Recognition, Intervention and Management of Digit

RECOGNITION, INTERVENTION AND MANAGEMENT OF DIGIT SUCKING: A CLINICAL GUIDE FOR THE GENERAL DENTAL PRACTITIONER OHSUN KWON, PARAS JITESHKUMAR HARIA, SHEENA KOTECHA Prim Dent J. 2016;5(4):56-60

ABSTRACT Digit sucking is a common habit in young children, which if allowed to continue for a prolonged period, can adversely affect the development of the face and dental occlusion. Patients with digit sucking habits often present with an increased overjet, reduced overbite, anterior open bite, posterior crossbite and possible skeletal changes which can be challenging and costly to correct if the habit is not ceased in a timely manner. This article aims to provide guidance for general dental practitioners to recognise and appropriately manage patients with a digit sucking habit.

S

ucking is a primitive reflex of mammals, which allows nutrients to be obtained through breastfeeding. In the early months after birth, many children develop a non-nutritive sucking (NNS) habit with their own digit, blanket or pacifier (or ‘dummy’). It has been reported from studies that a NNS habit is prevalent in 51-84% of babies in the first 24 months,1,2 and it is believed to provide psychological comfort and security for the child.3

KEY WORDS Digit Sucking, Non-nutritive Sucking, Malocclusion, Habit Cessation, Orthodontic Treatment AUTHORS Ohsun Kwon BDS MJDF RCS (Eng) AKC DCT2 Oral and Maxillofacial Surgery, University Hospitals Birmingham Paras Jiteshkumar Haria BDS iBSc (Hons) MFDS RCSEd AFHEA Orthodontic StR, Birmingham Dental Hospital Sheena Kotecha FDS Ortho RCS Ed MPhil MOrth RCS Ed, BDS (Hons) Consultant Orthodontist, Birmingham Dental Hospital

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In most children, the NNS habit gradually diminishes with age and increased social interaction at schools. Bishara et al4 followed behaviour in a cohort of children and observed a decrease in both the use of a pacifier, from 40% at the age of one year to less

than 1% at the age of eight years, and a digit-sucking habit from 31% to 4%. They also found that after the age of four, digit sucking becomes the dominant form of NNS behaviour.

Effect of digit sucking on dental occlusion

It has been well established that prolonged digit sucking is a risk factor for dental malocclusion,5,6,7 the features of which are summarised in Table 1. Figure 1 illustrates some of the features present in a patient with a digit sucking habit. The force applied from the digit to the palate stimulates displacement of maxillary incisors in a labial direction and mandibular incisors in a lingual direction, resulting in an increased overjet and reduced overbite or an anterior open bite (AOB). The AOB may be symmetrical or asymmetrical, depending on the position of the digit during the habit. Meanwhile, the tongue position is displaced away from the maxillary arch, and instead expands mandibular arch width. This, combined with narrowing of the maxillary arch caused by the negative pressure of the cheek, results in a posterior buccal crossbite. The overall severity of malocclusion depends on the extent of the digit sucking habit,8 including: • Duration and frequency. • Amount of force applied from the digit. • Position and direction of force applied from the digit.

Figure 2: The second and third fingers provide evidence of a digit sucking habit when compared to the rest of the hand

P R I M A R Y D E N TA L J O U R N A L

TABLE 1

FEATURES OF MALOCCLUSION ASSOCIATED IN PATIENTS WITH DIGIT SUCKING BEHAVIOUR9,10 Dentoalveolar features

• • • • • •

P roclined maxillary incisors R etroclined mandibular incisors R educed overbite or anterior open bite Increased overjet P osterior crossbite R otation of occlusal plane

Soft tissue changes

• L ip incompetence • L ower lip trap

Skeletal features

• • • •

N arrowing of maxillary arch W idening of mandibular arch Increased lower face height C lass II skeletal relationship due to backward rotation of mandible

Extra-oral signs of digit sucking

The extent of the habit may not be fully disclosed by the patient and family. Examining the digit which is used for sucking may provide some insight. It may have a pink surface colour and appear contrastingly clearer compared to the remaining fingers, sometimes with calluses and blisters.11 Figure 2 illustrates some of the signs that may be observed on digits that are being sucked.

Importance of habit cessation

Pictures used with kind permission from Mr John Turner, Consultant Orthodontist

When the child is in the deciduous dentition, the parents can be reassured

that so long as the habit can be weaned off with gentle persuasion, there is no requirement for further treatment. Usually, the AOB and posterior crossbite resolves spontaneously after complete cessation of the habit.10 If the child shows no sign of giving up the habit at the mixed dentition stage (around the age of seven), there comes a need to be more proactive with interventions rather than simple verbal persuasion. With age, dentoskeletal maturity is achieved, and the likelihood of spontaneous resolution of the AOB is decreased.12 Patients with an AOB

can experience difficulties with speech (lisping) and incising food, and may also express aesthetic concerns.10,13,14 The closure of the AOB usually requires a course of orthodontic fixed appliance treatment, and orthognathic surgery may also be required for patients with severe discrepancies.13 Further problems arise even after these treatments are provided, as patients with AOB are prone to relapse. Jensen and Ruf15 observed 41 patients with combined orthodontic treatment and orthognathic surgery, and found only 40% of patients had maintained sound incisal contacts, overjet and overbite at the end of retention period (10-26 months) without relapse. Greenlee et al16 reported relapse rates of 18% and 25% with surgical and non-surgical AOB treatment respectively. In addition, it is also important to consider the overall time and expenses that are incurred by patients and healthcare providers. Borrie and colleagues17 calculated that in NHS Tayside, a move from providing orthodontic appliances to a more preventive regime could save service expenses of up to £20,000 in the region. This calculation, however, is based on local demographic data and the Scottish orthodontic commissioning model, and therefore there will be variation between different regions of the UK. The general dental practitioner (GDP) has a pivotal role in educating parents and offering effective methods of habit intervention to halt a largely preventable malocclusion developing.

Principles of patient management Figure 1: Clinical photographs showing some of the features of a malocclusion in the permanent dentition due to a digit sucking habit: proclined upper incisors, anterior open bite, posterior crossbite, narrowing of the upper arch and widening of the lower arch

Taking a detailed history and examination are the first steps in ascertaining the full extent of the problem. The history should include questions on the approximate onset, average daily duration and frequency of digit sucking habit. It is useful to note any attempts which have been previously made by the patient and family to stop the habit, and if the pattern of the habit has improved or worsened in recent times. Once the behaviour pattern has been discerned, the next step is to discuss the nature of the problem and how the habit can be stopped. Behavioural interventions are reliant on co-operation

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RECOGNITION, INTERVENTION AND MANAGEMENT OF DIGIT SUCKING: A CLINICAL GUIDE FOR THE GENERAL DENTAL PRACTITIONER

Psychological intervention

There are several different models of psychological intervention described in the scientific literature.20

Figure 3: Thumb and finger guard from Thumbsie® from patients and parents, and this must be first checked and documented during assessment. To encourage the patient and family to follow the advice, a motivational interviewing format18 should be used, where the patient has most of the control during discussion. This means: • The patient can raise their concerns with regard to the digit sucking habit in a free manner, without fear or embarrassment. • The GDP can explain the benefits of stopping the habit, the likely consequences of carrying on otherwise and different options for intervention method (see next section). • Being given the information, the patient is empowered to set their own goals which are realistic, time-specific and measurable (for example, using a calendar to check progress).

Picture used with kind permission from Mr John Scholey, Consultant Orthodontist

Figure 4: ‘Mavala Stop’ and ‘Stop and Grow’

Figure 5: Bluegrass roller appliance

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It is also useful to learn if the habit is an unconscious behaviour or an indication of another underlying emotional problem,19 as this can lead to different treatment needs and priorities for the patient. Taking a supportive and empathetic approach throughout the consultation is key in forming a good relationship with the patient. This increases the likelihood of successful habit cessation. The methods used for breaking the digit sucking habit can be mainly divided into the following three groups: • Psychological intervention. • Aversive therapy. • Orthodontic appliance.

Positive and negative reinforcement Reinforcement can be defined as a stimulus which increases the likelihood of a particular behaviour in an individual.21 To encourage the child to avoid digit sucking, the type of reinforcement can be either positive or negative: • In positive reinforcement, a pleasant stimulus is added to motivate the child. This can be a verbal praise or gift when the child is not digit sucking. • In negative reinforcement, a child stops digit sucking because the habit results in an unpleasant experience (see ‘Aversive therapy’ and ‘Orthodontic appliances’ sections later in this paper). The child is discouraged from digit sucking to avoid this negative experience. Differential reinforcement of other behaviour This method is used by Christensen,22 where reinforcement is not given for digit sucking behaviour, but given for any other behaviour, during set period of time. This selective reinforcement process eliminates the unwanted habit by extinction, without using punishments. Habit reversal training This method has been first described by Azrin et al23 in 1973. The five major components of habit reversal training include the following:24 1 Awareness training – this involves being aware of situations where the habit is likely to occur, which allows the child to gain more self-control. 2 Relaxation training – to manage stress levels which may be a triggering factor for digit sucking. Examples of relaxation exercises include deep breathing and progressive muscle relaxation. 3 Competing response training – where a child is encouraged to carry out an alternative behaviour in place of digit sucking and to repeatedly practice performing the behaviour.


Instead of thumb sucking, the child may be clenching fists with the thumb inside.22 4 Motivation procedures – measures to ensure ongoing compliance from the child and the family, consisting of review, social peer support and reward systems. 5 Generalisation training – helping the child to apply the principles of habit control on common everyday situations. Due to the complexity of the training itself, it is recommended to involve a child psychologist in this type of programme.

TABLE 2

SUMMARY OF ADVANTAGES AND DISADVANTAGES OF DIFFERENT INTERVENTIONS Intervention approach

Advantages

Disadvantages

Psychological

• L east invasive for child’s

• R equires strong co-

emotional development • E ncourages parents to become involved together with patient

• • • •

Orthodontic appliance

• E ffective deterrent of

Aversive therapy

Physical methods of deterring the child can be a physical cover in the form of a plaster, glove or long sock which are all available for purchase readily and cheaply. Micropore tape can be used to secure a glove or sock in place to prevent the barrier from being dislodged or easily removed by the child. Commercially manufactured thumb and finger guards as shown in Figure 3 are available. Alternatively, chemical substances with a bitter taste can be applied to nail of the thumb/fingers and has also been shown to be effective.25 Products such as ‘Mavala Stop’ (MAVALA, Switzerland) and ‘Stop and Grow’ (The Mentholatum Company, Australia) can be purchased from retail stores (Figure 4). The active ingredients for bitterness include denatonium benzoate and sucrose octa acetate. The advantages of aversive therapy include that it can be a quick, costeffective, easy method for parents. It must be borne in mind that aversive therapy relies on patient compliance. It will be unsuccessful if, for example, the patient continues to suck digits that haven’t been treated with the aversive substance or the patient removes the physical barrier outside supervised hours.

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digit sucking and tongue thrusting • A bility to treat other occlusal features by adding active orthodontic components

Orthodontic appliance

Orthodontists and dentists with sufficient orthodontic training can provide a removable or fixed orthodontic appliance, which has a crib, rake or Teflon® roller (Bluegrass appliance as shown in Figure 5) on the surface of the hard palate.2 Removable appliances offer versatility as the child can remove the device before eating or brushing, but may not be the appropriate option for patients with poor compliance11 or with a contraindicating medical history such as epilepsy.27 Figure 6 illustrates a case where provision of such an appliance has successfully discouraged the digit

3 Larsson E. The prevalence and aetiology of prolonged dummy and 1 Larsson E. Sucking, Chewing, and finger-sucking habits. Eur J Orthod Feeding Habits and the Development 1985;7:172–176. of Crossbite: A Longitudinal Study of 4 Bishara SE, Warren JJ, Broffitt B, Levy Girls from Birth to 3 Years of Age. SM. Changes in the prevalence of Angle Orthod 2001;71:116–119. nonnutritive sucking patterns in the first 2 Ravn JJ. The prevalence of dummy 8 years of life. Am J Orthod Dentofac and finger sucking habits in Orthop 2006;130:31–36. Copenhagen children until the age 5 Mistry P, Moles DR, O’Neill J, Noar of 3 years. Community Dent Oral J. The occlusal effects of digit sucking Epidemiol 1974;2:316–322. habits amongst school children in

REFERENCES

N on-invasive Q uick C ost-effective A vailable for purchase by patient

Aversive (physical and chemical barriers)

operation from parents

• T ime-consuming

• P atient may be restricted

from other daily activities during wear of physical barrier • L ong-term exposure to the aforementioned chemical agents can result in skin irritation and mucous membrane damage

• M ost costly option for

provision and repair work during treatment • Inconvenience for child during eating • D ifficult oral hygiene control • C an be negatively perceived by the patient as ‘punishment’

sucking habit, followed by spontaneous resolution of AOB. The effectiveness of the Bluegrass appliance has been well documented in literature. Haskell and Mink26 used the appliance to successfully break the habit in all 24 patients within six months. Greenleaf and Mink28 used the appliance to cease the habit in 93% of patients (28 out of 30). Another advantage of an orthodontic appliance is the ability to add active orthodontic components to simultaneously treat the malocclusion. For example, Kulkarni29 added a palatal expander to the Bluegrass appliance to treat a patient with posterior crossbite.

Northamptonshire (UK). J Orthod 2010;37:87–92. 6 Viggiano D, Fasano D, Monaco G, Strohmenger L. Breast feeding, bottle feeding, and non-nutritive sucking; effects on occlusion in deciduous dentition. Arch Dis Child 2004; 89:1121–3. 7 Vázquez-Nava F, Quezada-Castillo JA, Oviedo-Treviño S, SaldivarGonzález AH, Sánchez-Nuncio HR, Beltrán-Guzmán FJ et al. Association

between allergic rhinitis, bottle feeding, non-nutritive sucking habits, and malocclusion in the primary dentition. Arch Dis Child 2006;91:836–40. 8 Lindner A, Modeer T. Relation between sucking habits and dental characteristics in preschoolchildren with unilateral cross-bite. Eur J Oral Sci 1989;97:278–283. 9 Phulari BS. Orthodontics: Principles and Practice. London: JP Medical Ltd; 2011.

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RECOGNITION, INTERVENTION AND MANAGEMENT OF DIGIT SUCKING: A CLINICAL GUIDE FOR THE GENERAL DENTAL PRACTITIONER

to be the preferred first-line of treatment amongst dental practitioners, with physical barriers being more effective than chemical deterrents.

Pictures used with kind permission from Mr John Turner, Consultant Orthodontist

Whichever form of intervention is used, the relapse of habit is always a possibility after the end stage of intervention. If the patient is unable to cease the habit, referral to an orthodontist should be considered. Patients should be advised that fixed appliance treatment should not be commenced until the habit has completely ceased.

Figure 6: Transpalatal arch with re-curved bow following palatal contour. Clinical photographs show spontaneous resolution after cessation of digit sucking habit

Selection of intervention method and follow-up

Although the use of orthodontic appliances has been shown to be effective, they may have a negative impact on a child’s emotional wellbeing and ability to eat and speak.26 For this reason, appliances are left as a last resort of treatment when behavioural and aversive approaches have failed. Ideally, active orthodontic treatment should not be started until the habit has been ceased.

The benefits and limitations of each intervention methods are summarised in Table 2. A recent Cochrane review20 has compared the effectiveness of different methods of intervention and has found that with any form of intervention, there is a higher likelihood of habit cessation when compared to having no treatment. Between different methods of intervention, no single method of intervention was found to be significantly more effective than the other. The authors recommend that due to its low cost, ease and non-invasive application, aversive therapy is likely

The follow up period for these patients is determined by various factors including age and type of intervention. Where advice on habit cessation has been provided, dental development may be monitored for up to one year to observe if any spontaneous improvement occurs in the malocclusion. If an orthodontic appliance is provided, the patient should be reviewed every six to eight weeks to continue monitoring progress with habit cessation and correction of the malocclusion.

Summary

Digit sucking can negatively affect development of the dentition, which may lead to complex treatment needs involving lengthy orthodontic and possible surgical treatment. Emphasis is therefore placed on making a timely diagnosis and intervention. With an awareness of treatment options available, GDPs can provide an effective first line of intervention by educating patients and families to set up habit intervention regimes.

10 Cobourne MC, DiBiase AT. Handbook bite malocclusion: a meta-analysis. Aspects of Disruption of Thumbsucking 2011;38:522-524-528-532. of Orthodontics. London: Mosby; 2010. 14 Hamdan AM, Singh V, Rock W. Am J Orthod Dentofac Orthop by Means of a Dental Appliance. 11 Matthew Clover. Ross Hobson. Digit 2011;139:154-69. Angle Orthod 1955;25:23–31. Perceptions of dental aesthetics of Class Sucking – What to do. Orthod Updat 20 Borrie FRP, Bearn DR, Innes NPT, III and anterior open bite malocclusions. 17 Borrie FRP, Elouafkaoui P, Bearn DR. 2013;6:6–9. A Scottish cost analysis of interceptive Iheozor-Ejiofor Z. Interventions for the Angle Orthod 2011;82:202–208. 12 Silva M, Manton D. Oral habits--part orthodontics for thumb sucking habits. J cessation of non-nutritive sucking habits 15 Jensen U, Ruf S. Success rate of anterior 1: the dental effects and management Orthod 2013;40:145–54. in children. Cochrane database Syst open-bite orthodontic-orthognathic of nutritive and non-nutritive sucking. J 18 Freeman R. the psychology of dental Rev 2015. doi:10.1002/14651858. surgical treatment. Am J Orthod Dent Child 2015;81:133–139. patient care: Strategies for motivating CD008694.pub2. Dentofac Orthop 2010;138:716–719. 13 Sandler PJ, Madahar a K, Murray the non-compliant patient. Br Dent J 21 Skinner B. The Behavior of Organisms: 16 Greenlee GM, Huang GJ, Chen a. Anterior open bite: aetiology 1999;187:307–312. An Experimental Analysis. BF Skinner SS, Chen J, Koepsell T, Hujoel P. and management. Dent Updat 19 Korner AF, Reider N. Psychologic Foundation, 1990. Stability of treatment for anterior open

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