Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Oral habits and orofacial development in children

Arthur J Nowak, DMD
John J Warren, DDS, MS
Section Editor
Ann Griffen, DDS, MS
Deputy Editor
Mary M Torchia, MD


Oral habits that are acquired during infancy (eg, nonnutritive sucking) can have adverse health consequences, such as early cessation of breastfeeding or increased risk of otitis media. The identification of such habits and assessment of immediate and long-term effects on the teeth and orofacial development should be made as early as possible [1,2]. After infancy, persistent oral habits have little effect on health but can affect facial growth, oral function, the occlusal relationship, and facial esthetics [3].

The short- and long-term effects of oral habits are reviewed here. Preventive dental care and counseling for infants and young children are discussed separately. (See "Preventive dental care and counseling for infants and young children".)


Nonnutritive sucking behavior (eg, sucking on a pacifier, thumb, or fingers) is a normal part of early development that may become a learned habit. It is a self-soothing behavior that occurs in 70 to 90 percent of infants in various populations [4-8]. The frequency of sucking on digits or pacifiers decreases with increasing age; by the age of four to five years, nonnutritive sucking usually is replaced by other coping mechanisms, and the prevalence decreases [4].

Children who use a pacifier are less likely to suck on their thumb or fingers [9,10]. Compared with pacifier sucking, digit sucking is more likely to persist into the fourth or fifth year of life, when it may become problematic [11-13]. If it persists into the period of permanent tooth eruption, nonnutritive sucking may contribute to the development of malocclusion [14]. Pacifier use does not appear to be related to an increased risk of development of early childhood caries [15].

Overview of effects — Nonnutritive sucking habits may be associated with increased prevalence of malocclusion in the primary dentition and mixed dentition, and increased risk of trauma to the upper front teeth [16-19].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 18, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Johnson ED, Larson BE. Thumb-sucking: literature review. ASDC J Dent Child 1993; 60:385.
  2. American Academy of Pediatric Dentistry. Guideline on management of the developing dentition and occlusion in Pediatric Dentistry. Pediatr Dent 2014; 36:251.
  3. Josell SD. Habits affecting dental and maxillofacial growth and development. Dent Clin North Am 1995; 39:851.
  4. Augustyn M, Frank DA, Zuckerman BS. Infancy and toddler years. In: Developmental-Behavioral Pediatrics, 4th, Carey WB, Crocker AC, Coleman WL, et al (Eds), Saunders Elsevier, Philadelphia 2009. p.24.
  5. BRAZELTON TB. Crying in infancy. Pediatrics 1962; 29:579.
  6. Blum N.. Repetitive behaviors and tics. In: Developmental-Behavioral Pediatrics, 4th, Carey WB, Crocker AC, Coleman WL, et al (Eds), Saunders Elsevier, Philadelphia 2009. p.629.
  7. Field T, Goldson E. Pacifying effects of nonnutritive sucking on term and preterm neonates during heelstick procedures. Pediatrics 1984; 74:1012.
  8. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am 2000; 47:1043.
  9. Larsson E. The prevalence and aetiology of prolonged dummy and finger-sucking habits. Eur J Orthod 1985; 7:172.
  10. Zadik D, Stern N, Litner M. Thumb- and pacifier-sucking habits. Am J Orthod 1977; 71:197.
  11. Köhler L, Holst K. Malocclusion and sucking habits of four-year-old children. Acta Paediatr Scand 1973; 62:373.
  12. Larsson E. Treatment of children with a prolonged dummy or finger-sucking habit. Eur J Orthod 1988; 10:244.
  13. Warren JJ, Bishara SE. Duration of nutritive and nonnutritive sucking behaviors and their effects on the dental arches in the primary dentition. Am J Orthod Dentofacial Orthop 2002; 121:347.
  14. Friman PC, Schmitt BD. Thumb sucking: pediatricians' guidelines. Clin Pediatr (Phila) 1989; 28:438.
  15. Peressini S. Pacifier use and early childhood caries: an evidence-based study of the literature. J Can Dent Assoc 2003; 69:16.
  16. Lindner A, Modéer T. Relation between sucking habits and dental characteristics in preschoolchildren with unilateral cross-bite. Scand J Dent Res 1989; 97:278.
  17. Adair SM, Milano M, Lorenzo I, Russell C. Effects of current and former pacifier use on the dentition of 24- to 59-month-old children. Pediatr Dent 1995; 17:437.
  18. Warren JJ, Slayton RL, Bishara SE, et al. Effects of nonnutritive sucking habits on occlusal characteristics in the mixed dentition. Pediatr Dent 2005; 27:445.
  19. Ravn JJ. Sucking habits and occlusion in 3-year-old children. Scand J Dent Res 1976; 84:204.
  20. Engelberts AC, L'Hoir MP. Pacifier use and SIDS. Arch Dis Child 2000; 82:267.
  21. Campbell M. Fruitless sucking. Brit J Dent Sci 1870; 13:371.
  22. Chandler TH. Thumb-sucking. Dent Cosmos 1878; 20:440.
  23. Helle A, Haavikko K. Prevalence of earlier sucking habits revealed by anamnestic data and their consequences for occlusion at the age of eleven. Proc Finn Dent Soc 1974; 70:191.
  24. Ogaard B, Larsson E, Lindsten R. The effect of sucking habits, cohort, sex, intercanine arch widths, and breast or bottle feeding on posterior crossbite in Norwegian and Swedish 3-year-old children. Am J Orthod Dentofacial Orthop 1994; 106:161.
  25. Infante PF. An epidemiologic study of finger habits in preschool children, as related to malocclusion, socioeconomic status, race, sex, and size of community. ASDC J Dent Child 1976; 43:33.
  26. Adair SM, Milano M, Dushku JC. Evaluation of the effects of orthodontic pacifiers on the primary dentitions of 24- to 59-month-old children: preliminary study. Pediatr Dent 1992; 14:13.
  27. Katz CR, Rosenblatt A, Gondim PP. Nonnutritive sucking habits in Brazilian children: effects on deciduous dentition and relationship with facial morphology. Am J Orthod Dentofacial Orthop 2004; 126:53.
  28. Viggiano D, Fasano D, Monaco G, Strohmenger L. Breast feeding, bottle feeding, and non-nutritive sucking; effects on occlusion in deciduous dentition. Arch Dis Child 2004; 89:1121.
  29. Moore MB, McDonald JP. A cephalometric evaluation of patients presenting with persistent digit sucking habits. Br J Orthod 1997; 24:17.
  30. Bowden BD. A longitudinal study of the effects of digit- and dummy-sucking. Am J Orthod 1966; 52:887.
  31. Bowden BD. The effects of digital and dummy sucking on arch widths, overbite, and overjet: a longitudinal study. Aust Dent J 1966; 11:396.
  32. Larrson E. Dummy- and finger-sucking habits with special attention to their significance for facial growth and occlusion. Swed Dent J 1972; 65:605.
  33. Larsson E. Dummy- and finger-sucking habits with special attention to their significance for facial growth and occlusion. 7. The effect of earlier dummy- and finger-sucking habit in 16-year-old children compared with children without earlier sucking habit. Swed Dent J 1978; 2:23.
  34. Chen DR, McGorray SP, Dolce C, Wheeler TT. Effect of early Class II treatment on the incidence of incisor trauma. Am J Orthod Dentofacial Orthop 2011; 140:e155.
  35. Melsen B, Stensgaard K, Pedersen J. Sucking habits and their influence on swallowing pattern and prevalence of malocclusion. Eur J Orthod 1979; 1:271.
  36. Niemelä M, Uhari M, Möttönen M. A pacifier increases the risk of recurrent acute otitis media in children in day care centers. Pediatrics 1995; 96:884.
  37. Uhari M, Mäntysaari K, Niemelä M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis 1996; 22:1079.
  38. Warren JJ, Levy SM, Kirchner HL, et al. Pacifier use and the occurrence of otitis media in the first year of life. Pediatr Dent 2001; 23:103.
  39. Larsson E. Dummy- and finger-sucking habits in 4-year-olds. Sven Tandlak Tidskr 1975; 68:219.
  40. Niemelä M, Uhari M, Hannuksela A. Pacifiers and dental structure as risk factors for otitis media. Int J Pediatr Otorhinolaryngol 1994; 29:121.
  41. Jackson JM, Mourino AP. Pacifier use and otitis media in infants twelve months of age or younger. Pediatr Dent 1999; 21:255.
  42. Righard L, Alade MO. Breastfeeding and the use of pacifiers. Birth 1997; 24:116.
  43. Victora CG, Tomasi E, Olinto MT, Barros FC. Use of pacifiers and breastfeeding duration. Lancet 1993; 341:404.
  44. Ford RP, Mitchell EA, Scragg R, et al. Factors adversely associated with breast feeding in New Zealand. J Paediatr Child Health 1994; 30:483.
  45. Clements MS, Mitchell EA, Wright SP, et al. Influences on breastfeeding in southeast England. Acta Paediatr 1997; 86:51.
  46. Barros FC, Victora CG, Semer TC, et al. Use of pacifiers is associated with decreased breast-feeding duration. Pediatrics 1995; 95:497.
  47. Victora CG, Behague DP, Barros FC, et al. Pacifier use and short breastfeeding duration: cause, consequence, or coincidence? Pediatrics 1997; 99:445.
  48. Howard CR, Howard FM, Lanphear B, et al. The effects of early pacifier use on breastfeeding duration. Pediatrics 1999; 103:E33.
  49. Aarts C, Hörnell A, Kylberg E, et al. Breastfeeding patterns in relation to thumb sucking and pacifier use. Pediatrics 1999; 104:e50.
  50. Levy SM, Slager SL, Warren JJ, et al. Associations of pacifier use, digit sucking, and child care attendance with cessation of breastfeeding. J Fam Pract 2002; 51:465.
  51. Kramer MS, Barr RG, Dagenais S, et al. Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial. JAMA 2001; 286:322.
  52. Righard L, Alade MO. Sucking technique and its effect on success of breastfeeding. Birth 1992; 19:185.
  53. Righard L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth 1998; 25:40.
  54. Mitchell EA, Taylor BJ, Ford RP, et al. Dummies and the sudden infant death syndrome. Arch Dis Child 1993; 68:501.
  55. Fleming PJ, Blair PS, Bacon C, et al. Environment of infants during sleep and risk of the sudden infant death syndrome: results of 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Confidential Enquiry into Stillbirths and Deaths Regional Coordinators and Researchers. BMJ 1996; 313:191.
  56. Fleming PJ, Blair PS, Pollard K, et al. Pacifier use and sudden infant death syndrome: results from the CESDI/SUDI case control study. CESDI SUDI Research Team. Arch Dis Child 1999; 81:112.
  57. Arnestad M, Andersen M, Rognum TO. Is the use of dummy or carry-cot of importance for sudden infant death? Eur J Pediatr 1997; 156:968.
  58. Li DK, Willinger M, Petitti DB, et al. Use of a dummy (pacifier) during sleep and risk of sudden infant death syndrome (SIDS): population based case-control study. BMJ 2006; 332:18.
  59. Zotter H, Kerbl R, Kurz R, Müller W. Pacifier use and sudden infant death syndrome: should health professionals recommend pacifier use based on present knowledge? Wien Klin Wochenschr 2002; 114:791.
  60. McGarvey C, McDonnell M, Chong A, et al. Factors relating to the infant's last sleep environment in sudden infant death syndrome in the Republic of Ireland. Arch Dis Child 2003; 88:1058.
  61. Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics 2005; 116:e716.
  62. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 2011; 128:e1341.
  63. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 2011; 128:1030.
  64. Rayan GM, Turner WT. Hand complications in children from digital sucking. J Hand Surg Am 1989; 14:933.
  65. Ollila P, Niemelä M, Uhari M, Larmas M. Prolonged pacifier-sucking and use of a nursing bottle at night: possible risk factors for dental caries in children. Acta Odontol Scand 1998; 56:233.
  66. Mattos-Graner RO, de Moraes AB, Rontani RM, Birman EG. Relation of oral yeast infection in Brazilian infants and use of a pacifier. ASDC J Dent Child 2001; 68:33.
  67. Hannula J, Saarela M, Jousimies-Somer H, et al. Age-related acquisition of oral and nasopharyngeal yeast species and stability of colonization in young children. Oral Microbiol Immunol 1999; 14:176.
  68. Dalton MA, Sargent JD, Stukel TA. Utility of a risk assessment questionnaire in identifying children with lead exposure. Arch Pediatr Adolesc Med 1996; 150:197.
  69. North K, Fleming P, Golding J. Pacifier use and morbidity in the first six months of life. Pediatrics 1999; 103:E34.
  70. Johnson ED, Larson BE. Thumb-sucking: classification and treatment. ASDC J Dent Child 1993; 60:392.
  71. Borrie FR, Bearn DR, Innes NP, Iheozor-Ejiofor Z. Interventions for the cessation of non-nutritive sucking habits in children. Cochrane Database Syst Rev 2015; :CD008694.
  72. Strnad J. The cause and effect of mouth-breathing as related to malocclusion. Rhinology 1978; 16:191.
  73. Principato JJ. Upper airway obstruction and craniofacial morphology. Otolaryngol Head Neck Surg 1991; 104:881.
  74. Hairfield WM, Warren DW, Seaton DL. Prevalence of mouthbreathing in cleft lip and palate. Cleft Palate J 1988; 25:135.
  75. Warren DW, Hairfield WM, Seaton D, et al. The relationship between nasal airway size and nasal-oral breathing. Am J Orthod Dentofacial Orthop 1988; 93:289.
  76. Kluemper GT, Vig PS, Vig KW. Nasorespiratory characteristics and craniofacial morphology. Eur J Orthod 1995; 17:491.
  77. Parker LP, Crysdale WS, Cole P, Woodside D. Rhinomanometry in children. Int J Pediatr Otorhinolaryngol 1989; 17:127.
  78. Warren DW, Hairfield WM, Dalston ET. Effect of age on nasal cross-sectional area and respiratory mode in children. Laryngoscope 1990; 100:89.
  79. Gross AM, Kellum GD, Franz D, et al. A longitudinal evaluation of open mouth posture and maxillary arch width in children. Angle Orthod 1994; 64:419.
  80. Gurley WH, Vig PS. A technique for the simultaneous measurement of nasal and oral respiration. Am J Orthod 1982; 82:33.
  81. Proffit WR. The etiology and development of orthodontic problems. In: Contemporary Orthodontics, Proffit WR, Fields HW (Eds), Mosby, St. Louis 1986.
  82. Gross AM, Kellum GD, Morris T, et al. Rhinometry and open-mouth posture in young children. Am J Orthod Dentofacial Orthop 1993; 103:526.
  83. Kerr WJ, McWilliam JS, Linder-Aronson S. Mandibular form and position related to changed mode of breathing--a five-year longitudinal study. Angle Orthod 1989; 59:91.
  84. Hultcrantz E, Larson M, Hellquist R, et al. The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology. Int J Pediatr Otorhinolaryngol 1991; 22:125.
  85. Höjensgaard E, Wenzel A. Dentoalveolar morphology in children with asthma and perennial rhinitis. Eur J Orthod 1987; 9:265.
  86. Ousterhout DK, Vargervik K, Miller AJ. Nasal airway function as it relates to the timing of mid and lower facial osteotomies. Ann Plast Surg 1983; 11:175.
  87. Bresolin D, Shapiro GG, Shapiro PA, et al. Facial characteristics of children who breathe through the mouth. Pediatrics 1984; 73:622.
  88. Bresolin D, Shapiro PA, Shapiro GG, et al. Mouth breathing in allergic children: its relationship to dentofacial development. Am J Orthod 1983; 83:334.
  89. Gross AM, Kellum GD, Michas C, et al. Open-mouth posture and maxillary arch width in young children: a three-year evaluation. Am J Orthod Dentofacial Orthop 1994; 106:635.
  90. Venetikidou A. Incidence of malocclusion in asthmatic children. J Clin Pediatr Dent 1993; 17:89.
  91. Oulis CJ, Vadiakas GP, Ekonomides J, Dratsa J. The effect of hypertrophic adenoids and tonsils on the development of posterior crossbite and oral habits. J Clin Pediatr Dent 1994; 18:197.
  92. Adamidis IP, Spyropoulos MN. The effects of lymphadenoid hypertrophy on the position of the tongue, the mandible and the hyoid bone. Eur J Orthod 1983; 5:287.
  93. Trask GM, Shapiro GG, Shapiro PA. The effects of perennial allergic rhinitis on dental and skeletal development: a comparison of sibling pairs. Am J Orthod Dentofacial Orthop 1987; 92:286.
  94. Carra MC, Huynh N, Morton P, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci 2011; 119:386.
  95. Bayardo RE, Mejia JJ, Orozco S, Montoya K. Etiology of oral habits. ASDC J Dent Child 1996; 63:350.
  96. Widmalm SE, Christiansen RL, Gunn SM. Oral parafunctions as temporomandibular disorder risk factors in children. Cranio 1995; 13:242.
  97. Kieser JA, Groeneveld HT. Relationship between juvenile bruxing and craniomandibular dysfunction. J Oral Rehabil 1998; 25:662.
  98. Vanderas AP, Menenakou M, Kouimtzis T, Papagiannoulis L. Urinary catecholamine levels and bruxism in children. J Oral Rehabil 1999; 26:103.
  99. Weideman CL, Bush DL, Yan-Go FL, et al. The incidence of parasomnias in child bruxers versus nonbruxers. Pediatr Dent 1996; 18:456.
  100. Rugh JD, Harlan J. Nocturnal bruxism and temporomandibular disorders. Adv Neurol 1988; 49:329.