Karolina Mockė¹

¹ Faculty of Dentistry, Medical Academy, Lithuanian University of Health Sciences

Abstract

            Para functional oral habits are often found in children and adults, although their etiology is clear, these habits are seldomly linked to a person’s emotional well-being.  The aim of this study was to examine the relationship between para functional oral habits and child’s emotions. An additional aim was later raised to determine whether a psychologist is a key specialist in deleterious oral habit treatment. This study contained 412 subjects which were from 3 to 16 years old. The subject’s parents had to answer a questionnaire and to subjectively state their child’s para functional oral habits and associated emotions with it. Deleterious oral habits were present in 44,7% of the subjects. Females had higher para functional oral habit prevalence (56,5%) than males (43,5%). 3-5-year-old group (n=98) had more para functional oral habits than any other age group. 3-5 and 11-12-year-old groups and “calm” emotion showed statistical significance (P=0,040) (P=0,048) respectively. Lip, nail, pencil biting was the most prevalent para functional oral habit (n=54). Most of the children were found to be calm while executing their para functional oral habit, although statistical significance was not found. Statistical significance was seen between non- nutritive sucking oral habits and angry (P=0,012) and happy emotion (P=0,005). No statistical significance was found between parental status, emotions and their child’s para functional oral habits. A psychologist is a key specialist in the treatment of deleterious oral habits.

Keywords: oral habits, children, orthodontics, emotions.

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Medical Sciences 2021 Vol. 9 (2), p. 267-278

The relationship between child's emotions and deleterious

oral habits. A study conducted in Kaunas City

Karolina Mockė

1

1

Faculty of Dentistry, Medical Academy, Lithuanian University of Health Sciences

Abstract

Para functional oral habits are often found in children and adults, although their etiology is clear,

these habits are seldomly linked to a person’s emotional well-being. The aim of this study was to examine

the relationship between para functional oral habits and child’s emotions. An additional aim was later raised

to determine whether a psychologist is a key specialist in deleterious oral habit treatment. This study

contained 412 subjects which were from 3 to 16 years old. The subject’s parents had to answer a

questionnaire and to subjectively state their child’s para functional oral habits and associated emotions with

it. Deleterious oral habits were present in 44,7% of the subjects. Females had higher para functional oral

habit prevalence (56,5%) than males (43,5%). 3-5-year-old group (n=98) had more para functional oral

habits than any other age group. 3-5 and 11-12-year-old groups and “calm” emotion showed statistical

significance (P=0,040) (P=0,048) respectively. Lip, nail, pencil biting was the most prevalent para

functional oral habit (n=54). Most of the children were found to be calm while executing their para

functional oral habit, although statistical significance was not found. Statistical significance was seen

between non- nutritive sucking oral habits and angry (P=0,012) and happy emotion (P=0,005). No statistical

significance was found between parental status, emotions and their child’s para functional oral habits. A

psychologist is a key specialist in the treatment of deleterious oral habits.

Keywords: oral habits, children, orthodontics, emotions.

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1. INTRODUCTION

Typical oral habits include swallowing,

breathing, talking, chewing and less specific ones

like emotional communication, facial expression

and facial appearance [1]. Oral dysfunctions or

para functional oral habits are habits known as

nail and finger biting, atypical swallowing, teeth

grinding (bruxism), mouth breathing, tongue

thrusting and non-nutritive sucking habits such

as finger, pacifier sucking. Deleterious oral

habits are described as those that are done over a

long period of time. Most of the time these habits

are done unconsciously, but it also could be done

consciously during normal daily activities. The

etiology of the deleterious habits can be a

disharmonious relationship of parents and their

children, premature weaning, emotional

disturbances, dental and skeletal anomalies and

different oral diseases, parasomnia, neurological

disabilities and even brain injury [2,4].

Emotional distress in early childhood has been

said to cause problems in later life such as

different psychological difficulties, crime,

antisocial behavior, violence, drug use and

abnormal habits like para functional oral habits

[3]. Having these atypical oral habits over a long

period of time and not treating them causes harm

to various oral structures in the mouth and the

body [4]. Deleterious oral habits cause

malocclusion, faster deterioration of teeth and

the periodontal tissue, inflammation, muscular

dysfunction, temporomandibular disorders,

incorrect posture and many more [5].

Dubey et al. (2018) [6] divides these

dysfunctional oral habits into two groups.

Acquired oral habits are described as habits that

are learned and could be easily stopped if the

child wants to or is told to. On the other hand,

compulsive oral habits form due to emotional

stress that a child is put under and the oral

dysfunction is a way of coping for them. This

form of oral habit is much harder to stop as the

child will experience an increase in stress levels

and cause more anxiety [6]. According to some

authors deleterious oral habits are said to be

abnormal and need to be treated, when the child

reaches 6 years old, otherwise they are

considered normal and can spontaneously stop

[2].

It has been known for many years that

emotional stress is one of the key factors causing

and exacerbating oral para functional oral habits.

The emotional status of a child and stress relates

to para functional oral habits as it's usually seen

as the way that a person responds to and/or

recovers from stress [4]. The emotional stress

that a child experiences will usually cause an

increased activity in para functional oral habit

frequency [7]. Para functional oral habit such as

nail biting is highly associated with stress,

obsessive compulsive disorder, depression,

anxiety and many other emotional disorders.

These para functional oral habits help children to

soothe themselves and to let out their

experienced frustration and disappointment [8].

The deleterious oral habits are an adaptive means

of dealing with tense situations and that’s why

they can’t be quickly eliminated or stopped and

the treatment may take a while. First the child

should be taught to control and solve their

emotional problems and then the oral habit

should be taken care of [9]. According to

Massler [9] non-nutritive sucking, transitions to

nail biting due to a demanding environment that

the child is put in. This happens as the child is

asked to stop or control their childish whims and

emotions, then they are given more responsibility

that they can cope with or are told to follow

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certain rules that make them feel depressed,

annoyed and/or frustrated.

A relationship between para functional

oral habits and socio-economic status is also a

very important factor in deleterious oral habit

occurrence and frequency. A study done in 2011

[10] found that parents with higher education

level and higher income have fewer children that

are nail bitters, compared to those with lower

socio-economic status overall. Some authors say

that stress related disturbances such as

depression, anxiety, nervousness is a problem of

a highly developed society and the fast living

pace negatively affects the human psyche

[11,12]. The higher developed society stressors

include large number of duties, the need for good

education, the uncertainty of the future, the need

of good career and high income earnings [13]. It

is also said that mental health can be affected by

culture and their value system on education, life

goals, their life expectations, cultural standards

and concerns [1].

There are very few studies done only

examining the relationship of child's emotional

being and their present dysfunctional oral habits.

It is necessary to evaluate the child’s emotional

status in order to make orthodontic treatment

successful and long lasting. According to

Schwartz [14] para functional oral habit such as

nail biting is a bigger issue than it seems and the

child may need psychotherapy to identify the

underlying psychological issues. Thus the aim of

this study is to examine the relationship between

various oral para functional oral habits and

child's emotional state according to their parents.

An additional aim is to understand and identify if

a child psychologist is a key specialist in the

treatment of para functional oral habits.

2. MATERIALS AND METHODS

Population and sampling

This study was conducted in July of 2019.

Eligibility criteria was chosen to be parents who

had preschool and school aged children and were

living in Kaunas city at the moment of the

questionnaire passing. Exclusion criteria were

parents who had older children and weren’t

living in Kaunas City. The questionnaire was

distributed through social media platform

“Facebook”. The sample size was calculated

using a sample size calculator formula. The

sample size needed was 350 subjects, with a

margin error of 5% and confidence level at 95%.

The actual sample size came to be 412

participants who met eligibility criteria.

Data collection

The data was collected though a third

party website called “Apklausa.lt”. The main

objective of the questionnaire was that parents

had to select and identify their child’s specific

para functional oral habits and to subjectively

evaluate the child’s emotions.

The questionnaire had 6 different

sections. First section included demographic

questions about the child, their gender and age.

Second section asked about the child’s nutritive

habits up to 6 months and up to 1 year. It further

asked if the child was bottle fed and if so, what

was the bottle teat: physiological or non-

physiological. In the third section the parents

were asked about the child’s history of oral

dysfunctions. They were asked to select one or

few of the listed para functional oral habits (if

applicable) and the length of time that the child

had this para functional oral habit. In the fourth

section the questions were the same as in the

third, except that it was inquiring about current

dysfunctional oral habits. In the fifth section

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parents were asked about the most common place

where they saw the child executing the para

functional oral habits, how long it took at a single

time and what was the child's emotional status.

In the sixth and final section the parents had to

state their educational status.

Data analysis

The collected data was analyzed using

SPSS 25th version. The difference between

subjects and variables were evaluated using

nonparametric tests: Chi square independent test.

P values <0.05 were considered to be statistically

significant. Categorical variables were presented

in terms of frequency and percentage.

3. RESULTS

There were 412 subjects, that matched the

inclusion criteria. 224 (54,4%) of those were

girls and 188 (45,6%) were boys. The age

dispersed as follows: 266 (64,5%) subjects were

between 3-5 years old, 89 (21,7%) were between

7-9 years old, 37 (8,9%) were between 11-12

years old and 20 (4,9%) subjects were between

15-16 years old.

Out of the 412 subjects, 184 (44,7%)

children have at least one deleterious oral habit

of those 104 (56,5%) are girls and 80 (43,5%) are

boys. Nail, pencil and lip biting is the most

occurring para functional oral habit (n=77).

Second and third most occurring para functional

oral habit is non-nutritive sucking habit and

mouth breathing both having 47 subjects. 37

children have bruxism and only 3 participants

have tongue thrusting deleterious oral habit. 158

(85,9%) out of 184 children have only one para

functional oral habit and 26 (14,1%) children

have 2 or more para functional oral habits.

According to the subject’s parents out of

184 children with para functional oral habits, 133

(72,3%) of them experience at least one sort of

emotion and 29 (15,7%) children experience two

or more different emotions while executing the

para functional oral habits. The remaining

parents (12%) reported that they are not aware of

their children’s emotions and didn’t choose an

answer. 75 of the subjects are calm, 21 are

annoyed, 1 is angry, 5 subjects are annoyed and

angry, 2 are annoyed and experiencing another

emotion and 5 subjects are happy. 31 parent said

that the child experienced some other emotion

that was not included in the questionnaire.

Across the gender and emotion dispersion

(table 1), females experienced more emotions,

excepts for the “anger” emotion, which was

experienced more often by males. Although no

statistical significance between gender and

emotion were found.

Between all of the age groups, most

commonly felt emotion was “calm” (Table 1).

The 3-5-year-old as well as 11-12-year-old

findings with “calm” emotion showed statistical

significance. Most prevalent emotion between

11-12 year olds was chosen to be another

emotion not included in the questionnaire.

Table 2 shows emotion and para function

oral habit dispersion, the calm and annoyed

children were found to have nail, lip and pencil

biting most often. Statistical significance was

found in the angry and happy emotion group and

non-nutritive sucking habit group.

Table 3 examines parental education level

and the link between their child’s experienced

emotions. No statistical significance between

parental education and child’s emotions was

found, but the most chosen emotion was “calm”

across all parental education levels.

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Parents across all education levels most

often has children with nail, lip and pencil biting

oral para functional oral habit (Table 4).

Although this discovery, no statistical

significance was found between parental

education status and their child’s para functional

oral habits.

Table 1 Emotion dispersion across gender and age of sampled group

Calm

n

Annoyed

n

Angry

n

Happy

n

Another

emotion n

Doesn’t

know

n

Gender

Male

40

P= 0,796

16

P=0,514

10

P=0,276

4

P=0,242

18

P=0,587

11

P=0,511

Female

54

P= 0,796

25

P=0,514

8

P=0,276

10

P=0,242

28

P=0,587

11

P=0,511

Age (years)

3-5

65

P=0,040

23

P=0,381

11

P=0,938

9

P=0,852

20

P=0,184

11

P=0,218

7-9

21

P=0,178

11

P=0,974

4

P=0,656

5

P=0,424

12

P=0,438

8

P=0,271

11-12

4

P=0,048

5

P=0,283

2

P=0,629

0

P=0,246

6

P=0,053

3

P=0,316

15-16

4

P=0,438

2

P=0,508

1

P=0,564

0

P=0,475

0

P=0,204

0

P=0,359

n:frequency, P: p-value *P value statistically significant <0,05

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Table 2 Emotion dispersion and deleterious oral habits

Calm

n

Annoyed

n

Angry

n

Happy

n

Another

emotion n

Doesn’t know

n

Oral habits

Non-nutritive

sucking habit

27

P=0,312

14 P=0,152

9

P=0,012

8

P=0,005

8

P=0,476

3

P=0,172

Nail, lip, pencil

biting

38

P=0,689

21

P=0,168

8

P=0,814

4

P=0,295

15

P=0,739

10

P=0,715

Teeth grinding

20

P=0,553

5

P=0,068

2

P=0,565

1

P=0,428

12

P=0,128

1

P=0,138

Tongue thrusting

0

P=0,074

1

P=0,643

0

P=0,565

1

P=0,090

0

P=0,373

1

P=0,250

Mouth breathing

26

P=0,501

8

P=0,315

5

P=0,819

4

P=0,787

8

P=0,476

7

P=0,472

n:frequency, P: p-value *P value statistically significant <0,05

Table 3 Parent educational status and emotion dispersion

Calm

n

Annoyed

n

Angry

Happy

n

Another emotion n

Doesn’t know

n

Education level

Primary

education

8 P=0,856

4

P=0,670

1

P=0,672

1

P=0,886

3

P=0,948

0

P=0,136

Secondary

education

26

P=0,302

8

P=0,403

5

P=0,730

3

P=0,784

7

P=0,331

12

P=0,984

Higher education

47

P=0,226

23 P=0,799

9

P=0,697

8

P=0,827

26

P=0,051

12

P=0,984

Post graduate

diploma

13

P=0,746

6

P=0,732

3

P=0,631

2

P=0,886

2

P=0,110

4

P=0,446

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Table 3 Parent educational status and emotion dispersion

Calm

n

Annoyed

n

Angry

Happy

n

Another emotion n

Doesn’t know

n

n:frequency, P: p-value *P value statistically significant <0,05

Table 4 Parent educational status and oral para functional habits

Non-

nutritive

sucking

n

Nail, lip,

pencil biting

n

Teeth grinding

n

Tongue

thrusting

n

Mouth breathing

n

Education level

Primary education

5

P=0,470

7

P=0,693

1

P=0,376

1

P=0,108

4

P=0,917

Secondary education

10

P=0,557

17

P=0,524

8

P=0,197

0

P=0,320

11

P=0,846

Higher education

28

P=0,404

41

P=0,799

25

P=0,115

2

P=0,666

25

P=0,854

Post graduate diploma

4

P=0,285

12

P=0,385

3

P=0,556

0

P=0,499

7

P=0,662

n:frequency, P: p-value *P value statistically significant <0,05

4. DISCUSSION

There are very few studies done that

evaluate various para functional oral habits and a

child's emotions. Some studies briefly discuss the

relationship between temporomandibular joint

disorders and emotional status in children and

adults. Other studies highlight the importance of

income and family life in terms of para functional

oral habit occurrence.

Overall this study findings of para

functional oral habit prevalence (44,7%) in

preschool and school aged children matches

Leme et al. [1] study, which found that 71,3% of

children have at least one deleterious oral habit.

In a study done by Dubey et al. [s6] the para

functional oral habit prevalence matched this

study findings, with the oral habit occurrence at

45,2%. In the Leme et al. study they found, that

the para functional oral habit prevalence was

higher in the girl group. It is also seen that nail,

pencil and lip biting is the most prevalent oral

habit [1]. Para functional oral habits most

frequently occur in the 3-6-year-old group [6].

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Bano et al. (2019) found that people with

dependent personality disorder, which is

explained as people with anxiousness, fear and

feeling nervous, have higher levels of nail biting,

compared to those that don’t have this disorder.

It is also quite clear that children that have non-

nutritive sucking habits like pacifier or digit

sucking, later in life adopt nail biting, pencil

biting or smoking habits as a way of coping [16].

If a child persists with non-nutritive sucking

habits for a long period of time, some authors

suggest that they are under physical or

psychological stress, feeling anxious, bored or

even excited [23]. A study done in Brazil

confirms these findings, as their study shows that

children with oral dysfunctions have worse oral

health related quality of life, and thus it further

impacts their oral health related quality of life

and their dysfunctional oral habits intensify [1].

A study found that children who have

bruxism, especially sleep bruxism most often

have obsessive compulsive disorder as well as

they tend to have a controlling and aggressive

personality [15]. A Mexican study [19] found

that children who had deleterious oral habits

were found to be tired, emotionally unstable or

even often annoyed. Leme et al. study done in

Brazil confirm these findings and found that

58,7% of children with various para functional

oral habits had depressive symptoms and an

increased cortisol blood levels [21]. Another

study found that children who had anxiety

disorders and bruxism, also had pacifier sucking

and biting habits [23]. A study conducted by

Brancher et al. (2020) [26] shows that children

with sleep bruxism are the ones who internalize

their problems, often have peer pressure issues

and abnormal emotional symptoms.

According to Santos et al. [17] para

functional oral habit like non-nutritive sucking

can be a positive emotion expression way for

children. This connection is formed when a

newborn is breast fed and the positive bond

between mouth, lips, tongue and the sucking

sensation occurs. Later on in life these children

try to find this positive sensation and recreate it

with other objects like pencils or fingers. A study

done in Mexico in 2019 [18] showed that

children that had various deleterious oral habits

more often were found to be calm, bored and

having nothing to do. A Spanish study done in

2005 [23] agrees with the previous data, as they

found that children with oral habits often were

bored or even excited.

A study conducted in Saudi Arabia (2016)

[3] investigated para functional oral habit

prevalence in orphan children and non-orphans.

It was discovered that orphaned children had

more para functional oral habits with the most

prevalent being digit sucking, whereas non

orphans had more nail biting. It was known that

all of these children were orphans from infancy,

were raised by foster mothers and were not breast

fed at all. The authors made a presumption that

these children were in lack of the intimate, close

positive feeling that children get while being

breast fed by their mothers and so they tried to

stimulate this feeling by choosing digit sucking

oral habit.

A study done in 2019 [8] investigated the

link between socioeconomic status and nail

biting in adult population. The study collected

data such as income, education level, the

subject’s specific profession and nail biting para

functional oral habit. It was found low

socioeconomic status more times leads to nail

biting oral habit prevalence development than

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those with higher standards of living. This study

also discovered that subjects with higher

education level had less chance to develop nail

biting para functional oral habit. Contradicting

findings were made in a study done in Poland

[11] which showed that highly developed

societies are more likely to suffer from stress

related disorders and so the number of

deleterious oral habits that people experience is

rising. Authors in Mexico agree with this, as in

their study same conclusions were drawn that,

children with highly educated parents have more

para functional oral habits than those with low

education levels. Calisti et al. [22] in their study

found that dysfunctional oral habits especially

non-nutritive sucking was more prevalent in

children living in towns and cities, rather than

rural areas. Children with mothers who work

outside of their homes found themselves feeling

lonely and dissatisfied and as a mean of

compensating this feeling they adapted a para

functional oral habit [22].

A case-control report done in Spain

evaluated para functional oral habits with family

status and discovered that children who were

raised by grandparents, single parent or had

arguing parents had an increased chance to

develop para functional oral habits than those

children who had a harmonious family life with

both of the parents involved [27].

A study done in Saudi Arabia [4]

evaluating the para functional oral habit and

emotional status relationship on adults showed

similar results as in those studies done with

children. The findings came to be that people

who are emotionally stable tend to have less para

functional oral habits including nail biting, teeth

grinding, teeth clenching and lip/pencil biting.

Also these people were less likely to report

temporomandibular joint disorders. It becomes

clear that if para functional oral habits are not

treated in childhood, they tend to carry over to

adulthood. Another study found that adults with

lower income were 1.4 times more susceptible to

have teeth clenching. It was also discovered that

younger males in particular had 1.95 more

chances of lip/object biting and 1.4 more times to

object and lip bite if they were single. From this

we can say that younger people are more

susceptible to stress and not knowing how to deal

which leads to an increase in deleterious oral

habit occurrence. Financial status and marital

status also plays an important role in para

functional oral habit prevalence.

A study done back in 2002 by Alamoudi

[25] had drawn similar conclusions to this study

as their study principle was almost identical. In

both of these studies the subject’s parents had to

choose and evaluate their child's emotions

subjectively. As in this study they found no

significant correlation between all child's

emotions and para functional oral habits.

5. CONCLUSION

64,5% of children in this study were

between 3-5 years old. 44,7% of children have at

least one para functional oral habit. The most

prevalent deleterious oral habit is nail, pencil and

lip biting. Overall girls experience more

emotions than boys.

“Angry” and “happy” emotions showed

statistical significance with non-nutritive

sucking oral habit. Other emotions and para

functional oral habits showed no statistical

significance. 3-5 and 11-12 year olds and “calm”

emotion showed statistical significance. From

this we can say that a psychologist is a key

specialist in diagnosing and treating deleterious

oral habits as child’s emotions play an important

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role in para functional oral habit occurrence and

frequency.

Parents that have higher education level

more often have children with 1 or more para

functional oral habits. Although no statistical

significance was found between parental

educational level, para functional oral habits and

their child’s emotions.

In the end each and every person receives

the world and its caused stress differently. Some

people are seen to deal with stress by clenching

or grinding their teeth and biting their nails.

Interdisciplinary approach is very important

while treating children and adults with

dysfunctional oral habits. These deleterious oral

habits can be managed by the means of

orthodontic treatment and psychological

approach of attention giving, support,

counselling, reward and a remainder system [9].

This study needs to further examine the

emotional status of children by a professional

psychologist before orthodontic treatment

begins, to fully understand the etiology of para

functional oral habits. This is important in order

to have successful treatment without the

possibility of habit or malocclusion

reoccurrence.

6. LIMITATIONS

The limitations of this study were that the

parents considered their children’s emotions

subjectively. To understand the true child’s

experienced emotions, the children need to be

asked and evaluated by a professional.

To truly apprehend and link the

relationship between socioeconomic status and

para functional oral habits, the questionnaire

should be extended and the parents should be

asked to state their profession, and income

margins, not just their education level alone.

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