Post on 27-Nov-2014
ORAL HABITS
By Dr Bomatuyibapre Ogoli
Outline
INTRODUCTIONDEFINITIONAETIOLOGYTYPESMANAGEMENTCONCLUSIONREFERENCES
Introduction
The process of oral habit in the 3 to 6 year old is an important finding in the clinical examination
A habit that has resulted in the movement of the primary teeth requires some form of intervention prior to the eruption of the permanent teeth
Changes in the dentition brought about by oral habit vary and these may depend on the intensity duration and frequency of the habit
Intensity ndash This is the amount of force applied to the teeth while performing the habit
Duration ndash Defined as the amount of time spent practicing a habit Duration plays the most critical role in tooth movements
Frequency ndash It is the number of times the habit is performed throughout the day
Definition
Habit is a tendency towards an act or an act that has become repeated performances relatively fixed consistent easy to perform and almost automatic (Boucher OC)
A relationship exists between the physiologic development of the oral cavity and -The nature -The onset and -The duration of the oral habit Arise from -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen
later in life Generally the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral
cavity
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Outline
INTRODUCTIONDEFINITIONAETIOLOGYTYPESMANAGEMENTCONCLUSIONREFERENCES
Introduction
The process of oral habit in the 3 to 6 year old is an important finding in the clinical examination
A habit that has resulted in the movement of the primary teeth requires some form of intervention prior to the eruption of the permanent teeth
Changes in the dentition brought about by oral habit vary and these may depend on the intensity duration and frequency of the habit
Intensity ndash This is the amount of force applied to the teeth while performing the habit
Duration ndash Defined as the amount of time spent practicing a habit Duration plays the most critical role in tooth movements
Frequency ndash It is the number of times the habit is performed throughout the day
Definition
Habit is a tendency towards an act or an act that has become repeated performances relatively fixed consistent easy to perform and almost automatic (Boucher OC)
A relationship exists between the physiologic development of the oral cavity and -The nature -The onset and -The duration of the oral habit Arise from -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen
later in life Generally the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral
cavity
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Introduction
The process of oral habit in the 3 to 6 year old is an important finding in the clinical examination
A habit that has resulted in the movement of the primary teeth requires some form of intervention prior to the eruption of the permanent teeth
Changes in the dentition brought about by oral habit vary and these may depend on the intensity duration and frequency of the habit
Intensity ndash This is the amount of force applied to the teeth while performing the habit
Duration ndash Defined as the amount of time spent practicing a habit Duration plays the most critical role in tooth movements
Frequency ndash It is the number of times the habit is performed throughout the day
Definition
Habit is a tendency towards an act or an act that has become repeated performances relatively fixed consistent easy to perform and almost automatic (Boucher OC)
A relationship exists between the physiologic development of the oral cavity and -The nature -The onset and -The duration of the oral habit Arise from -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen
later in life Generally the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral
cavity
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Intensity ndash This is the amount of force applied to the teeth while performing the habit
Duration ndash Defined as the amount of time spent practicing a habit Duration plays the most critical role in tooth movements
Frequency ndash It is the number of times the habit is performed throughout the day
Definition
Habit is a tendency towards an act or an act that has become repeated performances relatively fixed consistent easy to perform and almost automatic (Boucher OC)
A relationship exists between the physiologic development of the oral cavity and -The nature -The onset and -The duration of the oral habit Arise from -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen
later in life Generally the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral
cavity
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Definition
Habit is a tendency towards an act or an act that has become repeated performances relatively fixed consistent easy to perform and almost automatic (Boucher OC)
A relationship exists between the physiologic development of the oral cavity and -The nature -The onset and -The duration of the oral habit Arise from -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen
later in life Generally the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral
cavity
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
A relationship exists between the physiologic development of the oral cavity and -The nature -The onset and -The duration of the oral habit Arise from -Reflex and instinct - seen in infancy -Complex and Controlled behavior - seen
later in life Generally the longer the habit is practiced -The harder it will be to break -The more the pathology seen in the oral
cavity
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Aetiology
Anatomical Factor Abnormal Physical size of an organ can result in
development of habits For example infantile swallow occurs due to a
large tongue in a small oral cavity
Emotional Instability of the child This can result in parafunctional
habit for example digit sucking may give a feeling of security Family
conflicts peer group pressure lack of satisfaction through
nourishment stress all have a direct bearing on oral habits
Mechanical Interferences These lead to undesirable oral habits For
example ectopic eruption of permanent incisors can make achieving
a proper anterior oral seal difficult during swallowing This can result
in mouth breathing
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Pathological factor Disease conditions of oral and
perioral structures can result in oral habits Eg
Deviated nasal septum and hypertrophy of inferior
nasal turbinate can cause nasal blockage Also
enlarged adenoids can cause obstruction of the
upper air way These factors result in mouth
breathing
Imitation The child may imitate jaw position or
speech disorders of parents siblings friends
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Types
Compulsive Non compulsive Fixated in a childrsquos behavior
pattern Malocclusion frequently results
due to persistent and intense habit
Generally reflects a psychologic dependency on certain behavior
Compelling reason for the behavior to continue
-Insecurities
-Fears
-Lack of ego-defense mechanism development
Naturally modified or eliminated through the maturation process
Not so entrenched in the childrsquos behavior that they cannot be not changed in response to the childrsquos changing physiologic psychologic profile
Resolve on their own and child ldquogrowsrdquo out of
No detrimental effects seen
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
The oral habits of dental significance include
ndash Digit Sucking (thumb or finger sucking)
- Tongue Thrusting- Mouth breathing- Bruxism
- Lip sucking - Lip biting
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Digit Sucking (Thumb Finger Sucking)
These make up majority of the
oral habits
Sucking is the first coordinated
muscular activity of the infant
which enables bottles feeding
- Two forms of sucking are
- Nutritive sucking (bottle)
- Non nutritive sucking
(thumb digit pacifier etc)
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Most commonly seen non-nutritive
habit in children Normal for newborns to
engage in digit sucking Commonly develop in the
first year of life Psychological factors
contribute to the continuation of this habit past 6-7 months of age
Most habits abandoned prior to the eruption of the permanent incisors
No Tx needed if habit stopped by 6-7 years of age
Earlier Tx instituted if maxillary arch constricted or parentchild is concerned
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Sucking mechanism
During infancy it is the most well-developed sensation
-Helps with sustenance as well as deriving sensory pleasures
-Gives a feeling of security warmth and euphoria
An impatiently nursed baby loses the warmth and feeling of well being and is therefore deprived of the suckling pleasures
This deprivation may motivate the infant to suck on the thumb or finger for additional gratification
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Malocclusion and digit sucking The type of malocclusion
produced by the habit is dependant on the following
variables1 Position of the
digitpacifier etc2 Associated orofacial
muscle contraction force3 Mandibular position during
sucking4 Facial skeletal genetic
pattern5 Amount frequency amp
duration of force applied
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Digit sucking and age
During the first 3 yrs the damage from the habit is mainly confined to the anterior segment producing an anterior open bite
Damage can be detrimental if the habit is continued beyond the age of 35 yrs
After 4 years of age the habit becomes strongly established The damage seen is more significant
After the eruption of the permanent incisors the worst amount of damage seen
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Effects of digit sucking
AOB Posterior Crossbite Increased Overjet Decreased Overbite Narrow Nasal floor and high palatal vault Decrease palatal width Leftright side is usually
affected The deformation depends on whether the right or left thumb is sucked
Lip incompetence Hypotonic upper lip Tongue thrust Deformation of digits Speech defects (lisping
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Management
Diagnosing Digit SuckingHx taking which is obtained from the parents Frequency of Sucking Duration Intensity (Amount of force applied)
Extra oral Examination Cleaner digit Redness Wrinkling of digits due to regular sucking Dishpan Thumb ndash clean thumb with short finger nails Short Upper lip higher incidence of middle ear infections enlarged tonsils and mouth breathing
Intra oral examination Malocclusion
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Treatment
3 categories of treatment
- Behavioral modifications - Counseling- Reinforcement either positive or negative
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Appliance therapy
Removable appliance -Goal post -Tongue spikes -Tongue guard Fixed appliance -Fixed rake -Quad helix - hay rakes
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Tongue spike
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Tongue guard
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Fixed rake appliance
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Quad helix
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Goal post appliance
Goal post appliance is an upper removable appliance used to dissuade the sucking habit It is composed of the functional component which consists of a palatal bar which is shaped like a goal post made of 09mm HSSW
It functions by preventing the patient from attaining a comfortable position for the digit
The goal post appliance is applicable to patients who are aware that the habit is bad and are ready to stop
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Fixed rake appliance
Fixed rake appliance is for a patient with both a tongue thrusting habit and a digit sucking habit
It consists of molar bands banded to the 1st or 2nd molars The wire is made of 09mm HSSW which extends across the palate forming vertical spurs or loops in the anterior region
This prevents the digit from gaining a comfortable position and in addition deters associated tongue thrust habit It is usually worn for a period of 6-10 months to prevent recurrence of the habit
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Tongue thrusting habit
Defined as the placement of the tongue tip forward between
the incisors during swallowing
2 types of swallow patterns are the infantile and the adult
swallow patterns
Infantile type In the new born the tip of the tongue rests
between the gum pads anteriorly to form the anterior lip seal
Mature Adult Swallow pattern placement of the tip of the
tongue against the palate and behind the upper incisors This
usually happens when the incisors begins to erupt by age 6 ndash
9 months
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Delayed transition between the infantile and adult swallowing pattern
Transition usually begins to happen around the age of 2 years
By the age of 6 years 50 have completed the transition
10-15 estimated never to fully complete the transition
Commonly associated with mouth breathing and anterior open bite
Functional adaptation of malocclusion and not the etiology
Can cause speech problems - lisping Most cases (80) will self correct by 12 years
of age
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Abnormally large tongue causing a tongue thrust
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Effects of tongue thrusting habit1) Open bite ndash Anterior posterior
(lateral)2) Proclined upper anterior teeth 3) Bimaxillary proclination with spaced
arches between incisors and canines
4) High arched Vndash Shaped palate resulting in posterior cross bite
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Abnormal placement of the tongue
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Management
Hx taking which is obtained from the parents child Frequency of tongue thrust Duration Intensity (Amount of force applied)
Extra oral Examination ndash This is done to examine the facial profile in order to assess growth pattern (favorable or unfavorable) anterior facial height
Intra oral Examination of the tongue to assess the tongue posture and its function At rest the dorsum of the tongue touches the palate while the tip rests against the Cingular or fossa of mandibular incisors loss of posterior teeth can result in lateral open bite
Tongue protraction due to retained infantile swallow pattern or enlarged tonsils or adenoids or pharyngitis or macroglossia
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Treatment
Treatment involves interception of the habit first before treating malocclusion
Treatment is based on age because tongue thrust decreases with age
Myofunctional Therapy The patient is trained to develop a new swallow
pattern There are different ways to achieve this These include
1) Patient is advised to swallow 20 times before each meal The child takes a sip of water close the teeth into occlusion place the tip of the tongue against incisive papilla and swallow
2) Using a sugar less mint the tip of the tongue is used to hold it in the roof of the mouth until saliva floors which makes it necessary for the child to swallow
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Appliances Therapy Tongue muscles function properly
during swallowing once the child has been trained
Mandibular lingual arch with a crib or rake can be worn by the patient
Appliance serves as a reminder in positioning the tongue properly during swallowing
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Mouth breathing habit
Defined as habitual respiration through the mouth instead of the nose
Mouth Breathing - can be caused by physiologic or anatomic conditions such as enlarged adenoids enlarged tonsils deviated nasal septum etc it can be transitional when exercise induced or due to a nasal obstruction
True mouth breathing when the habit continues after the obstruction is removed
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Effect of mouth breathing Adenoid Facies
-Long narrow face
-Narrow nose and nasal airway
-Flaccid lips with short upper lip
-Upturned nose exposing nares frontally
Skeletal Open Bite or ldquoLong Face Syndromerdquo
-Excessive eruption of posteriors
-Constricted maxillary arch
-Excessive overjet
-Anterior openbite
-Mandibular downforward growth is poor
Hypertrophic gingivitis Drying of the gingiva causes irritation as a result of increased plaque accumulation
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Constricted arches of mouth breathers
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Effect of mouth breathing on the gingiva and occlusion
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Diagnosing mouth breathing habit
A good history from parents and patients History of nasal
stiffness sore throats repeated cold attacks night thirst
Hoarseness of voice
Examination Study patientrsquos breathing unobserved Mouth
breathers are likely to keep the lips parted during relaxed
breathing
Ask patient to take a deep breathe
The nose does not change in size or shape
in mouth breathers
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Investigation Cephalometry assessment of naso-pharyngeal space
size of adenoids and long face syndrome
Water Test patients is asked to hold water in the mouth for 4 minutes A mouth breather will be unable to do so and will spit out the water as soon hersquos unable to breath
Cotton Test A butterfly shaped piece of cotton is placed over the upper lip below the nostrils If the cotton flutters down it indicates nasal breathing
Mirror Test Use of a double sided mirror which is held between the nose and mouth Fogging on the nasal size indicates nasal breathing Fogging on the oral side indicates mouth breathing
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Management
Rule out airway impairment ENT referral in case of nasopharyngeal obstruction
Myofunctional Therapy A child is taught certain exercise which will gradually train him to breath through the nose
reg During the day Hold a pencil or a piece of paper between the lips
reg Night Time Tape the lips together with surgical tape
reg Draw upper lip over the upper incisors and hold under tension for a count of 10
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Appliance therapy
reg Oral Screen it fits into the vestibule and shuts off air ingress through the mouth and retrain the lips
reg It is contraindicated in a case of nasopharyngeal obstruction
Breathing holes can be bored initially to allow passage of some air in the mouth As the child learns to breath through the nose fill some holes with acrylic so that less air enters through the mouth and finally close all the holes
reg Rapid maxillary expansion
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Oral screen
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Bruxism
Defined as non functional contact of the teeth which may include clenching grinding and tapping of the teeth
Bruxism is usually seen in nervous children patients with psychogenic disturbances and restlessness
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Generalized attrition following Bruxism
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Effects of Bruxism Occlusal trauma resulting tooth mobility Occlusal wear which may result in dentine
sensitivity and Pulpal exposures Can be seen in both primary and permanent teeth TMJ Pan
Diagnosing Detailed Hx and clinical examination The two most reliable signs of active Bruxism are
- Scalloping of the lateral border of the tongue- Ridging of the buccal mucosa along the occlusal line
Both signs disappear when the parafunctional habit stops
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Management
Determine the underlying cause and eliminate it Eg Occlusal adjustment is done to correct occlusal interferences Stressful patients are counseled and reassured Ant anxiety
drugs valium 5mg nocte can also be prescribed Restoration of lost vertical dimension (onlays or an overlay
denture help in achieving this) thus overcoming the problem of over closure
Bite planes occlusal splints bite guards are used to cover the occlusal surface They raise the bite therefore resulting in passive stretching of painful muscle fibers They also minimize tooth wear and reduce tooth contact that act as trigger factors eliciting bruxism
Muscle relaxation Ethylchoride is sprayed over the TMJ area
Local anesthesia for TMJ muscles
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Occlusal guard
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Lip sucking
May be a compensatory mechanism for an excessive overjet and difficulty in closing the lips properly during swallowing
Effects - proclined upper
incisors - retroclined lower
incisors -crowding of lower
anterior segment
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Lip biting
Either of the lips may be involved
Cuts abrasions marks of incisors are the major features seen in this habit
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Management
Lip over lip exercise
Lip bumper Oral screen
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Prevention of oral habits Usually starts with proper nursing -on the part of the parent Time Patience Holding the baby while nursing using a physiologically designed
nursing nipple and pacifier to augment normal functional and deglutitional maturation
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Consideration for oral habit therapy
Age of the patient -7 yrs Maturity of the patient -understands the problem desires to correct it Parent cooperation -Support and encouragement Timely deliberation -Alert to suggestive psychologic problems Assessment of deformity -Degree and the presenceabsence of other
complexities
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Treatment options
Accurate assessment in context of the childrsquos physiologic and psychologic state of development for proper and effective management
-Dentist-Patient Discussion -Reminder Therapy -Reward System -Appliance Therapy
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Dentist patient discussion Straight-forward discussion Express concern and explain why the
habit should be dropped Encourage them to call the office and
speak to you if the habit urge returns
Parents can help monitor only
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Reminder therapy
Tx principles of Aversive conditioning -Association of unpleasant stimuli with a
particular behavior Unpleasant and more difficult method Reminder and not a punishment -Adhesive bandage -Cotton glove -Fingernail polish -Bitters -Arm wraps
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Reward system
Highly recommended as it is effective Consult parents to find out what are the
childrsquos likes and what prizes are suitable and special to the child
Above the age of 5 yrs use self esteem rewards
Formulate a contract between the child and parent for a short period of time (1-2 weeks)
Greater the involvement of the parent and child the more successful the outcome
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Appliance therapy
Intra-oral appliance 1048673Child must welcome continued
assistance 1048673Permanent reminder
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Summary
Abnormal habits typically interfere with regular facial development
The longer a habit is practiced the harder it is to break
Duration frequency and intensity play important roles in the permanency of the damage seen
When considering treatment make sure the child wants to break the habit
Placing fixed appliances should be the last resort for habit cessation
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex
Conclusion
Oral habits have been known to have serious long term effects on dentofacial structures Hence early diagnosis of these habits and prompt management are extremely important in order to avoid unpleasant effects on the dentofacial complex