The use of dummies (pacifiers) blankets and digit sucking are common behaviours in children. These habits are grouped together as ‘non-nutritive sucking habits’ (NNSHs) and are usually stopped as the child ages. If the habits persist until the permanent teeth erupt, they may cause or contribute to malocclusion. A wide range of approaches has been used to break these NNSHs. The main aim of this review was to evaluate the effects of different interventions for cessation of NNSHs in children.

Methods

Searches were conducted in the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE via OVID EMBASE, PsycINFO, CINAHL,the US National Institutes of Health Trials Register (Clinical Trials.gov) and the WHO International Clinical Trials Registry Platform without restrictions.

Randomised controlled clinical trials (RCTs) and quasi-randomised controlled clinical trials comparing an intervention for cessation of non-nutritive sucking habits with either a different intervention(s) or no treatment or control were considered. Two reviewers independently selected studies and extracted data with a third arbitrating in cases of disagreement. Two reviewers independently assessed risk of bias. Standard Cochrane methodological methods were followed.

Results

• 6 studies involving 252 patients were included.
• All studies were at high risk of bias.
• Digit sucking was the only NNSH assessed in the studies.
• 5 studies compared single or multiple interventions with a no- intervention or waiting list control group and one study made a head-to-head comparison
  • 2 trials assessed orthodontic appliances (with or without psychological intervention) versus no treatment
  • One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches.
  • The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the
  • short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; two trials, 70 participants) or
  • long term (RR 5.81, 95% CI 1.49 to 22.66; one trial, 37 participants) or
  • in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; one trial, 32 participants).
• Two trials (78 participants) assessed psychological intervention versus no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I2 = 0%). One study, with data from 57 participants, reported on the long-term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65).
• One trial (22 participants) compared palatal crib with palatal arch finding a higher likelihood of habit cessation with the palatal crib (RR 0.13, 95% CI 0.03 to 0.59).

Conclusions

The authors concluded:

Orthodontic appliances or psychological intervention seems to be effective to help children stop sucking that does not have a feeding purpose but the evidence is low quality. Further high quality clinical trials are required to guide decision making for what is a common problem that can require lengthy and expensive dental treatment to correct.

Comments

There were only a small number of low quality studies available to address the question posed by this review. A wide range of appliance have been suggested and the authors note that no studies using removable appliances, an approach commonly used in the UK, but not considered good practice in USA were included. As the Cochrane Oral Health Group note in their blog on this review,  ‘use of a bitter tasting substance requires no clinical input, is a non-invasive, low risk procedure, is cheap and can be carried out by parents in the home setting, it is likely to continue as first line of treatment despite little evidence to support it.’

However, it would be helpful to have higher quality trials to have better information around a range of issues identified by the authors in the background to this review related to:

• effectiveness in habit cessation;
• ease for children to cope with and ease of implementation from a parent/carer perspective;
• time to stop the NNSH; and,
• 
reduction in severity of the malocclusion.

 Links

Borrie FRP, Bearn DR, Innes NPT, Iheozor-Ejiofor Z. Interventions for the cessation of non-nutritive sucking habits in children. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD008694. DOI: 10.1002/14651858.CD008694.pub2

Cochrane Oral Health Group – Breaking the habit: long-term dummy or pacifier use may be prevented by braces