Portuguese Version

Year:  2003  Vol. 69   Ed. 1 - (16º)

Artigo Original

Pages: 106 to 110

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Suction oral habits: initial study in low income population

Author(s): Valdinês G.S. Cavassani,
Sonize G. Ribeiro,
Nair K. Nemr2, Ana M.Greco,
Juliana Köhle3,
Carlos N. Lehn

Keywords: suction oral habits, socioeconomic determinants, malocclusion, phonoaudiological disturbances.

Abstract:
Introduction: Suction oral habits have usually observed in childhood due to emotional and nutritional factors with odontological and phonoaudiological consequences. Objective: The purpose of this study was the observation of the odontological and phonoaudiological alterations in low-income children with suction oral habits. Study Design: Retrospective clinical no randomized. Material and Method: Nine Brazilian children (8 girls and 1 boy) were examined in "I Mutirão da Comunicação" in Heliópolis Hospital, Hosphel/São Paulo, Brazil, in October 27, 2001. Results: Common phonoaudiological disturbance detected was articulatory (55,56%) followed by oral motor disturbance (33,33%). The bite opening was usual in eight cases (88,89%). In seven cases (77,78%) mouth breathing occurred. Conclusions: Phonoaudiological and odontological disturbances occurred commonly in children with suction oral habits. The importance of the interrelationship among odontology, phonoaudiology and otorrinolaringology in association with public health programs must be established in low-income population.

INTRODUCTION

Oral habits have been a matter of major interest among health care professionals linked to the field of motor skills. Oral motor skill involves action-related aspects of muscle groups in characteristic morphological movements and the description of functional processes such as phoneme articulation movement, suction, mastication and deglutition movements and their respective normal and pathological patterns1. Due to the fact that they are connected to posture, mobility, tone and sensitivity of phonation coordination organs. The latter received this designation because they control phoneme articulation and the oral swallowing phase. Due to the anatomic complexity of these muscle structures and since they are closely connected, any change may result in disorders, both speech and odontological disturbances, whose sequels considerably affect functional and aesthetical aspects.

The habits are muscle contraction patterns; some of them may be the etiology of malocclusions, of muscle, skeletal and dental nature.

The behavioral evaluation of oral motor development should be performed in order to find out difficulties and easiness of the child concerning mastication, suction, swallowing, breathing aspects and global postural. Once repetitive oral habits are found, the stomathognatic system may present significant dysfunction depending on the frequency, intensity and interval of such oral habits. 2

Some factors that cause oral habits may include: familiar conflict, school pressure, stress of living in a large city, irritability related to dental eruption, occlusion interferences, breathing obstruction, poor posture and other emotional factors3. In addition, there are causes related to tonsils, adenoids and the nose (septum deviation and conchae hypertrophy). These symptoms may result in mouth breathing that consequently affects tonus, posture, mobility and sensitivity of phonation coordination organs generating noxious oral habits. It is essential that ENT evaluation be always performed in case of noxious oral habits in order to rule out anatomical-functional factors as the etiology of the existing clinical picture. 4

The consequences of ENT changes may lead to occlusion and bite alterations, and indicated treatment should be an association of orthodontics and speech therapy, as orthodontic correction depends on posture reeducation and treatment may be affected without it. 5.

Similarly to other behavioral issues, oral habits may be influenced by some social factors, such as if the mother has a part-time or full-time job to help with family income, initial breastfeeding patterns, difficult access to dental care, some respiratory diseases and some speech issues, among others6. A study conducted with 357 pediatric patients (3 to 5 years old) in the city of Belo Horizonte, focusing the association between breastfeeding, oral habits and malocclusions, reported that there was an association between natural breastfeeding and the lack of oral habits in children that were breastfed at least for 6 months and the association of oral habits and malocclusions was significant7. These variables should be studied in depth in order to determine how socio-economic factors may affect malocclusion through oral habits, psychological factors and patterns of general diseases.

The most frequent noxious oral habits are lip, finger and cheek suction or suction of objects that may affect dental arch, the bite, and lead to alterations such as hypotonia of phonation coordination organs, mouth breathing, onycophagy and others. Finger or pacifier suction or the suction of any other object has been source of study, since its use is widely spread and it may cause damages. The suction habits result in important consequence for hard palate morphology, alterations in dental positioning, movement of the tongue, with perioral muscle and phonation coordination alterations, leading to a higher risk of developing open bite and oral motor skill disorders1,8. Noxious oral habits result from the need to fulfill emotional deficiency, in general they give the sense of security and comfort, and feeding and non-feeding elements may be involved. Suction is the primary muscle activity of a coordinated child and is a phenomenon strictly linked to swallowing, and is also perceived before birth as mouth contractions and other reflex responses. Suction is considered a nutrition habit until the child is three years old and a noxious habit after this age9,10,11,12 Several epidemiological studies were carried out to evaluate the prevalence of suction habits in children, and figures obtained were 54.60 % (3 to 5 years old), being that most of them were mouth breathers13. Other studies with children aged 7 to 10 years old, of both genders, concluded that the persisting habit of sucking the pacifier did not affect skeletal characteristics. It promoted, however, a reduction of inter-incisor angle, mainly in vestibule inclination of the upper incisors and a reduction in the level of dental-alveolar height, which also affected the increase in overjet and overbite decrease. However, they were not able to permanently compromise facial skeletal measures. 14.Other authors, evaluating children between 2 to 6 years of age, concluded that oral habit of sucking the pacifier or the finger could lead to higher prevalence of anomalies in deciduous dental occlusion. Another aspect related to suction habit is the likelihood of developing maxilla narrowing, leading to open and posterior crossed bite. 16,7 Regarding speech disorders in patients with finger suction habit with ages ranging from 4 to 7 years, it was found that those children presented distortions in /s/ and /f/ phonemes, which could be associated with presence of open bite caused by noxious habit17. However, longitudinal studies with pediatric patients followed up from 3 to 21 years old demonstrated that if the habit was discontinued at an early age, the effects over occlusion were transient, although none of the children that discontinued the habit after 6 years old presented normal occlusion at 12 years old, justifying the proposition that treatment before 6 years old should be directed to discontinuing the noxious oral habit, whereas after this age, it should focused on the use of mechanical orthodontic treatment.

Articulation disorders could be direct or indirectly related to oral noxious habits, and are explained from existing isolated or associated alterations such as: omission, replacement, distortion, addition, transposition of phonemes and are considered pathological if they occur after 4 years old. 18

Several studies have been carried out relating cause and effect of noxious suction oral habits, also referred to as deleterious or harmful2,5,9,10,20,21. Therefore, we became aware of the importance of the interrelationship between the disciplines of Speech Therapy, Dental Sciences and Otorhinolaryngology and the need for studies that deal with this issue and strengthen this interdisciplinary treatment of noxious suction oral habits.

The purpose of the present study was to check speech and dental alterations and the likely correlations with otorhinolaryngology aspects in pediatric patients with noxious oral suction habits. The patients were gathered from a health promotion event that was provided for low income population in the city of Sao Paulo as a preventive measure, offering a day for free speech screening test and mouth examination.

MATERIAL AND METHOD

The sample consisted of 9 Brazilian boys and girls (1 boy and 8 girls) from 5 to 9 years old, with noxious oral suction habits, screened in the I Mutirão da Comunicação (Massive Communication Campaign). The event was carried out in Hospital Heliópolis-SP on October, 27, 2001 and the primary objective was to make the population aware of communication disorders that could be prevented and treated as soon as the first symptoms of speech, voice, breathing, mastication, oral and written language abnormalities appear.

First, patients watched a video presented by a dentist and a speech pathologist, which explained about normal development stages from birth to elderly age. Then, patients were pre-screened by a speech pathologist, if any alteration was found; the patient was requested to wait to be submitted to actual speech therapy evaluation and dental inspection.

Data were collected in standardized form evaluations and applied by 07 speech pathologists and 6 dentists, and answers were provided by those responsible for the patient and were complemented by professional examinations.

One hundred and fifty six patients received care, making a total of 252 procedures carried out (156 speech screenings, 50 oral inspections and 46 hearing screenings) and 109 patients were referred to specialists (77 to Speech Therapy, 25 to ENT, 02 to Psychiatry/Psychology, 02 to Neurology, 02 to Neck and Head Surgery, 01 to Ophthalmology and Odontology).

Data related to gender, age, type and breathing mode (nose, oral, combined), speech disorder (fluency disorders, oral motor skill alteration, articulation disorders), type of bite (normal, open, unilateral crossing bite and overbite).

Due to the size of the sample, statistical tests were not carried out and we present a description of the data.

The Free Informed Consent Term was introduced to parents/and or responsible people that authorized the research, which was approved by the Ethical Research Committee of Hospital Heliopolis.

RESULTS

The sample of this study consisted of 09 children (1 boy and 8 girls) from 5 to 9 years old (two children were 5 years old, one was 6, two were 7, three were 8, and 1 was 9 years old). In relation to the type of breathing, 7 individuals had predominantly mouth breathing (77.78%), 1 case of combined breathing (11.11%) and 1 normal breathing (11.11%).

We checked the symptoms of speech disorders and detected 5 cases of articulation disorders (55.56%), 3 cases of oral motor skill disorders (33.33%) and 1 case without any speech pathology (11.11%). We considered as oral motor skill disorder the alterations of tonus, posture and mobility and/sensitivity disorders of phonation coordination organs (Graph 1), and we also found 8 cases of open bite (88.89%), and 1 case of normal bite, with clear correlation between open bite and suction habit (Graph 2).

Graph 1. Distribution of Occurrence of Speech Disorders


Graph 2. Distribution by type of bite

DISCUSSION

Hospital Heliópolis is located in São Paulo, and its surroundings host about 90 thousand low-income inhabitants. The idea of having the I Mutirão da Comunicação was based upon the increasing need of this population for some specialized therapies and preventive measure approach by means of presentations from professionals of different specialties such as Speech Pathology, Dental Science, and ENT, which would be able to increase the awareness of the population. Since the public health care does not provide Orthodontic care to effectively act on mechanical corrections of bite alterations observed in the studied subjects (open bite), such patients could not be referred. We would like to point out the need for incorporating this specialty in public health care, so that low income population would have access to orthodontics, enhancing speech and dental esthetics and restoring functional speech, providing improved quality of life. The concept of health promotion was defined in the Letter of Ottawa, a document that was put together in the First International Health Promotion Conference in November 1986, as being " a process of enabling the community to work in the improvement of their quality of life and health, including a higher level of participation in the control of the process." The document also stated that several aspects and resources were required to have health, such as peace, housing, education, food, income, environment, social justice and equality. According to this document the care of the specialties such as Dental Sciences, Speech Pathology and ENT should be available for needy population with free access to public health care.

The type of respiration was an aspect that captured our attention in the research, since 77.78% of the cases predominantly presented mouth breathing. According to the literature, some causes of mouth breathing involve obstructed upper airways, nasal septum deviation, basal membrane inflammation, turbinate hypertrophy, and pharyngeal tonsil hypertrophy, among others2,22. We noticed in the studied cases that there was palate morphological alteration with palate deepening. These children presented elongated and narrow face, drooped eyes, semi-opened, hypotonic dry lips, deep nasolabial folds, in addition to poor posture, with shoulder dropped forwardly. These children were referred to ENT Care Center for treatment.

The suction habit causes poor posture of the tongue, open bite and production of the phonemes /t/, /d/,/s/,/z/, /l/8 in the teeth. Moreover, the habit of sucking pacifier and bottle until the child is three years old is a nutritional habit, but after it, becomes noxious and deleterious10. When the habit is discontinued at three years of age, the balance of the stomathognatic system is restored. It was also found that if the habit is discontinued early, the child's occlusion becomes normal depending on the level of deformity2,9,10. For this reason, based on our sample and on the literature, we suggest that noxious suction habits have to be discontinued by eliminating the etiology of such habits (emotional and nutritional factors). It was evident that the child's response to being apart from the his/her mother that was working, was to have regression in the habits by using compensatory mechanisms to compensate the feeling of insecurity; this fact was reported in another study7.

Orthodontic care should start with preventive procedures, such as discontinuation of the habit, family guidance, and after 6 years of age, to intercept the consequences of such habits in the development of occlusion by using removable orthodontic appliances16,19,22. According to some authors, the mechanical orthodontic care should occur only after 6 years old 4,22. Nevertheless, only the multidisciplinary approach of open bite caused by suction habit leads to treatment success, with the participation of the orthodontist, psychologist, ENT and speech pathologist in order to provide a more effective therapy and to decrease the risk of malocclusion relapse.

With respect to speech alterations, we noticed that the most prevalent symptom was articulation disorder (55.55%), followed by oral motor skill disorder (33.33%). We observed, however, that noxious oral habits might cause tonus and motor skill disorders of the phonation coordination organs, respiratory, bite alterations leading to speech defects, which was consistent with data from another study. 21. It is important to point out the role of the speech pathologist when speech disorders resulting from oral suction habits are present. The speech pathologist works in the modification of improper behavior in terms of lip, tongue, cheek and mandible posture, besides coordinating the type of breathing, trying to make the child and his/her family aware of the importance of the improper habit.

It was found that facial structures that develop in childhood do not follow an immutable growth pattern, but a pattern that changes with the application of forces that vary the bone-muscle ratio. These forces may result form noxious habits that change the stomathognatic system. Certainly, noxious oral suction habits are responsible for the onset of several issues such as atypical phonation and malocclusions, as highlighted in the literature 2,4,5,8. Therefore, the need to promote health with an interdisciplinary approach of ENT, Speech Pathology, and Dental Science in order to prevent disorders caused by suction habit is evident. It is also essential to provide rehabilitation care in the public health care system to treat these disorders caused by suction habits when they occur in low-income population.

CONCLUSIONS

Oral suction habits were the etiology of malocclusions and speech disorders in the present study. The role of the ENT is fundamental for the understanding and progression of cases with disorders associated with anatomical-functional changes of the phonation coordination organs and the symptoms of noxious oral habits. Therefore, the access to specialties involved in the treatment of such dysfunctions should be available in the public health care system provided for low-income population.

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1 Master Studies under course, Post-Graduation Program, Department of Health Sciences at Hospital Heliópolis - Hosphel, São Paulo.
2 Faculty Member, Health Sciences Post-Graduate Program, Hospital Heliópolis - Hosphel, São Paulo.
3 Speech Pathologists, Hospital Heliópolis - Hosphel, São Paulo.
4 Head of the Department of Head, Neck and Otorhinolaryngology, Hospital Heliópolis - Hosphel, São Paulo.

Study conducted at Hospital Heliópolis - Hosphel, São Paulo, SP.

Address correspondence to: Valdinês Gonçalves dos Santos Cavassani - Rua José Patrício, 43 Rudge Ramos São Bernardo do Campo SP 09601-010 - Tel/fax: (55 11) 4368-9666 - E-mail: hmpsa_comercial@ig.com.br

Article submitted on September 10, 2002. Article accepted on November 29, 2002.

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