INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.com
Psychological
aspects
of
orthodontic treatment
www.indiandentalacademy.com
Contents
Introduction
Theories of psychological &behavioral development
a. Learning & development of behavior
b. Psychos...
Use of educational & psychological principle in orthodontic practice
Psychologic factors influencing Orthognathic surger...
INTRODUCTION
Definition:-Psychology is a branch of science
which deals with mind & mental processes in
relation to human &...
Diagnosis of orthodontic case now includes a greater
emphasis on the functional & the psychosocial ramifications
Of Dentof...
A series of 297 adolescent patients screened at the
university of north carolina listed reasons for taking
Orthodontic tre...
Not just the way the teeth fit, Psychosocial and facial
considerations, play a role in defining orthodontic treatment
need...
Psychological Development
Linked to growth of the brain (cognitive areas)

Influenced by genetic factor which is modified ...
Theories of Psychology & Behavioural
development.
Behavior is a result of interaction between innate
& instinctual behavio...
Classical conditioning:• First described by Ivan Pavlov during his studies
on reflexes.
• “Learning by Association”.- asso...
Reinforcement

Every time they occur, the association between a
conditioned and unconditioned stimulus is strengthened.
Ex...
Operant conditioning:• According to B.F Skinner – Operant conditioning
is a significant extension of classical
conditionin...
•

Four basic types of operant conditioning:-

•

Positive Reinforcement:- If a pleasant
consequence follows a response, t...
Observational Learning
(Modeling).
• This is acquired through imitation of behaviour.
• Two distinct stages :-Acquisition
...
•A child acquires a behaviour by first observing it &
then actually performing it.
•Important tool in the management of de...
Theories of Emotional Development
 Stanley Hall{1846-1924} is recognized as the founder of
Emotional development and Psyc...
1) Nature VS Nurture – Biological process VS Environmental process

Theorist advice is think less about nature vs nurture ...
Psychoanalytic Theory: (Sigmund Freud)
Freud hypothesized three structures in the theory of the understanding
of the intra...
EGO:
It describes as that part of the self-concerned with the overall
functioning and organization of the personality thro...
SUPER EGO:
The super ego is derived from familial and cultural
restrictions placed upon the growing child. Freud hypothesi...
Emotional development
From infant to adult
The Infant :(First year of life) oral phase
 Unlike other mammals human infant...


This phase of development is called as SYMBIOTIC PHASE. It
will last until 10 months of age, then the separation and
in...
Third year of life
 By 3 years of age the child has attained a degree of intelligence, which
consist of acquired patterns...
Second Third Year: (4-6 years) (phallic phase)
(Preschool child)
 In this period child has to distinguish between reality...
 The factor, which inhibits use of their ability to initiate
activity is GUILTY. GUILTY is a feeling of fear that ones
ac...
Grade school years:(7-12 years)(latency)
 This period is also called as latency period.
 The child has sufficient self- ...
The most effective of these are
1] Reaction formation

2] Sublimation

1. Reaction formation:
Reaction formation is doing ...
Adolescence (12-18years)
Adolescence is a psychological state of maturation while puberty
is a physical state of maturatio...
 MIDDLE ADOLESCENCE: 14-16 YEARS OF AGE
This is associated with TURMOIL OF ADOLESCENCE. There is
STRUGGLE between depende...
Erikson’s theory

www.indiandentalacademy.com
Erickson Theory
Development of Basic Trust: Birth to 18 months::
Development of the basic Trust depends on caring and
cons...
Basic mistrust:
A child who never developed a sense of basic trust will
have difficulty in entering into situations that r...
Shame and Doubt


Failure to develop a proper sense of autonomy results in the
development of Doubts in the child mind ab...
Thus Erickson Quotes "From a sense of self control without a
loss of self esteem comes a losing sense of goodwill and prid...
Development of initiative(3-6 years)
( initiative vs guilt)
During this stage the child continues to develop greater auton...
Thus Erickson quotes "The child ultimate ability to initiate new
ideas or activities depends on how well he or she thinks ...
Mastery of skills (7-11years)
(industry vs inferiority)


During this period child is learning about the rules by which t...


Children are usually experienced their first visit to the dentist but some
may not. But children at this age are trying...
Development of personal identity (12-17 years)
(identity vs role confusion)
Adolescence, a period of intense physical deve...
Confusion


During adolescence separation from the peer group is necessary to
establish ones own uniqueness and values .A...
Development of Intimacy (Young adult)
(intimacy vs isolation)
The adult stage of development begins with the attainment of...
Most of the Young adults who seek orthodontic treatment to
correct their dental appearance because they perceived their
de...
Guidance of the next generation (Adults )
(generativity vs stagnation)
A major responsibility of a mature adult is the est...
Attainment of integrity (Late Adult)
(integrity vs despair)
At this stage the individual has adapted to the combination of...
Cognition Theory
 Cognition refers to the higher mental process involved in
understanding and dealing with the world arou...


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

Assimilation:
It describes the ability ...
Schemata represent a dynamic process of differentiation and
reorganization of knowledge, with the resultant evolution of
b...
Sensorimotor Period: (0-2 year)
During the first 2 year of life, a child develops from newborn
infants who are almost tota...
Preoperational period: (2-7year)
During the preoperational period, the capacity develops to
form mental symbols representi...
Features of Thought process
1) Egocentrism

2) Animism

Egocentrism:
It is defined as the inability of the child to assume...
Most of the thumb sucking patients fall in to this
category of age.
Since the child’s view of time is centered around the
...
Period of concrete operations: ( 7 – 11year)
 During this stage, the ability to see another point view develops,
while an...
Period of Formal operations: (11 years – adult)
 The ability to deal with abstract concepts develops by the age
of 11 yea...
 The imaginary audience is a powerful influence on young
adolescents, making them quite self-conscious and susceptible to...
Behavior is an observable act. It is defined as any
change observed in the functioning of an organism.
Learning as related...
Models of health behavior (sem in ortho 2000)
 
 

Models of health behavior and Their implication
for orthodontic treatme...
1. HEALTH BELIEF MODEL
 
This  model  proposes  that  an  individual’s  beliefs  are  important 
determinants of his/her h...
2. THEORY OF PLANNED BEHAVIOR
 
This theory proposes that people are reasonable and make 
decisions about health-related b...
As in the health belief model, both internal events such as attitudes 
and environmental factors including social pressure...
3. SELF-REGULATION THEORY
 
This theory suggests that individuals regulate their own behavior 
using the following 3 proce...
Third,  patients  adjust  their  behavior  depending  on  how  it 
Third
compares with these personal standards (“I am rea...
4. STAGES OF CHANGE MODEL
 
This model proposes that people progress through 5 stages when 
making a behavior change, Brod...
 
Third stage is preparation, and this stage involves making specific 
stage
plans for behavior change.
 
Fourth stage, ac...
Based on these theoretical models, the following
recommendations for clinical practice are suggested.
 

1. Assess patient...
3.  Be  aware  that  the  patient  seek  treatment  at  very  different  points 
along the stage of change, and parents an...
When  these  barriers  are  identified,  steps  should  be  taken  to 
reduce the barriers or to tailor treatment around t...
Psycho-orthodontic theory
(A.j.o –Do 1981 dec 604-622)
This theory was put forwarded by El-Mangoury. Motivation is
a very ...
B) Affiliation motivation of orthodontic patients was defined as
a hypothetical construct of seeking orthodontic care for ...
1. Orthodontic cooperation is predictable through psychological
testing.
2. High-need achievers cooperate better orthodont...
Emotional Development And Orthodontic Treatment
Need
Body Image

Self Concepts

Body Image:
Body image of the patient is c...
Parents

Culture

Peers
Body Image

Ethnicity

Teachers

www.indiandentalacademy.com
Parents, Teachers and peers
The earliest influences on a child’s body awareness are a parent
or other caregiver’s physical...
Culture and Ethnics
A person's response to dental-facial attractiveness can be
viewed as a type of psychosocial response t...
Self concept
Body Image

Accomplishment
•Academic
•Athletic

Social Competence

Self Concepts
Self Esteem
www.indiandental...
Self Concepts
Self Esteem

Desire to Change
•Appearance
•Accomplishment
•Social Skills

SELF ACCEPTANCE

www.indiandentala...
 To the extent that the child holds himself or herself in high
regard, there is greater self- acceptance and the desire t...
 In contrast, for many children whose self-acceptance is not very
high, the desire to chance one or more components of se...
 It behooves the orthodontist to recognize these differences, to
identify children who attend the initial orthodontic con...
 Questioning the child about his or her areas of satisfaction with
the face and other aspects of the self , motives for a...
COMPLIANCE (sem in ortho 2000)
 
As suggested by Haynes: Compliance is "the extent to which 
Haynes
a person's behavior (i...
When  a  patient  deviates  from  these  therapeutic 
recommendations,  the  presumption  is  that  the  likelihood  of 
a...
Self-Regulation Approach to Orthodontic Patient Compliance
 Self-regulation principles are being applied in diverse areas ...
A regulatory model of patient compliance suggests that poor 
compliance can result from a variety of factors
1. PATIENT DO...
Current  orthodontic  research  focuses  on  a  critical  aspect  of  the 
feedback;  specifically,  the  input  received ...
Measuring Headgear Use
Orthodontists are understandably interested in the amount of time a 
headgear is worn. 
Typical  cl...
Unfortunately,  such  methods  are  poor  and  commonly  provide  an 
overestimate  of  compliance.  There  is  a  clear  ...
A conceptual model of factors influencing orthodontic treatment decisions

Patient’s
Perceptions of
Dental-facial
attracti...
CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT
PRE-TREATMENT

EARLY IN 
TREATMENT

THROUGH 
TREATMENT

CHILD

 P...
PREDICTING PATIENT COMPLIANCE IN
ORTHODONTIC TREATMENT
To  ensure  efficient  clinical  management  of  orthodontic  patie...
1. DEMOGRAPHIC ASPECT
In  the  search  for  potential  predictors  of  treatment  compliance, 
considerable  attention  ha...
Gender:
Kreit and Starnbach et al  have  emphasized  that  the  patient's 
al
gender  might  help  predict  treatment  com...
Socioeconomic status:
Several investigations have addressed the issue of potential 
influence of patients' socioeconomic s...
 
2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS
Considerable  attention  has  been  devoted  to  evaluation  of  the 
effects of...
EDUCATION LEVEL:
Richter, Nanda and Sinha  et  al  (ANGLE  1996)  reported  that 
1996)
cooperative  orthodontic  patients...
PARENTS ATTITUDE:
Mehra et al (ANGLE 1996) suggested that parental beliefs are 
1996)
important  for  a  child's  complian...
Study  by  Nanda and Kierl et al (AJO 1992)  evaluated  several 
1992)
factors of potential relevance to compliance predic...
PATIENTS PERSONALITY
Substantial  evidence  has  accumulated  suggesting  that  patients' 
personality  characteristics  a...
Specific psychologic diagnostic tests were used for evaluation of 
patients'  cooperation,  responsibility,  reliability, ...
 
PERSONALITY TEST
Personality  tests  have  been  used  by  a  number  of  investigators, 
generally with the goal of bei...
McDonald  reported  a  significant  correlation  between  scores 
McDonald
on the California Test of Personality and patie...
Initial Experience With Orthodontics and Acceptance of
Treatment
As patients may experience a considerable amount of disco...
Pain,  functional  and  esthetic  impairment,  and  associated 
complaints  are  the  principal  reasons  for  the  patien...
Effects of appliance type on oral complaints, such as higher 
degree of pain or speech impairment during wearing of the bi...
General  personality  variables  and  specific  attitudes  to 
orthodontics seem to play an important role.
 
Sergl et al ...
SOCIAL INEQUALITY & DISCONTINUATION
OF ORTHODONTIC TREATMENT
Social inequality influences general health, dental disease,
...
IIIM

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

constables,
IV
Semi-skilled e....
Results:The results showed that discontinued cases were:
1. Less likely to have been treated with fixed appliances
2. A li...
Psychological
aspects
of
orthodontic treatment
Dr. I.
ROHINI

www.indiandentalacademy.com
ACHIEVING PATIENTS COMPLIANCE
                        (sem in orthodontics 2000 dec)
Patient noncompliance is a limiting f...
In addition, many of these "noncompliant" techniques have 
now reverted back. E.g.,traditional methods of anchorage contro...
Various prevention and improvement concepts that can
positively affect orthodontic patient compliance are:
A  shift  from ...
1. Patient-Centered Care versus Practitioner Centered Care
 Traditionally, orthodontic treatment prescribed by the practit...
A patient-centered approach would place some of the responsibility 
of successful patient compliance on the practitioner. ...
Patient Education
Patient management may be greatly enhanced when patients
understand the nature of their condition and th...
At the same time, parents may not be clear about treatment
goals and mechanics. In addition, the parents' ability to expla...
Various demonstration tools are available to aid in the education
process.
Good standard patient records such as study ca...
USE OF EDUCATIONAL –PSYCHOLOGICAL
PRINCIPLES IN ORTHODONTIC PRACTICE ……..
(AJO 2001 JUNE, VOL.119 NO 6)

The principles th...
PROGRESSIONS:Progression learning involves segmenting the skill to be learned into
a number of simple and sequential compo...
SHAPING
Shaping, or close approximation, is an operant conditioning
principle that involves reinforcing behavior that appr...
REINFORCEMENT THEORY
• Positive and negative reinforcement, and, to a limited degree,
punishment, can be used in orthodont...
• KINESTHETIC LEARNING
• Obviously, individuals learn differently. Some are more visual,
others are more auditory, and som...
Patient Empowerment and Contracting Procedures
Educating patients regarding their condition gives them the
tools to make i...
Most often, alternatives are available and should be offered
following an understanding of the limitations of different
ap...
2. Patient's Causal Attributions
Patients attribute events in their lives to external and internal
causes. External causes...
Therefore, patients who attribute internally are better
compliers compared with those who attribute externally.
Those pati...
3. Patient Support at Home and at the Orthodontic Office
Family support for the patient to follow pre­scribed instructions...
An example is of patients who have to use the reverse facemask
headgear used for Class III skeletal growth modification. T...
Methods of feedback to the patients can range from
completing report cards,
rewarding them for compliant behavior,
verbal ...
4. Rewarding Compliant Behavior
Improving patient compliance in day­to­day practice is very
challenging and often a comple...
A study carried out by Ritcher, Nanda and Sinha et al at
the University of Oklahoma revealed the following
findings regard...
5. Doctor/Patient Rapport and Communication
The successful practice of orthodontics is significantly
dependent on the inte...
Attention to the behavioral issues can greatly enhance the
rapport and can result in superior patient experiences and
trea...
Patient co-operation- how it can be improved?…
( BJO 1997 NOV.)

1) Being polite, friendly and making the patient feel wel...
6) Reassuring the child that you will do everything to prevent
pain

7) Express concern about the child’s well-being
8) Do...
Psychosocial characteristics of patients with facial
deformities
• Children with craniofacial anomalies are more introvert...
• A seriously handicapping orthodontic condition is the one that
“severely compromises a person’s physical or emotional he...
• Research in the areas of self-esteem and attractiveness
indicates that the face is a major source of one’s
psychologic i...
Patients before surgery
•
•
•
•
•

Motives for treatment
A scale to assess patient’s motives
Self-perceptions of facial pr...
Motives for surgery
Parameter

Male

Female

Orthodontist

24(83%)

34(76%)

Family dentist

12(41%)

17(38%)

Other

5(17...
A scale to assess patient’s motives
• Subjective Expected Utility (SEU) Model
– Items are based on interviews with Orthogn...
A scale to assess patient’s motives
Questions

Score

Less difficulty with chewing

3

Stop jaw from clicking

0

Eat food...
Self-perceptions of facial profile
• For all dimensions of facial deformity, patients who accept
surgical treatment view t...
Sex differences
• Broverman and colleagues have found experimental evidence that
women place relatively greater importance...
Response to treatment
• Overall satisfaction with the outcomes is generally high at all
post surgical assessments
• Overal...
Application of research findings to patient
management
-The patients undergoing orthognathic surgery are always within the...
Recommendations for interaction
with patients
There is a need for systematic selection of
patients,
Provide greater psyc...
Pre- and post surgical psycho-emotional aspects of the
orthognathic surgery patient - Bertolini et al
• Levels of pre surg...
Rivera and Hatch (SEM in orthodontics 2000 )evaluated emotional
status of the patient before and after orthodontic and
ort...
Conclusion
An orthodontist who recognizes the emotional
reactions of the patient, not only treat
malocclusion but also psy...
Thank you
www.indiandentalacademy.com
Upcoming SlideShare
Loading in …5
×

Psychologica /certified fixed orthodontic courses by Indian dental academy

562 views

Published on


The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

  • Be the first to comment

Psychologica /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Psychological aspects of orthodontic treatment www.indiandentalacademy.com
  3. 3. Contents Introduction Theories of psychological &behavioral development a. Learning & development of behavior b. Psychosocial theory c. Emotional development theory d. Cognition theory Models of health behavior Emotional Development And Orthodontic Treatment Need Patient compliance a. factors influencing adult cooperation in orthodontic treatment b. predicting patient compliance c. achieving patient compliance Social inequality and discontinuation of orthodontic treatment www.indiandentalacademy.com
  4. 4. Use of educational & psychological principle in orthodontic practice Psychologic factors influencing Orthognathic surgery conclusion www.indiandentalacademy.com
  5. 5. INTRODUCTION Definition:-Psychology is a branch of science which deals with mind & mental processes in relation to human & animal behavior. Social psychology: the scientific study of the way in which peoples thoughts, feelings and behaviors are influenced by the real or imagined presence of other people. www.indiandentalacademy.com
  6. 6. Diagnosis of orthodontic case now includes a greater emphasis on the functional & the psychosocial ramifications Of Dentofacial deformity. At the same time, treatment planning has become a More interactive process between the patient/ parents & the Orthodontist. The important issue is whether the doctor or parent makes the Final decision regarding treatment. This conflict is between paternalism and autonomy Paternalism:- action taken by one person without the second person’s consent. Autonomy:- demands that an individual must consent to take any action taken on his or her behalf and reflects a belief in the merit of individual self-determination. www.indiandentalacademy.com
  7. 7. A series of 297 adolescent patients screened at the university of north carolina listed reasons for taking Orthodontic treatment 1. Appearance of teeth 84% 2. Advice of dentist 52% 3. Appearance of face 41% Teasing about the malocclusion resulted in strong feeling of Unease and harassment significantly more often than did Other types of teasing. Treated children had a greater increase in self-esteem than Untreated controls, which suggests positive effect for Children who are being harassed about their teeth. www.indiandentalacademy.com
  8. 8. Not just the way the teeth fit, Psychosocial and facial considerations, play a role in defining orthodontic treatment need. The clinician must acquire knowledge to develop appropriate behavioral skills with an improved quality of communication and management of patients to treat patient’s Psychological and esthetic needs. www.indiandentalacademy.com
  9. 9. Psychological Development Linked to growth of the brain (cognitive areas) Influenced by genetic factor which is modified by the environment www.indiandentalacademy.com
  10. 10. Theories of Psychology & Behavioural development. Behavior is a result of interaction between innate & instinctual behavior learned after birth. Learning of Behavior. Behavioral responses can be learned by three mechanisms:Classical conditioning. Observational learning Operant conditioning www.indiandentalacademy.com
  11. 11. Classical conditioning:• First described by Ivan Pavlov during his studies on reflexes. • “Learning by Association”.- association of one stimulus with another www.indiandentalacademy.com
  12. 12. Reinforcement Every time they occur, the association between a conditioned and unconditioned stimulus is strengthened. Extinction of conditioned behavior:- if the stimulus is not reinforced Discrimination:- the opposite of Extinction of conditioned Stimulus- i.e generalization between all offices www.indiandentalacademy.com
  13. 13. Operant conditioning:• According to B.F Skinner – Operant conditioning is a significant extension of classical conditioning. • Consequence of behaviour is a stimulus for future behaviour. Stimulus Response Consequence www.indiandentalacademy.com
  14. 14. • Four basic types of operant conditioning:- • Positive Reinforcement:- If a pleasant consequence follows a response, the response has been positively reinforced. Negative Reinforcement:-Involves the withdrawal of an unpleasant stimulus after a response. Omission :- Involves removal of a pleasant stimulus after a particular response. • • • Punishment:-occurs when an unpleasant stimulus is presented after a response. www.indiandentalacademy.com
  15. 15. Observational Learning (Modeling). • This is acquired through imitation of behaviour. • Two distinct stages :-Acquisition -Performance. • Children are capable of acquiring any behaviour they observe. • Performing of an acquired behaviour depends on the role model. www.indiandentalacademy.com
  16. 16. •A child acquires a behaviour by first observing it & then actually performing it. •Important tool in the management of dental treatment. www.indiandentalacademy.com
  17. 17. Theories of Emotional Development  Stanley Hall{1846-1924} is recognized as the founder of Emotional development and Psychology.  He States that "Theories are nothing but more than a set of Concepts and Propositions that allow the Theorist to describe and explain some aspects of experience". It helps to explain various pattern of behavior and emotions.  During 17th and 18th century philosophers states that children are inherited as bad or good or as neither good or nor bad. But in 19th century , theorist noted that positive or negative activity of character depends on child experiences www.indiandentalacademy.com
  18. 18. 1) Nature VS Nurture – Biological process VS Environmental process Theorist advice is think less about nature vs nurture and more about how these two combine or interact to produce developmental changes. 2) Continuous and Discontinuous Development Continuous theorist hold development changes are Gradual and quantitative. It is an additive process that occurs continuously and it is not at all Stage like process. E.g. Erickson Theory Discontinuous theorist proposes that it progress through developmental stages and each of which is a distinct phase of life characterized by particular set of emotions, abilities, motives and behavior that forms a coherent pattern. E.g. Social learning Theory www.indiandentalacademy.com
  19. 19. Psychoanalytic Theory: (Sigmund Freud) Freud hypothesized three structures in the theory of the understanding of the intra psychic process and personality Development. 1) ID 2) EGO 3) SUPEREGO ID: Freud believed that the ID represented unregulated instinctual drives and energies striving to meet bodily needs and desires. They are governed by pleasure principle. The drives are necessary for the survival of the species through procreation and self-defense. E.g. Ideal occlusion for his face. www.indiandentalacademy.com
  20. 20. EGO: It describes as that part of the self-concerned with the overall functioning and organization of the personality through the egos capacity to test reality, the utilization of ego defense mechanisms and of other ego functions such as memory, language, integellence, and creativity. Thus ego is concerned with maintaining a stage in which an adequate expression of ID drives and satisfaction can occur within the constrains of reality and the demands and restrictions of the super ego. E.g. Accepting Camouflage Gabriel AJO1993 Showed low ego strength to be predictive of high compliance in prepubertal children, but predictive of low compliance in adolescents. www.indiandentalacademy.com
  21. 21. SUPER EGO: The super ego is derived from familial and cultural restrictions placed upon the growing child. Freud hypothesized that superego functions were derived from the struggle over the strong feeling of the child. The super ego stems from the internalization of feeling of good and bad, love and hate, praising and forbidding, reward and punishment. E.g. Peer acceptance of wearing braces, elastics, complications of surgery Thus super ego holds the ID in check www.indiandentalacademy.com
  22. 22. Emotional development From infant to adult The Infant :(First year of life) oral phase  Unlike other mammals human infants are totally depend upon another person for survival during a significant period of early childhood. This dependency not only includes physical care but also emotional needs. An infant deprived of Emotional nurturing beyond a critical time period can develop an ANACLITIC (PHYSIOLOGIC) DEPRESSION, MARASMUS, AND MAY EVEN DIE. www.indiandentalacademy.com
  23. 23.  This phase of development is called as SYMBIOTIC PHASE. It will last until 10 months of age, then the separation and individuation will began.  Stranger anxiety is seen a 9-month old child The Toddler (second year of life) Anal phase  During 2nd year of life, child will come in to contact with the REALITY PRINCIPLE. This principle is defined as the regulatory process of the environment over behavior. The reality principle demands that the child delay immediate gratification for a greater gain at a later time www.indiandentalacademy.com
  24. 24. Third year of life  By 3 years of age the child has attained a degree of intelligence, which consist of acquired patterns of cognition, perception and awareness of emotional associations to her or his experiences.  the most important emotional experience the child will cope with is separation anxiety. This is a very awful fear. This is also the period when a sense of AMBIVALENCE, that is love and hate for important people in ones life, is felt.  Ability or inability to separate from the primary caretaker and to relate well with other people will be forever important stage of the adequacy of completion of this early phase of personality development www.indiandentalacademy.com
  25. 25. Second Third Year: (4-6 years) (phallic phase) (Preschool child)  In this period child has to distinguish between reality and fantasy. Children are aware of the sexual parts of their bodies and curious about the meaning of the differences between boys and girls. This curiosity becomes satisfied with the resolution of Oedipal conflict.  The conflict was named by Sigmund Freud after the story of Oedipus rex by Sophocles in the 5th centaury B.C and early childhood of his patients. In this story Oedipus, the king unknowingly kills his father, and marries his mother, the widow.  In girls of this age Electra conflict is seen www.indiandentalacademy.com
  26. 26.  The factor, which inhibits use of their ability to initiate activity is GUILTY. GUILTY is a feeling of fear that ones activities might not be acceptable to oneself as a leftover sense of bad. These feeling often create conflicts manifested by sleep disturbance, nightmares.  Resolution of this struggle usually results when the child accepts the position as a son or a daughter and not a rival to their parents. Thus the child identifies with the parent of the same sex. www.indiandentalacademy.com
  27. 27. Grade school years:(7-12 years)(latency)  This period is also called as latency period.  The child has sufficient self- esteem and initiative to make friends.  They are capable of learning to read and compute numbers.  They have a secure sense of ability to participate in-group games.  They are able to tolerate frustration and anxiety.  They are able to allow themselves to be ruled and guided by standards set by adults if these are not too oppressive. www.indiandentalacademy.com
  28. 28. The most effective of these are 1] Reaction formation 2] Sublimation 1. Reaction formation: Reaction formation is doing the opposite of the desired activity. E.g. Cleanliness and Kindness are representation of reaction formation against the drive to be sloppy or cruel. 2. Sublimation: Sublimation is converting an unacceptable impulse to socially acceptable activity .e.g. Friendship, artistic interests, and competitive sports are example of sublimation of unacceptable aggressive and sexual drives. www.indiandentalacademy.com
  29. 29. Adolescence (12-18years) Adolescence is a psychological state of maturation while puberty is a physical state of maturation. During this period there is a wide difference of level of psychological maturation will develops..  EARLY ADOLESCENCE: 12-14 YEARS OF AGE During this period the child will re-experience the Oedipal conflict and separation conflict in order to resolve the residue of the earlier period. They strive for autonomy and rebel against rules and standards that were previously acceptable. www.indiandentalacademy.com
  30. 30.  MIDDLE ADOLESCENCE: 14-16 YEARS OF AGE This is associated with TURMOIL OF ADOLESCENCE. There is STRUGGLE between dependence and independence, which is greater and adolescent want the best of the both sides. to proceed to the last stage of adolescence, the teenager must free himself of the dependent tie to his parents.  LATE ADOLESCENCE:16-18 YEARS OF AGE During this period the STRUGGLE is more with the self than with the external environment. A Self-sufficient individual independent of his family and capable of filling his own role as a person in society. Thus by the end of adolescence the child develop a sense of identity and true resolution. www.indiandentalacademy.com
  31. 31. Erikson’s theory www.indiandentalacademy.com
  32. 32. Erickson Theory Development of Basic Trust: Birth to 18 months:: Development of the basic Trust depends on caring and consistent mother or mother substitute, who meets both the physiologic and emotional needs for the infants. The strong bond between mother and child is necessary for the child to develop a Basic trust in the world. Maternal Deprivation Syndrome: When the child receives inadequate maternal support, it will fail to gain weight and are retarded in both physical and emotional growth. This is seen in children of broken families or who lived in a series of foster homes. www.indiandentalacademy.com
  33. 33. Basic mistrust: A child who never developed a sense of basic trust will have difficulty in entering into situations that requires trust and confidence in another person. These individuals are extremely frightened and uncooperative. Development of Autonomy: 18 months to3 years ( autonomy vs shame or doubt) Children around the age of 2 years are said to be undergoing TERRIBLE TWOS because of their uncooperative nature. The child is moving away from mother and developing a sense of AUTONOMY OR IDENTITY. He varies between a being a little Devil to Angel www.indiandentalacademy.com
  34. 34. Shame and Doubt  Failure to develop a proper sense of autonomy results in the development of Doubts in the child mind about his ability to stand alone, and this in turn produce doubts about others. Erickson defines the resulting state as one of shame, a feeling of having all ones shortcoming exposed. e.g Bowel control  This stage is considered decisive in producing the personality characteristic of love as opposed to hate, cooperation as opposed to selfishness and freedom of expression as opposed to self- consciousness. www.indiandentalacademy.com
  35. 35. Thus Erickson Quotes "From a sense of self control without a loss of self esteem comes a losing sense of goodwill and pride; From a sense loss of self control and foreign over control come a lasting propensity for shame and doubt".  A key towards obtaining cooperation with treatment from a child at this stage is to have the child think that whatever the dentist wants was his own choice, not something advised by others.  A child who find situation is threatening is likely to retreat to mother and be unwilling to separate from her. It is preferable to do dental treatment when one of the parent present. www.indiandentalacademy.com
  36. 36. Development of initiative(3-6 years) ( initiative vs guilt) During this stage the child continues to develop greater autonomy, but now adds to it planning and vigorous pursuit of various activities. e.g. Extreme curiosity and questioning, aggressive talking, physical activity. A major task for parents and teacher at this stage is to channel the activity into manageable tasks, arranging things so that child is able to succeed, and preventing him or her from undertaking tasks where success is not possible. Guilty: The opposite of initiative is guilt resulting from goals that are contemplated but not attained, from acts initiated but not completed, or from faults or acts rebuked by persons the child respects. www.indiandentalacademy.com
  37. 37. Thus Erickson quotes "The child ultimate ability to initiate new ideas or activities depends on how well he or she thinks without being made to feel guilty about expressing a bad ideas or failing to achieve what was expected". For most children, the first visit to the dentist comes during the stage of initiative. A child at this stage will be intensely curious about the dentist office and eager to learn about the things found there. So going to the dentist can be constructed as a new and challenging adventure in which child can experience success. Success in coping with the anxiety of visiting the dentist can help develop greater independence and produces a sense of accomplishment. www.indiandentalacademy.com
  38. 38. Mastery of skills (7-11years) (industry vs inferiority)  During this period child is learning about the rules by which the world is organized and also he is working to acquire the academic and social skills that will allow him to compete in the environment. The influence of parents as a role model decreases and the influence of the peer group increases.  Thus Erickson quotes "The child acquires industriousness and begins the preparation for entrance into the competitive world. “ But competition with others within a reward system become a reality and also clears that some tasks can be accomplished only by cooperating with the others Inferiority:  The negative side of emotional development can be acquisition of a sense of inferiority. www.indiandentalacademy.com
  39. 39.  Children are usually experienced their first visit to the dentist but some may not. But children at this age are trying to learn the skills and rules that define success in any situation, that include the dental office. A key to guidance is setting attainable intermediate goals, clearly outlining the child how to achieve this goals and positively reinforcing success in achieving these goals. Because the child drives for a sense of industry and accomplishment, cooperation with the treatment can be obtained.  Children at this stage are not motivable by abstract concepts. This means Emphasizing how the tooth will look better as the child cooperates is more likely to be a motivating factor than Emphasizing if you wear the appliance your bite will be better. www.indiandentalacademy.com
  40. 40. Development of personal identity (12-17 years) (identity vs role confusion) Adolescence, a period of intense physical development, and is also the stage in psychosocial development in which a unique personality identity is acquired. Adolescence is an extremely complex stage because of the many new opportunities and challenges thrust upon the teenagers. e.g Emerging sexuality, academic pressures, earning money, esthetic desires, increased mobility, career aspirations and recreational interests combines to produce stress and rewards. www.indiandentalacademy.com
  41. 41. Confusion  During adolescence separation from the peer group is necessary to establish ones own uniqueness and values .As adolescence progress, inability to separate from the group indicates some failure in identity development. This in turn can lead to a poor sense of direction for the future, confusion regarding ones place in society, and low Self esteem.  Most orthodontic treatment is carried out during the adolescent years, and emotional and behavioral management of adolescents is extremely difficult. Since parental authority is being rejected, a poor psycho logic situation is created by orthodontic treatment, if it is being carried out primarily because of the parent needs and not the child. At this stage orthodontic treatment should be instituted only if not to just satisfy their parents. www.indiandentalacademy.com the patients need,
  42. 42. Development of Intimacy (Young adult) (intimacy vs isolation) The adult stage of development begins with the attainment of intimate relationships with other individuals. Successful development of intimacy depends on a willingness to compromise and even to sacrifice to maintain relationship. Other factor that affects the development of an intimate relationship includes all aspects of each person – appearance, personality, emotional qualities, intellect, and others. www.indiandentalacademy.com
  43. 43. Most of the Young adults who seek orthodontic treatment to correct their dental appearance because they perceived their dental appearance as flawed. They may feel that a change in their appearance will facilitate attainment of intimate relationships. On other hand a NEWLOOK resulting from orthodontic treatment may interfere with previously established relationships. Because of these potential problems, the potential psycho logic impact of orthodontic treatment must be fully explained to and explore with the young adult patient before beginning treatment. www.indiandentalacademy.com
  44. 44. Guidance of the next generation (Adults ) (generativity vs stagnation) A major responsibility of a mature adult is the establishment and guidance of the next generation. Becoming a successful parent is not only a major part of this but also services to the group, community and nation. Thus next generation is not only nurturing and influencing ones own children but also supporting the network of social services needed to ensure the next generation success. www.indiandentalacademy.com
  45. 45. Attainment of integrity (Late Adult) (integrity vs despair) At this stage the individual has adapted to the combination of gratification and disappointment that every adult experiences. The feeling of integrity is the feeling that one has made the best of their life. Despair: The opposite of attainment of integrity is Despair. This feeling is often expressed as disguise and unhappiness, frequently accomplished by a fear that death will occur before a life change that might leads to integrity can be accomplished. www.indiandentalacademy.com
  46. 46. Cognition Theory  Cognition refers to the higher mental process involved in understanding and dealing with the world around us.  Cognition includes process like perception, Thinking, Concept formation, Abstraction, and problem solving. Basic to all these processes is intelligence. Intelligence is a score derived from an intelligence test indicating how the individual’s mental ability compares with that of others of the same development age.  Cognition Theory was put forward by Jean Piaget. According to his concept childhood development proceeds from an egocentric position through a predictable, step like fashion. “The child is an active participant with the environment in the constant incorporation and reorganization of Data.” www.indiandentalacademy.com
  47. 47.  The process of adaptation by a child is through Assimilation and Accommodation Assimilation: It describes the ability of the child to deal with new situation and problems within his age specific skills. Accommodation: It describes the ability of the child to adapt and change his way of dealing with the world to handle a problem, which at first may be too difficult at his particular age and skill. Through this continuous dual process the child is constantly building various hierarchies of related behavior, which Piaget called Schemata. www.indiandentalacademy.com
  48. 48. Schemata represent a dynamic process of differentiation and reorganization of knowledge, with the resultant evolution of behavior and cognitive functioning appropriate for the age of the child. Piaget delineated four periods of Cognition growth, each characterized by distinct type of thinking and in which the child successfully relies more upon internal stimuli and symbolic thought and less upon external stimulation. www.indiandentalacademy.com
  49. 49. Sensorimotor Period: (0-2 year) During the first 2 year of life, a child develops from newborn infants who are almost totally dependent on reflex activities to an individual who can develop new behavior to cope with new situation. During this stage child will develop a rudimentary concepts of objects, including the idea that object in the environment are permanent; they do not disappear when the child is not looking them. The child has little ability to interpret sensory data and a limited ability to project forward or backward in time. www.indiandentalacademy.com
  50. 50. Preoperational period: (2-7year) During the preoperational period, the capacity develops to form mental symbols representing things and event not present, and children learn to use words to symbolize these absent objects. During this period child can understand the world in the way of 5 primary senses. 1) Feel 2) Smell 3) Hear 4)Taste 5) Concepts that cannot be seen They feel difficult to interpret Time and health. Thus child can understand language in a literal sense i.e. words only they have learned. www.indiandentalacademy.com
  51. 51. Features of Thought process 1) Egocentrism 2) Animism Egocentrism: It is defined as the inability of the child to assume another persons point of view. Because of this the child can only manage his own perspective and assumes another’s view is simply beyond his mental capabilities. Animism: It is defined as projection of inanimate object with life i.e. everything seen as being alive by a young child, and stories that invest with life are quite acceptable to children of this age. www.indiandentalacademy.com
  52. 52. Most of the thumb sucking patients fall in to this category of age. Since the child’s view of time is centered around the present, and he is dominated by how things look, feel, taste, and sound now, there is also no point in talking to a 4 year old about how much better his tooth will look in the future if he stops thumb sucking. At the same time it would not be useful to point out to the child how proud his father would be if he stopped thumb sucking, since the child would think his fathers attitude was same as the child (Egocentrism). Telling him that the teeth will feel better now or talking about how bad his thumb tastes . www.indiandentalacademy.com
  53. 53. Period of concrete operations: ( 7 – 11year)  During this stage, the ability to see another point view develops, while animism declines. The child’s thinking is still strongly tied to concrete situations and the ability to reason on an abstract level is limited. Presenting ideas as abstract concepts is difficult to understand than illustrating them with concrete objects.  E.g. It will be too abstract "Now wear your Functional appliance or retainer every night and be sure to keep it clean.” More concrete direction would be " this is your retainer.” Put it in your mouth like this and take it out like that. Put in every evening right after dinner before you go to bed, and take it out before breakfast every morning. Brush it like this with an old toothbrush to keep it clean. www.indiandentalacademy.com
  54. 54. Period of Formal operations: (11 years – adult)  The ability to deal with abstract concepts develops by the age of 11 years. They can understand the concepts like health, disease and preventive treatment.  In addition to the ability to deal with abstractions, teenagers have developed cognitively to the point where they can think about thinking.  When an adolescent consider what others are thinking about, he assumes that others are thinking about the same thing he is thinking about, namely himself. They feel they are constantly onstage being observed and criticized by those around them. Elkind has called this phenomenon the IMAGINARY AUDIENCE. www.indiandentalacademy.com
  55. 55.  The imaginary audience is a powerful influence on young adolescents, making them quite self-conscious and susceptible to peer influence. They are very worried about what peer will think about their appearance and actions, not realizing that others are too busy with themselves.  The reaction of the imaginary audience to braces on his teeth is an important consideration to a teenage patient. They are very susceptible to suggestions from their peer group. In some setting they tend to please for tooth colored plastic or ceramic brackets at other times bright colored Ligatures and elastics have been their tempt. www.indiandentalacademy.com
  56. 56. Behavior is an observable act. It is defined as any change observed in the functioning of an organism. Learning as related to behavior is a process in which past experience or practice results in relatively permanent changes in an individual’s behavior. Behavioral dentistry is an interdisciplinary science, which needs to be learned, practiced and reinforced in the context of clinical care and within community oral health care system. The objective of this science is to develop in a dental practitioner an understanding of the interpersonal, intrapersonal, social forces that influence the patients’ behavior www.indiandentalacademy.com
  57. 57. Models of health behavior (sem in ortho 2000)     Models of health behavior and Their implication for orthodontic treatment Health belief model Theory of planned behavior Self-regulation theory Stages of change model www.indiandentalacademy.com
  58. 58. 1. HEALTH BELIEF MODEL   This  model  proposes  that  an  individual’s  beliefs  are  important  determinants of his/her health-related behavior.  Four sets of beliefs are thought to predict health-related behavior 1. Perceived susceptibility to disease or problem 2. Perceived severity of the problem 3. Perceived benefits of health behaviors, and 4. Perceived barriers to health-enhancing behaviors.   www.indiandentalacademy.com
  59. 59. 2. THEORY OF PLANNED BEHAVIOR   This theory proposes that people are reasonable and make  decisions about health-related behavior by using available  information to achieve a desired goal. . Patient Intention is influenced by 3 factors  The person’s attitude toward the behavior (e.g., “I don’t like wearing the cumbersome device that make me look different”),  Social influences on the behavior (“People will make fun of me”)  The person’s perceived behavioral control, which reflects a person’s perceived ability to overcome obstacles and is influenced by their past www.indiandentalacademy.com behavior.
  60. 60. As in the health belief model, both internal events such as attitudes  and environmental factors including social pressure and perceived  obstacles  influence  the  behavior,  but  in  Planned  behavior  they  do  so  by  determining  whether  the  person  intends  to  perform  the  behavior.   Clear  implication  of  this  model  is  that  assessing  a  patient’s  intentions to adhere to the treatment regimen can be an important  first  step  in  identifying  potential  noncompliance.  If  intentions  to  change behavior are low, and then interventions to alter attitudes or  increase behavioral control may be indicated. www.indiandentalacademy.com
  61. 61. 3. SELF-REGULATION THEORY   This theory suggests that individuals regulate their own behavior  using the following 3 processes:   First, individual monitor both the determinants and outcomes of  First their behavior. For example, a patient evaluates why he or she is  wearing  appliance  (“Because  the  doctor  told  me  to.”),  and  monitors  the  outcome  of  that  behavior  (“I  feel  like  I’m  taking  good care of my teeth.”).   Second,  patients  evaluate  their  behavior  based  on  personal  Second standards  (“I’m  doing  pretty  well  for  me.”)  and  environmental  conditions  (“Understands  the  circumstances,  I  can’t  be  expected  to do much better.”)   www.indiandentalacademy.com
  62. 62. Third,  patients  adjust  their  behavior  depending  on  how  it  Third compares with these personal standards (“I am really not doing  as well as I can”).   Thus,  this  theory  proposed  reciprocal  interactions  among  behavior, the environment and personal factors, such as internal  standards  and  cognitive  process.  One  central  concept  in  selfregulation theory is self-efficacy, which refers to the belief that  one can produce a desired outcome through one’s own efforts.   www.indiandentalacademy.com
  63. 63. 4. STAGES OF CHANGE MODEL   This model proposes that people progress through 5 stages when  making a behavior change, Broder and Phillips et al apply this  al model to understanding decisions regarding treatment  First stage is pre-contemplation, which people typically fails to  stage acknowledge the need for behavior change and have no intention  of changing their behavior.   Second stage, contemplation, individuals recognize a need for  stage change and are considering a change in behavior, but have not yet  taken any steps in that direction www.indiandentalacademy.com
  64. 64.   Third stage is preparation, and this stage involves making specific  stage plans for behavior change.   Fourth stage, action, involves implementing those plans, and this is  stage the first stage in which overt behavior change occurs.   The  final stage  is  maintenance,  in  which  people  are  attempting  to  stage sustain the behavior changes that they have made. An important implication of this model is that patients at different  stages will require different interventions assist them with  behavior change.    An important implication of each of these models is that patients’  attitude, thoughts, feelings, and perceptions are important  determinants of their behavior.  www.indiandentalacademy.com
  65. 65. Based on these theoretical models, the following recommendations for clinical practice are suggested.   1. Assess patients’ intentions to adhere to treatment regimens  (e.g. “How often do you plan to brush and floss?”). One can  be  relatively  sure  that  if  intentions  to  change  behavior  are  low, then the likelihood of behavior change is also very low.  In these instances, educational or behavioral interventions to  increase intentions and promoter adhere will be needed. 2.  Assess  patients’  self-efficacy  for  successfully  completing  the prescribed treatment (e.g. “How capable do you feel you  are of using this appliance as prescribed?”). If patients doubt  their ability, then additional instruction and in office practice  in the required behavior are indicated.  www.indiandentalacademy.com
  66. 66. 3.  Be  aware  that  the  patient  seek  treatment  at  very  different  points  along the stage of change, and parents and children may also differ in  their  readiness  for  change.  Treatment  should  be  initiated  only  when  the patient reports being ready to assume the responsibility and make  the  behavioral  commitment  required  to  successfully  complete  treatment. 4.  Try  to  identify  barriers  to  compliance  with  treatment  recommendations.  These  may  include  personal  characteristic  of  the  patients  (e.g.  age,  education  level,  socioeconomic  status)  or  environmental factors, such as high levels of psychosocial stress or a  lack of understanding the importance of treatment.  www.indiandentalacademy.com
  67. 67. When  these  barriers  are  identified,  steps  should  be  taken  to  reduce the barriers or to tailor treatment around the barriers.  5.  Treatment  plans  should  incorporate  the  priorities  and  capabilities  of  the  patient.  This  approach  allows  patients  to  participate  in  the  decision  making  process  and  further  the  patient’s  commitment.  In  cases  in  which  patient  decision  conflicts  with  professional  standards,  limitations  of  the  selected  treatment  plan  should  be  presented.  Options  including  non-treatment  should  be  presented  to  the  patient  and parent.   www.indiandentalacademy.com
  68. 68. Psycho-orthodontic theory (A.j.o –Do 1981 dec 604-622) This theory was put forwarded by El-Mangoury. Motivation is a very broad psychological term which describes a hypothetical construct which aims to explain the reason for the stream of a goal-directed behavior driven by specific or nonspecific forces. A) Achievement motivation can be defined as the motivation characterized by striving for success in any situation in which standards of excellence apply. www.indiandentalacademy.com
  69. 69. B) Affiliation motivation of orthodontic patients was defined as a hypothetical construct of seeking orthodontic care for the purpose of improving the dento facial esthetics in order to facilitate the connection or association of oneself with other people for obtaining, maintaining, and/or restoring close interpersonal relationships. C) Attribution motivation can be defined as the motivation for perceiving the causes of success and failure, either internally (that is, to the self) or externally (that is, outside the self). www.indiandentalacademy.com
  70. 70. 1. Orthodontic cooperation is predictable through psychological testing. 2. High-need achievers cooperate better orthodontically than lowneed achievers. 3.A patient who is a good brusher does not have to be a good headgear wearer, and vice versa 4. Affiliation motivation seems to contribute the most in prediction of headgear wear, elastic wear, appliance maintenance, nonbroken appointments, and punctuality in appointments. 5. Achievement motivation appears to contribute the most for predicting oral hygiene. 6. Attribution motivation was not effective in predicting variables www.indiandentalacademy.com
  71. 71. Emotional Development And Orthodontic Treatment Need Body Image Self Concepts Body Image: Body image of the patient is classified in to "body sense" and "body concept.'' Body sense refers to the actual appearance the person sees when viewing him in a mirror or photograph. Body concept is the internal process of how the patient feels about his appearance. www.indiandentalacademy.com
  72. 72. Parents Culture Peers Body Image Ethnicity Teachers www.indiandentalacademy.com
  73. 73. Parents, Teachers and peers The earliest influences on a child’s body awareness are a parent or other caregiver’s physical and emotional interaction with the child. As the child’s world expands teachers and peers respond to his or her physical appearance. These messages may reinforce each other and the child’s subjective assessment or may conflict the child’s own perceptions. By integrating these appraisals (and in some cases by ignoring objective judgments) the child develops a cognitive representation of the self, a body image. www.indiandentalacademy.com
  74. 74. Culture and Ethnics A person's response to dental-facial attractiveness can be viewed as a type of psychosocial response to occlusal status. As such, psychosocial responses to dental-facial esthetics have a cultural emphasis. It is important to assess objectively the degree to which a person's dental-facial appearance deviates from the cultural norm. Thus, there is a rational and empirical basis for including an assessment of dental-facial appearance when evaluating the need for orthodontic treatment. Thus Ethnic and cross culture factors play a role in the development of a body image www.indiandentalacademy.com
  75. 75. Self concept Body Image Accomplishment •Academic •Athletic Social Competence Self Concepts Self Esteem www.indiandentalacademy.com
  76. 76. Self Concepts Self Esteem Desire to Change •Appearance •Accomplishment •Social Skills SELF ACCEPTANCE www.indiandentalacademy.com
  77. 77.  To the extent that the child holds himself or herself in high regard, there is greater self- acceptance and the desire to maintain the status ego. For such children, an orthodontist’s recommendations or a parents encouragement to obtain orthodontic treatment may be futile because the child is satisfied with his or her appearance, no matter how far outside the range of “ideal” or even normal his dentofacial features may lie. In such cases, if the child is forced by the parents to receive treatment, cooperation during active treatment and adherence to long term treatment recommendations may suffer. www.indiandentalacademy.com
  78. 78.  In contrast, for many children whose self-acceptance is not very high, the desire to chance one or more components of selfconcept may be great. Those who can identify the malocclusion or poor dentofacial disharmony as the source of their dissatisfaction are more highly motivated to obtain orthodontic treatment and are better risks for long-term cooperation and adherence to treatment protocol. www.indiandentalacademy.com
  79. 79.  It behooves the orthodontist to recognize these differences, to identify children who attend the initial orthodontic consult willingly versus those who are coerced by parents or other concerned adults, as well as those whose own & whose parents motives are unrealistic and inconsistent with the type of malocclusion presented. This requires an honest discussion with the child, perhaps with the parent listening but not participating in the session . www.indiandentalacademy.com
  80. 80.  Questioning the child about his or her areas of satisfaction with the face and other aspects of the self , motives for and concerns about treatment , and whether or not the child understands his or her responsibilities during each phase of treatment can prevent failure in the case of children who are unprepared or , more importantly , those who have few intrinsic motives for seeking orthodontic intervention . www.indiandentalacademy.com
  81. 81. COMPLIANCE (sem in ortho 2000)   As suggested by Haynes: Compliance is "the extent to which  Haynes a person's behavior (in terms of taking medications, following diets,  or  executing  lifestyle  changes)  coincides  with  medical  or  health  advice.   Orthodontists  ask  patients  to  behave  in  ways  that  will  maximize  the  likelihood  of  achieving  the  orthodontic  treatment  objectives.  For  example,  patients  are  asked  to  keep  their  appointments,  adhere  to  dietary  restrictions,  modify  their  oral  hygiene  practices,  and  follow  complicated  treatment  regimens  that  include  the  use  of  elastics, headgears, and other removable appliances. www.indiandentalacademy.com
  82. 82. When  a  patient  deviates  from  these  therapeutic  recommendations,  the  presumption  is  that  the  likelihood  of  achieving the desired goals is reduced.  There  are  a  myriad  of  strategies  for  dealing  with  patient  noncompliance. The strategy a clinician chooses is often influenced  by how he or she conceptualizes the cause(s) of poor compliance.  An  example  of  this  comes  from  an  early  view  of  noncompliance  that  suggested  it  resulted  from  a  character  "flaw"  that allowed an individual to deviate from a therapeutic regimen that  was intended for his or her own benefit. www.indiandentalacademy.com
  83. 83. Self-Regulation Approach to Orthodontic Patient Compliance  Self-regulation principles are being applied in diverse areas of  clinical psychology and have been particularly useful in guiding  work on compliance problems in orthodontics.  The component parts of a simple self-regulation model for patient  compliance are:     Negative Feed back loop www.indiandentalacademy.com
  84. 84. A regulatory model of patient compliance suggests that poor  compliance can result from a variety of factors 1. PATIENT DOES NOT KNOW THE THERAPEUTIC REGIMEN 2. PATIENT UNAWARE OF THE RECOMMENDED REGIMEN 3. POOR MOTIVATION OF PATIENT www.indiandentalacademy.com
  85. 85. Current  orthodontic  research  focuses  on  a  critical  aspect  of  the  feedback;  specifically,  the  input  received  by  the  comparator  that  quantifies the actual amount of adherent behavior. This aspect of the  feedback loop is particularly problematic  because  when  asked how  many hours a headgear has been worn, patients do not know how to  estimate the total.  Likewise, orthodontists cannot reliably estimate the amount of wear  and  parents  are  not  sure  of  their  child's  degree  of  appliance  use.  Patients,  parents,  and  clinicians  need  a  way  to  ascertain  this  information. Technology  may  provide  the  solution  to  this  problem  as  it  has  in  Technology other  areas  of  patient  compliance.  Research  suggests  that  patients  receiving feedback about their degree of compliance are better able  to follow a recommended regimen. www.indiandentalacademy.com
  86. 86. Measuring Headgear Use Orthodontists are understandably interested in the amount of time a  headgear is worn.  Typical  clinical  methods  for  estimating  the  amount  of  headgear  wear include:   evaluations of proxy measures of compliance (e.g., oral       hygiene)    condition of the appliance (e.g., a worn-looking neck     strap), mobility of the molar    ease of patient use, and    direct patient inquiry either verbally or by questionnaire.  www.indiandentalacademy.com
  87. 87. Unfortunately,  such  methods  are  poor  and  commonly  provide  an  overestimate  of  compliance.  There  is  a  clear  need  for  a  reliable  method of measuring the time a headgear has been worn and there  have been numerous attempts to pro-duce such a device. Northcutt introduced the first timing headgear in 1974. The timer  Northcutt consisted of 2 switches that were activated when the appliance was  worn and accumulated wear time until the appliance was removed.   A  study  by  Banks and Read,  found  that  only  4  of  13  head-gear  Read timers were accurate more than 90% of the time.   www.indiandentalacademy.com
  88. 88. A conceptual model of factors influencing orthodontic treatment decisions Patient’s Perceptions of Dental-facial attractiveness Patient’s Perceived Need for treatment Develop over Time as a Function of a. parent’s dental Facial appearance b. Social norms c. Social feedback Develops as a result Of a. Perceptions of Appearance b. parents’ Perceptions of Treatment need c. Professional Evaluations of occlusion www.indiandentalacademy.com Parent’s -Percieved need for treatment -Positive perceptions of treatment efficacy -relative value of treatment Decision to obtain treatment Orthodontists:-Professional evaluation of treatment -Understanding of Patient’s desire for treatment
  89. 89. CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT PRE-TREATMENT EARLY IN  TREATMENT THROUGH  TREATMENT CHILD  Perceives functional/    esthetic impairment  Perceives need for     treatment/desires     treatment  Develops realistic      expectations  Learning     coping/control     strategies  Assumes control of     behavior related to effect     outcomes of treatment  Shares responsibility for      treatment outcomes PARENTS  Perceives need for        treatment  Believes in efficacy of           treatment  Places high value on       occlusion/treatment  Enables treatment  Takes interest in     treatment  Encourages homecare      Supports and approves     child’s active       participations and     responsibility in     treatment ORTHODONTIST  Professionally evaluates      treatment needs  Seeks to understand     patient and parent     perceptions  Communicates  goals,     expectations, potential     problems in treatment  Engages parent and     patient in goals,      expectations  Acknowledges patient     and parent perceptions  Develops partnership     with patient  Shares responsibility      with patient for progress,     setbacks, outcomes of     treatment www.indiandentalacademy.com
  90. 90. PREDICTING PATIENT COMPLIANCE IN ORTHODONTIC TREATMENT To  ensure  efficient  clinical  management  of  orthodontic  patients,  it  is desirable to identify factors, which would enable the orthodontist  at  the  early  stages  of  treatment  to  predict  the  patient's  subsequent  behavior and compliance.  Predicting patient compliance Demographic aspect Psychosocial aspect Age 1. Education Gender 2. Parent’s attitude Socioeconomic status 3. Patient’s personality www.indiandentalacademy.com
  91. 91. 1. DEMOGRAPHIC ASPECT In  the  search  for  potential  predictors  of  treatment  compliance,  considerable  attention  has  been  directed  toward  evaluation  of  patients' demographic characteristics.        Patient Age: Allan et al (AJO 1968) studied that patient's age was found to be  1968) the best predictor of cooperation.   In  contrast,  studies  by  Albine and Sergl et al (EJO 1992)  have  1992) revealed  no  correlation  between  patients'  age  and  the  level  of  compliance   www.indiandentalacademy.com
  92. 92. Gender: Kreit and Starnbach et al  have  emphasized  that  the  patient's  al gender  might  help  predict  treatment  compliance  demonstrating  that  female  patients  tend  to  show  better  cooperation  compared  with males.   Studies  by  klima et al (AJO 1979)  suggest  that  in  contrast  to  1979) boys, girls tend to express lower body image satisfaction and are  more likely to be displeased, with their dental appearance www.indiandentalacademy.com
  93. 93. Socioeconomic status: Several investigations have addressed the issue of potential  influence of patients' socioeconomic status on their  compliance with orthodontic treatment.  Cucalon and Smith et al (ANGLE 1989) reported that  1989) female patients from higher socioeconomic groups show the  highest compliance levels.  Dorsey and Korabik et al (AJO1977) have indicated  (AJO1977) superior compliance shown either by children of civil servants  compared with those of working class and self-employed  parents, or by children of factory workers in contrast to  offspring's of intellectuals.  In contrast Sergl et al (EJO 1992) reported, no evidence of  1992) potential effects of parental occupational status on children's  compliance. www.indiandentalacademy.com
  94. 94.   2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS Considerable  attention  has  been  devoted  to  evaluation  of  the  effects of patients' psychologic traits and psychosocial background  on  compliance  during  orthodontic  treatment.  It  is  generally  believed  that  patient's  personality  characteristics,  his  or  her  relationships  with  the  family,  peers  and  orthodontist,  as  well  as  performance  at  school  are  closely  linked  with  compliance,  and  might  serve  as  valuable  sources  of  information  regarding  both  prediction and management of compliance www.indiandentalacademy.com
  95. 95. EDUCATION LEVEL: Richter, Nanda and Sinha  et  al  (ANGLE  1996)  reported  that  1996) cooperative  orthodontic  patients  tend  to  have  better  grades  and  show less deviant behavior at school, they are less frequently truant  from  school,  are  considered  academically  brighter  and  more  sociable by their teachers, and reveal higher levels of self-perceived  cognitive  competence.  On  these  grounds,  patients'  scholastic  performance  might  serve  as  a  useful  predictor  of  treatment  compliance.   Dausch and Neumann et al observations indicate that children of  al above-average  intelligence  are  more  cooperative  during  treatment,  which, however, does not necessarily imply that children of belowaverage intelligence show poor compliance, because both variables  appear  to  depend  strongly  on  a  number  of  other  psychosocial  factors.  www.indiandentalacademy.com
  96. 96. PARENTS ATTITUDE: Mehra et al (ANGLE 1996) suggested that parental beliefs are  1996) important  for  a  child's  compliance,  and  that  assessment  of  the  child-parent  relationship  may  help  predict  the  level  of  cooperation.  How-ever,  it  appears  from  other  studies  that  a  child's  personal  psychologic  characteristics  may  be  a  more  decisive factor determining the level of treatment compliance.   Nevertheless,  parents  seem  to  play  a  prominent  role  in  influencing a child's decision to seek orthodontic treatment, and  parental  attitudes  influence  the  child's  compliance  in  the  earlier  stages of treatment.  www.indiandentalacademy.com
  97. 97. Study  by  Nanda and Kierl et al (AJO 1992)  evaluated  several  1992) factors of potential relevance to compliance prediction.  Treatment-related psychosocial factors such as patient's and parents'  treatment  attitudes  and  expectations,  or  relationships  between  the  child, parents and orthodontic practitioner, were investigated.  These  observations  imply  that  development  of  an  effective  relationship  between  the  orthodontist  and  the  patient  at  the  earliest  stages of treatment is beneficial for future compliance, and that the  orthodontist's perception of his or her interpersonal relationship with  the patient may be useful in predicting compliance. www.indiandentalacademy.com
  98. 98. PATIENTS PERSONALITY Substantial  evidence  has  accumulated  suggesting  that  patients'  personality  characteristics  are  important  for  the  individually  attainable level of treatment compliance.  Studies  dealing  with  the  psychologic  assessment  of  patients  undergoing  orthodontic  treatment  have  out-lined  psychologic  profiles of uncooperative and cooperative patients.    Sergl et al  compared  extraordinarily  cooperative  orthodontic  al patients  with  patients  rated  by  their  clinicians  as  highly  uncooperative. www.indiandentalacademy.com
  99. 99. Specific psychologic diagnostic tests were used for evaluation of  patients'  cooperation,  responsibility,  reliability,  and  endurance  during  treatment.  The  results  indicated  that  irrespective  of  gender, the patients who tend to be uncooperative are inclined to  attitudinal  preferences  conventionally  regarded  as  masculine,  which  are  expressed  as  active,  aggressive,  and  realistic  behavioral  patterns  and  self-images,  rather  than  sensitive,  esthetic and idealistic ones. Allan and Hodgson (AJO 1968)  reported  that  patients  more  1968) likely  to  show  higher  levels  of  treatment  compliance  are  enthusiastic,  outgoing,  energetic,  self-controlled,  responsible,  trusting, diligent, and obliging persons.   www.indiandentalacademy.com
  100. 100.   PERSONALITY TEST Personality  tests  have  been  used  by  a  number  of  investigators,  generally with the goal of being able to predict patient cooperation  by identifying particular personality types.    Both  Gabriel  and  McDonald  used  the  California  Test  of  Personality. This test purports to measure a number of psychosocial  domains,  such  as  self-reliance,  sense  of  personal  worth,  or  social  skills.   Gabriel  (ANGLE  1965)  found  a  low  correlation  between  the  1965) scores  from  items  of  the  California  Test  of  Personality  and  a  post  treatment,  subjective  assessment  of  motivation.  He  believed  this  correlation was too low to be predictive.  www.indiandentalacademy.com
  101. 101. McDonald  reported  a  significant  correlation  between  scores  McDonald on the California Test of Personality and patient cooperation.   Southard and Tolley (AJO 1991) examined the feasibility of  1991) using  a  commercially  available  adolescent  personality  test  to  predict  the  behavior  of  adolescent  patients  in  an  orthodontic  practice. Specifically, this study tested  1. the  use  of  the  Million  Adolescent  Personality  Inventory  (MAPI)  as  an  appropriate  instrument  for  an  adolescent  orthodontic population and 2. the correlation between MAPI test results and orthodontic  compliance.  Authors  concluded  that  the  MAPI  has  potential  as  a  useful  instrument  in  assisting  the  management  of  adolescent  patient  behavior in an orthodontic practice. www.indiandentalacademy.com
  102. 102. Initial Experience With Orthodontics and Acceptance of Treatment As patients may experience a considerable amount of discomfort  from  orthodontic  treatment  it  is  reasonable  to  expect  that  patients' initial experience with orthodontic treatment, adaptation  to it and its acceptance at an early stage might strongly influence  the degree of compliance at the subsequent stages. It  is  recognized  that  insertion  of  a  new  orthodontic  appliance  may  diminish  cooperation  by  causing  considerable  discomfort  such as unpleasant tactile sensations, feeling of constraint in the  oral  cavity,  stretching  of  the  soft  tissues,  pressure  on  the  oral  mucosa,  displacement  of  the  tongue,  sore-ness  of  the  teeth  and  pain. www.indiandentalacademy.com
  103. 103. Pain,  functional  and  esthetic  impairment,  and  associated  complaints  are  the  principal  reasons  for  the  patient's  wish  to  discontinue treatment. The  patient's  self-confidence  might  be  affected  by  speech  impairment  and  visibility  of  the  appliance,  especially  during  social interactions when attention is focused on the face, eyes  and mouth. www.indiandentalacademy.com
  104. 104. Effects of appliance type on oral complaints, such as higher  degree of pain or speech impairment during wearing of the bionator  and  the  head-gear,  increased  incidence  of  perceived  pain,  tension,  sensitivity, and pressure under treatment with functional and fixed  appliances, or differences in initial acceptance of various designs of  functional appliances, have been described for non-compliance.  It  seems  likely  that  because  of  different  experiences  encountered, the type of appliance may have a substantial effect on  initial  adaptation  and  should  also  be  considered  in  compliance  prediction. www.indiandentalacademy.com
  105. 105. General  personality  variables  and  specific  attitudes  to  orthodontics seem to play an important role.   Sergl et al (AJO 1980)  indicated  that  patients'  attitudes  toward  1980) orthodontics  at  the  beginning  of  treatment  may  predict  their  capability to accommodate to initial discomfort associated with an  orthodontic  appliance,  which  in  turn,  may  predict  the  patient's  acceptance  of  the  appliance  and  the  degree  of  subsequent  compliance.  Appliance  adaptation  and  treatment  acceptance  or  denials  are  short-  term  events  occurring  within  a  few  days  after  the initiation of treatment.    This  evidence  suggests  that  attention  of  the  treating  clinician  to  patients' adaptation is necessary at the earliest treatment stages, to  ensure and enhance future compliance. www.indiandentalacademy.com
  106. 106. SOCIAL INEQUALITY & DISCONTINUATION OF ORTHODONTIC TREATMENT Social inequality influences general health, dental disease, and dental health-related behavior. However, reports on any links between orthodontics and social inequality are more equivocal. Registrar General’s social class groupings (by occupation of head* of household) Social class Definition and examples I Professional e.g. medical, dental, II IIIN Veterinary, and legal professions, chartered Engineers and accountants Intermediate and managerial e.g. school teachers Nurses, police officers, secretaries, publicans Skilled non-manual workers e.g. clerks, Draughtsman, shop assistants, travel agents www.indiandentalacademy.com
  107. 107. IIIM Skilled manual e.g. carpenters, electricians, Welders, instrument artificers, police constables, IV Semi-skilled e.g. lathe operators, process workers, Postmen/ women V Unskilled workers e.g. laborers, dustmen, Domestics Classification by occupation used by Rölling (1982) A. B. C. D. E. farmers Low e.g. unemployed, unskilled manual Lower middle—skilled manual Middle e.g. shop assistants, clerks, small self-employed Upper middle e.g. superior employees, shop owners, Upper e.g. academics, managers www.indiandentalacademy.com
  108. 108. Results:The results showed that discontinued cases were: 1. Less likely to have been treated with fixed appliances 2. A little older at start, on average 3. More likely to have been asked to wear EOT/EOA/‘headgear’ 4. More often from lower social class backgrounds 5. Less likely to have been treated by an orthodontically qualified practitioner 6. More likely to have attended practices in relatively deprived areas. www.indiandentalacademy.com
  109. 109. Psychological aspects of orthodontic treatment Dr. I. ROHINI www.indiandentalacademy.com
  110. 110. ACHIEVING PATIENTS COMPLIANCE                         (sem in orthodontics 2000 dec) Patient noncompliance is a limiting factor in the conversion  of  accurate  orthodontic  treatment  plans  to  excellent  treatment  results.  A  variety  of  treatment  techniques  have  been  devised  to  overcome this barrier in the attempt at obtaining good results.  Despite  earlier  claims  made  by  the  proponents  of  these  techniques, it is abundantly clear that none of these techniques are  completely successful without the patient's participation.  www.indiandentalacademy.com
  111. 111. In addition, many of these "noncompliant" techniques have  now reverted back. E.g.,traditional methods of anchorage control by  headgear and elastics for a portion of the treatment period. Factors Influencing Orthodontic Patient Compliance  During  the  initial  treatment  stages,  the  parent's positive attitudes toward orthodontic treatment predict patient compliance.  In  the  later  stages,  the  patient's own cognition  regarding  treatment directly correlates with compliance levels.    Those  patients  who  believe  that  their  actions  directly  lead  to  superior  treatment  results  are  better  compliers  compared  with  those  who  believe  that  they  do  not  have  control  over  treatment  outcomes.           Parent’s previous orthodontic experience          Financial implications          Doctor- patient relationship www.indiandentalacademy.com
  112. 112. Various prevention and improvement concepts that can positively affect orthodontic patient compliance are: A  shift  from  a  practitioner-centered  model  of  patient  care  to  a  patient-centered approach is emphasized. It include:  1. 2. 3. 4. 5. Patient-centered care versus practitioner-centered care, Patient’s causal attributions, Patient support at home and at the orthodontic office, Rewarding compliant behavior, and Doctor-patient rapport and communication www.indiandentalacademy.com
  113. 113. 1. Patient-Centered Care versus Practitioner Centered Care  Traditionally, orthodontic treatment prescribed by the practitioner  based  on  defined  professional  standards  without  considering  the  priorities and capabilities of the patient.  Patients  who  fail  to  follow  prescribed  instruction  are  labeled  as  "noncompliant."  This  is  often  done  without  considering  the  fact  that  the  treatment  prescribed  may  not  have  taken  into  account  the  capabilities,  motivations, and expectations of each individual patient.  Hence,  patients  have  had  to  bear  the  burden  and  the  outcome  of  noncompliance  rather  than  considering  the  inability  of  the  practitioner  to  understand  individual  patient  needs  and  to  make  appropriate treatment plans. www.indiandentalacademy.com
  114. 114. A patient-centered approach would place some of the responsibility  of successful patient compliance on the practitioner. In this model,  the  practitioner  would  prescribe  treatment  plans  based  on  individual patient expectations, priorities, and capabilities Repeated  treatment  progress  re-evaluations  and  patient/parent  consultations  are  a  key  component  of  success  in  this  proposed  model.  In the orthodontic treatment realm, key issues that relate to  this concept fall within the following:   (1) Patient education and (2) Patient empowerment and contracting procedures. www.indiandentalacademy.com
  115. 115. Patient Education Patient management may be greatly enhanced when patients understand the nature of their condition and the proposed treatment plan or procedure to be performed. Educating the patient regarding his or her malocclusion and the means to achieve an acceptable result is very important to success in motivating the patient to succeed. Often treatment is prescribed for patients who have limited or no understanding of their orthodontic problem and why some aspects of treatment mechanics are necessary for successful outcomes. www.indiandentalacademy.com
  116. 116. At the same time, parents may not be clear about treatment goals and mechanics. In addition, the parents' ability to explain details of the condition and the necessity for different appliances to their children may also be limited. The result is a patient who is less likely to achieve a successful treatment outcome. A strong effort to educate patients regarding their condition will allow them to make informed choices regarding appliance selection and the limitations of their selection. As treatment progresses, the' education component needs to be revisited to ensure their complete understanding. This will result in individuals who take greater responsibility for their actions during orthodontic treatment. www.indiandentalacademy.com
  117. 117. Various demonstration tools are available to aid in the education process. Good standard patient records such as study casts and photo­graphs can be used to describe the problem.  A presentation customized for the patient by different commercially available computer software programs is an excellent method for explaining mechanics and appliances.  The use of demonstration models and appliances are important for the patient to completely understand different appliances. In addition, the practitioner can prepare a database of examples that can be digitally stored and used for these presentations. www.indiandentalacademy.com
  118. 118. USE OF EDUCATIONAL –PSYCHOLOGICAL PRINCIPLES IN ORTHODONTIC PRACTICE …….. (AJO 2001 JUNE, VOL.119 NO 6) The principles that will be discussed are: • Progressions • Backward chaining • Shaping (close approximation) • Reframing (symptom prescription, reverse psychology) • Reinforcement theory • Hypnosis • Kinesthesia • Learning by doing www.indiandentalacademy.com
  119. 119. PROGRESSIONS:Progression learning involves segmenting the skill to be learned into a number of simple and sequential component parts, or progressive steps. Progressions are used when learning complex skills. This includes both cognitive and psychomotor skills. For example, teaching a patient to insert a cervical headgear for the first time could be sequenced BACKWARD CHAINING Backward chaining is the educational principle that incorporates stages, or progressions, into learning, only reverse sequence. In backward chaining, the last steps in sequence, from beginning to end, are taught first, working backwards toward the first step in the progression. Backward chaining is particularly useful in learning complicated psychomotor skills when the last step is easier to learn than any of the beginning steps.. At times, it is only necessary to teach the last step first, then go to the first and work forward. www.indiandentalacademy.com
  120. 120. SHAPING Shaping, or close approximation, is an operant conditioning principle that involves reinforcing behavior that approaches the desired behavior. This form of operant conditioning was popularized years ago by B. F. Skinner. EX:- tooth brushing technique REFRAMING Reframing (symptom prescription or reverse psychology) is the psychological technique in which a behavior that is considered undesirable but pleasurable is made to appear, or reframed, as a duty, or vice versa. Ex:- to lessen finger sucking habit www.indiandentalacademy.com
  121. 121. REINFORCEMENT THEORY • Positive and negative reinforcement, and, to a limited degree, punishment, can be used in orthodontics. The overriding principle of reinforcement theory is to give more praise than criticism. It has been suggested that at least 3 words of praise be used for every word of criticism (punishment). HYPNOSIS • Hypnosis, and other techniques closely associated with hypnosis, can be used for fearful and apprehensive patients • Ex:- impression making, bonding, debonding, and extraction of very loose deciduous teeth. www.indiandentalacademy.com
  122. 122. • KINESTHETIC LEARNING • Obviously, individuals learn differently. Some are more visual, others are more auditory, and some are both. Others learn kinesthetically, particularly with psychomotor skills. Kinesthetic learning, sometimes called “muscle memory,” can be a powerful teaching aid for learning a physical skill • • • • • • LEARNING BY DOING There is a proverb that states: I hear and I forget; I see and I remember; I do and I understand The more we can get our patients and our staff to do, rather than observe, when we teach them new tasks, the faster they will learn www.indiandentalacademy.com
  123. 123. Patient Empowerment and Contracting Procedures Educating patients regarding their condition gives them the tools to make informed decisions. The individual feels involved in the process of selecting what is most suited for the necessary change. Sometimes the patient's decision conflicts with their best interests and also goes against the wishes of the parents regarding possible outcomes. In these situations, flexible treatment strategies need to be devised in order to succeed. A compromise treatment plan may offer the best solution in some instances. In other situations, a suggestion to postpone treatment or the decision to withdraw from seeking treatment may solve the conflict. www.indiandentalacademy.com
  124. 124. Most often, alternatives are available and should be offered following an understanding of the limitations of different approaches. Once a decision has been reached using this process, the patient is empowered and selects a treatment option from choices offered. This process obligates the patients to comply with a previously reached agreement. A contract made with each individual patient has been shown to be successful in improving compliance in different areas of orthodontic care. www.indiandentalacademy.com
  125. 125. 2. Patient's Causal Attributions Patients attribute events in their lives to external and internal causes. External causes are outside of their control (external locus of control), versus internal, which are within their control (internal locus of control). El­­Mangoury et al (AJO1981) found that orthodontic patients who attributed outcomes to internal causes were significantly more cooperative. Albino et al (J Behav Med1991) also found that those patients who attributed responsibility for their orthodontic condition and treatment externally to either chance or their orthodontists showed lower levels of compliance scores compared with others. www.indiandentalacademy.com
  126. 126. Therefore, patients who attribute internally are better compliers compared with those who attribute externally. Those patients who make fewer external attributions possess a sense of responsibility and consequences consequently believe that their participation and cooperation facilitates treatment progress. These findings can be used clinically to improve patient compliance by initially developing strong relationships and a high level of communication with patients. Good rapport along with patient education can empower patients to make informed decisions regarding their role in determining the success of treatment. www.indiandentalacademy.com
  127. 127. 3. Patient Support at Home and at the Orthodontic Office Family support for the patient to follow pre­scribed instructions is necessary for successful implementation of this program. Also, continuous encouragement and feedback from the orthodontic office is significant in creating a supportive environment, which is important for the patient. Patients are often required to wear cumbersome appliances that are difficult to use. If a difficult task is suddenly introduced requiring substantial effort from the patient, a noncompliance problem is created. www.indiandentalacademy.com
  128. 128. An example is of patients who have to use the reverse facemask headgear used for Class III skeletal growth modification. The headgear appears as a complicated device to the patient. This appliance has to be worn for a long period of time for successful correction. Often a rapid palatal expander is used in combination with this appliance. The patients should be started with the expansion device for 2 weeks followed by introducing the headgear gradually. The initial wear may be for I or 2 hours and progress to 4 hours in 3 to 4 weeks. The wear should progress to 12 to 14 hours of wear as dictated by the treatment plan. This method of gradually introducing tasks to patients may help them in their adaptation to newer difficult tasks. www.indiandentalacademy.com
  129. 129. Methods of feedback to the patients can range from completing report cards, rewarding them for compliant behavior, verbal praise, regular patient/parent consultations. In addition, charted notations, which are highly visible to patients, can also affect compliance. Knerim et al (JCO 1992) www.indiandentalacademy.com
  130. 130. 4. Rewarding Compliant Behavior Improving patient compliance in day­to­day practice is very challenging and often a complex problem. Behavior modification by way of a re­ward program can be effective in improving patient compliance to prescribed instructions. In the orthodontic literature, recommendations of establishing a reward program to motivate patients and improve patient compliance have been cited. www.indiandentalacademy.com
  131. 131. A study carried out by Ritcher, Nanda and Sinha et al at the University of Oklahoma revealed the following findings regarding the use of awards as a motivating tool: 1. The award/reward program resulted in improvement in patient compliance scores in below average compliers as reflected in the improvement of oral hygiene scores. 2. Above average compliers remained above average throughout the length of the study. Below average compliers improved with re­wards, however, they never reached the compliance levels achieved by the above average compliers. It was concluded that rewards could be a means of positive feedback for patients in the orthodontic treatment of malocclusions www.indiandentalacademy.com
  132. 132. 5. Doctor/Patient Rapport and Communication The successful practice of orthodontics is significantly dependent on the interaction between the orthodontist and patient. Therefore, it is important to improve this relationship for superior treatment outcomes, patient satisfaction, and doctor satisfaction. In the busy orthodontic practice, it is often difficult to establish a close rapport with the patient. Better doctor/ patient communication can result in increased and more accurate transfer of information, thus improving the quality of care. The patient's perception that the orthodontist paid attention and took seriously what the patient had to say is significantly related to superior doctor/patient relationships. Making the patient feel welcome is also a significant factor in establishing this rapport. www.indiandentalacademy.com
  133. 133. Attention to the behavioral issues can greatly enhance the rapport and can result in superior patient experiences and treatment results. Improving doctor/patient/parent communication is an important factor in improving patient compliance as reported by practicing orthodontists. Mehra et al (ANGLE 1998) www.indiandentalacademy.com
  134. 134. Patient co-operation- how it can be improved?… ( BJO 1997 NOV.) 1) Being polite, friendly and making the patient feel welcome 2) Having a calm, confident manner 3)Giving information about the problem, the proposed treatment plan and the procedure you are going to perform. 4) Not using jargon. 5) Paying attention to what the parent and child says www.indiandentalacademy.com
  135. 135. 6) Reassuring the child that you will do everything to prevent pain 7) Express concern about the child’s well-being 8) Do not criticize the child’s tooth brushing or oral hygiene . www.indiandentalacademy.com
  136. 136. Psychosocial characteristics of patients with facial deformities • Children with craniofacial anomalies are more introverted, neurotic and demonstrate poor self-concept – Perschuk et al • Children with Down’s syndrome were rated as being less intelligent, less attractive, and less socially acceptable. Postoperative ratings of these same children were significantly more positive in all three domains – Strauss et al www.indiandentalacademy.com
  137. 137. • A seriously handicapping orthodontic condition is the one that “severely compromises a person’s physical or emotional health” – AL Morris et al • Physical compromise – serious problems with breathing, speaking, or eating, especially if accompanied by tissue destruction • Emotional health – includes other’s reactions to the individual in a way that influences self-esteem www.indiandentalacademy.com
  138. 138. • Research in the areas of self-esteem and attractiveness indicates that the face is a major source of one’s psychologic identity • Orthognathic surgery differs from surgery for congenital anomalies (in that the changes in appearance are less dramatic and improvements in occlusion, mastication, speech, and TM joint function are likely to be major reasons for treatment) – but patients undergoing this surgeries also expect esthetic changes. They must adapt not only to changes in their oral function, but also to changes in their perceived appearance and interactions with others. www.indiandentalacademy.com
  139. 139. Patients before surgery • • • • • Motives for treatment A scale to assess patient’s motives Self-perceptions of facial profile Sex differences Orthognathic-surgery patients www.indiandentalacademy.com
  140. 140. Motives for surgery Parameter Male Female Orthodontist 24(83%) 34(76%) Family dentist 12(41%) 17(38%) Other 5(17%) 1(2%) Desire esthetic changes 12(41%) 13(53%) Mastication 12(41%) 13(29%) Speech 4(14%) 1(2%) TM joint 1(3%) 7(16%) Social: family, friends 12(41%) 24(53%) Professional advice Functional problems www.indiandentalacademy.com
  141. 141. A scale to assess patient’s motives • Subjective Expected Utility (SEU) Model – Items are based on interviews with Orthognathic surgery patients, orthodontists, and oral-maxillofacial surgeons – Using a 10 point scale, patients are asked to indicate the importance of each item in the list above and whether they consider it positive , negative or neutral. – In this study, SEU suggest that the decision to seek surgical correction is influenced by functional reasons. Conversely, the decision to reject surgery and undergo conventional orthodontics seems to be based more on a desire for improved esthetics www.indiandentalacademy.com
  142. 142. A scale to assess patient’s motives Questions Score Less difficulty with chewing 3 Stop jaw from clicking 0 Eat foods unable to eat now 0 Better fit of upper/lower teeth 1.5 General health improvement 1.5 Possible pain after surgery 0 Better smile 0 Improved profile, jaw and chin 0 Straight teeth 0 Cost of surgery 0 Lost time from work/school 0.8 Chance of unsuccessful surgery 1.9 Be able to speak clearer 0 Less self-conscious 0 Perform better in job/school 0 Advice of family/friends 0 Advice of dentist/orthodontist 0.9 Know of someone else’s surgery www.indiandentalacademy.com 0
  143. 143. Self-perceptions of facial profile • For all dimensions of facial deformity, patients who accept surgical treatment view themselves as less normal than do those who opt for no treatment or orthodontics • At the 24-month follow-up assessment, nearly all the surgery patients rated themselves as normal. Orthodontics-only patients also rated themselves improved on all scales, but the improvement was not as great. www.indiandentalacademy.com
  144. 144. Sex differences • Broverman and colleagues have found experimental evidence that women place relatively greater importance on physical attractiveness • Kurtz et al found that women can more easily distinguish what they like and dislike about their bodies than can men of the same age, who give only global self-descriptions. www.indiandentalacademy.com
  145. 145. Response to treatment • Overall satisfaction with the outcomes is generally high at all post surgical assessments • Overall body image was found to be in the moderate range throughout the course of treatment • Surgery patients initially expressed a lower body image than did non surgical and no-treatment patients • Surgical patients had high levels of tension and anxiety just before surgery, with a steady decline later • Orthodontics-only patients had negative mood states at 6 months which later improved • In surgical-orthodontic patients, expectations matched the actual experience for most patients. www.indiandentalacademy.com
  146. 146. Application of research findings to patient management -The patients undergoing orthognathic surgery are always within the psychologically normal range – They are more stable than people who seek plastic surgery – Their greatest concern before treatment appears to be selfconsciousness regarding their facial body image, but functional problems also are important – Orthodontics-only patients report negative emotions during the later stages of their treatment – Contrary to literature on cosmetic surgery, most patients undergoing Orthognathic surgery readily accept changes in appearance and are satisfied with the esthetic effects – 85% to 90% of the patients undergoing surgical-orthodontic treatment eventually indicate that they are satisfied with the treatment www.indiandentalacademy.com
  147. 147. Recommendations for interaction with patients There is a need for systematic selection of patients, Provide greater psychosocial support and encouragement for the patient Patient education materials provide information in a standard way www.indiandentalacademy.com
  148. 148. Pre- and post surgical psycho-emotional aspects of the orthognathic surgery patient - Bertolini et al • Levels of pre surgical anxiety, post surgical depression, body concept, and all the important changes in physiologic functions. • The results of this study suggest that surgery does in fact, produce improvements in self-esteem and body image and in mastication and speech, and therefore in their lifestyles • All patients experienced a medium to high level of pre surgical anxiety, but no major problems after surgery. www.indiandentalacademy.com
  149. 149. Rivera and Hatch (SEM in orthodontics 2000 )evaluated emotional status of the patient before and after orthodontic and orthognathic surgery patients and concluded;  Individuals with mild facial disfigurement was affected more than severe deviation.  60% believed self confidence,social acceptance,communication and body image will improve after treatment.  Patient after orthognathic surgery showed more positive benefits with increased self judgment,self esteem, self confidence and body image when compared with orthodontic alone treated patients.  Social potency, social responsiveness social interaction, and behavior improved after surgery. Immediately after surgery negative mood last for 4-6 weeks because of pain, numbnesswww.indiandentalacademy.com problems but it was and oral function
  150. 150. Conclusion An orthodontist who recognizes the emotional reactions of the patient, not only treat malocclusion but also psychological fears, frustrations and behavior. www.indiandentalacademy.com
  151. 151. Thank you www.indiandentalacademy.com

×