Classification of Oral Habits

Oral habits can be classified based on various criteria, including their nature, impact, and the underlying motivations for the behavior. Below is a detailed classification of oral habits:

1. Based on Nature of the Habit

• Obsessive Habits (Deep Rooted):

  • International or Meaningful:
    • Examples: Nail biting, digit sucking, lip biting.
  • Masochistic (Self-Inflicting):
    • Examples: Gingival stripping (damaging the gums).
  • Unintentional (Empty):
    • Examples: Abnormal pillowing, chin propping.

• Non-Obsessive Habits (Easily Learned and Dropped):

  • Functional Habits:
    • Examples: Mouth breathing, tongue thrusting, bruxism (teeth grinding).

2. Based on Impact

• Useful Habits:
  • Habits that may have a positive or neutral effect on oral health.
• Harmful Habits:
  • Habits that can lead to dental issues, such as malocclusion, gingival damage, or tooth wear.

3. Based on Author Classifications

• James (1923):

  • a) Useful Habits
  • b) Harmful Habits

• Kingsley (1958):

  • a) Functional Oral Habits
  • b) Muscular Habits
  • c) Combined Habits

• Morris and Bohanna (1969):

  • a) Pressure Habits
  • b) Non-Pressure Habits
  • c) Biting Habits

• Klein (1971):

  • a) Empty Habits
  • b) Meaningful Habits

• Finn (1987):

  • I. a) Compulsive Habits
  • b) Non-Compulsive Habits
  • II. a) Primary Habits

4. Based on Functionality

• Functional Habits:
  • Habits that serve a purpose, such as aiding in speech or feeding.
• Dysfunctional Habits:
  • Habits that disrupt normal oral function or lead to negative consequences.

Wright's Classification of Child Behavior

1. Hysterical/Uncontrolled

   • Description: This behavior is often seen in preschool children during their first dental visit. These children may exhibit temper tantrums, crying, and an inability to control their emotions. Their reactions can be intense and overwhelming, making it challenging for dental professionals to proceed with treatment.

2. Defiant/Obstinate

   • Description: Children displaying defiant behavior may refuse to cooperate or follow instructions. They may argue or resist the dental team's efforts, making it difficult to conduct examinations or procedures.

3. Timid/Shy

   • Description: Timid or shy children may be hesitant to engage with the dental team. They might avoid eye contact, speak softly, or cling to their parents. This behavior can stem from anxiety or fear of the unfamiliar dental environment.

4. Stoic

   • Description: Stoic children may not outwardly express their feelings, even in uncomfortable situations. This behavior can be seen in spoiled or stubborn children, where their crying may be characterized by a "siren-like" quality. They may appear calm but are internally distressed.

5. Overprotective Child

   • Description: These children may exhibit clinginess or anxiety, often due to overprotective parenting. They may be overly reliant on their parents for comfort and reassurance, which can complicate the dental visit.

6. Physically Abused Child

   • Description: Children who have experienced physical abuse may display heightened anxiety, fear, or aggression in the dental setting. Their behavior may be unpredictable, and they may react strongly to perceived threats.

7. Whining Type

   • Description: Whining children may express discomfort or displeasure through persistent complaints or whining. This behavior can be a way to seek attention or express anxiety about the dental visit.

8. Complaining Type

   • Description: Similar to whining, complaining children vocalize their discomfort or dissatisfaction. They may frequently express concerns about the procedure or the dental environment.

9. Tense Cooperative

   • Description: These children are on the borderline between positive and negative behavior. They may show some willingness to cooperate but are visibly tense or anxious. Their cooperation may be conditional, and they may require additional reassurance and support.

1. Crown Dimensions

• Primary Anterior Teeth: The crowns of primary anterior teeth (incisors and canines) are characterized by a wider mesiodistal dimension and a shorter incisocervical height compared to their permanent counterparts. This means that primary incisors are broader from side to side and shorter from the biting edge to the gum line, giving them a more squat appearance.

• Primary Molars: The crowns of primary molars are also shorter and narrower in the mesiodistal direction at the cervical third compared to permanent molars. This results in a more constricted appearance at the base of the crown, which is important for accommodating the developing permanent teeth.

2. Root Structure

• Primary Anterior Teeth: The roots of primary anterior teeth taper more rapidly than those of permanent anterior teeth. This rapid tapering allows for a more pronounced root system that is essential for anchoring the teeth in the softer bone of children’s jaws.

• Primary Molars: In contrast, the roots of primary molars are longer and more slender than those of permanent molars. This elongation and slenderness provide stability while also allowing for the necessary space for the developing permanent teeth beneath them.

3. Enamel Characteristics

• Enamel Rod Orientation: In primary teeth, the enamel rods in the gingival third slope occlusally (toward the biting surface) rather than cervically (toward the root) as seen in permanent teeth. This unique orientation can influence the way primary teeth respond to wear and decay.

• Thickness of Enamel: The enamel on the occlusal surfaces of primary molars is of uniform thickness, measuring approximately 1 mm. In contrast, the enamel on permanent molars is thicker, averaging around 2.5 mm. This difference in thickness can affect the durability and longevity of the teeth.

4. Surface Contours

• Buccal and Lingual Surfaces: The buccal and lingual surfaces of primary molars are flatter above the crest of contour compared to permanent molars. This flatter contour can influence the way food is processed and how plaque accumulates on the teeth.

5. Root Divergence

• Primary Molars: The roots of primary molars are more divergent relative to their crown width compared to permanent molars. This divergence is crucial as it allows adequate space for the developing permanent dentition, which is essential for proper alignment and spacing in the dental arch.

6. Occlusal Features

• Occlusal Table: The occlusal table of primary molars is narrower in the faciolingual dimension. This narrower occlusal surface, combined with shallower anatomy, results in shorter cusps, less pronounced ridges, and shallower fossae. These features can affect the functional aspects of chewing and the overall occlusion.

• Mesial Cervical Ridge: Primary molars exhibit a prominent mesial cervical ridge, which serves as a distinguishing feature that helps in identifying the right and left molars during dental examinations.

7. Root Characteristics

• Root Shape and Divergence: The roots of primary molars are not only longer and more slender but also extremely narrow mesiodistally and broad lingually. This unique shape contributes to their stability while allowing for the necessary divergence and minimal curvature. Additionally, primary molars typically have little or no root trunk, which is a stark contrast to the more complex root structures of permanent molars.

Eruption Gingivitis

• Eruption gingivitis is a transitory form of gingivitis observed in young children during the eruption of primary teeth. It is characterized by localized inflammation of the gingiva that typically subsides once the teeth have fully emerged into the oral cavity.

Characteristics

• Age Group:

  • Eruption gingivitis is most commonly seen in young children, particularly during the eruption of primary teeth. However, a significant increase in the incidence of gingivitis is often noted in the 6-7 year age group when permanent teeth begin to erupt.

• Mechanism:

  • The increase in gingivitis during this period is attributed to several factors:
    • Lack of Protection: During the early stages of active eruption, the gingival margin does not receive protection from the coronal contour of the tooth, making it more susceptible to irritation and inflammation.
    • Food Impingement: The continual impingement of food on the gingiva can exacerbate the inflammatory process, leading to gingival irritation.

Contributing Factors

• Accumulation of Debris:
  • Food debris, material alba, and bacterial plaque often accumulate around and beneath the free gingival tissue. This accumulation can partially cover the crown of the erupting tooth, contributing to inflammation.
• Common Associations:
  • Eruption gingivitis is most frequently associated with the eruption of the first and second permanent molars. The inflammation can be painful and may lead to complications such as:
    • Pericoronitis: Inflammation of the soft tissue surrounding the crown of a partially erupted tooth.
    • Pericoronal Abscess: A localized collection of pus in the pericoronal area, which can result from the inflammatory process.

Clinical Management

• Oral Hygiene:

  • Emphasizing the importance of good oral hygiene practices is crucial during this period. Parents should be encouraged to assist their children in maintaining proper brushing and flossing techniques to minimize plaque accumulation.

• Professional Care:

  • Regular dental check-ups are important to monitor the eruption process and manage any signs of gingivitis or associated complications. Professional cleanings may be necessary to remove plaque and debris.

• Symptomatic Relief:

  • If the child experiences pain or discomfort, topical analgesics or anti-inflammatory medications may be recommended to alleviate symptoms.

Dens in Dente (Tooth Within a Tooth)

Dens in dente, also known as "tooth within a tooth," is a developmental dental anomaly characterized by an invagination of the enamel and dentin, resulting in a tooth structure that resembles a tooth inside another tooth. This condition can affect both primary and permanent teeth.

Diagnosis

• Radiographic Verification:
  • The diagnosis of dens in dente is confirmed through radiographic examination. Radiographs will typically show the characteristic invagination, which may appear as a radiolucent area within the tooth structure.

Characteristics

• Developmental Anomaly:
  • Dens in dente is described as a lingual invagination of the enamel, which can lead to various complications, including pulp exposure, caries, and periapical pathology.
• Occurrence:
  • This condition can occur in both primary and permanent teeth, although it is most commonly observed in the permanent dentition.

Commonly Affected Teeth

• Permanent Maxillary Lateral Incisors:
  • Dens in dente is most frequently seen in the permanent maxillary lateral incisors. The presence of deep lingual pits in these teeth should raise suspicion for this condition.
• Unusual Cases:
  • There have been reports of dens invaginatus occurring in unusual locations, including:
    • Mandibular primary canine
    • Maxillary primary central incisor
    • Mandibular second primary molar

Genetic Considerations

• Inheritance Pattern:
  • The condition may exhibit an autosomal dominant inheritance pattern, as evidenced by the occurrence of dens in dente within the same family, where some members have the condition while others present with deep lingual pits.
• Variable Expressivity and Incomplete Penetrance:
  • The variability in expression of the condition among family members suggests that it may have incomplete penetrance, meaning not all individuals with the genetic predisposition will express the phenotype.

Clinical Implications

• Management:
  • Early diagnosis and management are crucial to prevent complications associated with dens in dente, such as pulpitis or abscess formation. Treatment may involve restorative procedures or endodontic therapy, depending on the severity of the invagination and the health of the pulp.

Causes:
The primary cause of CP is any factor that leads to decreased oxygen supply (hypoxia) to the developing brain. This can occur due to various reasons, including complications during pregnancy, childbirth, or immediately after birth.

Classification of Cerebral Palsy:

1. Based on Anatomical Involvement:

   • Monoplegia: One limb is affected.
   • Hemiplegia: One side of the body is affected.
   • Paraplegia: Both legs are affected.
   • Quadriplegia: All four limbs are affected.

2. Based on Neuromuscular Involvement:

   • Spasticity: Characterized by stiff and tight muscles; this is the most common type, seen in 70% of cases. Affected individuals may have limited head movement and a limp gait.
   • Athetosis: Involves involuntary, writhing movements, seen in 15% of cases. Symptoms include excessive head movement and drooling.
   • Ataxia: Affects balance and coordination, seen in 5% of cases. Individuals may exhibit a staggering gait and slow tremor-like movements.
   • Mixed: A combination of more than one type of cerebral palsy, seen in about 10% of cases.

1. Spastic Cerebral Palsy (70% of cases)

Characteristics:

• Limited Head Movement: Individuals have restrictions in moving their head due to increased muscle tone.
• Involvement of Cerebral Cortex: Indicates that the motor control areas of the brain (especially those concerning voluntary movement) are affected.
• Limping Gait with Circumduction of the Affected Leg: When walking, the patient often swings the affected leg around instead of lifting it normally, due to spasticity.
• Hypertonicity of Facial Muscles: Increased muscle tension in the facial region, contributing to a fixed or tense facial expression.
• Unilateral or Bilateral Manifestations: Symptoms can occur on one side of the body (hemiplegia) or affect both sides (diplegia or quadriplegia).
• Slow Jaw Movement: Reduced speed in moving the jaw, potentially leading to functional difficulties.
• Hypertonic Orbicularis Oris Muscles: Increased muscle tone around the mouth, affecting lip closure and movement.
• Mouth Breathing (75%): The individual may breathe through their mouth due to poor control of oral musculature.
• Spastic Tongue Thrust: The tongue pushes forward excessively, which can disrupt swallowing and speech.
• Class II Division II Malocclusion (75%): Dental alignment issue often characterized by a deep overbite and anterior teeth that are retroclined, sometimes accompanied by a unilateral crossbite.
• Speech Involvement: Difficulties with speech articulation due to muscle coordination problems.
• Constricted Mandibular Arch: The lower jaw may have a narrower configuration, complicating dental alignment and oral function.

2. Athetoid Cerebral Palsy (15% of cases)

Characteristics:

• Excessive Head Movement: Involuntary, uncontrolled movements lead to difficulties maintaining a stable head position.
• Involvement of Basal Ganglia: Damage to this area affects muscle tone and coordination, leading to issues like chorea (involuntary movements).
• Bull Neck Appearance: The neck may appear thicker and less defined, owing to abnormal muscle development or tone.
• Lack of Head Balance, Drawn Back: The head may be held in a retracted position, affecting posture and balance.
• Quick Jaw Movement: Involuntary rapid movements can lead to difficulty with oral control.
• Hypotonic Orbicularis Oris Muscles: Reduced muscle tone around the mouth can lead to drooling and lack of control of oral secretions.
• Grimacing and Drooling: Facial expressions may be exaggerated or inappropriate due to muscle tone issues, and there may be problems with managing saliva.
• Continuous Mouth Breathing: Patients may consistently breathe through their mouths rather than their noses.
• Tissue Biting: Increased risk of self-biting due to lack of muscle control.
• Tongue Protruding: The tongue may frequently stick out, complicating speech and intake of food.
• High and Narrow Palatal Vault: Changes in the oral cavity structures can lead to functional difficulties.
• Class II Division I Malocclusion (90%): Characterized by a deep bite and anterior open bite.
• Speech Involvement: Affected due to uncontrolled muscle movements.
• Muscle of Deglutition Involvement: Difficulties with swallowing due to affected muscles.
• Bruxism: Involuntary grinding or clenching of teeth.
• Auditory Organs May be Involved: Hearing impairments can coexist.

3. Ataxic Cerebral Palsy (5% of cases)

Characteristics:

• Slow Tremor-like Head Movement: Unsteady, gradual movements of the head, indicative of coordination issues.
• Involvement of Cerebellum: The cerebellum, which regulates balance and motor control, is impacted.
• Lack of Balance Leading to Staggering Gait: Individuals may have difficulty maintaining equilibrium, leading to a wide-based and unsteady gait.
• Hypotonic Orbicularis Oris Muscles: Reduced muscle tone leading to difficulties with oral closure and control.
• Slow Jaw Movement: The jaw may move slower, affecting chewing and speech.
• Speech Involvement: Communication may be affected due to poor coordination of the speech muscles.
• Visual Organ May be Involved (Nystagmus): Involuntary eye movements may occur, affecting visual stability.
• Varied Type of Malocclusion: Dental alignment issues can vary widely in this population.

4. Mixed:
Mixed cerebral palsy involves a combination of the above types, where the individual may exhibit spasticity, athetosis, and ataxia to varying degrees.

Dental Considerations for Mixed CP:
- Dental care for patients with mixed CP is highly individualized and depends on the specific combination and severity of symptoms.
- The dentist must consider the unique challenges that arise from the combination of muscle tone issues, coordination problems, and potential for involvement of facial muscles.
- A multidisciplinary approach, including occupational therapy and speech therapy, may be necessary to address oral function and hygiene.
- The use of sedation or general anesthesia might be considered for extensive dental treatments due to the difficulty in managing the patient's movements and ensuring safety during procedures.

Associated Symptoms:
Children with CP may exhibit persistent reflexes such as the asymmetric tonic neck reflex, which can influence their dental treatment. Other symptoms may include mental retardation, seizure disorders, speech difficulties, and joint contractures.

Dental Problems:
Children with cerebral palsy often experience specific dental challenges:

• They may have a higher incidence of dental caries (tooth decay) due to difficulty in maintaining oral hygiene and dietary preferences.
• There is a greater likelihood of periodontal disease, often exacerbated by medications like phenytoin, which can lead to gum overgrowth and dental issues.

Dental Treatment Considerations:
When managing dental care for children with cerebral palsy, dentists need to consider:

• Patient Stability: The child’s head should be stabilized, and their back should be elevated to minimize swallowing difficulties.
• Physical Restraints: These can help manage uncontrolled movements during treatment.
• Use of Mouth Props and Finger Splints: These tools can assist in controlling involuntary jaw movements.
• Gentle Handling: Avoid abrupt movements to prevent triggering the startle reflex.
• Local Anesthesia (LA): Administered with caution, ensuring stabilization to prevent sudden movements.
• Premedication: Medications may be given to alleviate muscle hypertonicity, manage anxiety, and reduce involuntary movements.
• General Anesthesia (GA): Reserved for cases that are too challenging to manage with other methods.