Oral Habits with Associated Oral Disorders.

Oral Habit

Oral Habit is an increased tendency of performance of a single or multiple acts repeatedly. Such acts are relatively fixed and easy to perform by an individual. Initially these acts are a result of conscious efforts by the individual. Later these acts become less conscious and more of an unconscious act. Thus the Act gets converted into a Habit. This kind of phenomenon is frequently seen in Children in their developmental stages of dentition. Hence these habits if persist have a definite effect on the Dental Occlusion and its supporting structures. They also cause abnormal facial growth in the children leading to aesthetics problems.

               

                   Various Oral Habits

• Thumb Sucking
• Finger Sucking
• Pacifier or Dummy Sucking
• Tongue Thrusting
• Mouth Breathing 
• Bruxism
• Lip Biting
• Nail Biting
• Cheek Biting
• Pencil Biting
• Pencil or foreign object sucking
• Lip Sucking
• Clenching
• Occupational habits

Classification of Habits

1. Useful and Harmful Habits  (James 1923)

   Useful habits are considered essential for normal function such as proper Respiration, Normal Degluttion, etc.
   
   
   Harmful habits have a deleterious effects on the normal dentition e.g., Thumb Sucking, Tongue Thrusting, etc.

2. Empty and Meaningful Habits   (Klein 1971)

   Empty habits are not associated with deep rooted psychological problems.
   
   
   Meaningful habits have a psychological bearing.
    

3. Pressure, Non pressure and Biting Habits (Morris and Bohanna 1969)

   Pressure Habits include sucking habits.
   Non Pressure habits do not apply a direct force on the teeth and their supporting structures. e.g., Mouth Breathing.
   Biting Habits includde nail biting, lip biting, pencil biting, etc.
    

4. Compulsive and Non Compulsive Habits (Finn 1987)

   Compulsive Habits are deep rooted and have acquired fixation in the child to the extent that the child retreats to the habit whenever his security is threatened by events which occur around him. The child tends to suffer increased anxiety when attempts are made to correct the habit.
   Non Compulsive Habits are easily learned and dropped easily as the child matures.

5. Primary and Secondary Habits

   
   
   

   Thumb/Digit Sucking

                              

      Digit sucking is the placement of thumb or one or more fingers in varying depths  into the mouth. It is the most common type of Oral Habit. It is seen in very early age because sucking is the first co-ordinated muscular activity of infants and recent researches suggest its presence even in the IntraUterine Life. Till the age of 3-4 yr, this habit is considered normal, however, beyond this age, it can lead to the various malocclusions.
   
              SUBTELNY (1973) divided thumb sucking into different types on the basis of the portion of thumb or digit into the mouth:
   
   

   Type A (50%):

     Whole Digit  kept inside and the thumb pad  kept over palate, making contact with the Anterior Maxillary Teeth and the hand rests on the Mandibular Incisors.
   
   

   Type B (13-24%):

   The Thumb Pad does not touch the palate vault and only makes contact with the Anteriors.
   
   

   Type C (18%):

   The Thumb is kept just beyond first digit only and the contact is made only with maxillary Anteriors.
   
   

   Type D (6%): 

   Only the little portion of Thumb or just tip of Thumb remains inside mouth. 
   

    

   Phases of Development

   Phase I: (Normal and Sub-Clinically Significant)

   Seen during first 3yr of age and is considered normal because it usually terminates at the end of Phase I (3rd yr).
   

   Phase II: (Clinically Significant Sucking)

   This Phase extends between 3-6 yr of age. The presence of Habit during this period suggests some anxiety issues with the child and proper intervention should be made to solve the dental problems.
   

   Phase III: (Intractable Sucking)

   Any Sucking Habit persisting beyond 5th or 6th year relates to the underlying psychological aspects of the habit. A psychologist along with the Dentist is recommended for the consultation.
   
   

   Clinical Features

   • Maxillary Anterior Proclination and Retro-Mandibular Anterior Teeth.
                                   
   • Anterior Open Bite and Increase in the overjet. 
           
   • Narrow Maxillary Arch due to cheek muscle contraction leading to the Posterior Open Bite.
   • Development of Tongue Thrust Habit.
                            
   • Upper lip is hypotonic while lower lip is hyperactive.

   Management

   1. Psychological Approach:
   2. Mechanical Aids: 
    a) Removable habit breakers

                                  
           b) Fixed habit Breaker
                                  
  3. Chemical Approach:
           - Quinine
           - Pepper dissolved in volatile medium
           - Asafoetida

    Tongue Thrust Habit

The condition in which the tongue makes contact with any teeth anterior to the molars during swallowing.

Classification

 A) By James Barner and Holt

Type I  :  Non deforming Tongue thrust

Type II : Deforming Tongue Thrust

                Sub group 1: Anterior open bite

                Sub group 2: Anterior proclination

                Sub group 3: Posterior Crossbite

Type III: Deforming lateral tongue thrust

                Sub group 1: Posterior open bite

                Sub group 2: Posterior crossbite

                Sub group 3: deep overbite

Type IV: Deforming anterior and lateral tongue thrust
                Sub group 1: Anterior and posterior open bite

                Sub group 2: Anterior proclination

                Sub group 3: Posterior Crossbite

B)  Simple Classification

            a) Simple tongue thrust

            b) Comple tongue thrust

Clinical Features 

• Proclination of Anterior teeth
• Anterior open bite
• Bimaxillary protrusion
• Posterior open bite in case of lateral tongue thrust
• Posterior crossbite

Management

a) Habit interception
    Habit breaker appliances as used in thumb sucking.
    Teaching the correct method of swallowing
    Various muscle exercises

b) Treatment
     Correction of Malocclusion by removable and fixed orthodontic Appliances.

Bruxism

It is defined as the grinding of teeth for non-functional purposes.

Specifically Bruxism refers Nocturnal grinding while as Bruxomania is given for grinding during day time.

                       

 

Classification

1. Temporal pattern

     a) Sleep Bruxism

     b) Awake Bruxism 

2. Cause

    a) Primary Bruxism

    b) Secondary Bruxism

Clinical Features

• Occlusal wear facets on the teeth
• Fracture of teeth
• Mobilty of teeth
• Tenderness and hypeertrophy of masticatory muscles
• Muscle pain
• TMJ pain and discomfort
• Trismus 

Treatment

  a) Psychological Counselling
  b)Night Guards   
                        

Mouth Breathing 

Mouth breathing is a serious matter. In children of growing age, it may have devastating effects on general health and growth. Many seemingly unrelated conditions are related to mouth breathing.

CAUSES:

Chronic allergies, tonsil hypertrophy, nasal polyps, deviated nasal septum, constricted upper airways, a backward positioned lower jaw caused by thumb sucking, excessive dummy use or insufficient suckling as an infant.

Signs in Mouth Breathers

• Long, narrow face
• Difficulty breathing through nose
• Retarded physical growth
• Dry lips
• Dark circles under eyes
• Excessive creases between lower lip and chin
• Allergies
• Smaller jaws with crowded teeth
• Swollen tonsils

                              

Consequences of Mouth Breathing

• Jaw deformity
  The jaws and subsequently the whole facial structures grow in an altered fashion, resulting in long faces, constricted arches, tooth crowding, a narrowed nasal airway passage, and an altered head posture. The lower jaw remains too far behind in its growth, producing a small chin, dental malocclusion, a large overjet, and an unfavourable profile. If the mouth breathing is addressed, these children can often be treated for their malocclusions and skeletal growth discrepancies by a dentist or orthodontist who follows a functional - orthopaedic approach.
• Compromised airway
  Caused by: 1. the lower jaw being positioned too far back, along with the tongue, thereby constricting the upper airway. 2. Enlarged tonsils and adenoids due to chronic allergies may be the primary cause for mouth breathing; however mouth breathing in itself will also cause a further increase in tonsil size, thus constricting the airway to such an extent, that normal nasal breathing becomes an impossibility.
• Altered head, neck and body posture
  The unnatural and unphysiological process of breathing through the mouth, which in many children looks like they are "gasping" for air, produces a reflex forward head posture. This puts a large load on the upper back and neck muscles, which if sustained, will cause permanent posture changes, such as abnormal curvatures in the cervical and thoracic vertebrae, and an altered shoulder posture. Ultimately, we see a domino effect affecting hips, knees and feet. In adults, Jaw joint dysfunction (TMJ problems).
• Bad breath and gum disease
  Caused by the shift in the bacterial flora in the mouth.
• Lowered immune system and poor health
  Nasal breathing produces a tissue hormone that regulates normal blood circulation. It also filters, warms and moisturizes the air. The lack of oxygen in mouth breathers, who usually snore at night and struggle for air, weakens the immune system, disrupts deep sleep cycles, and interferes with growth hormone production.
• Obstructive sleep apnoea (OSA)
  In newborns, this is thought by many researchers to be related to SIDS, or Sudden Infant Death Syndrome. In children, this is manifested as snoring, bed-wetting, poor quality of sleep, obesity, and ultimately behavioural symptoms resembling ADHD.
  In adults, OSA is a silent killer. Snoring is a manifestation of a blocked airway, which in essence is a milder version of sleep apnoea. Most snorers, however, may not be aware that they may be suffering from OSA. On average, snorers are more likely to suffer from cardiovascular disease and stroke, and carry an increased risk for obesity, high blood pressure, stroke, severe obstructive sleep apnea, and diabetes.
• Poor performance
  The same lack of oxygen and other hormonal factors make these children tend to be overweight, tired, and not perform well at school. Physically they are not athletic.

Mouth breathing in children should be addressed as soon as possible by consulting a physician, a dentist, a myofunctional therapist or an ENT specialist, who are experienced in treating this condition.

Management in Mouth Breathers

Allergy elimination

Screening and elimination of allergens: Pollen, Fungi, Animal dander, chemicals. Evaluate heavy metal burden.

Nutritional guidelines

Cow’s milk and dairy products should be eliminated from the diet. Avoid foods with preservatives, dyes, artificial sweeteners, refined sugars and other additives. Screen for yeast intolerance or gluten allergy. Beware of soy milk.

Physical therapy and exercise

Craniosacral, osteopathic and massage therapy encourage circulation of blood, lymph, and cerebrospinal fluid, as well as unblocking energy channels. Daily exercise done breathing through the nose. Exercise produces adrenaline, is a natural antidote to histamine.

Nose breathing exercises

The aim is to encourage a lip seal to achieve:

• Air flow through the nasal cavity, which will automatically enlarge the airway passages through the nose and will improve the quality of air. It will also stimulate nitric oxide tissue hormone production for improved blood circulation and immune function.
• Increased muscle tone of the muscles around the mouth, which are weakened due to the chronic mouth open posture.
• Stimulation of a correct craniofacial and jaw growth pattern.

A good way of doing this is to get the child to hold a thin piece of stick between the lips twice a day. Start with five minute increments each time, and increase the interval by one minute every day. Keep a written log of this schedule and make sure it is not interrupted. Follow this schedule until you achieve 30 minutes twice a day. After this add a third time into the daily schedule. Try to coincide these sessions with homework or TV watching, so the effort in keeping the lips together is on a subconscious level, and is more tolerable.

Pacifiers Sucking The consequences of extensive use of a pacifier are similar to that of finger and thumb sucking but not as pronounced.  The pacifier habit tends to end earlier than digital habits because they are easier to lose intentionally or non-intentionally.  90% are ended before 5 years of age and 100% by age 8.  The earlier the pacifier is removed the greater the chance of the dentofacial changes self correcting.

Lip Habits Lip licking is the most common lip habit.  The most common clinical effects are inflamed chap lips exhibiting an erythematous wide border encircling the lips with normal skin area just around the vermillion border.  Severe lip licking, with the lower lip tucked behind the maxillary incisors, places excessive lingually directed forces on the mandibular teeth and facial forces on the maxillary teeth, resulting in retro-inclination of the mandibular incisors, proclination of the maxillary incisors and increased overjet.  There is little that can be done to stop the habit, however, the irritated areas can be controlled with the application of steroids, antibacterial and antifungal ointments.

 Nail Biting

Onychophagia (also onychophagy) or nail biting, is an oral compulsive habit  and is sometimes described as a parafunctional activity.

                                    

Nail biting is also related to oral problems, such as gingival injury, and malocclusion of the anterior teeth. It can also transfer pinworms or bacteria buried under the surface of the nail from the anus region to the mouth. When the bitten-off nails are swallowed, stomach problems can develop^.
Nail-biting is also associated to guilt and shame feelings in the nail biter, a reduced quality of life, and increased stigmatization in the inner family circles or at a more societal level.

Treatment

The most common treatment, which is cheap and widely available, is to apply a clear, bitter-tasting nail polish to the nails. Normally denatonium benzoate is used, the most bitter chemical compound known. The bitter flavor discourages the nail-biting habit.
Behavioral therapy is beneficial when simpler measures are not effective. Habit Reversal Training (HRT), which seeks to unlearn the habit of nail biting and possibly replace it with a more constructive habit, has shown its effectiveness versus placebo in children and adults.