oral habits

1. ORAL HABITS-
Masochistic habits &
Bruxism

2. REFERENCES
 Pinkham J Casamassimo P. Pediatric dentistry.
Philadelphia: W.B. Saunders; 1999.
 Tandon S. Textbook of pedodontics. Hyderabad, New Delhi:
Paras Medical Publisher; 2009.
 Damle S. Textbook of pediatric dentistry. New Delhi: Arya
(Medi) Publishing House; 2006.
 Gurkeerat singh. Textbook of orthodontics : 2nd
ed. Jaypee
brothers medical publishers (P) Ltd; 2007.
 Nikhil Marwah .Textbook Of Pediatric Dentistry –3rd
Edition

3. ORAL HABITS

4. Deliberate mutilation of a body part without the intention
of causing death.
Self injury is an effort to relieve intense, painful, and
distressing feelings.
Other names for self injury include: self-mutilation, self-
harm, self-inflicted violence, “cutting”, and parasuicidal
behavior.
Masochistic habits

5. Common self-injuries include
•Carving or cutting the skin
•Scratching burning, ripping or pulling skin or hair
•Pinching, biting
•Swallowing sublethal doses of toxic substances
•Head banging
•Needle sticking
•Breaking bones.
The usual targets are the arms, legs, areas within easy reach and
easily hidden by clothing.

6. • SELF INJURIOUS HABITS
 Habits in which the patient enjoys inflicting
damage to himself.
 Rare in normal children
 Mostly seen in mentally retarded children (10-
20%) and children with psychological
abnormalities.

7. • ETIOLOGY
• The etiology may either be:
• ORGANIC
• FUNCTIONAL
• Organic:
• Syndromes and syndrome-like De Lange’s
syndrome in which symptoms such as
repetitive lip, finger, tongue, knee and
shoulder biting are common.

8. • FUNCTIONAL:
• THIS CAN FURTHER BE DIVIDED INTO:
• TYPE A
• These are injuries superimposed on a
pre-existing lesion.
• A child with a finger nail biting habit is under
treatment for a skin lesion.
• occurs mainly at night.

9. • Type B
• Injuries secondary to another established
habit.
• May exacerbate the features existing due
to a primary habit.
• Rotation of the thumb while thumb
sucking can harm the soft tissues.

10. • Type C
• Injuries of unknown or complex etiology.
• Has a greater psychogenic component.
• Child may resort to various self-injurious
habits as a form of stress release.

11.  LIP HABITS
 Habits that involve manipulation of the lips
and perioral structures are termed as lip
habits.
 CLASSIFICATION
 Lip sucking
 Lip biting
 Lip wetting

12. • (Schneider, 1982)
• Wetting the lips with the tongue.
• Pulling the lips into the mouth between the teeth.
 Vermilion border of the lower lip is often everted
with its lingual aspect elevated into the mouth.
 Sublingual contracture line develops between the
lip and the chin.

13. •
• ETIOLOGY
• Malocclusion
• Habits
• Emotional Stress

14. • Clinical features
• Effects on teeth
 Protrusion of maxillary incisors and
retrusion of mandibular incisors
 Effects on lips
 reddened, irritated and chapped area
below the vermilion border.

15. • TREATMENT
• Should be directed initially towards the
etiology of the habit.
• CORRECTION OF MALOCCLUSION
 fixed or removable appliance to tip the
teeth back
• TREATING THE PRIMARY HABIT

16. • APPLIANCE THERAPY
• Oral shield
• Lip bumper

17. • CHEEK BITING
• Abnormal habit of keeping or biting the
cheek muscles in between the upper and
lower posterior teeth.

18. CLINICAL FEATURES
 Ulcer at the level of occlusion
 Open bite
 Tooth malposition in the buccal
segment.
• TREATMENT
• A removable crib may be constructed to break
the habit. A vestibular screen may also be
used.

19. • NAIL BITING
• One of the most common habits in children
and adults. It is a sign of internal tension.
• AGE OF OCCURRENCE
• Absent before 3 years of age, incidence rises
sharply from 4-6 years and remains at a
fairly constant level between 7 and 10 years
and rises again to a peak during
adolescence.

20. •
• ETIOLOGY
 Persistent nail biting may be indicative
of an emotional problem.
 After the age of 15, the nail biting habit
is replaced by pencil biting, hair
twirling.

21. • CLINICAL FEATURES
• DENTAL EFFECTS
 The common effects of nail biting on the
teeth are rotation & attrition of incisal
edges of the mandibular incisors.
• EFFECTS ON THE NAILS
 Inflammation of the nail and nail beds.

22. • MANAGEMENT
 Mild cases: no treatment is indicated.
 Treat the basic emotional factors causing the
act.
 Encourage outdoor activities which may help
in easing tension.
 Application of nail polish, as a reminder.

23. • FRENUM THRUSTING
 Rarely seen, is also a form of self
injurious habit.
 If the maxillary incisors are slightly
spaced apart, the child may lock his
labial frenum between these teeth &
permit it to remain in this position for
several hours.

24. • TREATMENT
• Treatment of self-injurious behavior
generally requires a multidisciplinary
approach.
• PSYCHOTHERAPY
• Some children experience a feeling of
neglect, and loneliness and through the
use of self injurious behaviour attempt
to gain attention and love.

25. • Palliative treatment
• Adjunctive therapy in the form of
bandages for any oral ulcerations will
help in healing of the wounds as well as
serve as a habit reminder.
• Mechano therapy
• An oral shield will also deter the child
from the unconscious continuation of
the habit.
• Treatment for self-mutilation may also
include use of restraints and protective
padding.

26. Bruxism

27. • Bruxism
• Greek word -brychein odontas- grinding the teeth
• French-Bruxomanie—to gnash
• It is a word used to describe a collection of oral
parafunctional habits.
• First described by Marie and Pietkiewics in 1907
• Destructive habit that may result in tooth wear.
Indian J Dent Sciences. 2011;3 (1):26

28. American Academy of Pediatric Dentistry 2006-
2007-“Diurnal or nocturnal parafunctional activity which
includes clenching, gnashing, gritting and grinding of teeth.
It can be clinically diagnosed based on the presence of
excessive tooth wear which could not have been caused by
mastication”.
 Ramjford 1961 refers it to a nocturnal, subconscious
activity but can occur during the day or night and may be
performed consciously or subconsciously. It is a conscious
activity when parafunctional activities are included in it.
Definitions

29. • M.B. Marks 1980 non-functional activity characterized
by repeated tooth clenching or grinding which may
occur during the day or more commonly at night in an
unconscious manner
• Rubina 1986 is the term used to indicate the non
functional contact of the teeth which may include
clenching, grinding and tapping of the teeth.
• Vanderas 1995: Nonfunctional movement of the
mandible with or without an audible sound occurring
during the day or night.
• S.E. Widmalm 1995 is involuntary, excessive grinding,
clenching or rubbing of teeth during nonfunctional
movements of the masticatory system

30.  Poselt &Wolff - the clenching or grinding of teeth when not
masticating and swallowing.
 Dorland 2003 “involuntary, non-functional, rhythmic or
spasmodic gnashing, grinding and clenching of teeth (not
including chewing movements of the mandible)”

31. CLASSIFICATION
1. Centric
2. Eccentric
S. Ramfjord in 1987

32. 1. Awake bruxism (AB)
2. Sleep bruxism (SB).
According to Miller

33. • Day Time BruxismDiurnal Bruxism, Bruxomania
 conscious or subconscious
 can occur along with parafunctional habits such as chewing
pencils, nails, cheeks and lips.
 usually silent except in patients with an organic brain
disease.
• Night Time Bruxism/Nocturnal Bruxism
 subconscious
 characterized by rhythmic patterns of masseter EMG
activity.
 can occur at any stage of sleep.
 during the transition from a deeper stage to a lighter stage
of sleep.
 during the rapid eye movement stage, reported to be the
most damaging.

34. INCIDENCE & PREVALENCEINCIDENCE & PREVALENCE
• The incidence of bruxism reported in the
literature ranges from 5 to 81% of different
age ranges
• The prevalence of awake bruxism in the
general population is approximately 20%,
while the prevalence of sleep bruxism is
about 8%
American Academy of Sleep Medicine2004

35. • A.J. Gross 1988, Egermark-Eriksson (1981), J.D.
Allen (1990) A.G. Glaros
• prevalence of AB between 5% and 25% in children
and adults, being more common in females and
decreasing with advancing age.
• G.J. Lavigne (1994) M.M. Ohayon (2001)
Prevalance of SB declines from 14% in children to
8% in adults to 3% in patients older than 60 years
without any sex differences.

36. • F. Lobbezoo(2006) Reported prevalence in children
ranges from 7% to 15.1% with girls apparently
more frequently affected
• B.A. Phillips (1991) & G. Bader (2000) SB is
manifested in the majority of the population at
some time (85%-90%).

37. ETIOLOGYETIOLOGY
Nadler (1957)Nadler (1957)
 1. Local factors
 2. Systemic factors
Lobbezoo 2006
1. Pathophysiologic factors
2. Psychologic factors
3. Morphologic factors

38. LOCAL FACTORS
 Faulty restorations
 Calculus and periodontitis
 Traumatic occlusal relationship.
 Functionally incorrect occlusion
 Faulty eruption of deciduous or permanent teeth.

39. SYSTEMIC FACTORS
• Nutritional deficiencies
• Calcium and vitamin deficiencies
• Intestinal parasite infection.
• Gastrointestinal disturbances from food allergy.
• Endocrine disorders, e.g. hyperthyroidism.
• Pubertal growth spurt peak in boys and start of spurt
in girls .
• Hereditary factors
• Allergy
• CNS disturbances

40. •Sleep disordersSleep disorders (G.M. Macaluso,1998)(G.M. Macaluso,1998)
•In younger children, the immaturity of the masticatoryIn younger children, the immaturity of the masticatory
neuromuscular systemneuromuscular system (V.S. Pierro)(V.S. Pierro)
•Altered brain chemistryAltered brain chemistry
•Effects of cigarette smoking, alcohol, drugs, trauma,Effects of cigarette smoking, alcohol, drugs, trauma,
disease and medicationdisease and medication (F. Lobbezoo,1997)(F. Lobbezoo,1997)
Pathophysiologic factors

41. Stress and anxiety
Bruxism is mainly centrally, not peripherally mediated.
Kampe et al., (2002) demonstrated the presence of a
higher level of anxiety in a group of people with
bruxism.
Vanderas et al., (1997) have demonstrated that stress
and anxiety may be directly related to bruxism, as
patients showed a higher catecholamine level, generally
ascribed to emotional stress.

42. •Dental occlusion
•Anatomy of the orofacial skeleton
•Occlusal discrepancies
(S.P. Ramfjord et al in 1996)
Morphologic factors

43. NEUROPHYSIOLOGY
The mechanism of
causation is tension and
spasm of the muscles
used for mastication.
The direction of forces
to stomatognathic system
in children may lead to
maladaptive growth or
structural destruction.

44. SIGNS AND SYMPTOMS
• On Teeth
•Tooth mobility
•Spread of gingivitis
•Soreness to biting stress
•Non functional pattern of occlusal wear
•Increased sensitivity
•Atypical facets-Shiny, uneven, occlusal wear with sharp edges,
abrasion on incisal edges of upper and lower incisors.
•Other features-Pulp exposure and abscess
•Fractures of crown/restorations
•Root fractures.

45. MUSCULATURE AND TMJ
• Muscular facial pain.
• Muscle tiredness or tightness and fatigue on rising in
morning.
• Tenderness of jaw muscles to palpation.
• Compensatory hypertrophy of muscles
• Muscular incoordination.
• Locking of jaws
• Difficulty in opening mouth for a long time
Order of muscle sensitivity Lateral pterygoid> medial
pterygoid> masseter.

46. TMJ
• Pain, crepitus/clicking, restricted jaw
movements, jaw deviations
• The disc may become worn or perforated and
wear patterns are often correlated with condylar
remodeling.

47. Patients may present with a variety of symptoms, including:
•Anxiety, stress, and tension
•Depression
•Earache
•Eating disorders
•Headaches
•Migraines
•Loose teeth
•Tinnitus
•Gum resession
•Neck pain
•Insomnia
•Sore or painful jaw

48. The skin now may bag below the eyes and curl around
the lips, causing the lips to seemingly disappear
(Schlott, 1997).

49. STUDIES FOR EFFECT OF BRUXISM
• Tahara Y, 2006 investigated the effects of chewing and
clenching on salivary cortisol levels as an indicator of stress
and found that salivary cortisol levels were significantly
reduced by chewing, compared with those in the controls (p
< 0.05).
• Rossetti LM, 2008 verified the association between sleep
bruxism and temporomandibular disorders and found that
SB was neither associated with TMD (p > 0.05) nor with
pain on palpation (p > 0.05).

50. • According to American Academy of Sleep, dental damage with
abnormal wear to the teeth is the most frequent sign of the
disorders.
• C.L. Weideman et al.,1996 Complications include dental
attrition, headaches, temporomandibular joint dysfunction and
soreness of the masticatory muscles
• (.A. Kieser1998 Preliminary evidence suggests that juvenile
bruxism is a self-limiting condition that does not progress to
adult bruxism

51. DIAGNOSIS OF BRUXISM
Difficult to diagnose by visual evidence alone, as it is not the only
cause of tooth wear
Over-vigorous brushing
Abrasives in toothpaste
Acidic soft drinks and
Abrasive foods

52. The most reliable way to diagnose bruxism is through EMG
(electromyographic) measurements
These measurements pick up electrical signals from the chewing
muscles (masseter and temporalis).
This is the method used in sleep labs.

53. There are three forms of EMG
measurement available to consumers
for use outside sleep labs
The first is bedside EMG units
similar to those used by sleep labs.
pick up their signals from facial
muscles through wires connecting
the bedside unit to electrodes that
are adhesively attached to the user's
face

54. EMG measurement
headband sold under the
trade name SleepGuard
The EMG measurement
headband does not require
adhesive electrodes or
wires attached to the face

55. A third method of diagnosis using EMG is available in disposable
form under the trade name BiteStrip.
The BiteStrip is a self-contained EMG module that adhesively
mounts to the side of the face over the masseter muscle

56. • Provocation Test by the full examination of one's mouth
• 60-second screening examination

57. • American Academy of Craniomandibular Disorders 1996
Continuous muscle constraction, measured by increased
electromyogram activity, even at rest, is an important
diagnostic criteria of spasm
• Burdette, B.H et al in 1988 Pre-treatment EMG values of
both masseteric and anterial temporal areas were
significantly higher for the bruxism group than for the
control group.
• Shiga H in 1998 Mean EMG frequency of the patient
group was significantly larger than the normal group so
suggested that EMG power spectra can be used as a tool
in differential diagnosis of CMD.

59. TREATMENT
1. Occlusal adjustments
2. Occlusal splints
Karolyi et al 1906, Ramfjord et al 1961, Matthews, 1942
concluded that most common treatment regime for bruxism relies on
the time-honored procedure of splint therapy
•customized, hard acrylic, variety
• soft, rubber-like, elastomeric
material
•prefabricated soft splints

60. Hydrostatic splint (Aqualizer)
a water-bearing pressure-equalizing appliance

61. • Night Guards,
• Bite Guards,
• Occlusal Splints,
• Biteplates,
• Removable Appliances,
• Interocclusal Orthopedic Appliances

62. BRUXISM-MICHIGAN SPLINT
FARRAR SPLINT

63. PANKEY STYLE SPLINT
B (Bruxism) Splints

64. • de Oliveira LV et al 2007 evaluated long-term effects of using an
occlusal splint in patients with sleep bruxism (SB), using surface
electromyography (EMG) of masseter and temporalis muscles and
found that no indication of a significant decrease in mean EMG
levels over the therapy in the muscles. A significant decrease in
TMD signs and symptoms were observed in SB patients after 60
days of occlusal splints therapy
• Manzini C et al 2006 concluded that the following treatments
reduce sleep bruxism: mandibular advancement device, clonidine
and occlusal splint. However, the first 2 of these have been linked
to adverse effects. The occlusal splint is therefore the treatment of
choice, as it reduces grinding noise and protects the teeth from
premature wear with no reported adverse effects

65. • Silva AB et al., 2006 concluded that the occlusal splint is
not effective for treating sleep bruxism but it may be that
there is some benefit with regard to tooth wear.
• Okura K 2006 stated that The occlusal splint and
clonazepam seem to be acceptable short-term alternatives
• Dubé C et al., 2004 Compared the efficacy and safety of
an occlusal splint (OS) vs. a palatal control device (PCD) A
statistically significant reduction in the number of SB
episodes per hour (decrease of 41%, p = 0.05) .

66. 3. Restorative treatment
4. Psychotherapy
1. Wakeful EMG Feedback
• Expensive
• conscious control
2. Exercise Quinn (1995)
• stretching exercises of the mandible

67. 5. Drugs
•Anti-anxiety agents, muscle relaxers, tricyclic antidepressants
•Vapocoolants such as ethyl chloride for pain within the TMJ
area
• Local anesthetic injections directly into the TMJ or into the
muscles
6. Equilibration Therapy was first used by Karolyi in 1901
7. Sleep Feedback: Sound Alarms
8. The Oral Sensor
9. Sleep Feedback: Electrical Stimulation
10. Acupuncture techniques for muscle relaxation

68. Biofeedback in bruxism This is a technique that utilizes positive
feedback to enable the patient to learn tension reduction. It is
accomplished by allowing the patient to view an EMG monitor,
while the mandible is postured with a minimum of activity.
The first wearable night time bruxism biofeedback device
introduced in 2001, was originally sold under the trademark Grind
Alert by BruxCare, and is now sold under the trademark Sleep
Guard.
The Sleep Guard biofeedback headband is a battery-powered device
that sounds a tone against the forehead when it senses EMG
(electromyographic) muscle activity in the temporalis muscles.
The tone starts out very quiet and then gets louder, allowing people
to stop clenching without waking up

69. A mild electric shock bio-feedback device for treating Bruxism,
GrindCare
The device works by using simple electrodes adhesively attached to
the skin close to the cheek bones prior to sleeping; it detects the
initial muscular contractions and immediately provides mild
electrical shock pulses to the facial muscles. The electric shocks
serve to interrupt bruxism activity

70. "The Taste-Based Approach to the Prevention of Teeth
Clenching and Grinding".
The therapy involves suspending sealed packets containing a
bad-tasting substance (e.g. hot sauce, vinegar, denatonium
benzoate, etc.) between the rear molars using an orthodontic
style appliance. Any attempt to bring the teeth together will
rupture the packets and alert the user to the habit.

71. Botox
(Botox) can be successful in lessening effects of
bruxism, though serious side-effects (including death)
are possible.
In extremely dilute form (Botox), this toxin is used as
an injectable local paralysis agent that weakens
(partially paralyzes) muscles and has been used
extensively in cosmetic procedures to 'relax' the
muscles of the face and decrease the appearance of
wrinkles.

72. Dietary supplements
There is anecdotal evidence that suggests taking certain
combinations of dietary supplements may alleviate
bruxism;
•pantothenic acid,
•magnesium and
•calcium.
Calcium is known to be a treatment for gastric problems,
and gastric problems such as acid reflux are known to
increase bruxism.

73. Repairing damage
Damaged teeth can be repaired by :
Prosthetic crowns like:
PFM crowns
Full gold crowns are preferred.
All-porcelain crowns
Materials used to make crowns vary; some are less prone to
breaking than others and can last longer.
To protect the new crowns and dental implants, an occlusal guard
should be fabricated to wear during sleep.

74. THANK YOU