my symposium 2
TRANSCRIPT
April 7, 2023 1
Good Morning
Success is the sum of small efforts,repeated day in and day out.
- Robert Collier
April 7, 2023 2
Symposium on ORAL HABITS
Batch 2010-2013
April 7, 2023 3
1) Normal oral musculature2) Historical background, beliefs,
definition, classification of habits
3) Etiology, theories, factors influencing the development of habits
4) Diagnosis, clinical features & its influences on occlusion
5) Treatment planning – behavioral therapy, mechanotherapy
6) Recent views & case reports.
April 7, 2023 4
A habit is the result or is a sign of lack of harmony between the child and his/her environment
When the child cant adjust to a sudden change in the environment
INTRODUCTION
April 7, 2023 5
Certain oral habits are considered normal in infancy, for eg.sucking
These are essential for survival of child and psychologic maturation
Believe that it is a normal sequence of maturation
April 7, 2023 6
Schroeder et al.in 1983 quoted that
When the behavior continues longer than is typical
When the behavior becomes severe enough to cause physical damage
When it interferes with ongoing physical,social & cognitive development
Habit …..a problem..?
April 7, 2023 8
Buccinator mechanism
Rationale behind …..
April 7, 2023 9
Numerous biologic and environment factors
Acquired by imitation
Infuse a certain sense of security and comfort
How the habit develops….
Presented by
Dr.Dhanraj
Post graduate student
Etiology &Factors Influencing Development
Of Oral Habits
April 7, 2023 11
The term pernicious means tending to a fatal issue
When the habits involving the oral cavity becomes fatal
Pernicious oral habit
April 7, 2023 12
Degree to which they interfere with child’s physical, emotional or social functioning
Duration Intensity Frequency
Factors that make a habit pernicious
April 7, 2023 13
Klein – Empty habits Meaningful
Morris &Bohanna:Pressure habitsNon pressure habitsBiting habits
Classification of oral habits
April 7, 2023 14
According to Brash:Purely muscularCombined activity of the muscles of the
jaws,mouth and thumbMuscular action combined with
introduction of passive objectNo active part by muscles ,only extraneous
pressureFunctional disturbance
April 7, 2023 15
Finn classificationNon compulsiveCompulsive
William JamesUseful Harmful habits
April 7, 2023 16
In a prevalence study conducted in 1998 by Munshi et al.
Out of the selected population ,29.7% children had oral habits
Common oral habits
J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6.
April 7, 2023 17
Age group of 3-6 years - Digit sucking, pencil biting and tongue thrust
Age group of 7-12years- Mouth breathing and bruxism
Age group of 13 -16 years- lip/cheek biting and nail biting
Age group and oral habits
J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6.
April 7, 2023 18
Digit sucking, tongue thrust, mouth breathing and bruxism were more prevalent among the boys
Lip/cheek biting, nail biting and pencil biting were more prevalent among the girls
Sex and oral habits
J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6.
April 7, 2023 19
A recent study conducted in 2003 reveals that
Thumb sucking was common in girls
Mouth breathing was more common in boys
Sex and oral habits
J Indian Soc Pedo Prev Dent September (2003) 21 (3) 120 - 124
April 7, 2023 20
Thumb or digit sucking Tongue thrusting Mouth breathing Lip biting habits Nail biting Cheek biting Bruxism Masochistic habits
Most common oral habits …
April 7, 2023 21
THUMB SUCKING
April 7, 2023 22
Thumb sucking or digit sucking is defined as, “the placement of thumb or one or more fingers in varying depths into the mouth”
Other terms used are non-nutritive sucking and finger sucking habits
Most prevalent with a reported incidence that ranges from 13 to 100 % ,decrease with age
Thumb sucking
April 7, 2023 23
PSYCHOLOGICAL FACTORS
SOCIAL OR ENVIRONMENTAL FACTORS
ETIOLOGY BEHIND ……
April 7, 2023 24
First coordinated muscular activity of the infant
Active movements of infants circumoral musculature
Lasts for approx.12 months
SUCKLING REFLEX
April 7, 2023 25
Tongue is relatively large and positioned forward
Tip protrudes through the gum pads
Visceral or infantile swallowing
In the newborn…
April 7, 2023 26
In breast feeding,gums are apart and tongue is brought forward in a plunger like fashion
Mandible moves up and down and forward and backward
Buccinator also contracts and relaxes
Oral gratification
April 7, 2023 27
Child feels the warmth of the breast not only in the area of contact but well away from the mouth
Enhances the feeling of euphoria
April 7, 2023 28
When the object is liked by the infant ,it tries to take it inside her mouth which is called as introjection
When the object is not liked ,it rejects it
This reflex not only serves to relieve the hunger but also makes it to feel what is good and bad
Rejection and Introjection
April 7, 2023 29
Using these past satisfying experiences,the child is able to provide some secondary gratification
The thumb here acts as a substitute for the mother
Implication ….
April 7, 2023 30
Classical Freudian theory
Rooting reflex
Lack of function
Oral Drive theory by Sears and Wise
Learned behavior
Psychological factors
April 7, 2023 31
Sigmond Freud - 1905 – five stages of psychosexual development
Each stage,there was a errogenous zone
According to him,oral cavity served as a errogenous zone in the first year of life
PSYCHOANALYICAL THORY
April 7, 2023 32
Child derives sexual pleasure during the suckling reflex
If there is frustration or overindulgence of oral needs during infancy,it results as an oral habit.ie.prolongation of finger sucking
What happens…
April 7, 2023 33
Peterson (1968) - lack of love and affection during breast feeding
Massler & Wood - parental rejection or pressure
Sheldon – emotionally disturbed children showed habit patterns
Kawata – parental displeasurement,admonition and punishment – emotional crisis
Supporting this theory…..
April 7, 2023 34
Finger sucking of the neonates is the continuation of their neonate reflexes.i.e.rooting and placing
Innate activity of infants for the first three months
Rooting – sudden turning of the head towards the stimulus
Placing – subsequent contact of the mouth with the stimulus
Rooting reflex
April 7, 2023 35
Improper or insufficient suckling in the infancy
Levy et al. believes – forced premature curtailing of suckling or effortless sucking from bottle
Sheldon – when more effort is expended ,there is less likelihood of developing habit
Rationale based on oral drive gratification
Lack of function
April 7, 2023 36
This theory also agrees with Freudian concept
Based on learning theory
More a baby learns to associate sucking with the satisfaction of hunger,being held and other pleasures ,the more he will engage in non nutritive sucking habits later
Oral drive theory
April 7, 2023 37
Based on the laws of conditioning
Sucking – Intake of food,attention from parents and release of aggression
Conditioning and stimulus generalization
Positively reinforced habit –Finger sucking
Finger Sucking –A learned Behaviour
April 7, 2023 38
By Larsson and johnson (1997)
Digit sucking is a combination of psychoanalytical and learning theory
Recent view
April 7, 2023 39
Keep in mind that there may be a psychological origin for its persistence
Be prepared for psychologcal damage from faulty intervention
Before treating….
April 7, 2023 40
Still remains debatable
Klein – beyond 3.5 yrs –abnormal Massler – at 3.5 yrs –stopped Haryett et al. – problem over 4 years
Finger sucking beyond 4 years is abnormal & it should be treated
WHEN TO CONSIDER ABNORMAL AND TREAT..
April 7, 2023 41
It refers to pacifier sucking habit
Pacifier use, which is the most common non-nutritive sucking habit, is usually introduced by parents to calm the child, not as an extra suction activity
Pacifier use alters occlusal development, depending on the intensity, frequency, and duration of the habit
DUMMY SUCKING
April 7, 2023 42
Prevalence of 75% to 79% in industrialized western countries in recent decades
A study conducted by Larsson et al..clearly states the fact..
He compared prevalence of Swedish & African children
April 7, 2023 43
Infant has a sucking urge in surplus amount
This can be satisfied by breast ,bottle and cup feeding
If the sucking urge is not satisfied,child finds satisfaction by non nutritive sucking ,thumb or dummy sucking
Reasons…
April 7, 2023 44
Age Gender Race Pacifier Feeding methods Siblings Parental socioeconomic status
INFLUENTIAL FACTORS
April 7, 2023 45
Many studies reported the prevalence of thumb sucking
Age and thunb sucking
Levin and Kaye et al.1964Singhal and Bhattia ,1988Garathini et al.1990
17% in 2-5years45% in 7yrs
Tandon et al.2006 Higher prevalence in 3-5 yrs and 6-8yr old
Traisman et al.1956 Low incidence in preschool children
April 7, 2023 46
Author result
Levin & Kaye et al,1964 No correlation
Traisman A.S. and Traisman H.S,1958
Sucking habits are equivalent for males and females until the age of 1 year
Shoba Tandon et al.2006 More common in females, because males give up the habit earlier
Gender
47
Higher incidence in the Western countries i.e.80-90 % of children
Low prevalence in Negroid race
Non-existent in Eskimos
April 7, 2023
Race
Moore M.B. Digits, Dummies and Malocclusions. Dental Update 1998
April 7, 2023 48
Author name Conclusions
Levy ,1928 Higher incidence in low duration breast fed children
Robert,1944 Longer feeding leads to habit
Yarrow et al.,1954 Related to amount of time spent in feeding
Tandon et al.2006 Low duration of breast feeding
Feeding methods
April 7, 2023 49
No correlation between the level of habit and the number of siblings – Larsson et al,1971
Recent evidence shows that if the second child is female and the first sibling is a male,then there is a higher incidence (Tandon et al.2008)
Siblings
April 7, 2023 50
Low socioeconomic groups – Higher incidence of dummy sucking
High socioeconomic groups – high incidence of digit sucking
Socioeconomic status
April 7, 2023 51
Phase I – birth to 3 years Normal and subclinically significant Preventive measures can be applied
Phase II – extends from 3 to 6-7years Clinically significant sucking Habit correction is must
Phase III –Intractable sucking Serious problem Requires psychotherapy
Three distinct phases
April 7, 2023 52
Agreement that if the habit continues beyond the age of 6-7 months,it is difficult to break until the child is 4-5 yrs of age
Should be viewed by a clinician as a behavioral pattern of multivariate in nature
Various thoughts….
April 7, 2023 53
Suckling reflex
Digit sucking is a learned habit
Factors influencing digit sucking
Three phases
Points to ponder…..
April 7, 2023 54
TONGUE THRUSTING
April 7, 2023 55
Tongue thrust is defined as a condition in which the tongue makes contact with any teeth anterior to the molars during swallowing
Tulley(1969 )- states tongue thrust as, “the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech, so that the tongue becomes interdental.”
Schneider et al.(1982) ,states that tongue thrust is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing
DEFINITION
April 7, 2023 56
Physiologic Habitual
Functional
Anatomic
Classification of Tongue Thrust
Dent Clin NorthAm. 2000 Jul;44(3):659-69.
April 7, 2023 57
Fletcher has proposed the following factors
Genetic
Learned Habit
Induction due to other habits
Psychogenic factors
Etiology of tongue thrusting
April 7, 2023 58
There are complexity of factors Tendency towards allergies & upper
respiratory congestion Extremely high or narrow palatal arch Unusually large tongue Deviated nasal septum Hypertonicity of orofacial musculature Imbalance between the number of teeth
and size of oral cavity
Genetic factors
April 7, 2023 59
Improper bottle feeding Prolonged thumb sucking Prolonged tonsillar and upper respiratory
tract infections Prolonged duration of tenderness of gum or
teeth can result in a change in swallowing pattern to avoid pressure on the tender zone
Tongue thrust ….a learned behavior
April 7, 2023 60
Easy flow of milk through light sucking is ensured
In order to stop the abundant flow,infant is forced to hold the tongue forward against the hole in the nipple
Thus the perverted tongue thrust habit is initiated
Bottle feeding
April 7, 2023 61
Antagonistic muscles to orbicularis oris are activated leading to everted lips
April 7, 2023 62
Subtelny stated that there is no much significant difference in the pattern of feeding and tongue thrust
Weinberg et al.attained the same conclusions
Najera et al.(1963).stated that the breast fed babies had a lower incidence of tongue thrust
Several studies,,,,
April 7, 2023 63
Results in an anterior open bite
Tongue thrusting occurs as a compensatory mechanism
Forms a lip tongue seal during swallowing act instead of lip lip seal
Prolonged thumb sucking
April 7, 2023 64
Moyers stated that tongue thrust is a residuum of thumb sucking
He explains that since it open the bite it induces malfunction of tongue in deglutition
April 7, 2023 65
Upper respiratory tract infections
Push the tongue forward due to pain and decrease in the amount of space which brings about a tongue thrust swallow.
It may also be present due to the physiological need
to maintain an adequate airway.
Prolonged respiratory infections
April 7, 2023 66
April 7, 2023 67
Tongue thrust occurs when the incisors are missing.
Following the loss of deciduous teeth and prior to full eruption of the permanent incisors
The tip of the tongue may protrude into the open area during swallowing
Functional adaptation(Rogers)
April 7, 2023 68
May disappear with the eruption of permanent centrals
May happen in the posterior region during transition
This is a form of adaptive tongue thrust
April 7, 2023 69
Hansen and Cohen et al.found an increased incidence of tongue thrust in 6 yr old children after a follow up upto 12 yrs
They stated that it is due to exploratory excursion of the tongue
This type of transitional tongue thrust account for a considerable amount
Studies
April 7, 2023 70
Induction due to other habits
April 7, 2023 71
Retained infantile swallow
The infantile swallow changes to a mature swallow once the posterior deciduous teeth start erupting.
Poorest prognosis
Maturational problems
April 7, 2023 72
April 7, 2023 73
Hypersensitive palate
Moderate motor disability
Poor sensory control and coordination of swallowing
Neurological disturbances
April 7, 2023 74
Narrow maxillary arch
Macroglossia
Enlarged adenoids
Mechanical restrictions
April 7, 2023 76
Sleeping patterns may be an etiologic factor
When patient sleeps on one side,the tongue rest in the mandibular arch and moves forward
Dewel in his study found that unilateral tongue thrust may result from sleeping patterns
Sleeping habits
April 7, 2023 77
Because of the consistency of diet
Oral laxity is encouraged
Underdeveloped orofacial muscles
Because of disuse tongue,it spreads between the teeth
Soft diet
April 7, 2023 78
Faulty prosthesis given by dentist
It has been found that there is a deviation in swallowing pattern leading to tongue thrust in those patients
Oral trauma
April 7, 2023 79
Classification (Brauer & Holt)
April 7, 2023 80
Genetic
Maturational
Induced due to other habits
Infections
Transitional
Points to ponder….
April 7, 2023 81
MOUTH BREATHING
April 7, 2023 82
A mouth breather is one who breathes orally even in relaxed and stressful situation
Defined as habitual breathing through mouth instead of nose
Mouth breathing
April 7, 2023 83
Nasal breathing
Nasal airways help to filter and humidify the air while entering through the respiratory passage
Normal breathing
April 7, 2023 84
Obstructive
Habitual
Anatomical
Classification
April 7, 2023 85
Hypertrophy of nasal turbinates
Deviated nasal septum
Enlarged adenoids
Resistance to nasal breathing
April 7, 2023 86
Anatomical and developmental abnormalities
Infection and inflammation
Localized benign tumors
Traumatic injuries to nasal cavity
Genetic Pattern
Thumb sucking
Etiology
April 7, 2023 87
Jaw deformity
Compromised airway
Altered head, neck and body posture
Bad breath and gum disease
Consequences
April 7, 2023 88
Low immune response
Obstructive sleep apnea
Poor oxygen saturation
April 7, 2023 89
Systemic
Anatomic deformities
Induced
Points to ponder….
April 7, 2023 90
LIP HABITS
April 7, 2023 91
Defined as a habit that involves manipulation of lips and perioral structures
May involve either of the lips
Predominance of lower lip
Lip habits
April 7, 2023 92
Lip wetting
Lip sucking /pulling
Classification
April 7, 2023 93
Malocclusion
In conjunction with digit sucking and tongue thrusting
Emotional stress
Etiology
April 7, 2023 94
The most common is the lower lip tucked behind the upper incisors
This places a inward force directly towards the tongue on the lower incisors. At the same time it creates an outward force on the upper incisors.
These forces cause the upper teeth to be pushed out and the lower teeth to be pushed inward.
This problem is most common in mixed dentition (baby and permanent teeth), and permanent teeth.
Clinically…..
April 7, 2023 95
NAIL BITING
April 7, 2023 96
Onychophagia, or nailbiting, is a common oral habit, observed in both children and adults
Onychophagy is classified as a nail disease caused by repeated injuries
Nail biting as autodestruction and onychophagy are its most aggressive forms
Onchyophagia
April 7, 2023 97
The need to bite and even to eat fingernails is linked to a psycho emotional state of anxiety.
A child, by biting his or her nails, is exhibiting an evolutionary disturbance linked to the oral stage of psychological development
April 7, 2023 98
Greater incidence is seen between the ages of 4 and 6
Stabilizes from 7 to 10and increases considerably during adolescence,
The incidence of nailbiting is relatively equal up to 10 years of age, but thereafter significantly fewer girls than boys are nailbiters
Incidence
April 7, 2023 99
Anxiety
Psychic disorders
Transference of the thumb-sucking habit
Etiology
April 7, 2023 100
Although nail biters have more anxiety than those without the habit, no significant difference was found when relating onychophagia to anxiety
Others explain it as a family trend, probably due to imitation
Anxiety
April 7, 2023 101
Nail biting is common habit
Attention deficit hyperactivity disorder (74.6%),
oppositional defiant disorder (36%),
separation anxiety disorder (20.6%)
compulsive disorder (11.1%)
Psychic disorders
Child and Adolescent Psychiatry and Mental Health 2008, 2:13
April 7, 2023 102
According to Massler and wood ,it is a continuation of thumb sucking habit after 3 years
Another form of oral gratification
Wechsler in 1931 ,also has stated that as the child discontinues thumb sucking ,it will be transferred as nail biting
Thumb sucking
April 7, 2023 103
Is the most common habit in times of stress
After adolescence, onychophagia is usually replaced by the habit of lip “pinching,” chewing of pencils or other objects, nose scratching, or hair twirling.
In adults,smoking or gum chewing seems to be a more common substitute, because these are socially accepted methods of oral gratification
In adolescents…
April 7, 2023 104
Malocclusion of the Incisors
Crowding, rotation, and attrition on the incisal edges of the mandibular incisors and protrusion of the maxillary incisors
Apical root resorption of the teeth
Nail bed infection
Consequences
April 7, 2023 105
BRUXISM
April 7, 2023 106
Defined as the clenching or grinding of teeth when not masticating or swallowing
Is a pathologic activity of stomatognathic system which involves grinding or clenching during parafunctional movemtns
Bruxomania – during day time
Bruxism or sleep bruxism
Bruxism
April 7, 2023 107
Jaw is open during sleep and tooth contact can take place only during sleep arousal
CNS is mostly involved rather than the autonomic nervous systems
Mostly seen during REM sleep
Pathogenesis
Crit Rev Oral Biol Med 2003
April 7, 2023 108
Related to growth and development of occlusion
Improper occlusion
Eruption
Tension ,anger
Pain due to ear ache or teething
In children….
Acta otorhinolaryngol Ital 2004
April 7, 2023 109
Intestinal parasite infestations
Subclinical nutritional deficiency
Endocrine disturbances
Other etiologies
April 7, 2023 110
Ranges from 7 to 15%
Males are more common than females
Prevalence
April 7, 2023 112
MASOCHISTIC HABITS
April 7, 2023 113
Term in German meaning pleasure in being abused or dominated : a taste for suffering
Termed as sado masochistic habits
Repetitive acts that result in physical damage to the individual
SELF MUTILATING HABITS
April 7, 2023 114
Organic
Functional
Etiology
April 7, 2023 115
Lesch Nyhan syndrome
DeLanges syndrome
Tourette syndrome
Organic syndromes
April 7, 2023 116
In Lesch Nyhan syndrome, there is a deficiency of hypoxanthine-guanine phosphoribosyltransferase (HGPRT)
High concentrations of uric acid
Affects the inhibitory centres of basal ganglia
Lower pain threshold
What happens…
April 7, 2023 117
Type A- Injuries superimposed on a pre-existing lesion
Type B –Injuries secondary to an established habit
Type C –unknown etiology
Functional
April 7, 2023 119
A clinician should know about the oral habits & diagnose whether it is normal or abnormal
Knowledge of etiology plays an important role in the assessment
Proper treatment plan can be designed for an individual
To summarize…..
April 7, 2023 120
Orthodontics –Principles & Practice –Graber -3rd edition Oral Myofunctional Disorders – Richard Barrett Pediatric Dentistry –Infancy through Adolecence – Pinkham -4th edition J Indian Soc Pedod Prev Dent. 1998 Jun;16(2):61-6. J Indian Soc Pedo Prev Dent September (2003) 21 (3) 120 – 124 Text book of Pedodontics –Shoba Tandon -2nd edition Annals & Essence of Dentistry 2009:1(3):14-23 Child and Adolescent Psychiatry and Mental Health 2008, 2:1-3 ASDC J Dent Child 1975 Aug :295-98 Am J orthod 1985:87(5):432-5 ASDC J Dent Child 1996 :321-8 Text book of pediatric dentistry – Nikhil Marwah Textbook of Pediatric Dentistry – MS Muthu Principles & practice of Pedodontics –Arathi Rao Pediatric Dentistry – 25:5, 2003:448-58 Am J Orthod Dentofacial Orthop 2008;134:305-8 West Indian Med J 2010; 59 (1): 92-95 www.google.co.in www.pubmed.gov.in www.en.wikipedia.org
References
April 7, 2023 121