1. 1 http://www.aap.org/oralhealth/pact Protecting All Children’s Teeth Oral Habits

2. 2 www.aap.org/oralhealth/pact Introduction 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. Used with permission from ANZ Photography

3. 3 www.aap.org/oralhealth/pact Learner Objectives 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. Used with permission from ANZ Photography

4. 4 www.aap.org/oralhealth/pact 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 inanimate object such as a blanket or toy. Used with permission from Content Visionary

5. 5 www.aap.org/oralhealth/pact 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

6. 6 www.aap.org/oralhealth/pact 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 often motivated to quit by peer pressure at school. Paper permission on file from David Krol

7. 7 www.aap.org/oralhealth/pact 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 Sudden Infant Death Syndrome published recommendations on pacifier use. Used with permission from Giusy Romano-Clarke

8. 8 www.aap.org/oralhealth/pact 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.

9. 9 www.aap.org/oralhealth/pact 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

10. 10 www.aap.org/oralhealth/pact 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 child’s mouth (at least 1¼ 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 child’s neck or hand

11. 11 www.aap.org/oralhealth/pact Dental Effects 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 incisors upward and anteriorly, which may result in an anterior open bite. Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham Anterior Open Bite

12. 12 Dental Effects of Non-nutritive sucking Anterior Open BiteRight Posterior Crossbite 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) Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

13. 13 www.aap.org/oralhealth/pact 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.

14. 14 www.aap.org/oralhealth/pact 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

15. 15 www.aap.org/oralhealth/pact 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

16. 16 www.aap.org/oralhealth/pact Physical Intervention If other methods are not effective, an intra-oral appliance can be placed by a dentist to prevent sucking. The appliance is removed after the habit is broken. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

17. 17 www.aap.org/oralhealth/pact 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.

18. 18 www.aap.org/oralhealth/pact 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.

19. 19 www.aap.org/oralhealth/pact 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. For older children, a dentist may recommend a mouth guard be worn at night. Used with permission from Content Visionary

20. 20 www.aap.org/oralhealth/pact 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.

21. 21 www.aap.org/oralhealth/pact 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.

22. 22 www.aap.org/oralhealth/pact 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.

23. 23 www.aap.org/oralhealth/pact 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.

24. 24 www.aap.org/oralhealth/pact Question #3 True or False? Nonnutritive sucking occurs in approximately 50% of all babies. A. True. B. False.

25. 25 www.aap.org/oralhealth/pact Answer True or False? Nonnutritive sucking occurs in approximately 50% of all babies. A. True. B. False.

26. 26 http://www.aap.org/oralhealth/pact 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.

27. 27 http://www.aap.org/oralhealth/pact 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.

28. 28 http://www.aap.org/oralhealth/pact 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.

29. 29 http://www.aap.org/oralhealth/pact 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.

30. 30 http://www.aap.org/oralhealth/pact 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 Professional’s Guide to Pediatric Oral Health Management; 2006. http://www.mchoralhealth.org/PediatricOH/index.htm. Accessed January 15, 2007.

31. 31 www.aap.org/oralhealth/pact 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.