Habits leading to dental mal-alignment in children

Certain habits exhibited by growing children could lead to abnormalities in the position of teeth and jaws. Such habitual patterns of muscle behavior are associated with faulty jaw growth and teeth positions, disturbed breathing habits, difficulties in speech, imbalance in the facial muscles and psychological problems. The same habits, if persistent could also prevent the correction of the mal-aligned teeth also.

Following are few of the commonly seen habits:

Tongue thrusting

Tongue thrusting is the abnormal habit of placing the tongue between / against the inner aspect of the front teeth before, and during the act of swallowing. It could be seen as one or more of any of the following:

1) Forward placement of tongue during swallowing so that the tip of the tongue contacts the lower lip.

2) Inappropriate placement of the tongue between or against the front teeth during speech.

3) Forward positioning of the tongue at rest.

During a normal swallow, the tongue touches the roof of the mouth.  When it is positioned between the front teeth or thrust against the inner aspect of the front teeth, it becomes abnormal. Since swallowing is a continuous process which occurs 24 hours per day and about 2000 times per day, the tongue exerts momentary pressures varying from 1 to 6 pounds on the surrounding structures of the mouth which will push the teeth and bone forward.

How does a child develop tongue thrust?

It is natural for all the infants to swallow with the tongue between the gums (gum pads) in order to facilitate the suckling of the milk from a mother’s breast. The gum pads (on which the milk teeth erupt later) will not be in contact during the act of swallowing. Gradually as the child grows and matures, the swallowing pattern also matures and the tongue retracts its position and gets placed against the roof of the mouth during the swallow. The teeth will be in full contact during a mature (adult) swallow. If this natural progression does not happen, it results in tongue thrusting habit. Here, the muscles surrounding the teeth and lips (circum-oral muscles) are used to gain suction rather than those of the throat.

How do we recognize if the child has tongue thrusting habit?

A person with tongue thrust may show one or more of the following signs or symptoms:

1.      Facial grimace and/or pursing of the lips while swallowing. Lip puckering and lip licking prior to a swallow are indicative of tongue thrusting.  

2.      When at rest (while watching television or reading a book), an open mouth position with a forward tongue posture might be noted.

3.      A lack of vertical overlap of front teeth. Teeth might be far apart instead of showing a normal overlap.

4.      Protrusion of the front teeth because of the constant pressure from the tongue.

5.      Difficulty with speech, especially the s and z sounds.

There is also a type of tongue thrust which is to the sides of the mouth along with the frontal thrust (complex tongue thrust) and is most commonly due to a large sized tongue. Tongue size could be large because of a hereditary pattern or due to an underlying systemic disease which needs evaluation. Complex tongue thrust prevents the back teeth from erupting to the normal level preventing normal bite development.

Thumb sucking habit

It is observed that more than 50% of the children tend to indulge in sucking their thumb.  Some children place their fingers also inside the mouth along with thumb. Majority of them abandon the habit by the age of four years. If they continue it beyond the age of eruption of permanent teeth, it might lead to disturbance in the position of the erupting teeth. A sucking habit which is considered normal till a certain age will be considered harmful when persisted upon for a longer period of time.

The presence of clean nails and callus on the finger is normally suggestive of thumb sucking.

There are certain factors which decide whether these habits will create any disturbance in the position of teeth / jaw or not.

1.      How long does the child keep sucking the thumb/fingers?

The longer the duration, the more harmful it could be.

2.      How often does he indulge in the habit?

The more frequent the habit, the more disturbances it could create.

3.      How vigorously he sucks?

Mere placement of the thumb or fingers is not as harmful as vigorous sucking where his/her facial muscles are also involved.

How does the child develop the habit?

Studies have shown that thumb sucking is practiced even before the child is born. It is postulated that it is needed for the normal psychological development of the child. Child is supposed to obtain emotional satisfaction by indulging in thumb sucking and forceful prevention of that habit could lead to emotional insecurity. It is believed that children deprived of parental love and care can indulge in thumb sucking. But there are some researchers who believe that it’s a mere learned behavior and there are no psychological reasons behind the habit. Persistence of the habit beyond three to four years should alert the parents and a doctor’s opinion should be sought if it continues beyond the fourth or fifth year of life

 

What are the effects of persistent thumb sucking?

1.      Because of the position of the thumb and/ or fingers against the inner surface of the upper front teeth, they tend to get forwardly placed along with the upper jaw. Spaces might be present between the front teeth.

2.      The prominent teeth prevent the upper lip from full closure leading to an open lip posture.  Prominences of these forwardly placed teeth make them particularly vulnerable to accidental fractures.

3.      The heavy muscle forces due to the sucking can constrict the upper arch making it narrow and tapered.  

4.      The lower teeth might get pushed inward or outward depending on the way of placement of the fingers. If pushed inward, it leads to an increased distance between the upper and lower front teeth.

5.      A space between the upper and lower front teeth when the child bite which might lead to a compensatory tongue thrusting habit and difficulties in speech.

Mouth breathing

It is quite frequent to see children breathing through their mouth instead of their nose. The mouth breathing per se may not bring about much damages but the posture of the jaws during the procedure and the dryness created by constantly inhaled air could produce some damaging effects.

Why is it important for a child to breathe through the nose?

Nasal breathing has certain advantages over the mouth breathing like

1.      Purification of the inspired air:  The nose filters and humidifies the inhaled air before its entry into the lungs. When air is inhaled through the mouth, it is not cleaned, warmed and moistened.  

2.      Normal development of nose, windpipe, lung and the stomach muscles which assist in breathing occur with a regular nasal breathing. With oral respiration, the airway resistance is lacking and normal development of lungs and chest does not occur.

3.      Certain studies have shown that mouth breathers have 20 % more carbon dioxide and 20% less oxygen in the blood as compared to nasal breathers.

In addition to these, the child might develop a long face as he / she bends the neck forward in order to straighten the airway. Mouth breathing may lead to middle ear infections and the speech could acquire nasal tone. In extreme cases, the sense of smell could be diluted and with it taste sensation and appetite could get affected.

Why does a child breathe through the mouth?

It could be due to any one of the following reasons:

1.      The child has an obstruction in the nose due to some deviation in the normal structure (deviated nasal septum) or some medical reasons (nasal polyps, allergic rhinitis, tumours etc.) which prevents him / her from breathing through the nose.

2.      Some children will have short upper lip or prominent front teeth which prevent the normal lip closure. They will also tend to breathe through the mouth (by virtue of open lip posture) along with nasal breathing.

3.      Habitually some people tend to breathe through the mouth even after correction of any existing obstruction or prominent teeth.

What happens if the child continues mouth breathing?

1.      Molding action of upper lip is lost thereby resulting in forward placement and spacing of upper front teeth. 

2.      Tongue is suspended between upper and lower jaws resulting in narrow jaws due to lack of normal muscle balance between the tongue and facial muscles.

3.      The lower jaw (mandible) tends to be pushed into a more vertical and backward direction, causing an increased lower facial height and retruded lower jaw.

4.      Mouth breathers hold their lips apart. So the gums become air-dried and cause irritation.

5.      Saliva over the exposed gums becomes thick and viscous; debris collects on the gums as well as on the tooth surfaces.

6.      Along with the gums, tongue and roof of the mouth also become dry. Most commonly the patients present with swelling of the gums related to the front teeth subsequent to mouth breathing. It may even develop on the inner aspect of upper front teeth also, even in presence of good oral hygiene.

7.      Due to stagnation of debris and bacteria in the front teeth, they are often affected by decay.

How do we confirm whether a child is a mouth breather or not?

Clinical signs and symptoms are suggestive of a mouth breathing habit. It could be confirmed with certain small tests as given below.

1.      Ask the child to hold water in mouth. A child who is habituated with mouth breathing will not be able to hold water for more than few seconds as he needs to breathe through the mouth.

2.      Hold a piece of cotton or feather below the nostrils. It will move up for a mouth breather where as it will move down if the child breathes through the nose.

3.      Hold a double sided mirror below the nostrils. Fogging at the side of nostrils suggests nasal breathing whereas fogging at the side of mouth suggests mouth breathing.

Bruxism (clenching of the teeth)

Grinding or clenching of the teeth other than for chewing purposes is called Bruxism.

Why does the child clench his teeth?

It is believed that children with psychological disturbances or emotional stresses tend to grind their teeth during night. If the child does not have a comfortable bite, he might also indulge in clenching. Sometimes a mild pain associated with gums or an erupting tooth could also lead to a clenching habit as it is a human tendency to clench on teeth when put under stress or pain.

How do we recognize Bruxism?

Clenching or night grinding could be observed directly. Teeth might be showing abnormal wear patterns. Teeth might become loose in their sockets. The child might complain of soreness of the facial muscles when he gets up in the morning.

Lip biting, lip sucking and nail biting are also some of the less frequently encountered habits which if left unattended could lead to harmful effects on teeth and jaws.

Significance of identifying whether the child indulges in these habits or not

Habits need to be broken to allow normal development of the teeth and jaws. Persistence of the habit even after correction of the faulty teeth and jaw position could push them back to their original position leading to failure of the treatment.

Do they require any treatment?

Habits need to be treated under the guidance of a trained clinician, provided there is adequate parental support and cooperation from the patient. Treatment could vary from educating the child and parent regarding the consequences of continuation of the habit to the use of appliance therapy as and when the case requires. The harmful effects which are already present need to be corrected by a specialist doctor.

GOOD NUTRITION FOR A GOOD SMILE

“You are what you eat”- is a well-known adage that all of us would have heard a thousand times, but the least heard adage is “your smile is also what you eat”!  Like in general health, the food that we eat and the liquid that we drink plays a major role in good dental health. The oral cavity (the teeth and the gums), like other parts of the body, also require nourishment – energy and nutrients for health and maintenance. The food we eat affects our teeth. At the same time, the health or lack of health of our teeth and gums affects what we can eat. Good dental health begins early in life and must be practiced throughout life.

Healthy Diet leads to Healthy teeth and gums

A well-balanced diet which includes water provides energy, nutrients (carbohydrate, protein, fat, vitamins) and minerals, essential for healthy teeth and gums as well as for rest of the body. When one gets all the nutrients that meet the daily needs, then he/she gets good nutrition and good nutrition is the fundamental requirement for positive health and functional efficiency. Good nutrition is possible throughout the life cycle only through healthy diet – a balanced diet. Balanced diet is made of foods selected from all food groups such as cereals, pulses, nuts, fruits and vegetables, milk and milk products, oil, meat, poultry and fish.

Composition of balanced diet that is the requirement of the food items from each of these food groups varies with age, gender and health, physiological status and physical activity level of the individual.

Development and integrity of oral tissues and structures

Good nutrition is essential to the initial growth and development of oral tissues. Tooth development begins shortly after conception, usually between the sixth and eighth weeks of gestation and continues throughout pregnancy. The most important long-term factor affecting the health of teeth and gums is nutrition, from the womb onward.

Malnutrition during periods of tooth development can have irreversible effects on the developing oral structures. Nutritional deficiencies can impair tissue regeneration and healing and can increase susceptibility to oral infections. Vitamin C deficiency will result in bleeding gums, Calcium deficiency would affect bones supporting the teeth, B-complex deficiencies will affect overall oral health with cracks in the lips and sores on the tongue or  inner mouth, Vitamin A deficiency would affect the cell integrity and Nutrients are interdependent – they cannot work in isolation.

Nutrients for Oral health:

Nutrients which maintain the bones and the muscles of the body are also accountable for maintaining the gums and teeth. These includes calcium and phosphorus, protein, magnesium, fluoride, zinc, copper, iron, selenium and vitamins D, A, C, K and folate.  Other nutrients that influence normal bone metabolism are energy, fat, carbohydrates and fibre intake, and the electrolytes, sodium and potassium and the remaining 32 odd nutrients!! The nutrients essential for general health do not function in isolation and all work together to keep one’s body strong and healthy lifelong.

Process of Tooth decay / Dental Caries:

Dental caries commonly occurs on the chewing surface or the inter-dental surfaces in posterior teeth. The chewing surfaces of these teeth are wide with pits and fissures for easy retention of food debris and microbes. The bacteria present in oral cavity form an invisible layer of plaque. The plaque is mainly composed of bacteria, salivary proteins, few cells and some bacterial products. When the food remnants, especially carbohydrates, come in contact with the bacteria in the plaque, fermentation begins, resulting in dissolution of tooth surface and dental caries.

Untreated dental caries can result in pain and subsequent tooth loss, which may lead to malnutrition or abnormal digestion, since these conditions often prevent a person from chewing and eating adequate amounts of food as well as eating some hard, high-fibre foods. Additionally, many diseases such as Type 1 and Type 2 diabetes, and cardiovascular disease, may exacerbate these conditions leading to poor oral health.

Factors causing tooth decay:

The food we eat and the beverages we drink can have a direct influence on the incidence and progression of tooth decay, depending upon:

• The form and consistency of food.
• Duration of exposure of teeth to food.
• Frequency : How often these are used –

o    sugary / acidic foods / beverages

• The combination of foods and the order (sequence) of eating.
• Medical conditions such as gastrointestinal reflux and eating disorders, which can increase risk of cavities and weaken teeth.

Food form determines the duration of exposure or retention time of a food in the mouth, which in turn affects how long the acid-producing activity will last.  Liquids are rapidly cleared from the mouth and have low adherence (or retentiveness) capabilities.  Solid foods such as crackers, chips, dry cereals, and cookies can stick between the teeth (referred to as the interproximal spaces) and have high adherence or retention capability which results in prolonged sugar exposure in the mouth.

Consistency also effects adherence.  Chewy foods stimulate saliva production and have a lower adherence potential than solid, sticky foods such as pretzels, bagels, or bananas.

Sugar is the part of the triad that leads to tooth decay, the other two factors being acid forming bacteria harbouring the mouth and the susceptible tooth. Every time a person eats sweet food, mouth bacteria have an unlimited food supply and begin to produce acid that attacks the teeth for 20 minutes or more.  Saliva eventually neutralizes these acids and repairs tooth enamel.  

The amount of sugar present in the mouth plays a critical role in the process, so also the time. Longer the period sugar stays in the mouth, more damage to the teeth will occur. Day-long sipping of sugar-containing drinks exposes one’s teeth to constant sugar and, in turn, constant decay-causing acids.

Dental nutrition also involves a certain sense of timing. To prevent cavities and maintain good oral health, the diet – what one eats and how often one eats, are important factors. More frequent meals mean more risk for the tooth!  Saliva production is slowed down if one eats constantly, so there will not be enough in the mouth to neutralize the bacteria and prevent the damage.

Eating sequence and combination of foods also affect the caries potential of the substrate. Bananas, which are cariogenic because of their fermentable carbohydrate content and adherence capability, have less potential to contribute to decay when eaten with cereal and milk than when eaten alone as a snack.  Milk, as a liquid, reduces the adherence capability of the fruit. 

Factors preventing tooth decay:

·         Saliva

·         Water

·         Sequence of eating

Saliva decreases mouth acidity and washes away food particles. Saliva eventually neutralizes the acids and repairs tooth enamel. The food eaten should stimulate the gums, increase saliva flow and reduce the build-up of cavity-causing bacteria. Crunchy and chewy foods, such as carrots, celery, cucumber, popcorn, and nuts, cause saliva to flow. Foods that require a lot of chewing stimulate saliva flow, and saliva protects the teeth by cleaning them, neutralizing acid, and inhibiting harmful bacteria. Saliva flow slows during sleep; going to bed without brushing the teeth is especially harmful.

Good dental nutrition also calls for healthy water intake. Saliva production depends on hydration. Saliva production goes down if one does not drink enough water. A chronically dry mouth also contributes to decay. Good dental nutrition demands the plentiful intake of healthy water.  

Starches (cereals, potatoes etc.) and sweets should be combined when possible.  This will stimulate saliva production.  Dessert should therefore be eaten prior to a meal, never sometime afterwards. Cheese or milk at the end of the meal decreases the carcinogenicity (caries causing effect) of the meal.

Tips to preserve oral health

·         Eating a balanced diet high in fiber (high fiber foods – whole cereals, whole grams, fruits and vegetables) that is low in free sugars and fat protects oral and general health. The high fiber content in the foods will counteract the fermentation by bacteria and help to stop the decay.

·         Having a glass of water after eating and rinsing mouth with water for 30 seconds after eating food/beverages. Drinking a lot of water keeps the mouth moist, and helps ward off tooth decay and periodontal diseases by washing away food and neutralizing plaque.

·         Limiting the consumption of sugar-containing drinks, including soft drinks, lemonade, and coffee / tea with added sugar. The best beverage choices include water (especially fluoridated water), milk, and unsweetened tea. 

·         Spacing eating occasions at least 2 hours apart and limiting snack time to 15-30 minutes.

·         Controlling sugar levels in the diet is a key factor in caries prevention. Limiting the frequency of consumption of foods and/or drinks containing free sugars should be limited to a maximum of four times per day. Sugarless or sugar-free food sometimes simply means that no sugar was added to the foods during processing. However, this does not mean that the foods do not contain other natural sweeteners, such as honey, molasses, evaporated cane sugar, fructose, barley malt, or rice syrup. These natural sweeteners contain the same number of calories as sugar and can be just as harmful to teeth (look for the sugar content on the packaging label).

·         Combining desserts and sweets with other food items, or even better, be eaten as part of a full meal or just before the meal.

·         Eating acidic foods, such as citrus fruits, tomatoes, and lemons, as part of a larger meal to minimize the acid from them.

·         Avoiding day-long sipping of sugar-containing drinks.

·         Choosing crunchy and chewy foods, such as carrots, celery, cucumber, popcorn, and nuts, which cause saliva to flow.

·         Choosing whole grams, whole wheat products and vegetables with skin and seeds as these foods need thorough mastication.

·         Chewing sugar-free gum is another option that will increase saliva in the mouth and remove food particles that cause tooth decay.

·         Chewing unsweetened Fennel seeds (Saunf) can also be considered as it helps in production of saliva as well as acts as a mouth freshener. 

Summary

Optimal nutrition plays a key role in the development and maintenance of a healthy mouth, especially the teeth and gums. Use of good oral hygiene practices to prevent dental caries focuses on fluoridation, adequate oral hygiene, frequency of eating and drinking, and a varied diet, as opposed to sugar intake alone. Good nutrition is essential for good dental health as well as good general health.

Know the terminology

Cariogenic foods are those that contain fermentable carbohydrates (sugars), which when in contact with microorganisms in the mouth, can cause a drop in salivary pH to 5.5 or less and stimulate the caries process.

Cariostatic foods do not contribute to decay. Examples of cariostatic foods are protein foods such as eggs, fish, meat, and poultry; most vegetables; fats; and sugarless gums.  Sugarless gum may help to reduce decay potential because it uses non carbohydrate sweeteners.

Anticariogenic foods are those that, when eaten before an acidogenic food, prevent plaque from recognizing the acidogenic food, examples being Cheese and Xylitol containing chewing gum. The form and consistency of a food have a significant effect on its cariogenic potential and pH-reducing or buffering capacity.