing, some muscle contraction can be seen, and correction of malocclusion will correct the habit. Complex tongue thrust Complex tongue thrust is a more complicated type of swallowing pattern associated with chronic nasorespiratory issues such as mouth breathing, tonsillitis, or pharyngitis. When the tonsil is inflamed and enlarged, the root of the tongue exerts force on the tonsil and causes pain. To avoid this force and resulting pain, the mandible will drop reflexively, separating the maxillary and mandibular teeth, enlarging the freeway space, and providing more room for the tongue to move forward. This will create a more comfortable position during swallowing and a more adequate airway. The forward position of the tongue exerts continuous light force on the anterior teeth and alveoli, which will result in dental or dentoalveolar protrusion, interdental spacing, and open bite. Open bite might not be limited to anterior teeth. Treatment of this type of tongue thrust is more complicated; myofunctional therapy might also be required. Retained infantile swallow Infant gum pads are not brought together in function, because the mouth is designed for suckle feeding at this stage, and the space between the gum pads is occupied by the tongue. At this age, the tongue is advanced in development and is relatively larger than the surrounding jaws to facilitate suckling. The transition from the infantile swallowing pattern to an adult swallowing behavior occurs after 6 months, with tooth eruption. Moyers states that retained infantile swallow is an abnormal swallowing pattern in which the infantile swallow remains and the transition to an adult swallowing behavior has not occurred. Open bite is more severe in patients with this type of swallowing and may not be confined to the anterior segment. Treatment is also more complicated and may include orthognathic surgery and myofunctional therapy. Etiology The following have been proposed as local or general causes for these types of abnormal swallowing: Hereditary factors, such as a large tongue. Vertical skeletal problems such as a steep mandible or wide gonial angle. Thumb or other finger sucking. Short lingual frenum (tonguetie). Mouth breathing, which might be due to many factors that cause nasal obstruction, such as allergies, nasal congestion, deviated conchae, or large adenoid. Sore throat, enlarged tonsils, or adenoids that cause difficulty in swallowing. Premature loss of primary teeth and abnormal tongue adaptation. 6
Muscular, neurologic, or other physiologic abnormalities, such as loss of muscle coordination Different types of tongue thrust Anterior tongue thrust Anterior tongue thrust is one of the most common and typical types of tongue thrust. The resulting occlusal problem is anterior open bite Lateral tongue thrust Lateral tongue thrust is not as common as anterior tongue thrust and, depending on its etiology, can cause unilateral or bilateral open bite. The anterior bite is usually closed; however, the posterior teeth may be open on one or both sides, from the first premolar to the distalmost molars. Correction of these anomalies is much more difficult Problems associated with tongue thrust Abnormal pressure from the tongue during deglutition or speech can produce or maintain open bite, dental protrusion, or spacing. Treatment approaches Two methods for treatment of tongue thrust have been proposed: (1) mechanotherapy with an orthodontic device and (2) oral habit training. Oral habit training is an exercise technique taught by a qualified speech therapist who tries to reeducate the muscles associated with swallowing by changing the swallowing pattern. Mechanotherapy in tongue thrust patients can be accomplished with either a removable or a fixed appliance. The part of the appliance that controls the abnormal pressure from the tongue (tongue crib or tongue guard) must be designed in such a way that it covers the entire anterior tooth gap but does not interfere with the bite during chewing. The following is one useful exercise for tongue adaptation: The appliance is inserted, and the child is instructed to close the teeth, put the tip of tongue behind the tongue crib, and swallow while trying to hold the tongue tip so that it does not touch the crib. This exercise should be repeated several times during the day. Daily exercise with fixed tongue guard therapy facilitates tongue adaptation and is very effective in the treatment of tongue dysfunction. To prevent relapse and impairment of orthodontic results, tongue dysfunction must be eliminated before completion of orthodontic treatment. Some practitioners suggest bonding lingual cleats over the palatal side of the central incisors to help the patient to avoid tongue thrust. Nail biting Tension and conflicts in home or school may be a predisposing or contributory factor to nail biting. So psychological and social effects are powerful contributory factors for this habit. Nailbiting is most commonly seen in tense, excitable children, in contrast to thumb sucking, which is more likely to occur in children who are outwardly calm and placid. 7
Teeth are brought habitually into edge-to-edge contact anteriorly together with heavily cut nails and may be damaged finger tips. References Ø Contemporary orthodontics, Proffit, fifth edition, 2013. Ø EARLY-AGE ORTHODONTIC TREATMENT, Aliakbar Bahreman; 2013. Ø Handbook of orthodontics, Martyn and Andrew, second edition, 2016. Dr. Issam M. Abdullah Aljorani BDS, MSc. Ortho. University of Babylon, college of dentistry asd.issam@gmail.com 2017 8