Protecting All Children’s Teeth
Oral Habits
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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.
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Learner Objectives
Used with permission from ANZ Photography
Upon completion of this presentation, participants will be able to:
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
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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.
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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.
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Used with permission from Content Visionary
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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
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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.
Paper permission on file from David Krol
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Older children who are thumb suckers are
often motivated to quit by peer pressure at
school.
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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.
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Used with permission from Giusy Romano-Clarke
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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.
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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
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
Pacifiers should not be coated in any sweet solution
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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
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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)
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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
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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.
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Anterior Open Bite
Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry,
University of Alabama at Birmingham
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Dental Effects of Non-nutritive sucking
Anterior Open Bite
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of
Pediatric Dentistry, School of Dentistry University of North Carolina
Right Posterior Crossbite
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke 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
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• Movement of the central incisors forward in the horizontal plane (overjet)
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.
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Intervention
When a child persists with a sucking habit, consider the
following approaches:
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
Tell the child in basic terms why you want them to stop and
that you believe they can do so
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Implement reminder therapy, the use of aids such as rubber
bands or string, to help a child interrupt the habit
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Start a reward system
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Encourage the use of a stuffed animal or other comfort
object
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Physical Intervention
For physical intervention to work, the child must be ready and
agreeable.
Techniques include:
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
Covering hands at night with mittens or socks
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Dressing the child in a special shirt with the sleeves sewn
closed
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Placing a bandage or specialty plastic guard on the thumb or
finger
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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 Pediatric
Dentistry, Duke Children's Hospital
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The appliance is removed after
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.
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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.
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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.
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Question #1
Parents of an 18-month-old inquire about their son's thumb
sucking habit. What is your most appropriate reply?
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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.
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Answer
Parents of an 18-month-old inquire about their son's thumb
sucking habit. What is your most appropriate reply?
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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.
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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.
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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.
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Question #3
True or False? Nonnutritive sucking occurs in approximately
50% of all babies.
A. True.
B. False.
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Answer
True or False? Nonnutritive sucking occurs in approximately
50% of all babies.
A. True.
B. False.
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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.
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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.
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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.
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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.
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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.
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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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