Table of Contents    
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 207-210  

Prevalence of oral habits among 4–13-Year-Old children in Central Kerala, India

1 Department of Periodontics, PSM College of Dental Science and Research, Thrissur, India
2 Department of Public Health Dentistry, PSM College of Dental Science and Research, Thrissur, India
3 Department of Pedodontics and Preventive Dentistry, St. Gregorios Dental College, Ernakulam, Kerala, India

Date of Web Publication20-Jun-2018

Correspondence Address:
S Anila
Department of Periodontics, PSM College of Dental Science and Research, Akkikavu, Thrissur - 680 519, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsbm.JNSBM_14_18

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Aim: The present study was conducted to determine the prevalence of harmful oral habits among 4–13-year-old children in relation to their age and gender, in a dental college hospital in Central Kerala, India. Methods: A retrospective survey was conducted in 1034 children (478 males and 556 females) aged between 4 and 13 years. The participants were checked for the prevalence of oral habits in relation to their age and gender. Information regarding oral habits was obtained with the help of a questionnaire and clinical evaluation using mouth mirror and water tests. Chi-square test was used in the statistical analysis. Results: Overall prevalence of oral habits was 72.7% in the study participants. Nearly 47.1% of the children had only one habit, whereas 19.1% had two habits and 5.5% had three or more habits. Mouth breathing was the most commonly reported oral habit (29.4%), followed by tongue thrusting (23.5%), nail biting (20%), thumb-sucking (17%), pencil biting (8.7%), bruxism (4.9%), and lip/cheek biting (4.5%). Nail biting was reported significantly more in females and bruxism significantly more in males. Prevalence of thumb-sucking was very high in younger children (4–8 years) compared to older children (9–13 years). Conclusion: The prevalence of oral habits among 4–13–year-old children is very high in Central Kerala, compared to children in other Indian populations. Since oral habits can be intercepted and prevented, creating awareness regarding the adverse outcomes of oral habits is highlighted.

Keywords: Child, habits, mouth breathing, oral health, prevalence

How to cite this article:
Anila S, Dhanya R S, Thomas AA, Rejeesh T I, Cherry K J. Prevalence of oral habits among 4–13-Year-Old children in Central Kerala, India. J Nat Sc Biol Med 2018;9:207-10

How to cite this URL:
Anila S, Dhanya R S, Thomas AA, Rejeesh T I, Cherry K J. Prevalence of oral habits among 4–13-Year-Old children in Central Kerala, India. J Nat Sc Biol Med [serial online] 2018 [cited 2021 Mar 2];9:207-10. Available from:

   Introduction Top

An important part of general health and well-being is oral health. Traditionally, the presence or absence of oral disease has been the main method of measuring oral health. This has now been substituted by a multidimensional concept which includes the psychosocial aspects of dental health and its influence on quality of life.[1]

Any repetitive action being done automatically is called a habit.[2] Stimulation of mouth with tongue, finger, nail, or cigarette is a source of relief in passion and anxiety in both children and adults.[3] Some repetitive and self-injurious behaviors in the oral cavity include mouth breathing, tongue thrusting, digit sucking, nail/lip/cheek biting, and bruxism. The subsequent effect of an oral habit is dependent on the onset, duration, and nature of the habit.[4]

Thumb-sucking is forceful and repeated sucking of thumb with associated contraction of lip and buccal musculature. It is considered normal in infants and young children below the age of 3 years and 6 months.[5] Dental changes due to prolonged thumb-sucking beyond 5 years of age include increase in overjet, open bite in anteriors, labial inclination of upper incisors, and posterior crossbite.[6],[7],[8],[9]

Delayed transition between infantile and adult swallowing patterns leads to tongue thrusting. Tongue thrusting and mouth breathing may be associated with labial inclination of maxillary incisors, open bite,[10] and Class II malocclusions.[11] Bruxism is a forceful nonfunctional contact of tooth surfaces that can be triggered due to emotional stress.[12] It can lead to attrition of teeth, soreness of masticatory muscles, and dysfunction of temporomandibular joint.

Persistence of oral habits beyond a certain age frequently leads to malocclusion and facial deformities. Harmful oral habits can also result in bone malformations.[13] When prolonged beyond 5 years of age, these habits can be socially stigmatizing and interfere with clarity of speech along with various dental malocclusion.

To the best of our knowledge, the prevalence of oral habits in children has not been previously studied in Kerala population.

   Methods Top

The survey was conducted in a sample of 1034 children, aged between 4 and 13 years, reporting to a dental college and hospital in Thrissur district, Kerala state. Simple random sampling technique was used for case selection. The Institutional Review Board reviewed the study protocol and granted ethical clearance.

The inclusion criteria were as follows: children (1) should be 4–13-year-old; (2) should have permanent or deciduous central incisors; (3) should not have any syndromes or clefts lip/palate; (4) should not have a current/past orthodontic history; and (5) currently should not have any respiratory infections.

A pilot survey was conducted in which oral habits' prevalence was estimated at 27.5%. Assuming a confidence interval of 95%, a sample size calculation indicated that 1025 participants were required to detect the prevalence of oral habits, with a power of 90% (α < 0.05). Kappa coefficient for interexaminer agreement was determined to be 0.81 during the pilot study.

A closed-ended questionnaire was used to get data from the parents of the study participants. After completion of the pilot study, some modifications were made in the questionnaire. Face validity and content validity of the questionnaire were assessed by four experts in the field of dentistry and one methodologist. A written informed consent for the study was obtained from the respective parent/guardian. Deleterious oral habits were screened by trained personnel from the Department of Public health dentistry, using mouth mirrors and probes. Clinical evaluation for mouth breathing was done with water test. The child was asked to take a little amount of water in his/her mouth with lips in contact without swallowing. Children unable to maintain lips in contact position for 3 min were considered as mouth breathers.[14] Apart from mouth breathing, the children were screened for tongue thrusting, thumb-sucking, bruxism, pencil/nail biting, and lip/cheek biting. Following the examination, a health educational talk was delivered using study models.

SPSS version 15.0 (Statistical Package for the Social Sciences, SPSS Inc; Chicago, Illinois, USA), was used to derive the prevalence rates of different oral habits. Chi-square test was done to compare the prevalence of oral habits according to age group and gender. The probability level was set at α = 0.05. <5% (P< 0.05) differences in probabilities were considered to be statistically significant.

   Results Top

A total of 1034 children, 478(46.2%) males and 556 (53.8%) females; aged 4-13 years, were screened for oral habits. The composition of the sample by age and gender is represented in [Table 1].
Table 1: Composition sample (n=1034) by age and gender

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Among the children assessed, 752 (72.7%) children had at least one oral habit, of which 402 (53.5%) were females and 350 (46.5%) were males. There was no significant gender-wise difference in the oral habits' prevalence. Four hundred and eighty-seven (47.1%) children reported with only one oral habit, 197 (19.1%) had 2 oral habits, and 57 (5.5%) had 3 oral habits [Graph 1]. The two oral habits occurring most concurrently were tongue thrusting and mouth breathing reported in 42 (4.1%) children. The three oral habits occurring most concurrently were tongue thrusting, mouth breathing, and thumb-sucking, reported in 12 (1.2%) children.

Assessment of individual prevalence of oral habits revealed that 304 (29.4%) children had mouth breathing habit, 243 (23.5%) had tongue thrusting habit, 171 (17%) had thumb-sucking, 207 (20%) had habit of nail biting, 90 (8.7%) had pencil biting habit, 51 (4.9%) had bruxism, and lip/cheek biting was found in 47 (4.5%) children [Graph 2]. Gender-wise prevalence assessment of each oral habit indicated significantly higher rates of nail biting in females (P = 0.0093) and significantly higher rates of bruxism in males (P = 0.0325) [Table 2].
Table 2: Oral habits distribution by gender

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Age-wise prevalence assessment of oral habits in the study population divided into two groups of 4–8 years and 9–13 years revealed significantly higher prevalence of thumb-sucking in the younger age group children of 4–8 years (P = 0.001) and higher prevalence of tongue thrusting in older children of 9–13 years (P = 0.0389) [Table 3].
Table 3: Distribution of oral habits in two age groups

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   Discussion Top

The present study represents the first epidemiological survey conducted in Central Kerala population with the aim of assessing the prevalence of oral habits in 4–13-year-old schoolchildren. It is a well-documented fact that oral habits affect occlusal development and thus play a major role in the facial appearance of the child.[15]

The finding of this study indicates that 72.7% of children had at least one oral habit. This prevalence rate is higher than that reported by Garde et al.,[16] who reported 51% prevalence rate in 6–12-year-old children. Motta et al. reported that, among preschoolers, 87.4% had oral habits.[17] Quashie-Williams,[18] Shetty and Munshi,[19] and Kharbanda et al.[20] reported lower prevalence rates of 34.1%, 29.7%, and 25.5%, respectively. The higher prevalence rate of oral habits found in the present study may be due to the fact that it was a hospital-based study. Since the children reported to the hospital for an oral complaint, it can be assumed that the prevalence of oral habits will be higher in such population.

Mouth breathing and tongue thrusting were the most prevalent habits in the present study. This is similar to the results reported by Guaba et al.[21] and Kharbanda et al.[20] In majority of studies, tongue thrusting was reported as the most prevalent habit followed by mouth breathing.[20],[21] In the present study, a high prevalence of mouth breathing was noted (29.4%). Since mouth breathing is one of the etiologic factors in growth alterations in the face, it should be diagnosed early and proper intervention should begin. Abou-Ei-Ezz et al.[22] have reported that mouth breathing is highly associated with malocclusion and this association is statistically highly significant (P< 0.001).

Tongue thrusting was reported in 23.5% of children. Shetty and Munshi,[19] Kharbanda et al.,[20] and Amitha and Arun [23] have reported tongue thrusting prevalence to be 3.02%, 18.1%, and 33.65%, respectively. Thumb-sucking was found in 17% of the study group. Amitha and Arun [23] reported a prevalence of 1.9% and Kharbanda et al.[20] reported 0.7% prevalence. Highly stressful and anxiety-related behavior has been indirectly related to nail biting and thumb-sucking by Agarwal et al.[24]

Nail biting was seen in 20% of children in the present study which is very high compared to the prevalence reported by Garde et al.,[16] Shetty and Munshi,[19] and Sharma et al.,[25] who reported a prevalence of 5.8%, 12.7%, and 3%, respectively. Baydaş et al.[26] have reported an increased prevalence of Enterobacteriaceae in the oral cavities of children having nail-biting habit.

The prevalence of bruxism and pencil biting in the present study is 4.9% and 8.7%, respectively. This is in agreement to the study reported by Shetty and Munshi,[19] who reported 6.2% prevalence of bruxism and 9.8% prevalence of pencil biting. The prevalence of lip/cheek biting in this study of 5% is also similar to that reported by Shetty and Munshi [19] of 6%. Bruxism, nail biting, and pencil biting were found to be elevated in 7–17-year-old children suffering from attention-deficit hyperactivity disorder.[27]

Nail biting was found to be significantly more in females (P = 0.0088) in the present study. Bruxism was reported significantly more in male children (P = 0.0331), similar to that reported by Shetty and Munshi.[19] Hormonal changes and diet may be the reason for this gender-wise difference of habits.

A higher prevalence of thumb-sucking was derived in the present study in the younger age group of 4–8-year children (P = 0.0001). Tongue thrusting was reported more in older age group of 9–13-year children (P = 0.0389) in the present study. If tongue thrusting is not corrected by this age, it can lead to short flaccid upper lip, speech problems, and increased anterior facial height.

A limitation of the present study is that the study sample was obtained from a dental hospital. A higher prevalence rate can be expected in this sample compared to general population. Further studies are recommended by selecting the samples from the general population to know the actual prevalence rate.

   Conclusion Top

Prevalence of adverse oral habits was 72.7% in children reporting for dental treatment in Central Kerala, India. Majority of the children had only one habit, of which mouth breathing was the most commonly occurring habit, followed by tongue thrusting and nail biting. Nail biting was seen significantly more in female children and bruxism more in male children. Prevalence of thumb-sucking was more in younger children (4–8 years) and tongue thrusting in older children (9–13 years). As the prevalence of oral habits is very high in this population, compared to other Indian populations, preventive and interceptive strategies to eradicate the oral habits should be planned at the earliest.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3]


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