ORAL HABITS AND OPEN BITE Dr. Hoori Mirmohamadsadeghi.

ORAL HABITS AND OPEN BITE

Dr. Hoori Mirmohamadsadeghi

Introduction

Oral habits, including nonnutritive sucking, teeth grinding (bruxism), and nail biting, are extremely common in children and are often a source of concern for families and questions for pediatricians.

The information provided in this presentation is intended to help health professionals appropriately reassure parents, address concerns and, when necessary, intervene.

Outline

Introduction Thumb/Finger Habits Pacifier Habits Lip Habits Tongue Thrust/and Mouthbreathing Habits Nail Biting Bruxism Self-Mutilation Appliance Therapy

Oral Habits--Introduction--

The presence of an oral habit in the 3 to 6 year old is an important finding in the clinical examination.

An oral habit is no longer considered “normal” for children near the end of this age group.

If the habit has resulted in movement of the primary incisors, some form of intervention is warranted prior to the eruption of the permanent incisors.

The types of changes in the dentition that an oral habit may cause vary, depending on the intensity, duration, and frequency of the habit.


Intensity Intensity is the amount of force that is applied to the

teeth while performing the habit (i.e. Sucking).

Duration Duration is defined as the amount of time spent sucking

a digit.

Frequency Frequency is the number of times the habit is practiced

throughout the day.


DURATION PLAYS THE MOST CRITICAL ROLE IN TOOTH MOVEMENT!!!


Clinical and experimental evidence suggests that 4 to 6 hours of force per day are necessary to cause tooth movement.

The most important thing to remember about any intervention is that the child must want to discontinue the habit for treatment to be successful.


Some Important Questions to Consider/Ask

How long has the child had the habit?

When does he/she indulge in the habit? Day? Night? Constantly?

Does the child indulge in the habit at school?

Does anyone ridicule the child in regards to the habit? Badgering the child about the habit tends to negatively

reinforce the habit.

Nonnutritive Sucking

Sucking is a normal baby reflex,

beginning around the 29th week

of gestation.

Almost 100% of normal babies

engage in nonnutritive sucking.

Babies may suck their thumb,

fingers, hand, a pacifier, or other

inanimate object such as a blanket or toy.


Depending on the willingness of the child to stop the habit, three different approaches to treatment have been advocated.

They are:

1. Reminder Therapy2. Reward Therapy3. Appliance Therapy


Reminder Therapy

Reminder therapy is appropriate for those who want to stop the habit but need some help to stop completely.

An adhesive bandage taped to the offending finger can serve as a constant reminder not to place the finger/digit in the mouth.

The “reminder” must be neutral and not perceived as any form of punishment


Reward Therapy A contract is agreed upon between the child

and parent or between the child and dentist.

The contract simply states that the child will discontinue the habit for a specified period of time and in return he/she will receive a reward if the requirements of the contract are met.

The reward does not need to be extravagant but special enough to motivate the child.

The more involvement the child can take in the project, the more likely the project will succeed.

Physical Intervention

For physical intervention to work, the child must be ready and agreeable.

Techniques include: 1. Covering hands at night with mittens or

socks

2. Dressing the child in a special shirt with the sleeves sewn closed

3. Placing a bandage or specialty plastic guard on the thumb or finger


Appliance Therapy Appliance therapy should only be used when reminder

and reward therapy have failed.

The dentist should explain to the patient and parent that the appliance is not a punishment but rather a permanent reminder.

The parent and the child should be informed that certain side effects may temporarily appear after the delivery of an appliance. These include: Eating difficulties. Speaking/speech problems. Disturbed sleeping patterns.

Habit discouragement appliances should be left in the mouth for six months. Six months allows the habit to be completely extinguished.

Oral Habits--Thumb and Finger Habits--

Thumb and finger habits make up to majority of oral habits.

The classic symptoms of an active habit are reported to be the following:

1. Anterior open bite.2. Facial movement of the upper incisors and

lingual movement of the lower incisors.3. Maxillary constriction.


Anterior open bite, the lack of vertical overlap of the upper and lower incisors when the teeth are in occlusion, develops because the digit rests directly on the incisors. A slightly increased vertical opening is created.

The digit impedes eruption of the anterior teeth, while the posterior teeth are free to erupt.

Passive eruption of the molars will result in an anterior open bite.

Although to a lesser degree, anterior open bite can also be caused by intrusion of the incisors.


Facio-lingual movement of the incisors depends on how the thumb or finger is placed in the mouth.

Usually, the thumb is placed so that it exerts pressure on the lingual surfaces of the maxillary incisors and on the labial surfaces of the mandibular incisors. The result is increased overjet.


Maxillary arch constriction is due to the change in equilibrium balance between the oral musculature and the tongue.

When the thumb is placed in the mouth, the tongue is forced down and away from the palate.

The obicularis oris and buccinator muscles continue to exert a force on the buccal surfaces of the maxillary dentition.

Without the tongue’s counterbalancing force on the lingual surfaces, the posterior maxillary arch collapses into crossbite.


Timing of treatment is critical.

The child should be given every opportunity to stop the habit spontaneously before the eruption of the permanent teeth.

Treatment is usually undertaken by age 6 years.

Oral Habits--Pacifier Habits--

Dental changes created by pacifier habits are similar to changes created by thumb habits.

Anterior open bite and maxillary constriction are seen consistently in pacifier suckers.

Labio-lingual movement of incisors may not be as pronounced as with a digit habit but is usually present nonetheless.

Manufacturers have developed pacifiers that claim to be more like a mother’s nipple and not as deleterious to the dentition as a thumb or conventional pacifier.

Research has not substantiated these statements.

Oral Habits--Pacifier Habits--

Pacifier habits are theoretically easier to stop than digit habits.

The pacifier can be discontinued gradually or at one point in time under the control of the parent.

In a few cases, the child may subsequently start sucking a finger or thumb.

Oral Habits--Lip Habits--

Habits that involve manipulation of the lips and perioral structures are termed lip habits.

Although most lip habits do not cause dental problems, lip sucking and lip biting certainly can maintain an existing malocclusion.

The most common presentation of lip sucking is the lower lip tucked behind the maxillary incisors.

A lingually directed force is placed on the mandibular teeth and a facial force on the maxillary teeth resulting in proclination of the maxillary incisors, a retroclination of the mandibular incisors, and an increased amount of overjet.

The aforementioned problems are most common in the mixed and permanent dentitions.

Treatment depends on the skeletal relationship of the child and on the presence or absence of space in the arch.

Oral Habits--Tongue Thrust and Mouthbreathing Habits--

Epidemiological data indicate that there is not a simple cause-and-effect relationship between tongue thrusting and open bite.

Further research suggests that tongue thrusting may be able to sustain an open bite but not create one.

Tongue thrusting should be considered a finding and not a problem to be treated.

Oral Habits--Tongue Thrust and Mouthbreathing Habits--

Often individuals appear to be mouthbreathers because of their mandibular posture or incompetent lips.

It is normal for a 3 to 6 year old to be slightly lip incompetent.

Despite the difficulties in identifying mouthbreathing individuals, there is an indication that a weak relationship may exist between mouthbreathing and malocclusions characterized by a long lower face and maxillary constriction.

Oral Habits--Nail Biting--

Nail biting is a habit rarely seen before 3 to six years of age.

The number of people who bite their nails is reported to increase until adolescence.

There is no evidence that nail biting can cause malocclusion or dental change.

There is no recommended treatment.

Oral Habits--Bruxism--

Bruxism is a grinding or gnashing of the teeth and is usually reported to be nocturnal.

Most children engage in some bruxism that results in moderate wear of the primary canines and molars.

Rarely, with the exception of handicapped individuals, does the wear endanger the pulp by proceeding faster than secondary dentin is produced.

Oral Habits--Bruxism--

Treatment should begin with simple measures, including the elimination of occlusal interferences and occlusal equilibration if necessary.

If occlusal interferences are not located or equilibration is not successful, referral to appropriate medical personnel should be considered to rule out any systemic problems (intestinal parasites, allergies, endocrine disorders, etc.).

If neither of these two steps is successful, a mouth guard-like appliance can be constructed to protect the teeth and try to eliminate the grinding habit.

Oral Habits--Self-Mutilation--

Self-mutilation, repetitive acts that result in physical damage to the individual, is extremely rare in the healthy child.

The incidence of self-mutilation in the mentally retarded population is between 10 and 20%.

Due to the fact that it always garners attention, it has been suggested that self-mutilation is a learned behavior.

A frequent manifestation of self-mutilation is biting of the lips, tongue, and oral mucosa.

Besides behavior modification, treatment for self-mutilation includes use of restraints, protective padding, and sedation. Also, the extraction of selected teeth may be necessary.

Oral Habits--Appliance Therapy--

There are two major categories of commonly used appliances:

1. Removable

2. Fixed

Removable Easily misplaced or lost Patient compliance is a major factor

Fixed “Cemented” in-place using a dental cement/adhesive Does not rely on patient compliance

Oral Habits--Appliance Therapy-- Removable Appliance

Example: Modified Hawley


Fixed Appliance Examples: Hayrake Appliance

Palatal Crib


Fixed Appliance Examples (continued): Bluegrass Appliance


Bluegrass Appliance

Based on a concept from the horse industry

Created and designed by Bruce S. Haskell, DMD, PhD and John R. Mink, DDS, MSD

Indicated for thumb sucking habits

Utilizes the principles of positive reinforcement


Bluegrass Appliance (continued)

Extremely well tolerated by patients and parents

Indicated for children in the early or late mixed dentition who have a desire to stop their thumb sucking

Works through a counter-conditioning response to the original conditioned stimulus for thumb sucking

Extremely high success rate


A Little About the Teflon Roller Beveled on 3 sides 5/8 inch in length ¼ inch in diameter

ORAL HABITS

References

Proffit, William R. Contemporary Orthodontics, 2nd edition, Chapter 25, 1993.

Haskell, Bruce S and Mink, John R. “An Aid to Stop Thumb-Sucking: The “Bluegrass” Appliance”, Paediatric Dentsitry, Volume 13, Number 2.

ORAL HABITS AND OPEN BITE Dr. Hoori Mirmohamadsadeghi.

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