Prevention of Oral Habits PDF

PREVENTION OF ORAL HABITS By: Dr Nour Wahba Lecturer of Pediatric Dentistry Faculty of Dentistry Ain Shams University Future University...

PREVENTION OF ORAL HABITS By: Dr Nour Wahba Lecturer of Pediatric Dentistry Faculty of Dentistry Ain Shams University Future University 2024-2025 ILOs: By the end of this chapter, every student should be able to: 1. Understand what’s meant by non-nutritive sucking and what its benefits are. 2. Explain the factors affecting movement of teeth from oral habits 3. Recognize different types of oral habits and their effects on dentition 4. Apply different approaches of treatment or oral habits 1 Introduction: It is important to identify the presence of oral habits during history taking and examination especially in preschool children (3-6 year-old). If certain oral habits are not eliminated before the eruption of permanent incisors, permanent dento-alveolar changes can occur. For any habit, it is important to ask about the following: 1- How long the habit is practiced. 2- When the habit is practiced (day, night, during sleep, constantly). 3- Does the child indulge in the habit at school? 4- Is there any ridicule in regards to the habit? 5- Do parents badger the child to stop the habit? “The most important thing to remember before any intervention is that the child should have the will to stop the habit for treatment to be successful”. 1. Non-nutritive Digit (thumb/finger) Sucking: - Thumb sucking is a normal physiological process during infancy (0-1), and a normal baby reflex. Some children suck their thumbs before they are even born (29 week IU), and others begin sucking their thumbs soon after birth. Digit sucking is soothing to the small child and aids in digestion. - Normal under the age of 2 years. - prolonged thumb sucking is usually a manifestation of insecurity, and mal- adjustment or a consequence of deprivation of breast feeding. - Many children with this habit will spontaneously stop the habit in preschool years (usually at the age of four), but some continue till the mixed dentition stage. - Even if there are no dento-alveolar changes, the habit is socially unacceptable and should be discouraged when the child is mentally capable of understanding why it should be stopped, especially if appliance therapy is attempted. - Therefore, interventions to stop the habit should not be undertaken before the age of 4, otherwise, preventing the child from such act can stress the child and passes the risk of the child engaging into other habits. - The classical dento-alveolar changes of thumb or finger sucking are: 2 1- Increased overjet: Due to facial movements of upper incisors and lingual movements of lower incisors due to pressure exerted by the digit during sucking. 2- Anterior open bite: Due to over (passive) eruption of posterior teeth when the digit is being sucked, and to a lesser degree, may be due to intrusion of incisors. 3- Maxillary arch constriction and posterior cross bite: Due to the change in equilibrium balance between the oral musculature and the tongue. When the digit is placed in the mouth, the tongue is forced down and away from the palate. The orbicularis oris and buccinator muscles continue to exert a force on the buccal surfaces of the maxillary dentition. Without the tongue’s counterbalancing force on the lingual surfaces, the maxillary posterior segments collapse into crossbite. 4- Proclined maxillary incisors and retroclined mandibular incisors. 5- Can be associated with tongue thrust as a consequence. The severity of dento-alveolar changes depends on: - Intensity: The amount of force that is applied to the teeth while performing the habit. - Frequency: The number of times the habit is practiced throughout the day. - Duration: The amount of time spent sucking a digit. This is the most important as evidence suggests that 4-6 hours of force per day are necessary to cause tooth movement. - Diagnosis: 3 1. History: a complaint from the caregiver about thumb sucking. 2. Clinical Examination: finger involved clean, chapped, eczema, fibrous roughened callus, fungal infections, keratotic lesions that cause deformation of the finger. Management: An age based approach is usually followed:- A- before the age of 4: OBSERVATION At this age, the level of understanding of the child complicates cooperation with any type of intervention. Therefore, the child should be given every opportunity to stop the habit spontaneously. Moreover, the effects of the habit on occlusion are not permanent at this age period. Parents are advised to observe the child without being aggressive. If the child gradually diminishes the habit, then it will probably cease without intervention. Sometimes, engaging the child hands in any child activity is a good approach. B- Children older than 4 years-old: Reward Therapy: - A contract between the child and parent or between the child and dentist is drawn which states that the child will discontinue the habit within a specified period of time and in return will be rewarded. The reward must be motivating for the child to stop the habit. The more involvement the child takes in the therapy, the more likely it will succeed. Reward and reminder therapy are usually combined to improve the likelihood of success. Involvement of the child increases the likelihood of success. For example, the child can place a stick-on star on specially made calendar when the child has entirely stopped the habit for a day. In month 1, the child receives the reward if the calendar has at least 28 stars (i.e. 2 bad days are allowed). In month 2, the goal is 29 stars and 30 stars in month 3, and the gifts are progressively enhanced. If the child stops the habit in 3 months, the chance of complete cessation is good. 4 Reminder Therapy: - Indicated for those children who desire to stop the habit but need some help. The purpose of the treatment should be thoroughly explained to the child. An adhesive bandage is secured on the offending finger to serve as a constant reminder not to place his finger in his mouth. Since some parents fear that the bandage might be aspired during sleep, a mitten or tube sock to give the finger may be used. Other products include plastic sleeves, shirts that cover the hand are available. Also, painting the finger with a bitter tasting material can be used as well. Adjunctive Therapy/ Appliance therapy (Habit Breaking Appliance): - This approach is used after failure of the first approaches and when the child wants to stop the habit. It is a method that physically interrupt the habit and reminds the patient as well. This includes restraining the patient’s arm in an elastic bandage so it cannot be flexed and brought to his mouth. Another approach is by placing an intraoral appliance that makes it difficult for the child to place his finger in his mouth. The dentist must explain to the child that this is not a punishment but a constant reminder. The appliance should be worn for 6-8 months up to 12months. Parents and child should be informed that certain side effects may temporarily appear after the delivery of an appliance for 2 or 3 day. These include eating, speaking and sleeping difficulties. - Intraoral appliances include: - Quad Helix: is used to expand the maxillary arch in patients with posterior cross bites and through its helices it reminds the patient not to place his finger in his mouth. 5 - Palatal Crib: is designed to interrupt the habit by interfering with the finger when placed inside the mouth thus preventing thumb sucking satisfaction. It is used when posterior crossbite does not exist or as a retainer after maxillary expansion had been achieved by quad helix. Parents and children should be informed that eating, speaking and sleeping patterns will be temporarily affected by the palatal crib in the first few days only and subside between 3days-2 weeks. An indentation from the crib usually appears on the tongue and may persist for 1 year after removal of the appliance. – The major problem related to these appliances is the ability to maintain proper oral hygiene. - Bluegrass appliance: a Teflon roller is placed in the most superior area of the palate and the patient is encouraged to use the tongue to turn the roller. It is less disruptive to eating and speech. It is privileged with a W arch to correct the transverse constriction if present. - These appliances should be left in the mouth from 6-12 months. Follow up in 1-2months intervals to monitor how the child is doing with the habit. - Hay rake Appliance looks like palatal crib but with spikes behind the front teeth to interfere with thumb placement. 6  2- Pacifier Habit Pacifiers are soothing and calming to fussy babies and also reduce the risk of Sudden Infant Death Syndrome (SIDS) by 50% when used at bedtimes. However, after 6 months of age, a pacifier is more of a habit than a helpful product. The dento-alveolar changes created by pacifier habit are largely similar to those of digit sucking. However, pacifier habit is easier to stop than digit habits as it can be withdrawn gradually or completely at once. Pacifiers are usually introduced after 1st month of age to ensure that breast feeding is firmly established. It is best introduced at bedtime only to decrease the risk of SIDS. Weaning from a pacifier should start by the end of the first year, and it should be completely cut-off maximum at 4 years of age to avoid dental problems. 3- Lip Habits Habits that involve manipulation of the lips and perioral structures are termed lip habits. Some lip habits do not cause dental problems (as in the case of lip licking habit). However, lip sucking, and lip biting can be associated with malocclusion. It is not clearly known whether lip sucking and biting are the cause of malocclusion or a result of an existing malocclusion such as increased overjet or class II skeletal malocclusion. 1. Proclination of the maxillary incisors. 2. Retroclination of the mandibular incisors. 3. Increased overjet. 7 Management: 1- If the lip is only associated with signs of inflammation (Red, swollen, and may be ulcerated), then it is most probably a result of stress and anxiety. In such case only palliative treatment (eg. lip palm) is needed and probably psychological counseling. A lip bumper can be installed to separate the lips from teeth. 2- In case of class I skelatal relationship and increased anterior over jet, the lip habit is eliminated with a lip bumber appliance, and orthodontic correction of increased overjet. 3- Skeletal Class II cases need skeletal growth modification. 4- Mouth Breathing Mouth breathers usually have special facial features, sometimes called adenoid faces, which are: Face is long & narrow Tired eyes Lips are apart Retruded chin Protruded upper anterior teeth 8  Intra-oral features include: Lips are open with the lower lip extending behind the upper incisors. Anterior open bite and increased overjet V-shaped maxilla and high arched palate leading to posterior cross- bite. This is due to lower tongue position and negative air pressure in the oral cavity created during mouth breathing. Maxillary teeth Crowding. Inflamed gingival tissue in the anterior maxillary arch due to lack of the protective effect of saliva. N.B: Sometimes individuals appear to be mouth breathers because of their mandibular posture or incompetent lips. It is also normal for a 3 to 6-year-old to be slightly lip incompetent. Mouth breathing habit could be: Obstructive: Due to enlarged adenoids, tonsils, deviated nasal septum, chronic allergy or infection. Habitual: Mouth breathers who breathe through their mouth by force of habit and absence of any nasal obstruction. Anatomical: Due to short upper lip which does not allow complete mouth closure without undue effort (incompetent lip). 9 Management: 1- Refer to an ENT specialist to diagnose and treat anatomical causes of mouth breathing, if present or to exclude anatomical mouth breathing etiology. 2- This is followed by fitting a passive oral screen at night to encourage nasal breathing. An active oral screen is used in the presence of flared upper incisors. 5- Nail Biting It is commonly seen in adolescents and rarely in preschool children. It rarely causes malocclusion but is socially unacceptable. Management: - It is usually a manifestation of anxiety and may need psycological counselling. Other interventions include: Painting the finger/s with bitter tasting preparations. Using stress balls to engage the fingers and relief stress. 6- Self Mutilation It is self-induced injury to the soft tissues. It is extremely rare in the healthy child, and most commonly seen in children with mental disabilities or psycological problems. A frequent manifestation of self-mutilation is biting of the lips, tongue, and oral mucosa, or gingival stripping. 10 Management: One or more of the following interventions can be used: Behavior modification Use of restraints protective padding. Also, extraction of selected teeth may be necessary 11  7- Bruxism -Bruxism is the habitual grinding or clenching of teeth. It most often occurs at night but can also occur when awake. -Approximately 30% of children develop bruxism during the early-school years (juvenile bruxism) which usually decreases by the age of 7 to 8 years and stops before the age of 12, after eruption of all the permanent teeth. -If bruxism persists into adulthood, it is termed adult bruxism. The etiology of bruxism is usually unknown but may include; Tooth malocclusion causing occlusal interferences. Emotional stress (response to anxiety, tension, anger, or pain). Intestinal parasites. Neurologic abnormalities, eg. cerebral palsy. 12 The consequences of bruxism include; Tooth wear and sensitivity Gingival recession Temporomandibular joint disorder Headaches Management: Eliminate any occlusal interferences, if present Stool analysis Behavioral therapy Soft vinyl night guard Biofeedback The Biofeedback headband is attached around the forehead. Once the muscles contract to start clenching, the biofeedback headband senses it and sends an audio signal to the person in order to disrupt the sleep, just enough to stop clenching. 13