Annali di Stomatologia | 2026; 17(3): 623-632

ISSN 1971-1441 | DOI: 10.59987/ads/2026.3.623-632

Articles

The impact of oral habits and parafunctions on dental and skeletal development in pediatric populations: a literature review

Federica Macrì^1,2, Luca Esposito^1,2, Gregorio Menozzi^1,2, Giovanni Cattaneo², Antonio Rizzo³, Lucia Giannini¹, Francesca Calò³

¹Department of Biomedical, Surgical and Dental Sciences, School of Dentistry, University of Milan, Milan, Italy

²Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

³Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy

^*Corresponding author: Federica Macrì - federica.macri@unimi.itmail.com

Article History

Received: March 10, 2026

Accepted: July 18, 2026

Published: July 30, 2026

Abstract

Objective

Harmful oral habits and parafunctions (e.g., thumb/finger sucking, prolonged pacifier use, atypical swallowing, onychophagia, bruxism, and oral/oronasal breathing) are common in pediatric populations and may interfere with dentoskeletal development when they persist beyond the expected developmental period. This review summarizes their associations with malocclusion traits and functional alterations during growth.

Materials and Methods

A structured literature search was conducted in PubMed/MEDLINE, Scopus, and Embase for articles published between January 1990 and December 2024. The search combined terms related to oral habits/parafunctions and malocclusion and was limited to English or Italian. A total of 787 records were identified (PubMed/MEDLINE: 50; Scopus: 237; Embase: 500). After duplicate removal, title/abstract screening, and full-text assessment, 23 studies were included and narratively synthesized.

Results

The evidence most consistently links prolonged non-nutritive sucking habits with anterior open bite, increased overjet, maxillary arch constriction, and a higher risk of posterior crossbite. Altered swallowing patterns and oral/oronasal breathing are frequently reported as co-factors that may contribute to vertical and transverse discrepancies. Pediatric bruxism is commonly reported and has been associated with muscle symptoms and temporomandibular complaints, potentially complicating the clinical picture. Across studies, designs, diagnostic criteria, and outcome reporting were heterogeneous, limiting comparability.

Conclusion

Harmful oral habits and parafunctions are modifiable risk factors for the development or worsening of malocclusion during growth. Early identification, counseling, and multidisciplinary interceptive approaches may reduce the likelihood of stable dentoskeletal discrepancies. Future studies should adopt standardized definitions and outcomes and better quantify habit-related biomechanical effects to improve comparability and clinical guidance.

Keywords: oral habits; non-nutritive sucking; pacifier use; malocclusion; anterior open bite; posterior crossbite; bruxism; atypical swallowing; mouth breathing; tongue thrust; pediatric orthodontics.

1. Introduction

Oral functions, muscular activity, and overall neuromuscular balance influence craniofacial growth and occlusal development. Several oral behaviors that may be physiologic during early developmental stages can become harmful if they persist beyond the expected age, potentially contributing to altered dentoskeletal development. These behaviors include non-nutritive sucking habits (thumb/finger sucking and prolonged pacifier use), lip or cheek sucking, insertion of objects into the oral cavity, and parafunctions or functional alterations such as atypical swallowing (tongue thrust), oral/oronasal breathing, bruxism, and nail biting/onychophagia. Epidemiological evidence suggests that these habits and parafunctions are common in childhood. For example, pediatric bruxism has been reported as a frequent parafunction in school-age children, with prevalence estimates varying widely across studies due to differences in diagnostic criteria and assessment methods [1–7]. Regardless of prevalence variability, the clinical relevance of these behaviors lies in their potential to exert abnormal forces on the developing dentition and supporting structures during growth [8–9]. Among harmful habits, thumb or finger sucking is consistently associated with characteristic occlusal changes. When the digit is positioned between the dental arches, altered force vectors may promote proclination of maxillary incisors and retroclination of mandibular incisors, contributing to increased overjet and anterior open bite. Importantly, the severity of dental displacement appears more strongly related to the persistence and daily duration of the habit than to force intensity alone. Intermittent habits may have limited clinical impact, whereas habits maintained for several hours per day, particularly during sleep, have been associated with a higher risk of clinically relevant malocclusion traits, including anterior open bite and posterior crossbite [10–12]. Functional patterns may further modulate occlusal development and contribute to multifactorial clinical presentations. Swallowing evolves with growth and is influenced by neuromuscular maturation, tooth eruption, phonation, postural development, and dietary transition. Persistence of an immature swallowing pattern, characterized by tongue interposition or pressure against the teeth and increased perioral muscle activity, has been described in association with malocclusion traits, including sagittal discrepancies. Likewise, oral/oronasal breathing has been linked to altered mandibular and tongue posture. It has been proposed as a contributor to vertical and transverse discrepancies, potentially favoring posterior tooth overeruption, increased vertical dimension, and anterior open bite. In this context, occlusal traits such as anterior open bite are typically multifactorial and rarely attributable to a single etiological factor [13].

Parafunctional behaviors such as bruxism have also been described in association with headaches, muscle stiffness, and psychosocial stressors. They may complicate the functional status of the stomatognathic system and clinical management in susceptible individuals. Therefore, a careful etiological assessment is essential and should integrate history-taking with the child and parents/ caregivers, clinical examination, and appropriate diagnostic records (e.g., casts, radiographs, and photographs). Early clinical signs potentially associated with harmful habits include anterior open bite, tongue interposition during swallowing, increased overjet, a high-arched palate with possible posterior crossbite, and transverse constriction. During adolescence, these features may coexist with temporomandibular symptoms, which have been reported to be associated with parafunctional behaviors in some studies. Early identification and interception of harmful habits are clinically relevant because delayed management may increase the likelihood that transient functional imbalances evolve into more stable dentoskeletal discrepancies during growth. Preventive counseling and timely interceptive approaches have been proposed as useful tools to reduce the incidence and severity of malocclusions [14–17]. Moreover, available evidence suggests that the risk of developing malocclusion may increase with the number of concurrent habits, supporting comprehensive assessment rather than focusing on a single behavior.

Therefore, this study aimed to provide a narrative literature review with a structured search strategy on the association between harmful oral habits/parafunctions and the development of malocclusion in pediatric populations, with specific attention to commonly reported dentoskeletal traits, including anterior open bite, posterior crossbite, and increased overjet.

2. Materials and Methods

This narrative literature review with a structured search strategy was conducted to summarize and critically discuss the available evidence on the association between harmful oral habits and parafunctions (e.g., non-nutritive sucking, prolonged pacifier use, atypical swallowing/tongue thrust, oral/oronasal breathing, bruxism, and nail biting/onychophagia) and the development of malocclusion traits and dentoskeletal alterations in pediatric populations. The objective was to provide an integrative qualitative synthesis of the literature, with particular attention to the most frequently reported outcomes during growth (e.g., anterior open bite, posterior crossbite, increased overjet, and transverse and/or vertical discrepancies).

2.1. Search Strategy

A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, and Embase to identify human studies published between January 1990 and December 2024. Searches combined controlled vocabulary (MeSH/Emtree, where applicable) and free-text terms related to oral habits/parafunctions, pediatric age groups, and malocclusion/dentoskeletal outcomes. Searches were limited to articles published in English or Italian (Figure 1). Records retrieved from each database were exported to Zotero (Corporation for Digital Scholarship) for reference management, and the PubMed search strategy was adapted to the syntax and indexing of the other databases. The search strategy combined the following concepts: oral habits/parafunctions AND malocclusion traits AND pediatric population. The main search terms were:

(“oral habits” OR “non-nutritive sucking” OR “thumb sucking” OR “finger sucking” OR pacifier* OR “mouth breathing” OR “oral breathing” OR “oronasal breathing” OR “tongue thrust” OR “atypical swallowing” OR bruxism OR onychophagia OR “nail biting”) AND (malocclusion* OR “open bite” OR crossbite* OR overjet)

AND (child* OR adolescent* OR pediatric* OR pediatric*). Overall, 787 records were identified (PubMed/MEDLINE: 50; Scopus: 237; Embase: 500).

2.2. Eligibility Criteria

Studies were considered eligible if they: (i) investigated pediatric populations (children and/or adolescents) and (ii) evaluated associations between one or more oral habits/parafunctions (e.g., non-nutritive sucking, pacifier use, mouth/oronasal breathing, atypical swallowing/tongue thrust, bruxism, nail biting/onychophagia) and malocclusion traits and/or dentoskeletal outcomes. Primary clinical evidence included observational studies (cross-sectional, case-control, and cohort studies) and clinical trials.

Exclusion criteria were: studies focusing exclusively on adults; studies not reporting occlusal or dentoskeletal outcomes; conference abstracts without full text; editorials, commentaries, and letters without original data; in vitro or animal studies; and publications not written in English or Italian.

2.3. Study Selection and Data Extraction

Titles and abstracts were screened for relevance, followed by full-text assessment of potentially eligible records. After screening and full-text evaluation, 23 studies were included in the narrative synthesis, as summarized in the PRISMA 2020 flow diagram.

For each included study, the following information was extracted and summarized qualitatively:

study design and country/setting;
sample size and age range;
type of habit/parafunction investigated;
habit duration and/or intensity (when reported);
malocclusion outcomes (e.g., anterior open bite, posterior crossbite, increased overjet);
diagnostic methods;
main findings and clinically relevant considerations.

Due to heterogeneity in study designs, diagnostic criteria, and outcome reporting, no formal risk-of-bias/quality assessment was performed. Findings were therefore interpreted narratively and were not pooled quantitatively.

**Figure 1.** PRISMA 2020 flow diagram showing study identification, duplicate removal, screening, eligibility assessment, exclusion reasons, and inclusion.

3. Results

The included studies most frequently investigated non-nutritive sucking habits (thumb/finger sucking) and pacifier use. Nail biting (onychophagia) was less frequently addressed and tended to be reported at older ages.

3.1. Thumb/Finger Sucking (Non-nutritive Sucking)

Across the included studies, thumb/finger sucking was consistently associated with occlusal alterations, particularly anterior open bite and increased overjet. In a comparative study of children aged 7–13 years, Mistry et al. [18] reported significant differences in anterior open bite and overjet between children with and without digit-sucking habits based on dental cast analysis, whereas no significant difference was found for posterior crossbite. Similarly, Peres et al. [19], in a larger birth cohort, found that anterior open bite was significantly associated with thumb sucking and pacifier use.

Evidence from longitudinal observation also supports an association between digit sucking and both anterior and transverse discrepancies. In a cohort study conducted at the University of Bristol, children aged 0–5 years were followed using parental questionnaires; dental cast assessments suggested that digit sucking was associated with anterior tooth misalignment, anterior open bite, and posterior crossbite [20]. In addition, studies investigating the etiology of posterior crossbite in the deciduous and mixed dentitions have reported a higher frequency of sucking habits among children with transverse discrepancies, supporting a potential etiological contribution of this habit to crossbite development [21–22].

A smaller experimental investigation explored the relationship between sucking forces and occlusal changes. Yokota et al. [23] used pressure sensors to assess thumb pressure during sucking in three girls (8–12 years) and reported forces of approximately 2–4.5 kg on the anterior palate; higher pressures were associated with more severe transverse alterations, including posterior crossbite. Further evidence from cast-based evaluations and population studies suggests reduced transverse arch dimensions and a higher prevalence of posterior crossbite among children with persistent sucking habits compared with controls [24].

Persistence of habit appeared to be an important modifier of clinical impact. Warren et al. [25] assessed children in deciduous dentition. They observed that habits persisting beyond early childhood were associated with a higher prevalence of anterior open bite, posterior crossbite, and increased overjet, with severity increasing with longer habit duration. Subsequent longitudinal evidence in mixed dentition also suggested that early habit cessation was associated with a reduced occurrence of anterior open bite and posterior crossbite. Consistently, clinical reviews and interventional evidence emphasize the relevance of interrupting persistent sucking habits before eruption of the permanent dentition, through behavioral/motivational approaches and, when indicated, orthodontic appliances [26–27].

3.2. Pacifier Use

Pacifier use was also reported as a relevant risk factor for malocclusion traits. In studies of children in deciduous dentition, prolonged pacifier use was associated with a higher prevalence of posterior crossbite, with risk increasing as the duration of the habit increased [28–30]. Bishara et al. highlighted that persistent non-nutritive sucking patterns may be associated with clinically relevant occlusal changes in late deciduous dentition.

Evidence syntheses on pacifier use have reported an increased risk of anterior open bite and posterior crossbite, reduced maxillary arch width, and a high-arched palate, particularly when the habit persists beyond early preschool age. Cessation between approximately 2 and 3 years of age has generally been considered less likely to produce stable clinically relevant consequences than persistence beyond 3 years. However, study heterogeneity and variable diagnostic criteria limit the certainty of this conclusion.

3.3. Nail Biting/Onychophagia

Evidence regarding nail biting was limited. The included literature described onychophagia as common in both children and adults and often associated with anxiety-related behaviors [31–32]. Onychophagia has been reported to emerge during childhood, increase in some children during school age or adolescence, and decrease in many individuals thereafter; however, estimates and developmental patterns vary across studies.

Nail biting was described in association with anterior dental alterations such as incisal abrasions, rotations, crowding, and protrusion, and in severe cases, possible root resorption. However, the available evidence did not support a consistent association with any specific malocclusion pattern, and the findings were not statistically robust [33–34].

3.4. Other Parafunctions and Functional Alterations (Brief Overview)

Some studies also reported parafunctional behaviors (e.g., bruxism) and functional alterations (e.g., atypical swallowing and mouth breathing) in pediatric populations and suggested possible associations with malocclusion traits (including increased overjet and anterior open bite) and temporomandibular symptoms [35–38,6,39–41]. However, compared with non-nutritive sucking habits and pacifier use, evidence for these conditions was reported less consistently and remained heterogeneous in study design, diagnostic criteria, and outcome definitions [42].

4. Discussion

This narrative literature review, using a structured search strategy, aimed to synthesize the available evidence on the association between harmful oral habits/parafunctions and malocclusion traits during growth. By searching three major biomedical databases (PubMed/MEDLINE, Scopus, and Embase) over a long time window (1990–2024) and documenting study selection through a PRISMA flow diagram, the present work provides an integrative overview of a clinically relevant and highly prevalent set of behaviors in pediatric populations [43–45]. Although the included evidence was heterogeneous in study design, diagnostic criteria, and outcome definitions, a consistent pattern emerged: prolonged non-nutritive sucking habits (thumb/finger sucking) and prolonged pacifier use were the behaviors most repeatedly associated with anterior open bite, increased overjet, maxillary arch constriction, and a higher likelihood of posterior crossbite [46–49].

Across the included studies, non-nutritive sucking was the most frequently addressed habit and showed the most reproducible associations with occlusal changes [50–53]. Several investigations based on dental cast analysis described differences in anterior open bite and overjet between children with and without sucking habits, supporting an association between persistent digit sucking and anterior sagittal/vertical alterations. Longitudinal observations further suggested that digit sucking may contribute not only to anterior open bite but also to posterior crossbite and anterior tooth misalignment, indicating that its potential effects extend beyond the anterior region. While not all studies reported a statistically significant relationship with posterior crossbite, the overall evidence supports a plausible contribution of sucking habits to transverse discrepancies, especially when the habit is persistent.

A clinically meaningful aspect emerging from the literature is the importance of duration and persistence. Several studies indicated that habits maintained beyond early childhood were more frequently associated with anterior open bite, increased overjet, and posterior crossbite. In contrast, early cessation was associated with reduced occurrence of these traits [54–55]. This finding is particularly relevant for clinical practice, as it supports counseling strategies focused on limiting the persistence and daily exposure of the habit rather than emphasizing intensity alone. The observation that severity may increase with longer persistence is consistent with the concept that sustained low-to-moderate forces, applied repeatedly during critical growth stages, can influence tooth eruption trajectories and arch form over time. From this perspective, non-nutritive sucking should be interpreted as a modifiable risk factor whose impact is likely influenced by timing (growth phase), exposure (duration/frequency), and coexistence with other functional characteristics [56].

Pacifier use showed a similar overall association with malocclusion traits, particularly posterior crossbite and anterior open bite, and has been repeatedly linked to reduced transverse maxillary dimensions and a high-arched palate in the literature. Importantly, evidence suggests a duration-dependent effect, with a higher likelihood of clinically relevant outcomes when the habit persists beyond early preschool age and increasing severity with longer persistence. These findings have direct implications for early clinical identification. The recognition of early signs that may precede stable transverse discrepancies reinforces the importance of routine screening in pediatric dental settings and anticipatory guidance aimed at timely discontinuation of the habit [57–58].

In contrast to sucking habits and pacifier use, evidence on nail biting (onychophagia) was limited in the included literature. It did not support a consistent association with any specific malocclusion pattern. While onychophagia has been described in relation to anterior dental changes (e.g., incisal wear, rotations, crowding, or protrusion) and may be linked to anxiety-related behaviors, available data did not provide statistically robust or reproducible links to defined occlusal outcomes. Therefore, nail biting should be approached as a potential contributor to localized dental effects rather than a clearly established determinant of a specific malocclusion trait, at least based on the current evidence summarized in this review.

Other parafunctional behaviors and functional alterations (e.g., bruxism, atypical swallowing, and mouth breathing) have been reported in the pediatric literature and suggested as potential co-factors that may complicate the occlusal and functional picture, including associations with temporomandibular symptoms in some reports. However, compared with non-nutritive sucking and pacifier use, these topics were addressed less consistently across the included studies, and variability in diagnostic definitions and outcome reporting limited comparability. This heterogeneity underscores an important interpretative point: many malocclusion traits, particularly anterior open bite and transverse discrepancies, are multifactorial and seldom attributable to a single etiological factor. Oral habits may interact with growth pattern, airway status, and neuromuscular function, and their clinical relevance may increase when multiple behaviors coexist or when functional adaptations are present [59].

From a clinical standpoint, the findings support a practical message: early identification and timely interception of harmful habits are likely beneficial. History-taking should systematically address habit type, onset, frequency, daily duration, and persistence over time, ideally integrating caregiver report with clinical indicators. Clinical signs that may prompt closer monitoring include an anterior open bite, increased overjet, a constricted maxillary arch form, a posterior crossbite, and a high-arched palate. When habits persist beyond early childhood, counseling and behavior-focused strategies may be reinforced, and interceptive orthodontic or multidisciplinary approaches may be considered when indicated to reduce the likelihood of stable dentoskeletal discrepancies. Importantly, this review supports the clinician’s role in framing habits as modifiable risk factors and guiding families toward timely discontinuation, rather than treating malocclusion as an unavoidable outcome [60].

4.1 Limitations

This study has limitations that should be acknowledged. Although a structured search strategy across multiple databases and PRISMA-based reporting were used to enhance transparency, the synthesis was narrative, and no formal risk-of-bias/quality assessment tool was applied due to heterogeneity in study designs, diagnostic criteria, and outcome measures. Many included studies were observational, which limits causal inference and increases the risk of confounding (e.g., craniofacial growth patterns, concomitant habits, and airway-related conditions). Habit assessment was frequently based on parental report, potentially introducing recall bias and misclassification. Additionally, variability in occlusal outcome definitions and in dentition stages (primary vs. mixed dentition) limits the ability to compare findings across studies quantitatively.

Despite these limitations, the present review provides a clinically oriented synthesis emphasizing the behaviors most consistently linked to malocclusion traits, namely digit sucking and pacifier use, and highlights duration/persistence as a key modifier. Future research should adopt standardized definitions of habits and parafunctions, harmonize diagnostic criteria and outcome reporting, and more consistently quantify exposure (frequency and duration) to facilitate comparability. Well-designed longitudinal studies with consistent assessment protocols would be particularly valuable for clarifying dose-response relationships and identifying clinically meaningful thresholds for the development of stable dentoskeletal discrepancies. In parallel, studies evaluating preventive counseling and interceptive strategies could support more evidence-based recommendations regarding timing and management pathways.

5. Conclusions

Within the limits of a narrative synthesis, this review supports a clear and clinically meaningful message: among the harmful oral behaviors described in pediatric populations, prolonged non-nutritive sucking (thumb/finger sucking) and prolonged pacifier use show the most consistent associations with malocclusion traits during growth. Across the included evidence, these habits are repeatedly linked to anterior open bite, increased overjet, maxillary arch constriction, and a higher likelihood of posterior crossbite, with habit persistence and exposure over time emerging as key modifiers of severity. In contrast, the available literature on nail biting (onychophagia) remains limited. It does not identify a reproducible malocclusion pattern, while evidence regarding other parafunctional and functional alterations is reported less consistently and characterized by heterogeneous diagnostic approaches and outcome definitions.

Funding:

This study was partially funded by the Italian Ministry of Health - Current Research IRCCS

Institutional Review Board Statement: Not applicable. This article is a literature review and did not involve new data collection from human participants or animals.

Data Availability Statement:

No new datasets were generated or analyzed for this article. Data supporting the synthesis are derived from the studies cited in the reference list.

Conflicts of Interest:

The authors declare no conflicts of interest.

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