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.

Soldered Lingual Holding Arch as a Space Maintainer

Introduction

The soldered lingual holding arch is a classic bilateral mixed-dentition space maintainer used in the mandibular arch. It is designed to preserve the space for the permanent canines and premolars during the mixed dentition phase, particularly when primary molars are lost prematurely.

Design and Construction

• Components:

  • Bands: Fitted to the first permanent molars.
  • Wire: A 0.036- or 0.040-inch stainless steel wire is contoured to the arch.
  • Extension: The wire extends forward to make contact with the cingulum area of the incisors.

• Arch Form: The wire is contoured to provide an anterior arch form, allowing for the alignment of the incisors while ensuring it does not interfere with the normal eruption paths of the teeth.

Functionality

• Stabilization: The design stabilizes the positions of the lower molars, preventing them from moving mesially and maintaining the incisor relationship to avoid retroclination.
• Leeway Space: The arch helps sustain the canine-premolar segment space, utilizing the leeway space available during the mixed dentition phase.

Clinical Considerations

• Eruption Path: The lingual wire must be contoured to avoid interference with the normal eruption paths of the permanent canines and premolars.
• Breakage and Hygiene: The soldered lingual holding arch is designed to present minimal problems with breakage and minimal oral hygiene concerns.
• Eruptive Movements: It should not interfere with the eruptive movements of the permanent teeth, allowing for natural development.

Timing of Placement

• Transitional Dentition Period: The bilateral design and use of permanent teeth as abutments allow for application during the full transitional dentition period of the buccal segments.
• Timing of Insertion: Lower lingual arches should not be placed before the eruption of the permanent incisors due to their frequent lingual eruption path. If placed too early, the lingual wire may interfere with normal incisor positioning, particularly before the lateral incisor erupts.
• Anchorage: Using primary incisors as anterior stops does not provide sufficient anchorage to prevent significant loss of arch length.

Salivary Factors and Their Mechanisms

1. Buffering Factors

Buffering factors in saliva help maintain a neutral pH in the oral cavity, which is vital for preventing demineralization of tooth enamel.

• HCO3 (Bicarbonate)

  • Effects on Mineralization: Acts as a primary buffer in saliva, helping to neutralize acids produced by bacteria.
  • Role in Raising Saliva or Plaque pH: Increases pH by neutralizing acids, thus promoting a more favorable environment for remineralization.

• Urea

  • Effects on Mineralization: Releases ammonia (NH3) when metabolized, which can help raise pH and promote mineralization.
  • Role in Raising Saliva or Plaque pH: Contributes to pH elevation through ammonia production.

• Arginine-rich Proteins

  • Effects on Mineralization: Releases ammonia, which can help neutralize acids and promote remineralization.
  • Role in Raising Saliva or Plaque pH: Increases pH through ammonia release, creating a less acidic environment.

2. Antibacterial Factors

Saliva contains several antibacterial components that help control the growth of pathogenic bacteria associated with dental caries.

• Lactoferrin

  • Effects on Bacteria: Binds to iron, which is essential for bacterial growth, thereby inhibiting bacterial proliferation.
  • Effects on Bacterial Aggregation or Adherence: May promote clearance of bacteria through aggregation.

• Lysozyme

  • Effects on Bacteria: Hydrolyzes cell wall polysaccharides of bacteria, leading to cell lysis and death.
  • Effects on Bacterial Aggregation or Adherence: Can indirectly promote clearance by breaking down bacterial cell walls.

• Peroxidase

  • Effects on Bacteria: Produces hypothiocyanate (OSCN), which inhibits glycolysis in bacteria, reducing their energy supply.
  • Effects on Bacterial Aggregation or Adherence: May help in the aggregation of bacteria, facilitating their clearance.

• Secretory IgA

  • Effects on Bacteria: Neutralizes bacterial toxins and enzymes, reducing their pathogenicity.
  • Effects on Bacterial Aggregation or Adherence: Binds to bacterial surfaces, preventing adherence to oral tissues.

• Alpha Amylase

  • Effects on Bacteria: Produces glucose and maltose, which can serve as energy sources for some bacteria.
  • Effects on Bacterial Aggregation or Adherence: Indirectly promotes bacterial aggregation through the production of glucans.

3. Factors Affecting Mineralization

Certain salivary proteins play a role in the mineralization process and the maintenance of tooth enamel.

• Histatins

  • Effects on Mineralization: Bind to hydroxyapatite, aiding in the supersaturation of saliva, which is essential for remineralization.
  • Effects on Bacteria: Some inhibition of mutans streptococci, which are key contributors to caries.

• Proline-rich Proteins

  • Effects on Mineralization: Bind to hydroxyapatite, aiding in saliva supersaturation.
  • Effects on Bacteria: Promote adherence of some oral bacteria.

• Cystatins

  • Effects on Mineralization: Bind to hydroxyapatite, aiding in saliva supersaturation.
  • Effects on Bacteria: Promote adherence of some oral bacteria.

• Statherin

  • Effects on Mineralization: Bind to hydroxyapatite, aiding in saliva supersaturation.
  • Effects on Bacteria: Promote adherence of some oral bacteria.

• Mucins

  • Effects on Mineralization: Provide a physical and chemical barrier in the enamel pellicle, protecting against demineralization.
  • Effects on Bacteria: Facilitate aggregation and clearance of oral bacteria.

Degrees of Mental Disability

Mental disabilities are often classified based on the severity of cognitive impairment, which can be assessed using various intelligence scales, such as the Wechsler Intelligence Scale and the Stanford-Binet Scale. Below is a detailed overview of the degrees of mental disability, including IQ ranges and communication abilities.

1. Mild Mental Disability

• IQ Range: 55-69 (Wechsler Scale) or 52-67 (Stanford-Binet Scale)
• Description:
  • Individuals in this category may have some difficulty with academic skills but can often learn basic academic and practical skills.
  • They typically can communicate well enough for most communication needs and may function independently with some support.
  • They may have social skills that allow them to interact with peers and participate in community activities.

2. Moderate Mental Disability

• IQ Range: 40-54 (Wechsler Scale) or 36-51 (Stanford-Binet Scale)
• Description:
  • Individuals with moderate mental disability may have significant challenges in academic learning and require more support in daily living.
  • Communication skills may be limited; they can communicate at a basic level with others but may struggle with more complex language.
  • They often need assistance with personal care and may benefit from structured environments and support.

3. Severe or Profound Mental Disability

• IQ Range: 39 and below (Severe) or 35 and below (Profound)
• Description:
  • Individuals in this category have profound limitations in cognitive functioning and adaptive behavior.
  • Communication may be very limited; some may be mute or communicate only in grunts or very basic sounds.
  • They typically require extensive support for all aspects of daily living, including personal care and communication.

Space Maintainers: A fixed or removable appliance designed to maintain the space left by a prematurely lost tooth, ensuring proper alignment and positioning of the permanent dentition.

Importance of Primary Teeth

• Primary teeth serve as the best space maintainers for the permanent dentition. Their presence is crucial for guiding the eruption of permanent teeth and maintaining arch integrity.

Consequences of Space Loss

When a tooth is lost prematurely, the space can change significantly within a six-month period, leading to several complications:

• Loss of Arch Length: This can result in crowding of the permanent dentition.
• Impaction of Permanent Teeth: Teeth may become impacted if there is insufficient space for their eruption.
• Esthetic Problems: Loss of space can lead to visible gaps or misalignment, affecting a child's smile.
• Malocclusion: Improper alignment of teeth can lead to functional issues and bite problems.

Indications for Space Maintainers

Space maintainers are indicated in the following situations:

1. If the space shows signs of closing.
2. If using a space maintainer will simplify future orthodontic treatment.
3. If treatment for malocclusion is not indicated at a later date.
4. When the space needs to be maintained for two years or more.
5. To prevent supra-eruption of opposing teeth.
6. To improve the masticatory system and restore dental health.

Contraindications for Space Maintainers

Space maintainers should not be used in the following situations:

1. If radiographs show that the succedaneous tooth will erupt soon.
2. If one-third of the root of the succedaneous tooth is already calcified.
3. When the space left is greater than what is needed for the permanent tooth, as indicated radiographically.
4. If the space shows no signs of closing.
5. When the succedaneous tooth is absent.

Classification of Space Maintainers

Space maintainers can be classified into two main categories:

1. Fixed Space Maintainers

•  These are permanently attached to the teeth and cannot be removed by the patient. Examples include band and loop space maintainers.

  Common types include:

  • Band and Loop Space Maintainer:

    • A metal band is placed around an adjacent tooth, and a wire loop extends into the space of the missing tooth. This is commonly used for maintaining space after the loss of a primary molar.

  • Crown and Loop Space Maintainer:

    • Similar to the band and loop, but a crown is placed on the adjacent tooth instead of a band. This is used when the adjacent tooth requires a crown.

  • Distal Shoe Space Maintainer:

    • This is used when a primary second molar is lost before the eruption of the permanent first molar. It consists of a metal band on the first molar with a metal extension (shoe) that guides the eruption of the permanent molar.

  • Transpalatal Arch:

    • A fixed appliance that connects the maxillary molars across the palate. It is used to maintain space and prevent molar movement.

  • Nance Appliance:

    • Similar to the transpalatal arch, but it has a small acrylic button that rests against the anterior palate. It is used to maintain space in the upper arch.

2. Removable Space Maintainers

• These can be taken out by the patient and are typically used when more than one tooth is lost. They can also serve to replace occlusal function and improve esthetics.

  Common types include:

  • Removable Partial Denture:

    • A prosthetic device that replaces one or more missing teeth and can be removed by the patient. It can help maintain space and restore function and esthetics.

  • Acrylic Space Maintainer:

    • A simple acrylic appliance that can be used to maintain space. It is often used in cases where esthetics are a concern.

  • Functional Space Maintainers:

    • These are designed to provide occlusal function while maintaining space. They may include components that allow for chewing and speaking.

Types of Removable Space Maintainers

• Non-functional: Typically used when more than one tooth is lost.
• Functional: Designed to provide occlusal function.

Advantages of Removable Space Maintainers

1. Easy to clean and maintain proper oral hygiene.
2. Maintains vertical dimension.
3. Can be worn part-time, allowing circulation of blood to soft tissues.
4. Creates room for permanent teeth.
5. Helps prevent the development of tongue thrust habits into the extraction space.

Disadvantages of Removable Space Maintainers

1. May be lost or broken by the patient.
2. Uncooperative patients may not wear the appliance.
3. Lateral jaw growth may be restricted if clasps are incorporated.
4. May cause irritation of the underlying soft tissues.

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.