JDC LITERATURE REVIEW

Oral Habits—Part 1: The Dental Effects and Management

Mihiri Silva, BDSc, MDSc 1

ABSTRACT
Nutritive sucking and non-nutritive sucking are among the most commonly reported
oral habits in children. These habits generally cease around four years of age as
interaction with other children increases. However, prolonged habits may alter dento-
skeletal development, leading to orthodontic problems, which may persist into the
permanent dentition. Rewards, reminder therapy, and appliance therapy have been
described for the management of nutritive and non-nutritive sucking habits. Remin-
der therapy includes the use of gloves, thumb-guards, mittens, and tastants applied
to fingers. When other modes of treatment have failed, appliance therapy, such as
palatal cribs or Bluegrass appliances, may be necessary to prevent the placement of the
digit in its sucking position. These tools are very effective and are associated with few
adverse effects; however, they must be used with the cooperation of the child and
never as punishment. The purpose of this paper is to update clinicians about nutritive
and non-nutritive sucking habits in children and their impact on dental/skeletal
development, and management options. (J Dent Child 2014;81(3):133-9)
Receieved August 29, 2013; Last Revision October 21, 2013; Revision Accepted
November 6, 2013.
Keywords: habits, pacifier, thumb sucking

C
hildren frequently engage in nutritive and non- influence the impact of habits on development. Com-
nutritive sucking, atypical swallowing such as mon orthodontic problems resulting from oral habits
tongue thrusting, mouth breathing, lip sucking, include anterior open bite, increased overjet, posterior
and bruxism. Although such behaviors may be harmless, crossbite, and long facial height. In severe cases, func-
related habits of sufficient duration, frequency, and tional changes, such as deviation of the mandible due to
magnitude may lead to significant changes in cranio- a unilateral crossbite, can result in asymmetrical growth
facial development, causing orthodontic problems that with significant repercussions that may extend into
can compromise function and esthetics.1-7 adulthood.
Although such changes are consistent with Moss’ Two main types of sucking have been described:
functional matrix theory of craniofacial growth, the rela- nutritive and non-nutritive. The former is related to the
tionship between form and function is not clearly process of obtaining nutrition, and the latter is a habit
understood, and the underlying growth pattern may also which may involve sucking of pacifiers (also known as
dummies), or digits.8
The purpose of this paper, the first of two on the
1
Dr. Silva is a graduate student and 2Prof. Manton is Elsdon Storey
Chair of Child Dental Health, Department of Pediatric Dentistry, School
management of habits in pediatric dentistry, was to
of Dentistry, University of Melbourne, Melbourne, Victoria, Australia. discuss nutritive and non-nutritive sucking habits and
Correspond with Dr. Manton at [email protected] their management in children and adolescents.

Journal of Dentistry for Children-81:3, 2014 Oral habits review—Part 1 Silva and Manton 133
NUTRITIVE AND NON-NUTRITIVE SUCKING sucking needs of an infant, who is then less likely to
DEVELOPMENT OF SUCKING engage in NNS behaviors.13,20 Alternatively, the large
Sucking movements, which are among the earliest coor- bottle teat and subsequently increased flow may lead to
dinated muscle activities, develop during prenatal life.8-12 a preference for the pacifier as the infant grows.18
Oral and gag reflexes emerge at 12 to 16 weeks of gesta- Further research, ideally longitudinal in nature, is
tion, slightly earlier than the sucking reflexes which needed to confirm the association between nutritive
develop at approximately 24 weeks.11 By contrast, the sucking and malocclusion, particularly in the mixed
highly energetic and complex activity of feeding, in- and permanent dentitions. Nevertheless, given the vast
volving a suck/swallow/breathe cycle, starts to develop evidence for the advantages of breast-feeding and current
much later in prenatal life and is only fully coordinated World Health Organization guidelines, mothers should
by 32 to 34 weeks. The two types of sucking also vary be encouraged to exclusively breast-feed infants for the
concerning duration, rate, and strength of sucking. first six months of life and continue breast-feeding until
Nutritive sucking occurs at a constant rate of one suck 12 months old and beyond with the introduction of
per second during breast- or bottle-feeding. 8 Non- appropriate solids.21,22
nutritive sucking (NNS) occurs at a higher rate of two
sucks per second and is believed to satisfy an infant’s NON-NUTRITIVE SUCKING
natural sucking urge or as a means of behavioral state There are many benefits from NNS for healthy and
modulation.8 The differences in development and pattern preterm infants. In addition to helping calm infants,
between the two types of sucking may account for the particularly as an aid to get them to sleep and attenuate
different effects on craniofacial development. crying, NNS has been associated with decreased risk of
sudden infant death syndrome. 12,23-25 There are three
NUTRITIVE SUCKING possible mechanisms for this association: (1) the main-
Nutritive sucking, which occurs during breast- and tenance of airway patency by pacifiers, which prevents
bottle-feeding, may influence craniofacial development. the backward positioning of the tongue during sleep;
Improvement of craniofacial development may be related (2) reduced gastric reflux; and (3) stimulation of respi-
to the nutritional, immunological, and developmental ration, which reduces apneic episodes.10
benefits of breast-feeding, with some investigators re- A Cochrane review concluded that preterm infants,
porting lower rates of malocclusion among breast-fed whose ability to feed is underdeveloped and who are fed
children. However, due to the high rates of NNS, the through feeding tubes initially, transition more rapidly
effect of breast-feeding has been difficult to assess and to oral feeding if provided with pacifiers.11 NNS was
findings are conflicting, with several studies failing to also found to reduce the length of the hospital stay in
find any association. 13,14 Nevertheless, there is some preterm infants. The development of sucking is helped
evidence that breast-feeding is likely to lead to lower by NNS, allowing the infant to progress to nutritive
rates of anterior open bite and posterior crossbite than sucking and may also help digestion by stimulating
bottle-feeding, due the vastly different patterns of muscle vagal innervation in the oral mucosa, which increases
activity between the two forms of feeding.15-17 the production of enzymes, such as lipase, insulin, and
The lack of a continuous flow of milk during breast- motilin.11
feeding places higher demands on the infant’s orofacial
muscles, encouraging muscle development and growth EFFECT OF NNS HABITS ON THE DEVELOPING
of the mandible.18 The action of the infant’s mouth DENTITION
during breast-feeding has been described more as a Although sucking has been shown to be beneficial, parti-
squeezing of the mother’s nipple, compared to a pistol- cularly early in life, prolonged NNS has been associated
like action of the tongue during sucking of the nursing with a range of adverse effects on dental and oral devel-
bottle teat.17 In addition to that, the nipple of the mother’s opment. NNS may be considered normal or acceptable
breast is positioned more anteriorly in the child’s mouth, in the first two years of life, but, if extended beyond
compared to the teat of a nursing bottle which is three to four years of age, may lead to changes in the
directed farther back toward the pharyngeal wall, thus primary and/or permanent dentitions. The prevalence of
displacing the tongue anteriorly. These factors may lead NNS in infancy is high, with rates of 40 percent to 90
to the development of irregular swallowing patterns, percent reported. In most cases, it refers to pacifier or
such as tongue thrust, which may, in turn, contribute to digit sucking, although other objects, such as toys and
malocclusion. blankets, may also be involved.26 Pacifier sucking is
A third mechanism for the association between infant more common in infancy than digit sucking, and,
feeding and malocclusion may be explained by the lower although uncommon, a child may have both habits.27
rates of non-nutritive habits, particularly pacifier suck- Non-nutritive habits may also be more common among
ing, among children who are breast-fed.15,18,19 A greater children from higher socioeconomic groups and with
sense of fulfilment and security may satisfy the intuitive mothers who are older or more educated.26,27

134 Silva and Manton Oral habits review—Part 1 Journal of Dentistry for Children-81:3, 2014
 NNS has been shown to decline in prevalence with illary arch width.14,27-29 These alterations in arch form
increasing age. 27 Pacifier use decreases rapidly from may be attributed to increasing muscle contraction. The
infancy and generally ceases by approximately four years lower positioning of the tongue in NNS leads to dento-
of age, when interaction with other children increases alveolar expansion of the lower arch, and the opening
and pacifier sucking becomes very uncommon.26,27 Digit- of the upper and lower jaws increases vertical di-
sucking prevalence also declines until approximately mension. This effectively heightens muscle contraction
four years of age, at which point the prevalence steadies in the cheeks near the canine teeth, leading to an in-
until seven years before once again decreasing.27 A small wards or narrowing force directed against the maxillary
minority of children continues digit sucking beyond arch form.2,26
eight years. Overall, the duration of the habit is longer A posterior crossbite can be established as early as 18
among digit suckers than pacifier suckers, with the months old and, if unilateral, may lead to a functional
difference in the prevalence of pacifier and digit sucking shift of the mandible upon interdigitation. Such devi-
attributed to the ability to remove a pacifier from a ation of the jaw upon closing has been associated with
child.26 long-term complications due to changes in growth
NNS is a common habit in children, but malocclu- and mandibular development. 2,26 Physiological or
sions are only encountered in a small percentage. Several orthodontic pacifiers are designed to better fit the
factors may determine the extent to which the primary child’s oral structures and prevent palatal distension,
and permanent dentitions are affected, including the thereby limiting adverse effects. 30,31 A small number
duration, magnitude, and force (intensity) of the habit. of studies have compared the impact of these altered
The dental manifestations of NNS include anterior designs upon the developing occlusion; generally, the
open bite, posterior crossbite, increased overjet, and results are mixed, with little clinical difference.32
higher risk of developing a Class II malocclusion. Although both digit and pacifier sucking may lead to
Pacifier and digit sucking have been shown to alter malocclusion, the latter has been found to have a more
dental development differently. Extended pacifier use consistent impact on the anterior and posterior occlu-
has been associated with anterior open bites, Class II sions.26 However, as pacifier sucking is more likely to
molar relationships, and posterior crossbites, while digit be of a comparatively reduced duration, the effect on
sucking may manifest in anterior open bite and increased the mixed and permanent dentitions may be less than
overjet. 14,26 The anterior open bite associated with for prolonged digit sucking.26,33
pacifier sucking is usually symmetrical. This is due to the The duration of the habit can be both the time for
shape of the pacifier, which limits its positioning in the which the habit actively occurs or the overall time that
mouth, as the pacifier pushes the maxillary four incisors the child has the habit. Although few studies have
together as a block and in close proximity to each investigated the impact of the former, habits of less
other.14,26 Digit sucking, however, is associated with an than six hours duration are unlikely to alter craniofacial
asymmetric open bite, as dictated by the position of development because orthodontic forces of shorter
the digit in the mouth, with the upper incisors pro- duration are generally inconsequential.5
clined and spaced (Figure 1). The overjet is increased, Pacifier sucking for longer than 24 months and digit
mostly due to proclination of the maxillary incisors; sucking for longer than 36 months result in significantly
however, in severe cases of digit sucking, retrusion of higher rates of posterior crossbite and anterior open bite
the lingual incisors may also contribute.2 at five years of age.14
Pacifier sucking has been associated with posterior Of greater concern is the influence of NNS on the
crossbite due to a combination of a significant increase mixed and, particularly, permanent dentitions. NNS for
in mandibular intercanine width and a decrease in max- more than 36 months was found to significantly increase
the risk of malocclusion in the mixed dentition.6 Among
children who used pacifiers beyond four years of age, 23
percent had an anterior open bite at eight years. The
prevalence of Class II molar relationships was also signi-
ficantly higher among children who sucked pacifiers
beyond four years of age versus those who had habits of
shorter duration. Regarding digit sucking, the prevalence
of anterior open bite was significantly higher among
those whose habit persisted for longer than 60 months.6
In most cases, the malocclusion resulting from NNS
improves after cessation of the habit, although this process
may take two to five years for complete resolution and is
Figure 1. An asymmetric open bite and malocclusion in a dependent on various factors, including growth pattern,
10-year-old boy with a digit-sucking habit. overall duration of the habit, and the presence of other

  Journal of Dentistry for Children-81:3, 2014 Oral habits review—Part 1 Silva and Manton 135
habits such as tongue thrust.34,35 Some studies have in- APPLIANCE THERAPY
dicated that posterior crossbites may be more resistant Due to the increased risk of irreversible malocclusion,
against self-correction than anterior open bites.26,35 The once the permanent incisors start erupting and other
effect of NNS, if ceased by six years of age, is likely to reward-based reminder techniques have failed to correct
be transient, leading to spontaneous resolution by eight a digit-sucking habit, the use of removable or fixed
to 12 years; however, NNS beyond six years of age is appliances may be indicated. However, this must be
less likely to result in spontaneous resolution. 4 There- based on the child’s willingness and should not be
fore, although habit cessation should be encouraged by used as a means of punishment but rather explained
approximately three to four years of age, the critical as a tool to assist the child in overcoming his or her
time appears to be six years, beyond which age sponta- digit-sucking habit.2 Lack of cooperation from the child
neous correction of an associated malocclusion is is likely to lead to failure, development of new habits,
unlikely. deformation, or early removal of the appliance.
Palatal cribs of various designs have been used success-
MANAGEMENT OF NNS HABITS fully to overcome digit-sucking habits and are designed
Early dental visits should be used to provide parents with to prevent both the comfortable positioning of the digit
anticipatory guidance by explaining the influence of against the palate and any associated tongue thrust, thereby
habits on the developing occlusion.1 Parents should be allowing the natural force of the lips to correct an anterior
encouraged to monitor the frequency and intensity of open bite.2,40,41 The basic design utilizes the permanent
NNS, particularly in the case of digit sucking, which is first molars or the primary second molars as abutments
more likely to persist beyond four years of age. If the with a major connecting wire of 0.04-inch stainless steel
habits do not diminish, intervention may be indicated. orthodontic wire extending anteriorly along the palate
Parental nagging and punishment may lead to the (Figure 2).2 The wire forms a fence or crib at the level
opposite of the desired effect, and parents should be of the maxillary canines, which extends vertically lin-
encouraged to adopt a more positive approach toward gual to the level of the incisor edges of the lower anterior
the habit.1,2 teeth. However the appliance should not lead to any
In addition to providing information to the parents, occlu-sal interferences and should have sufficient clear-
the effect of the habit should also be carefully explained ance to allow for the lingual movement of the maxillary
to the child in age-appropriate language. Between four incisors. Various other features, such as rakes or spurs,
and six years of age, positive reinforcement through the may be incorporated to the design of palatal cribs but
use of rewards may be sufficient to curb NNS habits. may be unnecessarily punitive.40,42
Calendars can be used to track a child’s progress and The insertion of palatal cribs has been associated with
provide rewards. If the child is able to abstain from the high success rates, resulting in thumb sucking cessation
habit for three months, this is likely to indicate cessa- within a week in 80 percent of cases and little relapse
tion of the habit.2 after three years.40,41,43 The appliance is more likely to be
In cooperative children who express a willingness to successful if in situ for six to ten months, and is asso-
cease digit sucking but who require additional assistance, ciated with significantly higher rates of relapse when
either response prevention therapy or appliance therapy removed after three months. 41 The effectiveness of
may be successful.36 the appliance in improving an anterior open bite is
dependent upon various factors, including the presence
RESPONSE PREVENTION THERAPY
Response prevention therapy is aimed at either physically
preventing children from placing their fingers in their
mouth or providing an unpleasant taste that discourages
children from engaging in the habit. Products such as
thumb guards, bandages, gloves, mittens, and hot- and
bitter-tasting medicaments have been found to be effective
in ceasing both daytime and nocturnal digit sucking.37,38
Being relatively easy to use and inexpensive, they are
recommended as an alterative when rewards and positive
reinforcement have failed to curb an NNS habit. How-
ever, children often ignore these reminders or remove
them, which limits their effectiveness.39 The small per-
centage of children who continue NNS into the early
mixed dentition is likely to have a more ingrained habit;
thus, appliance therapy may be indicated.2 Figure 2. A palatal crib appliance with abutments on the
permanent maxillary first molars.

136 Silva and Manton Oral habits review—Part 1 Journal of Dentistry for Children-81:3, 2014
 of any additional habits, such as lip sucking, and the has been reported to result in fewer complications with
patient’s dental maturity.2 Improvement in the align- speech and eating and is better accepted by patients and
ment of the teeth should be evident within three months parents, although the child’s enthusiasm was reported to
of insertion of the appliance, and complete resolution wane with time.42
of the anterior open bite is expected by six months. 2 Both the crib and Bluegrass appliances have been
The lack of such resolution may necessitate investigation modified further to broaden their applications, and many
and management of additional habits or indicate an different variations are currently available.45-48 In chil-
underlying occlusal discrepancy. dren who have developed a dentoalveolar anterior open
Several minor problems have been reported with the bite and posterior crossbite in the mixed dentition due
use of palatal cribs. Children with palatal cribs may be to persistent digit sucking, a quad-helix with a crib
initially upset regarding the appliance and experience attachment can successfully resolve both the maloc-
difficulty eating sticky and hard foods. These are usually clusion and the causative habit.43,45-49 This technique has
accommodated within three to four weeks.2,40 In addi- been shown to lead to a significant increase in overbite
tion to that, transient changes in speech, such as slurring due to extrusion of the permanent incisors and
and lisping, are corrected once the appliance is re- downward rotation of the palatal plane, leading to
moved at the completion of treatment, if not during improved skeletal relationships.43 The Bluegrass appliance
the active treatment stage.40 There is little evidence to has also been incorporated into a quad-helix, with an
show that children who undergo appliance therapy additional crib attachment in a fixed-removable design
develop other compensatory mannerisms, such as nail- that allows easy activation of the quad-helix following
biting, scratching of the body, and knuckle-cracking, as insertion.46
reported in digit-sucking children who received palatal Removable appliances, such as a Hawley retainer, with
crib therapy (e.g., in the control group).40 a series of loops palatal to the incisors may be effective
Palatal irritation following insertion of the appliance in treating digit sucking; however, as with any remov-
has been reported in a minority of children and may able appliance, success may be limited due to lack of
reflect poor fabrication or be caused by the mechanical patient compliance (Figure 3).2,50
irritation of the palatal mucosa and/or tongue due to It appears that the association between NNS and
the upward pushing of the crib by the tongue. 2,40 A psychopathology is likely to have been overestimated in
simple bending of the crib wire intraorally may relieve the past.51 However, adolescents with persistent habits
any such irritation until the tongue adapts to a new and who are either unwilling or nonresponsive to treat-
position. ment may benefit from referral to an appropriate
Loss or loosening of palatal cribs has also been re- psychologist or medical practitioner for assessment.2
ported in a small minority.40 The risk of dental caries
and lack of patient cooperation may contraindicate the
use of appliance therapy in some children.36
There is currently no clearly prescribed recall schedule
for patients undergoing appliance therapy. However, to
detect any adverse effects and monitor response to ther-
apy, a review one to two weeks following insertion and
then every two to three months thereafter is appropriate.
The Bluegrass appliance was developed as a non-
punitive alternative to crib appliances in treating chronic
digit sucking.42 The appliance is provided to children
as a distractive toy which they can roll with their
tongue instead of digit sucking, leading to cessation of
the habit by approximately 12 weeks.44 Although the
appliance prevents the placement of the finger against Figure 3. A removable appliance with crib for correction
the palate, its primary goal is not to impede digit of thumb sucking.
sucking but to create a counter conditioning response
to the original conditioned stimulus for thumb sucking.
The appliance contains a six-sided, Teflon-coated roller CONCLUSIONS
or colorful bead(s) slipped over a 0.045-inch stainless Nutritive and non-nutritive sucking habits are common
steel wire, which is soldered to bands on either the per- in childhood, although most habits cease by four years
manent first molars or primary second molars. The of age. The role of nutritive sucking on craniofacial
roller is positioned at the highest point in the palate but development is not yet clearly proven. However, breast-
must not contact the palatal mucosa so that it may roll feeding appears to have a favorable influence on cranio-
properly when contacted by the tongue. The appliance facial development, whereas bottle-feeding has been

  Journal of Dentistry for Children-81:3, 2014 Oral habits review—Part 1 Silva and Manton 137
associated with an increased tendency toward mal- 11. Pinelli J, Symington A. Non-nutritive sucking for
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