Psychosocial Factors of Malocclusion

Psychosocial Factors of
Malocclusion

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Content
Wrights Classification
Models of health Behaviour
Psychosocial Impact on Malocclusion
Psychosocial effects of orthodontic treatment
Psychosocial issues in children with special needs
Psychology of orthognathic surgery patient
Conclusion


Childs Behavior pattern in the Dental Office:
Wrights classification 1975
A) Cooperative(positive Bahavior)
Cooperative:
Children engage in conversation with the dentist
Understands the procedure to be accomplished and
follows directions courteously.
2. Lacking cooperative ability:
Not able to communicate with the dentist.
Very young children or those with mental or physical
disabilities.
Management is best accomplished through the use
of drugs for sedation.
3. Potentially cooperative behavior
Has the potential to cooperate, but due to the inherent
fears (subjective/ Objective) the child does not cooperate

B)Uncooperative (Negative Behaviour)
a)Hysterical or Uncontrolled behaviour:
presented by 3- 4 yr old children at their first dental visit.
Loud crying, kicking and temper tantrum.
b)Defiant or Obstinate Behaviour “Spoiled Kid”:
Seen in any age group
Usually in spoilt or stubborn children.
They can be made to cooperate.
c)Tense cooperative:
They are borderline between positive and negative
behaviour.
Does not resist treatment but the child is tensed at mind.
d) Timid behaviour/ Shy:
Usually seen in overprotective child at the first visit.
Is shy but cooperative

e) Whining type:
Complaining type behaviour allows for
treatment but complains throughout the procedure.
f) Stoic behaviour:
Seen in physically abused children.
They cooperate and passively accept all treatment
without any facial expression.


Self Concept is composed of selfimpressions
and personal evaluations of one's selfadequacy.
(Rathus,Rinehart,Winston 1990)
Coppersmith (1967) it is the personal judgement of
worthiness that is expressed in the attitudes the individual
holds.
It is multidimensional in nature.
These dimensions include selfefficacy, self-evaluation
of intelligence, strengths and weaknesses,
self-esteem, and self-perceptions of physical appearance
(ie, body image).
Rosenberg (1965) A positive or negative attitude towards a
particular object, namely the self.

Body image. It is the degree to which one feels satisfied
or dissatisfied with various parts or processes of the
body.
It is distinguishable from general self-concept in that it
concerns perceptions specifically related to physical
aspects of the body.


Lyons and Ramsey 2000.. The authors discuss 4
important models of health behavior and their
implications for orthodontic treatment:'
(I) The health belief model;
(2) The theory of reasoned action;
(3) Self-regulation theory
(4) The stage of change model.
Health Belief Model
This model proposes that an individual's beliefs are
important determinants of his/her health related behaviors.
Four sets of beliefs thought to predict health-related behaviors
(1) Perceived susceptibility to disease or problems,
(2) Perceived severity of the problem,
(3) Perceived benefits of health behaviors, and
(4) Perceived barriers to health-enhancing behaviors.

Eg:If the patient believes their susceptibility to that
outcome is low, the patient is less likely to wear the
appliance.
Likewise, if the patient acknowledges that the outcome
may occur, but judges this outcome to be low in severity,
again engaging in the recommended behavior is
improbable.
On the other hand, if the patient believes that wearing the
appliance will confer significant benefits, then the
behavior is more likely.
So efforts to improve compliance should address these
patient beliefs through education, and barriers to
compliance should be minimize while maximizing the
perceived benefits of the behavior

Theory of Planned Behavior
In this theory, a person's intention to engage in a
behavior directly determines
whether they perform that behavior.
Intention is influenced by 3 factors
(I) the person's attitude toward the behavior (eg, "I
don't like wearing cumbersome devices that make me
look different")
(2)Social influences on the behavior ("People will
make fun of me")


(3) The person's perceived behavioral control,
which reflects a person's perceived ability to
overcome obstacles and is influenced by their
past behavior.
This model determines whether the person
intends to perform the behavior and is the first
step in identifying potential noncompliance. If
intentions to change behavior are low, then
intentions to alter attitudes or increase
behavioral control may be indicated


Self-Regulation Theory
Individuals regulate their own behavior using the
following 3processes.
1) individuals monitor both the determinants and
outcomes of their behavior.
For example, a patient evaluates why he or she is
wearing his/her appliance (eg, "Because the doctor told
me to."), and monitors the outcome of that behavior (eg,
"I feel like I'm taking good care of my teeth.").


2) patients evaluate their behavior based -on personal
standards ("I'm doing pretty well for me.") and
environmental conditions ("Under the circumstances, I
can't be expected to do much better.
3) patients adjust their behavior depending on how it
compares with these personal standards ("I really am
not doing as well as I can."). Thus, this theory proposes
reciprocal interactions among behavior, the environment
and personal factors, such as internal standards and
cognitive processes.


One of the central concepts in self-regulation
theory is self-efficacy, which refers to the belief
that one can produce a desired outcome
through one's own efforts. Several research
studies have shown that high self-efficacy for
specific health-related behavior changes (eg,
exercise,smoking cessation) is associated with
improved adherence with those behavior
changes


Selfefficacy has been associated with increased
frequency of brushing and flossing. These
findings suggest that increasing a patient's belief
that he or she can successfully perform the
behaviors requested (eg, proper brushing and
flossing, appliance use) can improve their
adherence


Stages of Change Model
This model proposes that people progress through 5
stages when making a behavior change, and Broder
and Phillips apply this model to understanding
decisions regarding treatment.
1) Precontemplation--In which people typically fail to
acknowledge the need for behavior change and have
no intention of changing their behavior.
2) Contemplation, individuals recognize a need for
change and are considering a change in behavior,
but have not yet taken any steps in that direction.


3) Preparation, involves making specific plans for
behavior change.
4)Action, involves implementing those plans, and this
is the first stage in which overt behavior change
occurs.
5)The final stage is maintenance, in which people are
attempting to sustain the behavior changes that they
have made.


An important implication of each of these models is that
patients' attitudes, thoughts, feelings, and perceptions are
important determinants of their health-related behavior.
Therefore, clinicians must take these patient factors into
account in order to provide optimal treatment.
This is most effectively' implemented through a patientcentered approach.
Patients who fail to follow prescribed instruction are
labeled as "noncompliant.“


Practical Implications
It has also been noted that patients‘ personal beliefs,
locus of control, and their social developmental status can
have important effects on compliance and treatment
results. This highlights the substantial influence that
psychologic variables can have on the process and
outcome of orthodontic treatment.
Psychosocial variables can also impact decisions
regarding whether to seek orthodontic or orthognathic
surgical treatment (Broder and Phillips), and these
treatments can also produce psychologic benefits for
patients (Rivera et al).
This information clearly indicates that psychologic
processes are a central component of orthodontic
treatment, and optimal clinical practice requires an
appreciation of these factors.

Based on these theoretical models, the following
recommendations for clinical practice are
suggested.
1). Assess patients' intentions to adhere to treatment
regimens (eg, "How often do you plan to brush and
floss?").
2) Assess patients' self-efficacy for successfully
completing the prescribed treatment (eg,"How capable
do you feel you are of using this appliance as
prescribed?")
3) Be aware that patients seek treatment at very
different points along the stages of change,and parents
and children may also differ in their readiness for
change. Treatment should be initiated only when the
patient reports being ready to assume the responsibility

4)Try to identify barriers to compliance with
treatment, recommendations. These may
include,personal characteristics of the patients.
Identify the barriers
Tailor treatment around the barriers
5) Treatment plans should incorporate the
priorities
and capabilities of the patient. It allows patients
to participate in the decision-making process
and furthers the patient's
commitment.


The ability to implement such changes
depends on an effective relationship
between the clinician and the patient,
which requires open communication in
both directions leading to improved
treatment outcome as well as
increased satisfaction for both the
patient and the provider to provide a
high return on investment.


Adolescent perception of Dentofacial appearance
and treatment decision
The preferred time for treatment in most cases continues
to be during adolescence,the behaviors of these patients
may also be significantly affected by the developmental
tasks of their age group.
Example:
Development of independent identity involves
separation from parental values and movement
toward peer group standards-psychologic activity that may
manifest as general resistance to adult authority.


So social developmental context for these individuals
must be considered in a way that takes into account the
attitudes and behaviors of parents,
and perhaps the treating professionals, as well as the
social milieu of the patient and the patient's own
perceptions.
Albino 1980 carried out longitudinal
studies of adolescent orthodontic patients at the State
University of NewYork and found that the severity of
malocclusion and the need for orthodontic
treatment are assessed in very different
ways by patients, their parents, and orthodontists.
Because the salient concerns of these 3
groups with respect to malocclusion are almost
certain to vary.

The judgement of self perception of malocclusion is highly
dependant on esthetic factors. On the contrary, Shaw(1981)
found that majority of children he studied could not identify
photographs of their own occlusal features, nor could they
accurately describe their occlusal features
The attractiveness and perceptions of family members
provide the foundation on which a child builds
his or her self-perception of appearance, including
dental-facial appearanc,Data from the Buffalo
Studies(Albino 1980)showed that family members
tended to make similar assessments of attractiveness.
Significant positive correlation was found
between children's self-perceptions of dental-facial
attractiveness and their mothers' and siblings'
perceptions.

Psychological influences on orthodontic
treatment demand
Personality theorists from Freud to Erikson as well as
psychologists who have focused on cognitive development
such as Piaget have emphasized the role of body
awareness the development of self-concept.
Self-concept is composed of self impression and
personal evaluations of one’s self-adequacy. Self-concept
is multidimensional in nature. These dimensions include
self efficacy (ones perceived ability to achieve goals
through ones efforts), self- evaluation of intelligence,
strengths and weaknesses, selfesteem, and self
perceptions of physical appearance(body-image).

At the same time, other people’s qualitative reaction and
responses to our appearance influence the development
of body image and self-esteem. Academic and athletic
achievement, ability to interact with peers, teachers and
others all come into play an increasingly important role
in our selfesteem. Hence, most measure of selfesteem
are multidimensional;body image that represents just
one dimension.
For many children one or more components of selfconcept is great. Those who can identify their
malocclusion as the source of their dissatisfaction are
more highly motivated to obtain orthodontic treatment.

Grewal K, Sunny JP, Valiathan A(2003)
A questionnaire study done at Manipal regarding
patients expectations and perceptions towards
orthodontic treatment reported
67%- Believed that their self confidence
may be positively enhanced
42%- Felt that improved facial
appearance would not be an advantage as far as
their career opportunities are concerned.
More than half of the total respondants felt that, to
attain straight teeth was the first motivating factor
to undergo treatment.
Only 31.8% - felt that improvement in dental
appearance may lead to enhanced facial
appearance

Psychosocial Impact of Malocclusion:
The demand for correction of malocclusion is of the
psychological and sociological rather than somatic.
Class I is considered to be the most attractive
dental occlusion among white Americans,
Class III the least. However, treatment demand
is higher among those with Class II than with
Class III malocclusion.(Wilmont ,Barber,Angle ortho 1993).
lt is in contrast, in a study conducted in Singapore,
young Asian respondents rated Class III malocclusion as
more attractive than Class II and those with the former
condition were less likely to seek treatment than
those with the latter.(Soh, Lew ,1992)

However psychologic and social repercussions of these
conditions are diverse and vary across individuals and their
culture.
The impact of malocclusion on psychosocial factors can be
understood in the context of 2 interrelated processes.
1)social judgement and responses of others to malocclusion.
2) involves patients' self-adjustment to malocclusion.
Social judgements of Malocclusion:
Numerous studies have examined the effects of physical
attractiveness on social judgement and social relations.
, Unattractive individuals are perceived to be less liked, less
friendly, less intelligent, less successful, and less
competent as dates and marriage partners.
(walster, Adams 1977)

Some studies have found physical attractiveness to be
significantly associated with teachers' expectations about
intelligence, popularity, and success.(Clifford 1973)
Many of these studies focus on what
Shaw terms "background attractiveness" whereby
judgement of attractiveness is based on total facial
appearance.
Malocclusion gives rise to similar stereotype. Normal
incisor relationships are associated with higher levels of
friendliness, social class, popularity, attractiveness,'
and lower levels of aggressiveness when
compared with prominent incisors, crowded incisors,
and absence of lateral incisor.(shaw 1985)

Most studies show that patients with malocclusions
have a positive self-concept(Kiyak 1982,Dann 1995)
and self-esteem.(Kiyak 1982,Forsell1998)
More recent research indicates that patients have well
adjusted personalities.(Hatch et al 1999)
Patients are comparable to the general population
on several personality characteristics including
locus of control, introversion and extroversion.
Although individuals with malocclusion may report
feeling negatively impacted and socially
disadvantaged,these circumstance do not have large
negative repercussions on patients' psychologic
well-being.

For the most part, individuals with
malocclusion report a positive self-concept and
body image that is comparable with the general
population.
Also, the objective severity of the malocclusion does
not seem to be associated with self judgments of selfesteem or body image.


Psychosocial Effects of Orthodontic Treatment:
I.Patient Expectations:
Research (Garvill, Finlay1995)shows that patients with
malocclusion are motivated to undergo corrective treatment
primarily for esthetic and functional reasons.
There is also evidence that patients
expect certain psychosocial benefits after treatment.
For example, patients hope that treatment
will positively influence interpersonal relationships
and psychologic well-being as well as
improve self-confidence and self-image. In
addition, patients expect that their life will improve
in some way because of treatment

It is unclear regarding the extent to which corrective
treatment contributes to increased levels of self-concept
and social Interactions.
(Wictorin et al 1969).
The physical results of treatment
are usually favorable, producing improvements
in occlusion, function, and facial appearance.
The psychologic implications of these changes
are less apparent but of equal importance in
assessing the impact of treatment.


II.Orthodontic treatment
a)Self concept
Orthodontic treatment, which often produces
positive changes in facial appearance, is
assumed to Improve self-concept”(klima 1979).
A review of the literature, however, provides little evidence.
For instance, adult patients
with mild-severe degrees of malocclusion,
undergoing fixed-appliance orthodontic
treatment, show no significant differences in
self-concept from pretreatment to 6 months after
the start of treatment or 1 to 4 weeks after the
end of treatment. (Varela 1995).

Similarly, a comparison of orthodontic patients 15 months
after the start of treatment and 1 year after the completion of
active treatment indicates that self-concept is
comparable with that of a group receiving no
treatment.(Dann1995)
Literature suggests that selfconcept undergoes
little change over the course of orthodontic
treatment and remains stable after active treatment
is completed.
Kiyak 2000 reasons that
1. research shows that patients are comparable with the
general population in regard to self-concept before orthodontic
treatment

2. Orthodontic treatment may not produce
sufficient changes in total facial appearance
to significantly impact the physical appearance
dimension of self-concept.
b)Body Image: general body and facial
image significantly increased from pretreatment
levels when assessed 4 weeks following the completion of
active treatment. At 1 year following
the completion of active treatment, self-evaluations
of dentofacial attractiveness in adolescents
significantly improved when compared with pretreatment
levels. However, these improvements
did not generalize to other facial characteristics
or to general perceptions of the face.(Albino 1994)

This could be because the specific changes to dental
features become incorporated into one's self-concept and
the enthusiasm associated with a"new look" decreases.
Patients may continue to be satisfied with the esthetic
changes produced in dentofacial features. However,
attention may be refocused on imperfections of other body
parts, lowering previously held selfperceptions
of general body image.


Few psychologically adverse effects are reported
following orthodontic treatment. Most discomfort is physical
and is experienced during the initial 4 weeks of treatment
and during appliance adjustment visits. However, the
problems appear to be short lived and did not cause large
amount of distress.
Thus,orthodontic treatment doesnot significantly
increase or decrease self concept.
Finally the psychosocial problems experienced during and
after treatment is minimal and generally declines over the
course of treatment.


Psychological aspects of chidren with special needs:
Special needs describe a wide range of conditions
that result in patient requiring extra attention or special
facility in order to attain and maintain oral health.
Handicap and disability:
The handicap child may be, at best, passive and
apathetic and at worst, frightened, defensive and hostile,
constituting a stark antithesis to the ideal orthodontic patient.
Concerned and caring parents of the child will have
come to accept the inevitability of the childs physical and/or
mental condition and turn their attention to improving the
remaining area where there is frequently sever disability,
namely the facial appearance.

Personal experience of parents, who have
approached with the view to providing orthodontic
treatment for their handicapped children, is likely to
have been disappointed. It may be inferred that,
although treatment undoubtedly exists, the
conditions are not conducive to pursuit and its
eventful successful outcome.
In orthodontics analysis of patient cooperation factor
yields four basic requirements ( Becker 979)
1.Motivation- not only is motivation totally lacking
but it is frequently supplemented by exaggerated
fear and apprehension which is heightened when
the mouth is invaded by orthodontist.

2.Oral Hygiene- Tooth brushing is usually not practiced
and food from recent meals can be seen stagnating
around the teeth, the palatal vault, sulcus and the
floor of the mouth. This is often due to lack of
clearance resulting from a lessened activity of the
musculature of the tongue, lips and cheeks or frame
a frank hypotonicity that is characteristic of many
conditions and syndromes.
3.Behaviour Management: Patient will usually not
submit to develop procedures and even when they
do, they exhibit a marked reduced ability to sit still for
any length of time. This is fine, painstaking and
precision orthodontic procedures are out of question.


4.Manual dexterityThis may be on a reduced level and serves patient
governed functions such as inserting removable
appliances, placing headgears and hooking up elastics
beyond their capabilities.
Plan of Treatment:
The role of the ParentTransfer of responsibility for certain important
functions to the parent- the tasks that they must be
recruited are
1)Oral Hygiene
2 )caries –prevetion prophylaxis
3)appliance care.

Regular daily tooth brushing has a very important role
in that the patient learns to accept foreign odjects
being manoeured around his mouth by a third party.
Since the party is the parent, the childs perceived
threat is minimal and he quickly adapts. This is a vital
step towards successful patient management.
Lateron, foreign objects such as radiographic films
,impressions and finally orthodontic appliances will
need to be be introduced into the mouth, by the
parent.


The role of the Orthodontist:
1.There is the need too aim for the realistic
treatment goals which must be adapted to the
individual patients.
2.It is advisable to use a simplified appliance design
to make activation independent of the patient.
3.Application of conscious sedation- Midazolam
nasal drops
4.Strategic extractions that will allow spontaneous
corrective movements of adjacent teeth. This will
often minimize the need for and extent of
mechanotherapy.
5.Use of enbloc extaoral removable appliance(Bass
1975,Thurow1975)

Psychosocial considerations in surgery:
Patients willing for orthognathic surgery have
the desire to improve their facial and dental
appearance rather than their occlusal function, the
benefits have constant pychosocial consequences.
Kiyak et al ( 1981, 1988, 1984) presents
perhaps the most comprehensive evidence of
psychological benefits of orthognathic treatment.
Kiyak 1982 reported orthognathic patients had
high body image scores both beforeand after
surgery. However at 9 months postsurgery, facial
body image had dropped significantly. Facial body
image increased significantly again at 24 months
postsurgery.

Overall body image was signifivantly higher 24 months
after surgery than it was at presurgery. But the selfesteem level were slightly lower at 24 months after
surgery compared with presurgery levels.
Kiyaket al 1985, compared the psychological status of
156 patients who were referred for possible
orthognathic surgery.
90 of them eventually received orthognathic surgery
33 declined but underwent orthodontic treatment only
33 declined any form of treatment


According to many other longitudinal data, the
psychosocial benefits gained by patients who
undergo orthognathic surgery are
Better Social functioning ( Garvill et al 1988, ostler
1992)
Social adjustment ( Barbosa et al 1993)
Self-Confidence(Harary et al 1990)


Conclusion:
Although there is dramatic improvements in
esthetics, following orthodontic and orthognathic
surgery. and patient-reported satisfaction with
outcomes, how can it be that nearly 30 years of
research produces onlv limited evidence supporting
significant long lasting psychosocial benefits?
There are 2 possible explanations. First, it
is possible that the psvchosocial impact is, in
fact, not as significant as clinical observation has
led us to believe. This may be partly true,Just as
patients may exaggerate the benefits of treatment
shortly after completion, clinicians may be
subject to a similar halo effect.

Alternatively, it may be that current research methods are
simplyinadequate; ie, there are significant psychosocial
changes, but the research methodology to date
has been inadequate to document the psychosocial
changes.
There is also the need to re-evaluate the assessment
Methodology.It is possible that the psychosocial
assessments used to date are not detecting
the psychosocial changes that are observed clinically,
These factors have not been well controlled
in many of the research reports to date.
Prospective studies with appropriate control
groups, calibrated examiners, and carefully selected
patient relevant outcome measures are needed.

References:
1.Grewal K, Sunny JP, Valiathan A: Expectation and
perception of patients towards orthodontic treatment
in Manipal, JPFA 2003;19: 83-88
2.Sachdeva ST , Valiathan A: Cooperation in
Orthodontics , Stomatalogica India, 1995;9:3-6
3. Sachdeva ST, Valiathan A: Whose mouth is it
anyway? JIOS 1994; 25:105- 108.
4. Irfan Dawoodbhoy, Valiathan A:Psychological
Implications of Dentofacial deformities. KDJ 17:913916.

5. Riolo M, Avery JK: Essentials for Orthodontic

practice
1st Ed 2003 pg 11-51
6. Grover S, Arora D: Psychological aspects of
orthodontic treatment. JIOS 2001; 34:9-15
7.Sinha PK,Nanda RS: Improving patient compliance
in Orthodontic practice, Semin orthod 2000; 6:23741
8.Judith Albino: Factors influencing adolescent
cooperation in orthodontic treatment. Semin orthod
2000;6 :214-223

9. Kiyak HA: Cultural and Psychological
influences on treatment demand, Semin Orthod
2000; 6;242-248
10.Rivera SM, Hatch JP, Rugh JD: Psychological
factors associated with orthodontic and
orthognathic surgery treatment. Semin orthod
2000;6;259-269.
11.Hunt et al: The Psychological Impact of
Orthognathic Surgery: A systematic
review.AJO-DO 2001; pg 490- 497

12. Macgregor FE. Social and psychological
implications of dentofacial disfigurement Angle
Orthod 1970;40:231
13. Klima RJ, Wittemann JK, Mciver JE. Body
image, selfconcept, and the orthodontic patient.
Am J Orthod 1979;75:507-516.
14. Kiyak HA, McNeill RW, West RA, et al.
Personality characteristics as predictors and
sequelae of surgical and conventional
orthodontics. Am J Orthod 1986;89:383-392.

15.Shaw WC, Rees G, Dawe M, et al. The influence of
dentofacial appearances on the social attractiveness
of young adults. Am J Orthod 1985;87:21-26.
16.Shaw. The influence of children's dentofacial
appearance on their social attractiveness as judged
by peers and lay adults. Am.J Orthod 1981 ;77:399415.
17.O`Regan, E Dewey, J Lovius: Self Esteem and
Aesthetics, BJO 1991; 18:115- 120
18. William Proffit: Contemporary Orthodontics
3rd Edition, 2000 pg45-60

Thank you
For more details please visit


Psychosocial Factors of Malocclusion

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (19)

Similar to Psychosocial Factors of Malocclusion

Similar to Psychosocial Factors of Malocclusion (20)

More from Indian dental academy

More from Indian dental academy (20)

Psychosocial Factors of Malocclusion