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The thumb-sucking paradox
Editorial -.
The Thumb-Sucking RITING vu
Edward
Paradox
in the Journal of th,e Anrwicnn Dental Association, July, 1951. S. Mack, D.D.S., opened his subject with the observation that:
In the controversial subject of thumb-sucking, there are two principal schools of thought, This has resulted in confusion the psychological and the dent,al and the two have never met. Shall she risk the danger of on the part of the mother as to what course of action to follow. psychological frustration in her child or a dental deformity? The situation must be analyzed from both the psychological and the dental point of view and a conclusion drawn which will satisfy everyone concerned. A plan of proeedurc should be aff0rde.d the bewildered parent.
The above article was responsible for considerable comment both in la!, press and scientific journals. When Dr. Borden Veeder, editor of the Journal of Pediatrics, gave permission to reprint in the Lk~~~~cL4~ JOURNAL OF ORTHODOXTICS his editorial comment which appeared in the October issue of The Journal of Pediattics, he said that he was pleased to give this permission inasmuch as the article would reach more people who are vitally interested in the subject, and that the subject is badly in need of better understandin, Q between both the medical and dental groups. It seems plain that the editorial comment was inspired by both the Mack article and by “Thumb-Sucking and the Oral Structures,” by J. H. Sillman, D.D.S. (an orthodontist). The Sillman paper w.as read before the Annual Meeting of the Society for Research in Child Development in Detroit, Mich., Feb. 20, 1951. This paper was later published in the October, 1951, issue of The Journal of Pediatrics. That leads up to the observation that if you are the average day-to-day practicing orthodontist, and you were asked, “What is the most frequent question asked by parents? ” you would no doubt answer by saying, “Mothers most frequently ask, ‘How can I stop my child from sucking the thumb and will it ruin the mouth ?’ ” She usually adds, however, that the family pediatrician tells her to forget the thumb for the present, not to worry about it, and that it will probably work out. all right. The physician sometimes adds the inferential comment that it, is bett-cr to tolerate the unruly thumb than to develop a frustrated child. Anyway it is obvious that many pediat,ricians regard the thumb-sucking habit with not too much alarm in it,s ultimate bossible damage, and that they feel in many instances t.hat the cure (if any) is worse than the habit. Physicians will t,ell you informally that in their clinical practice the realistic and practical outcome is that many children discontinue the habit as they grow older and that the actual damage done is overemphasized. Another reason the subject is so controversial no doubt is that lay newspapers, magazines, and periodicals of various kinds continually publish articles on the subject. Such articles usually reflect t,he theme of a lay writer, based 13n
131
EDITORIAL
upon an interview with someone whose opinion is presumed to important. The AMERICAN JOURNAL. OF ORTHODONTICS in the years past articles on both the subject of thumb-sucking and other habits; articles usually feature the dental point of view and not too said about the medical viewpoint in the dental literature. Then check with your Read the following article carefully. as a clinical orthodontist.
be regarded
published many however, such much has been own experience
THUMB-SUCKING+ Thumb-sucking has been a cause of concern and annoyance to parents for many years, and will undoubtedly continue to be so for many more to come. From a medical standpoint it interests the pediatriOn the surface cian, the psychologist and psychiatrist, and the dentist. their attitudes and viewpoints seemingly are often in conflict. Much of this conflict can be resolved, however, if careful consideration is given to just what each is talking about. Because the subject is so frequently brought up by anxious parents, the JOURNAL has from time to time presented discussions of various aspects of thumb-sucking. As one looks back twenty to thirty years ago, a decided change has taken place in our ideas as to its importance and management. Bakwin,l in a short but comprehensive article in 1948, presented the present-day pediatric thought and attitude . In infancy thumb-sucking is a normal .activity that requires no interference. It usually disappears during the second year when the infant acquires new ways of obtaining pleasure and satisfaction. Kaplan,* last year, discussed the psychiatrist’s attitude toward thumb-sucking. He views its active practice after the time when disappearance is usual as a symptom of an emotional disturbance, If we leave for which the therapeutic approach is based on etiology. aside the rather academic ideas of some psychiatrists as to its being an expression of sexual gratification, the pediatrician and psychiatrist are not far apart. Both regard it up to 2 years as a normal habit to be left alone, and its active practice beyond that age as an indication of some maladjustment in the child’s life. It is when we turn to the dental aspects that we find decided differences of opinion. Many articles have appeared in the dental and orthodontic journals on the effect of thumb-sucking on the development of the jaws and teeth, and on its significance as an etiological factor in malocclusion. Mack3 states that if thumb-sucking has not been corrected by the time the child is 31/s years old. it should be determined if the habit is “meaningful” or “empty,” that is, whether or not it stems from psychologic maladjustment. If it is an “empty” habit, it should be corrected by a dentist; if further psychologic needs are evident, the child is a psychiatric problem. It is important to consider Mack’s definition of thumb-sucking, as he seemingly eliminates the necessity of dental care for most children who suck their thumbs after the usual time of its disappearance. “Thumb-sucking, as discussed here, . . . does not refer to the gentle insertion of the thumb part way into the mouth coupled with an occasional mild sucking pressure. Rather it implies an insertion many times every day of the whole thumb or fingers deep into the oral cavity. ” If this is’what the dental group mean when they tell *Reprinted
from
the
Journal
of
Pediatrics,
October,
1951.
as
parents that thumb-suckin g leads to dental deformities, it certainly is a rare cause when thumb-sucking as a whole is considered. It is unfortunate that a reference was made to Rlack’s article in one of the weekly news magazines a few weeks ag!:~,~ah on reading the article in its entirety we feel the itern gives an erroneous idea of his views ou thumbsucking and the necessity of dental treatment to prevent dental deformities. In this issue (page 424) wc publish an article by Sillman” which represents the viewpoint of the dental group who feel that the persistence of thumb-sucking after the period when it is a normal habit is not a particularly important factor in producing malocclusion. He bases his conclusions on serial records of casts from impressions of the upper and lower jaws made at frequent intervals from birth to 14 years of age. Sillman”s observations on thumbsucking are part of a comprehensive study of the growth and development of the oral structures from birth to maturity. His group consists of sixtv children, twcnt) of whom were thumb-suckers. In many of his subjects. studies were also made of the parents and siblings. It is Sillman’s view that failure to consider all the factors involved in dentition has led to undue emphasis on thumb-sucking. Without ignoring the influence of the habit on the dentition, it is his view that heredity is the principal factor governing development of the oral structures. The use of restraints is not only ineffective; it ignores basic problems when present, and intensifies the sucking habit thereby increasing whatever effect the habit may have on the oral structures. The point is t,hat the pediatricians, psychiatrists, and our dental colleagues are not so far apart in their conception of the importance Seemingly all three agree that it and management of thumb-sucking. is a. normal habit in the first two years of life and should not be interfered with. Its persistence durin g the third and fourth years may he indicative of an underlying emotional maladjustment of which the thumb-sucking is a symptom. Whether the cases as defined by Mark persist&F aft,er t,hree and one-half years will or will not lead to oral deformities we will leave to our dental friends to quarrel over. What is most important is that in discnssinp thumb-sucking with anxious parents all three should be in agreement in presenting the story as outlined above. Then everyone, pediatrician, psychiatrist. dent&t, child, ant1 parents, can live happily and without worry or conflict. REFFKFS(‘ES . 1 1. 2. 3. 4. 5.
Bakwin, H.: ,J. Pediat. 32: 99. 194X. Kaplan, &I.: J. Pediat. 37: 55.5, 1950. Mack, E. H.: J. Am. Dent. A. 43: :i.?, 19.51. ‘rime, July !I. 1951, p. 34. .T. Pediat. 39: 424, 1951. Billman, ;1. H.:
The comments of Hr. Cecder and others, it is to be hoped, will be the inspiration for more careful study in order that there can be a better meeting of the minds. In this connection it is interesting to note, for instance, the new edition of Infant Care, a Children’s bureau publication by the Federal Security Agency, just now off the press. It has this to say to its readers about thumb-sucking (Children’s Bureau Publication no. 8, 1.951, pp. 56-57) : 1914
Thumb edition
sucking came in even recomniendcd
for
sharp pinning
criticism in the early the sleeve of the
editions baby’s
of Infant Care. jacket down over
The the
133
EDITORIAI.
‘ ( Fingers of the offending hand for several days and nights” to stop thumb sucking. This attitude has been increasingly modified, until in the new edition: “Sucking is the first way a baby gets pleasure. So when he is tired, or hungry, or doesn’t have anything interesting to watch or to do, he may try to get a little pleasure out of his thumb or fingers. Sucking is a poor substitute for being held, or talked to, or fed; but it is better than nothing. And sometimes, mothers say, it seems to result in a very satisfied child.
Fig.
l.-The
thumb-sucking
Fig. Fig. :ing. Fig.
technique
shown in
here Fig.
often 2.
2.
causes
classical
Fig.
X-Open-bite
type
3.-Open-bite
in
of Fig.
oral
deformity
2 corrected
at by
about
orthodontic
7 years
open-bite
as observed
3. of
age
caused
by
thumb-
treatment.
Anyway, under the head 6f what might be called “what every orthodontist knows, ” here are a few observations about thumb-sucking subsequent to 4 years of age: 1. The thumb-sucking technique employed in Fig. 1 does cause classical open-bite (as in Fig. 2), and it can be corrected by orthodontic means (Fig. 3). It will stay corrected provided the thumb-sucking habit is corrected and there is no secondary tongue habit.
234
EDITORIAL
2. By far the most effective remedy for thumb-sucking, when the child is old enough to understand, is the influence of the child’s playmates. 3. The point, in the Sillman article that children can be aided to stop thumb-sucking when they are physiologically and psychologically ready to assume such responsibility checks with t,he opinion of many widely experienced orthodontists and with the previous statement (2,1. 4. Many children do discontinue thumb-sucking during the process of orthodontic treatment, no doubt because they become conscious of the element oi cause and effect. 5. To try and break infants of the habit often proves to be a lost cause, method notwithstanding. 6. Thumb-sucking can be cured in young patients by placing cemented mech,anical devices in the mouth. However, many physicians do not approve of sharp mechanical point,s in the oral cavity, whether it be child or adult, and in this position they are no doubt correct. ‘7. The majority of children who suck their thumbs discontinue the habit after 4 or 5 years of age; however, many of them continue to do so after that age. Some report, cases up to and including 15 years of age. 8. It is the all-out effort to break a young child of thumb-sucking, regardless of resistance, that the pediatricians strenuously object to, and it is obvious that many in the dental profession assume the same position. 9. The practical answer is probably somewhere between the position taken by the pediatricians and that taken by the dentists. Break the habit, of coruse, if possible and practical. H. C. P.
The Thumb-Sucking RITING vu
Edward
Paradox
in the Journal of th,e Anrwicnn Dental Association, July, 1951. S. Mack, D.D.S., opened his subject with the observation that:
In the controversial subject of thumb-sucking, there are two principal schools of thought, This has resulted in confusion the psychological and the dent,al and the two have never met. Shall she risk the danger of on the part of the mother as to what course of action to follow. psychological frustration in her child or a dental deformity? The situation must be analyzed from both the psychological and the dental point of view and a conclusion drawn which will satisfy everyone concerned. A plan of proeedurc should be aff0rde.d the bewildered parent.
The above article was responsible for considerable comment both in la!, press and scientific journals. When Dr. Borden Veeder, editor of the Journal of Pediatrics, gave permission to reprint in the Lk~~~~cL4~ JOURNAL OF ORTHODOXTICS his editorial comment which appeared in the October issue of The Journal of Pediattics, he said that he was pleased to give this permission inasmuch as the article would reach more people who are vitally interested in the subject, and that the subject is badly in need of better understandin, Q between both the medical and dental groups. It seems plain that the editorial comment was inspired by both the Mack article and by “Thumb-Sucking and the Oral Structures,” by J. H. Sillman, D.D.S. (an orthodontist). The Sillman paper w.as read before the Annual Meeting of the Society for Research in Child Development in Detroit, Mich., Feb. 20, 1951. This paper was later published in the October, 1951, issue of The Journal of Pediatrics. That leads up to the observation that if you are the average day-to-day practicing orthodontist, and you were asked, “What is the most frequent question asked by parents? ” you would no doubt answer by saying, “Mothers most frequently ask, ‘How can I stop my child from sucking the thumb and will it ruin the mouth ?’ ” She usually adds, however, that the family pediatrician tells her to forget the thumb for the present, not to worry about it, and that it will probably work out. all right. The physician sometimes adds the inferential comment that it, is bett-cr to tolerate the unruly thumb than to develop a frustrated child. Anyway it is obvious that many pediat,ricians regard the thumb-sucking habit with not too much alarm in it,s ultimate bossible damage, and that they feel in many instances t.hat the cure (if any) is worse than the habit. Physicians will t,ell you informally that in their clinical practice the realistic and practical outcome is that many children discontinue the habit as they grow older and that the actual damage done is overemphasized. Another reason the subject is so controversial no doubt is that lay newspapers, magazines, and periodicals of various kinds continually publish articles on the subject. Such articles usually reflect t,he theme of a lay writer, based 13n
131
EDITORIAL
upon an interview with someone whose opinion is presumed to important. The AMERICAN JOURNAL. OF ORTHODONTICS in the years past articles on both the subject of thumb-sucking and other habits; articles usually feature the dental point of view and not too said about the medical viewpoint in the dental literature. Then check with your Read the following article carefully. as a clinical orthodontist.
be regarded
published many however, such much has been own experience
THUMB-SUCKING+ Thumb-sucking has been a cause of concern and annoyance to parents for many years, and will undoubtedly continue to be so for many more to come. From a medical standpoint it interests the pediatriOn the surface cian, the psychologist and psychiatrist, and the dentist. their attitudes and viewpoints seemingly are often in conflict. Much of this conflict can be resolved, however, if careful consideration is given to just what each is talking about. Because the subject is so frequently brought up by anxious parents, the JOURNAL has from time to time presented discussions of various aspects of thumb-sucking. As one looks back twenty to thirty years ago, a decided change has taken place in our ideas as to its importance and management. Bakwin,l in a short but comprehensive article in 1948, presented the present-day pediatric thought and attitude . In infancy thumb-sucking is a normal .activity that requires no interference. It usually disappears during the second year when the infant acquires new ways of obtaining pleasure and satisfaction. Kaplan,* last year, discussed the psychiatrist’s attitude toward thumb-sucking. He views its active practice after the time when disappearance is usual as a symptom of an emotional disturbance, If we leave for which the therapeutic approach is based on etiology. aside the rather academic ideas of some psychiatrists as to its being an expression of sexual gratification, the pediatrician and psychiatrist are not far apart. Both regard it up to 2 years as a normal habit to be left alone, and its active practice beyond that age as an indication of some maladjustment in the child’s life. It is when we turn to the dental aspects that we find decided differences of opinion. Many articles have appeared in the dental and orthodontic journals on the effect of thumb-sucking on the development of the jaws and teeth, and on its significance as an etiological factor in malocclusion. Mack3 states that if thumb-sucking has not been corrected by the time the child is 31/s years old. it should be determined if the habit is “meaningful” or “empty,” that is, whether or not it stems from psychologic maladjustment. If it is an “empty” habit, it should be corrected by a dentist; if further psychologic needs are evident, the child is a psychiatric problem. It is important to consider Mack’s definition of thumb-sucking, as he seemingly eliminates the necessity of dental care for most children who suck their thumbs after the usual time of its disappearance. “Thumb-sucking, as discussed here, . . . does not refer to the gentle insertion of the thumb part way into the mouth coupled with an occasional mild sucking pressure. Rather it implies an insertion many times every day of the whole thumb or fingers deep into the oral cavity. ” If this is’what the dental group mean when they tell *Reprinted
from
the
Journal
of
Pediatrics,
October,
1951.
as
parents that thumb-suckin g leads to dental deformities, it certainly is a rare cause when thumb-sucking as a whole is considered. It is unfortunate that a reference was made to Rlack’s article in one of the weekly news magazines a few weeks ag!:~,~ah on reading the article in its entirety we feel the itern gives an erroneous idea of his views ou thumbsucking and the necessity of dental treatment to prevent dental deformities. In this issue (page 424) wc publish an article by Sillman” which represents the viewpoint of the dental group who feel that the persistence of thumb-sucking after the period when it is a normal habit is not a particularly important factor in producing malocclusion. He bases his conclusions on serial records of casts from impressions of the upper and lower jaws made at frequent intervals from birth to 14 years of age. Sillman”s observations on thumbsucking are part of a comprehensive study of the growth and development of the oral structures from birth to maturity. His group consists of sixtv children, twcnt) of whom were thumb-suckers. In many of his subjects. studies were also made of the parents and siblings. It is Sillman’s view that failure to consider all the factors involved in dentition has led to undue emphasis on thumb-sucking. Without ignoring the influence of the habit on the dentition, it is his view that heredity is the principal factor governing development of the oral structures. The use of restraints is not only ineffective; it ignores basic problems when present, and intensifies the sucking habit thereby increasing whatever effect the habit may have on the oral structures. The point is t,hat the pediatricians, psychiatrists, and our dental colleagues are not so far apart in their conception of the importance Seemingly all three agree that it and management of thumb-sucking. is a. normal habit in the first two years of life and should not be interfered with. Its persistence durin g the third and fourth years may he indicative of an underlying emotional maladjustment of which the thumb-sucking is a symptom. Whether the cases as defined by Mark persist&F aft,er t,hree and one-half years will or will not lead to oral deformities we will leave to our dental friends to quarrel over. What is most important is that in discnssinp thumb-sucking with anxious parents all three should be in agreement in presenting the story as outlined above. Then everyone, pediatrician, psychiatrist. dent&t, child, ant1 parents, can live happily and without worry or conflict. REFFKFS(‘ES . 1 1. 2. 3. 4. 5.
Bakwin, H.: ,J. Pediat. 32: 99. 194X. Kaplan, &I.: J. Pediat. 37: 55.5, 1950. Mack, E. H.: J. Am. Dent. A. 43: :i.?, 19.51. ‘rime, July !I. 1951, p. 34. .T. Pediat. 39: 424, 1951. Billman, ;1. H.:
The comments of Hr. Cecder and others, it is to be hoped, will be the inspiration for more careful study in order that there can be a better meeting of the minds. In this connection it is interesting to note, for instance, the new edition of Infant Care, a Children’s bureau publication by the Federal Security Agency, just now off the press. It has this to say to its readers about thumb-sucking (Children’s Bureau Publication no. 8, 1.951, pp. 56-57) : 1914
Thumb edition
sucking came in even recomniendcd
for
sharp pinning
criticism in the early the sleeve of the
editions baby’s
of Infant Care. jacket down over
The the
133
EDITORIAI.
‘ ( Fingers of the offending hand for several days and nights” to stop thumb sucking. This attitude has been increasingly modified, until in the new edition: “Sucking is the first way a baby gets pleasure. So when he is tired, or hungry, or doesn’t have anything interesting to watch or to do, he may try to get a little pleasure out of his thumb or fingers. Sucking is a poor substitute for being held, or talked to, or fed; but it is better than nothing. And sometimes, mothers say, it seems to result in a very satisfied child.
Fig.
l.-The
thumb-sucking
Fig. Fig. :ing. Fig.
technique
shown in
here Fig.
often 2.
2.
causes
classical
Fig.
X-Open-bite
type
3.-Open-bite
in
of Fig.
oral
deformity
2 corrected
at by
about
orthodontic
7 years
open-bite
as observed
3. of
age
caused
by
thumb-
treatment.
Anyway, under the head 6f what might be called “what every orthodontist knows, ” here are a few observations about thumb-sucking subsequent to 4 years of age: 1. The thumb-sucking technique employed in Fig. 1 does cause classical open-bite (as in Fig. 2), and it can be corrected by orthodontic means (Fig. 3). It will stay corrected provided the thumb-sucking habit is corrected and there is no secondary tongue habit.
234
EDITORIAL
2. By far the most effective remedy for thumb-sucking, when the child is old enough to understand, is the influence of the child’s playmates. 3. The point, in the Sillman article that children can be aided to stop thumb-sucking when they are physiologically and psychologically ready to assume such responsibility checks with t,he opinion of many widely experienced orthodontists and with the previous statement (2,1. 4. Many children do discontinue thumb-sucking during the process of orthodontic treatment, no doubt because they become conscious of the element oi cause and effect. 5. To try and break infants of the habit often proves to be a lost cause, method notwithstanding. 6. Thumb-sucking can be cured in young patients by placing cemented mech,anical devices in the mouth. However, many physicians do not approve of sharp mechanical point,s in the oral cavity, whether it be child or adult, and in this position they are no doubt correct. ‘7. The majority of children who suck their thumbs discontinue the habit after 4 or 5 years of age; however, many of them continue to do so after that age. Some report, cases up to and including 15 years of age. 8. It is the all-out effort to break a young child of thumb-sucking, regardless of resistance, that the pediatricians strenuously object to, and it is obvious that many in the dental profession assume the same position. 9. The practical answer is probably somewhere between the position taken by the pediatricians and that taken by the dentists. Break the habit, of coruse, if possible and practical. H. C. P.