Oral Habits

Protecting All Childrens Teeth
Oral
Habits
http://www.aap.org/oralhealth/p
1 act
Introduction
Used with permission from ANZ Photography
Oral habits, including nonnutritive sucking, teeth grinding

(bruxism), and nailbiting, are extremely common in children
and are often a source of concern for families and questions
for pediatricians.
The information provided in this presentation is intended to
help health professionals appropriately reassure parents,
address concerns and, when necessary, intervene.
2 www.aap.org/oralhealth/pact
Learner Objectives
Used with permission from ANZ Photography
Upon completion of this presentation, participants will be

able to:
Discuss the benefits of non-nutritive sucking.

Summarize the AAP policy on pacifier use and Sudden
Infant Death Syndrome.
State the dental effects of non-nutritive sucking and
the suggested age for intervention.
Describe the oral effects and suggested management
of bruxism.
Nonnutritive Sucking
Sucking is a normal baby reflex,

beginning around the 29th week
of gestation.
Almost 100% of normal babies

engage in nonnutritive sucking.
Babies may suck their thumb,
fingers, hand, a pacifier, or other Used with permission from Content Visionary
inanimate object such as a

blanket or toy.
Nonnutritive Sucking, continued
Nonnutritive sucking has several benefits.

It is an early step in an infant's ability to
self regulate emotions
It helps the child to relax and focus his
or her attention
It provides comfort and security.
Sucking tends to occur more often when
the child is tired, bored, anxious, or upset.
Used with permission from Melinda B. Clark,
MD; Associate Professor of Pediatrics at
Albany Medical Center
Nonnutritive Sucking, continued
Although most children discontinue

nonnutritive sucking between 2 and 4 years
of age, more than 20% still engage in the
habit at age 3.
Pacifier users typically discontinue

nonnutritive sucking earlier than thumb
suckers.
Older children who are thumb suckers are

Paper permission on file from David Krol
often motivated to quit by peer pressure at

school.
Pacifiers and SIDS
The use of pacifiers has been

shown
to decrease the incidence of
Sudden
Infant Death Syndrome (SIDS).
In 2005, the American Academy

of
Pediatrics (AAP) Task Force on Used with permission from Giusy Romano-Clarke
Sudden Infant Death Syndrome

published recommendations on
pacifier use.
Pacifiers and SIDS, continued
Consider offering a pacifier at nap time and bedtime.
Although the mechanism is not known, the reduced

risk of
SIDS associated with pacifier use during sleep is
compelling.
The evidence that pacifier use interferes with
breastfeeding or
causes later dental complications is not as compelling.
Pacifier Recommendations
The task force recommends use of a pacifier throughout the

first year of life, according to the following procedures:
The pacifier should be used when placing the infant down
for sleep and not be reinserted once the infant falls asleep
Pacifiers should not be coated in any sweet solution
Pacifiers should be cleaned often and replaced regularly
For breastfed infants, delay pacifier introduction until 1
month of age to ensure that breastfeeding is firmly
established
Pacifier Recommendations, continued
Pacifiers should never be used to replace or delay

meals and should be offered only when the caregiver is
certain the child is not hungry
Pacifiers should have ventilation holes and a shield

wider than the childs mouth (at least 1 inches in
diameter)
Pacifiers should be one piece and made of a durable

material, replaced when worn, and never tied by a string
to the crib or around a childs neck or hand
Dental Effects
Anterior Open Bite

The dental effects of
nonnutritive sucking directly
correlate with the frequency,
intensity, duration, and
nature
of the habit.
The most common effect is

movement of the central Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric
incisors upward and

Dentistry, University of Alabama at Birmingham
anteriorly,
which may result in an
anterior
11 open bite. www.aap.org/oralhealth/pact
Dental Effects of Non-nutritive
sucking
Anterior Open Bite Right Posterior Crossbite
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke
Department of Pediatric Dentistry, School of Dentistry University of North Carolina Pediatric Dentistry, Duke Children's Hospital
Other possible effects of nonnutritive sucking include:

Maxillary constriction (decreased hard palate width) with can result in
posterior crossbite
Movement of the central incisors forward in the horizontal plane (overjet)
12
Dental Effects, continued
Dental effects are generally reversible and unlikely to

cause any long-term problems if the habit is discontinued
early.
It is important to counsel families to help children break

the habit before the permanent teeth erupt, preferably
beginning intervention by age 3.
If the child is struggling to break the oral habit, 36

months is
an appropriate age to consider referral for dental
evaluation
and management.
Intervention
When a child persists with a sucking habit, consider the

following approaches:
Tell the child in basic terms why you want them to stop and
that you believe they can do so
Implement reminder therapy, the use of aids such as rubber
bands or string, to help a child interrupt the habit
Start a reward system
Encourage the use of a stuffed animal or other comfort
object
Physical Intervention
For physical intervention to work, the child must be

ready and agreeable.
Techniques include:
Covering hands at night with mittens or socks
Dressing the child in a special shirt with the sleeves
sewn closed
Placing a bandage or specialty plastic guard on the
thumb or finger
Physical Intervention
If other methods are not

effective, an intra-oral
appliance
can be placed by a
dentist to prevent sucking.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke The appliance is removed
after
Pediatric Dentistry, Duke Children's Hospital
the habit is broken.
Bruxism
Bruxism is the habitual grinding of teeth. It most often occurs

at night but can occur when awake or asleep.
The etiology of bruxism includes habit, emotional stress
(response to anxiety, tension, anger, or pain), parasomnias,
neurologic abnormalities, tooth malocclusion, and, rarely, a
medication side-effect.
Often, the etiology of bruxism is unknown.
Bruxism
Bruxism can result in enamel wearing of the front and

back teeth.
If severe, bruxism can result in tooth sensitivity or root

exposure, which requires treatment.
Bruxism may also contribute to temporomandibular

joint disorder and headaches.
Bruxism, continued
For children younger than 8

years, treatment is usually not
required.
If the bruxism appears to be a

stress response, stress
management, behavioral therapy, or
biofeedback may be effective. Used with permission from Content Visionary
For older children, a dentist may recommend a mouth guard

be worn at night.
Question #1
Parents of an 18-month-old inquire about their son's thumb

sucking habit. What is your most appropriate reply?
A. Suggest that they try to substitute a pacifier for the thumb sucking.
B. Reassure that this is a normal habit and the child will stop on his
own when he is ready.
C. Reassure that this is a normal habit for this developmental age and
intervention should be reserved until after age 3.
D. Attempt to break the habit now to prevent damage to the erupting
teeth, using a distasteful liquid applied to the thumb or a barrier
method (eg, socks or gloves), especially at night.
E. Recommend they speak to the child's dentist and follow his or her
recommendations.
Answer
Parents of an 18-month-old inquire about their son's thumb

sucking habit. What is your most appropriate reply?

A. Suggest that they try to substitute a pacifier for the thumb
sucking.
B. Reassure that this is a normal habit and the child will stop on his
own when he is ready.
C. Reassure that this is a normal habit for this developmental age and
intervention should be reserved until after age 3.
D. Attempt to break the habit now to prevent damage to the erupting
teeth, using a distasteful liquid applied to the thumb or a barrier
method (eg, socks or gloves), especially at night.
E. Recommend they speak to the child's dentist and follow his or her
recommendations.
Question #2
Which of the following statements about bruxism is not

true?

A. It tends to occur most often at night.
B. Approximately 30% of children develop bruxism during the
early school years.
C. It can result in enamel wearing of the front and back teeth.
D. It is often caused by habit or stress, although sometimes the
etiology is unknown.
E. It requires treatment at all ages to prevent long-term
complications.
Answer
Which of the following statements about bruxism is not

true?

A. It tends to occur most often at night.
B. Approximately 30% of children develop bruxism during the
early school years.
C. It can result in enamel wearing of the front and back teeth.
D. It is often caused by habit or stress, although sometimes the
etiology is unknown.
E. It requires treatment at all ages to prevent long-term
complications.
Question #3
True or False? Nonnutritive sucking occurs in

approximately 50% of all babies.

A. True.
B. False.
Answer
True or False? Nonnutritive sucking occurs in

approximately 50% of all babies.

A. True.
B. False.
Question #4
Which of the following factors have been shown to be

associated with a prolonged nonnutritive sucking
habit?

A. First-born child.
B. Younger maternal age.
C. Less education by primary caregivers.
D. Breastfeeding.
E. All of the above.
http://www.aap.org/oralhealth/pa
26 ct
Answer
Which of the following factors have been shown to be

associated with a prolonged nonnutritive sucking
habit?

A. First-born child.
B. Younger maternal age.
C. Less education by primary caregivers.
D. Breastfeeding.
E. All of the above.
27 ct
Question #5
Which of the following is the most common effect of a

prolonged thumb sucking habit?

A. Maxillary constriction.
B. Posterior open bite.
C. Upward movement of central incisors.
D. Temporomandibular Joint Disorder.
E. All of the above are equally common.
28 ct
Answer
Which of the following is the most common effect of a

prolonged thumb sucking habit?

A. Maxillary constriction.
B. Posterior open bite.
C. Upward movement of central incisors.
D. Temporomandibular Joint Disorder.
E. All of the above are equally common.
29 ct
References
1. Adair SM. Pacifier Use in Children: A Review of Recent Literature. Pediatr Dent. 2003;
25(5): 449-458. Available online at: http://www.aapd.org/upload/articles/adair-25-
05.pdf. Accessed January 15, 2007.
2. American Academy of Pediatric Dentistry, Council on Clinical Affairs. Guideline on
Infant Oral Health Care. 2012. Reference Manual 35(6): 137-141. Available online at:
www.aapd.org/media/Policies_Guidelines/G_infantOralHealthCare.pdf . Accessed November
11th, 2013.
3. American Academy of Pediatrics. The Changing Concept of Sudden Infant Death
Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping
Environment, and New Variables to Consider in Reducing Risk. Policy Statement: Task
Force on Sudden Infant Death Syndrome. Pediatrics. 2005; 116(5): 1245-1255.
Available online at: http://aappolicy.
aappublications.org/cgi/content/full/pediatrics;116/5/1245. Accessed January 15, 2007.
4. Fleming PJ et al. Pacifier use and sudden infant death syndrome: results from the
CESDI/SUDI case control study. Arch Dis Child. 1999; 81: 112-116.
5. Holt K and Barzel R. A Health Professionals Guide to Pediatric Oral Health
Management; 2006. http://www.mchoralhealth.org/PediatricOH/index.htm. Accessed
January 15, 2007.
30 ct
References, continued
6. Montaldo L, Montaldo P, Cuccaro P, et al. Effects of feeding on non-nutritive sucking

habits and implications on occlusion in mixed dentition. Int J Paediatr Dent. 2011;
21(1):68-73.
7. North K, Fleming P, Golding J. Pacifier Use and Morbidity in the First Six Months of
Life. Pediatrics. 1999; 103(3): e34. Available at:
http://www.pediatrics.org/cgi/content/full/ 103/3/e34. Accessed January 15, 2007.
8. Nowak AJ, Warren JJ. Infant Oral health and Oral habits. Pediatr Clinics of N Am.
2000; 47(5): 1043-66.
9. Warren JJ et al. Effects of oral habits duration on dental characteristics in the
primary dentition. JADA. 2001; 132(12): 1685-93.
10. Warren JJ et al. Nonnutritive sucking behaviors in preschool children: A
longitudinal study. Pediatr Dent. 2000; 22(3): 187-91.
11. Zardetto CG, Rodrigues C, Stefani FM. Effects of different pacifiers on the primary
dentition and oral myofunctional structures of preschool children. Pediatr Dent.
2002; 24(6): 552-560. Available online at: http://www.aapd.org/upload/articles-
old/zardetto11-02.pdf. Accessed January 15, 2007.

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Protecting All Childrens Teeth

Oral habits, including nonnutritive sucking, teeth grinding

Upon completion of this presentation, participants will be

Discuss the benefits of non-nutritive sucking.

Sucking is a normal baby reflex,

Almost 100% of normal babies

inanimate object such as a

Nonnutritive sucking has several benefits.

Although most children discontinue

Pacifier users typically discontinue

Older children who are thumb suckers are

often motivated to quit by peer pressure at

The use of pacifiers has been

In 2005, the American Academy

Sudden Infant Death Syndrome

Consider offering a pacifier at nap time and bedtime.

Although the mechanism is not known, the reduced

The task force recommends use of a pacifier throughout the

Pacifiers should never be used to replace or delay

Pacifiers should have ventilation holes and a shield

Pacifiers should be one piece and made of a durable

Anterior Open Bite

The most common effect is

incisors upward and

Anterior Open Bite Right Posterior Crossbite

Other possible effects of nonnutritive sucking include:

Dental effects are generally reversible and unlikely to

It is important to counsel families to help children break

If the child is struggling to break the oral habit, 36

When a child persists with a sucking habit, consider the

For physical intervention to work, the child must be

If other methods are not

the habit is broken.

Bruxism is the habitual grinding of teeth. It most often occurs

Bruxism can result in enamel wearing of the front and

If severe, bruxism can result in tooth sensitivity or root

Bruxism may also contribute to temporomandibular

For children younger than 8

If the bruxism appears to be a

For older children, a dentist may recommend a mouth guard

Parents of an 18-month-old inquire about their son's thumb

Parents of an 18-month-old inquire about their son's thumb

Which of the following statements about bruxism is not

Which of the following statements about bruxism is not

True or False? Nonnutritive sucking occurs in

True or False? Nonnutritive sucking occurs in

Which of the following factors have been shown to be

Which of the following factors have been shown to be

Which of the following is the most common effect of a

Which of the following is the most common effect of a

6. Montaldo L, Montaldo P, Cuccaro P, et al. Effects of feeding on non-nutritive sucking

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