Psychologica

PsychologicalPsychological
aspectsaspects
ofof
orthodontic treatmentorthodontic treatment
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ContentsContents
IntroductionIntroduction
Theories of psychological &behavioral developmentTheories of psychological &behavioral development
a. Learning & development of behaviora. Learning & development of behavior
b. Psychosocial theoryb. Psychosocial theory
c. Emotional development theoryc. Emotional development theory
d. Cognition theoryd. Cognition theory
Models of health behaviorModels of health behavior
Emotional Development And Orthodontic Treatment NeedEmotional Development And Orthodontic Treatment Need
Patient compliancePatient compliance
a. factors influencing adult cooperation in orthodontic treatmenta. factors influencing adult cooperation in orthodontic treatment
b. predicting patient complianceb. predicting patient compliance
c. achieving patient compliancec. achieving patient compliance
Social inequality and discontinuation of orthodontic treatmentSocial inequality and discontinuation of orthodontic treatment

Use of educational & psychological principle in orthodontic practiceUse of educational & psychological principle in orthodontic practice
Psychologic factors influencing Orthognathic surgeryPsychologic factors influencing Orthognathic surgery
conclusionconclusion

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

Diagnosis of orthodontic case now includes a greaterDiagnosis of orthodontic case now includes a greater
emphasis on the functional & the psychosocial ramificationsemphasis on the functional & the psychosocial ramifications
Of Dentofacial deformity.Of Dentofacial deformity.
At the same time, treatment planning has become aAt the same time, treatment planning has become a
More interactive process between the patient/ parents & theMore interactive process between the patient/ parents & the
Orthodontist.Orthodontist.
The important issue is whether the doctor or parent makes theThe important issue is whether the doctor or parent makes the
Final decision regarding treatment.Final decision regarding treatment.
This conflict is betweenThis conflict is between paternalismpaternalism andand autonomyautonomy
Paternalism:-Paternalism:- action taken by one person without the secondaction taken by one person without the second
person’s consent.person’s consent.
Autonomy:-Autonomy:- demands that an individual must consent to take anydemands that an individual must consent to take any
action taken on his or her behalf and reflects a belief in theaction taken on his or her behalf and reflects a belief in the
merit of individual self-determination.merit of individual self-determination.

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

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

Psychological Development
Linked to growth of the brain (cognitive areas)
Influenced by genetic factor which is modified by the
environment

Theories of Psychology & BehaviouralTheories of Psychology & Behavioural
development.development.
Behavior is a result of interaction between innateBehavior is a result of interaction between innate
& instinctual behavior learned after birth.& instinctual behavior learned after birth.
Learning of Behavior.Learning of Behavior.
Behavioral responses can be learned byBehavioral responses can be learned by
three mechanisms:-three mechanisms:-
Classical conditioning.Classical conditioning.
Operant conditioningOperant conditioning
ObservationalObservational
learninglearning

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

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

Operant conditioning:-Operant conditioning:-
• According toAccording to B.F SkinnerB.F Skinner – Operant conditioning– Operant conditioning
is a significant extension of classicalis a significant extension of classical
conditioning.conditioning.
• Consequence of behaviour is a stimulus forConsequence of behaviour is a stimulus for
future behaviour.future behaviour.
Stimulus Response
Consequence

• Four basic types of operant conditioning:-Four basic types of operant conditioning:-
• Positive ReinforcementPositive Reinforcement:- If a pleasant:- If a pleasant
consequence follows a response, the responseconsequence follows a response, the response
has been positively reinforced.has been positively reinforced.
• Negative ReinforcementNegative Reinforcement:-Involves the:-Involves the
withdrawal of an unpleasant stimulus after awithdrawal of an unpleasant stimulus after a
response.response.
• Omission :-Omission :- Involves removal of a pleasantInvolves removal of a pleasant
stimulus after a particular response.stimulus after a particular response.
• PunishmentPunishment:-occurs when an unpleasant:-occurs when an unpleasant
stimulus is presented after a responsestimulus is presented after a response..

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

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

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

1)1) Nature VS Nurture –Nature VS Nurture – Biological process VS Environmental processBiological process VS Environmental process
Theorist advice is think less about nature vs nurture and moreTheorist advice is think less about nature vs nurture and more
about how these two combine or interact to produceabout how these two combine or interact to produce
developmental changesdevelopmental changes..
2)2) Continuous and Discontinuous DevelopmentContinuous and Discontinuous Development
Continuous theorist hold development changes are GradualContinuous theorist hold development changes are Gradual
and quantitative. It is an additive process that occursand quantitative. It is an additive process that occurs
continuously and it is not at all Stage like processcontinuously and it is not at all Stage like process..
E.g. Erickson TheoryE.g. Erickson Theory
Discontinuous theorist proposes that it progressDiscontinuous theorist proposes that it progress
through developmental stages and each of which is a distinctthrough developmental stages and each of which is a distinct
phase of life characterized by particular set of emotions,phase of life characterized by particular set of emotions,
abilities, motives and behavior that forms a coherent patternabilities, motives and behavior that forms a coherent pattern..
E.g. Social learning TheoryE.g. Social learning Theory

Psychoanalytic Theory: (Sigmund Freud)Psychoanalytic Theory: (Sigmund Freud)
Freud hypothesized three structures in the theory of the understandingFreud hypothesized three structures in the theory of the understanding
of the intra psychic process and personality Development.of the intra psychic process and personality Development.
1) ID 2) EGO 3) SUPEREGO1) ID 2) EGO 3) SUPEREGO
ID:ID:
Freud believed that the ID represented unregulatedFreud believed that the ID represented unregulated
instinctual drives and energies striving to meet bodily needs andinstinctual drives and energies striving to meet bodily needs and
desires. They are governed by pleasure principle. The drives aredesires. They are governed by pleasure principle. The drives are
necessary for the survival of the species throughnecessary for the survival of the species through procreation andprocreation and
self-defense.self-defense.
E.g. Ideal occlusion for his faceE.g. Ideal occlusion for his face..

EGO:EGO:
It describes as that part of the self-concerned with the overallIt describes as that part of the self-concerned with the overall
functioning and organization of the personality through the egosfunctioning and organization of the personality through the egos
capacity to test reality, the utilization of ego defense mechanisms andcapacity to test reality, the utilization of ego defense mechanisms and
of other ego functions such as memory, language, integellence, andof other ego functions such as memory, language, integellence, and
creativity.creativity.
Thus ego is concerned with maintaining a stage in which an adequateThus ego is concerned with maintaining a stage in which an adequate
expression of ID drives and satisfaction can occur within theexpression of ID drives and satisfaction can occur within the
constrains of reality and the demands andconstrains of reality and the demands and restrictions of the super ego.restrictions of the super ego.
E.g. Accepting CamouflageE.g. Accepting Camouflage
Gabriel AJO1993Gabriel AJO1993 Showed low ego strength to be predictive ofShowed low ego strength to be predictive of
high compliance in prepubertal children, but predictive of lowhigh compliance in prepubertal children, but predictive of low
compliance in adolescents.compliance in adolescents.

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

Emotional developmentEmotional development
From infant to adultFrom infant to adult
The Infant :(First year of life) oral phaseThe 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,
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 This phase of development is called as SYMBIOTIC PHASE. ItThis phase of development is called as SYMBIOTIC PHASE. It
will last until 10 months of age, then the separation andwill last until 10 months of age, then the separation and
individuation will began.individuation will began.
 Stranger anxiety is seen a 9-month old childStranger anxiety is seen a 9-month old child
The Toddler (second year of life) Anal phaseThe Toddler (second year of life) Anal phase
 During 2nd year of life, child will come in to contact with theDuring 2nd year of life, child will come in to contact with the
REALITY PRINCIPLE. This principle is defined as the regulatoryREALITY PRINCIPLE. This principle is defined as the regulatory
process of the environment over behavior. The reality principleprocess of the environment over behavior. The reality principle
demands that the child delay immediate gratification for ademands that the child delay immediate gratification for a
greater gain at a later timegreater gain at a later time

Third year of lifeThird year of life
 By 3 years of age the child has attained a degree of intelligence, whichBy 3 years of age the child has attained a degree of intelligence, which
consist of acquired patterns of cognition, perception and awareness ofconsist of acquired patterns of cognition, perception and awareness of
emotional associations to her or his experiences.emotional associations to her or his experiences.
 the most important emotional experience the child will cope with isthe most important emotional experience the child will cope with is
separation anxiety. This is a very awful fear. This is also the periodseparation anxiety. This is a very awful fear. This is also the period
when a sense ofwhen a sense of AMBIVALENCEAMBIVALENCE, that is love and hate for important, that is love and hate for important
people in ones life, is felt.people in ones life, is felt.
 Ability or inability to separate from the primary caretaker and toAbility or inability to separate from the primary caretaker and to
relate well with other people will be forever important stage of therelate well with other people will be forever important stage of the
adequacy of completion of this early phase of personality developmentadequacy of completion of this early phase of personality development

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

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

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

The most effective of these areThe most effective of these are
1] Reaction formation 2] Sublimation1] Reaction formation 2] Sublimation
1. Reaction formation:1. Reaction formation:
Reaction formation is doing the opposite of the desiredReaction formation is doing the opposite of the desired
activity. E.g. Cleanliness and Kindness are representation ofactivity. E.g. Cleanliness and Kindness are representation of
reaction formation against the drive to be sloppy or cruel.reaction formation against the drive to be sloppy or cruel.
2. Sublimation:2. Sublimation:
Sublimation is converting an unacceptable impulse to sociallySublimation is converting an unacceptable impulse to socially
acceptable activity .e.g. Friendship, artistic interests, andacceptable activity .e.g. Friendship, artistic interests, and
competitive sports are example of sublimation of unacceptablecompetitive sports are example of sublimation of unacceptable
aggressive and sexual drives.aggressive and sexual drives.

Adolescence (12-18years)Adolescence (12-18years)
Adolescence is a psychological state of maturation while pubertyAdolescence is a psychological state of maturation while puberty
is a physical state of maturation. During this period there is ais a physical state of maturation. During this period there is a
wide difference of level of psychological maturation willwide difference of level of psychological maturation will
develops..develops..
 EARLY ADOLESCENCE: 12-14 YEARS OF AGEEARLY ADOLESCENCE: 12-14 YEARS OF AGE
During this period the child will re-experience the OedipalDuring this period the child will re-experience the Oedipal
conflict and separation conflict in order to resolve the residueconflict and separation conflict in order to resolve the residue
of the earlier period. They strive for autonomy and rebel againstof the earlier period. They strive for autonomy and rebel against
rules and standards that were previously acceptablerules and standards that were previously acceptable..

 MIDDLE ADOLESCENCE: 14-16 YEARS OF AGEMIDDLE ADOLESCENCE: 14-16 YEARS OF AGE
This is associated with TURMOIL OF ADOLESCENCE. There isThis is associated with TURMOIL OF ADOLESCENCE. There is
STRUGGLE between dependence and independence, which is greaterSTRUGGLE between dependence and independence, which is greater
and adolescent want the best of the both sides. to proceed to theand adolescent want the best of the both sides. to proceed to the
last stage of adolescence, the teenager must free himself of thelast stage of adolescence, the teenager must free himself of the
dependent tie to his parents.dependent tie to his parents.
 LATE ADOLESCENCE:16-18 YEARS OF AGELATE ADOLESCENCE:16-18 YEARS OF AGE
During this period the STRUGGLE is more with the self than withDuring this period the STRUGGLE is more with the self than with
the external environment. A Self-sufficient individual independentthe external environment. A Self-sufficient individual independent
of his family and capable of filling his own role as a person in society.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 ofThus by the end of adolescence the child develop a sense of
identity and true resolution.identity and true resolution.

Erikson’s theoryErikson’s theory

Erickson TheoryErickson Theory
Development of Basic Trust: Birth to 18 monthsDevelopment of Basic Trust: Birth to 18 months::::
Development of the basic Trust depends on caring andDevelopment of the basic Trust depends on caring and
consistent mother or mother substitute, who meets both theconsistent mother or mother substitute, who meets both the
physiologic and emotional needs for the infants. The strong bondphysiologic and emotional needs for the infants. The strong bond
between mother and child is necessary for the child to develop abetween mother and child is necessary for the child to develop a
Basic trust in the worldBasic trust in the world..
Maternal Deprivation Syndrome:Maternal Deprivation Syndrome:
When the child receives inadequate maternal support, it willWhen the child receives inadequate maternal support, it will
fail to gain weight and are retarded in both physical andfail to gain weight and are retarded in both physical and
emotional growth. This is seen in children of broken families oremotional growth. This is seen in children of broken families or
who lived in a series of foster homes.who lived in a series of foster homes.

Basic mistrustBasic mistrust::
A child who never developed a sense of basic trust willA child who never developed a sense of basic trust will
have difficulty in entering into situations that requires trusthave difficulty in entering into situations that requires trust
and confidence in another person. These individuals areand confidence in another person. These individuals are
extremely frightened and uncooperativeextremely frightened and uncooperative..
Development of Autonomy: 18 months to3 yearsDevelopment of Autonomy: 18 months to3 years
( autonomy vs shame or doubt)( autonomy vs shame or doubt)
Children around the age of 2 years are said to be undergoingChildren around the age of 2 years are said to be undergoing
TERRIBLE TWOS because of their uncooperative nature. The childTERRIBLE TWOS because of their uncooperative nature. The child
is moving away from mother and developing a sense of AUTONOMYis moving away from mother and developing a sense of AUTONOMY
OR IDENTITY. He varies between a being a little Devil to AngelOR IDENTITY. He varies between a being a little Devil to Angel

Shame and DoubtShame and Doubt
 Failure to develop a proper sense of autonomy results in theFailure to develop a proper sense of autonomy results in the
development of Doubts in the child mind about his ability todevelopment of Doubts in the child mind about his ability to
stand alone, and this in turn produce doubts about others.stand alone, and this in turn produce doubts about others.
Erickson defines the resulting state as one of shame, a feelingErickson defines the resulting state as one of shame, a feeling
of having all ones shortcoming exposed. e.g Bowel controlof having all ones shortcoming exposed. e.g Bowel control
 This stage is considered decisive in producing the personalityThis stage is considered decisive in producing the personality
characteristic of love as opposed to hate, cooperation ascharacteristic of love as opposed to hate, cooperation as
opposed to selfishness and freedom of expression as opposed toopposed to selfishness and freedom of expression as opposed to
self- consciousnessself- consciousness..

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

Development of initiative(3-6 years)Development of initiative(3-6 years)
( initiative vs guilt)( initiative vs guilt)
During this stage the child continues to develop greater autonomy, butDuring this stage the child continues to develop greater autonomy, but
now adds to it planning and vigorous pursuit of various activities.now adds to it planning and vigorous pursuit of various activities.
e.g. Extreme curiosity and questioning, aggressive talking, physicale.g. Extreme curiosity and questioning, aggressive talking, physical
activity.activity.
A major task for parents and teacher at this stage is to channelA major task for parents and teacher at this stage is to channel
the activity into manageable tasks, arranging things so that child is ablethe activity into manageable tasks, arranging things so that child is able
to succeed, and preventing him or her from undertaking tasks whereto succeed, and preventing him or her from undertaking tasks where
success is not possible.success is not possible.
Guilty:Guilty:
The opposite of initiative is guilt resulting from goals that areThe opposite of initiative is guilt resulting from goals that are
contemplated but not attained, from acts initiated but not completed,contemplated but not attained, from acts initiated but not completed,
or from faults or acts rebuked by persons the child respects.or from faults or acts rebuked by persons the child respects.

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

Mastery of skills (7-11years)Mastery of skills (7-11years)
(industry vs inferiority)(industry vs inferiority)

During this period child is learning about the rules by which the worldDuring this period child is learning about the rules by which the world
is organized and also he is working to acquire the academic and socialis organized and also he is working to acquire the academic and social
skills that will allow him to compete in the environment. The influenceskills that will allow him to compete in the environment. The influence
of parents as a role model decreases and the influence of the peerof parents as a role model decreases and the influence of the peer
group increases.group increases.
 Thus Erickson quotes "The child acquires industriousness and beginsThus Erickson quotes "The child acquires industriousness and begins
the preparation for entrance into the competitive world. “ Butthe preparation for entrance into the competitive world. “ But
competition with others within a reward system become a reality andcompetition with others within a reward system become a reality and
also clears that some tasks can be accomplished only by cooperatingalso clears that some tasks can be accomplished only by cooperating
with the otherswith the others
Inferiority:Inferiority:
 The negative side of emotional development can be acquisition of aThe negative side of emotional development can be acquisition of a
sense of inferiority.sense of inferiority.

 Children are usually experienced their first visit to the dentist but someChildren 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 thatmay 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 todefine success in any situation, that include the dental office. A key to
guidance is setting attainable intermediate goals, clearly outlining the childguidance is setting attainable intermediate goals, clearly outlining the child
how to achieve this goals and positively reinforcing success in achievinghow to achieve this goals and positively reinforcing success in achieving
these goals. Because the child drives for a sense of industry andthese goals. Because the child drives for a sense of industry and
accomplishment, cooperation with the treatment can be obtained.accomplishment, cooperation with the treatment can be obtained.
 Children at this stage are not motivable by abstract concepts. This meansChildren at this stage are not motivable by abstract concepts. This means
Emphasizing how the tooth will look better as the child cooperates is moreEmphasizing how the tooth will look better as the child cooperates is more
likely to be a motivating factor than Emphasizing if you wear the appliancelikely to be a motivating factor than Emphasizing if you wear the appliance
your bite will be better.your bite will be better.

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

ConfusionConfusion
 During adolescence separation from the peer group is necessary toDuring adolescence separation from the peer group is necessary to
establish ones own uniqueness and values .As adolescence progress,establish ones own uniqueness and values .As adolescence progress,
inability to separate from the group indicates some failure in identityinability to separate from the group indicates some failure in identity
development. This in turn can lead to a poor sense of direction for thedevelopment. This in turn can lead to a poor sense of direction for the
future, confusion regarding ones place in society, and low Self esteem.future, confusion regarding ones place in society, and low Self esteem.
 Most orthodontic treatment is carried out during the adolescent years,Most orthodontic treatment is carried out during the adolescent years,
and emotional and behavioral management of adolescents is extremelyand emotional and behavioral management of adolescents is extremely
difficult. Since parental authority is being rejected, a poor psycho logicdifficult. Since parental authority is being rejected, a poor psycho logic
situation is created by orthodontic treatment, if it is being carried outsituation is created by orthodontic treatment, if it is being carried out
primarily because of the parent needs and not the child. At this stageprimarily because of the parent needs and not the child. At this stage
orthodontic treatment should be instituted only if the patients need,orthodontic treatment should be instituted only if the patients need,
not to just satisfy their parents.not to just satisfy their parents.

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

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

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

Attainment of integrity (Late Adult)Attainment of integrity (Late Adult)
(integrity vs despair)(integrity vs despair)
At this stage the individual has adapted to the combination ofAt this stage the individual has adapted to the combination of
gratification and disappointment that every adult experiences.gratification and disappointment that every adult experiences.
The feeling of integrity is the feeling that one has made theThe feeling of integrity is the feeling that one has made the
best of their life.best of their life.
Despair:Despair:
The opposite of attainment of integrity is Despair. ThisThe opposite of attainment of integrity is Despair. This
feeling is often expressed as disguise and unhappiness,feeling is often expressed as disguise and unhappiness,
frequently accomplished by a fear that death will occur before afrequently accomplished by a fear that death will occur before a
life change that might leads to integrity can be accomplished.life change that might leads to integrity can be accomplished.

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

 The process of adaptation by a child is through Assimilation andThe process of adaptation by a child is through Assimilation and
AccommodationAccommodation
Assimilation:Assimilation:
It describes the ability of the child to deal with newIt describes the ability of the child to deal with new
situation and problems within his age specific skills.situation and problems within his age specific skills.
Accommodation:Accommodation:
It describes the ability of the child to adapt and changeIt describes the ability of the child to adapt and change
his way of dealing with the world to handle a problem, which athis way of dealing with the world to handle a problem, which at
first may be too difficult at his particular age and skill.first may be too difficult at his particular age and skill.
Through this continuous dual process the child isThrough this continuous dual process the child is
constantly building various hierarchies of related behavior,constantly building various hierarchies of related behavior,
which Piaget called Schemata.which Piaget called Schemata.

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

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

Preoperational period: (2-7year)Preoperational period: (2-7year)
During the preoperational period, the capacity develops toDuring the preoperational period, the capacity develops to
form mental symbols representing things and event not present,form mental symbols representing things and event not present,
and children learn to use words to symbolize these absentand children learn to use words to symbolize these absent
objects.objects.
During this period child can understand the world in the wayDuring this period child can understand the world in the way
of 5 primary senses.of 5 primary senses.
1) Feel 2) Smell1) Feel 2) Smell
3) Hear 4)Taste3) Hear 4)Taste
5) Concepts that cannot be seen5) Concepts that cannot be seen
They feel difficult to interpret Time and health.They feel difficult to interpret Time and health.
Thus child can understand language in a literal sense i.e.Thus child can understand language in a literal sense i.e.
words only they have learned.words only they have learned.

Features of Thought processFeatures of Thought process
1)1) EgocentrismEgocentrism 2)2) AnimismAnimism
Egocentrism:Egocentrism:
It is defined as the inability of the child to assumeIt is defined as the inability of the child to assume
another persons point of view. Because of this the child can onlyanother persons point of view. Because of this the child can only
manage his own perspective and assumes another’s view is simplymanage his own perspective and assumes another’s view is simply
beyond his mental capabilitiesbeyond his mental capabilities..
Animism:Animism:
It is defined as projection of inanimate object with lifeIt is defined as projection of inanimate object with life
i.e. everything seen as being alive by a young child, and storiesi.e. everything seen as being alive by a young child, and stories
that invest with life are quite acceptable to children of this age.that invest with life are quite acceptable to children of this age.

Most of the thumb sucking patients fall in to thisMost of the thumb sucking patients fall in to this
category of age.category of age.
Since the child’s view of time is centered around theSince the child’s view of time is centered around the
present, and he is dominated by how things look, feel, taste, andpresent, 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 aboutsound 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 stopshow much better his tooth will look in the future if he stops
thumb sucking. At the same time it would not be useful to pointthumb sucking. At the same time it would not be useful to point
out to the child how proud his father would be if he stoppedout to the child how proud his father would be if he stopped
thumb sucking, since the child would think his fathers attitudethumb sucking, since the child would think his fathers attitude
was same as the child (Egocentrism). Telling him that the teethwas same as the child (Egocentrism). Telling him that the teeth
will feel better now or talking about how bad his thumb tasteswill feel better now or talking about how bad his thumb tastes..

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

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

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

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

Models of health behavior (sem in ortho 2000)Models of health behavior (sem in ortho 2000)

Models of health behavior and Their implication
for orthodontic treatment

Health belief modelHealth belief model
Theory ofTheory of
planned behaviorplanned behavior
Stages of change modelStages of change model
Self-regulation theorySelf-regulation theory

1. HEALTH BELIEF MODEL1. HEALTH BELIEF MODEL

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


2. THEORY OF PLANNED BEHAVIOR2. 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. www.indiandentalacademy.com

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

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

3. SELF-REGULATION THEORY3. SELF-REGULATION THEORY

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

FirstFirst, 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.”).

SecondSecond, 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.”)


ThirdThird, 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 self-
regulation theory is self-efficacy, which refers to the belief that
one can produce a desired outcome through one’s own efforts.


4. STAGES OF CHANGE MODEL4. STAGES OF CHANGE MODEL

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

Second stageSecond 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

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

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

The final stagefinal 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. www.indiandentalacademy.com

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

3. Be aware that the patient seek treatment at very different points
along the stage of change, and parents and children may also differ in
their readiness for change. Treatment should be initiated only when
the patient reports being ready to assume the responsibility and make
the behavioral commitment required to successfully complete
treatment.
4. Try to identify barriers to compliance with treatment
recommendations. These may include personal characteristic of the
patients (e.g. age, education level, socioeconomic status) or
environmental factors, such as high levels of psychosocial stress or a
lack of understanding the importance of treatment.

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


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

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

1. Orthodontic cooperation is predictable through psychological1. Orthodontic cooperation is predictable through psychological
testing.testing.
2. High-need achievers cooperate better orthodontically than low-2. High-need achievers cooperate better orthodontically than low-
need achievers.need achievers.
3.A patient who is a good brusher does not have to be a good3.A patient who is a good brusher does not have to be a good
headgear wearer, and vice versaheadgear wearer, and vice versa
4. Affiliation motivation seems to contribute the most in prediction4. Affiliation motivation seems to contribute the most in prediction
of headgear wear, elastic wear, appliance maintenance, nonbrokenof headgear wear, elastic wear, appliance maintenance, nonbroken
appointments, and punctuality in appointments.appointments, and punctuality in appointments.
5. Achievement motivation appears to contribute the most for5. Achievement motivation appears to contribute the most for
predicting oral hygiene.predicting oral hygiene.
6. Attribution motivation was not effective in predicting variables6. Attribution motivation was not effective in predicting variables

Emotional Development And Orthodontic TreatmentEmotional Development And Orthodontic Treatment
NeedNeed
Body ImageBody Image Self ConceptsSelf 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.

Body Image
Parents
Teachers
Peers
Ethnicity
Culture

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

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

Self Concepts
Self Esteem
Body Image
Social Competence
Accomplishment
•Academic
•Athletic
Self concept

Self Concepts
Self Esteem
SELF ACCEPTANCE
Desire to Change
•Appearance
•Accomplishment
•Social Skills

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

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

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

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

COMPLIANCE (sem in ortho 2000)COMPLIANCE (sem in ortho 2000)

As suggested by HaynesHaynes: 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.

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

Self-Regulation Approach to Orthodontic Patient ComplianceSelf-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:

NegativeNegative
Feed backFeed back
looploop

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

Current orthodontic research focuses on a critical aspect of the
feedback; specifically, the input received by the comparator that
quantifies the actual amount of adherent behavior. This aspect of the
feedback loop is particularly problematic because when asked how
many hours a headgear has been worn, patients do not know how to
estimate the total.
Likewise, orthodontists cannot reliably estimate the amount of wear
and parents are not sure of their child's degree of appliance use.
Patients, parents, and clinicians need a way to ascertain this
information.
TechnologyTechnology 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.

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

Unfortunately, such methods are poor and commonly provide an
overestimate of compliance. There is a clear need for a reliable
method of measuring the time a headgear has been worn and there
have been numerous attempts to pro-duce such a device.
NorthcuttNorthcutt 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 ReadBanks and Read, found that only 4 of 13 head-gear
timers were accurate more than 90% of the time.


Patient’sPatient’s
Perceptions ofPerceptions of
Dental-facialDental-facial
attractivenessattractiveness
Develop overDevelop over
Time as aTime as a
Function ofFunction of
a.a. parent’s dentalparent’s dental
Facial appearanceFacial appearance
b. Social normsb. Social norms
c. Social feedbackc. Social feedback
Patient’sPatient’s
PerceivedPerceived
Need forNeed for
treatmenttreatment
Develops as a resultDevelops as a result
OfOf
a.a. Perceptions ofPerceptions of
AppearanceAppearance
b. parents’b. parents’
Perceptions ofPerceptions of
Treatment needTreatment need
c. Professionalc. Professional
Evaluations of occlusionEvaluations of occlusion
Parent’sParent’s
-Percieved need for treatment-Percieved need for treatment
-Positive perceptions of-Positive perceptions of
treatment efficacytreatment efficacy
-relative value of treatment-relative value of treatment
Orthodontists:-Orthodontists:-
-Professional evaluationProfessional evaluation
of treatmentof treatment
-Understanding ofUnderstanding of
Patient’s desire for treatmentPatient’s desire for treatment
Decision to obtainDecision to obtain
treatmenttreatment
A conceptual model of factors influencing orthodontic treatment decisionsA conceptual model of factors influencing orthodontic treatment decisions

PRE-TREATMENTPRE-TREATMENT EARLY IN EARLY IN
TREATMENTTREATMENT
THROUGH THROUGH
TREATMENTTREATMENT
CHILDCHILD   Perceives functional/Perceives functional/
      esthetic impairmentesthetic impairment
  Perceives need for Perceives need for
      treatment/desires treatment/desires
      treatmenttreatment
  Develops realistic Develops realistic
        expectationsexpectations
  Learning Learning
      coping/control coping/control
      strategiesstrategies
  Assumes control of Assumes control of
      behavior related to effect behavior related to effect
      outcomes of treatmentoutcomes of treatment
  Shares responsibility for Shares responsibility for
        treatment outcomestreatment outcomes
PARENTSPARENTS   Perceives need for    Perceives need for
      treatmenttreatment
  Believes in efficacy of      Believes in efficacy of
        treatmenttreatment
  Places high value on   Places high value on
      occlusion/treatmentocclusion/treatment
  Enables treatmentEnables treatment
  Takes interest in Takes interest in
      treatmenttreatment
  Encourages homecareEncourages homecare

  Supports and approves Supports and approves
      child’s active   child’s active
      participations and participations and
      responsibility in responsibility in
      treatmenttreatment
ORTHODONTISTORTHODONTIST   Professionally evaluates  Professionally evaluates
      treatment needstreatment needs
  Seeks to understand Seeks to understand
      patient and parent patient and parent
      perceptionsperceptions
  Communicates  goals, Communicates  goals,
      expectations, potential expectations, potential
      problems in treatmentproblems in treatment
  Engages parent and Engages parent and
      patient in goals,  patient in goals,
      expectationsexpectations
  Acknowledges patient Acknowledges patient
      and parent perceptionsand parent perceptions
  Develops partnership Develops partnership
      with patientwith patient
  Shares responsibility  Shares responsibility
      with patient for progress, with patient for progress,
      setbacks, outcomes of setbacks, outcomes of
      treatmenttreatment
CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENTCRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT

PREDICTING PATIENT COMPLIANCE INPREDICTING PATIENT COMPLIANCE IN
ORTHODONTIC TREATMENTORTHODONTIC 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.
Age 1. Education
Gender 2. Parent’s attitude
Socioeconomic status 3. Patient’s personality
Predicting patient compliancePredicting patient compliance
Demographic aspectDemographic aspect Psychosocial aspectPsychosocial aspect

1. DEMOGRAPHIC ASPECT1. DEMOGRAPHIC ASPECT
In the search for potential predictors of treatment compliance,
considerable attention has been directed toward evaluation of
patients' demographic characteristics.

Patient Age:Patient Age:
Allan et al (AJO 1968)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)Albine and Sergl et al (EJO 1992) have
revealed no correlation between patients' age and the level of
compliance


Gender:Gender:
Kreit and Starnbach et alKreit 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)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

Socioeconomic status: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)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)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)Sergl et al (EJO 1992) reported, no evidence of
potential effects of parental occupational status on children's
compliance.

2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS
Considerable attention has been devoted to evaluation of the
effects of patients' psychologic traits and psychosocial background
on compliance during orthodontic treatment. It is generally
believed that patient's personality characteristics, his or her
relationships with the family, peers and orthodontist, as well as
performance at school are closely linked with compliance, and
might serve as valuable sources of information regarding both
prediction and management of compliance

EDUCATION LEVEL:EDUCATION LEVEL:
Richter, Nanda and SinhaRichter, Nanda and Sinha et al (ANGLE 1996) 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 alDausch 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 below-
average intelligence show poor compliance, because both variables
appear to depend strongly on a number of other psychosocial
factors.

PARENTS ATTITUDE:PARENTS ATTITUDE:
Mehra et al (ANGLE 1996)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.

Study by Nanda and Kierl et al (AJO 1992)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.

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

Specific psychologic diagnostic tests were used for evaluation of
patients' cooperation, responsibility, reliability, and endurance
during treatment. The results indicated that irrespective of
gender, the patients who tend to be uncooperative are inclined to
attitudinal preferences conventionally regarded as masculine,
which are expressed as active, aggressive, and realistic
behavioral patterns and self-images, rather than sensitive,
esthetic and idealistic ones.
Allan and Hodgson (AJO 1968)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.


PERSONALITY TESTPERSONALITY 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.
GabrielGabriel (ANGLE 1965) (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.

McDonaldMcDonald reported a significant correlation between scores
on the California Test of Personality and patient cooperation.
Southard and Tolley (AJO 1991)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.

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

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

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

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

Sergl et al (AJO 1980)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.

SOCIAL INEQUALITY & DISCONTINUATIONSOCIAL INEQUALITY & DISCONTINUATION
OF ORTHODONTIC TREATMENTOF ORTHODONTIC TREATMENT
Social inequality influences general health, dental disease,Social inequality influences general health, dental disease,
and dental health-related behavior. However, reports onand dental health-related behavior. However, reports on
any links between orthodontics and social inequality areany links between orthodontics and social inequality are
more equivocal.more equivocal.
Registrar General’s social class groupings (by occupation of head* ofRegistrar General’s social class groupings (by occupation of head* of
householdhousehold))
Social classSocial class Definition and examplesDefinition and examples
I Professional e.g. medical, dental,I Professional e.g. medical, dental,
Veterinary, and legal professions, charteredVeterinary, and legal professions, chartered
Engineers and accountantsEngineers and accountants
II Intermediate and managerial e.g. school teachersII Intermediate and managerial e.g. school teachers
Nurses, police officers, secretaries, publicansNurses, police officers, secretaries, publicans
IIIN Skilled non-manual workers e.g. clerks,IIIN Skilled non-manual workers e.g. clerks,
Draughtsman, shop assistants, travel agentsDraughtsman, shop assistants, travel agents

IIIM Skilled manual e.g. carpenters, electricians,IIIM Skilled manual e.g. carpenters, electricians,
Welders, instrument artificers, policeWelders, instrument artificers, police
constables,constables,
IV Semi-skilled e.g. lathe operators, processIV Semi-skilled e.g. lathe operators, process
workers,workers,
Postmen/ womenPostmen/ women
V Unskilled workers e.g. laborers, dustmen,V Unskilled workers e.g. laborers, dustmen,
DomesticsDomesticsClassification by occupation used by Rölling (1982)
A. Low e.g. unemployed, unskilled manual
B. Lower middle—skilled manual
C. Middle e.g. shop assistants, clerks, small self-employed
D. Upper middle e.g. superior employees, shop owners,
farmers
E. Upper e.g. academics, managers

Results:-Results:-
The results showed that discontinued cases were:The results showed that discontinued cases were:
1. Less likely to have been treated with fixed appliances1. Less likely to have been treated with fixed appliances
2. A little older at start, on average2. A little older at start, on average
3. More likely to have been asked to wear3. More likely to have been asked to wear
EOT/EOA/‘headgear’EOT/EOA/‘headgear’
4. More often from lower social class backgrounds4. More often from lower social class backgrounds
5. Less likely to have been treated by an orthodontically5. Less likely to have been treated by an orthodontically
qualified practitionerqualified practitioner
6. More likely to have attended practices in relatively6. More likely to have attended practices in relatively
deprived areas.deprived areas.

PsychologicalPsychological
aspectsaspects
ofof
orthodontic treatmentorthodontic treatment
Dr. I.Dr. I.
ROHINIROHINIwww.indiandentalacademy.com

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.

Psychologica

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