ORAL HABITS AND MANAGEMENT

Contents :
Definition of Habits
Classification
Thumb sucking
Tongue thrusting
Mouth breathing
Bruxism
Lip habits
Self injurious habits
Cheek biting
References

Definitions of Habits:
 Dorland (1957)
Defined habit as a fixed or constant practice established by frequent repetition
 Buttersworth ( 1961)
Defined a habit as a frequent or constant practice or acquired tendency, which has been
fixed by frequent repetition
 Mathewson ( 1982 )
Oral habits are learned patterns of muscular contractions

Classification:
James ( 1923 )
Useful habits – essential for normal function
Harmful habits
Morris and Bohanna ( 1969 )
Pressure habits
Non pressure habits
Klein ( 1971 )
Empty habits – without psychological bearing
Meaningful habits
Finn ( 1987 )
I (a) compulsive habits (b) non compulsive habits –easily learned and dropped
II(a) primary habits (b) secondary habits – hair pulling, nose probing

Digit sucking:
Definition:
Gellin (1978): Placement of thumb/finger – varying depths of mouth.
Moyer (1988): Repeated and forceful sucking associated buccal/lip contractions

Thumb sucking and finger sucking can be more generally be termed as digit sucking (most common
habit)

Classification
O’Brien ( 1996 ) classified sucking habits as
1. Nutritive sucking habits e.g. breast feeding, bottle feeding
 2. Nonnutritive sucking habits e.g. thumb or finger sucking, pacifier sucking
Subtelny ( A O 1973 )
Type A
 Seen in 50% of children,
 Whole digit is placed inside the mouth beyond the first knuckle,
with pad of the thumb pressing over the palate.
 Lower incisor pressed into thumb and contacted it some where
beyond the first joint

Type B
 Seen in 13-34% of children
 Thumb is placed into the oral cavity without touching the vault of
the palat
 Contact between the tongue and lower incisor was found

Type C
 Seen in 18% of children
 Thumb is placed into the mouth just beyond first joint and
contacts the hard palate and only maxillary incisors but no
contact with mandibular incisor

Type D
 Seen in 6% of children
 Very little portion of thumb is placed into the mouth
 Lower incisor touched the thumb at level of the thumb nail

The sucking reflex

 The process of sucking is a reflex occurring in oral stage of
development and is seen even at 29 weeks of intrauterine life and may
disappear during normal growth between ages of 1 and 3 ½ years
 It is the first coordinated muscular activity of the infant
 Apart from seeking nutritional satisfaction they also experience pleasurable stimuli from lips,
tongue, oral mucosa and learn to associate these with enjoyable sensations such as fondling,
closeness of a parent

THEORIES FOR THUMB SUCKING

1)Classical freudian theory ( 1905 )

 One of the concept of this theory is that humans posses a biologic sucking drive and child
associates sucking with pleasurable feelings such as satiety and being held by parents.
 These events will be replaced in later life by transferring the sucking action into most
suitable objects available namely the thumb or finger

2) The learning theory: Davidson ( 1967 )

  This theory advocates that non nutritive sucking stems from an adaptive response
 The infant associates sucking with such pleasurable feelings as hunger
 These event are recalled by sucking the suitable objects available mainly thumb or finger

3) Benjamin’s theory
 Thumb sucking arises from the rooting reflex common to all mammalian infants.
 Rooting reflex: the movement of an infant head and tongue towards a stimulus touching an
infants cheek

4) Oral drive theory: Sears and Wise ( 1982 )

 They suggested that strength of oral drive is in part a function of how long a child continues
to feed by sucking. Thus thumb sucking is result of prolongation of nursing and not
frustration of weaning

5) Johnson and Larson ( 1993 )

 They believed that it is a combination of psychoanalytical and learning theories which
explains that all children posses a inherent biologic drive for sucking.
 The rooting and placing reflex are merely a expression of this drive for sucking
 Environmental factors may also contribute to this drive to nonnutritive sources as thumb or
fingers

Causative factors
1. Parents occupation
Sucking habit commonly observed in children with working parents
2. Socioeconomic status
Child in low socioeconomic group had to suckle intensively for long time to get required
nourishment thereby exhausting the sucking urge. This theory explains increased incidence of
thumb sucking in industrialized areas compared to rural areas (Adair et al, Pediatr Dent 1992)
3. Number of siblings
4. Order of birth of a child
5. Age of child
Time of appearance of habit has significance
 In neonates- related to primitive demand as hunger
 During first few weeks of life- related to feeding problems
 During eruption of primary molar- used as toothing device
 Still later- use for release of emotional tensions with which they are unable to cope, taking
refuge in regressing to an infantile behavior pattern

Clinical features of thumb sucking

Extra oral
The digits
Digit involved in the habit will be reddened, exceptionally clean, with a short finger nail
Lips
Chronic thumb suckers are frequently characterized by short hypertonic upper lip. Upper lip is
passive and incompetent during swallowing
Facial form
 Child has mandibular retrusion, maxillary protrusion, high mandibular plane angle and convex
profile
Intra oral characters
Effect on maxilla
 Increased proclination of maxillary incisors
 Increased maxillary arch length
 Increased anterior placement of apical bone of maxilla
 Increased SNA
 Increased clinical crown length of maxillary incisors
 Increased counterclockwise rotation of maxilla
 Decreased palatal arch width
Effects on the mandible
 Increased mandibular intermolar distance
 Increased distal position of B point
Effect on inter arch relationship
 Decreased interincisal angle
 Increased overjet
 Anterior open bite ( Cozza 2005 AJODO )
 Increased posterior cross bite
 Increased unilateral and bilateral class II malocclusion
Effect on tongue placement and function
 Increased tongue thrust
 Increased lip to tongue resting position
 Increased lower tongue position
Other effects
 Higher incidence of middle ear infections
 Blocked Eustachian tubes
 Enlarged tonsils
 Risk to psychological health
 Increased deformation to digits
 Increased risk of speech defects esp., lisping

DIAGNOSIS
The diagnosis of thumb sucking consists of four diagnostic procedures.
1.History of digital sucking: Information on whether the child has had an history of digital sucking,
obtained by parents. When there is a positive answer, one should ask the question, How frequently?,
How long it lasted? And its intensity and what remedies have been tried at home?
2. Emotional status:
The Childs emotional status should be assessed by asking questions like
- Feeding habits
- Parental care of child
- Whether the parents are working
3. Extra-oral examination: The dentist should check the patients digits. They should be compared with
the opposite finger of the other hand. The finger engaged sucking with often appear reddened or
exceptionally cleaned, chapped, with a short fingernail thumb. Due to constant sucking the thumb or
finger may have thick callus formed
4. Intra-oral examination: A good intra-oral examination could be a key to diagnosis of the habit, with its
clear picture of clinical features.

These features are:

 Flared maxillary anteriors with diastema

 High probability of buccal cross-bite
 Narrow maxillary arch
 Lingual tipping of the mandibular incisors
 Open bite

MANAGEMENT
Management may be divided into

- Preventive- Primary dentition between (3-5 yrs)

- Interceptive - Eruption of permanent incisors in progress (6-8 yrs)
- Corrective (a) early treatment- - Eruption of permanent molars in progress (8 yrs-upto
eruption of all permanent tooth)
(b) Late treatment
- Post treatment or retention

A) Preventive treatment
 Hughes says- prevention of finger sucking habit is very easy if the following simple
procedures are followed. Firstly, feed the child whenever it is hungry, and let him to eat as
much as he wants (treatment for nutritive sucking). Dispense and scheduling and routine
practice till 3 yrs of age when he has considerable social learning and enough maturity to
understand their importance. Secondly- feed the child in the natural way. Importance of
breast-feeding is primarily psychological and secondarily nutritive.
 McBride believes that if one wishes to prohibit sucking, never let the habit get started, the
practice must be discontinued at its inception. In the beginning the finger is routinely
removed from the mouth and is kept out during sleeping-hours by pinning sleeves of the
sleeping garments so that the child will not acquire the motion.

B] Interceptive treatment:
• psychological methods
• Reminder therapy
– chemical,
– mechanical
(1)Psychological:

• Scolding or frightening the child should be avoided.

• Brauer says that in the younger child, education of the parent is the clue to discontinue the
habit. He continues, to say, “intelligent attention must be given to the following principles:

1. Promote favorable contact of the child to his immediate environment.

2. Provide play materials suited to the childs age.
3. 3. See that the child has the opportunities and space to be active, to experiment, to explore and
play.
4. Reduce unnecessary regulation for the child and provide as much freedom as possible.
5. The home atmosphere should be one of happiness, sympathy, patience and understanding.

Lewis states thumb-sucking is not a disease be cured, but the symptoms of maladjustment, the
correction of which requires considerable patience, skillful handling, self discipline, one of the part
of those whose responsibility is to handle it.

Dunlop’s beta hypothesis (1929)

• By Dr. Knight Dunlap of John Hopkins university – concept of negative practice
• Dunlop believed that if a child can be forced to concentrate on performance of an act, at that
time he practices it, he can learn to stop performing the act
• Forced purposeful repetition of a habit eventually associates it with unpleasant reaction and
habit is abandoned
• The child should be asked to sit in front of a mirror and asked to suck his thumb, observing
himself as he indulges in the act
• It is an effective method in children older than 8 years of age

Reminder Therapy
• Reminder therapy is appropriate for those who want to stop the habit but need some help to
stop completely.
• Two kinds of aids are available as given by KOOI 1982
Passive aids
• This reminds the child that means not to suck when he unconsciously returns to sucking
• These can be used especially during sleep to influence unconscious activities
Active aids
• It includes exercise that are performed when the child is tempted to suck and wants to prevent
it.

Non-appliance: (Mechanical)
• Adhesive tapes
• Socks – neoprene (Dennison PJ et al, 1999)
• Long-sleeved gowns (Al Emran,2000; Al Emran & Al Jobair, 2005)
3-alarm system (Norton and Gellin,1968):
• Taping of offending digit
• Bandage on elbow with lengthwise safety pin
• Bandage tightened
Chemical approach:
• Bitter tasting, foul smelling preparations/substances
• Cayenne (red pepper), asafoetida, quinine
• Patient is willing

Reminder appliances:
• Thermoplastic thumb posts (Allen KD et al, 1992)
 • Thumb guard: is a soft acrylic covering over the thumb worn at night. Fabricated by the dentist,
made of soft acrylic has holes of approximately 3/16” in diameter drilled into it, to break the
sucking seal. It is tied to the wrist at night.
• Ace bandage approach (Adair SM, 1999)

C] Corrective treatment:
(1) Removable appliances: A removable appliance is used for child, who in our clinical judgment
wants to stop and asks for help ,but who wants to be engaged in meaningful sucking. the removable
appliance is the choice, because the child can easily remove it ,if his emotional status demands it.
• Appliance therapy
There are two major categories of commonly used appliances:
• Removable
1. Easily misplaced or lost
2. Patient compliance is a major factor
• Fixed
1. “Cemented” in-place using a dental cement/adhesive
2. Does not rely on patient compliance

The removable appliances include

• Palatal cribs: It may be a fixed or removable appliance. The cribs act as

1. To break the suction

2. To remind the patient of his habit.
3. To make the habit a non-pleasurable one.

Rakes: It has spur projecting from the acrylic retainer into the palatal vault. The hay-rake type appliance
frequently are destroyed by habitual sucking There are also fixed types of rakes. Here the palatal
assembly is made of 0.040” inch (st. steel wire) wire. Crowns are made of steel.

ORAL SCREEN: is made of acrylic.

It acts in a number of ways.
1. Prevents the habit.
2. Corrects the open-bite.
3. Exercises the hypo tonic lip and the mentalis muscle.

(2)Fixed appliances:
Bluegrass Appliance
Created and designed by Haskell,
 Utilizes the principles of positive reinforcement
 Extremely well tolerated by patients and parents,
and issndicated for children in the early or late
mixed dentition who have a desire to stop their
thumb sucking
 Extremely high success rate
 It has a hexagonal teflon roller on a palatal wire and the child is instructed to turn the roller
instead of digit sucking
  Treatment time is 4 – 6 months

Triple loop connector – Viazis AJODO 1991

 Simple thumb sucking habit control appliance,
easily constructed by bending 3 consecutive loops
 Requires minimal chair side time and can be
designed to cover whole span of patient open bite
to make insertion if thumb difficult
 This appliance works if there is significant openbite
and marked overjet
Quad helix:

• The quad helix is fixed appliance used to expand the constricted maxillary arch. The helixes of
the appliance serve to remind the child not to place the finger in the mouth.
• The quad helix is a versatile appliance because it can correct a posterior cross-bite and
discourage a digit sucking habit at the same time.

Pacifiers and its effect on malocclusion

• O¨ gaard et al. examined posterior crossbite in 445 , 3-year-old children with and without
previous or continued finger or pacifier sucking habits.

• They reported that pacifier use decreased maxillary intercanine arch width and increased
mandibular intercanine arch width, resulting in crossbite.

• A pacifier habit of 2 years or longer was necessary to cause decreased maxillary arch width, and
a pacifier habit of 3 years duration was significantly associated with increased mandibular arch
width.

• Warren and Bishara (AJODO 2002) : Prolonged pacifier habits resulted in increased mandibular
arch width and a tendency for a decrease in maxillary arch width leading to greater prevalence
of posterior crossbite and anterior open bite.

TONGUE THRUSTING:
DEFINITION:
• Barber (1975) : Oral habit pattern related to the persistence of an infantile swallow pattern
during childhood and adolescence producing open bite and protrusion of anterior tooth
segments
• Schneider (1982): Forward placement of the tongue between the anterior teeth and against
the lower lip during swallowing

Classification:
According to Backlund (1963):
Anterior tongue thrust
Posterior tongue thrust

According to Picketts (1966):

 Adaptive
Transitory
Habitual

James S. Braner and Holt:

Type I: non-deforming
Type II: deforming anterior
Sub group 1: anterior open bite
Sub group 2: anterior proclination
Sub group 3: posterior cross bite
Type III: deforming lateral
Sub group 1: posterior open bite
Sub group 2: posterior cross bite
Sub group 3:deep overbite
Type IV: deforming anterior and lateral
Sub group 1:anterior and posterior open bite
Sub group 2: anterior proclination
Sub group 3:posterior cross bite

MOYERS CLASSIFICATION

1) Simple tongue thrust:

 Normal tooth contact
 Increased overjet, reduced overbite,
 Anterior open bite
 Good intercuspation
 Abnormal mentalis activity

2) Complex tongue thrust:

 Teeth apart swallow
 Anterior open bite – may be absent
 Occlusion may be poor
 Contraction of circum oral muscles
 Lateral tongue thrust nay be seen
 Unilateral crossbite may also be seen

3) Retained infantile swallow

 Is defined as the under persistence of the infantile swallow well past the normal time.
 Very few people have a retained infantile swallow, those who do ordinarily occlude on just one
molar on each quadrant.
 They also demonstrate strong contraction of the facial muscle during swallow.
 Persons with retained infantile swallow do not have expressive faces, since the muscles of 7th
cranial nerve are being used for the massive effort of stabilizing the mandible and not for the
delicate facial movements of facial expression.
 They also have serious difficulties in mastication and may have low gag threshold.
Etiology:
 Retained infantile swallow :With the eruption of incisors at 6 months of age, tongue does not
drop back as it should and continues to thrust forward
 Upper Respiratory Tract Infection e.g.. Enlarged adenoids.
 Neurological disturbances: Hyposensitive palate, moderate motor disability, disruption of
sensory control and coordination of swallowing can lead to tongue thrust
 Functional adaptability- transient change in anatomy: Loss of incisors, or loss of deciduous
posterior teeth before complete eruption of permanent incisors leaves natural opening for
tongue, which protrude into open area while swallowing
 Feeding practices: There is controversy that whether bottle feeding or breast feeding leads to
tongue thrusting habit
 Induced due to other habits: Thumb or finger sucking habit can cause anterior open bite, and
tongue is seen to protrude between teeth during swallowing
 Mechanical restrictions: Macroglossia

Clinical Features
Extra-oral findings:
 Lip posture: Greater lip separation both at rest and function
 Mandibular movements: Erratic, no co-ordination with tongue
 Speech: Lisping, problems in articulation of s/n/ t/ d etc..
 Facial form: Increase in facial height

Intraoral findings:
 Tongue movements: Jerky and irregular,Chin posterior
 Tongue posture: Lower rest position
 Effects on mandible: Proclination of mandibular incisors, Increased inter – molar width
 Effects on maxilla:
 Proclination of maxillary anteriors resulting in increased overjet
 Generalized spacing between the teeth
 Maxillary constriction
 Anterior or posterior open bite based on posture of the tongue
 Posterior teeth crossbite

Treatment of Tongue Thrusting:

• Children below 3 years – no active treatment
• Habit awareness alone might resolve tongue thrusting in few children
• Training of correct swallow and position of tongue
• Myofunctional exercises
• Child is asked to place the tip of tongue in rugae and asked to swallow
• Child is instructed to place Orthodontic elastics or sugarless fruit drop on tongue and
hold it against palate in correct position till it dissolves. While doing this child
unconsciously learns correct swallowing
• 4 S exercise- this includes identifying the Spot, Salivating, Squeezing the spot, and Swallowing.
The spot is shown as papillae behind the incisors and it should be the rest position of tip of the tongue
• Other exercises includes
1. whistling,
 2. reciting the count from 60 to 69,
3. gargling, yawning etc
4. Elastic band swallow
5. Water swallow
6. Candy swallow
7. Speech excercises – practise syallables c, g, h, k while keeping an elastic band between
tongue and palate

Guiding appliances
• Pre orthodontic trainer: This is oral screen like appliance with tongue tags which aids in correct
positioning of the tongue. Tongue guards prevent tongue thrusting when in place
• Nance palatal arch: In this acrylic button can be used as guide to place the tongue in correct
position
• Speech therapy: First step towards speech therapy should be to train correct positioning of the
tongue. The child is asked to repeat simple multiplication tables of six. To pronounce words
beginning with S sounds. However such a therapy is not indicated before the age of 8 years

Mechanotherapy
Removable appliance
Fixed appliance

MOUTH BREATHING HABIT:

Definitions:
Chopra RB (1951):
Habitual respiration through mouth instead of nose
Chacker FM (1961):
Prolonged or continuous exposure of tissues of anterior areas of mouth to the drying effects of
inspired air
Sassouni (1971):
Habitual respiration through mouth instead of nose
Merle (1980):
Oro – nasal breathing instead of mouth breathing

Classification:
Finn (1987):
• Obstructive :Due to obstruction of nasal passages e.g.. Enlarged tonsils
• Anatomica l:Short upper lip
• Habitual :No other problem – still persists

Sassouni (1971):
• Total :Present when nasal passages are completely blocked
• Habitual:When nasal breathing is accompanied by intermittent mouth breathing

Etiology:
 Enlarged turbinates of nose
 Hypertrophy of pharyngeal lymphoid tissue
 Intra nasal defects:
 Deviated nasal septum
  Thick septum
 Bony spurs
 Polyps
 Allergic rhinitis (Sacre JA, 2006)
 Abnormally short upper lip
 Obstruction in bronchial tree
 Obstructive sleep apnoea syndrome
 Long faced children with narrow pharyngeal spaces
 Habits such as tongue thrusting/ digit sucking
 Feeding pattern: Use of the bottle - negative oral facial development and breathing pattern
(carrascoza kC, 2006) (Trawitzki LV et al, 2005) less breast feeding – more mouth breathers

Clinical features:
General effects:
Nasal passage aids in purification and humidification of air so in mouth breathers there is increase of
net water loss by 42% (Svensson S et al, 2006)
Pigeon chest:
Nasal passage has increased resistance to air flow and so diaphragm and intercostal muscles has to
perform work to create required negative pressure
Pulmonary development:
With oral respiration breathing is shallow and air does not reach deep alveolus of lungs and so poor
pulmonary compliance and development is seen
Lubrication of esophagus:
Esophagus lacks intrinsic mucous glands and mucous from nose and pharynx serves to lubricate it .In
mouth breathers oropharynx is dry and mucous often collects to get expectorated ,This denies
esophagus essential lubrication and produce low grade esophagitis
Blood gas constituents:
Mouth breathers have 20% more carbon monoxide and 20% less oxygen

Effects on dento - facial structures:

Facial form:
 Vertical growth pattern
 Long, narrow face
 Narrow nose and nasal passage
 Short upper lip
 Heavy and everted lower lip
 Nose tipped superiorly
 Expressionless face
 V-shaped palate
 High palatal vault
 Increased mandibular plane angle
 Retrognathic mandible

Dental effects:
 Proclined upper incisors
 Retroclined lower incisors
 Narrow palatal width (Aznar T, 2006)
  Constricted maxilla
 Speech defects:
 Nasal tone

Lips:
 Incompetent
 Short upper lip
 Thick and everted lower lip
 Gummy smile
 Increased orbicularis oris and mentalis muscle activity- EMG (Dutra EH et al, 2006)

Nose:
 Narrow nose
 Superiorly tipped
 Slit-like nares
 Atrophied nasal mucosa

Gingiva:
 Inflamed, red in anterior maxilla
 Rolled margin, inflamed papilla
 Increased drying causes increased plaque
 Periodontal problems

Diagnosis:
Clinical tests:
1) Mirror test
2) Butterfly test
3) Water holding test
4) Rhinomanometry (inductive plethysmography):
 Most reliable way
 It measures Total airflow through mouth and nose and % of nasal and oral respiration
 <40% nasal breathing is seen in most adenoid facies

Treatment steps:
 Elimination of the cause:
Surgical removal - Nasal / pharyngeal obstruction
Allergic rhinitis to be treated

 Interception of the habit: If continues after removal of cause

 Exercises:
Physical exercises:Deep breathing exercises through nose (inhaling and exhaling)

Lip exercises
 Upper lip hypo tonicity and flaccidity are most obvious characteristics. Exercises to correct
these includes
  Extending lip : as far as possible below and behind the maxillary incisors, 15-30 mins/day for
4-5 months
 Hold paper between lips
 Holding piece of card 1x1 ½ inches between lips
 Button pull exercise : 1 ½ inch diameter button is threaded and placed inside the mouth,
pull thread and button and lips should resist pulling
 Blow under upper lip: to slow count of 4 - repeat 25 times/day

Oral screen (Newell, 1912):

It is used to prevent air from entering through oral cavity
It is effective and can be used during sleeping hours as well
During initial phases windows are placed on oral screen not to completely block the air way

Management:
Worn at night - 2-3 hrs during day
Maintain lip seal
Modifications:
For tongue thrust
Oral screen with holes

BRUXISM:
Definitions:
 Ramfjord (1966): Is the habitual grinding of teeth when the individual is not chewing or
swallowing
 Rubina (1986): Indicates non functional contact of teeth which may include clenching, grinding,
and tapping of teeth.
 Vanderas (1995): Non functional movement of mandible with or without an audible sound
occurring during the day or night.

Types:
Day time/ diurnal:
It is conscious / unconscious grinding of teeth
Can occur along with other parafunctional habits like chewing pencils, nails etc

Night time/ nocturnal:

Sub conscious grinding
Characterized by rhythmic patterns of masseter in EMG activity

Etiology:
CNS
Bruxomania may be due to definite cortical lesions as found in cerebral palsy children
Psychological factors
Bruxism is associated with feelings of anger and aggression or could be manifestation of ability to
express emotions such as hate, rage, anxiety etc
Occlusal discrepancies
Various occlusal abnormalities that prevent stable occlusion may be a cause attributed to alteration
in afferent impulse originating in periodontium
Genetics
 Children with bruxing parents have increased incidence of bruxism
Systemic factors
Magnesium deficiency has been reported as an etiological cause for bruxism
Gastrointestinal disturbance from food allergies, chronic abdominal distress could be a cause
Allergies
Occupational factors
Compulsive overachievers, competition sports leads to significant clenching

Clinical features
 Occlusal trauma: Tooth mobility especially more in morning
 Nonfunctional patterns of occlusal wear
 Muscular tenderness: Tenderness of jaw muscles, hypertrophy of masseter muscle
 Tempromandibular disorders: Pain, crepitation, restriction of mandibular movements
 Headache
 Grinding and tapping sounds

Treatment of bruxism:
 Occlusal adjustments
Prematurities or occlusal interferences should be corrected
Coronoplasty plays an important role in occlusal treatment
 Occlusal splints
Vulcanite splints to cover occlusal surfaces of all teeth have been recommended
Reduction in increased muscle tone is observed with its use
In case of children use of soft splint is advisable
 Drugs
Vapocoolants like ethyl chloride, local anesthetic injection directly into tempromandibular joint,
muscle tranquilizers, sedatives and muscle relaxants
 Psychotherapy
Counseling of patient can lead to decrease in tension and also creates a habit awareness
This may lead to increased voluntary control that can lead to reduced tooth Para functions
Behavior modality is initiated by dentist through explanation and arousal of patients awareness of
habit
 Orthodontic correction
Malocclusion like class I, class II occlusions, frontal openbite and cross bite when associated with
functional malocclusion may create a predisposing to bruxism. This should be corrected
orthodontically

LIP HABIT:
 Habits that involve manipulation of the lips and perioral structures
 Normal lip activity is essential for speaking, eating and maintaining a balanced occlusion
 Lip sucking habit is a compensatory activity due to excessive overjet and the relative
difficulty in closing the lips properly during deglutition
- Wetting
- Licking
- Sucking
- Pulling

Mentalis habit:
 Here the lower vermilion border is everted and the lingual aspect elevated into the mouth.
A sublingual contracture line develops between the lip and the chin [Schneider 1982]

Manifestation:
- Protrusion of maxillary incisor and retrusion of mandibular incisor as lip is wedged between
the upper and lower incisors
- Sucking can be recognized by reddening and chapped area below the vermilion border
- Vermilion border may be relocated far outside the mouth due to constant wetting
- Mentolabial sulcus becomes accentuated

Treatment:
- Lip habit is not self correcting and becomes more deleterious with age
- Correction of malocclusion: It there is class II malocclusion or excessive overjet it should be
corrected before going to break the habit
- Treating the habit: Oral shield is a useful appliance in class I malocclusion
- Lip bumper: Used in both comprehensive and interceptive treatment. It is positioned in
vestibule of mandibular arch and serves to prohibit lip from exerting excessive force on
mandibular incisor

CHEEK BITING:
- This is abnormal habit of keeping or biting the cheek muscles in between the upper and
lower posterior teeth
- It may injure soft tissues causing ulcers at level of occlusion, may cause open bite or an
individual tooth malposition in buccal segment where persistent cheek biting habit exists
Treatment
A removable crib may be constructed to break the habit or a vestibular screen may also be used

NAIL BITING (Motohiro O.AJODO 2008)

- It is one of the most common oral habits in adults and adolescents
- Nail biting is absent before the age of 3 and rises sharply from 4-6 yrs of age and remains
constant till 7-10yrs and raises again to peak during adolescence
Etiology
- Nail biting is a sign of internal tension and persistence nail biting habits may be indicative of
emotional problem

Effects
- Dental – common effects are crowding, rotation, and attrition of incisal edges of incisors
- Nails – inflammation of nail beds

Management:
 Mild cases no treatment is indicated
 Avoid punitive methods like scolding, nagging and threats
 Treat the basic emotional factors causing the act
 Encourage outdoor activities which may help in easing the tension
 Application of nail polish, light cotton mittens as a remainder

SELF INJURIOUS HABITS: (Masochistic or Self mutilating habit )

 - Self injurious habits are those in which patient enjoys inflicting damage to himself and can
be defined as Repetitive acts that results in physical damage to the individual
- It is rare in normal children and mostly seen in mentally retarded children with psychological
abnormalities
Etiology:
Organic
Syndromes or syndromes like maladies in which symptoms like repetitive lip, finger, knee, tongue
biting are common
Functional
- Type A
These are injuries superimposed on pre-existing lesions.
The lesions shows no signs of healing as it is perpetuated by this injurious habit which mainly occurs
at night
- Type B
This includes injuries secondary to another established habit, and may exacerbate features existing
due to primary habit
For example, rotation of thumb while thumb sucking causing soft tissue injuries
-Type C
This may be injuries of unknown or complex etiologies
This type of behavior has greater psychogenic component
Child may resort to various self injurious habits as a form of stress release
Treatment:
 Treatment should first be initiated towards psychotherapy
 Some children experience a feeling of neglect, abandonment and loneliness and through the
use of self injurious behavior attempt to solicit attention and love
 Care should be taken in dealing with this form of behavior because of under lying
psychological component, continued concern for the habit may support or reinforce the
habit
 Palliative treatment: Adjunctive therapy in the form of bandages for any ulceration will help
in healing of wounds as well as serve as a habit remainder
 Mechanotherapy : An oral shield will also deter the child from unconscious continuation of
the habit. Treatment for self mutilation may also include use of restraints and protective
padding

FRENUM THRUSTING
 This rarely seen habit is also a form of self injurious habits
 If the maxillary incisor is slightly spaced apart, the child may lock his labial frenum between
his teeth and permit it remain in that position for hours
 On constant repetition this may turn into a habit which may displace the tooth

BOBBY PIN OPENING:

- Usually seen in teen age girls wherein opening bobby pin with anterior incisors is done
- Clinically notched incisors with partially denuded labial enamel is seen
- At this age, calling attention to the harmful habit is generally all that is necessary to stop the
habit