Psychologica /certified fixed orthodontic courses by Indian dental academy


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Psychologica /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Psychological aspects of orthodontic treatment
  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
  4. 4. Use of educational & psychological principle in orthodontic practice Psychologic factors influencing Orthognathic surgery conclusion
  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.
  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.
  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.
  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.
  9. 9. Psychological Development Linked to growth of the brain (cognitive areas) Influenced by genetic factor which is modified by the environment
  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
  11. 11. Classical conditioning:• First described by Ivan Pavlov during his studies on reflexes. • ―Learning by Association‖.- association of one stimulus with another
  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
  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
  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.
  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.
  16. 16. •A child acquires a behaviour by first observing it & then actually performing it. •Important tool in the management of dental treatment.
  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
  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
  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.
  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.
  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
  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.
  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
  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
  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
  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.
  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.
  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.
  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.
  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.
  31. 31. Erikson’s theory
  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.
  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
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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. 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.
  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.
  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.
  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.
  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.‖
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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
  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
  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.
  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 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.
  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 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 standards (“I’m doing pretty well for me.”) and environmental conditions (“Understands the circumstances, I can’t be expected to do much better.”)
  62. 62. Third, patients adjust their behavior depending on how it 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.
  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 model to understanding decisions regarding treatment First stage is pre-contemplation, which people typically fails to acknowledge the need for behavior change and have no intention of changing their behavior. Second stage, contemplation, individuals recognize a need for change and are considering a change in behavior, but have not yet taken any steps in that direction
  64. 64. Third stage is preparation, and this stage involves making specific plans for behavior change. Fourth stage, action, involves implementing those plans, and this is the first stage in which overt behavior change occurs. The final stage is maintenance, in which people are attempting to 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.
  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.
  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.
  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.
  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.
  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).
  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
  71. 71. Emotional Development And Orthodontic Treatment Need Body Image Body Image: Self Concepts 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.
  72. 72. Parents Culture Peers Body Image Ethnicity Teachers
  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.
  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
  75. 75. Self concept Body Image Accomplishment •Academic •Athletic Social Competence Self Concepts Self Esteem
  76. 76. Self Concepts Self Esteem Desire to Change •Appearance •Accomplishment •Social Skills SELF ACCEPTANCE
  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.
  78. 78.  In contrast, for many children whose self-acceptance is not very high, the desire to chance one or more components of self- concept 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.
  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 .
  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 .
  81. 81. COMPLIANCE (sem in ortho 2000) As suggested by Haynes: Compliance is "the extent to which 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.
  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.
  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
  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
  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 other areas of patient compliance. Research suggests that patients receiving feedback about their degree of compliance are better able to follow a recommended regimen.
  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 neckstrap), mobility of the molar  ease of patient use, and  direct patient inquiry either verbally or by questionnaire.
  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 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 timers were accurate more than 90% of the time.
  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 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
  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
  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 the best predictor of cooperation. In contrast, studies by Albine and Sergl et al (EJO 1992) have revealed no correlation between patients' age and the level of compliance
  92. 92. Gender: Kreit and Starnbach et al have emphasized that the patient's 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 boys, girls tend to express lower body image satisfaction and are more likely to be displeased, with their dental appearance
  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 female patients from higher socioeconomic groups show the highest compliance levels. Dorsey and Korabik et al (AJO1977) have indicated 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 potential effects of parental occupational status on children's compliance.
  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
  95. 95. EDUCATION LEVEL: Richter, Nanda and Sinha et al (ANGLE 1996) reported that 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 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.
  96. 96. PARENTS ATTITUDE: Mehra et al (ANGLE 1996) suggested that parental beliefs are 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.
  97. 97. Study by Nanda and Kierl et al (AJO 1992) evaluated several 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.
  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 patients with patients rated by their clinicians as highly uncooperative.
  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 likely to show higher levels of treatment compliance are enthusiastic, outgoing, energetic, self-controlled, responsible, trusting, diligent, and obliging persons.
  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 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.
  101. 101. McDonald reported a significant correlation between scores on the California Test of Personality and patient cooperation. Southard and Tolley (AJO 1991) examined the feasibility of 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.
  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.
  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.
  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.
  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 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.
  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 I II IIIN Definition and examples Professional e.g. medical, dental, 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
  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
  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.
  109. 109. Psychological aspects of orthodontic treatment Dr. I. ROHINI
  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.
  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
  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
  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.
  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.
  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.
  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.
  117. 117. Various demonstration tools are available to aid in the education process. Good standard patient records such as study casts and photo-graphs 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.
  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
  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.
  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
  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.
  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
  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.
  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.
  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). El--Mangoury 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.
  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.
  127. 127. 3. Patient Support at Home and at the Orthodontic Office Family support for the patient to follow pre-scribed 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.
  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.
  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)
  130. 130. 4. Rewarding Compliant Behavior Improving patient compliance in day-to-day practice is very challenging and often a complex problem. Behavior modification by way of a re-ward 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.
  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 re-wards, 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
  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.
  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)
  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
  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.
  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
  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
  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.
  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
  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
  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
  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 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.
  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.
  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.
  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
  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
  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.
  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, numbness and oral function problems but it was recovered within 3 months.
  150. 150. Conclusion An orthodontist who recognizes the emotional reactions of the patient, not only treat malocclusion but also psychological fears, frustrations and behavior.
  151. 151. Thank you