p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 1 0 3 e1 0 8

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Original Article

Finger sucking callus as useful indicator for

malocclusion in young children

Yu Oyamada 1, Tomoko Ikeuchi 1, Makiko Arakaki, Ryoko Hino,

Mariko Ono, Mayu Kobayashi, Satoko Yamaguchi, Kan Saito,
Aya Yamada, Satoshi Fukumoto*
Division of Pediatric Dentistry, Department of Oral Health and Development Sciences, Tohoku University Graduate
School of Dentistry, Sendai 980-8575, Japan

article info abstract

Article history: Purpose: Finger sucking is the most commonly observed habit in children. However, a
Received 11 April 2016 prolonged sucking habit may have negative effects on dentition and occlusal development,
Received in revised form including maxillary protrusion, anterior open bite, and posterior cross-bite. For treatment
22 June 2016 of malocclusion, early detection is important, especially in children, though it is difficult to
Accepted 25 July 2016 exam oral habits using typical dental examination methods. In this study, we report the
Available online 5 November 2016 relationship between a callus on the sucking finger and malocclusion.
Methods: While performing dental examinations, we checked the fingers of 719 children (0
Keywords: e6 years old) who were attending 10 different kindergartens in Sendai City, Japan, in 2009
Sucking callus to determine the presence of a sucking callus formed by a finger sucking habit.
Malocclusion Results: The peak ratios of children with a sucking callus and malocclusion was at the age
Maxillary protrusion of 2 years (13.6% and 11.0%, respectively), and then decreased with age. Maxillary protru-
Habit sion was detected in 42.9%, 56.2%, 42.9%, and 37.5% of the children with a sucking callus at
the age of 1, 2, 3, and 4 years old, respectively. In those with maxillary protrusion, a sucking
callus was detected in 42.9%, 75%, 75%, and 60%, respectively.
Conclusion: We concluded that the presence of a sucking callus is a useful indicator for
malocclusion caused by an oral habit.
© 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

report noted that 23.3% of 1946 Japanese children examined

1. Introduction
An important factor in the development of malocclusion in
children is oral habit, such as thumb sucking, nail biting (ony-
chophagia), lip chewing, and bruxism [1], with finger sucking
the most commonly encountered childhood habit. A previous
had a finger sucking habit [2]. The habit of sucking a finger is
considered to be derived instinctively, and it may improve the
ability to eat and drink foods by use of the mouth and tongue.
However, children who persist in nonnutritive sucking beyond
early childhood likely have an underlying psychologic distur-
bance and this can be considered as an overt sign of an attempt

* Corresponding author. Fax: þ81 22 717 8386.

E-mail address: fukumoto@dent.tohoku.ac.jp (S. Fukumoto).
1
These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.pdj.2016.07.003
0917-2394/© 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
104 p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 1 0 3 e1 0 8

to manage increased anxiety, while it has also been suggested

Table 1 e Distribution of subjects by age.
that increased anxiety or stress in a child's life can transform an
“empty” thumb habit into a “meaningful” stress reduction Age Number of children
response [3]. Although sucking may be necessary in younger 0 37
years, a prolonged habit may have harmful effects. For 1 95
example, it has been reported that thumb sucking can affect 2 118
3 123
not only dentition and occlusal development, such as maxillary
4 146
protrusion [4], anterior open bite [5e7], and posterior cross-bite
5 167
[8], but also oral function development including an abnormal 6 33
swallowing habit [9] and speech defects [10]. According to pre- Total 719
viously reported findings, sucking habit must be considered as
a factor of major influence in the aetiology of malocclusion, as
well as a causative factor for malocclusion at the end of the
by a finger-sucking habit. Seven examiners with 1e3 years of
mixed dentition period because of direct (disharmony of mus-
experience as dentists performed the examinations and a
cles surrounding the oral cavity) and indirect (abnormal swal-
senior dentist with a specialty pediatric dentist license made
lowing habit) effects [11]. Evidence of a finger sucking habit is
the diagnoses. Three types of malocclusion were noted,
the presence of a callus on the finger along with eczema due to
maxillary protrusion (more than 5e6 mm in an overjet
alternating dryness and moisture [12].
configuration), open bite (negative for overbite), and cross-
Knowledge regarding occlusion has been increasing and
bite (posterior cross-bite on one side). Another oral habit
parents often choose treatment for their affected child. Thus,
including mouth breathing, lip bite, was not checked in this
detecting malocclusion at an appropriate time and treating it
study.
effectively is important. Early orthodontic treatment is benefi-
cial to enhance skeletal and dental development, as well as to
correct habits, functions, and malocclusion that may lead to 2.3. Ethical approval
temporomandibular joint problems or facial asymmetry in an
early stage [11,13]. However, detection of malocclusion is not Tohoku University Graduate School of Dentistry approved the
always possible, because of limited availability of appropriate protocol used in this study.
medical personnel such as dentists and medical doctors.
Ovsenik et al. reported that intra-oral recordings and mea-
surements were as reliable as assessments of study casts [14].
3. Results
However, an easier method to detect malocclusion is needed.
Conventionally, a number of studies have been made about
3.1. Sucking callus frequency
the relationship between finger sucking habit and home
environment. Since the 1940s, the importance of nuclear
Subjects with a sucking callus ranged in age from 1 to 5 years
family relationships has increased. It was reported children
old. That was detected in 7 (7.4%) at the age of 1 year, in 16
who grew up in nuclear family had a finger sucking habit more
(13.6%) at the age of 2 years (age of peak incidence), in 14
than children who grew up with grandparents and the rela-
(11.4%) at the age of 3 years, in 8 (5.5%) at the age of 4 years
tionship between grandparents is important [15]. Indeed, re-
old, and in 4 (2.4%) at the age of 5 years. No child less than 1
ports of children with a sucking habit have been increasing.
year old or older than 5 years had a sucking callus (Fig. 1A
Here, we report an easy method for malocclusion detection
and B). A callus was most frequently observed on the thumb
based on the presence of a callused sucking finger, which has
(right hand, n ¼ 20; left hand, n ¼ 21), with a decrease in
rarely been investigated. Our results may help with under-
frequency from the index finger to little finger for both hands
standing and recognition of the early stages of malocclusion
(Fig. 2).
in childhood.

3.2. Malocclusion frequency

2. Methods
Subjects with malocclusion ranged from 1 to 5 years old. That
2.1. Subjects was detected in 8 (8.4%) at the age of 1 year, in 13 (11%) at the
age of 2 years (age of peak incidence), in 10 (8.1%) at the age of
We examined 719 children aged 0e6 years old who were 3 years, in 6 (4.1%) at the age of 4 years, and in 7 (4.2%) at the
attending 10 different kindergartens in Sendai, Japan, from age of 5 years. No child less than 1 year old or older than 5
June to July 2009 (Table 1). years had malocclusion (Fig. 3A and B). Among all subjects,
All children who had a dental check up in kindergartens malocclusion was found in 36 (5%) as maxillary protrusion, in
were included in our study without any exclusion. 5 (0.7%) as open bite, and in 3 (0.42%) as cross-bite. Maxillary
protrusion was found in subjects aged from 1 to 5 years old,
2.2. Examinations with the highest rate of incidence found at the age of 2 years
(n ¼ 12, 10.2%) and then a decrease with age. Open bite and
While performing dental examinations, we checked the cross-bite were found in approximately 0e1% of our subjects
subject hands to determine the presence of a callus caused of all ages (Table 2).
 p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 1 0 3 e1 0 8 105

Fig. 1 e Sucking callus frequency. (A) Numbers of subjects with sucking callus from 0 to 6 years old. (B) Rate of subjects with
sucking callus.

Table 2 e Numbers of subjects (%) with malocclusion from

0 to 6 years old.
Years Number of children (percentage %)
Maxillary protrusion Open bite Cross bite
0 0 (0) 0 (0) 0 (0)
1 7 (7.4) 0 (0) 1 (1.1)
2 12 (10.2) 1 (0.85) 0 (0)
3 8 (6.5) 1 (0.81) 1 (0.81)
4 5 (3.4) 1 (0.68) 0 (0)
5 4 (2.4) 2 (1.2) 1 (0.6)
6 0 (0) 0 (0) 0 (0)
Total 36 (5) 5 (0.7) 3 (0.42)

cross-bite in 2%. These results indicate that maxillary pro-

Fig. 2 e Sucking callus classified by finger in subjects from
0 to 6 years old.
3.3. Protrusion frequency in subjects with sucking callus
Among subjects with a sucking callus, maxillary protrusion
was detected in 3 (42.9%) at the age of 1 year, in 9 (56.2%) at the
age of 2 years, in 6 (42.9%) at the age of 3 years, and in 3 (37.5%)
at the age of 4 years old. No child less than 1 year old or older
than 4 years with a sucking callus had maxillary protrusion
(Fig. 4A and B). As for the other types of malocclusion in
subjects with a sucking callus, open bite was found 4.1% and
trusion occurs frequently in subjects with a sucking callus. In
subjects from 1 to 4 years old with a sucking callus, 40e60%
showed maxillary protrusion, whereas relatively few had an
open bite or cross-bite at the ages of 2 and 3 years old, and no
malocclusion was seen in subjects less than 1 year old or older
than 5 years (Table 3).
3.4. Sucking callus frequency in subjects with maxillary
protrusion
Among all subjects with maxillary protrusion, 58.3% had a
sucking callus (Table 4). For those with maxillary protrusion, 3
(42.9%) had a sucking callus at the age of 1 year, 9 (75%) had

Fig. 3 e Malocclusion frequency. (A) Numbers of subjects with malocclusion from 0 to 6 years old. (B) Rate of subjects with
malocclusion from 0 to 6 years old.
106 p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 1 0 3 e1 0 8

Fig. 4 e Maxillary protrusion frequency in subjects with sucking callus from 0 to 6 years old. (A) Numbers of subjects with
maxillary protrusion and sucking callus. (B) Rate of subjects with maxillary protrusion children and sucking callus from 0 to
6 years old.

Table 3 e Numbers of subjects (%) with sucking callus and 4. Discussion

malocclusion from 0 to 6 years old.
Years Number of children (percentage %) Finger sucking is necessary for sensory development in early
Maxillary protrusion Open bite Cross bite childhood, while recent findings indicate that sucking
behavior also arises and continues due to psychological needs.
0 0 (0) 0 (0) 0 (0)
1 3 (42.9) 0 (0) 0 (0) Normally developed infants have an inherent biological drive
2 9 (56.2) 1 (6.2) 0 (0) for sucking, which can be satisfied by nutritive sucking,
3 6 (42.9) 1 (7.1) 1 (7.1) including breast and bottle feeding, whereby the infant ob-
4 3 (37.5) 0 (0) 0 (0) tains food, or non-nutritive sucking on objects such as digits,
5 0 (0) 0 (0) 0 (0) pacifiers, and toys that may serve primarily to satisfy psy-
6 0 (0) 0 (0) 0 (0)
chological needs [16]. Although finger sucking has a variety of
Total 21 (42.8) 2 (4.1) 1 (2.0)
benefits, it can also expose a child to unsanitary conditions, or
cause malocclusion and otitis media with effusion [17].
There are 2 types of finger sucking, active and passive.
Table 4 e Numbers of subjects (%) with sucking callus and With the former, a strong force from facial muscles can affect
three types of malocclusion. mandible, maxilla, and tooth development. In contrast, with
Number of children (percentage %) passive finger sucking, children only place their finger in the
Maxillary protrusion Open bite Cross bite mouth without applying force, and there is no effect on the
skeletal form or teeth [1]. Children who have active finger
Total 21 (58.3) 2 (40) 1 (33.3)
sucking for at least 6 hours each day show severe abnormal-
ities in the dental alveolar system [18], while minor effects on
that at the age of 2 years, 6 (75%) had that at the age of 3 years skeletal development are also seen [19].
old, and 3 (60%) had that at the age of 4 years old. No subjects Most children are able to quit finger sucking by themselves.
with protrusion and less than 1 year old or older than 4 years However, if it continues when permanent teeth begin to
had a sucking callus (Fig. 5A and B). emerge, it is important to encourage the child to stop. Scolding

Fig. 5 e Sucking callus frequency in subjects with maxillary protrusion from 0 to 6 years old. (A) Numbers of subjects with
sucking callus and maxillary protrusion. (B) Rate of subjects with sucking callus and maxillary protrusion children from 0 to
6 years old.
 p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 1 0 3 e1 0 8
or giving punishment may discourage the child and not have
good effects, thus other strategies are necessary. For example,
praise and rewards for not finger sucking may give a sense
of accomplishment and increase motivation. If the child is
sucking a finger during an idle moment, it may be necessary to
distract then with busyness or a time of fun. In addition, it
may be possible to explain why finger sucking should be
stopped in a manner so that the child can understand [20].
Another clinical approach is use of a palatal arch, as a previ-
ous report noted that use of a palatal crib with spurs for 10
months was effective to stop finger sucking [16].
Most of our subjects had a sucking habit and maxillary
protrusion was most frequently found in those, with the
thumb most often used. A few subjects had open bite or cross
bite. In contrast, other reports have noted a higher incidence
of cross-bite than found in the present study [4]. These results
suggest that the primary sucking finger has an effect on
malocclusion type. Thumb sucking tends to push the maxil-
lary incisors to the labial side and the mandibular incisors to
the lingual side. Usually, children suck a finger with the nail
facing them. Thus, the ball of the finger may push the rugae
palatinae, and strong force pushes the maxilla forward and
prolusion occurs [21]. In addition, thumb sucking places
pressure on the side molars from the cheek, which causes a
narrow arch in the maxillary dentoalveolar or skeletal pro-
trusion [22,23]. Also, the position of the tongue may be
important to form a cross-bite. When a finger is placed in the
mouth, the tongue is positioned low, under the finger, which
may have an effect on expansion of the mandibular dental
arch, resulting in cross-bite. On the other hand, finger sucking
causing maxillary protrusion has a strong forward force from
the thumb, thus that causing cross-bite has less force and a
lower tongue position. When the sucking callus is lower on
the thumb, the mandibular dental arch is narrower.
In the present study, we examined children to determined
the presence of a callus on the finger to show a finger sucking
habit. The incidence of finger sucking and a sucking callus
peaked at the age 2 years in the present subjects, then showed
a decreasing trend with age. In previous study, finger sucking
was detected in 20%, 32.4% at the age of 1 year, in 34.5%, 21.9%
at the age of 2 years, in 29.3%, 21.2% at the age of 3 years, in
18.6%, 20.7% at the age of 4 years, in 9.8%, 15.9% at the age of 5
years and in 12.5%, 11.7% at the age of 6 years [24,25]. Although
the prevalence of finger sucking in previous reports was
higher because of differences in survey methods, the inci-
dence of finger sucking peaked 2, 3 years old was almost
similar to our present study. During hand and finger skill
development, children learn to separate the thumb and other
fingers in order to point with the index finger, which makes
finger sucking easy to perform [20]. Children also grow in their
abilities to handle small items by controlling the wrist, fingers,
and palm, thus allowing them to perform such tasks as
drawing, turning pages in a book, and using a spoon [20].
Among the present subjects, the percentage of those who had
malocclusion also increased with age until 2 years old (11.1%)
and then decreased with age until there were none at 6 years
old. The majority of malocclusion cases among subjects with a
finger callus showed protrusion. Malocclusion is a result of
such a sucking habit, and also showed a peak at the age of 2
years and then decreased with age. Our findings indicate that
107
children with a finger sucking habit are significantly more
likely to develop malocclusion (open bite, protrusion, cross-
bite) as compared to those with no such habit, which also
suggests a relationship between finger callus development
from sucking and maxillary protrusion.
Malocclusion, including maxillary protrusion, open bite,
and cross-bite, discovered prior to the age of 4 years may
disappear by stopping the finger sucking habit. On the other
hand, if that habit continues into an older age, it is important
to attempt to stop it, and also check for malocclusion and oral
function [16]. Furthermore, it is important to determine
whether the child will require clinical treatment [26,27]. A
continued finger sucking habit is likely to induce an anterior
open bite and posterior cross-bite [19]. In another study, it was
noted that thumb and finger sucking should be stopped before
the terminal plane is affected, which would be between 3 and
4 years of age [28].
In Japan, malocclusion in children is generally found
during public health dental examinations of children
attending a preschool, indicating a limited opportunity to
find such affected children. Malocclusion diagnosis in an
early developmental stage leads to successful treatment,
which results in healthy dentition and occlusion develop-
ment, as well as healthy feeding, swallowing, and pro-
nunciation [21]. In addition, appropriately timed treatment
can be maximally efficient with a minimum effort. It is
important for pediatric dentists to pay attention to not only
the oral cavity, but other parts of the body and patient
habits as well.
The maternal and child health handbook produced by the
Ministry of Health in Japan suggests that medical staff check
for a finger sucking habit in children aged from 3 to 5 years old.
An unusual finger sucking habit potentially reveals that a
child has some type of relationship problem with their parents
or a developmental disorder. Checking for a finger sucking
callus is useful for finding malocclusion as well as other child
developmental issues.
From preliminary our study, we thought that frequency of
finger sucking was increasing after The Great East Japan
Earthquake. In the future, we should examine the relationship
between earthquake and finger sucking.
5. Conclusion
We found that maxillary protrusion occurred much more
frequently in the present subjects with a sucking callus as
compared to all subjects. Evidence of a sucking callus was
easily found and considered to be a sign of potential maloc-
clusion for such individuals as parents and teachers. When
such a callus is noted, an examination by a pediatric dentist
would be helpful to manage malocclusion. Evidence of finger
sucking is a novel approach for detecting malocclusion in
children.
1) The peak age for finger sucking and malocclusion was 2
years old.
2) As children aged, finger sucking and malocclusion were
decreased until 4 years old.
3) Finger sucking callus has a relationship with malocclusion.
108 p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 1 0 3 e1 0 8
Conflict of interest
None of the authors has any conflict of interest that should be
declared.
references
[1] Shahraki N, Yassaei S, Moghadom MG. Abnormal oral habits:
a review. J Dent Oral Hyg 2012;4(2):12e5.
[2] Kazuo I, Taketo Y, Tadashi U, et al. A study of yearly changes
and factors of oral habits during a period of 15 years. Jpn J
Ped Dent 1994;32(4):769e77.
[3] Johnson ED, Larson BE. Thumb-sucking: literature review.
ASDC J Dent Child 1993;60(4):385e91.
[4] Larsson E. The effect of finger-sucking on the occlusion: a
review. Eur J Orthod 1987;9(4):279e82.
[5] Gale EN, Ayer WA. Thumb-sucking revisited. Am J Orthod
1969;55(2):167e70.
[6] Josell SD. Habits affecting dental and maxillofacial growth
and development. Dent Clin North Am 1995;39(4):851e60.
[7] Yemitan TA, daCosta OO, Sanu OO, et al. Effects of digit
sucking on dental arch dimensions in the primary dentition.
Afr J Med Med Sci 2010;39(1):55e61.
[8] Warren JJ, Bishara SE, Steinbock KL, Yonezu T, Nowak AJ.
Effects of oral habits duration on dental characteristics in the
primary dentition. J Am Dent Assoc 2001;132(12):1685e93.
[9] Straub WJ. The etiology of the prevented swallowing habit.
Am J Orthod 1951;37(8):603e10.
[10] Bishara SE. Textbook of orthodontics. 1st ed. 2001. p. 250e1.
[11] Ovsenik M, Farcnik FM, Korpar M, et al. Follow-up study of
functional and morphological malocclusion trait changes
from 3 to 12 years of age. Eur J Orthod 2007;29(5):523e9.
[12] Vogel LD. When children put their fingers in their mouths.
Should parents and dentists care? N Y State Dent J
1998;64(2):48e53.
[13] Proffit WR. The timing of early treatment: an overview. Am J
Orthod Dentofac Orthop 2006;129(4 Suppl):S47e9.
[14] Ovsenik M, Farcnik FM, Verdenik I. Comparison of intra-oral
and study cast measurements in the assessment of
malocclusion. Eur J Orthod 2004;26(3):273e7.
[15] Toshihiko T, Yutaka Y, Yukari M, et al. A longitudinal study
on oral habits and malocclusion. 1. Prevalence of
malocclusion. Jpn J Ped Dent 1994;32(5):1122e31.
[16] Haryett RD, Hansen FC, Davidson PO, et al. Chronic thumb-
sucking: the psychologic effects and the relative
effectiveness of various methods of treatment. Am J Orthod
1967;53(8):569e85.
[17] Rall G, Ruoppolo G, Mora R, et al. Deleterious sucking
habits and atypical swallowing in children with otitis
media with effusion. Int J Pediatr Otorhinolaryngol
2011;75(10):1260e4.
[18] Proffit WR. Contemporary orthodontics. 3rd ed. 2000.
p. 129e35. 445-447.
[19] Moore MB, McDonald JP. A cephalometric evaluation of
patients presenting with persistent digit sucking habits. Br J
Orthod 1997;24(1):17e23.
[20] American Academy of Pediatrics. Caring foe your baby and
young child. 5th ed. 2009. p. 584, Birth to Age 5.
[21] American Academy of Pediatric Dentistry. Guideline on
Management of the Dentition and Occlusion in Pediatric
Dentistry. 2009. p. 13.
[22] Goto S, Boyd RL, Nielsen L, et al. Long-term followup of
orthodontic treatment of a patient with maxillary
protrusion, severe deep overbite and thumb-sucking. Angle
Orthod 1994;64(1):7e12.
[23] Crouzon ME. Dental implications of thumb-sucking.
Pediatrics 1974;54(2):196e200.
[24] Kurosu K, Fukuta O, Yoshioka T, et al. A study of the
psychosomatic Odontology on Oral Habits e the condition
of the appearance, life environment and its influence on
the oral habit of children-. Jpn J Ped Dent
1978;16(1):123e36.
[25] Yokoi K, Yamauchi T, Suzuki Y, et al. A clinical observation
on oral habits for ten years Part 1. Appearances and changes
in the year. Jpn J Ped Dent 1986;24(3):450e8.
[26] Maguire JA. The evaluation and treatment of pediatric oral
habits. Dent Clin North Am 2000;44(3):659e69.
[27] Larson E. The prevalence and aetiology of prolonged dumy
and finger-sucking habit. Eur J Orthod 1985;7(3):172e6.
[28] Fukuta O, Braham RL, Yokoi K, et al. Damage to the primary
dentition resulting from thumb and finger(digit) sucking.
ASDC J Dent Child 1996;63(6):403e7.