344 Section 7  Pediatric Orthodontics

Noncompulsive Habit Morris and Bohanna Classification 1969

Children appear to undergo continuing behavior Habit Example
modification, which permit them to release certain Nonpressure habits Mouth breathing
undesirable habit patterns and form new ones which are Pressure habits a. Sucking habit
socially accepted. –– Lip sucking
–– Thumb and digit sucking
Primary Habit and Secondary Habits
b. Biting habit
Secondary habit is a habit that is due to a supplemental
problem, for example, large tongue causes tongue –– Nail biting/needle holding
thrusting habit. –– Pillow rest
Postural habit –– Chin rest
Meaningful and Empty Habits (Klein,
1971) Miscellaneous –– Bruxism

Meaningful Habit
Habit with a deep-rooted psychological problem.
THUMB SUCKING
Empty Habit Thumb sucking is defined as the placement of the thumb in
Meaningless habit that can be treated easily by a dentist varying depths into the mouth (Fig. 30.1).
using reminder therapy.

Normal and Abnormal Habits

Normal Habits
Those habits that are deemed normal by children of a
particular age group.

Abnormal Habits
Those habits that are pursued after their physiological
period of cessation.

Physiologic and Pathologic Habits

Physiologic Habits
Physiologic habits are those that are required for normal
physiologic fractioning, for example, nasal respiration,
Fig. 30.1: Child performing the act of thumb sucking.
sucking during infancy.

Pathological Habits Classification

Habits that are pursued due to pathological reasons such as
adenoids and nasal septal defects that may lead to mouth
breathing.
Retained and Cultivated Habits
Normal Thumb Sucking
The thumb-sucking habit is considered normal during the
first one and half years of life. Such a habit is usually seen
to disappear as the child matures.

Retained Habit Abnormal Thumb Sucking

Those that are carried over from childhood into adulthood. When thumb-sucking habit persists beyond the preschool
period, then it could be considered as an abnormal habit.
Cultivated Habit If the habit is not controlled and treated during this stage, it
Those cultivated during the socio-active life of an individual. may cause deleterious effects on the dentofacial structures.
 Chapter 30  Oral Habits
Psychological
The habit may have a deep-rooted emotional factor
involved and may be associated with neglect and loneliness
experienced by the child.
™™ Habitual: The habit does not have a psychological
bearing; however, the child performs the act
™™ Nutritive sucking habits: Breastfeeding, bottle feeding
™™ Non-nutritive sucking habit: Thumb or finger sucking,
pacifier sucking.
According to Subtelny (1973) (Figs. 30.2A to D)
Type A: This type is seen in almost 50% of the children wherein
whole digit is placed inside the mouth with the pad of the thumb
pressing over the palate, while at the same time, maxillary and
mandibular oral contact is present.
Type B: This type is seen in almost 13–24% of the children
wherein the thumb is placed into the oral cavity, and at the
same time, maxillary and mandibular contact is maintained.
Type C: This type is seen in almost 18% of the children wherein
the thumb is placed into the mouth just beyond the first joint and
contacts hard palate and the maxillary incisors, but there is no
contact with mandibular incisors.
Type D: This type is seen in almost 6% of the children wherein
only a little portion of the thumb is placed into the mouth.
A B
C D
Figs. 30.2A to D: Pathophysiology of thumb sucking.
Theories and Concepts of Thumb Sucking
Classical Freudian Theory (Sigmund Freud,
1919)
The psychoanalytic theory has proposed that a child
goes through various distinct phases of psychological
345
development. In oral phase, it is believed that the
mouth is the erogenous zone. During this phase, the
child takes anything and everything to the oral cavity.
It is believed that any kind of the deprivation of this
activity will probably cause an emotionally insecure
individual.
Oral Drive Theory (Sears and Wise, 1982)
They suggest that the strength of the oral drive is in
part a function of how long a child continues to feed by
sucking. It is not the frustration of weaning that produces
thumb sucking, but in fact, it is the prolonged nursing
that causes it.
Rooting Reflex (Benjamin, 1962)
The rooting reflex is movement of the infant’s head
and tongue toward an object touching its cheeks. He
suggested that thumb-sucking arises from the rooting
and placing reflexes common to all mammalian infants
during the first 3 months of life.
Sucking Reflex (Ergel, 1962)
The process of sucking is a reflex occurring in the oral
stage of development and is seen even at 29 weeks of
intrauterine life and may disappear during normal
growth between the ages of 1 and 3.5 years. It is the
first coordinated muscular activity of the infant. Babies
who are restricted from sucking due to disease or other
factors become restless and irritable. This deprivation
may motivate the infant to suck the thumb and finger for
additional gratification.
Learning Theory (Davidson, 1967)
This theory advocates that non-nutritive sucking stems
from an adaptive response. The infant associates sucking
with feelings like pleasure and hunger and recalls these
events by sucking the suitable objects available, which
is mainly thumb or finger.
Etiological Factors Associated with Thumb
Sucking
Socioeconomic Status
In high socioeconomic status , the mother is in a better
position to feed the baby and in a short time the baby’s
hunger is satisfied, whereas in the low socioeconomic
group, mother is unable to provide sufficient breast milk
to the infants; hence, in the process, the infant suckles
intensively for a long time, thereby exhausting the sucking
urge. This theory explains the increased incidence of thumb
sucking in industrialized areas when compared to rural
areas.
346 Section 7  Pediatric Orthodontics
Working Mother
The sucking habit is commonly observed to be present in
children with working parents because such children are
brought up in the hands of caretaker and develop feelings
of insecurity.
Number of Siblings
The development of the habit can be related to the
number of siblings because more the number increases,
the attention meted out by the parents to the child gets
divided. A child who feels neglected by the parents may
attempt to compensate his feelings of insecurity by
means of this habit.
Order of Birth of the Child
Later the sibling ranks in the family, greater is the chance
of having an oral habit.
Social Adjustment and Stress
Digit sucking has also been proposed as an emotionally
based behavior.
Age of the Child
The time of appearance of digit-sucking habit has
significance.
™™ In the neonate: Insecurities are related to primitive
demands as hunger
™™ During the first weeks of life: Related to feeding problems
™™ During the eruption of the primary teeth: It may be used
to relieve teething.
Fig. 30.3: Callus formation on nails.
Diagnosis of thumb-sucking habit
History
Once the positive history of habit is determined, the question
regarding the frequency, intensity, and duration of the habit is
determined. The remedies that have been tried at home, the
feeding patterns, parental care of the child are also ascertained.
Emotional Status
It is essential to determine if the habit is meaningful or empty. This
requires an insight into the emotional security and familial well-
being of the child.
Extraoral Examination (Figs. 30.3 and 30.4)
Digits that are involved in the habit will appear reddened,
exceptionally clear, chapped, and a short fingernail, that is, a clean
dishpan thumb.
Lips: The position of the lips at rest or during swallowing should
be observed. A short, hypotonic upper lip frequently characterizes
chronic thumb suckers. Lower lip is hyperactive and this leads to
further proclination of upper anterior teeth.
Profile: Usually convex profile
Other features: Active thumb sucking also have a higher incidence
of middle ear infections and frequently have enlarged tonsils
accompanied by mouth breathing.
Intraoral Examination
The type of malocclusion produced by digit sucking is dependent
on a number of variables like position of the digit, associated
orofacial muscle contractions, mandibular position during
sucking, facial skeletal pattern, intensity, frequency, and duration
of habit.
Fig. 30.4: Skin keratotic lesions.
 Chapter 30  Oral Habits 347

Dentofacial Changes Associated with

Thumb Sucking (Figs. 30.5 to 30.7)

Fig. 30.5: Open bite

Source: Pic courtesy Nancy L Wehner www.omahamyology.com.

Management
The strategy for management of thumb sucking should
be started when the child shows any signs of the habit or Fig. 30.6: Proclination of incisors.
whenever a familial tendency of the habit is discovered.

Preventive Treatment
™™ First, feed the child whenever he is hungry and let him
eat as much as he wants. Second, feed the child the
natural way; importance of breastfeeding is primarily
psychological and secondarily nutritive. Third, never
let the habit to start, the practice must be discontinued
at its inception (Hughes, 1941).
™™ Use of a dummy/pacifier: Encouraging the baby to suck
a dummy instead of his thumb can prevent him from
acquiring the habit.

Psychological Therapy
™™ Nagging, scolding, or frightening the child should be
avoided since this could cause negativism and tend to
make him resort to the habit. Fig. 30.7: Deep palate.
348 Section 7  Pediatric Orthodontics
™™ b-Hypothesis or Dunlop hypothesis: He believed
that if a subject can be forced to concentrate on the
performance of the act at the time he practices it,
he could learn to stop performing the act. Forced
purposeful repetition of habit eventually associates
with unpleasant reactions and the habit is abandoned.
The child should be asked to sit in front of the mirror
and asked to observe himself as he indulges in the
habit.

Six Steps in Cessation of Habit (Larson and Johnson)

Step 1: Screening for psychological component
Step 2: Habit awareness
Step 3: Habit reversal with a competing response
Step 4: Response attention
Figs. 30.8: Anti-thumb sucking solution.
Step 5: Escalated DRO (differential reinforcement of other
behaviors)
Step 6: Escalated DRO with reprimands (consists of holding the
child, establishing eye contact, and firmly admonishing the child to
stop the habit)

™™ Three-alarm system (Norton and Gellin–1968):1 A chart

is designed with days of the week and blank spaces.
When the child engages in his habit, he is told to wrap
the digit he sucks with coarse adhesive tapes. The
child feels the tape in his mouth; it is the first alarm
and this reminds him to stop the habit. The elbow of
the arm with the offending thumb is firmly wrapped
in 2 inch elastic bandage; safety pins are placed at
proximal and distal ends of bandage, and one safety
pin is placed lengthwise at the mesial end of the elbow,
and when the child sucks the thumb again, the closed
pin on the medial end of elbow, mildly jabbing the Fig. 30.9: Thumb guard.
elbow, indicates second alarm. If the habit persist, the
Intraoral approach: The early years of life culminating
bandage is tightened; this is the final or third alarm,
in the oedipal period at the age of 5 years are inappropriate
which will definitely remind the child of the habit.
psychologically for this approach; therefore, the optimal
Chemical Treatment time for appliance placement is between the ages of 3 and
4.5 years preferably during spring or summer, when the
It is the least effective method. Bitter and sour chemicals child’s health is at its peak and the sucking desires can be
have been used over the thumb to terminate the practice but sublimated in outdoor play and social activity. The following
with very minimal success, for example, quinine, asafetida, appliances are recommended:
pepper, castor oil, etc. Nowadays, new anti-thumb sucking ™™ Removable or fixed palatal crib (Figs. 30.10A to C):
solutions like femite, thumb-up, anti-thumb are also being It breaks the suction force of the digit on the anterior
marketed, but they have also had a very moderate success segment, reminds the patient of his habit, and makes
(Fig. 30.8). the habit a nonpleasurable one
™™ Oral screen: Oral screen is a functional appliance
Mechanical Therapy or Reminder Therapy introduced by Newell in 1912. It produces its effects by
Extraoral approach: Mechanical restraints applied to the redirecting the pressure of the muscular and soft tissue
hand and digits like splints, adhesive tapes. Thumb guard curtain of the cheeks and lips. It prevents the child from
is the most effective extraoral appliance for control of the placing the thumb or finger into the oral cavity during
habit (Fig. 30.9). sleeping hours
 Chapter 30  Oral Habits 349

A
Fig. 30.11: Hay rakes.

are persistent thumb suckers. The device was called hay

rake as it was designed with a series of fence like lines
that prevented sucking
™™ Blue grass appliance: Developed by Haskell (1991). It
is a fixed appliance using a Teflon roller, together with
positive reinforcement. Used to manage thumb-sucking
habit in children between 7 and 13 years of age. The
patient believes that he has acquired a new toy to play
with. Instructions are given to them to roll the roller
instead of sucking the digit
™™ Quad helix: The quad helix is fixed appliance used to
expand the constricted maxillary arch. The helixes of
B the appliance serve to remind the child not to place the
finger in the mouth
™™ Modified blue grass appliance (Fig. 30.12): This
is a modification of the original appliance with the

C
Figs. 30.10A to C: Different designs of Palatal crib.

™™ Hay rakes (Fig. 30.11): Mack (1951) advocated the use

of dental appliance in children over 3.5 years of age who Fig. 30.12: Modified blue grass appliance.
350 Section 7  Pediatric Orthodontics
difference being that this has two rollers of different
colors and material instead of one. If the patient tries
to suck on his thumb, the suction will not be created
and his thumb will slip from the rollers thus breaking
the act.
Current Strategies
™™ Increasing the arm length of the night suit: This is
useful in children who sincerely want to discontinue the
habit and only perform during their sleep. The arms of
their night suit are lengthened so that they cannot reach
the thumb during night
™™ Thumb-home concept (Figs. 30.13A to C): This is the
most recent concept. In this, a small bag is given to
the child to tie around his wrist during sleep, and it is
explained to the child that just as the child sleeps in his
home, the thumb will also sleep in its house, and so the
child is restrained from thumb-sucking during night
™™ Currently the use of hand puppets is gaining
popularity (Fig. 30.14A)
„„ Fill toe sock with stuffing. Pack very tightly
„„ Cut tag board approximately 2 inch wide and 4 inch
long
„„ Roll tag board loosely around index finger and then
wrap thread around it to make a tube
„„ Make hole in filling with index finger
„„ Insert tag board tube in filling
„„ Cut sock off about 1 inch below heel
„„ Wrap thread around sock at exposed end of tube and
sew sock to end of tube
„„ Dress your puppet with cloth and trimmings
„„ Paint face on puppet with marking pen, crayons, or
fabric paints or stitch on with colored thread
™™ Thumb-sucking book (Fig. 30.14B): “The Little Bear
who Sucked his Thumb” is a book directed at children,
for children. The book has been written and illustrated

B C
Figs. 30.13A to C : Thumb-home concept.

A B
Figs. 30.14A and B: (A) Hand puppets; (B) Child reading thumb-sucking book.
 Chapter 30  Oral Habits
by Dr Dragan Antolos, an experienced dentist with a
special interest in thumb-sucking habits in children. He
deals first hand in management of dental, social, and
functional problems which can arise with persistent
thumb sucking. The book and chart are a noninvasive
and effective strategy for stopping thumb sucking and
have received positive support from psychiatrists,
speech pathologists, and pedodontic societies. He is
very mindful that parents and practitioners should not
place pressure on children to stop as this is only met with
resistance and can entrench the problem.
The book is beautifully illustrated, with characters
that will appeal to both boys and girls. As well as a
stand-alone story, The Little Bear who Sucked his Thumb
is especially useful to parents with children that have
a thumb-sucking habit. It addresses the problem in a
fun and non-threatening way. The wall chart can be
personalized with your child’s name, helping to further
motivate them, and in conjunction with the book, find
the desire to stop sucking their thumb.
™™ My Special Shirt (Fig. 30.15A): This helps in minimizing
the damage of finger sucking by providing a number of
tools to address the habit in a phased manner. This shirt
keeps the child busy; thereby, avoiding the habit. By
working as a team, your child will gain confidence, balance
emotions, and stop their dependence on need to suck
™™ Thumbusters (Fig. 30.15B): It is a glove like device,
which is worn around the thumb with support at the
wrist, which provides the child with repeated reminders
at all times.
A B
Figs. 30.15A and B: (A) Special shirt; (B) Special gloves.
351
™™ Elbow guard and three-alarm system (Fig. 30.16):
RURS’ elbow guard is an innovative and unique
appliance to prevent thumb/finger sucking habit in
children, which was developed by Shetty et al. in
20031 (Table 30.1). RURS’ elbow guard will allow some
movement of the elbow but will not allow the thumb to
reach the mouth. Children usually accept the appliance
easily. They perceive it something like a wrist band and
thought themselves to be fashionable, so they won’t try
to take it off.
Advantages of RURS’ elbow guard:
™™ Easy parent supervision and follow-up
™™ Convenience and comfort to the patient
™™ Easier to make impression of the elbow
™™ Patient acceptance is better
™™ Loose enough to allow sufficient blood flow
™™ Can be given in any age group
™™ Can be worn under full sleeve shirt
™™ Very economical.
Three-alarm system: Revisited to treat thumb-sucking
habit
RURS’ elbow guard was modified along with the
incorporation of revised three-alarm system. A musical
chip with speaker was incorporated on the outer side of
the acrylic elbow guard during acrylization. So, whenever,
the child tries to suck the thumb or digit, the switch button
will be pressed by the elbow joint and music would play
reminding the child to stop the habit.
Fig. 30.16: RURS’ elbow guard.
352 Section 7  Pediatric Orthodontics

Table 30.1:  Difference between the previous and ™™ Advise parents and caregivers to exercise judgment and
revised three-alarm system. restraint regarding pacifier use
Alarm Previous three-alarm Revised three-alarm system ™™ Clean pacifiers routinely and avoid sharing between
system (Norton and (Shetty et al., 2015)2 siblings
Gellin, 1968)3 ™™ Suggest to parents that pacifier use be curtailed
First The child feels the The child wearing the elbow beginning at 2 years of age.
tape in his mouth guard
Second The closed pin mildly The music/vibration/siren/ TONGUE THRUSTING
jabbing the elbow recorded voice played when
tried to bend the elbow Tongue thrusting is the most controversial of all oral habits.
Third/final The bandage is The elbow guard restricting There is a wide range of attitudes and opinions among various
tightened thumb/finger reaching the authors regarding diagnosis and effect of tongue thrusting.
mouth Tulley (1969) defined tongue thrust as the forward
movement of the tongue tip between the teeth to meet the
PACIFIER HABIT lower lip during deglutition and in sounds of speech, so that
Pacifiers have been used by mankind for more than the tongue lies interdentally (Fig. 30.17).
thousands of years. They have been identified to help
children in transitioning to sleep, to soothe infants, to provide
comfort while teething. The effects of pacifier sucking are the
same as NNS or thumb sucking, but some other associated
risks with pacifier sucking are explained here.

Effect of Pacifier use on Breastfeeding

Newman hypothesized that the use of pacifier causes
“nipple confusion” in the infant and a faulty technique of
breastfeeding which eventually leads to early weaning. This
was also supported by Mitchell who found out that infants
given pacifiers in hospitals are less likely to breastfeed
mothers on discharge as compared to those who were
not given pacifiers. Although there are a variety of authors
like Schubiger, Franco, Fleming who feel that pacifier and
Fig. 30.17: Tongue thrusting.
breastfeeding have no correlation.

Pacifier and Caries Classification of Tongue Thrusting

Prolonged use of pacifiers in children and specially those
used with sugar syrups or sweetened liquids have a positive
relation with caries.
Safety Issues
™™ Physical safety: Materials and designs of pacifiers that
have been associated with asphyxia, infection, and death
™™ Chemical safety: Due to presence of N-nitrosamines in
pacifiers which are proven to be carcinogenic
™™ Immunologic safety: Latex allergy and early sensitization
Recommendations
™™ Educate parents and caregivers about the safe use of
pacifiers
™™ Withhold the use of pacifiers until breastfeeding is
established. After that point, limit their use for soothing
breastfeeding infants.
™™ Physiologic: This comprises of the normal tongue thrust
swallow of infancy
™™ Habitual: The tongue thrust swallow is present as a habit
even after the correction of the malocclusion
™™ Functional: The tongue thrust mechanism is an
adaptive behavior developed to achieve oral seal
™™ Anatomic: Persons having enlarged tongue can have an
anterior tongue posture.
Etiology of Tongue Thrusting
™™ Genetic influence: There is a complexity of factors
that might predispose a child toward this habit like
an extremely high narrow palatal arch, an imbalance
between the number and size of teeth, and the size of
the oral cavity
™™ Thumb sucking: This act depresses the tongue and
keeps the teeth apart so one can suspect that it also
induces malfunctions of the tongue during deglutition