341 PDS ORAL HABITS Dr. Thamer Alkhadra BDS, MS, PhD If a habit that causes dental changes is not eliminated before the permanent incisors erupt, they too will be affected On the other hand, these are not irreversible changes If the habit is stopped during the mixed dentition years, the adverse dental changes will begin to be reversed naturally Thumb & Finger Habits Make up the majority of oral habits About two thirds are ended by 5 years of age. The types of dental changes that a digit habit may cause vary with the intensity, duration, and frequency of the habit as well as the manner in which the digit is positioned in the mouth Thumb & Finger Habits Intensity is the amount of force that is applied to the teeth during sucking. Duration is defined as the amount of time spent sucking a digit Frequency is the number of times the habit is practiced throughout the day Thumb & Finger Habits Clinical and experimental evidence suggests that 4 to 6 hours of force per day are probably the minimum necessary to cause tooth movement A child who sucks intermittently wit high intensity may not produce much tooth movement at all, whereas a child who sucks continuously (for more than 6 hours) can cause significant dental change The most common dental signs of an active habit are reported to be the following: Anterior open bite Facial movement of the upper incisors and lingual movement of the lower incisors Maxillary constriction Thumb & Finger Habits Anterior open bite, the lack of vertical overlap of the upper and lower incisors when the teeth are in occlusion, develops because the digit rests directly on the incisors Anterior open bite may also be caused by intrusion of the incisors Thumb & Finger Habits Faciolingual movement of the incisors depends on how the thumb or finger is placed and how many are placed in the mouth Usually, the thumb is placed so that it exerts pressure on the lingual surface of the maxillary incisors and on the labial surface of the mandibular incisors The result is an increased overjet and, by virtue of the tipping, decreased overbite Thumb & Finger Habits Maxillary arch constriction is probably due to the change in equilibrium balance between the oral musculature and the tongue Thumb & Finger Habits Timing of treatment must be gauged carefully If parents or the child do not want to engage in treatment, it should not be attempted It is generally undertaken between the ages of 4 and 6 years Delay until the early school age years allows for spontaneous discontinuation of the habit by many children Thumb & Finger Habits Counseling with the patient This involves discussion between the dentist and the patient of the problems created by non-nutritive sucking (NNS) This approach is best aimed at older children who can conceptually grasp the issue and who may be feeling social pressure to stop the habit Thumb & Finger Habits The second approach, reminder therapy, is appropriate for those who desire to stop the habit but need some help An adhesive bandage secured with waterproof tape on the offending finger can serve as a constant reminder Another approach is to paint a commercially available bitter substance on the fingers that are sucked Thumb & Finger Habits A third treatment for oral habits is a reward system. A contact is drawn up between the child and the parent or between the child and the dentist. The contract simply states that the child will discontinue the habit within a specified period of time and in return will receive a reward. Thumb & Finger Habits Placing stick-on stars on a homemade calendar when the child has successfully avoided the habit for an entire day. If the habit continues to persist after reminder and reward therapy and the child truly wants a method to physically interrupt the habit a reminder of the patient can be used. Thumb & Finger Habits Involves either wrapping the patient’s arm in an elastic bandage so it cannot be flexed and the hand inserted in the mouth, or placing an appliance in the mouth that physically discourages the habit by making it difficult to suck a thumb or finger. The appliance is not a punishment but rather a permanent reminder not to place the finger in the mouth. Thumb & Finger Habits The two appliances used most often to discourage the sucking habit are the quad helix and the palatal crib The quad helix is a fixed appliance commonly used to expand a constricted maxillary arch – a common finding accompanied by posterior crossbite in NNS patients. The palatal crib is designed to interrupt a digit habit by interfering with finger placement and sucking satisfaction. Thumb & Finger Habits The palatal crib is generally used in children in whom no posterior crossbite exists It may, however, also be used as a retainer after maxillary expansion with a quad helix in a child who has not stopped sucking with quad helix For a palatal crib, bands are fitted on the permanent first molars or primary second molars. A heavy lingual arch wire (38 mil) is bent to fit passively in the palate and is soldered to the molars bands Thumb & Finger Habits The parent and child should be informed that certain side effects appear temporarily after the palatal crib is cemented Eating, speaking, and sleeping patterns may be altered during the first few days after appliance delivery These difficulties usually subside within 3 days to 2 weeks. An imprint of the appliance usually appears on the tongue as an indentation Thumb & Finger Habits The major problem with the palatal crib is the difficulty of maintaining good oral hygiene. The appliance traps food and is difficult to clean thoroughly. Thumb & Finger Habits Habit discouragement appliances should be left in the mouth for 6 to 12 months as a retainer. The palatal crib usually stops sucking immediately least another 6 months of wear to extinguish the habit completely. The quad helix also requires a minimum of 6 months of the treatment. Three months are needed to correct the crossbite, and 3 months are required to stabilize the movement. Pacifier Habits Dental changes created by pacifier habits are largely similar to changes created by thumb habits, and no clear consensus indicates a therapeutic difference Anterior open bite and maxillary constriction occur consistently in children who suck pacifiers Pacifier habits appear to end earlier than digit habits Lips Habits Habits that involve manipulation of the lips and perioral structures are called up lip habits Lip licking and lip pulling habits are relatively benign as far as dental effects are concerned. Red, inflamed, and chapped lips and perioral tissues during cool weather Little can be done to stop these habits effectively, and treatment is usually palliative and limited to moisturizing the lips some have used appliances to interrupt Lips Habits The result is a proclination of the maxillary incisors, a retroclination of the mandibular incisors, and an increased amount of overjet. This problem is mot common in the mixed and permanent dentitions. TONGUE THRUST AND MOUTHBREATHING HABITS Tongue thrust is characteristic of the infantile and transitional swallows. Therefore, tongue thrusting should be considered a finding and not a problem to be treated. Mouth breathing and its association with malocclusion is a complex issue. It is normal for a 3-to-6-year old to be slightly lipincompetent. NAIL BITING Nail biting is a rare habit before 3 to 6 years of age. The number of person who bite their nails is reported to increase until adolescence. There is no evidence that nail biting can cause malocclusion or dental change other than minor enamel fractures, therefore, there is no recommended treatment. Bruxism Bruxism is a grinding of teeth and is usually reported to occur while a child is sleeping. Children grind their teeth when awake, most children engage in some bruxism that results in moderate wear of the primary canines and molars capped persons. Masticatory muscle soreness and temporomandibular joint pain have also been attributed to bruxism. The exact cause of significant brusixm is unknown, although most explanations center around local, systemic, and psychological reasons. Bruxism The local theory suggests that bruxism is a reaction to an occlusal interference, high restoration, or some irritating dental condition. Systemic factors implicated in bruxism include intestinal parasites, subclinical nutritional deficiencies, allergies, and endocrine disorders. The psychological theory submits that bruxism is the manifestation of a personality disorder or increased stress. Bruxism Treatment should begin with simple measures. Occlusal interferences should be identified and equilibrated if necessary If occlusal interferences are not located or equilibration is not successful, referral to appropriate medical personnel should be considered to rule out any systemic problems. If neither of these two steps is successful a mouthguard like appliance can be constructed of soft plastic to protect the teeth and attempt to eliminate the grinding habit. Self-mutilation Repetitive acts that result in physical damage to the person, is extremely rare in the normal child. It has been suggested that self-mutilation is a learned behavior A frequent manifestation of self-mutilation is biting of the lips, tongue and oral mucosa. Any child who willfully inflicts pain or damage to himself should be considered psychologically abnormal. Such children should be referred. Besides behavior modification treatment for self mutilation includes use of restraints, protective padding and sedation.
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