Abstracts

Tiny Tots and Thumb Sucking

1

2 Professor & HOD

3 Reader

Senior lecturer,

Department of Pediatric and Preventive dentistry,

Dr. PunithavathyC-12, Sri Kumaran grand palace,Thindal Post,Erode, Tamilnadu – IndiaPhone No : 9843518986E – mail : [email protected]

KSR Institute of Dental Science & Research,Tiruchengode, Tamil Nadu.Pin : 637 209

Address for correspondence :

ABSTRACT: Thumb sucking is a natural reflex in infants that usually starts in intrauterine life. It is the first co-ordinated muscular activity in humans. Few children accommodate with the habit if they use it to comfort themselves for deep rooted psychological reasons. The examination of a Pediatric dental patient with an oral habit, the practitioner requires to make a series of relatively complex evaluations before arriving at a diagnosis or making any recommendations for care .The assessment of these behaviors must be coupled with a sensitive assessment of the physical and emotional status of the child and the relationship of the parent or caregiver. Treating and intercepting the habit with psychological counseling is more important and effective than mechanotherapy that usually we do. Keywords:

Thumb sucking, psychology, psychosocial, counseling

1 2 3Dr. Punithavathy , Dr. Baby John , Dr. Stalin .

REVIEW ARTICLE

Introduction :

Oral habits may be a part of normal development, a symptom with a deep rooted psychological basis or may

1be the result of abnormal facial growth . Thumb and finger habits are considered to be the most prevalent of oral habits, ranges from 13% to 100% at the time of infancy. The prevalence of digit habits decreases with age, by 3.5 to 4 years but some may continue into adulthood. When these habits persist, a number of factors like the frequency, duration, intensity, relationship of the dental arches, and the childs state of health affect the development of oral

2structures.

Classification :

Based on clinical observation thumb sucking is st ndconsidered normal during 1 and 2 year of life then it

disappears as child matures, and does not generate any malocclusion. When the habit persist beyond the preschool period it is considered as abnormal habit and if ignored may cause deleterious effects on dentofacial structures. This is again divided in to psychological and habitual.

Habit with deep rooted emotional factors is called psychological and is associated with insecurities, neglect, and loneliness. Habitual cause is when there is no psychological

3bearing and child performs the act out of habit .

Phases of Development of Thumb Sucking (moyers)

Phase I – Normal and sub clinically significant. It is seen during first three years of life. The habit is considered

normal during this phase and unusually terminates at the end of phase one.

ndPhase II – Clinically significant sucking: the 2 phase extends between 3 – 6 years of age. The presence of sucking during this period is an indication that the child is under great anxiety. Treatment should be initiated during this phase.

Phase III – Intractable sucking: any thumb sucking th thpersisting beyond 4 and 5 year of life should alert the

4dentist to the psychological aspect of approach .

Causative Factors:

Feeding practices:

Thumb sucking is most frequent among breast fed but many studies have proven this consumption to be wrong. The time spent in nutritive sucking was a significant factor in the incidence of thumb sucking. Duration of early feeding in infancy has little effect on the development of this habit.

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.

Socioeconomic status:

Generally families in high status are blessed with

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ample nourishment and hence child's hunger is easily satisfied .While child of low economic status has to suckle intensively for long time to get nourished, so the meantime sucking urge gets exhausted . Calisti et al proposed that children of high economic status demonstrate more oral

5habits than the middle or low class counterparts .

Psychological factor :

Most children practice the habit to comfort themselves from psychological stressful conditions. There is total change in body chemistry whenever the children suck their thumb. It actually makes the brain to produce endorphins which are chemical neurotransmitters that are produced and released within the nervous system. These endorphins calm the body and provide pleasure for the children. Due to this reason, most of the children develop

6the habit to combat the psychological reasons .

If the habit becomes more intense when the child feels that its security is threatened then the cause of the habit will be clearly emotional. Such emotional conditions are feeling of insecurity, fear, frustration, stress, anxiety, boring, afraid etc. There are many psychological factors that make the child emotionally disturbed like working mother, caretaker insecurity, disputed parents, emotional neglect,

7order of siblings, alcoholic father etc .

Clinical Features :

Extraorally the key areas to be examined include digits, involved in sucking. It appears extremely clean, reddened, chapped with short finger nails. Fibrous roughened callus on superior aspect of the finger. Lips may be short and hypotonic, Facial form & profile analysis can also be checked for mandibular retrusion, maxillary protrusion, high mandibular plane angle and convex profile.

Intraorally examine the size of tongue, position at rest and during swallowing, dentoalveolar structures, gingiva, anterior open bite, constricted maxillary arch and

4posterior cross bite

Prevention:

a. Motive based approach.

b. Child engagement in various activities – child practices habit when bored and left alone. Parents should engage the child in various activities by following his hobbies of interest such as painting, engaging in out door activities with his fellow mates.

c. Prevent psychological disturbance by giving proper care, affection, equal attention to all siblings and always making the child to feel secured and well cared.

d. Feeding practices should also be in such a way that baby satisfies both hunger and its sucking urge. In case

of bottle feeding the habit can be prevented by use of physiological nipple and keeping more of vacuum in bottle. Babies who are fed every three hours are less likely to suck their thumb than those who are fed every four hours. But some studies reveals that there is no correlation between feeding practices and thumb sucking, thus it is still

8controversial…

Treatment Modalities:

Once the decision for treatment has been made, one must next determine what intervention is appropriate. The treatment considerations are psychological status, age factor, maturity of the patient, and patient co-operation. The combinations of explanations with consideration of physical appearance and social acceptance may be sufficient for the child to give up the behavior. In addition to their own intention some children may require additional help. Another tool that is helpful for this type of child is the use of positive reinforcement. Rewards for progress in diminishing the habit should include praise and something

2special that is agreeable to patient and parent.

Psychological Therapy :

A. Dunlop's hypothesis

If a subject is forced to concentrate on the performance of the act and 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

1himself as he indulges in the habit .

B. Six steps in cessation of habit (Larson & Johnson)

Step 1: Screening for psychological component.

Step 2: Habit awareness.

Step 3: Habit reversal with a competing response.

Step 4: Response attention.

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

8admonishing the child to stop the habit .

C. Three alarm system: (Norton & Gellin-1968)

A chart is designed with days of the week and blank spaces. When the child engage 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 two inch elastic bandage safety pins are placed at proximal & distal ends of

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Tiny Tots and Thumb Sucking Punithavathy, Baby John & Stalin

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 elbow indicates second alarm. If the habit persist, the bandage is tightened this is the final or third alarm, which will definitely remind the child of the habit.

D. Reward system:

Children should be encouraged and rewarded for not practicing the habit. “contingency contracting” is a contract made between the child and dentist or child and parent. The contract simply states that the child should not suck their thumb for specific period of time. The child should be rewarded if the requirement of the contract is met.

E. Ace bandage approach:

In this approach, bandage should be wrapped around the finger and stars should be entered into the calendar .This reminds the parents to wrap the bandage the previous day and also the child for not sucking their thumb. For every twenty stars entered in the calendar, the child

3should be rewarded .

F. Thumb buddy to love:

This is commercially available and is a positive teaching tool and chemical free method. It contains thumb puppet that is inserted into the child's thumb and a calendar at the back of the book. By having the thumb puppet, the child stays motivated to stop the habit.

G. Thumb - Home concept:

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

1is restrained from thumb sucking during night .

Eliminating chronic thumb sucking by preventing a covarying response: “The behavior is believed to lose its appeal by being reframed as a duty. Thus, make the child to suck all the ten finger the same length of time so that it produce unpleasant reaction and gradually it quits the habit”. Forced repetition of the habit will eventually associate it with unpleasant reaction.

H. Chemical Treatment:

Bitter and sour Chemicals have been used over the thumb causally to terminate the practice but with very minimal success e.g. quinine, asafetida, pepper, caster oil, etc. Nowadays new anti-thumb sucking solutions like femite, thumb-up, anti-thumb are also being marketed but

9they have also had a very moderate success .

I. Remainder therapy:

Painting something that tastes yucky on the thumbs can make them less satisfying. Physical barriers like band aids, gloves etc can also be used.

J. Thumb guard:

It is an appliance that is worn when the child is tempted to suck. Once the guard is worn they cannot generate vacuum and so sucking is not much satisfying. Another approach is long sleeve gown by doubling the length of the sleeve. It makes difficulty for the child to suck. While providing remainder therapy the child should be instructed that these are just to remind them to take the

1thumb out and it is not a punishment .

K. Parent counseling:

A different approach that can be practiced when its known that the child, wants to discontinue the habit, it requires the cooperation of the parent and their consent to disregard the habit and not mention it to the child. In private conversation with the child, the problem and its effect must be elicited. The parents' role in correction is very significant. Over anxiety and the resulting nagging approach or punishment often creates greater tension and intensification of the habit. Thus a change in the home environment and routine help the child to overcome the habit.

Nagging, scolding or frightening the child should be avoided since this could cause negativism and tend to make him resort to the habit.

From a psychological point of view the child should make the decision that he doesn't want to do it anymore. “Parents should not force the preschoolers to break the habit since they only know the pleasure derived from the habit but they cannot understand why the habit to be stopped”. Some children practice the habit while watching T.V especially when there is no other person to take care of them during day time. So in such case, parents should

10spend more time with children during day time .

Other Possible Approaches:

I. Mechanotherapy:

Removable or fixed palatal crib

It breaks the suction force of the digit on the anterior segment, makes the habit a non-pleasurable one.

Hay Rakes

Mack (1951) advocated the use of dental appliance in children over 3 ½ years of age who are persistent thumb suckers. The device was called hay rake as it was designed with a series of fence like lines that

1prevented sucking .

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Tiny Tots and Thumb Sucking Punithavathy, Baby John & Stalin

Blue Grass appliance

Developed by Bruce S Hasked (1991). It is a fixed appliance using a teflon rolled together with positive reinforcement which is 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.

Modified Blue Grass appliance

This is a modification of the original appliance with the 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 this thumb

11will slip from the rollers thus breaking the act .

Quad helix

The quad helix is fixed appliance used to expand the constricted maxillary arch. The helixes of the appliance serve to remind the child not to place the finger in the

1mouth .

Oral Screen

Oral screen is a functional appliance introduced by Newell in 1912. It produces its effects by redirecting the pressure of the muscular and soft tissue curtain of the cheeks and lips. It prevents the child from placing the thumb

3or finger into the oral cavity during sleeping hours .

Conclusion:

To conclude, the essence of this extract is that, this habit has more psychological factors involved and can be best managed through counseling and psychological approach than the usual mechanotherapy, thereby preventing a full-blown stage of malocclusion that the habit may cause. The management of the habit is accessible to all practioners as it does not demand any special or technique sensitive procedures. Awareness must be created at a community level so that early interception of the habit can be achieved.

References:nd1. Nikhil Marwah, Textbook of Pediatric Dentistry 2 edition 2009.page 281 - 89.

2. John A Maguire., The Evaluation and treatment of Pediatric oral habits, Dental Clinics of North America. Volume 44, No.3, July 2000.

nd3. Shobha Tandon, Textbook of Pedodontics 2 edition 2008.page 492 – 504.nd4. Arathi Rao, Principles and Practice of Pedodontics, 2 edition 2008.page

115 – 126.

5. Eric D.Johnson, Brent E.Larson., Thumb sucking: Literature review. Journal of Dentistry for Children ,Nov - Dec 1993.page 385 – 391.

6. Singh S.P., Utreja A.,Chawla H.S., Distribution of malocclusion types among thumb suckers seeking orthodontic treatment. J Indian Soc Pedo Prev Dent –Supplement 2008.page – s114 – s117.

7. Amitha M Hegde, Arun M Xavier., Childhood Habits: Ignorance is not bliss – A Prevalence Study. International journal of clinical pediatric dentistry, Jan – April 2009;2 (1):26-29.

8. Johnson ED, Larson BE, Thumb sucking: classification and treatment, ASDC J.Dent Child, 1993 Nov-Dec 60(4) : 392-398.

9. Sulaiman Al-Emran., A modified palatal crib appliance for children with predetermined thumb-sucking habit – case report. Saudi Dental Journal, Volume 20, No.1, Jan – April 2008.page 31-35

th10. Mc. Donald Avery, Dentistry for the Child and Adolescent, 8 edition.

11. Bruce S. Haskell., John R. Mink., An aid to stop thumb sucking: the “Bluegrass” appliance. Pediatric Dentistry, Volume 13, No.2.page 64 – 66.

Figure 1: Ace bandage

Figure 3: long sleeve shirt

Figure 2: Thumb guard

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Tiny Tots and Thumb Sucking Punithavathy, Baby John & Stalin