An occasionally irregular blog about orthodontics

How should we stop thumb sucking?

How should we stop thumb sucking?

How should we stop thumb sucking?

We are all familiar with the young patient who sucks their thumb and has a developing malocclusion. I am also sure that we all have our favourite methods of helping these patients stopping their habit. But what is the evidence we have for recommending these  interventions?

This was in a recent Cochrane systematic review  carried out by a team based in Dundee, Scotland and Manchester, North of England.

Published Online: 31 MAR 2015

DOI: 10.1002/14651858.CD008694.pub2

They did a really nice outline of the previous literature on none nutritive sucking habits (NNSH).  This included the use of pacifiers, blankets and digit sucking. When they looked at incidence of NNSH they found that this varied from 82% in the first five months of life and 73% between two and five years old. The most important figure for orthodontists was that 12.1% of children greater than seven carried out in NNSH.

When they looked at interventions they outlined the removal of an object (blankets, pacifier etc), the use of orthodontic appliances to prevent digit sucking, painting and unpleasant tasting solution on the offending digit and behavioural modifying techniques. But which is best?

What did they do?

The review had the following primary objective

“To evaluate the effects of different interventions for cessation of nine nutritive sucking habits in children”.

They use standard well established Cochrane review methodology. The primary outcome was whether the habit stopped.

They initially identified 195 publications. After further filtering they obtain their final sample of 6 randomised controlled trials dating from 1967 to 1997, involving 252 participants.

They found that there was a wide variety of interventions testing in the studies.  Three studies evaluated orthodontic appliances using variations of a fixed plate or crib. Five types of psychological interventions were used and in some studies these were combined with orthodontic appliances. When I looked at risk of bias all studies were at high risk of bias. So this was getting messy as there must have been many stray interactions flying around!

What did they find?

They carried out a nice narrative to review and the overall conclusions were:

Both orthodontic appliances and psychological interventions were beneficial in comparisons to no treatment. They calculated the risk ratio for these interventions and this was 6.1 for the  psychological and 6.5 for the orthodontic appliances. This means that with treatment the child is six times more likely to stop their sucking habit than with no treatment.

They could not make any meaningful comparisons between  psychological interventions and orthodontic appliances. Interestingly, there was no evidence to support the use of aversive tasting substances but they suggested that this was likely to continue to be the first line of treatment for many practitioners, as it is cheap and may carried out by parents in the home setting

What did I think?

This was a good systematic review that investigated a common clinical problem. But I was disappointed that the authors were not able to make firm recommendations because of the differences between studies and the high risk of bias. This is perfectly understandable because the investigators who carried out trials many years ago would not be familiar with the high standards of trial design that are currently required. Nevertheless, I did obtain useful information and it was interesting to see that both psychological and orthodontic appliances were successful with a clinically significant effect.

This type of intervention also reminds me of a previous blog post into myofunctional and functional orthodontics. When you consider the design of these appliances they could also be used to stop thumb-sucking. However, I’m not sure that this would be my first choice.

What is my practice?

This study reinforces my current practice. My first line is to simply advise the parent and child to stop digit sucking, I will also suggest the use of a taste aversive substance. If this is not successful, and the child requests that I help them stop their habit, I will frequently use a preformed quad helix which can also correct any posterior cross bite at the same time stopping the habit. This can be fitted quickly and easily by anyone who can still bend wire!

All in all, this was a very useful review that does help with a common clinical problem.

 

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There Are 9 Comments

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  1. Gordon Strole says:

    My protocol was identical to yours.
    I found Mavala Stop, a clear nail polish, extremely effective in helping children stop.

  2. Ioannis Ioannidis says:

    Hi Professor, what is the evidence in regards to how long after the cessation of the habit the appliance should stay in the mouth before removal? I believe there is a general rule of 6 months but is there evidence? What is your current practice about this? Best wishes!

  3. I have been providing “THUMB THERAPY” for 40+ years, always with behavior modification techniques and the establishment of proper tongue posture and nasal breathing exercises. My success rate is 99.7 who stop sucking on the first day! My husband is an orthodontist who never placed an appliance for this habit and we have thousands of patients who are still sporting great occlusions. We know this because we are now seeing second generations and many are thumb suckers, as well! Could there be a genetic component? Is it possible that they have low serotonin levels that are increased with good tongue posture?

  4. Is it possible that they have low serotonin levels that are increased with good tongue posture?

    Interesting comment. I’ve asked many patients over the years as to why they finger/thumb suck and some of them have answered “Because it feels good.”

    Perfectly understandable.

    I wonder if there is any science that a normal tongue posture increases serotonin levels?

  5. Jeff Lee says:

    HI Dr. O’Brien! Just subscribed to your blog, great evidence-based information on here. When you say “preformed quad-helix”, is it simply with a quad helix with an anterior extension with spurs on it? I have a patient with a bilateral posterior lingual crossbite (on almost all posterior teeth) and a finger habit and was wondering if your practice protocol would still be the same.

  6. Jouna says:

    I tried Mavala Stop on my daughter to make her stop thumb sucking. I did a deep investigation on its ingredients before buying, and feel that my mavala stop review was good. The best website I found for review of the thumb sucking nail polish is stopthumbsucking.org/mavala-stop and surprisingly they recommend it very low because it is ineffective at night time when the problem is worst. That actually makes sense. I tried the product anyway and found that it did work though but only about 10% of the time. And it is indeed as bad tasting as advertised.

  7. As a Orofacial Myofunctional therapist, I feel that the crib will do more harm than good. It is a torture technique. This technique does nothing but maybe stop the thumb, it doesn’t help expand the maxillary arch, or prevent tongue thrust, or correct the swallow and open mouth breathing which all are connected to digit sucking. I would like to add that Myofunctional therapy is here to stay, we have so many talented therapists to help these children with their oral disorders and build their self-esteem. I prefer a more tolerant method to help the child/adult in a variety of ways, prior to placing in ortho. Orthodontists work hard at their talents and MYO therapy will enhance their talents and keep the teeth/occlusion where they belong. Teach the tongue where it belongs. It works and children live a healthier life for it.

  8. Polly Muir says:

    I work at the very interesting interface of Paeds/Ortho, quietly observing developing dentitions.
    Observation: Currently, health visitors recommend the use of dummies up to the age of 6 months to help prevent Sudden Infant Deaths (SIDS). However, we see more than a fair number of infants who continue to use these pacifiers for protracted periods of time, well into their toddling days & some time beyond this. We offer all children the opportunity of a screening dental check, aged 3 1/2 years and I note a number of children who have unilateral crossbites and AOB’s, which seem to directly relate to their NNSH. I feel, at least, an audit coming on. and then I anticipate more orthodontic activity to correct these posterior and anterior malocclusions!!
    Do you ever use a conventional URA with a midline screw, or is that too old-fashioned?

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