Psychological aspects of orthodontic treatment

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

Psychological
aspects
of
orthodontic treatment

Contents
Introduction
Theories of psychological &behavioral development
a. Learning & development of behavior
b. Psychosocial theory
c. Emotional development theory
d. Cognition theory
Models of health behavior
Emotional Development And Orthodontic Treatment Need
Patient compliance
a. factors influencing adult cooperation in orthodontic treatment
b. predicting patient compliance
c. achieving patient compliance
Social inequality and discontinuation of orthodontic treatment

Use of educational & psychological principle in orthodontic practice
Psychologic factors influencing Orthognathic surgery
conclusion


INTRODUCTION
Definition:-Psychology is a branch of science
which deals with mind & mental processes in
relation to human & animal behavior.
Social psychology: the scientific study of the
way in which peoples thoughts, feelings and
behaviors are influenced by the real or imagined
presence of other people.


Diagnosis of orthodontic case now includes a greater
emphasis on the functional & the psychosocial ramifications
Of Dentofacial deformity.
At the same time, treatment planning has become a
More interactive process between the patient/ parents & the
Orthodontist.
The important issue is whether the doctor or parent makes the
Final decision regarding treatment.

This conflict is between paternalism and autonomy
Paternalism:- action taken by one person without the second
person’s consent.
Autonomy:- demands that an individual must consent to take any
action taken on his or her behalf and reflects a belief in the
merit of individual self-determination.

A series of 297 adolescent patients screened at the
university of north carolina listed reasons for taking
Orthodontic treatment
1. Appearance of teeth 84%
2. Advice of dentist 52%
3. Appearance of face 41%
Teasing about the malocclusion resulted in strong feeling of
Unease and harassment significantly more often than did
Other types of teasing.
Treated children had a greater increase in self-esteem than
Untreated controls, which suggests positive effect for
Children who are being harassed about their teeth.


Not just the way the teeth fit, Psychosocial and facial
considerations, play a role in defining orthodontic treatment
need.
The clinician must acquire knowledge to develop
appropriate behavioral skills with an improved quality of
communication and management of patients to treat patient’s
Psychological and esthetic needs.


Psychological Development
Linked to growth of the brain (cognitive areas)

Influenced by genetic factor which is modified by the
environment


Theories of Psychology & Behavioural
development.
Behavior is a result of interaction between innate
& instinctual behavior learned after birth.

Learning of Behavior.
Behavioral responses can be learned by
three mechanisms:Classical conditioning.
Observational
learning

Operant conditioning

Classical conditioning:• First described by Ivan Pavlov during his studies
on reflexes.
• “Learning by Association”.- association of one
stimulus with another


Reinforcement

Every time they occur, the association between a
conditioned and unconditioned stimulus is strengthened.
Extinction of conditioned behavior:- if the
stimulus is not reinforced
Discrimination:- the opposite of Extinction of
conditioned Stimulus- i.e generalization between all
offices

Operant conditioning:• According to B.F Skinner – Operant conditioning
is a significant extension of classical
conditioning.
• Consequence of behaviour is a stimulus for
future behaviour.
Stimulus

Response

Consequence


•

Four basic types of operant conditioning:-

•

Positive Reinforcement:- If a pleasant
consequence follows a response, the response
has been positively reinforced.
Negative Reinforcement:-Involves the
withdrawal of an unpleasant stimulus after a
response.
Omission :- Involves removal of a pleasant
stimulus after a particular response.

•
•
•

Punishment:-occurs when an unpleasant
stimulus is presented after a response.


Observational Learning
(Modeling).
• This is acquired through imitation of behaviour.
• Two distinct stages :-Acquisition
-Performance.
• Children are capable of acquiring any behaviour
they observe.
• Performing of an acquired behaviour depends on
the role model.

•A child acquires a behaviour by first observing it &
then actually performing it.
•Important tool in the management of dental treatment.

Theories of Emotional Development
 Stanley Hall{1846-1924} is recognized as the founder of
Emotional development and Psychology.
 He States that "Theories are nothing but more than a set of
Concepts and Propositions that allow the Theorist to describe
and explain some aspects of experience". It helps to explain
various pattern of behavior and emotions.
 During 17th and 18th century philosophers states that children
are inherited as bad or good or as neither good or nor bad. But
in 19th century , theorist noted that positive or negative
activity of character depends on child experiences


1) Nature VS Nurture – Biological process VS Environmental process

Theorist advice is think less about nature vs nurture and more
about how these two combine or interact to produce
developmental changes.
2) Continuous and Discontinuous Development
Continuous theorist hold development changes are Gradual
and quantitative. It is an additive process that occurs
continuously and it is not at all Stage like process.
E.g. Erickson Theory
Discontinuous theorist proposes that it progress
through developmental stages and each of which is a distinct
phase of life characterized by particular set of emotions,
abilities, motives and behavior that forms a coherent pattern.
E.g. Social learning Theory

Psychoanalytic Theory: (Sigmund Freud)
Freud hypothesized three structures in the theory of the understanding
of the intra psychic process and personality Development.

1) ID

2) EGO

3) SUPEREGO

ID:
Freud believed that the ID represented unregulated
instinctual drives and energies striving to meet bodily needs and
desires. They are governed by pleasure principle. The drives are
necessary for the survival of the species through procreation and
self-defense.
E.g. Ideal occlusion for his face.

EGO:
It describes as that part of the self-concerned with the overall
functioning and organization of the personality through the egos
capacity to test reality, the utilization of ego defense mechanisms and
of other ego functions such as memory, language, integellence, and
creativity.
Thus ego is concerned with maintaining a stage in which an adequate
expression of ID drives and satisfaction can occur within the
constrains of reality and the demands and restrictions of the super ego.
E.g. Accepting Camouflage

Gabriel AJO1993 Showed low ego strength to be predictive of
high compliance in prepubertal children, but predictive of low
compliance in adolescents.

SUPER EGO:
The super ego is derived from familial and cultural
restrictions placed upon the growing child. Freud hypothesized
that superego functions were derived from the struggle over
the strong feeling of the child. The super ego stems from the
internalization of feeling of good and bad, love and hate, praising
and forbidding, reward and punishment.
E.g. Peer acceptance of wearing braces, elastics,
complications of surgery
Thus super ego holds the ID in check

Emotional development
From infant to adult
The Infant :(First year of life) oral phase
 Unlike other mammals human infants are totally depend

upon another person for survival during a significant period of
early childhood. This dependency not only includes physical
care but also emotional needs. An infant deprived of
Emotional nurturing beyond a critical time period can develop
an ANACLITIC (PHYSIOLOGIC) DEPRESSION,
MARASMUS, AND MAY EVEN DIE.



This phase of development is called as SYMBIOTIC PHASE. It
will last until 10 months of age, then the separation and
individuation will began.

 Stranger anxiety is seen a 9-month old child

The Toddler (second year of life) Anal phase
 During 2nd year of life, child will come in to contact with the
REALITY PRINCIPLE. This principle is defined as the regulatory
process of the environment over behavior. The reality principle
demands that the child delay immediate gratification for a
greater gain at a later time

Third year of life
 By 3 years of age the child has attained a degree of intelligence, which
consist of acquired patterns of cognition, perception and awareness of
emotional associations to her or his experiences.
 the most important emotional experience the child will cope with is
separation anxiety. This is a very awful fear. This is also the period
when a sense of AMBIVALENCE, that is love and hate for important
people in ones life, is felt.


Ability or inability to separate from the primary caretaker and to
relate well with other people will be forever important stage of the
adequacy of completion of this early phase of personality development

Second Third Year: (4-6 years) (phallic phase)
(Preschool child)
 In this period child has to distinguish between reality and fantasy.
Children are aware of the sexual parts of their bodies and curious
about the meaning of the differences between boys and girls. This
curiosity becomes satisfied with the resolution of Oedipal conflict.
 The conflict was named by Sigmund Freud after the story of Oedipus
rex by Sophocles in the 5th centaury B.C and early childhood of his
patients. In this story Oedipus, the king unknowingly kills his father,
and marries his mother, the widow.
 In girls of this age Electra conflict is seen

 The factor, which inhibits use of their ability to initiate
activity is GUILTY. GUILTY is a feeling of fear that ones
activities might not be acceptable to oneself as a leftover sense
of bad. These feeling often create conflicts manifested by
sleep disturbance, nightmares.
 Resolution of this struggle usually results when the child
accepts the position as a son or a daughter and not a rival to
their parents. Thus the child identifies with the parent of the
same sex.

Grade school years:(7-12 years)(latency)
 This period is also called as latency period.
 The child has sufficient self- esteem and initiative to make
friends.
 They are capable of learning to read and compute numbers.
 They have a secure sense of ability to participate in-group
games.
 They are able to tolerate frustration and anxiety.
 They are able to allow themselves to be ruled and guided by
standards set by adults if these are not too oppressive.

The most effective of these are
1] Reaction formation

2] Sublimation

1. Reaction formation:
Reaction formation is doing the opposite of the desired
activity. E.g. Cleanliness and Kindness are representation of
reaction formation against the drive to be sloppy or cruel.
2. Sublimation:
Sublimation is converting an unacceptable impulse to socially
acceptable activity .e.g. Friendship, artistic interests, and
competitive sports are example of sublimation of unacceptable
aggressive and sexual drives.

Adolescence (12-18years)
Adolescence is a psychological state of maturation while puberty
is a physical state of maturation. During this period there is a
wide difference of level of psychological maturation will
develops..

 EARLY ADOLESCENCE: 12-14 YEARS OF AGE
During this period the child will re-experience the Oedipal
conflict and separation conflict in order to resolve the residue
of the earlier period. They strive for autonomy and rebel against
rules and standards that were previously acceptable.

 MIDDLE ADOLESCENCE: 14-16 YEARS OF AGE
This is associated with TURMOIL OF ADOLESCENCE. There is
STRUGGLE between dependence and independence, which is greater
and adolescent want the best of the both sides. to proceed to the
last stage of adolescence, the teenager must free himself of the
dependent tie to his parents.


LATE ADOLESCENCE:16-18 YEARS OF AGE
During this period the STRUGGLE is more with the self than with
the external environment. A Self-sufficient individual independent
of his family and capable of filling his own role as a person in society.
Thus by the end of adolescence the child develop a sense of
identity and true resolution.


Erikson’s theory


Erickson Theory
Development of Basic Trust: Birth to 18 months::
Development of the basic Trust depends on caring and
consistent mother or mother substitute, who meets both the
physiologic and emotional needs for the infants. The strong bond
between mother and child is necessary for the child to develop a
Basic trust in the world.

Maternal Deprivation Syndrome:
When the child receives inadequate maternal support, it will
fail to gain weight and are retarded in both physical and
emotional growth. This is seen in children of broken families or
who lived in a series of foster homes.


Basic mistrust:
A child who never developed a sense of basic trust will
have difficulty in entering into situations that requires trust
and confidence in another person. These individuals are
extremely frightened and uncooperative.

Development of Autonomy: 18 months to3 years
( autonomy vs shame or doubt)

Children around the age of 2 years are said to be undergoing
TERRIBLE TWOS because of their uncooperative nature. The child
is moving away from mother and developing a sense of AUTONOMY
OR IDENTITY. He varies between a being a little Devil to Angel

Shame and Doubt


Failure to develop a proper sense of autonomy results in the
development of Doubts in the child mind about his ability to
stand alone, and this in turn produce doubts about others.
Erickson defines the resulting state as one of shame, a feeling
of having all ones shortcoming exposed. e.g Bowel control

 This stage is considered decisive in producing the personality
characteristic of love as opposed to hate, cooperation as
opposed to selfishness and freedom of expression as opposed to
selfconsciousness.

Thus Erickson Quotes "From a sense of self control without a
loss of self esteem comes a losing sense of goodwill and pride;
From a sense loss of self control and foreign over control come a
lasting propensity for shame and doubt".
 A key towards obtaining cooperation with treatment from a
child at this stage is to have the child think that whatever the
dentist wants was his own choice, not something advised by
others.
 A child who find situation is threatening is likely to retreat to
mother and be unwilling to separate from her. It is preferable
to do dental treatment when one of the parent present.


Development of initiative(3-6 years)
( initiative vs guilt)
During this stage the child continues to develop greater autonomy, but
now adds to it planning and vigorous pursuit of various activities.
e.g. Extreme curiosity and questioning, aggressive talking, physical
activity.
A major task for parents and teacher at this stage is to channel
the activity into manageable tasks, arranging things so that child is able
to succeed, and preventing him or her from undertaking tasks where
success is not possible.

Guilty:
The opposite of initiative is guilt resulting from goals that are
contemplated but not attained, from acts initiated but not completed,
or from faults or acts rebuked by persons the child respects.

Thus Erickson quotes "The child ultimate ability to initiate new
ideas or activities depends on how well he or she thinks without
being made to feel guilty about expressing a bad ideas or failing
to achieve what was expected".
For most children, the first visit to the dentist comes
during the stage of initiative. A child at this stage will be
intensely curious about the dentist office and eager to learn
about the things found there. So going to the dentist can be
constructed as a new and challenging adventure in which child
can experience success. Success in coping with the anxiety of
visiting the dentist can help develop greater independence and
produces a sense of accomplishment.


Mastery of skills (7-11years)
(industry vs inferiority)


During this period child is learning about the rules by which the world
is organized and also he is working to acquire the academic and social
skills that will allow him to compete in the environment. The influence
of parents as a role model decreases and the influence of the peer
group increases.

 Thus Erickson quotes "The child acquires industriousness and begins
the preparation for entrance into the competitive world. “ But
competition with others within a reward system become a reality and
also clears that some tasks can be accomplished only by cooperating
with the others
Inferiority:


The negative side of emotional development can be acquisition of a
sense of inferiority.



Children are usually experienced their first visit to the dentist but some
may not. But children at this age are trying to learn the skills and rules that
define success in any situation, that include the dental office. A key to
guidance is setting attainable intermediate goals, clearly outlining the child
how to achieve this goals and positively reinforcing success in achieving
these goals. Because the child drives for a sense of industry and
accomplishment, cooperation with the treatment can be obtained.

 Children at this stage are not motivable by abstract concepts. This means
Emphasizing how the tooth will look better as the child cooperates is more
likely to be a motivating factor than Emphasizing if you wear the appliance
your bite will be better.


Development of personal identity (12-17 years)
(identity vs role confusion)
Adolescence, a period of intense physical development, and is
also the stage in psychosocial development in which a unique
personality identity is acquired. Adolescence is an extremely
complex stage because of the many new opportunities and
challenges thrust upon the teenagers. e.g Emerging sexuality,
academic pressures, earning money, esthetic desires, increased
mobility, career aspirations and recreational interests combines
to produce stress and rewards.

Confusion


During adolescence separation from the peer group is necessary to
establish ones own uniqueness and values .As adolescence progress,
inability to separate from the group indicates some failure in identity
development. This in turn can lead to a poor sense of direction for the
future, confusion regarding ones place in society, and low Self esteem.

 Most orthodontic treatment is carried out during the adolescent years,
and emotional and behavioral management of adolescents is extremely
difficult. Since parental authority is being rejected, a poor psycho logic
situation is created by orthodontic treatment, if it is being carried out
primarily because of the parent needs and not the child. At this stage
orthodontic treatment should be instituted only if
not to just satisfy their parents.

the patients need,

Development of Intimacy (Young adult)
(intimacy vs isolation)
The adult stage of development begins with the attainment of
intimate relationships with other individuals. Successful
development of intimacy depends on a willingness to compromise
and even to sacrifice to maintain relationship. Other factor that
affects the development of an intimate relationship includes all
aspects of each person – appearance, personality, emotional
qualities, intellect, and others.


Most of the Young adults who seek orthodontic treatment to
correct their dental appearance because they perceived their
dental appearance as flawed. They may feel that a change in
their appearance will facilitate attainment of intimate
relationships. On other hand a NEWLOOK resulting from
orthodontic treatment may interfere with previously
established relationships. Because of these potential problems,
the potential psycho logic impact of orthodontic treatment must
be fully explained to and explore with the young adult patient
before beginning treatment.

Guidance of the next generation (Adults )
(generativity vs stagnation)
A major responsibility of a mature adult is the establishment
and guidance of the next generation. Becoming a successful
parent is not only a major part of this but also services to the
group, community and nation. Thus next generation is not only
nurturing and influencing ones own children but also supporting
the network of social services needed to ensure the next
generation success.

Attainment of integrity (Late Adult)
(integrity vs despair)
At this stage the individual has adapted to the combination of
gratification and disappointment that every adult experiences.
The feeling of integrity is the feeling that one has made the
best of their life.

Despair:
The opposite of attainment of integrity is Despair. This
feeling is often expressed as disguise and unhappiness,
frequently accomplished by a fear that death will occur before a
life change that might leads to integrity can be accomplished.


Cognition Theory
 Cognition refers to the higher mental process involved in
understanding and dealing with the world around us.
 Cognition includes process like perception, Thinking, Concept
formation, Abstraction, and problem solving. Basic to all these
processes is intelligence. Intelligence is a score derived from an
intelligence test indicating how the individual’s mental ability
compares with that of others of the same development age.
 Cognition Theory was put forward by Jean Piaget. According to
his concept childhood development proceeds from an egocentric
position through a predictable, step like fashion. “The child is an
active participant with the environment in the constant
incorporation and reorganization of Data.”



The process of adaptation by a child is through Assimilation and
Accommodation

Assimilation:
It describes the ability of the child to deal with new
situation and problems within his age specific skills.

Accommodation:
It describes the ability of the child to adapt and change
his way of dealing with the world to handle a problem, which at
first may be too difficult at his particular age and skill.
Through this continuous dual process the child is
constantly building various hierarchies of related behavior,
which Piaget called Schemata.

Schemata represent a dynamic process of differentiation and
reorganization of knowledge, with the resultant evolution of
behavior and cognitive functioning appropriate for the age of
the child.
Piaget delineated four periods of Cognition growth, each
characterized by distinct type of thinking and in which the child
successfully relies more upon internal stimuli and symbolic
thought and less upon external stimulation.


Sensorimotor Period: (0-2 year)
During the first 2 year of life, a child develops from newborn
infants who are almost totally dependent on reflex activities to
an individual who can develop new behavior to cope with new
situation.
During this stage child will develop a rudimentary concepts of
objects, including the idea that object in the environment are
permanent; they do not disappear when the child is not looking
them.
The child has little ability to interpret sensory data and a
limited ability to project forward or backward in time.

Preoperational period: (2-7year)
During the preoperational period, the capacity develops to
form mental symbols representing things and event not present,
and children learn to use words to symbolize these absent
objects.
During this period child can understand the world in the way
of 5 primary senses.
1) Feel

2) Smell

3) Hear

4)Taste

5) Concepts that cannot be seen
They feel difficult to interpret Time and health.
Thus child can understand language in a literal sense i.e.
words only they have learned.

Features of Thought process
1) Egocentrism

2) Animism

Egocentrism:
It is defined as the inability of the child to assume
another persons point of view. Because of this the child can only
manage his own perspective and assumes another’s view is simply
beyond his mental capabilities.

Animism:
It is defined as projection of inanimate object with life
i.e. everything seen as being alive by a young child, and stories
that invest with life are quite acceptable to children of this age.

Most of the thumb sucking patients fall in to this
category of age.
Since the child’s view of time is centered around the
present, and he is dominated by how things look, feel, taste, and
sound now, there is also no point in talking to a 4 year old about
how much better his tooth will look in the future if he stops
thumb sucking. At the same time it would not be useful to point
out to the child how proud his father would be if he stopped
thumb sucking, since the child would think his fathers attitude
was same as the child (Egocentrism). Telling him that the teeth
will feel better now or talking about how bad his thumb tastes .

Period of concrete operations: ( 7 – 11year)
 During this stage, the ability to see another point view develops,
while animism declines. The child’s thinking is still strongly tied
to concrete situations and the ability to reason on an abstract
level is limited. Presenting ideas as abstract concepts is difficult
to understand than illustrating them with concrete objects.
 E.g. It will be too abstract "Now wear your Functional appliance
or retainer every night and be sure to keep it clean.” More
concrete direction would be " this is your retainer.” Put it in
your mouth like this and take it out like that. Put in every
evening right after dinner before you go to bed, and take it out
before breakfast every morning. Brush it like this with an old
toothbrush to keep it clean.

Period of Formal operations: (11 years – adult)
 The ability to deal with abstract concepts develops by the age
of 11 years. They can understand the concepts like health,
disease and preventive treatment.
 In addition to the ability to deal with abstractions, teenagers
have developed cognitively to the point where they can think
about thinking.
 When an adolescent consider what others are thinking about, he
assumes that others are thinking about the same thing he is
thinking about, namely himself. They feel they are constantly
onstage being observed and criticized by those around them.
Elkind has called this phenomenon the IMAGINARY AUDIENCE.

 The imaginary audience is a powerful influence on young
adolescents, making them quite self-conscious and susceptible to
peer influence. They are very worried about what peer will think
about their appearance and actions, not realizing that others are
too busy with themselves.
 The reaction of the imaginary audience to braces on his teeth is
an important consideration to a teenage patient. They are very
susceptible to suggestions from their peer group. In some
setting they tend to please for tooth colored plastic or ceramic
brackets at other times bright colored Ligatures and elastics
have been their tempt.

Behavior is an observable act. It is defined as any
change observed in the functioning of an organism.
Learning as related to behavior is a process in
which past experience or practice results in relatively
permanent changes in an individual’s behavior.
Behavioral dentistry is an interdisciplinary
science, which needs to be learned, practiced and
reinforced in the context of clinical care and within
community oral health care system.
The objective of this science is to develop in a
dental practitioner an understanding of the
interpersonal, intrapersonal, social forces that
influence the patients’ behavior

Models of health behavior (sem in ortho 2000)

Models of health behavior and Their implication
for orthodontic treatment
Health belief model

Theory of
planned behavior

Self-regulation theory

Stages of change model

1. HEALTH BELIEF MODEL

This model proposes that an individual’s beliefs are important
determinants of his/her health-related behavior.
Four sets of beliefs are thought to predict health-related behavior
1. Perceived susceptibility to disease or problem
2. Perceived severity of the problem
3. Perceived benefits of health behaviors, and
4. Perceived barriers to health-enhancing behaviors.


2. THEORY OF PLANNED BEHAVIOR

This theory proposes that people are reasonable and make
decisions about health-related behavior by using available
information to achieve a desired goal. .
Patient Intention is influenced by 3 factors
 The person’s attitude toward the behavior (e.g.,
“I don’t like wearing the cumbersome device that
make me look different”),
 Social influences on the behavior (“People will
make fun of me”)
 The person’s perceived behavioral control, which
reflects a person’s perceived ability to overcome
obstacles and is influenced by their past
behavior.

As in the health belief model, both internal events such as attitudes
and environmental factors including social pressure and perceived
obstacles influence the behavior, but in Planned behavior they do
so by determining whether the person intends to perform the
behavior.

Clear implication of this model is that assessing a patient’s
intentions to adhere to the treatment regimen can be an important
first step in identifying potential noncompliance. If intentions to
change behavior are low, and then interventions to alter attitudes or
increase behavioral control may be indicated.


3. SELF-REGULATION THEORY

This theory suggests that individuals regulate their own behavior
using the following 3 processes:

First, individual monitor both the determinants and outcomes of
First
their behavior. For example, a patient evaluates why he or she is
wearing appliance (“Because the doctor told me to.”), and
monitors the outcome of that behavior (“I feel like I’m taking
good care of my teeth.”).

Second, patients evaluate their behavior based on personal
Second
standards (“I’m doing pretty well for me.”) and environmental
conditions (“Understands the circumstances, I can’t be expected
to do much better.”)


Third, patients adjust their behavior depending on how it
Third
compares with these personal standards (“I am really not doing
as well as I can”).

Thus, this theory proposed reciprocal interactions among
behavior, the environment and personal factors, such as internal
standards and cognitive process. One central concept in selfregulation theory is self-efficacy, which refers to the belief that
one can produce a desired outcome through one’s own efforts.


4. STAGES OF CHANGE MODEL

This model proposes that people progress through 5 stages when
making a behavior change, Broder and Phillips et al apply this
al
model to understanding decisions regarding treatment
First stage is pre-contemplation, which people typically fails to
stage
acknowledge the need for behavior change and have no intention
of changing their behavior.

Second stage, contemplation, individuals recognize a need for
stage
change and are considering a change in behavior, but have not yet
taken any steps in that direction


Third stage is preparation, and this stage involves making specific
stage
plans for behavior change.

Fourth stage, action, involves implementing those plans, and this is
stage
the first stage in which overt behavior change occurs.

The final stage is maintenance, in which people are attempting to
stage
sustain the behavior changes that they have made.
An important implication of this model is that patients at different
stages will require different interventions assist them with
behavior change.

An important implication of each of these models is that patients’
attitude, thoughts, feelings, and perceptions are important
determinants of their behavior.

Based on these theoretical models, the following
recommendations for clinical practice are suggested.

1. Assess patients’ intentions to adhere to treatment regimens
(e.g. “How often do you plan to brush and floss?”). One can
be relatively sure that if intentions to change behavior are
low, then the likelihood of behavior change is also very low.
In these instances, educational or behavioral interventions to
increase intentions and promoter adhere will be needed.
2. Assess patients’ self-efficacy for successfully completing
the prescribed treatment (e.g. “How capable do you feel you
are of using this appliance as prescribed?”). If patients doubt
their ability, then additional instruction and in office practice
in the required behavior are indicated.

3. Be aware that the patient seek treatment at very different points
along the stage 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 and make
the behavioral commitment required to successfully complete
treatment.
4. Try to identify barriers to compliance with treatment
recommendations. These may include personal characteristic of the
patients (e.g. age, education level, socioeconomic status) or
environmental factors, such as high levels of psychosocial stress or a
lack of understanding the importance of treatment.


When these barriers are identified, steps should be taken to
reduce the barriers or to tailor treatment around the barriers.
5. Treatment plans should incorporate the priorities and
capabilities of the patient. This approach allows patients to
participate in the decision making process and further the
patient’s commitment. In cases in which patient decision
conflicts with professional standards, limitations of the
selected treatment plan should be presented. Options
including non-treatment should be presented to the patient
and parent.


Psycho-orthodontic theory
(A.j.o –Do 1981 dec 604-622)
This theory was put forwarded by El-Mangoury. Motivation is
a very broad psychological term which describes a hypothetical
construct which aims to explain the reason for the stream of a
goal-directed behavior driven by specific or nonspecific forces.
A) Achievement motivation can be defined as the motivation
characterized by striving for success in any situation in which
standards of excellence apply.


B) Affiliation motivation of orthodontic patients was defined as
a hypothetical construct of seeking orthodontic care for the
purpose of improving the dento facial esthetics in order to
facilitate the connection or association of oneself with other
people for obtaining, maintaining, and/or restoring close
interpersonal relationships.
C) Attribution motivation can be defined as the motivation
for perceiving the causes of success and failure, either
internally (that is, to the self) or externally (that is, outside the
self).


1. Orthodontic cooperation is predictable through psychological
testing.
2. High-need achievers cooperate better orthodontically than lowneed achievers.
3.A patient who is a good brusher does not have to be a good
headgear wearer, and vice versa
4. Affiliation motivation seems to contribute the most in prediction
of headgear wear, elastic wear, appliance maintenance, nonbroken
appointments, and punctuality in appointments.
5. Achievement motivation appears to contribute the most for
predicting oral hygiene.
6. Attribution motivation was not effective in predicting variables

Emotional Development And Orthodontic Treatment
Need
Body Image

Self Concepts

Body Image:
Body image of the patient is classified in to "body sense"
and "body concept.''
Body sense refers to the actual appearance the person
sees when viewing him in a mirror or photograph.
Body concept is the internal process of how the patient
feels about his appearance.


Parents

Culture

Peers
Body Image

Ethnicity

Teachers


Parents, Teachers and peers
The earliest influences on a child’s body awareness are a parent
or other caregiver’s physical and emotional interaction with the
child. As the child’s world expands teachers and peers respond
to his or her physical appearance. These messages may reinforce
each other and the child’s subjective assessment or may conflict
the child’s own perceptions. By integrating these appraisals (and
in some cases by ignoring objective judgments) the child
develops a cognitive representation of the self, a body image.


Culture and Ethnics
A person's response to dental-facial attractiveness can be
viewed as a type of psychosocial response to occlusal status. As
such, psychosocial responses to dental-facial esthetics have a
cultural emphasis. It is important to assess objectively the
degree to which a person's dental-facial appearance deviates
from the cultural norm. Thus, there is a rational and empirical
basis for including an assessment of dental-facial appearance
when evaluating the need for orthodontic treatment. Thus
Ethnic and cross culture factors play a role in the development
of a body image

Self concept
Body Image

Accomplishment
•Academic
•Athletic

Social Competence

Self Concepts
Self Esteem

Self Concepts
Self Esteem

Desire to Change
•Appearance
•Accomplishment
•Social Skills

SELF ACCEPTANCE


 To the extent that the child holds himself or herself in high
regard, there is greater self- acceptance and the desire to
maintain the status ego. For such children, an orthodontist’s
recommendations or a parents encouragement to obtain
orthodontic treatment may be futile because the child is
satisfied with his or her appearance, no matter how far outside
the range of “ideal” or even normal his dentofacial features may
lie. In such cases, if the child is forced by the parents to
receive treatment, cooperation during active treatment and
adherence to long term treatment recommendations may suffer.

 In contrast, for many children whose self-acceptance is not very
high, the desire to chance one or more components of selfconcept may be great. Those who can identify the malocclusion
or poor dentofacial disharmony as the source of their
dissatisfaction are more highly motivated to obtain orthodontic
treatment and are better risks for long-term cooperation and
adherence to treatment protocol.


 It behooves the orthodontist to recognize these differences, to
identify children who attend the initial orthodontic consult
willingly versus those who are coerced by parents or other
concerned adults, as well as those whose own & whose parents
motives are unrealistic and inconsistent with the type of
malocclusion presented. This requires an honest discussion with
the child, perhaps with the parent listening but not participating
in the session .

 Questioning the child about his or her areas of satisfaction with
the face and other aspects of the self , motives for and
concerns about treatment , and whether or not the child
understands his or her responsibilities during each phase of
treatment can prevent failure in the case of children who are
unprepared or , more importantly , those who have few intrinsic
motives for seeking orthodontic intervention .


COMPLIANCE (sem in ortho 2000)

As suggested by Haynes: Compliance is "the extent to which
Haynes
a person's behavior (in terms of taking medications, following diets,
or executing lifestyle changes) coincides with medical or health
advice.

Orthodontists ask patients to behave in ways that will
maximize the likelihood of achieving the orthodontic treatment
objectives.
For example, patients are asked to keep their appointments,
adhere to dietary restrictions, modify their oral hygiene practices,
and follow complicated treatment regimens that include the use of
elastics, headgears, and other removable appliances.


When a patient deviates from these therapeutic
recommendations, the presumption is that the likelihood of
achieving the desired goals is reduced.
There are a myriad of strategies for dealing with patient
noncompliance. The strategy a clinician chooses is often influenced
by how he or she conceptualizes the cause(s) of poor compliance.
An example of this comes from an early view of
noncompliance that suggested it resulted from a character "flaw"
that allowed an individual to deviate from a therapeutic regimen that
was intended for his or her own benefit.


Self-Regulation Approach to Orthodontic Patient Compliance
Self-regulation principles are being applied in diverse areas of
clinical psychology and have been particularly useful in guiding
work on compliance problems in orthodontics.
The component parts of a simple self-regulation model for patient
compliance are:

Negative
Feed back
loop


A regulatory model of patient compliance suggests that poor
compliance can result from a variety of factors
1. PATIENT DOES NOT KNOW THE THERAPEUTIC REGIMEN
2. PATIENT UNAWARE OF THE RECOMMENDED REGIMEN
3. POOR MOTIVATION OF PATIENT


Current orthodontic research focuses on a critical aspect of the
feedback; specifically, the input received by the comparator that
quantifies the actual amount of adherent behavior. This aspect of the
feedback loop is particularly problematic because when asked how
many hours a headgear has been worn, patients do not know how to
estimate the total.
Likewise, orthodontists cannot reliably estimate the amount of wear
and parents are not sure of their child's degree of appliance use.
Patients, parents, and clinicians need a way to ascertain this
information.
Technology may provide the solution to this problem as it has in
Technology
other areas of patient compliance. Research suggests that patients
receiving feedback about their degree of compliance are better able
to follow a recommended regimen.

Measuring Headgear Use
Orthodontists are understandably interested in the amount of time a
headgear is worn.
Typical clinical methods for estimating the amount of headgear
wear include:
  evaluations of proxy measures of compliance (e.g., oral
     hygiene)
  condition of the appliance (e.g., a worn-looking neck     strap), mobility of the molar
  ease of patient use, and
  direct patient inquiry either verbally or by questionnaire.


Unfortunately, such methods are poor and commonly provide an
overestimate of compliance. There is a clear need for a reliable
method of measuring the time a headgear has been worn and there
have been numerous attempts to pro-duce such a device.
Northcutt introduced the first timing headgear in 1974. The timer
Northcutt
consisted of 2 switches that were activated when the appliance was
worn and accumulated wear time until the appliance was removed.

A study by Banks and Read, found that only 4 of 13 head-gear
Read
timers were accurate more than 90% of the time.


A conceptual model of factors influencing orthodontic treatment decisions

Patient’s
Perceptions of
Dental-facial
attractiveness

Patient’s
Perceived
Need for
treatment

Develop over
Time as a
Function of
a. parent’s dental
Facial appearance
b. Social norms
c. Social feedback

Develops as a result
Of
a. Perceptions of
Appearance
b. parents’
Perceptions of
Treatment need
c. Professional
Evaluations of occlusion

Parent’s
-Percieved need for treatment
-Positive perceptions of
treatment efficacy
-relative value of treatment

Decision to obtain
treatment

Orthodontists:-Professional evaluation
of treatment
-Understanding of
Patient’s desire for treatment

CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT
PRE-TREATMENT

EARLY IN
TREATMENT

THROUGH
TREATMENT

CHILD

Perceives functional/
   esthetic impairment
Perceives need for
   treatment/desires
   treatment

Develops realistic
    expectations
Learning
   coping/control
   strategies

Assumes control of
   behavior related to effect
   outcomes of treatment
Shares responsibility for
    treatment outcomes

PARENTS

Perceives need for
   treatment
Believes in efficacy of
    treatment
Places high value on
   occlusion/treatment

Enables treatment
Takes interest in
   treatment
Encourages homecare


Supports and approves
   child’s active
   participations and
   responsibility in
   treatment

ORTHODONTIST

Professionally evaluates
   treatment needs
Seeks to understand
   patient and parent
   perceptions
Communicates  goals,
   expectations, potential
   problems in treatment

Engages parent and
   patient in goals,
   expectations
Acknowledges patient
   and parent perceptions

Develops partnership
   with patient
Shares responsibility
   with patient for progress,
   setbacks, outcomes of
   treatment


PREDICTING PATIENT COMPLIANCE IN
ORTHODONTIC TREATMENT
To ensure efficient clinical management of orthodontic patients, it
is desirable to identify factors, which would enable the orthodontist
at the early stages of treatment to predict the patient's subsequent
behavior and compliance.
Predicting patient compliance
Demographic aspect

Psychosocial aspect

Age
1. Education
Gender
2. Parent’s attitude
Socioeconomic status
3. Patient’s personality

1. DEMOGRAPHIC ASPECT
In the search for potential predictors of treatment compliance,
considerable attention has been directed toward evaluation of
patients' demographic characteristics.

Patient Age:
Allan et al (AJO 1968) studied that patient's age was found to be
1968)
the best predictor of cooperation.
In contrast, studies by Albine and Sergl et al (EJO 1992) have
1992)
revealed no correlation between patients' age and the level of
compliance


Gender:
Kreit and Starnbach et al have emphasized that the patient's
al
gender might help predict treatment compliance demonstrating
that female patients tend to show better cooperation compared
with males.
Studies by klima et al (AJO 1979) suggest that in contrast to
1979)
boys, girls tend to express lower body image satisfaction and are
more likely to be displeased, with their dental appearance


Socioeconomic status:
Several investigations have addressed the issue of potential
influence of patients' socioeconomic status on their
compliance with orthodontic treatment.
Cucalon and Smith et al (ANGLE 1989) reported that
1989)
female patients from higher socioeconomic groups show the
highest compliance levels.
Dorsey and Korabik et al (AJO1977) have indicated
(AJO1977)
superior compliance shown either by children of civil servants
compared with those of working class and self-employed
parents, or by children of factory workers in contrast to
offspring's of intellectuals.
In contrast Sergl et al (EJO 1992) reported, no evidence of
1992)
potential effects of parental occupational status on children's
compliance.

2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS
Considerable attention has been devoted to evaluation of the
effects of patients' psychologic traits and psychosocial background
on compliance during orthodontic treatment. It is generally
believed that patient's personality characteristics, his or her
relationships with the family, peers and orthodontist, as well as
performance at school are closely linked with compliance, and
might serve as valuable sources of information regarding both
prediction and management of compliance


EDUCATION LEVEL:
Richter, Nanda and Sinha et al (ANGLE 1996) reported that
1996)
cooperative orthodontic patients tend to have better grades and
show less deviant behavior at school, they are less frequently truant
from school, are considered academically brighter and more
sociable by their teachers, and reveal higher levels of self-perceived
cognitive competence. On these grounds, patients' scholastic
performance might serve as a useful predictor of treatment
compliance.

Dausch and Neumann et al observations indicate that children of
al
above-average intelligence are more cooperative during treatment,
which, however, does not necessarily imply that children of belowaverage intelligence show poor compliance, because both variables
appear to depend strongly on a number of other psychosocial
factors.

PARENTS ATTITUDE:
Mehra et al (ANGLE 1996) suggested that parental beliefs are
1996)
important for a child's compliance, and that assessment of the
child-parent relationship may help predict the level of
cooperation. How-ever, it appears from other studies that a
child's personal psychologic characteristics may be a more
decisive factor determining the level of treatment compliance.

Nevertheless, parents seem to play a prominent role in
influencing a child's decision to seek orthodontic treatment, and
parental attitudes influence the child's compliance in the earlier
stages of treatment.


Study by Nanda and Kierl et al (AJO 1992) evaluated several
1992)
factors of potential relevance to compliance prediction.
Treatment-related psychosocial factors such as patient's and parents'
treatment attitudes and expectations, or relationships between the
child, parents and orthodontic practitioner, were investigated.
These observations imply that development of an effective
relationship between the orthodontist and the patient at the earliest
stages of treatment is beneficial for future compliance, and that the
orthodontist's perception of his or her interpersonal relationship with
the patient may be useful in predicting compliance.


PATIENTS PERSONALITY
Substantial evidence has accumulated suggesting that patients'
personality characteristics are important for the individually
attainable level of treatment compliance.
Studies dealing with the psychologic assessment of patients
undergoing orthodontic treatment have out-lined psychologic
profiles of uncooperative and cooperative patients.

Sergl et al compared extraordinarily cooperative orthodontic
al
patients with patients rated by their clinicians as highly
uncooperative.


Specific psychologic diagnostic tests were used for evaluation of
patients' cooperation, responsibility, reliability, and endurance
during treatment. The results indicated that irrespective of
gender, the patients who tend to be uncooperative are inclined to
attitudinal preferences conventionally regarded as masculine,
which are expressed as active, aggressive, and realistic
behavioral patterns and self-images, rather than sensitive,
esthetic and idealistic ones.
Allan and Hodgson (AJO 1968) reported that patients more
1968)
likely to show higher levels of treatment compliance are
enthusiastic, outgoing, energetic, self-controlled, responsible,
trusting, diligent, and obliging persons.


PERSONALITY TEST
Personality tests have been used by a number of investigators,
generally with the goal of being able to predict patient cooperation
by identifying particular personality types.

Both Gabriel and McDonald used the California Test of
Personality. This test purports to measure a number of psychosocial
domains, such as self-reliance, sense of personal worth, or social
skills.
Gabriel (ANGLE 1965) found a low correlation between the
1965)
scores from items of the California Test of Personality and a post
treatment, subjective assessment of motivation. He believed this
correlation was too low to be predictive.


McDonald reported a significant correlation between scores
McDonald
on the California Test of Personality and patient cooperation.

Southard and Tolley (AJO 1991) examined the feasibility of
1991)
using a commercially available adolescent personality test to
predict the behavior of adolescent patients in an orthodontic
practice. Specifically, this study tested
1. the use of the Million Adolescent Personality Inventory
(MAPI) as an appropriate instrument for an adolescent
orthodontic population and
2. the correlation between MAPI test results and orthodontic
compliance.
Authors concluded that the MAPI has potential as a useful
instrument in assisting the management of adolescent patient
behavior in an orthodontic practice.

Initial Experience With Orthodontics and Acceptance of
Treatment
As patients may experience a considerable amount of discomfort
from orthodontic treatment it is reasonable to expect that
patients' initial experience with orthodontic treatment, adaptation
to it and its acceptance at an early stage might strongly influence
the degree of compliance at the subsequent stages.
It is recognized that insertion of a new orthodontic appliance
may diminish cooperation by causing considerable discomfort
such as unpleasant tactile sensations, feeling of constraint in the
oral cavity, stretching of the soft tissues, pressure on the oral
mucosa, displacement of the tongue, sore-ness of the teeth and
pain.

Pain, functional and esthetic impairment, and associated
complaints are the principal reasons for the patient's wish to
discontinue treatment.
The patient's self-confidence might be affected by speech
impairment and visibility of the appliance, especially during
social interactions when attention is focused on the face, eyes
and mouth.


Effects of appliance type on oral complaints, such as higher
degree of pain or speech impairment during wearing of the bionator
and the head-gear, increased incidence of perceived pain, tension,
sensitivity, and pressure under treatment with functional and fixed
appliances, or differences in initial acceptance of various designs of
functional appliances, have been described for non-compliance.
It seems likely that because of different experiences
encountered, the type of appliance may have a substantial effect on
initial adaptation and should also be considered in compliance
prediction.


General personality variables and specific attitudes to
orthodontics seem to play an important role.

Sergl et al (AJO 1980) indicated that patients' attitudes toward
1980)
orthodontics at the beginning of treatment may predict their
capability to accommodate to initial discomfort associated with an
orthodontic appliance, which in turn, may predict the patient's
acceptance of the appliance and the degree of subsequent
compliance. Appliance adaptation and treatment acceptance or
denials are short- term events occurring within a few days after
the initiation of treatment.

This evidence suggests that attention of the treating clinician to
patients' adaptation is necessary at the earliest treatment stages, to
ensure and enhance future compliance.

SOCIAL INEQUALITY & DISCONTINUATION
OF ORTHODONTIC TREATMENT
Social inequality influences general health, dental disease,
and dental health-related behavior. However, reports on
any links between orthodontics and social inequality are
more equivocal.

Registrar General’s social class groupings (by occupation of head* of
household)
Social class
Definition and examples
I
Professional e.g. medical, dental,

II
IIIN

Veterinary, and legal professions, chartered
Engineers and accountants
Intermediate and managerial e.g. school teachers
Nurses, police officers, secretaries, publicans
Skilled non-manual workers e.g. clerks,
Draughtsman, shop assistants, travel agents

IIIM

Skilled manual e.g. carpenters, electricians,
Welders, instrument artificers, police

constables,
IV
Semi-skilled e.g. lathe operators, process
workers,
Postmen/ women
V
Unskilled workers e.g. laborers, dustmen,
Domestics
Classification by occupation used by Rölling (1982)
A.
B.
C.
D.
E.

farmers

Low e.g. unemployed, unskilled manual
Lower middle—skilled manual
Middle e.g. shop assistants, clerks, small self-employed
Upper middle e.g. superior employees, shop owners,
Upper e.g. academics, managers

Results:The results showed that discontinued cases were:
1. Less likely to have been treated with fixed appliances
2. A little older at start, on average
3. More likely to have been asked to wear
EOT/EOA/‘headgear’
4. More often from lower social class backgrounds
5. Less likely to have been treated by an orthodontically
qualified practitioner
6. More likely to have attended practices in relatively
deprived areas.


Psychological
aspects
of
orthodontic treatment
Dr. I.
ROHINI


ACHIEVING PATIENTS COMPLIANCE
(sem in orthodontics 2000 dec)
Patient noncompliance is a limiting factor in the conversion
of accurate orthodontic treatment plans to excellent treatment
results. A variety of treatment techniques have been devised to
overcome this barrier in the attempt at obtaining good results.
Despite earlier claims made by the proponents of these
techniques, it is abundantly clear that none of these techniques are
completely successful without the patient's participation.


In addition, many of these "noncompliant" techniques have
now reverted back. E.g.,traditional methods of anchorage control by
headgear and elastics for a portion of the treatment period.
Factors Influencing Orthodontic Patient Compliance

During the initial treatment stages, the parent's positive
attitudes toward orthodontic treatment predict patient compliance.
In the later stages, the patient's own cognition regarding
treatment directly correlates with compliance levels.

Those patients who believe that their actions directly lead
to superior treatment results are better compliers compared with
those who believe that they do not have control over treatment
outcomes.
         Parent’s previous orthodontic experience
         Financial implications
         Doctor- patient relationship

Various prevention and improvement concepts that can
positively affect orthodontic patient compliance are:
A shift from a practitioner-centered model of patient care to a
patient-centered approach is emphasized. It include:
1.
2.
3.
4.
5.

Patient-centered care versus practitioner-centered care,
Patient’s causal attributions,
Patient support at home and at the orthodontic office,
Rewarding compliant behavior, and
Doctor-patient rapport and communication


1. Patient-Centered Care versus Practitioner Centered Care
Traditionally, orthodontic treatment prescribed by the practitioner
based on defined professional standards without considering the
priorities and capabilities of the patient.
Patients who fail to follow prescribed instruction are labeled as
"noncompliant."
This is often done without considering the fact that the treatment
prescribed may not have taken into account the capabilities,
motivations, and expectations of each individual patient.
Hence, patients have had to bear the burden and the outcome of
noncompliance rather than considering the inability of the
practitioner to understand individual patient needs and to make
appropriate treatment plans.

A patient-centered approach would place some of the responsibility
of successful patient compliance on the practitioner. In this model,
the practitioner would prescribe treatment plans based on
individual patient expectations, priorities, and capabilities
Repeated treatment progress re-evaluations and patient/parent
consultations are a key component of success in this proposed
model.
In the orthodontic treatment realm, key issues that relate to
this concept fall within the following:

(1) Patient education and
(2) Patient empowerment and contracting procedures.


Patient Education
Patient management may be greatly enhanced when patients
understand the nature of their condition and the proposed
treatment plan or procedure to be performed.
Educating the patient regarding his or her malocclusion and
the means to achieve an acceptable result is very important to
success in motivating the patient to succeed.
Often treatment is prescribed for patients who have limited or
no understanding of their orthodontic problem and why some
aspects of treatment mechanics are necessary for successful
outcomes.


At the same time, parents may not be clear about treatment
goals and mechanics. In addition, the parents' ability to explain
details of the condition and the necessity for different appliances to
their children may also be limited. The result is a patient who is less
likely to achieve a successful treatment outcome.
A strong effort to educate patients regarding their condition
will allow them to make informed choices regarding appliance
selection and the limitations of their selection.
As treatment progresses, the' education component needs to
be revisited to ensure their complete understanding. This will result
in individuals who take greater responsibility for their actions
during orthodontic treatment.


Various demonstration tools are available to aid in the education
process.
Good standard patient records such as study casts and photographs
can be used to describe the problem.
 A presentation customized for the patient by different commercially
available computer software programs is an excellent method for
explaining mechanics and appliances.
 The use of demonstration models and appliances are important for
the patient to completely understand different appliances.
In addition, the practitioner can prepare a database of examples that
can be digitally stored and used for these presentations.

USE OF EDUCATIONAL –PSYCHOLOGICAL
PRINCIPLES IN ORTHODONTIC PRACTICE ……..
(AJO 2001 JUNE, VOL.119 NO 6)

The principles that will be discussed are:
• Progressions
• Backward chaining
• Shaping (close approximation)
• Reframing (symptom prescription, reverse psychology)
• Reinforcement theory
• Hypnosis
• Kinesthesia
• Learning by doing

PROGRESSIONS:Progression learning involves segmenting the skill to be learned into
a number of simple and sequential component parts, or progressive
steps. Progressions are used when learning complex skills.
This includes both cognitive and psychomotor skills.
For example, teaching a patient to insert a cervical headgear for
the first time could be sequenced
BACKWARD CHAINING
Backward chaining is the educational principle that incorporates stages,
or progressions, into learning, only reverse sequence.
In backward chaining, the last steps in sequence, from beginning to end,
are taught first, working backwards toward the first step in the
progression. Backward chaining is particularly useful in learning
complicated psychomotor skills when the last step is easier to learn
than any of the beginning steps.. At times, it is only necessary to
teach the last step first, then go to the first and work forward.

SHAPING
Shaping, or close approximation, is an operant conditioning
principle that involves reinforcing behavior that approaches the desired
behavior.
This form of operant conditioning was popularized years ago by
B. F. Skinner.
EX:- tooth brushing technique
REFRAMING
Reframing (symptom prescription or reverse psychology) is
the psychological technique in which a behavior that is considered
undesirable but pleasurable is made to appear, or reframed, as a duty,
or vice versa.
Ex:- to lessen finger sucking habit


REINFORCEMENT THEORY
• Positive and negative reinforcement, and, to a limited degree,
punishment, can be used in orthodontics. The overriding principle
of reinforcement theory is to give more praise than criticism. It has
been suggested that at least 3 words of praise be used for every
word of criticism (punishment).
HYPNOSIS
• Hypnosis, and other techniques closely associated with hypnosis,
can be used for fearful and apprehensive patients
• Ex:- impression making, bonding, debonding, and extraction of
very loose deciduous teeth.

• KINESTHETIC LEARNING
• Obviously, individuals learn differently. Some are more visual,
others are more auditory, and some are both. Others learn
kinesthetically, particularly with psychomotor skills. Kinesthetic
learning, sometimes called “muscle memory,” can be a powerful
teaching aid for learning a physical skill
•
•
•
•
•
•

LEARNING BY DOING
There is a proverb that states:
I hear and I forget;
I see and I remember;
I do and I understand
The more we can get our patients and our staff to do, rather than
observe, when we teach them new tasks, the faster they will learn

Patient Empowerment and Contracting Procedures
Educating patients regarding their condition gives them the
tools to make informed decisions. The individual feels involved in
the process of selecting what is most suited for the necessary
change.
Sometimes the patient's decision conflicts with their best
interests and also goes against the wishes of the parents regarding
possible outcomes. In these situations, flexible treatment strategies
need to be devised in order to succeed.
A compromise treatment plan may offer the best solution in
some instances. In other situations, a suggestion to postpone
treatment or the decision to withdraw from seeking treatment may
solve the conflict.

Most often, alternatives are available and should be offered
following an understanding of the limitations of different
approaches.
Once a decision has been reached using this process, the
patient is empowered and selects a treatment option from
choices offered.
This process obligates the patients to comply with a
previously reached agreement.
A contract made with each individual patient has been shown
to be successful in improving compliance in different areas of
orthodontic care.

2. Patient's Causal Attributions
Patients attribute events in their lives to external and internal
causes. External causes are outside of their control (external locus
of control), versus internal, which are within their control (internal
locus of control).
ElMangoury et al (AJO1981) found that orthodontic patients
who attributed outcomes to internal causes were significantly more
cooperative.
Albino et al (J Behav Med1991) also found that those patients
who attributed responsibility for their orthodontic condition and
treatment externally to either chance or their orthodontists showed
lower levels of compliance scores compared with others.


Therefore, patients who attribute internally are better
compliers compared with those who attribute externally.
Those patients who make fewer external attributions
possess a sense of responsibility and consequences consequently
believe that their participation and cooperation facilitates
treatment progress.
These findings can be used clinically to improve patient
compliance by initially developing strong relationships and a high
level of communication with patients.
Good rapport along with patient education can empower
patients to make informed decisions regarding their role in
determining the success of treatment.

3. Patient Support at Home and at the Orthodontic Office
Family support for the patient to follow prescribed instructions is
necessary for successful implementation of this program.
Also, continuous encouragement and feedback from the
orthodontic office is significant in creating a supportive
environment, which is important for the patient.
Patients are often required to wear cumbersome appliances that are
difficult to use. If a difficult task is suddenly introduced requiring
substantial effort from the patient, a noncompliance problem is
created.

An example is of patients who have to use the reverse facemask
headgear used for Class III skeletal growth modification. The
headgear appears as a complicated device to the patient.
This appliance has to be worn for a long period of time for
successful correction. Often a rapid palatal expander is used in
combination with this appliance.
The patients should be started with the expansion device for 2 weeks
followed by introducing the headgear gradually. The initial wear
may be for I or 2 hours and progress to 4 hours in 3 to 4 weeks. The
wear should progress to 12 to 14 hours of wear as dictated by the
treatment plan.
This method of gradually introducing tasks to patients may help
them in their adaptation to newer difficult tasks.

Methods of feedback to the patients can range from
completing report cards,
rewarding them for compliant behavior,
verbal praise,
regular patient/parent consultations.
In addition, charted notations, which are highly
visible to patients, can also affect compliance.
Knerim et al (JCO 1992)


4. Rewarding Compliant Behavior
Improving patient compliance in daytoday practice is very
challenging and often a complex problem. Behavior
modification by way of a reward program can be effective in
improving patient compliance to prescribed instructions.
In the orthodontic literature, recommendations of establishing
a reward program to motivate patients and improve patient
compliance have been cited.


A study carried out by Ritcher, Nanda and Sinha et al at
the University of Oklahoma revealed the following
findings regarding the use of awards as a motivating tool:
1. The award/reward program resulted in improvement in
patient compliance scores in below average compliers
as reflected in the improvement of oral hygiene scores.
2. Above average compliers remained above average
throughout the length of the study. Below average
compliers improved with rewards, however, they
never reached the compliance levels achieved by the
above average compliers.
It was concluded that rewards could be a means of
positive feedback for patients in the orthodontic treatment
of malocclusions

5. Doctor/Patient Rapport and Communication
The successful practice of orthodontics is significantly
dependent on the interaction between the orthodontist and patient.
Therefore, it is important to improve this relationship for superior
treatment outcomes, patient satisfaction, and doctor satisfaction.
In the busy orthodontic practice, it is often difficult to
establish a close rapport with the patient. Better doctor/ patient
communication can result in increased and more accurate transfer
of information, thus improving the quality of care.
The patient's perception that the orthodontist paid attention
and took seriously what the patient had to say is significantly
related to superior doctor/patient relationships. Making the patient
feel welcome is also a significant factor in establishing this
rapport.

Attention to the behavioral issues can greatly enhance the
rapport and can result in superior patient experiences and
treatment
results.
Improving
doctor/patient/parent
communication is an important factor in improving patient
compliance as reported by practicing orthodontists.
Mehra et al (ANGLE 1998)

Patient co-operation- how it can be improved?…
( BJO 1997 NOV.)

1) Being polite, friendly and making the patient feel welcome
2) Having a calm, confident manner

3)Giving information about the problem, the proposed

treatment plan and the procedure you are going to perform.

4) Not using jargon.
5) Paying attention to what the parent and child says


6) Reassuring the child that you will do everything to prevent
pain

7) Express concern about the child’s well-being
8) Do not criticize the child’s tooth brushing or oral hygiene .


Psychosocial characteristics of patients with facial
deformities
• Children with craniofacial anomalies are more introverted, neurotic and
demonstrate poor self-concept – Perschuk et al
• Children with Down’s syndrome were rated as being less intelligent,
less attractive, and less socially acceptable. Postoperative ratings of
these same children were significantly more positive in all three
domains – Strauss et al


• A seriously handicapping orthodontic condition is the one that
“severely compromises a person’s physical or emotional health”
– AL Morris et al
• Physical compromise – serious problems with breathing,
speaking, or eating, especially if accompanied by tissue
destruction
• Emotional health – includes other’s reactions to the individual in
a way that influences self-esteem


• Research in the areas of self-esteem and attractiveness
indicates that the face is a major source of one’s
psychologic identity
• Orthognathic surgery differs from surgery for
congenital anomalies (in that the changes in appearance
are less dramatic and improvements in occlusion,
mastication, speech, and TM joint function are likely to
be major reasons for treatment) – but patients
undergoing this surgeries also expect esthetic changes.
They must adapt not only to changes in their oral
function, but also to changes in their perceived
appearance and interactions with others.

Patients before surgery
•
•
•
•
•

Motives for treatment
A scale to assess patient’s motives
Self-perceptions of facial profile
Sex differences
Orthognathic-surgery patients


Motives for surgery
Parameter

Male

Female

Orthodontist

24(83%)

34(76%)

Family dentist

12(41%)

17(38%)

Other

5(17%)

1(2%)

Desire esthetic changes

12(41%)

13(53%)

Mastication

12(41%)

13(29%)

Speech

4(14%)

1(2%)

TM joint

1(3%)

7(16%)

Social: family, friends

12(41%)

24(53%)

Professional advice

Functional problems


• Subjective Expected Utility (SEU) Model
– Items are based on interviews with Orthognathic surgery
patients, orthodontists, and oral-maxillofacial surgeons
– Using a 10 point scale, patients are asked to indicate the
importance of each item in the list above and whether they
consider it positive , negative or neutral.
– In this study, SEU suggest that the decision to seek surgical
correction is influenced by functional reasons. Conversely,
the decision to reject surgery and undergo conventional
orthodontics seems to be based more on a desire for
improved esthetics

Questions

Score

Less difficulty with chewing

3

Stop jaw from clicking

0

Eat foods unable to eat now

0

Better fit of upper/lower teeth

1.5

General health improvement

1.5

Possible pain after surgery

0

Better smile

0

Improved profile, jaw and chin

0

Straight teeth

0

Cost of surgery

0

Lost time from work/school

0.8

Chance of unsuccessful surgery

1.9

Be able to speak clearer

0

Less self-conscious

0

Perform better in job/school

0

Advice of family/friends

0

Advice of dentist/orthodontist

0.9

Know of someone else’s surgery


0

Self-perceptions of facial profile
• For all dimensions of facial deformity, patients who accept
surgical treatment view themselves as less normal than do those
who opt for no treatment or orthodontics
• At the 24-month follow-up assessment, nearly all the surgery
patients rated themselves as normal. Orthodontics-only patients
also rated themselves improved on all scales, but the
improvement was not as great.


Sex differences
• Broverman and colleagues have found experimental evidence that
women place relatively greater importance on physical
attractiveness
• Kurtz et al found that women can more easily distinguish what
they like and dislike about their bodies than can men of the same
age, who give only global self-descriptions.


Response to treatment
• Overall satisfaction with the outcomes is generally high at all
post surgical assessments
• Overall body image was found to be in the moderate range
throughout the course of treatment
• Surgery patients initially expressed a lower body image than did
non surgical and no-treatment patients
• Surgical patients had high levels of tension and anxiety just
before surgery, with a steady decline later
• Orthodontics-only patients had negative mood states at 6
months which later improved
• In surgical-orthodontic patients, expectations matched the actual
experience for most patients.

Application of research findings to patient
management
-The patients undergoing orthognathic surgery are always within the
psychologically normal range
– They are more stable than people who seek plastic surgery
– Their greatest concern before treatment appears to be selfconsciousness regarding their facial body image, but functional
problems also are important
– Orthodontics-only patients report negative emotions during the
later stages of their treatment
– Contrary to literature on cosmetic surgery, most patients
undergoing Orthognathic surgery readily accept changes in
appearance and are satisfied with the esthetic effects
– 85% to 90% of the patients undergoing surgical-orthodontic
treatment eventually indicate that they are satisfied with the
treatment

Recommendations for interaction
with patients
There is a need for systematic selection of
patients,
Provide greater psychosocial support and
encouragement for the patient
Patient education materials provide information
in a standard way


Pre- and post surgical psycho-emotional aspects of the
orthognathic surgery patient - Bertolini et al
• Levels of pre surgical anxiety, post surgical depression, body
concept, and all the important changes in physiologic functions.
• The results of this study suggest that surgery does in fact, produce
improvements in self-esteem and body image and in mastication
and speech, and therefore in their lifestyles
• All patients experienced a medium to high level of pre surgical
anxiety, but no major problems after surgery.


Rivera and Hatch (SEM in orthodontics 2000 )evaluated emotional
status of the patient before and after orthodontic and
orthognathic surgery patients and concluded;
 Individuals with mild facial disfigurement was affected more
than severe deviation.
 60% believed self confidence,social acceptance,communication
and body image will improve after treatment.
 Patient after orthognathic surgery showed more positive
benefits with increased self judgment,self esteem, self confidence
and body image when compared with orthodontic alone treated
patients.
 Social potency, social responsiveness social interaction, and
behavior improved after surgery.
Immediately after surgery negative mood last for 4-6 weeks
because of pain, numbnesswww.indiandentalacademy.com problems but it was
and oral function

Conclusion
An orthodontist who recognizes the emotional
reactions of the patient, not only treat
malocclusion but also psychological fears,
frustrations and behavior.


Thank you

Psychological aspects of orthodontic treatment

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