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SEMINAR ON: FOR DEPARTMENT OF PAEDIATRIC &PREVENTIVE DENTISTRY PRESENTED BY: SHALINI MITTAL ROLL NO. 76 BATCH: 2005-06 INDEX TOPICS Introduction Definition of habit Classification of oral habits Etiology of oral habits Diagnosis & management Various oral habits Thumbsucking Tongue thrusting Mouth breathing Bruxism Lip habit Cheek biting Nail biting Self injurious habits Frenum thrusting Bobby pin opening Conclusion Bibliography PAGE NUMBER 1 1 2 3 3 5 7 12 16 19 23 24 25 26 28 29 29 30 INTRODUCTION Habit is a voluntary or involuntary act performed by a peson, repeatedly and compulsively. Habits of sufficient frequency, duration and intensity are associated with various dento-alveolar and skeletal abnormalities. Persistent oral habits may result in long term problems hence evaluation of habits has been recommended for children beyond the age of 3 years. DEFINITION OF HABITS According to Boucher O.C. Habit is a tendancy towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic. According to Dorland(1957) Habit is a fixed or a constant practice established by frequent repetition. According toButtersworth(1961) Habit os a frequent or constant practice or an acquired tendancy which has been fixed by frequent repetition. According to Matthewson(1982) Oral habits are learned pattern of muscular contractions. CLASSIFICATION ACCORDING TO OTHER AUTHORS: James(1923) 1.useful habits 2.harnful habits Kingsley(1958) 1.functional oral habits 2.muscular habits 3.combined habits Morris & bohanna(1969) 1.pressure habits 2.non pressure habits 3.biting habits Klein(1971) 1.empty habits 2.meaningful habits Finns(1987) a) compulsive habits b) non compulsive habits 2. a) primary habits b) secondary habits ETIOLOGY • • • • • • • • • • • • family conflicts jealousy school pressure stress lack of satisfaction through nourishment limitations associated with tooth eruption occlusal interference breathing obstruction overprotection loneliness isolation problems of communication DIAGNOSIS &MANAGEMENT Management of oral habits is indicated whenever habits cause damage or there is a reasonable indication that oral habits will have infavourable sequelae in developing permanent dentition. Treatment modalities include: • behaviour modification • appliance therapy • referral to other dental or medicine specialists according to Melvinmoss, skull consists of a series of functional components each of which supports or protects the functional matrices. All skeletal and structural attributes reflect morphogenic prio demands of their matrices. Due to deleterious oral habits there occurs an inbalance between various soft tissue matrices, exerting abnormal pressure on jaw and causing altered growth of dentofacial complex. Oral habits & Melvimoss concept of growth Buccinator, superior constrictor, Pterygomandibular raphae tongue lips harmonious pressure balance habits pressure altered muscular contraction. Altered dentofacial & skeletal growth abnormal tissue VARIOUS ORAL HABITS 1. digit sucking 2. tongue thrusting 3. mouth breathing 4. bruxism 5. clenching 6. nail biting 7. lip biting 8. lip sucking 9. cheek biting 10. occupational habits 11. dummy sucking 12. pencil or foreign object sucking 13. frenum sucking THUMB SUCKING Definition: thumb sucking may be defined as placement of thumb into various depths in the mouth. CLASSIFICATION Based on clinical observation: 1. normal thumbsucking : thumbsucking is considered to be normal in first & second year of life. This habit usually disappears as the child matures. Habit at this age doesn’t generate any malocclusion. 2. abnormal thumbsucking: when this habit persists beyond preschool period, then it could be considered to be abnormal thumbsucking habit. If the habit is not treated at this stage, it may cause deteriorations in the dentofacial structures. Abnormal thumbsucking may be classified into 1. psychological: there may be a deep emotional factor associated with the habit like insecurities, neglect or loneliness. 2. habitual: habit doesn’t have psychological bearing. Sucking habits can also be classified as: • nutritive: e.g. breast feeding & bottle feeding • non- nutritive: e.g. thumbsucking, etc. Causative factors 1. parents’ occupation 2. working mother 3. number of siblings 4. order of birth of child 5. social adjustment & stress 6. feeding practices 7. age of child Clinical findings Due to sucking habits, various malocclusions occur in primary and permanent dentition. According to Nanda(1989), type of malocclusion produced by digit sucking is dependant on number of variables: • position of digits • associated orofacial muscle contractions • mandibular position during sucking • facial skeleton patterns • intensity, frequency & duration of force applied Commonly observed clinical problems - maxillary anterior proclination and mandibular retroclination - anterior open bite - constriction of maxillary arch - posterior cross bite TREATMENT a) psychological therapy b) reminder therapy c) mechano therapy Psychological therapy Thumbsucking children between ages of 4 and 8 yrs. Need only reassurance positive reinforcement and friendly reminders. Children and parents are informed about the problem and long term risks of the habit. During treatment adequate emotional support and concern should be provided to the child by parents. Reminder therapy a)Extraoral approaches It employs hot tasting, bitter flavored preparations to the digits. Thermoplastic thumb post was devised by Allen in 1991 where a total of 6 wks of time was reqd. for elimination of habits. b)intraoral approaches removable appliances like palatal cribs, rakes, palatal and lingual spurs, Hawley’s retainers with or without spurs are used. Fixed appliances such as upper lingual tongue screen appear to be effective in breaking these habits. d) mechanotherapy quad helix: this appliance prevents thumb from being inserted and also correct malocclusin by expanding the arch. Bluegrass appliance: Haskell(1991) introduced an appliance for childre with a continued thumbsucking habit. It consists of a modified size-sided roller slipped over a 0.048 stainless steel wire solderedto molar ortho. Bands. This appliance is placed for a period of 3-6 mths. TONGUE THRUSTING The lower jaw of infants is usually behind upper jaw. During infantile swallowing tongue is between gumpads in close approximation with lips and its contraction alongwith the facial muscles help to stabilise the mandible. Definition: According to Braver(1965) A tongue thrust was said to be present if tongue was observed thrusting between, and the teeth didn’t close in centric occlusion during deglutition. According to Tulley(1969) States tongue thrust as forward movement of tongue tip betweenteeth to meet lower lip during deglutition and in sounds of speech, so that tongue becomes interdental. According to Barber(1975) Tongue thrust is an oral habit pattern related to persistence of an infantile swallow pattern during childhood and adolescence and thereby produces an open bite and protrusion of anterior tooth segments. According to Schneider(1982) Tongue thrrust is a forward placement of tongue between anterior teeth and against lower lip during swallowing. CLASSIFICATION 1. physiologic: comprisesof normal tongue thrust swallow of infancy. 2. habitual: tongue thrust swallow is present as a habit even after correction of malocclusion. 3. functional: when tongu thrust mechanism is an adaptive behaviour developed to achieve an oral seal, it can be grouped as functional. 4. anatomic: person having enlarged tongue can have an anterior tongue posture. ETIOLOGY 1. retained infantile swallow 2. upper respiratory tract infection 3. neurologic disturbances 4. functional adaptibility to transient change in anatomy 5. feeding practices and tongue thrusting 6. other oral habits 7. hereditary 8. tongue size CLINICAL MANIFESTATIONS - anterior open bite - protrusion of maxillary incisors - high arched v-shaped palate - malocclusion - pronunciation difficulties - malformation of jaws TREATMENT -appliances are recommended for treatment of tongue thrust, however myofunctional therapy should be attempted first. -Treat swallow pattern which may help to correct pronunciation and correction of dental problems. Tongue thrust therapy focuses on correct positionig of jaws at rest, the muscular strength of chewing muscles and developing a new swallowing pattern. - use of sugarless mint: the child is asked to use tip of tongue to hold a mint in the roof of mouth until it melts. As mint is held, saliva flows and makes it necessary for the child to swallow. Once the child is trained , tongue muscles function proper during swallowing. A mandibular lingual arch with a rib or an acrylic retainer with a fence may be constructed. MOUTH BREATHING Definition According to Sassouni (1971) Habitual respiraton through mouth instead of nose. According to Merle(1980) suggested the term oro-nasal breathing instead of mouth breathing. CLASSIFICATION Finn(1987) classified mouth breathing into: 1. anatomic: anatomic mouth breather is one short upper lip doesn’t permit complete closure without undue effort. 2. obstructive: children who have increased resistance to or a complete obssruction of normal flow of air in nasal passages. Child is forced to breathe through the mouth. 3. habitual: chilg continually breathes through the mouth by force of habit although abnormal obstruction has been removed ETIOLOGY 1. enlarged turbinates 2. deviated septum and other naso-pharyngeal abnormalities 3. allergic rhinitis, nasal polyp. 4. enlarged adenoid or tonsilsabnormally short upper lip preventing proper lip seal 5. obstruction in bronchial tree or larynx 6. obstructive sleep apnoea syndrome 7. thumbsucking or similar oral habits 8. genetically predisposing factors CLINICAL MANIFESTATIONS increased anterior face height increased mandibular plane angle retrognathic mandible and maxilla upper and lower incisors retroclined psterior cross bite open bite nasal tone in voice atrophied nasal mucosa. inflammed and irritated gingival tissue in anterior maxillary arch. - Otitis media CLINICAL TESTS 1. MIRROR TEST: a double sided mirror is kept on philtrum. If fog is formed on the mirror facing the mouth, then patient is a mouth breather. 2. BUTTERFLY TEST: take a piece of cotton and shape it into a butterfly. Place it on the philtrum and check for the movement of cotton fibres. If they are moving in the direction of nose, the patient is a mouth breather. 3. WATER HOLDING TEST: patient is asked to hold a mouthful of water for few minutes without swallowing it. If the patient is a mouth breather, he wont be able to hold the water in mouth for a long period. 4. INDUCTIVE PLATHYSMOGRAPHY: reliable way to quantify extent of mouth breathing is ti establish how much of total airflow goes through mouth using platysmography. 5. CEPHALOMETRIES: to establish the amount of nasopharyngeal space size of adenoids and to know the skeletal pattern of patient by taking various cephalometric angles. MANAGEMENT -rule out nasal airway impairment -child is taught certain exercises for breathing through nose -an oral screen may be given. BRUXISM DEFINITION According to Ranifjord(1966) Bruxism is habitual grinding of teeth when individual is not chewing or swallowing. According to Rubina(1986) Bruxism is the term used to indicate non functional contact of teeth which may include clenching, grinding, gnashing and tapping of teeth. According to Vanderas((1995) Non functional movement of mandible with or without an audible sound occuring during day or night. TYPES 1. DAYTIME BRUXISM/ DIURNAL BRUXISM It is conscious or subconscious grinding of teeth usually during the day. 2. NIGHT TIME /NOCTURNAL BRUXISM It is subconscious grinding of teeth char. By rhythmic pattern of EMG activity. ETIOLOGY 1. CNS- cerebral palsy, mental retardation 2. psychological factors- anxiety, rage, hate, aggression 3. occlusal discrepencies 4. genetics 5. allergies 6. systemic factors- magnesium deficiency 7. occupational factors MANIFESTATIONS Signs and symptoms of bruxism depend on: • frequency of bruxing • intensity • age which may be associated with duration following clinical features are seen: • occlusal trauma • • • • • headache muscular tenderness TMJ disoders Tooth structures Soft tissue trauma TREATMENT Shephard recommended contruction of a palatal bite plate, which allows continuous eruption of posterior teeth. This is desirable if teeth are abraded due to this habit. A vinyl plastic bite guard that covers occlusal srfaces of all teeth, place 2mm. Of buccal and lingual surface can be worn at night to prevent abrasion. LIP HABITS DEFINITION: habits that involve manipulation of lips and periotal structures are lip habits. CLASSIFICATION: a) wetting the lips with tongue b) pullin lips into mouth between the teeth ETIOLOGY -malocclusion -oral habits like digit sucking -emotional stress CLINICAL MANIFESTATIONS - protrusion of maxillary incisors and retrusion of mandibular incisors - mentolabial sulcus becomes accentuated - malocclusion TREATMENT - correction of malocclusion - treating the primary habit - appliance therapy like oral shield Lip bumper: it is positioned in vestibule of mandibular arch and serves to profit lip from exerting extraforce on mandibulkar incisors and to reposition lip away from lingual aspect of maxillary incisors. This results in distal repositioning of maxillary incisors and reducing the overjet and overbite. CHEEK BITING This is an abnormal habit of keeping or biting cheek muscles in between upper nd lower posterior teeth. It may injure soft tissue and may cause an open bite or an individual tooth malposition I buccal segment where a persistent cheek biting habit exists. CINICAL FEATURES - ulcers at the level of occlusion - open bite - tooth malposition in buccal segment TREATMENT A removable crib may be constructed to break the habit. A vestibular screen may also be used. NAIL BITING One of the most common habits in children and adults. It is a sign of internal tension. ETIOLOGY Persistent nail biting may be indicative of an emotional problem. After the age of 15 yrs. Nail biting is replaced by pencil biting, hair twirling or gum chewing. EFFECTS Dental effects: crowding, retraction and attrition of incisal edges of incisos. Effects on nails: inflammation of nail beds and of nails. MANAGEMENT - mild cases need no treatment. - Treat basic emotional factor causing the habit. - Application of nail polish, light cotton mittens as a reminder - Avoid primitive methods like scolding, nagging or threatening. SELF INJURIOUS HABITS Also known as masochistic, sadomasochistic and self-mutillating habits. These are the habits in which the patient enjoys deliberately damaging himself. It is seen in mentally ill or psychologically disturbed children DEFINITION: repetitve acts that result in physical damage to the individual. ETIOLOGY • organic: in lesch nyham disease and De Lenge’s syndrome in which symptoms such as repetitive lip, finger, tongue, knee and shoulder biting are common • functional: a) type A: a child with a finger nail biting habit is under a treatment for a skin lesion which are superimposed or pre-existing. b) Type B: these are secondary to other estd.habits. rotation of thumb while thumbsucking can harm the tissues. c) Type C: this type of behaviour has a greater psychogenic component and child may resort to various self injurious habits as a form of stress release. FRENUM THRUSTING It is an example of self injurious habits. If maxillary incisors are slightly spaced apart. Child may lock his labial frenum between these teeth and permit it to remain in this positon for hours. On constant repetition this may become a habit which may displace the tooth. TREATMENT a) palliative treatment: adjunctive therapy in form of bandage for any oral ulcerationwill help in healing of wouns and serve as habit reminder. b) Mechanotherapy: an oral shield will also deter the cild from unconscious continuation of habit. Treatment for self mutilation may also include use of restraints snd protective padding. BOBBY PIN OPENING Usually seen in teenage girls wherein opening of bobby pin with anterior incisors is done. Clinically, we see notched incisors and partially denuded labial enamel. Treatment invoves stoppage of the habit. CONCLUSION Identification and assessment of an abnormal habit and its immediate and long term effects on craniofacial complex and dentition should be made as early as possible to minimze the potential deterious effects on dentofacial complex. BIBLIOGRAPHY  Text book of pedodontics by Shobha Tandon  Textbook of pedodontics by S.G. Damle  Textbook of pedodontics by Aarthi Rao  Textbook of orthodontics by T.M. Graber  Textbook of orthodontics by Balajhi  Internet