Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 9027 Deleterious Oral Habits and Management in Pediatric Patients: A Review

Fatma Shaghaf

Intern, Institute of Dental Sciences, Siksha O Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India

Abstract Habit is the constant and unconscious repetition of an act. Children (usually infants) frequently acquire oral habits that can be temporary, if continued can be permanent & harmful to dental occlusion and supporting structures. This article aims to throw lights on harmful habits, its cause, side effect and treatment available, as ignorance of these habits can cause facial abnormality; hence Dentists play an important role in the identification and removal of habits.

Keywords: oral habits, , Digit Sucking, Biting, Tongue Thrusting, Mouth Breathing, Lip Sucking.

Introduction According to Kingsley (1956): Functional Oral Habit like mouth breathing/Muscular Habit like tongue Oral Habit most commonly seen during infancy as thrusting/Combined Muscular Habit like thumb and it is part of normal development. It usually fades away finger habit/Postural Habit like chin propping. with time. If not, then it is a matter of great concern as it can cause serious dentoalveolar changes. It is According to Morris and Bohanna (1969): usually associated with several etiologies out of which Pressure Habit like lip sucking/Non Pressure Habitlike psychology is common and important. Hence, if a patient mouth breathing/Biting habit like lip biting. complains of habit understanding the associated deep- rooted psychology and management is very important According to Finn (1987): Compulsive/ for Dentist.1 Noncompulsive.

Oral habits is justified as a frequent or constant According to Klein (1971): Empty or unintentional 2 practice which is fixed due to frequent repetition Habit/Meaningful or intentional habit.

Oral Habits are classified in several headings by Bruxism: The word bruxism is derived from the word following scientist: ‘la bruxomaine’ coined by Marie Pietkiewicz (1907). It is a repetitive of mandible which is According to William James (1923): Useful habits characterized by unconscious clenching and grinding of such as nasal breathing/harmful habits such as thumb teeth. This type of Parafunctional movement is important sucking. for dentist’s knowledge as it is used to detect the reason behind broken restoration, tooth damage such as tooth fracture or any temporomandibular disorders. Bruxism is of two types Nocturnal bruxism/Sleep Bruxism which Corresponding Author: occurs in sleep and Diurnal Bruxism/Awake Bruxism Fatma Shaghaf which occurs when the patient is awake. Sleep bruxism Intern, Institute of Dental Sciences, Siksha O is of two types of primary or idiopathic (occurs without Anusandhan (Deemed to be University), Bhubaneswar, any medical reason), secondary or iatrogenic (may be Odisha, India caused due to use of the drug). e-mail: [email protected] 9028 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 Etiologies associated with bruxism are psychosocial the main cause behind the continuation of this habit.7-11 factor (emotional ), pathophysiology factor (illness, trauma, smoking, medication), genetic factor Classification: Subtelny (1973) has classified types (offspring of people with bruxism have more chances), of digit sucking into 4 types:- local factor (faulty restoration, calculus, ), Type A-(50%) of children place the entire thumb or systemic factor (a nutritional deficiency, intestinal digit inside the oral cavity witha pad of the thumb is a 3-6 parasite ). place such that is pressing the palate. Anterior teeth of 7-11 Clinical Feature: Bruxism affects the anatomy, the maxillary and mandibular region are in contact. morphology and dental occlusion. It causes mobility of Type B-(25%) of children place the whole thumb teeth, hypersensitivity, pain in facial muscle,restricted inside the mouth but it is not in contact with the vault mouth opening, pain in the temporomandibular region ofthe palate. Only anterior teeth mandibular and (frequent headache), tooth fracture, damage to the dental maxillary region are in contact prosthesis and dental fillings.3-6 Type C- (18%) of children place thumb just beyond Treatment: There is no such accepted treatment its first joint, there is no mandibular contact thumb is in available for bruxism as it is not life-threatening hence contact with maxillary incisor. conservative treatment is recommended. Eliminate the causative factor. Awake Bruxism can be reduced by Type D-(6%) of children doesn’t fully place thumb habit modification training or use of small chewing inside the mouth, only thumbnail is in approximate gum as a reminder in the molar region. Sleep bruxism contact with mandibular incisors.7-11 can be reduced by sleeping without pillow i.e. flat on back, occlusal splint and dental guards can be used. Etiology: Type of malocclusion during digit Medication such as benzodiazepines, beta-blockers, sucking depends on several factors such as the position dopamine agents, antidepressants, anticonvulsants, of the digit, related oro-facial muscle, the position of muscle relaxants can be used to treat Bruxism.3-6 the mandible during sucking, facial and skeletal design, intensity frequency and duration of force applied. Digit Sucking: Digit (Thumb, finger) sucking is the most common type of non-nutritive sucking habit. Clinical feature: Prolong Digit sucking can cause It is defined as positioning of digits at varying depths of damage to facial structure, dental structure and digits the oral cavity. This habit started during the 29th week involved in sucking. Maxillary changes due to a long of gestation continues till 2-3yrs of age after which time sucking habit areoverjet of the maxilla,increased children usually stop this habit on their own. If this habit maxillary arch length,reduced width of palatal arch, continues it can cause malocclusion and can also alter increased angle of sella-nasion-point A. Effects on the shape of a digit. the mandible include proclination of the mandibular incisors,increased distance in intermolar region and Two theories are involved to explain the etiology reduced angle of sella-nasion-point B. Other dental of digit sucking, emotional theory and learned behavior deformity includes increased overjet, reduced overbite, theory. Emotional theory is explained by Sigmund Freud and crossbite in posterior tooth region. Digit deformity according to him finger sucking is a type of pleasure in can be caused in chronic sucking patients.7-11 which a child derives from excitation of oral erogenous routes. If infants sucking needs are not fulfilled this Removal of psychological reason, engagement of habit become fixation, later continuation is known the child in various activities to divert the mind, adequate as regression. Fixation and regression are features of duration of breastfeeding, use of dummy or pacifiers can 7-11 emotional disturbances. In recent times learned behavior reduce the thumb sucking habit. theory is the most favored theory, according to this Management of thumb sucking involve following theory sucking is a natural desire in infant and digit therapy according to Pinkham: sucking is caused due to excess sucking urge because of efficient breast/bottle feeding by nutritionally proficient Preventive therapy (Hughes): Feed the child mother. Emotional and physical stimuli, such as enough in a natural way such that his feeding needs are hunger,boredom, stress, pleasure and other disability are fulfilled. Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 9029 Psychological Therapy: This habit usually acquire to mastication yet quitting this habit is necessary as this by those children who lack parental care, love and proper habit is socially unacceptable. Operational definition of care. Hence dentists and parents need to carefully handle Nail Biting is “putting one or more fingers in the mouth the situation with proper understanding and without and biting on the nail with teeth” shaming and punishment. Positive reinforcement or positive reward system should be used to modify The etiology of nail-biting is controversial some behavior. Dunlop’s beta hypothesis is the best way to studies believe it is due to behavioral disorder or break the habit. According to this hypothesis conscious anxiety while others deny this theory. It occurs due to and purposeful repetition can stop the habit. The child boredom,emotional stress or successor of thumb sucking. is asked to stand with the mirror and suck his/her digit Clinical features include attrition of incisal edge, looking at self, this procedure is very productive when rotation of teeth, crowding, resorption of apical root, a child is repeatedly asked to perform this act whenever gingivitis, fracture (in severe cases). Other feature he sucks thumb. Dr. Dragan Antolo’s book named ‘The includes damage to the cuticle, inflammation of nail bed, Little Bear Who Sucked His Thumb’ is also a positive bacterial . and pressure less way of removal of habit as a child relates himself to bear and willingly quit the habit. 7-11 Management includes behavioral modification and physical barriers. The patient must be treated with a Reminder Therapy: They are of two types little more attention, love, affection, and comprehension. chemical and mechanical. Chemical therapy includes Chewing bubble gum can be an alternative when patients the use of bitter-tasting or bad odor chemicals such as feel the urge to bite nails. The application of olive oil or quinine, asafetida, castor oil, red pepper in volatile liquid, bitter-tasting preparation might annoy the young patient. commercially available femite (Denatonium benzoate) Educating the child and creating awareness is the best in thumb. Mechanical therapy includes mechanical way to quit this habit. restrains applied to hand, wrist, thumb to quit habit examples of mechanical restrainers are Thermoplastic Tongue Thrusting: Tongue thrust is defined as thumb post (Allen in 1991), ace bandage system, use of the movement of the tongue tip in the forward direction long sleeves nightgown, three-alarm system introduced between the teeth to touch the lower lip during swallowing by Northan and Gellin (1968).According to them when and speaking, so that the tongue becomes interdental. the child putsa finger in mouth and feels the tape its This habit is most commonly seen during infancy first alarm when a child feels the pin which is tied with and subsides after a certain age. It can be Physiologic a bandage in the elbow is second alarm lastly when (normal tongue thrust swallow during infancy), bandage gets tightened serves as a third alarm. Habitual (presence of habit even after the rectifying the malocclusion), Functional (adaptive behavior developed Appliance Therapy: They are of two types to achieve an oral seal), and Anatomic (person with 12, 13 Removable Appliance: Palatal crib, oral screen, macroglossia). hay rakes. Etiology: According to Fletcher following factor Fixed Appliance: Quad helix, bluegrass appliance, may cause development of tongue thrusting 7-11 modified bluegrass appliance. Genetic factor: anatomic or neuromuscular Nail Biting: Nail-biting is also known deformity in head and neck region e.g.: macroglossia, asonychophagia is the most common stress-relieving hypertonic orbicularis oris activity, position of lingual oral habit seen in both children and adults. Nail-biting frenum Learned behavior: It is an acquired habit hence habit is due to anxiety which usually develops after following condition such as improper bottle feeding, sucking age. It includes biting of nail or its surrounding prolonged thumb sucking, prolong tonsillar infection soft tissue and cuticle. This habit starts after the age of and upper respiratory tract infection, prolong tenderness 4 and attains its peak in 4-6 yrs and get stable during of gums or teeth can alter the swallowing pattern and can 12, 13 7-10yrs of age again triggers in . It is not a cause tongue-thrusting habit. pernicious habit hence it does not cause malocclusion. Classification of tongue thrust according to James. Somehow, attrition of lower incisors can be seen in S. Barner and Holt: rare cases as the force applied in nail-biting is similar 9030 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 Type 1: Non-deforming tongue thrust or people with medical conditions like sleep apnea are of main concern. It shows the child needs additional Type 2: Deforming anterior tongue thrust. (2a) medical involvement or retraining on breathing easily anterior open bite, (2b) proclination of anterior teeth, through the nose. According to Finn mouth breathing (2c) posterior crossbite. can be obstructive, habitual, and anatomical.15,16

Type 3: Deforming lateral tongue thrust. (3a) Etiology: Airway obstruction (enlarged turbinate), posterior open bite, (3b) posterior crossbite, (3c) deep defect on the intranasal region (tumors, deviation of overbite the intranasal septum, bony spurs), hypertrophy of Type 4: Deforming anterior and lateral tongue thrust. pharyngeal lymphoid tissue, infection or inflammation (4a) anterior and posterior open bite, (4b) proclination of in the nose (nasal polyps, chronic allergic steatitis), birth anterior teeth, (4c) posterior crossbite. 12, 13 abnormality (cleft lip, cleft palate, tongue tie), abnormal facial musculature due to former habit like thumb Clinical feature: Intraoral clinical feature includes: sucking.15, 16 proclined upper anterior, retrocline lower anterior, anterior open bite, posterior crossbites, bimax protrusion Clinical Feature: General side effects include (complex tongue thrust) pigeon chest deformity, hoarseness voice, poorly developed sinuses, decrease sense of smell. Extraoral Extraoral feature includes: Doligocephalic face, features like adenoid face, gummy smile, short upper increase lower anterior facial height, incompetent lip lip, narrow nostrils, dryness and crack in lips can be seal, speech deformity can also be seen seen. Intraoral symptoms are proclination of maxillary anterior, generalized spacing, gingivitis, posterior Management: This habit is vanishes once permanent crossbite.15, 16 teeth erupt by age of 8-9 yrs. mayo functional therapy, speech therapy, subconscious therapy or orthodontic Treatment for mouth breathing depends on its treatment is required to correct this habit. Several underlying cause. It should be treated as early as exercises can also be performed such as lemon candy possible patients with nasal congestion should use nasal exercise, 4s exercise, whistling, counting from 60-69, spray. Surgery like Tonsillectomy, Sepatoplasty, and yawning, gargling, water holding exercise, lip exercise. Adenoids removal is advised. Dentists prescribe the use of orthodontic appliances such as oral screen, chin cap Following Removable orthodontic appliances are and activator.15, 16 used: Lip Sucking/Lip Biting: Child might occasionally Modified Hawley’s Appliance: acrylic is cut on suck their lip when anxious but some suck and bite their anterior hard palate region, crib or rake is attached on lip as deleterious habit which might cause soreness and the anterior side this increases anchorage and cribs act redness of lip below the vermillion border. This case as a reminder to the tongue. occurs almost in all cases of lower lip.17,18

Oral screen: it acts as a barrier to the tongue, corrects Etiology: It is caused due to physical causes such open bite, arranges the maxillary anterior teeth. Ring as malocclusion, TMJ disorder. Physiological disorder attached in oral screen helps in Lip muscle exercise. includes fear, stress, anxiety or body-focused repetitive A fixed orthodontic appliance includes Nance behavior (BFRB). This is also caused due to hyperactivity 17,18 palatal arch (acrylic button type).12,13 oh mentalis muscle.

Mouth Breathing: Breathing is the vital function Clinical Feature: It causes protrusion of maxillary of the human body, usually done through the nose. incisor, retrusion of mandibular incisor, generalized Breathing through the mouth instead of the nose is spacing in the upper arch, crowing in the lower anterior considered as abnormal breathing habit. Merle suggested arch. Lip will appear red, chapped, irritated below the name oro-nasal breathing. It’s the most common habit vermillion border. Vermillion border will become among children as well as adults. Mouth breathing due hypertrophic. to an acute illness, cold is not of main concern. Chronic Treatment depends on the cause physiological mouth breathers who completely depend on their mouth Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 9031 causes can b treated with habit modification counseling 4. Murali RV, Rangarajan P, Mounissamy A. and therapies such as Cognitive Behavioral Therapy, Bruxism: Conceptual discussion and review. J , Dialectical Behavior Therapy Pharm Bioallied Sci. 2015;7(Suppl 1): S265–S270. while physical cause requires clinical treatment such 5. Yap AU, Chua AP. Sleep bruxism: Current as correction of the underlying cause. Medications knowledge and contemporary management. J prescribed are antidepressant and anti obsessive Conserv Dent. 2016;19(5):383–389. medicine such as clomipramine or selective serotonin 6. Shetty S, Pitti V, Satish Babu CL, Surendra reuptake inhibitors.17,18 Kumar GP, Deepthi BC. Bruxism: a literature review. J Indian Prosthodont Soc. Conclusion 2010;10(3):141–148 Habits are increasing day by day due to stress and 7. Augustine. Thumb Sucking Habit. Slideshare.net poor attention from parents. Child needs proper care for 2013. good behavior development. Habits once developed are 8. Shetty RM, Shetty M, Shetty NS, Deoghare hard to break because repeated action becomes imprints A. Three-Alarm System: Revisited to treat in our neural pathway. Abnormal oral habit can cause Thumb-sucking Habit. Int J Clin Pediatr Dent. great destruction to both dental and facial structure; it 2015;8(1):82–86 also affects the general health. Hence, Dentist plays an important role in habit modification. Dentists not only 9. Shahraki N,Yassaei S, Moghadam MG. Abnormal repairs tooth and dentofacial structure but also identify oral habit: A review. JDentistry Oral Hyg 2012; unnoticed habits (due to parents unawareness) and 4(2):12-15 helps in the prevention and treatment of the underlying 10. Deepak D R, Manu Shankar, Karthika B Nair. cause. To replace bad habits with a good habit integrated Habits a contemporary review. Int J Dental Res approach is required between parents and patients, 2017; 5(2), 93-97 behavior modification technique, physical exercise, 11. Gairuboyina S, Chandra P, Anandkrishna L, habit breaking appliance and orthodontic treatment Kamath PS, Shetty AK, Ramya M. Non-nutritive are required. But most importantly parents should be sucking habits: A review. J Dent Orofac Res educated about harmful oral habits their etiology and 2014;10(2):22-7. side effects to stop habit in early age for healthy dentition 12. Ghanizadeh A. Nail biting; etiology, consequences and good health. and management. Iran J Med Sci. 2011;36(2):73– Ethical Permission: Not required 79. 13. Leung AK, Robson WL. Nailbiting. Clin Pediatr Conflict of Interests: None (Phila). 1990;29(12):690–692. Funding: None 14. Singaraju GS, Kumar C. Tongue thrust Habit- A review. Annals Essence Dentistry. 2009; 1(2): 14- References 23. 1. Basra AS, Kaur N, Singh A, Singh K, Singh KP. 15. Ziaul R. Mouth breathing. National health portal Deleterious Oral Habits among School Going 2019. Children - A Cross-Sectional Study. J Interdiscipl 16. Tandon S. Textbook of pedodontics. 2nd edition, Med Dent Sci 2016; 4:1-4. 2008. 2. Khan I, Mandava P, Singaraju GS. Deleterious 17. Rachel Nall, RN, MSN, CRNA. What’s wrong Oral Habit: A Review. Annals Essence Dentistry with breathing through the mouth. Medical News 2015;6(1): 28-33. Today 2017. 3. Demjaha G, Kapusevska B, Pejkovska-Shahpaska 18. Adrienne Stinson, review by Timothy J. Legg, B. Bruxism Unconscious Oral Habit in Everyday Ph.D., CRNP. How to stop anxious lip biting. Life. Open Access Maced J Med Sci. 2019;7(5):876– Medical News Today 2018 881.