Oral habits

Shrirang Anand Sevekar

Contents

Habit
Definition Classification Trident of habit Dental response to pressure habits Treatment phylosophy

Breast feeding Bottle feeding Thumb Or digit sucking

Pacifiers Tongue thrusting Mouth breathing Lip habits Bruxism Nail biting Cheek biting Masochistic habits

Habit
William

James-

From psychological view, Is a Pathway of discharge formed in brain by which certain incoming currents ever after tend to escape.

Habit: Definitions
Dorland

Fixed or constant practice established by frequent repetition

Buttersworth

Frequent or constant practice or acquired tendency, which has been fixed by frequent repetition

Habit: Definitions
Moyer

Habits are learnt pattern of muscle contraction of a very complex nature

Hogeboon

and Salder

It is a methodical way in which mind and body act as a result of frequent repetition of a certain definite sets of nervous impulses

Habit: Definitions
Mathewson Tandon

Learned pattern of muscular contraction

Settled tendency in response to a specific cause resulting from repeated learning

Boucher

As a tendency towards an act or an act that has become a repeated performance, relatively fixed , consistent, easy to perform and almost automatic

Development of habit
Unconscious

mental pattern

Instinct
Elementary

reflex Pattern and order

Incorrect outlet of energy Pain or discomfort Abnormal physical size Imitation of others

Habit

Dental response to pressure exerting oral habits : Forester

Functional

matrix theory Position of Dentition- skeletal growth pattern , muscular forces and masticatory forces

Orthopedic

effect (Swine hart) 2 types of forces acc. to site and duration

Ant. Force against palate (Sucking habit) Constriction force of buccal musculature (Mouth breathing)

Habits: Classification
Tandon

Obsessive
(Deep rooted) Intentional OR meaningful Masochistic or Selfinflicting injurious habit

Non-

obsessive

(Easily learned) Empty or Unintentional

Abnormal

pillowing, chin

propping

Functional
Tongue

thrusting

Habits: Classification
James

(1923)/ Graber

Finn (1987)
Compulsive habits Non- compulsive habit Primary habit Secondary habit

Useful Harmful
Kingsley

Functional oral habit Muscular habit combined

Klein

(1977)

Empty meaningful

Habits: Classification
Morris

and Bohanna (1969)

Non pressure habit Pressure habit

Sucking habit Lip, Thumb sucking, Tongue thrusting Biting habit Nail biting, Needle, Thread holding Posturing habit Pillow, Hand rest Miscellaneous Bruxism, Cheek biting

Habits: Classification
Normal

Abnormal
Retained

Sucking

habit JDC:1996:321
O Brian (1996)

Nutritive Sucking
Breast, Thumb

Bottle feeding

Cultivated

Nonnutritive
sucking Tongue thrusting

Physiologic
Pathologic

Trident of Habit

Intensity Frequency Duration

Frequency

Intensity

Direction

(Pinkham)

Habit
Direction

Duration

Treatment philosophy and considerations

Emotional

significance of habit in relation to family

Psychological approach

Excessive parental demand Prolonged separation Birth of sibling

Age
Existing or potential malocclusion asso. with a force exerting habit

Nutritive habits

Nutritive habits
Breastfeeding

JDC: 1996;321

Rooting reflex (Pinkham) Sucking reflex Psychological development Effect on orofacial development Malocclusion

Nutritive habits
Bottle feeding Artificial nipple Size, length, flow rate, location of holes Orthodontic or physiologic
Effect on dentofacial musculature development Malocclusion

JDC: 1996;321

Nonnutritive- Thumb sucking

Thumb or Digit sucking

Definition Placement of thumb or one or more fingers in various depths into the mouth or oral cavity

Synonyms
Thumb sucking/ Digit sucking/ Finger sucking

Thumb or Digit sucking

Prevalence
16- 45 % Age and Prevalence

(DCNA:1978;608)

Damage

(malocclusion)

Graber

Original morphology Suckle swallow pattern Maturational cycle of deglutition Intensity and duration of habit

Influence of different variables on incidence and Prevalence of Thumb Sucking Habit

Influence of different variables on incidence and Prevalence of Thumb Sucking Habit

Thumb sucking: Classification

Normal thumb sucking

Abnormal thumb sucking

Psychological Habitual

Thumb Sucking: Classification

Subtelny(1973)
Type A 50% Type B 13-20% Digit placement Type C 18% Digit placement Type D 6% Digit placement

Digit placement

Max/ Mand Ant Contact

Max/ Mand Ant Contact

Max/ Mand Ant Contact

Max/ Mand Ant Contact

Nonnutritive habits
Johnson(1993)

Thumb or Digit sucking

Sucking

reflex

Incidence

Forester

Starts at 29 week I.U. Disappear by 3 - 4 yr First coordinated muscular activity Psychological and nutritive need
Rooting(Placing)

reflex

Well defined sensory area around mouth Head turning and opening of mouth by stimulation

Thumb or Digit sucking

Initiation of digit sucking (Infantile)

Development of muscular coordination Ability to reach the face with hand Exploration of environment by placing objects in mouth Introjection and Projection

Retained digit sucking

Lack of oral gratification Separation from mother Social structure or culture
Eskimo

study Burlington study

Thumb or Digit sucking

Theories

(Etiology)

JDC:1993;385

Classical Freudian theory (1905)

Biologic

sucking drive (I.U.) Oral phase- Center of attraction (Oro -erotic zone) Deprivation of activity - Insecurity Assoc. With pleasurable stimuli, but not discarded at usual time due to psychological disturbance Substitution with less desirable habit

Counterview Gesell and Ila

Thumb or Digit sucking

Benjamin

theory (1962)

Experimentation on monkey Two theories

Thumb sucking - Expression associated with sucking along with primary reinforcing aspect of feeding Thumb sucking from Rooting and placing reflex

Thumb or Digit sucking

Learning theory: Davidson (1967)

Adaptive response to pleasurable feeling No underlying cause No emotional or psychological problem No substitute

Counterview increased anxiety

Thumb or Digit sucking

Oral drive theory (Sears and Wise;1982)

Duration of feeding Prolonged nursing

Oral drive

Habit

No correlation with frustration of weaning Sucking - Erontogenic zone of mouth (Freud)

Thumb or Digit sucking

Johnson and Larson (1993)

JDC:1993:385

Combination of two Inherent biologic drive for sucking Rooting and Placing reflex- Expression of drive Environmental factors for sucking drive

Thumb or Digit sucking

Maintenance

of habit

Normal upto 3 yrs (Psychoanalytic) Persistence - psychological disturbance

Anxiety management

Adaptation during development (Learning theory)

Thumb or Digit sucking

Causative factors
1. Parents occupation
1. Socioeconomic status

4. Order of birth of child

1. Imitation

2. Working mother
1. Absence - insecurity

5. Social adjustment and stress

1. Peer pressure, scolding parents

3. No. of siblings
1. Compensation for neglect

6. Feeding practices
1. Negative relation between breast feeding and habit

Thumb or Digit sucking: Causative factors

Causative factors
7 Age
1. In neonates
1. Well developed suckling mechanism 2. Primitive Demand for hunger

2. During eruption of primary molar- Teething 3. Still later (Active after 4 year)
1. Emotional tensions 2. Stress outlet mechanism

Thumb or Digit sucking

Diagnosis
Emotional status
Meaningful

or empty

Case history

Active performance Information from mother

Feeding practice Parental care Presence of other habits

Thumb or Digit sucking

Extra

oral examination
Reddened, clean, chapped, short fingernail (dishpan thumb) Chronic suckers - fibrous, roughened callus on superior aspect of finger Deformation of finger
Position at rest, During swallowing Hypotonic upper lip Hyperactive lower lips

Digit

Lip

Thumb or Digit sucking; Extra oral examination

Facial

form analysis

Maxillary protrusion
Mandibular retrusion High mandibular plane angle Profile Mentalis muscle contraction

Thumb or Digit sucking

Intraoral

examination

Tongue
Position

at rest , during swallowing of mouth breathing Itching Staining on max. labial surface

Gingiva
Evidence

Thumb or Digit sucking; Intra oral examination

Dento

alveolar structure

Flared , proclined maxillary anteriors with diastema Retroclined mandibular anteriors

Deformed right or left sided max. arch

Thumb or Digit sucking

Dentofacial

changes associated with prolonged sucking habit

JDC:1993:385

Effects on maxilla

Maxillary arch length Clinical crown length of incisors Counterclockwise rotation of occlusal plane Atypical root formation Trauma to incisors Palatal arch width

Thumb or Digit sucking: Cl/ F

Increased

SNA

Thumb or Digit sucking: Cl /F

Effect

on mandible

Proclination of incisors (Finger sucking) Increased Intermolar distance

Increased Distal position of B point

Thumb or Digit sucking: Cl /F

Effect

on interarch relationship
Anterior open bite

Increased over jet

Thumb or Digit sucking: Cl /F

Increased unilateral and bilateral Cl II malocclusion

Decreased U/ L incisal angle

Thumb or Digit sucking: Cl /F

Decreased overbite

Increased posterior cross bite

Thumb or Digit sucking: Cl /F

Effect on lip placement and function Increased lip incompetence Increased lower lip function under max. incisors Effect on tongue placement and function Increase tongue thrust Increased lip to tongue resting position Increased lower tongue position

Thumb or Digit sucking: Cl /F

Other effects
Risk to psychological health Increased risk of poisoning Increased risk of speech defects, especially lisping
Habitual mouth breathing Tongue thrusting Middle ear infection Enlarged tonsils

Thumb or Digit sucking

Clinical

aspect (Moyer: 1955)

Phase I
Normal

or sub clinically significant sucking (Pre school infant) Birth to 3 yr Prophylactic approach

Phase II
Clinically 3

significant sucking (Grade school)

7 yrs
Related to anxiety Time for dental correction

Firm

and definitive programme of correction

Thumb or Digit sucking

Clinical

aspect
sucking (Teenage child)

Phase III
Intractable

Beyond

4 th yr

Psychotherapy Treatment

for malocclusion

Psychological effects of malocclusion resulting from habits

introvert Oversensitive Immature social behavior Speech defect Singled out in crowd
Exceedingly

Thumb or Digit sucking

Treatment
Forester

Treatment rationale

Emotional significance of habit

Psychological status of child

Age of patient Status of occlusion

Management
Preventive

treatment

Littlefield
Best

when related to familial tendency

Hughes (1949)
Fulfillment

of hunger Natural feeding practices- Brest feeding

McBride
For

inhibition of sucking- Discontinuation at inception Removal of finger from mouth as much as possible At sleep- Pinning the sleeves to stop the motion towards mouth

Use of Dummy/ Pacifier

Management :Preventive treatment

Psychological

Avoidance of scolding, frightening Reassurance and positive reinforcement Friendly reminders Brauer (1965)
Constructive

parental education Favorable contact with environment Providence of age specific suitable play material Avoidance of unnecessary regulation

Lewis (1930)
Immediate

post weaning period- Most difficult time to handle Encouragement of chewing and biting

Management :Preventive treatment

-

Hypothesis or Dunlops hypothesis

Forced purposeful repetition Abandonment of habit following unpleasant reaction

Management: chemical treatment

Least Bitter

effective or sour chemical over the finger

E.g. : Foul smelling Quinine, Asofoctine, Pepper , Caster oil, Femite etc

Management: Mechanical or reminder therapy

Extra

oral approach

Mechanical restraints to hand/ Digit

Adhesive bandage Covering with cloths Heckman and Bready - Tubes attached around elbow, Gloves around wrist

Nail polish Thumb guard

Management: Mechanical or reminder therapy

Intra-

oral Approach
5 yr- No intervention placement between 3- 4 yr.

Weiss and Eiser (1993)

Upto

Graber(1972)
Appliance

Considerations before use of appliance

Childs

understanding Parent cooperation Friendly rapport Goal orientation maturity

Management: Mechanical or reminder therapy

Removable

and fixed

appliance
Palatal crib
Breaks

the suction and force on anterior segment Reminder Makes the habit nonpleasurable

Hay rakes
Not

much helpful Symptoms of irritability, night tremor, day wetting

Management: Mechanical or reminder therapy

Oral screen
Functional appliance
Redirection

of muscular and soft tissue pressure

Prevention of placement of thumb in mouth

Quad helix
Expansion of constricted maxillary arch Helixes as a reminder Posterior cross bite correction

Management: Mechanical or reminder therapy

Triple

loop corrector: Barber (1960)

Modified palatal arch Similar to transpalatal arch with 3 loops

Blue

grass appliance: Bruce Haskell (1991)

Between 7 13 yr Teflon roller appliance 3 6 month placement time

Thumb or Digit sucking: Treatment

According to Forester
Younger

than 3 yr

No active intervention Class I openbite self correcting Reverse Attention

Thumb or Digit sucking: Treatment: Forester

3 7 yr
Depending on type of habit
Active

puller Idle sucker

Good molar intercuspation with little ant. Pullbehavior modification

Permanent incisor eruption with openbite active intervention

Thumb or Digit sucking: Treatment; Forester

Under

6 yr
conditioning

Class I
Behavior

Openbite pictures Reward system Intentional contralateral thumb sucking Advise for ignorance by parents Band- aid, fingernail polish No need of appliance

Thumb or Digit sucking: Treatment; Appliance; under 6 yr; Forester

Class II (Non self correcting)

With anterior puller Appliance
With

spaced primary dentition=Activator mandibular angle with ant. openbite= High pull headgear crowding in primary dentition= Extraction

High

Severe

Thumb or Digit sucking: Treatment; Appliance ;under 6 yr; Forester

Class

III

Encouragement to suck

Cl III activator with orthopedic chin

Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; Forester

Class

With ant openbite and spacing

Hawleys

appliance Palatal crib Blue grass appliance

Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; Forester

Non

crowding Buccal cross bite

fixed or removable palatal expansion modified reminder (Quad helix)

Crowed

dentition

Serial extraction with digit sucking control appt

Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; Forester

Class II
Non crowded Cl II Div-I with low mandibular plane angle
Activator

and headgear that are habit breaking appliance

Class III
Simultaneous Cl III correction with habit control Appt.

Thumb or Digit sucking: Treatment: Older than 7 yrs; Forester

Openbite
Removable

Frankle IV Vestibular configuration protrusive bows

Thumb or Digit sucking: Treatment: Older than 7 yrs; Forester

Open

bite

Removable appliance
Modified

activatorintrusion of molars

Fixed orthodontic treatment

Thumb or Digit sucking: Treatment: Pinkham

Reminder therapy
Adhesive bandage Unpleasant stimuli

Reward system
Contract between child, Dentist, Parent

Thumb or Digit sucking: Treatment Pinkham

Appliance therapy
Attitude
Self

correcting malocclusion
Appliance as reminder

Fixed reminder
Quad

helix Palatal crib

Removable reminder

Pacifier habit

Pacifier habit

Ped.Dent:2002;552

Pacifier

Natural

sucking instinct or urge Restricted breast feeding and bottle feeding Surplus sucking urge- frustration or satisfaction Pacifier Satisfaction

Pacifier habit
Clinical

features

AJO;2002;347

Oral Myofunctional alteration

Decrease

muscular tonicity of tongue and lip Lip entrapment Lip incompetence Narrow hard palate

Pacifier habit: Cl / F
Dental

changes
mandibular

Posterior cross bite

Increased

arch width Decreased max. arch width

Anterior open bite Cl II primary canine relationship Increased overjet

Pacifier habit
Controversies

Ped Dent:2003;449

associated with pacifiers

Protects against SIDS

Pacifier habit
Increases risk of otitis media and other infections

Ped Dent:2003;449

Increases risk of otitis media and other infections

Pacifier habit
Recommendations

Should not use before breast feeding established More restraints for use Cleaned Avoidance of sharing among siblings Use should be curtailed before 2 yr, discontinued by 4 yrs

Tongue Thrusting

Tongue thrusting
Embryonic

life

Proportion of tongue to developing mandible

Spacing between Gum pads

Anatomy and Physiology of Sucking and swallowing JDC:1996:321

Sucking

First Coordinated muscular activity

Infantile

swallow (Moyer)

Anterior tongue thrust between gum pads Mandibular thrust, and stabilization by contraction of facial muscles Lip constriction

Anatomy and Physiology of Sucking and swallowing

JDC:1996:321

Infantile swallow
Muscles involved
1. 2. 3. 4. 5. 6.

Masseter Orbicularis oris Mentalis Buccinator Superior pharyngeal constrictor Pterygomandibular raphe

Anatomy and Physiology of Sucking and swallowing

Transitional

swallow

Inter mixing of normal infantile swallow and mature swallow Diminishing Buccinator activity Contraction of mandibular elevator during swallow to stabilize teeth in occlusion

Anatomy and Physiology of Sucking and swallowing

Mature

swallow

Position of tongue (Stewart)

Tongue

tip Mid portion Posterior aspect- 45angulation against pharyngeal wall

Lip seal Function of masseter, Mentalis, and facial muscles

Phases Of Swallowing Or Deglutition

Straub

(1957)

Preparatory phase/Oral phase

Voluntary

and conscious phase Bolus formation and transfer to

isthmus of fauces Adjustments of

palate, Tongue, Larynx, Hyoid bone Role of muscles of mastication- ant and lateral seal

Soft

Phases of swallowing or deglutition

Second

phase

Involuntary but conscious phase Bolus passes through pharyngeal tube Nasopharynx sealed off by closure of soft palate against the posterior pharyngeal wall Hyoid bone and tongue move forward to continue peristalsis

Phases of swallowing or deglutition

Esophageal

phase

Involuntary Reflex mechanism Bolus passes through cricopharyngeal sphincter continue through esophagus Return to original position of hyoid bone, palate and tongue

Anatomy and Physiology of swallowing

Process of normal swallowing

A. Resting posture B. Initiation of deglutitionTongue tip movement C. First tongue- tip contact D. Progression of deglutition: Tongue contacting palatal structure E. Completion of swallowing: Total contact with posterior pharyngeal wall

Anatomy and Physiology of Sucking and swallowing

Abnormal

swallow

(Stewart)
Position of tongue

Tip Mid portion Posterior aspect

Faulty Masseter activity Mentalis activity

Tongue Thrusting
Definition

Brauer Tongue thrust is said to be present if the tongue is observed thrusting between and the teeth did not close in centric occlusion during deglutition

Tulley Forward movement of tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech , so that the tongue becomes interdental

Tongue Thrusting: Definition

Barber-

It is an oral habit pattern related to persistence of an infantile swallow pattern during childhood and adolescent and thereby produces an openbite and protrusion of anterior tooth segment

Shneider-

it is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing

Tongue Thrusting
Prevalence
(DCNA:1978;603)

Newborn 97% 5-6 yrs 80% By 12 yrs 3% Physiology (Stewart)

At

birth- soft structure confined in skeletal environment Large tongue Forward movement

Tongue Thrusting
Significance
Adverse

(Forrester)

Function governs form

muscle forces Abnormal form

Occurrence

(Profit)
stage in physiologic maturation

Younger children with normal occlusion

Transitional

At any age with displaced incisorsAdaptation for seal

Tongue Thrusting
Equilibrium

theory (Profit)

Facial musculature vs. Tongue pressure

Light tongue forces Against teeth (Normal state) Duration of swallowing 1 Second 24 hr swallow 1000/day Tongue thrust- Forward resting posture of tongue Obvious light forces

Tongue Thrusting
Classification

Physiologic
Infancy

Habitual
Present

after correction of malocclusion Open bite

Functional (Profit)
Overjet,

Anatomical
Macroglossia

Tongue Thrusting: Classification

James S. Braner and Holt

Tongue Thrusting: Etiology

Retained

infantile

swallow
Retention of infantile suckling mechanism Incisor eruption No drop of tongue Altered Tongue posture at rest

Tongue Thrusting: Etiology

URTI

Obstruction of nasal passage Mouth breathing Forward tongue posture Physiologic need of adequate airway

Tongue Thrusting: Etiology

Adenoids

Location Complementary status: Growth of Adenoid and Upper face Infection, Allergy Hypertrophy - lost equilibrium Mouth breathing Tongue posture

Tongue Thrusting: Etiology

Lymphoid

tissue (Tonsils)

Location Hypertrophy Obstruction of oropharyngeal area Tongue posture

Tongue Thrusting: Etiology

Neurological

disturbances

Hypo sensitive palate Motor disability- brain injury Disrupted sensory control and coordination of swallowing

Tongue Thrusting: Etiology

Functional

adaptability ANTERIOR SEAL

Missing incisors
Protrusion overjet openbite

Tongue Thrusting: Etiology

Feeding

practices

Bottle feeding Breast feeding Consistency of infants foodDevelopment of adult swallow pattern

Tongue Thrusting: Etiology

Induced

due to other habits

Digit sucking Pacifier sucking Sleeping habits

Tongue Thrusting: Etiology

Hereditary

Inherited hyperactive orbicularis oris Anatomical configuration Neuromuscular activity

Tongue Thrusting: Etiology

Tongue size
Macroglossia

Anesthetic throat
Congenital physiologic discrepancies- Abnormal handling of bolus and Tongue thrust

Soft diet Disuse atrophy of musculature

Trauma
Persistent traumatic condition leading to abnormal deglutition

Classification of etiological factors: Fletcher (1975)

1.

Genetic factor
1. Inherited variation in orofacial form

4. Mechanical restriction
1. Macroglossia, constricted dental arches, Enlarged adenoids

Constricted arch

2.

Learned behavior
1. 2. Acquired habits Prolonged Tonsillar hypertrophy, URTI

5. Neurological disturbances
1. Hyposensitive palate, motor disability

6. Psychological factors
3.

Maturational
1. Delayed progression from infantile to mature

1. Effect from forced discontinuation of other habit

Tongue Thrusting: Diagnosis

History
swallow, Parent Previous respiratory infections , sucking habits , neuromuscular problem Examination
Tongue
Size

Sibling

Macroglossia - Lateral scalloping

Shape

Asymmetry

Tongue Thrusting: Diagnosis

Movements of tongue
Lateral Protrusive Retrusive Restricted movement (Ankyloglossia)

Functional examination
Observation of tongue
Mandibular

rest position Various swallow

Unconscious swallow Command swallow of saliva Command swallow of water Unconscious swallow during mastication

Tongue Thrusting: Diagnosis

Gag reflex
Palatal- Rare Pharyngeal

Abnormal tongue posture

Retracted tongue Withdrawn tongue tip from anterior Posterior openbite with lateral spread 10 % 0f all children, Edentulous patients

Tongue Thrusting: Diagnosis

Protracted tongue
Result in openbite Types
Endogenous

Retention of infantile swallow Continuous presence of tongue between teeth Excessive vertical anterior face height
Acquired

Transitory adaptation due to enlarged tonsils or pharyngitis

Tongue Thrusting: Diagnosis

Tests
Masseter

activity test

Temporalis

activity test

Lip

apart swallow test

Tongue Thrusting: Diagnosis

Simple

tongue thrust

Molar occlusion Ant. Open bite Contraction of lips, Mentalis, mandibular elevators

Tongue Thrusting: Diagnosis

Complex

tongue thrust

Generalized open bite Absence of contraction of lips, muscles

Lateral

tongue thrust

Posterior open bite Tongue thrusting laterally

Tongue Thrusting
CLINICAL FEATURES
Extra

oral

Lip posture Lip separation

Mandibular movement Upward and backward with tongue moving forward Speech Speech disorder Sibilant distortion, lisping, problem in articulation of s, n, m, t, d, l, th, z, v Facial form Increased Anterior face height

Tongue Thrusting: Cl/F

Intraoral

Tongue posture
Downward

and forward At rest- lower

Tongue Thrusting: Cl/F

Malocclusion

In relation to maxilla
Increased

overjet spacing

Generalized

Maxillary

constriction

Tongue Thrusting: Cl/F

In relation to mandible
Retroclination

or

proclination of mandibular teeth

In relation to Intermaxillary relationship

Ant.

Or post. Openbite Posterior crossbite

Tongue Thrusting
Treatment

considerations

Age

Self correcting by 8-9 yr

Improved muscular balance during swallowing

Orthodontic correction in early mixed dentition(9-11)

Presence or absence of associated manifestation

Not indicated without malocclusion or speech problem

Tongue Thrusting: Treatment considerations

Malocclusion
Correction

of malocclusion

Speech defect
Speech

therapy during elementary school yr.

Associated with other habits

Other

habit correction

Tongue Thrusting :Treatment

Myofunctional

therapy Speech therapy Mechano therapy Correction of malocclusion Surgical treatment

Tongue Thrusting :Treatment

Myofunctional Phase

therapy

Am.J.Ortho:1972:499

Tongue position during swallowing

Exercises for tongue Stabilization

Maintenance of tongue in bilateral contact with max. teeth during swallowing

Sucking,

holding, swallowing- Saliva, liquid, solids Liquid trapping exercise Between Tongue and roof Lip apart posture and approximation of teeth Tilting of head

Tongue Thrusting :Treatment Myofunctional therapy

Phase I
Other activities for superoposterior tongue posture
Retraction

of tongue when held Clicking of tongue Back-of-the-mouth sounds Sucking and holding tongue to roof of mouth

Phase II
Continuation of Phase I Bite-and-swallow exercises Development
Pliable

Masseter , Temporalis strength

Biting and relaxing exercises

rubber, soft plastic tubing between teeth

Teeth together swallowing test

Tongue Thrusting :Treatment Myofunctional therapy

Phase

III

Continuation of Phase I and II Chewing and swallowing with lips apart Keeping lower lip immobile Upper lip exercise-- Elevation, depression, protrusion, retraction against resistance

Tongue Thrusting :Treatment Myofunctional therapy

Phase

IV

Carry- over Reminder appliance

Treatment: Myofunctional therapy: Garliner

Guidance

of correct posture of tongue during swallowing by various exercises

Placement of tongue tip in rugae area for 5 min Orthodontic elastics and sugarless fruit drops 2 S ,4 S exercises
Identification of Spot Salivating Squeezing in spot Swallowing

Other exercise
Whistling Reciting

from 60 To 90

Yawning

Treatment :Myofunctional therapy: Garliner

Lip Lip

exercise massage

Tug of war and button pull exercise

Lower lip over upper massage
Subconscious

therapy

Time- Special time for reminding Subliminal therapy

Placing

reminder sign in sight during meal

Autosuggestion
6

times swallow before sleeping

Tongue Thrusting :Treatment

Speech

therapy

Training of correct position of tongue Articulation of speech Repetition of words with S sound

Not indicated before 8 yrs

Tongue Thrusting :Treatment

Mechano

therapy

Purpose
Reeducation

of tongue position Maintaining tongue in the confines of dentition Maintaining the interocclusal distance
Prevention of over eruption and narrowing of maxillary buccal segment

Tongue Thrusting :Treatment

Preorthodontic

trainer for myofunctional training

Aids in correct positioning of tongue with the help of tongue tags Tongue guard

Tongue Thrusting :Treatment

Appliance therapy
Removable appliance

Hawleys appliance
1. 2.

Modifications Active labial bow Addition of palatal crib

Oral screen and vestibular screen

Tongue Thrusting :Treatment

Treatment with myofunctional appliance

Promote lip closure Enlarge oral cavity Move incisors Improve relation among jaws, tongue, Dentition and soft tissue E. g
Activator Bionator

Tongue Thrusting :Treatment

Fixed appliance
Tongue

crib

Tongue Thrusting :Treatment

Correction

of malocclusion

Openbite
Removable

Frankle IV Vestibular configuration

Tongue Thrusting: Treatment : Malocclusion : Openbite

Removable

appliance

Modified activatorintrusion of molars

Fixed

orthodontic treatment

Tongue Thrusting :Treatment

Surgical

treatment

Removal of tonsils

Correction of skeletal malformation

Mouth breathing

Mouth breathing
Nasal

breathing Vs Mouth breathing

Purification of air Development of muscles of chest ,back, neck

Postural

defect

Functional

adaptation for mouth breathing

Mandible Tongue posture Head

Manifestations

Facial height, Openbite, Crossbite

Mouth breathing
Definition

Sassouni (1971) - Habitual respiration through the mouth instead of the nose

Merle (1980) - Suggested the term oro - nasal breathing instead of mouth breathing

Mouth breathing: Incidence

Common

among 5 15 yr

85%

nasal breathers suffer from some degree of obstruction

Mouth breathing
Classification

Finn (1987)
Anatomical

Short upper lip

Obstructive

Obstruction in nasal passage

Habitual

Mouth breathing
Etiology

Developmental and morphologic anomalies interfering nasal breathing

Asymmetry

of face

Hereditary Size of nasal passage Position of nasal septum Abnormal

development of nasal cavity, Nasal

turbinates Abnormally short upper lip Under developed or abnormal facial musculature

Mouth breathing: Etiology

Partial

obstruction due to

Deviated nasal septum Birth injury Localized benign tumor Narrow maxilla Leontiasis ossea

Traumatic

injuries to nasal cavity

Mouth breathing; Etiology

Infection

and inflammation

Ch. Inflammation of nasal mucosa Ch. Allergic stomatitis Ch. Atrophic rhinitis Enlarged adenoids, tonsils Nasal polyps
Genetic

factor

Ectomorphic child

Mouth breathing
Clinical

features
development

General features
Pulmonary

Pigeon chest
Lubrication

of esophagus

No mucous gland Dry - Esophagitis

Blood

gas constituent

20 % more CO2

Mouth breathing

Adenoid fancies
Debatable consequence Long narrow face Narrow nose and nasal passage Nose tipped superiorly Flat nasal bridge Flaccid lips Short upper lip Collapsed buccal segment of maxilla High palatal vault Dolicofacial pattern Expressionless face

Mouth breathing: Cl / F
Dental

effect

Protrusion with spacing of upper incisors

Decreased overbite Openbite

Lower tongue position

Posterior cross bite

Mouth breathing: Cl / F
Increased overjet

Constricted maxillary arch

Mouth breathing: Cl / F
Narrow palate and cranial vault Narrow long face

Mouth breathing: Cl / F

Lips
Incompetent upper lip Everted, heavy lower lips Voluminous curled lower lips Gummy smile

External nares
Slit like external nares with narrow nose Atrophied nasal mucosa

Mouth breathing: Cl / F

Gingiva
Ch. Keratinized marginal gingivitis Classic rolled margin and enlarged interdental papilla Heavy plaque deposition Salivary flow and bacterial overgrowth
Periodontal disease
Pocket

formation and interproximal bone loss

Mouth breathing: Cl / F
Other

effects

Narrow maxillary sinus and nasal cavity Turbinates- Swollen and engorged Atrophic nasal mucosa Speech- Nasal tone Infection of Lymphoid tissue Otitis media Dull sense of smell Loss of taste

Mouth breathing
Sleep

apnea syndrome

Increased enlargement of lingual tonsils Mechanism

Mouth breather lying on back Tongue fall posteriorly Touch post. Pharyngeal wall Occlusion of oropharynx

Sleep apnea syndrome

Signs

/ Symptoms

Snoring Loud pharyngeal snoring with interrupted silences Abnormal behavior

Movement

of limbs

Altered state of consciousness during attempted arousal

Unresponsive

to pain

Morning headache

Mouth breathing
Diagnosis

History
Lip

apart posture Tonsillitis, allergic rhinitis, otitis media

Mouth breathing: Diagnosis

Examination
Observation of breathing Lip posture Nasal orifices

Clinical test
Mirror test Butterfly test Water holding test Inductive plethysmography
Airflow

through nose and

mouth

cephalometrics

Mouth breathing
Treatment

consideration

Age E.N.T. examination Correction time

Mix

dentition

Mouth breathing: Treatment

Symptomatic

relief

Gingival coating Periodontal consideration

Prophylaxis

Mouth breathing: Treatment

Elimination

of cause of habit

Removal of nasal or pharyngeal obstruction

Interception

Exercises
Physical

deep inhalation exercise

Lip Upper lip extension exercise Upper, lower lip combined exercise

Playing

wind pipe Disc holding exercise

Mouth breathing: Treatment

Maxillothorax

myotherapy
Macaray activator Oral screen

Mouth breathing: Treatment

Correction

of malocclusion
Cl I
Oral

screen

Cl II Div-1
Noncrowded

dentition (59 yr) Monobloc

Mouth breathing: Treatment

Cl III
Interceptive

chin cap

Lip habits
Vary

with imagination of child

Basic type
Wetting

of lip with tongue Pulling the lip into mouth between teeth

Lip sucking Entire

lower lip with vermilion border pulled in mouth border everted

Mentalis habit Vermilion

Lip habits
Etiology

Association with digit sucking

Increased overjet Lip seal

(Graber)

Incompetent upper lip

Position of lower lip behind upper incisors

negative pressure for swallowing

Lip habits: Etiology

Malocclusion

Cl II Div-1
Large

overjet and overbite

Emotional stress
Increases

the intensity and duration

Lip habits: Cl / F
Lip
Reddened , irritated, chapped area below vermilion border
Vermilion border
Relocation

outside the mouth due to constant wetting Redundant and hypertrophied

Ch. Herpetic infection Cracking

Lip habits; Cl/ F

Accentuated mentolabial sulcus Malocclusion

Winder--force equilibrium Lip tongue

1.

Protrusion of upper incisors

1.

Flaring with interdental spacing Collapse with crowding

2.
3.

Retrusion of lower incisors

1.

openbite

Lip habits: Treatment

Not self- correcting Deleterious with age Treating primary habit

Correction of digit sucking followed by habit reminder (Hawleys appliance)

Chemical reminder Correction of malocclusion

ClI Div-1

Fixed or removable appliance

Activator

Lip habits: Treatment

Appliance
Cl

therapy

Oral shield
I malocclusion Lip exercise for improvement of lip tonus

Lip bumper
Prohibits

excessive force on mandibular incisors Reposition of lower lip away from upper incisors

Bruxism
Definitions

Ramfjord
Habitual

grinding of teeth when the individual is not chewing or swallowing contact of teeth which may include clenching, gnashing and tapping of teeth

Rubina
Nonfunctional

Vanderas

Nonfunctional movement of mandible with or without an audible sound occurring during the day or night

Bruxism
Classification
Okinuora
Bruxism

associated with stressful event No such association (Hereditary)

Types
Day time bruxism / Diurnal
Conscious

or subconscious grinding Along with parafunctional habits Silent

Night time / Nocturnal

Subconscious

grinding in rhythmic pattern of masseter

Bruxism
Occurrence

Infants
of first primary tooth More prevalent in mixed dentition Throughout life
Eruption

Sleep
Transition

from deeper stages to lighter REM stage

7- 88% in children

Bruxism
Etiology

Local theory
Reaction

to an occlusal interference

High restoration, irritating dental condition Disturbed afferent impulses from PD

CNS
Cortical

lesions, cerebral palsy, mental retardation

Bruxism: Etiology
Systemic
Intestinal parasites GI disturbance
Nutritional deficiencies - Mg deficiency Enzymatic distress Allergies - Food Endocrine disorder Ch. Abd distress

Bruxism: Etiology
Psychological

theory

Associated with feeling of anger, aggregation Stress Emotional status inability to express the emotion
Other

causes

Genetics Occupational factors

Enthusiastic

student , compulsive overachiever Competition sports

Bruxism
Related
Cl

Factors

Morphological malocclusion (Wigdoro)

I, II , III , over jet, over bite

Bruxism: Related factors

Functional

malocclusion

Intercuspation, lateral deviation, retruded position

Bruxism
Causal

hypothesis

Ped. Dent:1995;7-12

Malocclusion can initiate and maintain forceful grinding or clenching Mechanism

Occlusal discrepancies
PD mechanoreceptors Sensory input Activation of jaw closing muscles Clenching or grinding

Bruxism
Counterview
Continued

(Christensen)
bruxism

Removal of occlusal interference

Nocturnal bruxism
Protective

mechanoreceptor function cancelled Continuation of clenching

Correlation between malocclusion and bruxism is not consistent

Bruxism
Indicators

Presence of dental wear / Attrition Bruxofacet

Grinding or clenching

Bruxism
Clinical

manifestation

Occlusal trauma
mobility

Morning time

Tooth structure
Nonfunctional

occlusal

wear Sensitivity Atypical shiny wear facet with sharp edges Pulpal exposure # crown, restoration

Bruxism: Cl / F

Muscular tenderness
Lateral pterygoid, masseter on palpation Fatigue on waking Hypertrophy of masseter

TMJ disturbances
Crepitation , clicking , Restriction of mand. Movement Deviation of chin Pain Dull , unilateral

Bruxism: Cl / F
Headache

Muscular contraction type

Other

signs and symptoms

Sounds- Grinding and tapping Soft tissue trauma Small ulceration or ridging on buccal mucosa opposite the molar teeth

Bruxism: Treatment

Occlusal adjustment
Disappearance of habitual grinding
Coronoplasty High

point correction

Occlusal splints (Night guard)

Vulcanite splint to cover occlusal surfaces
Reduction

of increased muscle tone intra oral appliance for TMJ disorder

TMJ appliance
Prefabricated

Bruxism: Treatment
Restorative

Severe abrasion
Pulp

therapy Stainless steel crown

Psychotherapy

Counseling
Tension

relief Habit awareness Increase voluntary control

Bruxism: Treatment

Relaxing training
Tensing and relaxing exercise
Voluntary

relaxation

Hypnosis Behavior Conditioning Physical therapy

Musculoskeletal

pain and stiffness

Drugs
Placebo Vapocoolant Ethyl chloride for pain -TMJ Local anesthetics - TMJ Tranquilizers, sedatives, muscle relaxants Diazepam Anxiety and alteration of sleep arousal Tricyclic antidepressants- Reduce REM

Bruxism: Treatment
Biofeedback

Positive feedback for Learning of tension reduction

Electrical

method
relaxation

Electro galvanic stimulation

Muscle

Acupuncture Orthodontic

correction

Cl II,III, Ant. Openbite, Crossbite

Cheek biting
Definition-

keeping or biting the cheek muscles in between the upper and lower posterior teeth
Clinical

features

Ulcers at the level of occlusal line Open bite Tooth malposition in buccal segment

Cheek biting
Treatment

Vestibular screen Reminders

Nail biting

Sign of stressful condition Age of occurrence

Before 3 yr- absent 4-6 yr- sharp rise in incidence 7-10 yr- constant level Adolescence- sharp rise

Etiology
Emotional problem Stressful condition

Nail biting: Cl/ F

Nail

Inflammation of nail beds and nail Irregular nail margins

Dental

effect

Crowding Rotation Attrition of incisal edges of incisors

Nail biting
Management
Avoidance of punitive methods Mild case- No treatment Care for emotional condition Encouragement of stress relieving activities Nail polish, light cotton mittens as reminder Bitter or sour chemical over the finger
E.g.

: Foul smelling Quinine, Asofoctine, Pepper , Femite etc

Conclusion

References
Graber

Profitt
Moyer Tandon Forester Stewart Pinkham