Social psychology of orthodontics /certified fixed orthodontic courses by Indian dental academy


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Social psychology of orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Social psychology • It is the scientific study of the way in which people’s thoughts, feelings and behaviours are influenced by the real or imagined presence of other people
  3. 3. Social Psychology-of orthodontics Q1. Why do patients seek orthodontic care? Primary cause-Improve appearance –Social psychology of personal appearance-Landmark book (Bull & Ramsay)-1960s-70s Key points of the book 1. Facial appearance- most important determinant of a persons attractiveness 2. Have more difficult time in school 3. Disfigured people- less likely to do well in – employment, politics. A person’s Dentofacial deformity – can have significant effect on overall quality of life
  4. 4. • Adams examined the social psychology of beauty-and concluded that physical attractiveness appears to elicit different social exchanges • As a consequence of receiving a constant positive or negative social reaction – different interpersonal styles develop • In short- attractiveness has a lot to do with a person’s self confidence
  5. 5. • Appearance also has a lot to do with the way people are perceived • Secourd & Jourard-evaluated the importance of dentofacial appearance as determinants of personality traits compared to all other body clues • They found- correctly aligned teeth- reflects- sincerity, intelligence, conscientiousness & god looks • Crooked teeth-????? (Bishara) • Klima,Witterman & McIver-on the basis of facial appearance- personal attributes such as –good, worth ect is set • Bennett, Broder,& Phillips-dentofacial deformities-cause of teasing & harassment –associated with lowered social attractiveness
  6. 6. • Table 3-1- Proffit,White & Sarver
  7. 7. • Leslie Zebrowitz calls the preferential reaction to & treatment of people with attractive faces as the “attractiveness halo”
  8. 8. • Social Psychological impact – • 1.Parent- Child interaction – Langlois showed that even mothers were more affectionate & playful with their babies when they had more attractive faces – Other studies also showed similar results- and mothers also tended to behave less positively when their children had craniofacial abnormalities such as cleft lip & palate(Field & Vega-Lahr) – Parke et al- Fathers also showed a positive correlation between attractiveness & affectionate behaviour – Harsher punishments to less attractive children was also found among both parents
  9. 9. 2.Teacher-student interaction • The Halo extends from the home to school • Clifford & Walster-asked teachers to estimate IQ based on photographs, report card& attendance percentage • The child’s attractiveness had a large effect on the teachers expectation as to have a higher IQ • “Pygmalion effect”-A study was conducted to check this phenomenon • It was found that-the teachers expectations did in fact influence the students’ actual increase in IQ • Zebrowitz-Host of supportive behaviour by the teacher to a student causes this difference
  10. 10. • White et at showed that-attitude of the teachers are also influential in the opinions that students form of their peers • The same is true the other way round as well-Klein showed that-Students preferred teachers with a more attractive face as they felt he/she to be more smarter
  11. 11. 3.Occupational outcomes• Meta analysis by Hosoda et al-attractive individuals fare better than their less attractive counterparts in terms of perceived job qualification & success, hiring decisions etc • Study by Frieze et al-the MBA graduates found facial attractiveness correlated with benefits they obtained- such as higher salary.
  12. 12. • In 1990s –evolution in the understanding of the interplay of psychological factors & dentofacial deformity • Shaw et al-discussed the benefit of “social psychological well being” in terms of 3 subgroups 1. Nicknames & teasing 2.Dental appearance & social attractiveness 3.Self-esteem & popularity They concluded- dental conditions did effect certain characteristics such as popularity & intelligence & also that personal dissatisfaction felt in childhood can remain for a lifetime.
  13. 13. What is attractive? • “Tis not a lip or eye, we beauty call, but the joint force and full result of all” Is there a universal agreement on the concept of facial attractiveness or is it only in the eye of the beholder Current research shows- cross cultural agreement about who/what is attractive Langlois et at- found correlation as high asr=0.85-0.94 Even infants respond to attractiveness- one method to evaluate the infants’ respose- ‘Gaze time’ When presented simultaneously with 2 photographs- the infants tend to gaze longer at the face previously rated more attractive (by adults) Langlois- experimented with infants who had a attractive or non attractive caretaker( Mask was put)- found more avoidance behaviour when the non attractive mask was put. Above studies show-innate sense of attractiveness is present at birth though later influences of culture & environment are also a great influence
  14. 14. • 1. 2. 3. 4. 5. 6. 7. 8. Facial attractiveness has been postulated to consist of the following (in combination or alone)“Averageness” Symmetry Neonate-like features (baby face) Secondary-sexual charecteristics Youthfulness Familiarity Straight profiles Facial expression- esp. smiling
  15. 15. 1. “Averageness”- Sir Francis Galton’s serendipitous experiment with composite faces lead to the “averageness” hypothesis-i.e.-composites were more attractive than individual faces singly Langlois et al – found that the composites formed by computerized averaging of multiple faces more attractive The term “Averageness” does not denote mid-level attractiveness but indicates a representation of facial features closer to the population mean( attempts to bring the patients’ ceph readings close to that of the average reflects the clinical predilection to accept averageness as attractive
  16. 16. • Why is it attractive? 1.Preference for prototypes-on an evolutionary scale-face closer to representing population average recognized more easily as the member of the same species 2. Averageness-appears more familiar-makes faces familiar even when never seen before 3.Mate selection-Averageness equates with good genes
  17. 17. 2. Symmetry-Has a positive correlation with attractiveness Mealy et al- Twin study- monozygotic twins though genetically identical due to developmental differences phenotypic expression diffres The facially symmetrical twin within each of the 34 pairs was consistently rated more attractive Potential critique of the Averageness hypothesis- average faces are more symmetrical- therefore more attractive Current research by –Rhodes et al & Rubenstein et al –are contradictory thus concluding that both are equally important
  18. 18. • Why is symmetry important? • Signals Genetic fitness/& or good health • A variety of psychological & physical abnormalities area associated with facial anomalies- such as cretinism-receding chin associated with impaired brain fetal alcohol syndrome- midface deficiency, schizophrenia-crooked smile
  19. 19. 3.Babyfaceness-include characteristics such as- large forehead, lower set but large eyes, nose & mouth, smaller, shorter, more recessive chin, fuller lips, small nose and round less angular face • This has been found to be more attractive particularly in females and in males its more curvilinear( increasing to a point then decreasing) • Baby faced adults- perceived to be more honest, warm, approachable ,friendly, naïve & submissive • However certain mature characteristics-such as high cheek bones in women & larger chins in males is found attractive
  20. 20. • Why is baby face attractive? • They have a natural appeal to the adults-elicit affection & sympathy & care • On a evolutionary analysis- ‘cute’ children have a better survival rate • Baby faced females-associated with youthfulness-associated with fertility • Male faces- which are to acertain extent “feminized’ are preferred by females as partners as they are thought to make better parents
  21. 21. 4. Profile considerations- from Angle through Tweed to Mclaughlin –expounded preference for Class I profile Psychological research has mostly been based on frontal assessments- several studies validate the hypothesis that straight profile is more attractive Lucker et al -showed photographs of 10-14 yr olds to their peers- found that the children could find ‘something wrong’ when the profile was retrognathic or prognathic
  22. 22. • Why is straight profile attractive? • Evolutionary advantage-appropriate masticatory function is hypothesizedenhanced survival
  23. 23. 5. Expressiveness-certain features which gives cues to perceivers to infer certain characteristics Raised eyebrows-convey openness, interest ,nondominance Fuller lips- babyfaceness Smiling- conveys friendliness, social supportiveness Cunningham et al- expressive features are particularly attractive in women Smiling- increases attractiveness in males along with other masculine features- thick eyebrows, large chin
  24. 24. • Expressiveness: The smile • It is a very important positive social behaviour for human beings • Such positive facial expresiion increase the rating of attractiveness- it also elicits more positive person perceptions • The Duchenne or the ‘felt smile’-involves the use of both the muscles of the mouth & eye • The social smile –involves the mouth only • The former type of smiles are deemed to be more genuine • Attractive & smiling faces make us feel goodpleasurable regions of the brain is stimulated
  25. 25. NEXT SESSION
  26. 26. Various influences in seeking treatment Patient perception & reaction of others to a disharmony varies1. Ethnic group variation-e.g. In a population where mandibular prognathism is common – its not noticed as a severe deformity 2. Cultural background- Africans’ concept of beauty- such as enlarged lips & pointed teeth may not be acceptable to the rest of the world 3. Gender differences- generally considered more important in females 4. Social setting- Higher socio-economic statusmore important to be attractive
  27. 27. • 5.Extent of the problem –McGregor et al foundeasier to live with a severe problem than a mild one • Severe problem- reaction is predictable & consistent • 6. Patients reactions to their own condition- a severe deformity may not be affecting an individual and vice-versa- mild problem could cause severe anxiety • 7.Patients’ reactions –to the way they are perceived• Some people handling teasing better than others. How a person responds depends on complex interplay of behaviours, attitudes & beliefs
  28. 28. Psychological Outcomes of Treatment • Dann et al – all children with serious malocclusion did not necessary have poor self concept/esteem or poor body image • And post orthodontic treatment there was no significant improvement • Conversely Albino et al found that dental disharmonies do have social consequences & significant psychological effects • He also reported significant improvement in the dentofacial specific self-image scores (by patient, peer & parent) after orthodontic treatment • Though he also reported that there was no improvement in social competency or social goals •
  29. 29. • Why the difference between the 2 studies• Answer lies in the patients’ attitude before the treatment started • If the patient feels bad at the outset of treatment the treatment causes a greater change in the patients self-esteem. • worse it is at the beginning, more is the change perceived •
  30. 30. • Varela & Garcia- Camba –evaluated the extent to which orthodontic treatment effects the perception of self-esteem & image in adults • They found – orthodontic treatment does have a significant positive effect in adults regardless of their state of mind at the outset of treatment
  31. 31. How important is it to give the orthodontic treatment at the right time? • Shaw et al- evaluated the risk/ benefit appraisal for orthodontic treatment • They divided the socio-psychological well being into 3 sub groups 1. Dental abnormalities that cause a obvious dentofacial deviation –leads to hurtful mockery by the peers – the contribution of orthodontic treatment at such a stage should not be underestimated 2. Dental appearance & social attractiveness-change in the appearance causes a change in the social class & popularity 3. Self esteem & popularity They concluded that if personal dissatisfaction is felt in childhood- if not treated may remain for a lifetime
  32. 32. • Tung & Kiyak• They also concluded that the developing child’s psychologic well-being may be an indication for early orthodontic treatment • They also found racial differences – White children are far more critical in their esthetic judgments- thus require early care & attention • Fig-25.1- pg 457-bishara
  33. 33. Understanding the Adolescent patient • Period between childhood & adulthood • Period of immense-Physical & psychological changes • One of the most important factors for peer acceptability-Facial appearance • Changes in appearance at this point of time-contributes to anxiety on one hand or positive self confidence in the other
  34. 34. • Physical changes in adolescence- stessful • The timing & tempo of puberty have serious effects such as succumbing to eating disorders in females as they gain weight during puberty • Cognitively- adolescents can apply logic & abstract concepts but at the same time be impulsive without thinking about alternatives or consequences
  35. 35. • Difficult stage for the orthodontist• As the patient may not be internally motivated • Achieving total patient compliance
  36. 36. • Patient Compliance• Main requirements of an orthodontist are1.Maintain oral hygiene 2.Less breakage of the appliance- proper maintenance & diet 3.Maintaines appointments 4.Regulaly wears functional /orthopedic appliance
  37. 37. • Adults- generally seek care on their own & also have financial commitment- usually compliant • Adolescent- compliance is more difficult • May be taking treatment due to the parent • No financial commitment • Does not have a clear picture of the result
  38. 38. • Personality testing & compliance-is it possible to test the patients compliance levels before the start of the treatment so that appropriate changes can be made in the treatment plan • More than 80% of the orthodontists do not have a specific method for assessing compliance • Southard et al- examined a commercially available personality tester called-MAPI-Million Adolescent Personality Inventory • The results were correlated to an ordinal assessment of the patient’s compliance over a period of 2 years • They concluded that-MAPI could be a useful instrument in assessing adolescent compliance
  39. 39. • Calcalon & Smith-studied 252 patients between 11-17 years using 3 questionnaires • Comprehensive personal assessment system • Adolescent alienation index • Home index • They found• Females more compliant • Low compliance in patients with low self-esteem • Females higher socioeconomic backgrounds- more compliant •
  40. 40. Motivational psychology • Motivating an adolescent patient-Cooper & Shapiro-pitted health specific motivation against the non health related issues for motivation • He found that- adolescents were more concerned with• Self image & identity • Independence & autonomy • Peer relationships
  41. 41. • They concluded that• Taking time to identify the patient concerns & treating them as responsible individuals is important • And orthodontist should understand that adolescents are not motivated by strong health specific goals projected to them but rather by the peer group influences
  42. 42. • White –many orthodontists believe in positive reinforcement-key to motivation • Reward system – extensively used But White found that – compliance was unpredictable in his practice There seemed to be some influence of their personality beyond the positive & negative reinforces He said compliance more related to Sensitivity threshold relates to the patients pain tolerance Chase & Thomas said- Sensitivity threshold – unchangeable characteristic of the patients genetically determined personality Then –How do you make the patient more complaint?
  43. 43. Then –How do you make the patient more complaint? 1. Reduce discomfort by prescribing soft tooth brushes 2. Simplest appliance – low magnitude of forces 3. Prescribe analgesics 4. Lessen treatment time
  44. 44. • • 1. 2. 3. 4. 5. Rosen –proposed patient oriented approach A individualized compliance plan has to be devised The orthodontist first provides patient necessary information to educate them Motivates the patient – through an open & straight forward method- build mutual respect Family & peer support to be encouraged Should appreciate the patients perspective – work together to overcome barriers pic
  45. 45. • Orthodontist- patient communication-one of the most profound effects on patient compliance • Klages,Sergl & Burucker studied the doctor– patient communication by audiotaping the conversation • Found strong correlation between clinician’s encouraging behaviour & patient compliance • Barsch et al found –doctor- patient interaction was the best predictor of how well a patient could be expected to comply
  46. 46. • Nanda & Kierl-found certain variables to affect the patients’ compliance 1. Parent- child relationship 2. Psychosocial characteristics of the parent & patient 3. Patient & parents opinion about orthodontics 4. Patient & parents perception of the degree of social compromise 5. Patient demographics 6. Parent & child’s relationship with the orthodontist Authors found that the doctor- patient relationship, strongest association with patient compliance
  47. 47. Adult psychology- orthodontic perspective • Main motivation for adults-improve facial appearance • Less than half- want to improve jaw function • 1/3rd – want to improve pain & discomfort The type of the problem & how the problem is perceived is also a important determinant
  48. 48. • Patients own reason for seeking treatment may differ from their perception of why the treatment was recommended • Because in general – doctors place less emphasis on esthetic reasons for seeking treatment & patients are unwilling to admit to severe psychological problems • The orthodontist must evaluate the psychological distress of the patient
  49. 49. • Certain indices are used-GSI-Global severity index can help us achieve “positive diagnosis”- identify subjects with sufficiently pronounced distress • GSI represents a composite of dimensions & is the single most sensitive indication of in the SCL-90-R of psychological distress • RCT by Hatch et al- should 22% of the patients had sufficient distress for a positive diagnosis • 20% -North Carolina study • Patients scores- far outside normal range will benefit from face to face evaluation with mental health professional • Orthodontists who identify any kind of strange of difficult behaviour (Red Flag) – should immediately refer to a Mental health professional
  50. 50. • Acceptance Vs Rejection of treatment• What is the motive behind a patient accepting/rejecting a surgical treatment plan? • Kiyak et al- developed a measure of the patient expectancies based on SEU( subjective expected utility) theory • Theory assumes that – individuals likelihood of choosing a particular behaviour is determined by the weight he/she attributes to values associated with that behaviour
  51. 51. • On an 18 point scale-5 items were found to be the determining factors(80%) • Cost, Family or Friends’ advice, advice of dental professional, appearance of teeth & appearance of profile • Patients who agreed for treatment-found coat manageable & had support of family & friends • Cost was a major factor- for those who refused
  52. 52. • Second major decision-Surgery Vs Camouflage • The decision is influenced by almost the same factors as above but ranking & relative importance is different • Table 3-2
  53. 53. • Cost remains the single biggest influence• Surgery patient has to think of 4 major costs 1.Associated orthodontic treatment 2.surgeon’s fee 3.Hospital bill 4.Loss of productive income & time Lack of insurance –major obstacle BUT- whether you can afford something is affected by how badly you want it, so it ultimately depends on the patient If there is an insurance cover- then the 2nd most important factor – opinions of family & friends
  54. 54. • The patients who chose surgery- felt more negative about their mouth, chin or profile whereas those who chose camouflage felt more negative about their teeth • Other studies showed- Quality of life issues are strong underlying motivators for surgery • More than 50% of them felt socially disadvantaged & had self image issues
  55. 55. • Role of an orthodontist• Should learn to obtain sensitive information without giving offense • Best way to explain-Emphasize on the stress involved• Due to change in facial appearance • Due to stress of the treatment itself- esp. surgery • Emphasize the need for good stress management & need to understand the whole patient
  56. 56. • As the patient ‘opens up’ one must assess the individual’s practical &emotional readiness for treatment • One may use various techniques to gather information such as-silence & open ended questions
  57. 57. • One must also evaluate the patients expectations out of the treatment • They can vary from-realistic to impossible to satisfy category • If the patient has extraordinary expectations- then will end being bitterly disappointed when they are not met • The categories for unrealistic expectations1.Improvement in appearance- unattractive to extremely beautiful 2.Broader quality of life- get promotions or improve a failing marriage 3.Function- surgery may not improve TMJ problems drastically or predictably
  58. 58. • Evaluate coping skills• It is very important to know if the patient can cope up with the stress of a -protracted treatment time -stress of the surgery itself The orthodontist can judge this by finding out how the patient copes with other challenges in life Are the actions adaptive?- such as seeking support from family or maladaptive- using alcohol or drugs
  59. 59. • It is also important to focus on the social support of the of the patient • Find out who are the persons & how well will they support the patient in all stages of treatment emotionally • They should be urged to attend the sessions where treatment plan is reviewed
  60. 60. • Preparing patients for surgery1.Involve the patient as much as possible during decision making 2.Should present simulations of various treatment results 3.Appropriate cautions –and risk involved should be properly explained 4. As the surgery approaches – more detailed information about the surgery & its after effects should be discussed The amount of information – varies depending on the nature of the patient
  61. 61. • Box 3-2
  62. 62. • Treatment refusal & delay• Treatment may have to be refused due to the patient’s psychological condition or social situation • Eg.-unrealistic expectations or improper social support (abusive partner) • Very sensitive area for the orthodontist• The practitioner should be confident & clear about his decision but at the same time have empathy for the patient
  63. 63. • Orthodontist should learn to refer the patient to a mental health practitioner with ease • Can also have collaboration with one or two therapists- who can if possible come to the orthodontists office & even be a part of the discussion as the patient will feel more comfortable & the therapists will be able to understand the complexity of the problem
  64. 64. Response of treatment • Three ways to evaluate the treatment outcome1.Measure the physical dimensions 2.Evaluate function 3.Questionnaires-asking the patient how they feel The physical measurement is the most direct-the latter two varying from patient to patient
  65. 65. • Functional outcomes• Short term effectsMulticentre RCTs (Hatch et al) show that patient are more comfortable when they have shorter hospital stay & RIF is used But a study by Neuwirth shows that only half the patients felt that they have achieved normal levels of activity 4 weeks post-surgery & 70% felt the same at 6weeks At least 1/3rd of the patients felt that they experienced unexpected difficulty in the post operative period
  66. 66. • Perception of dental occlusion & masticatory ability• As the patient expect- they almost always get improvement in occlusion & masticatory ability • Table-3.4
  67. 67. • To measure improvements in facial movements- new approach (Trotman & co-workers) • 3-D video-based motion analysis is used to quantify movements of the peri-oral region • pic
  68. 68. • Oral sensation• All patients have a period of numbness after mandibular surgery –due to the traumatized IAN • Sensation should return in a few weeks • But UNC trial showed-almost 3/4ths of the patients reported altered sensation even 2 years after surgery • Fig 3.10
  69. 69. • Speech• Great fear in the patient- but very rare • UNC trial- 15% reported difficulty in speech-4 weeks post surgery & after 2 years- only 5% • TMJ• About 20-30% of the patients seek orthodontic treatment to alleviate TM pain • Literature reports shows only certain types of malocclusion show a higher prevalence of TMD • Nemeth et al-in a multicentre RCT showed shoed that patients with MMF rather than RIF showed improvement in TMD 2 yrs post surgery
  70. 70. • Satisfaction with treatment• UNC study showed 82% of patients being happy with the results 4-6 weeks after surgery • 90% after 2 years • There of course was reported dissatisfaction with specific aspects of the treatment in 5-40% • Females with neurotic tendency & introvert malesshowed more pain post-surgery-Kiyak et al • Scott et al showed- older patients & those with a positive attitude towards their esthetic impovement- were more satisfied
  71. 71. • Psychosocial assessment & consideration immediate post surgery • Box 3-3
  72. 72. • How does it help improve the social environment of the patient? • UNC study- most patients were happy with the esthetic results of the treatment even 2 years post surgically • 1/4th – said that they were receiving more positive comments & first time reaction of people was better • Kiyak’s study showed a slightly different pattern• There is an dip in the self esteem at 9 months post surgery with higher scores at 24 months • This could be due the result of prolongation of the orthodontic treatment post surgically
  73. 73. • Self-image• Kiyak et al compared 3 sets of patients1.Those who refused treatment 2.Those who opted for camouflage 3.Those who opted for surgery The scores were given by the patient -for facial body image Fig 3-13
  74. 74. • Similar effect seen when profile assessments of treated & untreated patients were compared • The camouflage patients rated themselves as normal whereas the untreated patients were aware that they were outside normal range
  75. 75. • HRQOL-health related quality of life • This is a new paradigm in area of health care • Medical care has shifted from-disease prevention paradigm to quality of life paradigm • The high levels of satisfaction with orthodontic treatment shows that there has been an increase in the quality of life • The HRQOL – has shown an improvement across health, emotional behaviour & psychosocial dimensions • To obtain insurance coverage-clinicians & patients should be able to demonstrate benefits that improve HRQOL
  76. 76. Psychological issues in cleft lip & palateThe social & emotional adjustment of a child is also a developmental process Various factors – Parental functioning Child functioning Societal acceptance
  77. 77. • Parental influence• Birth of a child with CLCP-traumatic experience for the child • First few months very difficult for the parents • Parental success to cope at his this time depends onmental health of the parents • Parents –reporting high levels of stress – more adjustment problems to the children • Mothers who believe that they can meet the child’s needs & take satisfaction in their role as parents- child learns better emotional self regulation
  78. 78. • Child’s characteristics- can also be controlled by the inherent temperament • Hart et al-Classified • 1.resilient child • 2.overcontrolled-shy & co-operative • 3.Uncontrolled- uncooperative & has difficulty with social relationships
  79. 79. • Most obviously the children with CLCP are viewed negatively or have a difficult time socially-testing the resilience of the child much more • This is largely due to the appearance and also a slightly below average cognitive skills • CLCP patients- demonstrate intellectual development within the broad range of normal although 3-5 points lower • The Verbal fluency was significantly less developed
  80. 80. • Bottom line- The orthodontist must understand the emotional & developmental psychology as well as social implications of dentofacial deformity • Building a rapport with the patient & communicating with them through out the treatment – is the key to successful orthodontics- as one must keep both the dental & the mental factors of the patient
  81. 81. Thank you For more details please visit