Psychology of malocclusion

contentscontents
• IntroductionIntroduction
• Theories of psychologyTheories of psychology
• Psychology of malocclusionPsychology of malocclusion
• Health behavior modelsHealth behavior models
• Psychology of adolescent treatmentPsychology of adolescent treatment
-Psychological factors in patient compliance-Psychological factors in patient compliance
-Predicting patient compliance-Predicting patient compliance
-Improving patient compliance-Improving patient compliance
• Psychology of oral hygiene maintenancePsychology of oral hygiene maintenance
• Psychology of removable appliance wearPsychology of removable appliance wear
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• Psychology of head gear usePsychology of head gear use
• Psychology of retention phasePsychology of retention phase
• Psychology of cleft lip & palatePsychology of cleft lip & palate
• Psychology of adult orthodonticsPsychology of adult orthodontics
• Psychology of orthognathic surgeryPsychology of orthognathic surgery
• Orthodontist & adolescent suicideOrthodontist & adolescent suicide

PSYCHOLOGYPSYCHOLOGY
Is defined as a) study of behaviors and of theIs defined as a) study of behaviors and of the
functions and processes of the mind ,especiallyfunctions and processes of the mind ,especially
as related to social and physical environment .as related to social and physical environment .
b)involves the practical application of knowledgeb)involves the practical application of knowledge
,and techniques in the understanding,and techniques in the understanding
of,prevention of,or solution to individual or socialof,prevention of,or solution to individual or social
problems,in regard of interaction between theproblems,in regard of interaction between the
individual and physical and social environmentsindividual and physical and social environments

PSYCHIATRYPSYCHIATRY
Is defined as branch of Medical Science that dealsIs defined as branch of Medical Science that deals
with causes ,treatment and prevention ofwith causes ,treatment and prevention of
mental ,emotional and behavioral disordersmental ,emotional and behavioral disorders
ORTHOPSYCHIATRYORTHOPSYCHIATRY
Is defined as a branch of Psychiatry thatIs defined as a branch of Psychiatry that
specializes in correcting incipient and borderlinespecializes in correcting incipient and borderline
mental and behavioral disorders in children ,andmental and behavioral disorders in children ,and
developing preventive techniques to promotedeveloping preventive techniques to promote
mental health and emotional growth andmental health and emotional growth and
developmentdevelopment

PSYCHOLOGIC GROWTH ANDPSYCHOLOGIC GROWTH AND
DEVELOPMENT CONCEPTSDEVELOPMENT CONCEPTS
• Freud’s Psychoanalytic theoryFreud’s Psychoanalytic theory
• Erikson’s Psychosocial theoryErikson’s Psychosocial theory
• Piaget’s Cognitive theoryPiaget’s Cognitive theory
• Social learning theorySocial learning theory

Freud’s Psychoanalytic theoryFreud’s Psychoanalytic theory
• Id –desires and needs based on pleasureId –desires and needs based on pleasure
principleprinciple
• Ego –capacity to fulfill Id under practicalEgo –capacity to fulfill Id under practical
situation-memory ,language,intelligencesituation-memory ,language,intelligence
and creativityand creativity
• Superego- social constraints ,conscienceSuperego- social constraints ,conscience
and family valuesand family values

Defense mechanismsDefense mechanisms
commonly employedcommonly employed
• Projection- earliest&most primitive mechanismProjection- earliest&most primitive mechanism
where the individual projects personal feelings ofwhere the individual projects personal feelings of
inadequacy onto someone else in order to feelinadequacy onto someone else in order to feel
comfortablecomfortable
• Denial -is the inability or reluctance to accept theDenial -is the inability or reluctance to accept the
psychological impact of a potentially stressfulpsychological impact of a potentially stressful
situationsituation
• Undoing- attempt to undo the harm an individualUndoing- attempt to undo the harm an individual
imagines his id impulse will produceimagines his id impulse will produce
• Identification- assumption of qualities ofIdentification- assumption of qualities of
someone else to vent frustration or createsomeone else to vent frustration or createwww.indiandentalacademy.comwww.indiandentalacademy.com

• Regression- age inappropriate response as aRegression- age inappropriate response as a
result of confrontation with anxiety producingresult of confrontation with anxiety producing
situationsituation
• Reaction formation -transfer of a hostile orReaction formation -transfer of a hostile or
aggressive impulses into their opposite, moreaggressive impulses into their opposite, more
socially desirable formsocially desirable form
• Repression -the process of unconsciousRepression -the process of unconscious
forgetting which allows for the suppression offorgetting which allows for the suppression of
painful experience into subconscious mindpainful experience into subconscious mind

• Rationalization -it is strategy to excuse orRationalization -it is strategy to excuse or
minimize the psychological consequences of anminimize the psychological consequences of an
eventevent
• Sublimation -the redirection of sociallySublimation -the redirection of socially
unacceptable drives into socially approvedunacceptable drives into socially approved
channels to allow the discharge of instinctivechannels to allow the discharge of instinctive
impulses in an acceptable formimpulses in an acceptable form
• Displacement- is the transfer of hostile orDisplacement- is the transfer of hostile or
aggressive feelings from their original source toaggressive feelings from their original source to
another person usually less importantanother person usually less important

Stages of developmentStages of development
• Oral stage –0 to 1 yearsOral stage –0 to 1 years
• Anal stage -2 to 3 yearsAnal stage -2 to 3 years
• Phallic stage –3 to 7 years(Oedipal andPhallic stage –3 to 7 years(Oedipal and
Electra complex)Electra complex)
• Latency stage -7 to 12 yearsLatency stage -7 to 12 years
• Genital stage – 12 to adulthoodGenital stage – 12 to adulthood

ERIK ERIKSON’S PSYCHOSOCIALERIK ERIKSON’S PSYCHOSOCIAL
THEORYTHEORY
TRUST VS
MISTRUST
AUTONOMY VS
SHAME DOUBT
INITIATIVE
VS GUILT
INDUSTRY VS
INFERIORITY
IDENTITY VS
ROLE CONFUSION
INTIMACY VS
ISOLATION
GENERATIVITY
VS STAGNATION
EGO INTEGRITY
VS DESPAIR
0-1
2-3
3-5
6-12
13-18
19-25
26-40
42+

JEAN PIAGET’S COGNITIVEJEAN PIAGET’S COGNITIVE
THEORYTHEORY
Process of adaptation –complementary processesProcess of adaptation –complementary processes
of assimilation &accommodationof assimilation &accommodation
2 types of cognitive structure2 types of cognitive structure
SCHEMA&OPERATIONSSCHEMA&OPERATIONS
• Sensorimotor period- 0 to 18 monthsSensorimotor period- 0 to 18 months
• Preoperational period –18 months to 7 yearsPreoperational period –18 months to 7 years
--preconceptual period( 18 months to 4 years)preconceptual period( 18 months to 4 years)
-intuitive period (4 to 7 years)-intuitive period (4 to 7 years)
• Period of concrete operations –7 to 12 yearsPeriod of concrete operations –7 to 12 years
• Period of formal operations –12 to 18 yearsPeriod of formal operations –12 to 18 years

SensorimotorSensorimotor
Description Major developments
Learning occurs through
activity
,exploration,&manipulatio
n of
environment,motor&sens
ory impressions form
foundation of later
learning
Learns to
differentiate self from
world
Formation&integratio
n of schemas,
Achieves object
permanence

PreoperationalPreoperational
Description Major development
Capable of symbolic
representations of
the world ,as in use
of play
,language,&deferre
d imitation
Engages with
symbolic play
Some decline in
egocentricity
Develops
drawing&language

Concrete operationsConcrete operations
DescriptionDescription Major developmentsMajor developments
Capable of limitedCapable of limited
logical thoughtlogical thought
process,seeingprocess,seeing
relationships&classifrelationships&classif
ying as long asying as long as
concrete material isconcrete material is
availableavailable
Understands conservationUnderstands conservation
,can mentally reverse a,can mentally reverse a
process/action ,focus onprocess/action ,focus on
more than one aspect of amore than one aspect of a
situation ,can order thingssituation ,can order things
in sequence can groupin sequence can group
objects –classifyobjects –classify

Formal operationsFormal operations
DescriptionDescription Major developmentsMajor developments
Reason logicallyReason logically
&abstractly ,can&abstractly ,can
formulate &testformulate &test
hypotheses ,thought nohypotheses ,thought no
longer depends onlonger depends on
concrete reality ,canconcrete reality ,can
play with possibilitiesplay with possibilities
Can deal with abstractCan deal with abstract
ideasideas
Can manipulate variables inCan manipulate variables in
a scientific situationa scientific situation
Can reflect on own thinkingCan reflect on own thinking
Can work out permutationsCan work out permutations
&combinations&combinations
Can deal with analogies &Can deal with analogies &
metaphorsmetaphorswww.indiandentalacademy.comwww.indiandentalacademy.com

SOCIAL LEARNING THEORY BYSOCIAL LEARNING THEORY BY
SEARS &MILLERSEARS &MILLER
• Theory based on stimulus response principleTheory based on stimulus response principle
and psychoanalytic principlesand psychoanalytic principles
• Behavior is learnt by reinforcementBehavior is learnt by reinforcement
• Attention seeking behavior is normal in motherAttention seeking behavior is normal in mother
child relationchild relation
• Most persons behaviors are learned from otherMost persons behaviors are learned from other
peoplepeople
• Learned behavior can be maintained or changedLearned behavior can be maintained or changed

• Learning through modelingLearning through modeling
attentionattention
retentionretention
reproductionreproduction
motivationmotivation

Self concept
Parent
expectations Attitude
towards
family
Physical
state
biological
development
Impact of
t.v. ,radio
School demands,
Opportunities
Religious
affiliations
Opinion
Of peers
Family economic
problems
Family
relations
Attitude towards
peers

Psychological implications ofPsychological implications of
malocclusionmalocclusion
• Concept of body imageConcept of body image
• Self concept theorySelf concept theory
Each individual develops a conscious image of hisEach individual develops a conscious image of his
own appearance which usually a pleasingown appearance which usually a pleasing
one .When it is not personally pleasing theone .When it is not personally pleasing the
individual develops anxieties about himselfindividual develops anxieties about himself
,which ,if unresolved may lead to mental illness,which ,if unresolved may lead to mental illness
• Individual’s attitude towards his bodyIndividual’s attitude towards his body
• Others response to the disabilityOthers response to the disability

Roots states that first and foremost psychologicalRoots states that first and foremost psychological
effect of dentofacial deformity manifests itself aseffect of dentofacial deformity manifests itself as
inferiority complex-incompetence,inadequacyinferiority complex-incompetence,inadequacy
and depressionand depression
Primary psychological impact does not result fromPrimary psychological impact does not result from
the response of others to the deformity but fromthe response of others to the deformity but from
individual’s own reactionindividual’s own reaction

Psychosocial impact of malocclusionPsychosocial impact of malocclusion
Approximately 70-75 % of the population isApproximately 70-75 % of the population is
affected with some form ofaffected with some form of
malocclusion ,however ,the psychologicmalocclusion ,however ,the psychologic
and social repercussions of theseand social repercussions of these
conditions are diverse and vary acrossconditions are diverse and vary across
individuals and their cultures ,this can beindividuals and their cultures ,this can be
understood in the context of 2understood in the context of 2
interrelated processesinterrelated processes

1.1. Social judgment of malocclusionSocial judgment of malocclusion
2.2. Self adjustment to malocclusionSelf adjustment to malocclusion

Social judgment of malocclusionSocial judgment of malocclusion
• Dental characteristics are fundamentalDental characteristics are fundamental
determinant of facial appearance ,an importantdeterminant of facial appearance ,an important
factor in personal identification and non verbalfactor in personal identification and non verbal
communicationcommunication
• Unattractive individuals are perceived to be lessUnattractive individuals are perceived to be less
liked ,less friendly, less intelligent , lessliked ,less friendly, less intelligent , less
successful, and less competent as dates andsuccessful, and less competent as dates and
marriage partnersmarriage partners
• Some studies have found physical attractivenessSome studies have found physical attractiveness
to be significantly associated with teachersto be significantly associated with teachers
expectations about intelligence ,popularity andexpectations about intelligence ,popularity and
successsuccess

• Many of these studies focus on what ShawMany of these studies focus on what Shaw
terms “background attractiveness” wherebyterms “background attractiveness” whereby
judgment of attractiveness is based on totaljudgment of attractiveness is based on total
facial appearancefacial appearance
• Normal incisor relationships are associated withNormal incisor relationships are associated with
higher levels of friendliness ,social class,higher levels of friendliness ,social class,
popularity ,attractiveness ,and lower levels ofpopularity ,attractiveness ,and lower levels of
aggressiveness when compared withaggressiveness when compared with
prominent/crowded/ absent lateral incisorsprominent/crowded/ absent lateral incisors

Self –adjustment to malocclusionSelf –adjustment to malocclusion
• It is suggested that patients with severe forms ofIt is suggested that patients with severe forms of
cranio-facial deformities ,such as cleft lip &palatecranio-facial deformities ,such as cleft lip &palate
are likely to internalize the negative reactions ofare likely to internalize the negative reactions of
othersothers
• Self image relates to the implications andSelf image relates to the implications and
problems associated with self concept and bodyproblems associated with self concept and body
imageimage
• Patients are comparable to normal population onPatients are comparable to normal population on
several personality characteristics includingseveral personality characteristics including
neuroticism ,locus ofneuroticism ,locus of
control,introversion,extroversioncontrol,introversion,extroversion

• Today there is greater acceptance of a widerToday there is greater acceptance of a wider
variety of occlusal derangements and lessvariety of occlusal derangements and less
stigma placed on corrective treatmentstigma placed on corrective treatment
• Patients with malocclusion may developPatients with malocclusion may develop
different coping mechanisms as a defensedifferent coping mechanisms as a defense
against negative social judgmentagainst negative social judgment
• More severe cases of malocclusion might beMore severe cases of malocclusion might be
expected to present the greatest psychologicexpected to present the greatest psychologic
distress ,research however suggests that it isdistress ,research however suggests that it is
the perceived degree of disfigurement andthe perceived degree of disfigurement and
not the objective severity of malocclusion thatnot the objective severity of malocclusion that
provides information about self-concept ,self-provides information about self-concept ,self-
esteemesteem www.indiandentalacademy.comwww.indiandentalacademy.com

Theories of health behaviorTheories of health behavior
ImportanceImportance
Identify factors associated withIdentify factors associated with
improvements in health behaviorimprovements in health behavior
Predict the circumstances in which healthPredict the circumstances in which health
behavior will be optimalbehavior will be optimal
Provide a rational basis for interventionsProvide a rational basis for interventions
designed to enhance health behaviordesigned to enhance health behavior

Models of health behaviorModels of health behavior
• HEALTH BELIEF MODELHEALTH BELIEF MODEL
• THEORY OF PLANNED BEHAVIORTHEORY OF PLANNED BEHAVIOR
• SELF REGULATION THEORYSELF REGULATION THEORY
• STAGES OF CHANGE MODELSTAGES OF CHANGE MODEL

Health belief modelHealth belief model
Individual’s beliefs are important determinants ofIndividual’s beliefs are important determinants of
his/her health related behaviorshis/her health related behaviors
• Perceived susceptibility to disease or problemsPerceived susceptibility to disease or problems
• Perceived severity of the problemPerceived severity of the problem
• Perceived benefits of health behaviorsPerceived benefits of health behaviors
• Perceived barriers to health enhancingPerceived barriers to health enhancing
behaviorsbehaviors

Theory of planned behaviorTheory of planned behavior
People are reasonable and make decisionsPeople are reasonable and make decisions
about health related behavior by usingabout health related behavior by using
available information to achieve desiredavailable information to achieve desired
goalgoal
• Person’s attitude towards behaviorPerson’s attitude towards behavior
• Social influence on the behaviorSocial influence on the behavior
• Person’s perceived behavior controlPerson’s perceived behavior control

Self regulation theorySelf regulation theory
Individuals regulate their own behavior using 3Individuals regulate their own behavior using 3
processesprocesses
1.1. Individual monitors determinants & outcome ofIndividual monitors determinants & outcome of
their behaviortheir behavior
2.2. Patient evaluates their behavior based onPatient evaluates their behavior based on
personal standards &environmental conditionspersonal standards &environmental conditions
3.3. Patient adjust their behavior depending on howPatient adjust their behavior depending on how
it compares with these personal standardsit compares with these personal standards

Stages of change modelStages of change model
This model proposes that people progress throughThis model proposes that people progress through
5 stages when making behavior change5 stages when making behavior change
1.1. Precontemplation-typically fail to acknowledgePrecontemplation-typically fail to acknowledge
the need for behavior changethe need for behavior change
2.2. Contemplation –recognize a need for changeContemplation –recognize a need for change
3.3. Preparation –specific plan to changePreparation –specific plan to change
4.4. Action- involves implementing those plansAction- involves implementing those plans
5.5. Maintenance –attempt to sustain behaviorMaintenance –attempt to sustain behavior
changechange

Psycho logic processes are a centralPsycho logic processes are a central
component of orthodontic treatment ,andcomponent of orthodontic treatment ,and
optimal clinical practice requires anoptimal clinical practice requires an
appreciation of these factorsappreciation of these factors

Implications for clinical practiceImplications for clinical practice
i.i. Assess patient’s intentions to adhere to RAssess patient’s intentions to adhere to Rxx
(how often u plan to brush &floss)(how often u plan to brush &floss)
ii.ii. Assess patient’s self efficacy for successfullyAssess patient’s self efficacy for successfully
completing the Rcompleting the Rxx (how capable do u feel u are(how capable do u feel u are
of using this appliance)of using this appliance)
iii.iii. RRxx should be initiated only when the patient isshould be initiated only when the patient is
ready to assume the responsibility & makeready to assume the responsibility & make
behavioral commitment required tobehavioral commitment required to
successfully complete Rsuccessfully complete Rxx

iv.iv. Try to identify barriers to complianceTry to identify barriers to compliance
with Rwith Rxx recommendationsrecommendations
(age,educational level,socioeconomic(age,educational level,socioeconomic
status,psychological stress)status,psychological stress)
v.v. RRxx plan should incorporate the prioritiesplan should incorporate the priorities
and capabilities of the patientand capabilities of the patient

Psychology of adolescent treatmentPsychology of adolescent treatment
Understanding cooperationUnderstanding cooperation
Motivation for seeking treatmentMotivation for seeking treatment
• Peer and self perceptions of malocclusionPeer and self perceptions of malocclusion
• Family perceptions and influenceFamily perceptions and influence

Common reasons for seeking orthodonticCommon reasons for seeking orthodontic
treatmenttreatment ::
• To improve & prolong the longevity ofTo improve & prolong the longevity of
teethteeth
• Improve physical appearanceImprove physical appearance
• Prevent teasingPrevent teasing
• Concern with body imageConcern with body image

• Parents may have guilty feeling of creating aParents may have guilty feeling of creating a
inherited malocclusion in the childinherited malocclusion in the child
• Feel inadequate as parents for not stopping theFeel inadequate as parents for not stopping the
child’s deleterious habits in young agechild’s deleterious habits in young age
• Sometimes the reason is not the child butSometimes the reason is not the child but
narcissitic needs of the parentsnarcissitic needs of the parents
e.g.socioeconomic status showoff,mothere.g.socioeconomic status showoff,mother
wanted to become an actresswanted to become an actress

• It is noted that mother is usually the mobilizingIt is noted that mother is usually the mobilizing
,deciding &determining member ,father’s tended,deciding &determining member ,father’s tended
to be less involved in the decision & if father wasto be less involved in the decision & if father was
the main factor it was for daughter’s treatmentthe main factor it was for daughter’s treatment
• It has been observed that children living withIt has been observed that children living with
divorced mother who often developdivorced mother who often develop
psychological shortcomings are often givenpsychological shortcomings are often given
orthodontic treatment as a ‘psychic gift’ inorthodontic treatment as a ‘psychic gift’ in
compensation for being deprived of fathercompensation for being deprived of father

Adolescent may have fantasies aboutAdolescent may have fantasies about
etiology of malocclusionetiology of malocclusion
• His habits & Diet he may feel guilty for itHis habits & Diet he may feel guilty for it
• He may relate it to heredity :anger towardsHe may relate it to heredity :anger towards
parentsparents
Orthodontist should not exaggerate theseOrthodontist should not exaggerate these
fantasies ‘overselling his professionalfantasies ‘overselling his professional
talent’talent’

Factors influencing adolescent cooperationFactors influencing adolescent cooperation
in orthodontic treatmentin orthodontic treatment
The behaviors required of the patient ,suchThe behaviors required of the patient ,such
as keeping appointments ,maintaining oralas keeping appointments ,maintaining oral
hygiene,adhering to dietaryhygiene,adhering to dietary
recommendations ,wearing andrecommendations ,wearing and
maintaining appliance are sometimesmaintaining appliance are sometimes
complex and may disrupt establishedcomplex and may disrupt established
routines or interfere with social activitiesroutines or interfere with social activities

• Severity of malocclusion & need of treatment areSeverity of malocclusion & need of treatment are
assessed in very different ways by patient ,theirassessed in very different ways by patient ,their
parents and orthodontistparents and orthodontist
• Understand the motivation for seekingUnderstand the motivation for seeking
treatment:facial esthetics –esthetic impairmenttreatment:facial esthetics –esthetic impairment
through its potentially negative impact on selfthrough its potentially negative impact on self
esteem or self efficacy ,could result in personalesteem or self efficacy ,could result in personal
&social difficulties&social difficulties

• Patient 12 year or less were more cooperativePatient 12 year or less were more cooperative
than teenagersthan teenagers
• Female patients are more cooperative than maleFemale patients are more cooperative than male
patientspatients
• There is decline in cooperative behavior withThere is decline in cooperative behavior with
timetime
• Discomfort of the applianceDiscomfort of the appliance

• the relative strength of peer and parentalthe relative strength of peer and parental
influences are changing during adolescentinfluences are changing during adolescent
maturation so the cooperation maymaturation so the cooperation may
change over period of timechange over period of time
• Children whose parents encouragedChildren whose parents encouraged
treatment were more cooperativetreatment were more cooperative
,uncooperative patients had poor,uncooperative patients had poor
relationship with parentsrelationship with parents

• Factors predicting cooperation within theFactors predicting cooperation within the
first 10 months of treatment differed fromfirst 10 months of treatment differed from
factors influencing cooperation when fixedfactors influencing cooperation when fixed
appliance was removed after 2 yearsappliance was removed after 2 years

Millon adolescent personality inventoryMillon adolescent personality inventory
1982 ,Millon , Green& Meagher1982 ,Millon , Green& Meagher
150 item personality test designed specifically for150 item personality test designed specifically for
adolescents ,6 grade reading takes 20 minutesadolescents ,6 grade reading takes 20 minutes
It was developed basically by school counselorsIt was developed basically by school counselors
,guidance personal,& mental health professionals,guidance personal,& mental health professionals
Tests are scored according to eight personality patternsTests are scored according to eight personality patterns
(scales) established from actuarial data and(scales) established from actuarial data and
according to 12 areas (scales) of psychosocialaccording to 12 areas (scales) of psychosocial
concern that relate to adolescents (Tables I and II).concern that relate to adolescents (Tables I and II).

Scale categoryScale category No ofNo of
scalescale
ss
MeasuredMeasured
characteristiccharacteristic
Scale nameScale name
Personality stylePersonality style 88 Expression of eachExpression of each
personality stylepersonality style
Introsive,inhibited,cooperativIntrosive,inhibited,cooperativ
e,sociable,confident,forceful,re,sociable,confident,forceful,r
espectful,sensitiveespectful,sensitive
ExpressedExpressed
concernconcern
88 Feelings& attitudesFeelings& attitudes
about issuesabout issues
concerningconcerning
adolescentsadolescents
Self concept,personalSelf concept,personal
esteem,body comfort,sexualesteem,body comfort,sexual
acceptance,peeracceptance,peer
security,socialsecurity,social
tolerance,familytolerance,family
rapport,academic confidencerapport,academic confidence
BehavioralBehavioral
correlatecorrelate
44 Behavior associatedBehavior associated
with adolescencewith adolescence
Impulse control,societalImpulse control,societal
conformity,scholasticconformity,scholastic
achievement,attendanceachievement,attendance
consistencyconsistency

The eightThe eight personality stylespersonality styles contained in the MAPI arecontained in the MAPI are
derived from a two-dimensional theoretical matrix.Thederived from a two-dimensional theoretical matrix.The
first dimension pertains to the primary source from whichfirst dimension pertains to the primary source from which
adolescents gain either positive or negativeadolescents gain either positive or negative
reinforcements. Persons who experience few rewards orreinforcements. Persons who experience few rewards or
little satisfaction from self or others are referred to aslittle satisfaction from self or others are referred to as
detacheddetached types; those who measure their satisfaction bytypes; those who measure their satisfaction by
how others react are identified ashow others react are identified as dependentdependent. If. If
gratification is determined primarily by one's own valuesgratification is determined primarily by one's own values
and desires without reference to the concerns of others,and desires without reference to the concerns of others,
the person is described as having anthe person is described as having an independentindependent
personality style.personality style.

AmbivalentAmbivalent personalities are those who suffer conflict overpersonalities are those who suffer conflict over
whether to be guided by others or by their own desires.whether to be guided by others or by their own desires.
The second dimension reflects the coping behavior usedThe second dimension reflects the coping behavior used
by adolescents to maximize rewards and minimize pain.by adolescents to maximize rewards and minimize pain.
This dimension is described as either anThis dimension is described as either an activeactive or aor a
passivepassive pattern. Persons of thepattern. Persons of the activeactive pattern arrangepattern arrange
life's events to achieve gratification and avoid discomfort.life's events to achieve gratification and avoid discomfort.
Those of theThose of the passivepassive type seem apathetic, restrained,type seem apathetic, restrained,
and content to allow events to take their own courseand content to allow events to take their own course
without personal control. By combining the four sourceswithout personal control. By combining the four sources
of primary reinforcement with the two coping patterns,of primary reinforcement with the two coping patterns,
eight basic personality styles are defined.eight basic personality styles are defined.

EightEight expressed concernsexpressed concerns scales measure the intensity ofscales measure the intensity of
feelings and attitudes that the adolescent mayfeelings and attitudes that the adolescent may
experience about issues that tend to concern mostexperience about issues that tend to concern most
adolescents. Theadolescents. The expressed concernsexpressed concerns scales focus onlyscales focus only
on voiced concerns, though, and not on observableon voiced concerns, though, and not on observable
behavior. Fourbehavior. Four behavioral correlatesbehavioral correlates scales measure thescales measure the
intensity of behavioral problems associated withintensity of behavioral problems associated with
adolescentsadolescents

Orthodontic attitudinal test survey (OATS):Orthodontic attitudinal test survey (OATS):
Miller &LarsonMiller &Larson
The OATS test consists of 28 itemsThe OATS test consists of 28 items
designed to tap patient attitudes withdesigned to tap patient attitudes with
regard to appearance ,authority andregard to appearance ,authority and
invasions,invasions,
An attempt has been made to evaluate andAn attempt has been made to evaluate and
measure the impact of aggressionmeasure the impact of aggression
,pain,authority,invasion and social,pain,authority,invasion and social
acceptance upon patient cooperation inacceptance upon patient cooperation in
orthodontic treatment .orthodontic treatment .

• Research has demonstrated that it isResearch has demonstrated that it is
easier to take a mildly positive attitude andeasier to take a mildly positive attitude and
make it more positive or a mildly negativemake it more positive or a mildly negative
attitude and make more negativeattitude and make more negative

The task with difficult patients is to do threeThe task with difficult patients is to do three
thingsthings
1.1. Conceptualize,desire and define the variousConceptualize,desire and define the various
attitudes towards orthodontics in youngattitudes towards orthodontics in young
patientspatients
2.2. Develop instruments which will assessDevelop instruments which will assess
attitudes before treatment ,predictiveattitudes before treatment ,predictive
psychological devices have long been used inpsychological devices have long been used in
industry ,government,education and attitudeindustry ,government,education and attitude
surveys and attitudinal instruments are widelysurveys and attitudinal instruments are widely
employed in variety of fields,both medical andemployed in variety of fields,both medical and
non medical ,devising such an instrumentnon medical ,devising such an instrument
would allow the orthodontist to predict whichwould allow the orthodontist to predict which
patient would require greater attention inpatient would require greater attention in
combating destructive attitudescombating destructive attitudeswww.indiandentalacademy.comwww.indiandentalacademy.com

3.3. Once the patient has been identified ,theOnce the patient has been identified ,the
next task is to develop plans andnext task is to develop plans and
processes to modify or counteract theprocesses to modify or counteract the
results of a negative attitude patternresults of a negative attitude pattern

Pre treatmentPre treatment Early in treatmentEarly in treatment Throughout treatmentThroughout treatment
childchild Perceives functional/estheticPerceives functional/esthetic
impairmentimpairment
Perceives need for treatmentPerceives need for treatment
Desires treatmentDesires treatment
Develops realisticDevelops realistic
expectationsexpectations
Learns coping/controlLearns coping/control
strategiesstrategies
Assumes control ofAssumes control of
behaviors related tobehaviors related to
effects/outcomes ofeffects/outcomes of
treatmenttreatment
Shares responsibility forShares responsibility for
treatment outcomestreatment outcomes
parentparent Perceives need for treatmentPerceives need for treatment
Believes in efficacy of treatmentBelieves in efficacy of treatment
Places high values onPlaces high values on
occlusion/treatmentocclusion/treatment
Enables treatmentEnables treatment
Takes interest in treatmentTakes interest in treatment
Encourages home careEncourages home care
Supports and approvesSupports and approves
child’s active participationchild’s active participation
and responsibility inand responsibility in
treatmenttreatment
orthodontistorthodontist Professionally evaluatesProfessionally evaluates
treatment needtreatment need
Seeks to understandSeeks to understand
patient/parent perceptionspatient/parent perceptions
CommunicatesCommunicates
goals,expectations,potentialgoals,expectations,potential
problems in treatmentproblems in treatment
Engages parent and patient inEngages parent and patient in
goals,expectationsgoals,expectations
Acknowledges patient andAcknowledges patient and
parent perceptionsparent perceptions
Develops partnership withDevelops partnership with
patientpatient
Shares responsibility withShares responsibility with
patient for progresspatient for progress
,setbacks,outcomes of,setbacks,outcomes of
treatmenttreatment

Perspectives on predictingPerspectives on predicting
patient compliancepatient compliance
Demographic aspectsDemographic aspects
•Age –higher cooperation is excepted in 12Age –higher cooperation is excepted in 12
years and below than adolescentsyears and below than adolescents
•In adolescence it is not the age but overallIn adolescence it is not the age but overall
development of the individual thatdevelopment of the individual that
influences cooperationinfluences cooperation
•Gender some research shows femalesGender some research shows females
are more cooperativeare more cooperative

• Socioeconomic status- children from highSocioeconomic status- children from high
socioeconomic families tend to develop bettersocioeconomic families tend to develop better
treatment compliance possibly based ontreatment compliance possibly based on
perception that attractive dentofacialperception that attractive dentofacial
appearance is a valuable asset for socialappearance is a valuable asset for social
&occupational success&occupational success
• Other studies show that patients from lowerOther studies show that patients from lower
middle class families show higher appreciationmiddle class families show higher appreciation
of treatment than upper middle class familiesof treatment than upper middle class families
because of better parent child relations &greaterbecause of better parent child relations &greater
need for social acceptanceneed for social acceptance

Psychosocial & psychologic aspectsPsychosocial & psychologic aspects
It is generally believed that patient’sIt is generally believed that patient’s
personality characteristics,his or herpersonality characteristics,his or her
relationship with the family , peersrelationship with the family , peers
&orthodontist ,as well as performance at&orthodontist ,as well as performance at
school are closely linked with compliance.school are closely linked with compliance.

• Cooperative patients tend to have better gradesCooperative patients tend to have better grades
and show less deviant behavior at school, theyand show less deviant behavior at school, they
are less frequently truant from schoolare less frequently truant from school
&considered brighter & sociable by their&considered brighter & sociable by their
teachersteachers
• Parental beliefs are important for child’sParental beliefs are important for child’s
compliancecompliance
• Development of effective relationship betweenDevelopment of effective relationship between
the patient and the orthodontist at a earlier stagethe patient and the orthodontist at a earlier stage
in treatment is beneficial for future compliancein treatment is beneficial for future compliance

• The patients who tend to be uncooperative areThe patients who tend to be uncooperative are
inclined to attitudinal preferences conventionallyinclined to attitudinal preferences conventionally
regarded as masculine ,expressed asregarded as masculine ,expressed as
active,aggressive &realistic behavioral patternactive,aggressive &realistic behavioral pattern
and self images ,rather than sensitive,esthetic,and self images ,rather than sensitive,esthetic,
and idealistic onesand idealistic ones
• Impulsiveness,need for ego-assertion,Impulsiveness,need for ego-assertion,
individualism,impatience, intolerance,andindividualism,impatience, intolerance,and
negligence are traits of uncooperative behaviornegligence are traits of uncooperative behavior

• Patients more likely to show higher level ofPatients more likely to show higher level of
compliance are enthusiastic ,outgoing,compliance are enthusiastic ,outgoing,
,energetic ,self,energetic ,self
controlled,responsible,trusting,diligent,andcontrolled,responsible,trusting,diligent,and
obliging personsobliging persons

Health-related behaviorHealth-related behavior
• Treatment compliance is strongly relatedTreatment compliance is strongly related
to perceived severity of malocclusion andto perceived severity of malocclusion and
internal control orientationinternal control orientation
• Patients desire for orthodontic correctionPatients desire for orthodontic correction
his or her values of dental esthetics,andhis or her values of dental esthetics,and
their attitude toward orthodontic treatmenttheir attitude toward orthodontic treatment
at its start may serve as useful predictorsat its start may serve as useful predictors
of the level of complianceof the level of compliance

• Initial experience with orthodontics andInitial experience with orthodontics and
acceptance of treatmentacceptance of treatment
• Insertion of new appliance may diminishInsertion of new appliance may diminish
cooperation by causing considerable discomfortcooperation by causing considerable discomfort
such as unpleasant tactile sensationsuch as unpleasant tactile sensation
• Pain,functional and esthetic impairment ,andPain,functional and esthetic impairment ,and
associated complaints are the principle reasonsassociated complaints are the principle reasons
for the patients wish to discontinue treatmentfor the patients wish to discontinue treatment

• Patients self confidence might be affectedPatients self confidence might be affected
by speech impairment &visibility ofby speech impairment &visibility of
applianceappliance

Improving patient complianceImproving patient compliance
• Patient centered care v/s practitionerPatient centered care v/s practitioner
centered carecentered care
• Patient’s casual attributionsPatient’s casual attributions
• Patient support at home and at thePatient support at home and at the
orthodontic officeorthodontic office
• Rewarding compliant behaviorRewarding compliant behavior
• Doctor patient rapport and communicationDoctor patient rapport and communication

Patient centered care v/sPatient centered care v/s
practitioner centered carepractitioner centered care
• Treatment plan based on individualTreatment plan based on individual
patient expectations ,prioritiespatient expectations ,priorities
&capabilities&capabilities
• Educate patient regarding theirEducate patient regarding their
condition,this will allow them to makecondition,this will allow them to make
informed choices regarding applianceinformed choices regarding appliance
selectionselection

• Patient attribute events in their lives toPatient attribute events in their lives to
external &internal causesexternal &internal causes
• Patient who attribute outcomes to internalPatient who attribute outcomes to internal
causes are more cooperativecauses are more cooperative
• Patients who attribute responsibility forPatients who attribute responsibility for
their orthodontic condition &treatmenttheir orthodontic condition &treatment
externally to either chance or theirexternally to either chance or their
orthodontist show less complianceorthodontist show less compliance

• Family support for the patient to followFamily support for the patient to follow
prescribed instructions is necessaryprescribed instructions is necessary
• Verbal praise and education are most importantVerbal praise and education are most important
methods of improving compliancemethods of improving compliance
• Rewarding compliant behaviorRewarding compliant behavior
• Attention to behavioral issues can greatlyAttention to behavioral issues can greatly
enhance the rapport and can result in superiorenhance the rapport and can result in superior
patient experience and treatment resultspatient experience and treatment results

Johari windowJohari window
• It is a model for explaining what takesIt is a model for explaining what takes
place as a patient & dentist talkplace as a patient & dentist talk
• An awareness of johari window model isAn awareness of johari window model is
vital to any dentist who cares to know howvital to any dentist who cares to know how
to approach his patientsto approach his patients
• Parker has applied these principles toParker has applied these principles to
dentistrydentistry

I readily revealed to others ;
seen by self
II seen by others ;
blind to self
III seen by self ;
hidden from others
IV hidden from others ;
blind to self

Psychology of oral hygiene maintenancePsychology of oral hygiene maintenance
The most desirable mark of orthodonticThe most desirable mark of orthodontic
patients cooperative ability is still their oralpatients cooperative ability is still their oral
hygienehygiene
Oral hygiene technique that has evolved inOral hygiene technique that has evolved in
orthodontic practice uses 3 principlesorthodontic practice uses 3 principles
• ModelingModeling
• ReinforcementReinforcement
• ShapingShaping

ModelingModeling
It consists of demonstrating to the patientIt consists of demonstrating to the patient
• How to stain plaqueHow to stain plaque
• how to hold &position tooth brush so thathow to hold &position tooth brush so that
teeth are cleanedteeth are cleaned
• How to vibrate brush so as to clean all theHow to vibrate brush so as to clean all the
areasareas

ReinforcementReinforcement
• Behavior is controlled to large extent by itsBehavior is controlled to large extent by its
consequenceconsequence
• Rewarding consequences or positiveRewarding consequences or positive
reinforcesreinforces
• Punishing consequences or negativePunishing consequences or negative
reinforcesreinforces

ShapingShaping
• Another behavoristic principle is shaping orAnother behavoristic principle is shaping or
reinforcement of successive approximationsreinforcement of successive approximations
• This is technique of getting someone to learn aThis is technique of getting someone to learn a
new way of doing things by starting where he isnew way of doing things by starting where he is
and rewarding every small step in direction ofand rewarding every small step in direction of
the thing we want him to dothe thing we want him to do
• A bigger task is broken into small sub tasks stepA bigger task is broken into small sub tasks step
by stepby step

Psychology of removable appliance wearPsychology of removable appliance wear
• Patients noncompliance with removablePatients noncompliance with removable
appliances is a challenge to theappliances is a challenge to the
orthodontist predicting the patientorthodontist predicting the patient
compliance & making the appliance leastcompliance & making the appliance least
cumbersome and modifying patient’scumbersome and modifying patient’s
behavior towards a cooperative behaviorbehavior towards a cooperative behavior
are responsibilities of the clinicianare responsibilities of the clinician

• Patient selectionPatient selection
• Appliance selectionAppliance selection
• Patient education that what is excepted ofPatient education that what is excepted of
himhim
• Asking parents that what their children findAsking parents that what their children find
rewardingrewarding
• Family friends & care providers can beFamily friends & care providers can be
used as treatment mediatorsused as treatment mediators

contractingcontracting
• It involves asking two parties to agree toIt involves asking two parties to agree to
perform specific responses ,the behaviorperform specific responses ,the behavior
that each person agrees to exhibit isthat each person agrees to exhibit is
rewarding for the other personrewarding for the other person

Psychology of the use of headgearPsychology of the use of headgear
The instructions given to the patients for theThe instructions given to the patients for the
use of headgear are clear and adequateuse of headgear are clear and adequate
but cooperation considerably reducesbut cooperation considerably reduces
with time especially the number of hourswith time especially the number of hours
greatly reduce ,but as the patient knowsgreatly reduce ,but as the patient knows
that treatment is soon to be completed thethat treatment is soon to be completed the
cooperation again increasescooperation again increases

• Females are poor candidates forFemales are poor candidates for
headgear as hairstyling and cheekheadgear as hairstyling and cheek
depression are major factors limiting itsdepression are major factors limiting its
useuse
• Public embarrassment is main limitingPublic embarrassment is main limiting
factor in both males & femalesfactor in both males & females

Measuring headgear useMeasuring headgear use
General methods of measuring areGeneral methods of measuring are
• Oral hygieneOral hygiene
• Condition of the appliance (e.g. worn –lookingCondition of the appliance (e.g. worn –looking
neck strap )neck strap )
• Mobility of the molarsMobility of the molars
• Ease of patient useEase of patient use
• Direct patient inquiry ,either verbal orDirect patient inquiry ,either verbal or
questionnairequestionnaire
Unfortunately such methods are poor andUnfortunately such methods are poor and
commonly provide overestimate of compliancecommonly provide overestimate of compliance

At university of Florida ,a microprocessorAt university of Florida ,a microprocessor
controlled headgear timing system hascontrolled headgear timing system has
been developed .A variable resistancebeen developed .A variable resistance
,linear potentiometer that measures volts,linear potentiometer that measures volts
at a preset sampling rate is attached to theat a preset sampling rate is attached to the
spring mechanism of a force modulespring mechanism of a force module

Head gear monitorHead gear monitor
At university of Washington ,a headgearAt university of Washington ,a headgear
monitor is being developedmonitor is being developed

Motivating headgear useMotivating headgear use
• Importance of headgear use must be repeatedlyImportance of headgear use must be repeatedly
stressed and explained to the patient as well asstressed and explained to the patient as well as
parentparent
• Progress in treatment should be discussed withProgress in treatment should be discussed with
the patients to involve him in treatment progressthe patients to involve him in treatment progress
• The possibility of increased quality of treatmentThe possibility of increased quality of treatment
with headgear use should be emphasizedwith headgear use should be emphasized
• Frequent reminders on how&why to use theFrequent reminders on how&why to use the
headgear should be sent to the patientheadgear should be sent to the patient
• Misconceptions like cheek depression should beMisconceptions like cheek depression should be
removedremoved

Psychology of retention phasePsychology of retention phase
• However there has been a considerableHowever there has been a considerable
improvement in appliances & mechanicsimprovement in appliances & mechanics
,varying amount of relapse continues to occur,varying amount of relapse continues to occur
• This should be clearly explained to the patient toThis should be clearly explained to the patient to
improve his cooperation in retention phaseimprove his cooperation in retention phase
• Often the adolescent patient is tired of 2-2.5Often the adolescent patient is tired of 2-2.5
years of treatment and if the retainer design isyears of treatment and if the retainer design is
slightly uncomfortable to him ,he may totally stopslightly uncomfortable to him ,he may totally stop
its wear on personal decision or peer influenceits wear on personal decision or peer influence

• Certain habit which were controlled duringCertain habit which were controlled during
treatment phase may come back sotreatment phase may come back so
appliance design should incorporateappliance design should incorporate
special designspecial design
• Oral hygiene neglect is common inOral hygiene neglect is common in
adolescents so recalls should be suchadolescents so recalls should be such
timed so as to evaluate oral hygienetimed so as to evaluate oral hygiene
maintenancemaintenance

Psychologic aspects of cleft lip & palatePsychologic aspects of cleft lip & palate
• Stigma experienced by CLP patientsStigma experienced by CLP patients
A negative response from outsiders, actual orA negative response from outsiders, actual or
perceived may adversely affect self imageperceived may adversely affect self image
• Social interactions –an imperfect image maySocial interactions –an imperfect image may
initiate overt teasing ,unfavorable responsesinitiate overt teasing ,unfavorable responses
may be interpreted as a form of socialmay be interpreted as a form of social
unacceptabilityunacceptability
• Speech - less significant than appearance inSpeech - less significant than appearance in
contributing to low self esteemcontributing to low self esteem

Incidence of psychological problemsIncidence of psychological problems
• 56%of the patients with clefts have56%of the patients with clefts have
problems warranting a psychosocialproblems warranting a psychosocial
referralreferral
• The incidence increases with ageThe incidence increases with age
• Problems are more frequently found inProblems are more frequently found in
males (69%) than females (42%)males (69%) than females (42%)
• Suicide rate in adult individuals with cleft isSuicide rate in adult individuals with cleft is
twice that of normal populationtwice that of normal population

TreatmentTreatment
• Enhancement of patient’s self esteem andEnhancement of patient’s self esteem and
parental acceptance of their cleft are importantparental acceptance of their cleft are important
goals for craniofacial teamgoals for craniofacial team
• Surgical procedures are less traumatic ifSurgical procedures are less traumatic if
performed at an early ageperformed at an early age
• Detailed case discussion between differentDetailed case discussion between different
specialists within the team to avoid conflict inspecialists within the team to avoid conflict in
between treatment and informing the familybetween treatment and informing the family
about the planabout the plan
• Show empathy &support to the family &patientShow empathy &support to the family &patient
• Easy instructions and comfortable applianceEasy instructions and comfortable appliance

Psychology of Adult OrthodonticsPsychology of Adult Orthodontics
Major motivation in children &adolescents is theMajor motivation in children &adolescents is the
parents desire for treatment, adults in contrastparents desire for treatment, adults in contrast
seek treatment because they themselves wantseek treatment because they themselves want
somethingsomething
That something is not always expressed they mayThat something is not always expressed they may
have a hidden set of motivationshave a hidden set of motivations
Some times the treatment is sought as a last ditchSome times the treatment is sought as a last ditch
effort to improve personal appearance to dealeffort to improve personal appearance to deal
with series of complicated social problemswith series of complicated social problems

It takes a good deal of ego strength to seekIt takes a good deal of ego strength to seek
orthodontic treatment, Patients who areorthodontic treatment, Patients who are
internally motivated rather than externallyinternally motivated rather than externally
respond better to treatmentrespond better to treatment
patients unrealistic expectations should bepatients unrealistic expectations should be
identified early, if patient thinks that theidentified early, if patient thinks that the
appearance or function of teeth is creating aappearance or function of teeth is creating a
severe problem ,while an objective assessmentsevere problem ,while an objective assessment
simply does not corroborate that ,orthodonticsimply does not corroborate that ,orthodontic
treatment should be approached with cautiontreatment should be approached with caution

Exceptional personality
(tries hard ,overcompensates
No problem
Inadequate personality
(uses deformity as shield)
Pathologic personality
(small deformity ,big problem)

• Adolescents passive acceptance of what isAdolescents passive acceptance of what is
being done is rarely found in adultsbeing done is rarely found in adults
• The fact that adult can be counted on to beThe fact that adult can be counted on to be
interested in the treatment does notinterested in the treatment does not
automatically translate into compliance withautomatically translate into compliance with
instructionsinstructions
• Unless adult patients understand why they haveUnless adult patients understand why they have
been asked to do things ,they may choose not tobeen asked to do things ,they may choose not to
do them from an active decision not to cooperatedo them from an active decision not to cooperate

• Adults as a rule are less tolerant of discomfortAdults as a rule are less tolerant of discomfort
and more likely to complain about pain afterand more likely to complain about pain after
adjustments and about difficulties in speechadjustments and about difficulties in speech
,eating ,tissue adaptation,eating ,tissue adaptation
• Additional chair time to meet these demandsAdditional chair time to meet these demands
should be anticipatedshould be anticipated
• If the expectations of both doctor & patient areIf the expectations of both doctor & patient are
realistic ,comprehensive treatment of adults canrealistic ,comprehensive treatment of adults can
be rewarding experience for bothbe rewarding experience for both

Psychology of Orthognathic surgeryPsychology of Orthognathic surgery
• Decision makingDecision making
Subtle/abstract factorsSubtle/abstract factors Concrete factorsConcrete factors
Social issuesSocial issues
Psychologic well beingPsychologic well being
Self worthSelf worth
Expectations for selfExpectations for self
&future&future
Patient/clinicianPatient/clinician
interactioninteraction
Financial resourcesFinancial resources
Health care providerHealth care provider
Time availabilityTime availability
Morphologic timingMorphologic timing
Physical problemsPhysical problems

• Developmental &psychosocial issuesDevelopmental &psychosocial issues
• Psychologic well being psychologic distressPsychologic well being psychologic distress
plays a complicated &contradictory role inplays a complicated &contradictory role in
treatment seeking behaviortreatment seeking behavior
Some psychologic disorders ,such as bodySome psychologic disorders ,such as body
dysmorphic disorder &obsessive –compulsivedysmorphic disorder &obsessive –compulsive
disorder ,the need to seek treatment is notdisorder ,the need to seek treatment is not
directly related to the presence of a problemdirectly related to the presence of a problem

• Patient doctor communication, listening toPatient doctor communication, listening to
patient concerns ,addressing patientpatient concerns ,addressing patient
expectations ,educating the patient andexpectations ,educating the patient and
using language understandable to theusing language understandable to the
patient are key elements in successfulpatient are key elements in successful
interpersonal communications in healthinterpersonal communications in health
carecare

Barriers/ Facilitators regarding decision makingBarriers/ Facilitators regarding decision making
• Health attitudes-knowledge/attitude towardsHealth attitudes-knowledge/attitude towards
health providers /dentistry ,concern abouthealth providers /dentistry ,concern about
infection or complicationsinfection or complications
• Family stress- business,dysfunction acrossFamily stress- business,dysfunction across
groups,divorce,child birth ,school/jobs,childgroups,divorce,child birth ,school/jobs,child
care,social supportcare,social support
• Logistics/quality of care –schedulingLogistics/quality of care –scheduling
,waiting,continuity of care ,prior orthodontic,waiting,continuity of care ,prior orthodontic
experienceexperience
• Facility /physical environment –Facility /physical environment –
comfortable,cleancomfortable,clean

• Interpersonal communication-dentist/staffInterpersonal communication-dentist/staff
behavior ,educating the patient/familybehavior ,educating the patient/family
• Access to care- cost ,transportationAccess to care- cost ,transportation
,insurance ,third party payers,insurance ,third party payers

Implications for clinicianImplications for clinician
• Accepting the diversity of patient concernsAccepting the diversity of patient concerns
without making value judgments ,which inhibitwithout making value judgments ,which inhibit
patient from sharing openly ,fostering inhibitionpatient from sharing openly ,fostering inhibition
serves as a barrier to care .allow patients to askserves as a barrier to care .allow patients to ask
questions &encourage them to discussquestions &encourage them to discuss
• Providing patients with background on theProviding patients with background on the
philosophy of your health teamphilosophy of your health team
,facilities,compliance with OSHA regulations,facilities,compliance with OSHA regulations

• Informing the patient about what can & cannotInforming the patient about what can & cannot
be achieved ,use of visual aids helps mostbe achieved ,use of visual aids helps most
patients ,whenever possible patients should bepatients ,whenever possible patients should be
allowed to speak with others who have had suchallowed to speak with others who have had such
carecare
• Screening patients for psychological distressScreening patients for psychological distress
using standardized questionnaires withusing standardized questionnaires with
mental /health questionnaires for patient tomental /health questionnaires for patient to
completecomplete
• Discussing the patients history of presentDiscussing the patients history of present
concern is critical in understanding the patient’sconcern is critical in understanding the patient’s
expectations .Why Now? It is an excellentexpectations .Why Now? It is an excellent
question to follow up the history ,typically thequestion to follow up the history ,typically the
patient who accepts treatment is aware &canpatient who accepts treatment is aware &canwww.indiandentalacademy.comwww.indiandentalacademy.com

• If patient is unable to answer ,it is a ‘red flag’If patient is unable to answer ,it is a ‘red flag’
that should be addressed or at least noted ,ifthat should be addressed or at least noted ,if
patient’s motivations are totally others directedpatient’s motivations are totally others directed
then adherence can be problematicthen adherence can be problematic
• Checking patient understanding is essential ,ifChecking patient understanding is essential ,if
patients repeat questions ,it is helpful to providepatients repeat questions ,it is helpful to provide
written summary ,such information may indicatewritten summary ,such information may indicate
unresolved issues ,the medical history formunresolved issues ,the medical history form
should query about obsessive thoughtsshould query about obsessive thoughts
&rituals ,history of depression ,anxiety ,reasons&rituals ,history of depression ,anxiety ,reasons
for visit to mental health practitionerfor visit to mental health practitioner

• Asking to meet another person who may beAsking to meet another person who may be
providing social support during the pre and postproviding social support during the pre and post
operative period ,patients and their supportoperative period ,patients and their support
systems may need to be clear about theirsystems may need to be clear about their
expectations as well as facilitating theexpectations as well as facilitating the
coordination of efforts to ensure adherence withcoordination of efforts to ensure adherence with
treatment regimen and satisfaction with care .Intreatment regimen and satisfaction with care .In
case of individual who can not identify a supportcase of individual who can not identify a support
system ,this may be a “red flag” regarding his orsystem ,this may be a “red flag” regarding his or
her psychologic developmenther psychologic development

• Developing a cadre of specialists who can beDeveloping a cadre of specialists who can be
consulted with and to refer to when addressingconsulted with and to refer to when addressing
the multiple associated features in patients withthe multiple associated features in patients with
dentofacial disharmony ,in addition to the moredentofacial disharmony ,in addition to the more
obvious physical concerns ,addressingobvious physical concerns ,addressing
psychosocial needs and consulting with mentalpsychosocial needs and consulting with mental
health professional may be warrantedhealth professional may be warranted
• Knowing our biases and preferences ,acceptingKnowing our biases and preferences ,accepting
and respecting patients questionsand respecting patients questions
,concerns,histories,and motives are crucial in,concerns,histories,and motives are crucial in
developing and tailoring the potential treatmentdeveloping and tailoring the potential treatment
plans for every patientplans for every patient

Psychosocial factors associated withPsychosocial factors associated with
orthodontic and orthognathic surgicalorthodontic and orthognathic surgical
treatmenttreatment
• Self conceptSelf concept
• Body imageBody image
• Social interpersonal relationsSocial interpersonal relations
• Adverse effectsAdverse effects

OrthodonticOrthodontic
treatmenttreatment
OrthognathicOrthognathic
surgerysurgery
Self conceptSelf concept SlightlySlightly
ImprovesImproves
SignificantlySignificantly
increases ,butincreases ,but
may fall belowmay fall below
presurgical ifpresurgical if
patient haspatient has
overexpectatiooverexpectatio
nsns

treatmenttreatment
surgerysurgery
BodyBody
imageimage
Increased bodyIncreased body
image just afterimage just after
removal ofremoval of
appliance ,andappliance ,and
drops back todrops back to
normal asnormal as
attention to itattention to it
decreasedecrease
MarkedlyMarkedly
increasedincreased
“halo“halo
effect”on theeffect”on the
bodybody

treatmenttreatment
surgerysurgery
Social/inteSocial/inte
rpersonalrpersonal
relationsrelations
Not conclusiveNot conclusive ImprovesImproves
rapidly withrapidly with
same sexsame sex
andand
improvesimproves
slowly butslowly but
significantlysignificantly
with oppositewith opposite

treatmenttreatment
surgerysurgery
AdversAdvers
ee
effectseffects
Short livedShort lived
discomfortdiscomfort
initially ,no largeinitially ,no large
amount ofamount of
distressdistress
Most difficult periodMost difficult period
just after surgeryjust after surgery
,increased mood,increased mood
swings,fatigue ,lossswings,fatigue ,loss
of vigor ,very fewof vigor ,very few
psychologicalpsychological
effects seen in longeffects seen in long
termterm

Orthodontist as psychologistsOrthodontist as psychologists
adolescent suicide in orthodonticsadolescent suicide in orthodontics
• By virtue of tradition of early treatment andBy virtue of tradition of early treatment and
periodic nature of orthodontic care during criticalperiodic nature of orthodontic care during critical
psychological development ,the orthodontist is inpsychological development ,the orthodontist is in
position to recognize early warning signs ofposition to recognize early warning signs of
adolescent suicideadolescent suicide
• Females attempting suicide are 4 times that ofFemales attempting suicide are 4 times that of
males ,however among suicides committedmales ,however among suicides committed
males are 4 times that of femalesmales are 4 times that of females

Risk factorsRisk factors
• DepressionDepression
• Disharmony between parent &childDisharmony between parent &child
• Child abuseChild abuse
• Disruption of familiesDisruption of families
• Illness, parental illness or deathIllness, parental illness or death
• Substance abuseSubstance abuse

• Depression can be due to loss of love ,failure inDepression can be due to loss of love ,failure in
love, ambition, status ,hopelove, ambition, status ,hope
• Adolescent suicide is a progressive illnessAdolescent suicide is a progressive illness
involving 3 phasesinvolving 3 phases
- Prolonged history of personal- Prolonged history of personal
or family problemsor family problems
-Recent escalation of stress because of new-Recent escalation of stress because of new
problems associated with adolescenceproblems associated with adolescence
- Final precipitant such as termination of- Final precipitant such as termination of
important interpersonal relationshipimportant interpersonal relationship

Warning signsWarning signs
• Signs of depression- sleeplessness,loss of appetite,Signs of depression- sleeplessness,loss of appetite,
persistent boredom or lack of interest,difficultypersistent boredom or lack of interest,difficulty
concentratingconcentrating
• Sudden changes in personality –withdrawal from familySudden changes in personality –withdrawal from family
friends ,apathy,unexplained rude &violent behaviorfriends ,apathy,unexplained rude &violent behavior
• Suicide threats, even made jokinglySuicide threats, even made jokingly
• Drug alcohol abuseDrug alcohol abuse
• Previous suicide attemptPrevious suicide attempt
• Statement that indicate preoccupation with deathStatement that indicate preoccupation with death
• Psychosomatic complainsPsychosomatic complains
• Final arrangements(giving away of personalFinal arrangements(giving away of personal
possessions)possessions)

Guidelines for interventionsGuidelines for interventions
• listen –every effort should be made tolisten –every effort should be made to
understand feelings &complainsunderstand feelings &complains
• Assess the intensity of emotional disturbanceAssess the intensity of emotional disturbance
• Evaluate seriousness of thoughtsEvaluate seriousness of thoughts
• View every complain seriouslyView every complain seriously
• Do not dismiss or minimize teenager’s feelingsDo not dismiss or minimize teenager’s feelings
• Be affirmative but supportiveBe affirmative but supportive
• Speak with parentsSpeak with parents
• Action should not be delayedAction should not be delayed
• Act specifically-suggest assistance ofAct specifically-suggest assistance of
psychiatristpsychiatrist www.indiandentalacademy.comwww.indiandentalacademy.com

Psychology of malocclusion

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