Psychosocial factors of malocclusion /certified fixed orthodontic courses by Indian dental academy


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Psychosocial factors of malocclusion /certified fixed orthodontic courses by Indian dental academy

  1. 1. Psychosocial Factors of Malocclusion INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Content Wrights Classification Models of health Behaviour Psychosocial Impact on Malocclusion Psychosocial effects of orthodontic treatment Psychosocial issues in children with special needs Psychology of orthognathic surgery patient Conclusion
  3. 3. Childs Behavior pattern in the Dental Office: Wrights classification 1975 A) Cooperative(positive Bahavior) Cooperative: Children engage in conversation with the dentist Understands the procedure to be accomplished and follows directions courteously. 2. Lacking cooperative ability: Not able to communicate with the dentist. Very young children or those with mental or physical disabilities. Management is best accomplished through the use of drugs for sedation. 3. Potentially cooperative behavior Has the potential to cooperate, but due to the inherent fears (subjective/ Objective) the child does not cooperate
  4. 4. B)Uncooperative (Negative Behaviour) a)Hysterical or Uncontrolled behaviour: presented by 3- 4 yr old children at their first dental visit. Loud crying, kicking and temper tantrum. b)Defiant or Obstinate Behaviour “Spoiled Kid”: Seen in any age group Usually in spoilt or stubborn children. They can be made to cooperate. c)Tense cooperative: They are borderline between positive and negative behaviour. Does not resist treatment but the child is tensed at mind. d) Timid behaviour/ Shy: Usually seen in overprotective child at the first visit. Is shy but cooperative
  5. 5. e) Whining type: Complaining type behaviour allows for treatment but complains throughout the procedure. f) Stoic behaviour: Seen in physically abused children. They cooperate and passively accept all treatment without any facial expression.
  6. 6. Self Concept is composed of selfimpressions and personal evaluations of one's selfadequacy. (Rathus,Rinehart,Winston 1990) Coppersmith (1967) it is the personal judgement of worthiness that is expressed in the attitudes the individual holds. It is multidimensional in nature. These dimensions include selfefficacy, self-evaluation of intelligence, strengths and weaknesses, self-esteem, and self-perceptions of physical appearance (ie, body image). Rosenberg (1965) A positive or negative attitude towards a particular object, namely the self.
  7. 7.
  8. 8. Body image. It is the degree to which one feels satisfied or dissatisfied with various parts or processes of the body. It is distinguishable from general self-concept in that it concerns perceptions specifically related to physical aspects of the body.
  9. 9. Lyons and Ramsey 2000.. The authors discuss 4 important models of health behavior and their implications for orthodontic treatment:' (I) The health belief model; (2) The theory of reasoned action; (3) Self-regulation theory (4) The stage of change model. Health Belief Model This model proposes that an individual's beliefs are important determinants of his/her health related behaviors. Four sets of beliefs thought to predict health-related behaviors (1) Perceived susceptibility to disease or problems, (2) Perceived severity of the problem, (3) Perceived benefits of health behaviors, and (4) Perceived barriers to health-enhancing behaviors.
  10. 10. Eg:If the patient believes their susceptibility to that outcome is low, the patient is less likely to wear the appliance. Likewise, if the patient acknowledges that the outcome may occur, but judges this outcome to be low in severity, again engaging in the recommended behavior is improbable. On the other hand, if the patient believes that wearing the appliance will confer significant benefits, then the behavior is more likely. So efforts to improve compliance should address these patient beliefs through education, and barriers to compliance should be minimize while maximizing the perceived benefits of the behavior
  11. 11. Theory of Planned Behavior In this theory, a person's intention to engage in a behavior directly determines whether they perform that behavior. Intention is influenced by 3 factors (I) the person's attitude toward the behavior (eg, "I don't like wearing cumbersome devices that make me look different") (2)Social influences on the behavior ("People will make fun of me")
  12. 12. (3) The person's perceived behavioral control, which reflects a person's perceived ability to overcome obstacles and is influenced by their past behavior. This model determines whether the person intends to perform the behavior and is the first step in identifying potential noncompliance. If intentions to change behavior are low, then intentions to alter attitudes or increase behavioral control may be indicated
  13. 13. Self-Regulation Theory Individuals regulate their own behavior using the following 3processes. 1) individuals monitor both the determinants and outcomes of their behavior. For example, a patient evaluates why he or she is wearing his/her appliance (eg, "Because the doctor told me to."), and monitors the outcome of that behavior (eg, "I feel like I'm taking good care of my teeth.").
  14. 14. 2) patients evaluate their behavior based -on personal standards ("I'm doing pretty well for me.") and environmental conditions ("Under the circumstances, I can't be expected to do much better. 3) patients adjust their behavior depending on how it compares with these personal standards ("I really am not doing as well as I can."). Thus, this theory proposes reciprocal interactions among behavior, the environment and personal factors, such as internal standards and cognitive processes.
  15. 15. One of the central concepts in self-regulation theory is self-efficacy, which refers to the belief that one can produce a desired outcome through one's own efforts. Several research studies have shown that high self-efficacy for specific health-related behavior changes (eg, exercise,smoking cessation) is associated with improved adherence with those behavior changes
  16. 16. Selfefficacy has been associated with increased frequency of brushing and flossing. These findings suggest that increasing a patient's belief that he or she can successfully perform the behaviors requested (eg, proper brushing and flossing, appliance use) can improve their adherence
  17. 17. Stages of Change Model This model proposes that people progress through 5 stages when making a behavior change, and Broder and Phillips apply this model to understanding decisions regarding treatment. 1) Precontemplation--In which people typically fail to acknowledge the need for behavior change and have no intention of changing their behavior. 2) Contemplation, individuals recognize a need for change and are considering a change in behavior, but have not yet taken any steps in that direction.
  18. 18. 3) Preparation, involves making specific plans for behavior change. 4)Action, involves implementing those plans, and this is the first stage in which overt behavior change occurs. 5)The final stage is maintenance, in which people are attempting to sustain the behavior changes that they have made.
  19. 19. An important implication of each of these models is that patients' attitudes, thoughts, feelings, and perceptions are important determinants of their health-related behavior. Therefore, clinicians must take these patient factors into account in order to provide optimal treatment. This is most effectively' implemented through a patientcentered approach. Patients who fail to follow prescribed instruction are labeled as "noncompliant.“
  20. 20. Practical Implications It has also been noted that patients‘ personal beliefs, locus of control, and their social developmental status can have important effects on compliance and treatment results. This highlights the substantial influence that psychologic variables can have on the process and outcome of orthodontic treatment. Psychosocial variables can also impact decisions regarding whether to seek orthodontic or orthognathic surgical treatment (Broder and Phillips), and these treatments can also produce psychologic benefits for patients (Rivera et al). This information clearly indicates that psychologic processes are a central component of orthodontic treatment, and optimal clinical practice requires an appreciation of these factors.
  21. 21. Based on these theoretical models, the following recommendations for clinical practice are suggested. 1). Assess patients' intentions to adhere to treatment regimens (eg, "How often do you plan to brush and floss?"). 2) Assess patients' self-efficacy for successfully completing the prescribed treatment (eg,"How capable do you feel you are of using this appliance as prescribed?") 3) Be aware that patients seek treatment at very different points along the stages of change,and parents and children may also differ in their readiness for change. Treatment should be initiated only when the patient reports being ready to assume the responsibility
  22. 22. 4)Try to identify barriers to compliance with treatment, recommendations. These may include,personal characteristics of the patients. Identify the barriers Tailor treatment around the barriers 5) Treatment plans should incorporate the priorities and capabilities of the patient. It allows patients to participate in the decision-making process and furthers the patient's commitment.
  23. 23. The ability to implement such changes depends on an effective relationship between the clinician and the patient, which requires open communication in both directions leading to improved treatment outcome as well as increased satisfaction for both the patient and the provider to provide a high return on investment.
  24. 24. Adolescent perception of Dentofacial appearance and treatment decision The preferred time for treatment in most cases continues to be during adolescence,the behaviors of these patients may also be significantly affected by the developmental tasks of their age group. Example: Development of independent identity involves separation from parental values and movement toward peer group standards-psychologic activity that may manifest as general resistance to adult authority.
  25. 25. So social developmental context for these individuals must be considered in a way that takes into account the attitudes and behaviors of parents, and perhaps the treating professionals, as well as the social milieu of the patient and the patient's own perceptions. Albino 1980 carried out longitudinal studies of adolescent orthodontic patients at the State University of NewYork and found that the severity of malocclusion and the need for orthodontic treatment are assessed in very different ways by patients, their parents, and orthodontists. Because the salient concerns of these 3 groups with respect to malocclusion are almost certain to vary.
  26. 26. The judgement of self perception of malocclusion is highly dependant on esthetic factors. On the contrary, Shaw(1981) found that majority of children he studied could not identify photographs of their own occlusal features, nor could they accurately describe their occlusal features The attractiveness and perceptions of family members provide the foundation on which a child builds his or her self-perception of appearance, including dental-facial appearanc,Data from the Buffalo Studies(Albino 1980)showed that family members tended to make similar assessments of attractiveness. Significant positive correlation was found between children's self-perceptions of dental-facial attractiveness and their mothers' and siblings' perceptions.
  27. 27.
  28. 28. Psychological influences on orthodontic treatment demand Personality theorists from Freud to Erikson as well as psychologists who have focused on cognitive development such as Piaget have emphasized the role of body awareness the development of self-concept. Self-concept is composed of self impression and personal evaluations of one’s self-adequacy. Self-concept is multidimensional in nature. These dimensions include self efficacy (ones perceived ability to achieve goals through ones efforts), self- evaluation of intelligence, strengths and weaknesses, selfesteem, and self perceptions of physical appearance(body-image).
  29. 29. At the same time, other people’s qualitative reaction and responses to our appearance influence the development of body image and self-esteem. Academic and athletic achievement, ability to interact with peers, teachers and others all come into play an increasingly important role in our selfesteem. Hence, most measure of selfesteem are multidimensional;body image that represents just one dimension. For many children one or more components of selfconcept is great. Those who can identify their malocclusion as the source of their dissatisfaction are more highly motivated to obtain orthodontic treatment.
  30. 30.
  31. 31. Grewal K, Sunny JP, Valiathan A(2003) A questionnaire study done at Manipal regarding patients expectations and perceptions towards orthodontic treatment reported 67%- Believed that their self confidence may be positively enhanced 42%- Felt that improved facial appearance would not be an advantage as far as their career opportunities are concerned. More than half of the total respondants felt that, to attain straight teeth was the first motivating factor to undergo treatment. Only 31.8% - felt that improvement in dental appearance may lead to enhanced facial appearance
  32. 32. Psychosocial Impact of Malocclusion: The demand for correction of malocclusion is of the psychological and sociological rather than somatic. Class I is considered to be the most attractive dental occlusion among white Americans, Class III the least. However, treatment demand is higher among those with Class II than with Class III malocclusion.(Wilmont ,Barber,Angle ortho 1993). lt is in contrast, in a study conducted in Singapore, young Asian respondents rated Class III malocclusion as more attractive than Class II and those with the former condition were less likely to seek treatment than those with the latter.(Soh, Lew ,1992)
  33. 33. However psychologic and social repercussions of these conditions are diverse and vary across individuals and their culture. The impact of malocclusion on psychosocial factors can be understood in the context of 2 interrelated processes. 1)social judgement and responses of others to malocclusion. 2) involves patients' self-adjustment to malocclusion. Social judgements of Malocclusion: Numerous studies have examined the effects of physical attractiveness on social judgement and social relations. , Unattractive individuals are perceived to be less liked, less friendly, less intelligent, less successful, and less competent as dates and marriage partners. (walster, Adams 1977)
  34. 34. Some studies have found physical attractiveness to be significantly associated with teachers' expectations about intelligence, popularity, and success.(Clifford 1973) Many of these studies focus on what Shaw terms "background attractiveness" whereby judgement of attractiveness is based on total facial appearance. Malocclusion gives rise to similar stereotype. Normal incisor relationships are associated with higher levels of friendliness, social class, popularity, attractiveness,' and lower levels of aggressiveness when compared with prominent incisors, crowded incisors, and absence of lateral incisor.(shaw 1985)
  35. 35. Most studies show that patients with malocclusions have a positive self-concept(Kiyak 1982,Dann 1995) and self-esteem.(Kiyak 1982,Forsell1998) More recent research indicates that patients have well adjusted personalities.(Hatch et al 1999) Patients are comparable to the general population on several personality characteristics including locus of control, introversion and extroversion. Although individuals with malocclusion may report feeling negatively impacted and socially disadvantaged,these circumstance do not have large negative repercussions on patients' psychologic well-being.
  36. 36. For the most part, individuals with malocclusion report a positive self-concept and body image that is comparable with the general population. Also, the objective severity of the malocclusion does not seem to be associated with self judgments of selfesteem or body image.
  37. 37. Psychosocial Effects of Orthodontic Treatment: I.Patient Expectations: Research (Garvill, Finlay1995)shows that patients with malocclusion are motivated to undergo corrective treatment primarily for esthetic and functional reasons. There is also evidence that patients expect certain psychosocial benefits after treatment. For example, patients hope that treatment will positively influence interpersonal relationships and psychologic well-being as well as improve self-confidence and self-image. In addition, patients expect that their life will improve in some way because of treatment
  38. 38. It is unclear regarding the extent to which corrective treatment contributes to increased levels of self-concept and social Interactions. (Wictorin et al 1969). The physical results of treatment are usually favorable, producing improvements in occlusion, function, and facial appearance. The psychologic implications of these changes are less apparent but of equal importance in assessing the impact of treatment.
  39. 39. II.Orthodontic treatment a)Self concept Orthodontic treatment, which often produces positive changes in facial appearance, is assumed to Improve self-concept”(klima 1979). A review of the literature, however, provides little evidence. For instance, adult patients with mild-severe degrees of malocclusion, undergoing fixed-appliance orthodontic treatment, show no significant differences in self-concept from pretreatment to 6 months after the start of treatment or 1 to 4 weeks after the end of treatment. (Varela 1995).
  40. 40. Similarly, a comparison of orthodontic patients 15 months after the start of treatment and 1 year after the completion of active treatment indicates that self-concept is comparable with that of a group receiving no treatment.(Dann1995) Literature suggests that selfconcept undergoes little change over the course of orthodontic treatment and remains stable after active treatment is completed. Kiyak 2000 reasons that 1. research shows that patients are comparable with the general population in regard to self-concept before orthodontic treatment
  41. 41. 2. Orthodontic treatment may not produce sufficient changes in total facial appearance to significantly impact the physical appearance dimension of self-concept. b)Body Image: general body and facial image significantly increased from pretreatment levels when assessed 4 weeks following the completion of active treatment. At 1 year following the completion of active treatment, self-evaluations of dentofacial attractiveness in adolescents significantly improved when compared with pretreatment levels. However, these improvements did not generalize to other facial characteristics or to general perceptions of the face.(Albino 1994)
  42. 42. This could be because the specific changes to dental features become incorporated into one's self-concept and the enthusiasm associated with a"new look" decreases. Patients may continue to be satisfied with the esthetic changes produced in dentofacial features. However, attention may be refocused on imperfections of other body parts, lowering previously held selfperceptions of general body image.
  43. 43. Few psychologically adverse effects are reported following orthodontic treatment. Most discomfort is physical and is experienced during the initial 4 weeks of treatment and during appliance adjustment visits. However, the problems appear to be short lived and did not cause large amount of distress. Thus,orthodontic treatment doesnot significantly increase or decrease self concept. Finally the psychosocial problems experienced during and after treatment is minimal and generally declines over the course of treatment.
  44. 44. Psychological aspects of chidren with special needs: Special needs describe a wide range of conditions that result in patient requiring extra attention or special facility in order to attain and maintain oral health. Handicap and disability: The handicap child may be, at best, passive and apathetic and at worst, frightened, defensive and hostile, constituting a stark antithesis to the ideal orthodontic patient. Concerned and caring parents of the child will have come to accept the inevitability of the childs physical and/or mental condition and turn their attention to improving the remaining area where there is frequently sever disability, namely the facial appearance.
  45. 45. Personal experience of parents, who have approached with the view to providing orthodontic treatment for their handicapped children, is likely to have been disappointed. It may be inferred that, although treatment undoubtedly exists, the conditions are not conducive to pursuit and its eventful successful outcome. In orthodontics analysis of patient cooperation factor yields four basic requirements ( Becker 979) 1.Motivation- not only is motivation totally lacking but it is frequently supplemented by exaggerated fear and apprehension which is heightened when the mouth is invaded by orthodontist.
  46. 46. 2.Oral Hygiene- Tooth brushing is usually not practiced and food from recent meals can be seen stagnating around the teeth, the palatal vault, sulcus and the floor of the mouth. This is often due to lack of clearance resulting from a lessened activity of the musculature of the tongue, lips and cheeks or frame a frank hypotonicity that is characteristic of many conditions and syndromes. 3.Behaviour Management: Patient will usually not submit to develop procedures and even when they do, they exhibit a marked reduced ability to sit still for any length of time. This is fine, painstaking and precision orthodontic procedures are out of question.
  47. 47. 4.Manual dexterityThis may be on a reduced level and serves patient governed functions such as inserting removable appliances, placing headgears and hooking up elastics beyond their capabilities. Plan of Treatment: The role of the ParentTransfer of responsibility for certain important functions to the parent- the tasks that they must be recruited are 1)Oral Hygiene 2 )caries –prevetion prophylaxis 3)appliance care.
  48. 48. Regular daily tooth brushing has a very important role in that the patient learns to accept foreign odjects being manoeured around his mouth by a third party. Since the party is the parent, the childs perceived threat is minimal and he quickly adapts. This is a vital step towards successful patient management. Lateron, foreign objects such as radiographic films ,impressions and finally orthodontic appliances will need to be be introduced into the mouth, by the parent.
  49. 49. The role of the Orthodontist: 1.There is the need too aim for the realistic treatment goals which must be adapted to the individual patients. 2.It is advisable to use a simplified appliance design to make activation independent of the patient. 3.Application of conscious sedation- Midazolam nasal drops 4.Strategic extractions that will allow spontaneous corrective movements of adjacent teeth. This will often minimize the need for and extent of mechanotherapy. 5.Use of enbloc extaoral removable appliance(Bass 1975,Thurow1975)
  50. 50. Psychosocial considerations in surgery: Patients willing for orthognathic surgery have the desire to improve their facial and dental appearance rather than their occlusal function, the benefits have constant pychosocial consequences. Kiyak et al ( 1981, 1988, 1984) presents perhaps the most comprehensive evidence of psychological benefits of orthognathic treatment. Kiyak 1982 reported orthognathic patients had high body image scores both beforeand after surgery. However at 9 months postsurgery, facial body image had dropped significantly. Facial body image increased significantly again at 24 months postsurgery.
  51. 51. Overall body image was signifivantly higher 24 months after surgery than it was at presurgery. But the selfesteem level were slightly lower at 24 months after surgery compared with presurgery levels. Kiyaket al 1985, compared the psychological status of 156 patients who were referred for possible orthognathic surgery. 90 of them eventually received orthognathic surgery 33 declined but underwent orthodontic treatment only 33 declined any form of treatment
  52. 52. According to many other longitudinal data, the psychosocial benefits gained by patients who undergo orthognathic surgery are Better Social functioning ( Garvill et al 1988, ostler 1992) Social adjustment ( Barbosa et al 1993) Self-Confidence(Harary et al 1990)
  53. 53. Conclusion: Although there is dramatic improvements in esthetics, following orthodontic and orthognathic surgery. and patient-reported satisfaction with outcomes, how can it be that nearly 30 years of research produces onlv limited evidence supporting significant long lasting psychosocial benefits? There are 2 possible explanations. First, it is possible that the psvchosocial impact is, in fact, not as significant as clinical observation has led us to believe. This may be partly true,Just as patients may exaggerate the benefits of treatment shortly after completion, clinicians may be subject to a similar halo effect.
  54. 54. Alternatively, it may be that current research methods are simplyinadequate; ie, there are significant psychosocial changes, but the research methodology to date has been inadequate to document the psychosocial changes. There is also the need to re-evaluate the assessment Methodology.It is possible that the psychosocial assessments used to date are not detecting the psychosocial changes that are observed clinically, These factors have not been well controlled in many of the research reports to date. Prospective studies with appropriate control groups, calibrated examiners, and carefully selected patient relevant outcome measures are needed.
  55. 55. References: 1.Grewal K, Sunny JP, Valiathan A: Expectation and perception of patients towards orthodontic treatment in Manipal, JPFA 2003;19: 83-88 2.Sachdeva ST , Valiathan A: Cooperation in Orthodontics , Stomatalogica India, 1995;9:3-6 3. Sachdeva ST, Valiathan A: Whose mouth is it anyway? JIOS 1994; 25:105- 108. 4. Irfan Dawoodbhoy, Valiathan A:Psychological Implications of Dentofacial deformities. KDJ 17:913916.
  56. 56. 5. Riolo M, Avery JK: Essentials for Orthodontic practice 1st Ed 2003 pg 11-51 6. Grover S, Arora D: Psychological aspects of orthodontic treatment. JIOS 2001; 34:9-15 7.Sinha PK,Nanda RS: Improving patient compliance in Orthodontic practice, Semin orthod 2000; 6:23741 8.Judith Albino: Factors influencing adolescent cooperation in orthodontic treatment. Semin orthod 2000;6 :214-223
  57. 57. 9. Kiyak HA: Cultural and Psychological influences on treatment demand, Semin Orthod 2000; 6;242-248 10.Rivera SM, Hatch JP, Rugh JD: Psychological factors associated with orthodontic and orthognathic surgery treatment. Semin orthod 2000;6;259-269. 11.Hunt et al: The Psychological Impact of Orthognathic Surgery: A systematic review.AJO-DO 2001; pg 490- 497
  58. 58. 12. Macgregor FE. Social and psychological implications of dentofacial disfigurement Angle Orthod 1970;40:231 13. Klima RJ, Wittemann JK, Mciver JE. Body image, selfconcept, and the orthodontic patient. Am J Orthod 1979;75:507-516. 14. Kiyak HA, McNeill RW, West RA, et al. Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthod 1986;89:383-392.
  59. 59. 15.Shaw WC, Rees G, Dawe M, et al. The influence of dentofacial appearances on the social attractiveness of young adults. Am J Orthod 1985;87:21-26. 16.Shaw. The influence of children's dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am.J Orthod 1981 ;77:399415. 17.O`Regan, E Dewey, J Lovius: Self Esteem and Aesthetics, BJO 1991; 18:115- 120 18. William Proffit: Contemporary Orthodontics 3rd Edition, 2000 pg45-60
  60. 60. Thank you For more details please visit