REVIEW ARTICLE

Tiny Tots and Thumb Sucking

Dr. Punithavathy1, Dr. Baby John2, Dr. Stalin3.
1

Senior lecturer,
Professor & HOD
3
Reader
2

Department of Pediatric and Preventive dentistry,

KSR Institute of Dental Science & Research,
Tiruchengode, Tamil Nadu.
Pin : 637 209
Address for correspondence :
Dr. Punithavathy
C-12, Sri Kumaran grand palace,
Thindal Post,
Erode, Tamilnadu India
Phone No : 9843518986
E mail : punithanaren@gmail.com

Introduction :
Oral habits may be a part of normal development,
a symptom with a deep rooted psychological basis or may
be the result of abnormal facial growth1. Thumb and finger
habits are considered to be the most prevalent of oral
habits, ranges from 13% to 100% at the time of infancy. The
prevalence of digit habits decreases with age, by 3.5 to 4
years but some may continue into adulthood. When these
habits persist, a number of factors like the frequency,
duration, intensity, relationship of the dental arches, and
the childs state of health affect the development of oral
structures.2
Classification :
Based on clinical observation thumb sucking is
considered normal during 1st and 2nd year of life then it
disappears as child matures, and does not generate any
malocclusion. When the habit persist beyond the preschool
period it is considered as abnormal habit and if ignored may
cause deleterious effects on dentofacial structures. This is
again divided in to psychological and habitual.
Habit with deep rooted emotional factors is called
psychological and is associated with insecurities, neglect, and
loneliness. Habitual cause is when there is no psychological
bearing and child performs the act out of habit3.
Phases of Development of Thumb Sucking (moyers)
Phase I Normal and sub clinically significant. It is
seen during first three years of life. The habit is considered

ABSTRACT:
Thumb sucking is a natural reflex in infants that usually starts
in intrauterine life. It is the first co-ordinated muscular activity in
humans. Few children accommodate with the habit if they use it to
comfort themselves for deep rooted psychological reasons. The
examination of a Pediatric dental patient with an oral habit, the
practitioner requires to make a series of relatively complex evaluations
before arriving at a diagnosis or making any recommendations for care
.The assessment of these behaviors must be coupled with a sensitive
assessment of the physical and emotional status of the child and the
relationship of the parent or caregiver. Treating and intercepting the
habit with psychological counseling is more important and effective
than mechanotherapy that usually we do.
Keywords:
Thumb sucking, psychology, psychosocial, counseling

normal during this phase and unusually terminates at the

end of phase one.
Phase II Clinically significant sucking: the 2nd
phase extends between 3 6 years of age. The presence of
sucking during this period is an indication that the child is
under great anxiety. Treatment should be initiated during
this phase.
Phase III Intractable sucking: any thumb sucking
persisting beyond 4th and 5th year of life should alert the
dentist to the psychological aspect of approach4.
Causative Factors:
Feeding practices:
Thumb sucking is most frequent among breast fed
but many studies have proven this consumption to be wrong.
The time spent in nutritive sucking was a significant factor in
the incidence of thumb sucking. Duration of early feeding in
infancy has little effect on the development of this habit.
Number of siblings:
The development of the habit can be related to the
number of siblings because more the number increases the
attention meted out by the parents to the child gets divided.
A child who feels neglected by the parents may attempt to
compensate his feelings of insecurity by means of this habit.
Socioeconomic status:
Generally families in high status are blessed with
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Tiny Tots and Thumb Sucking

ample nourishment and hence child's hunger is easily

satisfied .While child of low economic status has to suckle
intensively for long time to get nourished, so the meantime
sucking urge gets exhausted . Calisti et al proposed that
children of high economic status demonstrate more oral
habits than the middle or low class counterparts5.
Psychological factor :
Most children practice the habit to comfort
themselves from psychological stressful conditions. There is
total change in body chemistry whenever the children suck
their thumb. It actually makes the brain to produce
endorphins which are chemical neurotransmitters that are
produced and released within the nervous system. These
endorphins calm the body and provide pleasure for the
children. Due to this reason, most of the children develop
the habit to combat the psychological reasons6.
If the habit becomes more intense when the child
feels that its security is threatened then the cause of the habit
will be clearly emotional. Such emotional conditions are
feeling of insecurity, fear, frustration, stress, anxiety, boring,
afraid etc. There are many psychological factors that make
the child emotionally disturbed like working mother,
caretaker insecurity, disputed parents, emotional neglect,
order of siblings, alcoholic father etc7.
Clinical Features :
Extraorally the key areas to be examined include
digits, involved in sucking. It appears extremely clean,
reddened, chapped with short finger nails. Fibrous
roughened callus on superior aspect of the finger. Lips
may be short and hypotonic, Facial form & profile
analysis can also be checked for mandibular retrusion,
maxillary protrusion, high mandibular plane angle and
convex profile.
Intraorally examine the size of tongue, position at
rest and during swallowing, dentoalveolar structures,
gingiva, anterior open bite, constricted maxillary arch and
posterior cross bite4
Prevention:
a. Motive based approach.
b. Child engagement in various activities child
practices habit when bored and left alone. Parents should
engage the child in various activities by following his
hobbies of interest such as painting, engaging in out door
activities with his fellow mates.
c. Prevent psychological disturbance by giving
proper care, affection, equal attention to all siblings and
always making the child to feel secured and well cared.
d. Feeding practices should also be in such a way
that baby satisfies both hunger and its sucking urge. In case

Punithavathy, Baby John & Stalin

of bottle feeding the habit can be prevented by use of

physiological nipple and keeping more of vacuum in bottle.
Babies who are fed every three hours are less likely to suck
their thumb than those who are fed every four hours. But
some studies reveals that there is no correlation between
feeding practices and thumb sucking, thus it is still
controversial8
Treatment Modalities:
Once the decision for treatment has been made,
one must next determine what intervention is appropriate.
The treatment considerations are psychological status, age
factor, maturity of the patient, and patient co-operation.
The combinations of explanations with consideration of
physical appearance and social acceptance may be
sufficient for the child to give up the behavior. In addition to
their own intention some children may require additional
help. Another tool that is helpful for this type of child is the
use of positive reinforcement. Rewards for progress in
diminishing the habit should include praise and something
special that is agreeable to patient and parent.2
Psychological Therapy :
A. Dunlop's hypothesis
If a subject is forced to concentrate on the
performance of the act and the time he practices it, he could
learn to stop performing the act. Forced purposeful
repetition of habit eventually associates with unpleasant
reactions and the habit is abandoned. The child should be
asked to sit in front of the mirror and asked to observe
himself as he indulges in the habit1.
B. Six steps in cessation of habit (Larson & Johnson)
Step 1: Screening for psychological component.
Step 2: Habit awareness.
Step 3: Habit reversal with a competing response.
Step 4: Response attention.
Step 5: Escalated DRO (differential reinforcement of other
behaviors)
Step 6: Escalated DRO with reprimands. (Consists of
holding the child, establishing eye contact and firmly
admonishing the child to stop the habit8.
C. Three alarm system: (Norton & Gellin-1968)
A chart is designed with days of the week and blank
spaces. When the child engage in his habit he is told to
wrap the digit he sucks with coarse adhesive tapes. The
child feels the tape in his mouth it is the first alarm and this
reminds him to stop the habit. The elbow of the arm with the
offending thumb is firmly wrapped in two inch elastic
bandage safety pins are placed at proximal & distal ends of

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Tiny Tots and Thumb Sucking

bandage and one safety pin is placed lengthwise at the

mesial end of the elbow and when the child sucks the thumb
again, the closed pin on the medial end of elbow, mildly
jabbing the elbow indicates second alarm. If the habit
persist, the bandage is tightened this is the final or third
alarm, which will definitely remind the child of the habit.
D. Reward system:
Children should be encouraged and rewarded for
not practicing the habit. contingency contracting is a
contract made between the child and dentist or child and
parent. The contract simply states that the child should not
suck their thumb for specific period of time. The child should
be rewarded if the requirement of the contract is met.
E. Ace bandage approach:
In this approach, bandage should be wrapped
around the finger and stars should be entered into the
calendar .This reminds the parents to wrap the bandage the
previous day and also the child for not sucking their thumb.
For every twenty stars entered in the calendar, the child
should be rewarded3.
F. Thumb buddy to love:
This is commercially available and is a positive
teaching tool and chemical free method. It contains thumb
puppet that is inserted into the child's thumb and a calendar
at the back of the book. By having the thumb puppet, the
child stays motivated to stop the habit.
G. Thumb - Home concept:
This is the most recent concept. In this a small bag
is given to the child to tie around his wrist during sleep and it
is explained to the child that just as the child sleeps in his
home, the thumb will also sleep in its house and so the child
is restrained from thumb sucking during night1.
Eliminating chronic thumb sucking by preventing a
covarying response: The behavior is believed to lose its
appeal by being reframed as a duty. Thus, make the child to
suck all the ten finger the same length of time so that it
produce unpleasant reaction and gradually it quits the
habit. Forced repetition of the habit will eventually
associate it with unpleasant reaction.
H. Chemical Treatment:
Bitter and sour Chemicals have been used over the
thumb causally to terminate the practice but with very
minimal success e.g. quinine, asafetida, pepper, caster oil,
etc. Nowadays new anti-thumb sucking solutions like
femite, thumb-up, anti-thumb are also being marketed but
they have also had a very moderate success9.

Punithavathy, Baby John & Stalin

I. Remainder therapy:
Painting something that tastes yucky on the thumbs
can make them less satisfying. Physical barriers like band
aids, gloves etc can also be used.
J. Thumb guard:
It is an appliance that is worn when the child is
tempted to suck. Once the guard is worn they cannot
generate vacuum and so sucking is not much satisfying.
Another approach is long sleeve gown by doubling the
length of the sleeve. It makes difficulty for the child to suck.
While providing remainder therapy the child should be
instructed that these are just to remind them to take the
thumb out and it is not a punishment1.
K. Parent counseling:
A different approach that can be practiced when its
known that the child, wants to discontinue the habit, it requires
the cooperation of the parent and their consent to disregard
the habit and not mention it to the child. In private
conversation with the child, the problem and its effect must be
elicited. The parents' role in correction is very significant. Over
anxiety and the resulting nagging approach or punishment
often creates greater tension and intensification of the habit.
Thus a change in the home environment and routine help the
child to overcome the habit.
Nagging, scolding or frightening the child should
be avoided since this could cause negativism and tend to
make him resort to the habit.
From a psychological point of view the child should
make the decision that he doesn't want to do it anymore.
Parents should not force the preschoolers to break the
habit since they only know the pleasure derived from the
habit but they cannot understand why the habit to be
stopped. Some children practice the habit while watching
T.V especially when there is no other person to take care of
them during day time. So in such case, parents should
spend more time with children during day time10.
Other Possible Approaches:
I. Mechanotherapy:
Removable or fixed palatal crib
It breaks the suction force of the digit on the
anterior segment, makes the habit a non-pleasurable one.
Hay Rakes
Mack (1951) advocated the use of dental
appliance in children over 3 years of age who are
persistent thumb suckers. The device was called hay rake as
it was designed with a series of fence like lines that
prevented sucking1.

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Tiny Tots and Thumb Sucking

Punithavathy, Baby John & Stalin

Blue Grass appliance

Developed by Bruce S Hasked (1991). It is a fixed
appliance using a teflon rolled together with positive
reinforcement which is used to manage thumb sucking
habit in children between 7 and 13 years of age. The
patient believes that he has acquired a new toy to play with.
Instructions are given to them to roll the roller instead of
sucking the digit.
Figure 3: long sleeve shirt

Modified Blue Grass appliance

This is a modification of the original appliance with
the difference being that this has two rollers of different
colors and material instead of one. If the patient tries to suck
on his thumb the suction will not be created and this thumb
will slip from the rollers thus breaking the act11.
Quad helix
The quad helix is fixed appliance used to expand
the constricted maxillary arch. The helixes of the appliance
serve to remind the child not to place the finger in the
mouth1.
Oral Screen
Oral screen is a functional appliance introduced by
Newell in 1912. It produces its effects by redirecting the
pressure of the muscular and soft tissue curtain of the
cheeks and lips. It prevents the child from placing the thumb
or finger into the oral cavity during sleeping hours3.

Conclusion:
To conclude, the essence of this extract is that, this
habit has more psychological factors involved and can be
best managed through counseling and psychological
approach than the usual mechanotherapy, thereby
preventing a full-blown stage of malocclusion that the habit
may cause. The management of the habit is accessible to
all practioners as it does not demand any special or
technique sensitive procedures. Awareness must be created
at a community level so that early interception of the habit
can be achieved.
References:
1. Nikhil Marwah, Textbook of Pediatric Dentistry 2nd edition 2009.page 281 - 89.
2. John A Maguire., The Evaluation and treatment of Pediatric oral habits,
Dental Clinics of North America. Volume 44, No.3, July 2000.
3. Shobha Tandon, Textbook of Pedodontics 2nd edition 2008.page 492 504.
4. Arathi Rao, Principles and Practice of Pedodontics, 2nd edition 2008.page
115 126.
5. Eric D.Johnson, Brent E.Larson., Thumb sucking: Literature review. Journal
of Dentistry for Children ,Nov - Dec 1993.page 385 391.
6. Singh S.P., Utreja A.,Chawla H.S., Distribution of malocclusion types
among thumb suckers seeking orthodontic treatment. J Indian Soc Pedo Prev
Dent Supplement 2008.page s114 s117.
7. Amitha M Hegde, Arun M Xavier., Childhood Habits: Ignorance is not bliss
A Prevalence Study. International journal of clinical pediatric dentistry, Jan
April 2009;2 (1):26-29.
8. Johnson ED, Larson BE, Thumb sucking: classification and treatment,
ASDC J.Dent Child, 1993 Nov-Dec 60(4) : 392-398.

Figure 1: Ace bandage

9. Sulaiman Al-Emran., A modified palatal crib appliance for children with

predetermined thumb-sucking habit case report. Saudi Dental Journal,
Volume 20, No.1, Jan April 2008.page 31-35
10. Mc. Donald Avery, Dentistry for the Child and Adolescent, 8th edition.
11. Bruce S. Haskell., John R. Mink., An aid to stop thumb sucking: the
Bluegrass appliance. Pediatric Dentistry, Volume 13, No.2.page 64 66.

Figure 2: Thumb guard

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