patient psychology undergoing orthodontic treatment

1. Rabab Khursheed
PATIENT
PSYCHOLOGY

2. CONTENTS
 Introduction
 Health psychology
 Psychological implications of malocclusion
 Psychological factors motivating patient to seek Orthodontic treatment
-Self and parental perception of malocclusion
- peer pressure
-Severity of malocclusion
-Self-esteem
-Erickson's theory
-Piaget’s theory
-Gender
 Motivational factors in adults

3.  Orthognathic surgery patients
 Pain perception and control
 Difficult patient
 Anxious patient
 Phobic patient
 Angry patient
 Using psychology to improve patient compliance
 Conclusion

4. INTRODUCTION
• Psychology is an academic and applied discipline
involving the scientific study of mental processes and
behavior
• Psychology also refers to the application of such
knowledge to various spheres of human activity, including
issues related to everyday life (e.g., family, education and
employment) and the treatment of mental health
problems

5. HEALTH PSYCHOLOGY
Health psychology is the application of psychological
theory and research to health, illness and health care
it includes –
Doctor-patient relationship
Understanding of health information
Beliefs about illness
effect of illness on patient

6. Face is perhaps the most important component
of an individuals physical appearance. ‘the
face” leads a distinctive character and identity
to an individual. A beautiful face is often
associated with a pleasing personality and it
permeates our entire developmental process.
Hence a major motivation for seeking
orthodontic treatment is to enhance dental and
facial esthetics

7. • Thus, individuals who are perceived by their parents, peers
and employers to be attractive are more likely to
experience positive social interactions and evaluations.
• Studies of laypersons’ responses to attractive and
unattractive faces of strangers have shown that attractive
persons are described as more competent in interpersonal
relationships and friendlier than people with unattractive
faces, even when the test subjects had no additional
knowledge about the faces being examined.

8. PSYCHOLOGICAL IMPLICATIONS OF
MALOCCLUSION
The adverse effects of poor facial esthetics , motivating a patient to seek
orthodontic treatment can be divided into
• Low self esteem and maladjustment
• Restriction of social activities
• Adverse occupational outcomes

9. Low self esteem and adjustment:
the motivation to seek orthodontic treatment is strongly related to an
individuals perception of the extent to which his dentofacial appearance
deviates from the social norm. the psychological handicap imposed by an
unaesthetic dental appearance may have a negative impact on the
personality of children who are often subjected to ridicule in the form of
teasing , name calling, and mobbing by their peers this mental anguish
imposed in early childhood may evoke feelings of inadequacy I the child
which may well sustain for life , leading to a maladjusted individual

10. Restriction of social activities :
attractive individuals are believed to have more social appeal and
attractiveness. It affects perception of social characteristics like –
perceived friendliness
Popularity among peers
Academic performance

11. Adverse occupational outcomes:
malocclusion may become a big social handicap as the affected
individual may find it very difficult to smile, talk in public, or interact with
people. facial appearance may have important implications in job
opportunities, with attractive faces having an edge over less attractive
ones.
Hence malocclusion is closely related to an individuals social performance
and well being.

12. PSYCHOLOGICAL FACTORS MOTIVATING PATIENT
TO SEEK ORTHODONTIC TREATMENT
• Motivation according to the social cognitive theory is a dynamic and reciprocal
interaction of a triad of three factors
 Personal factors
 Behavioral factors
 Environment
not all of them interact equally
The order and degree to which these factors influence an individuals motivation and
expectation from orthodontic treatment governed by :
 Age
 Gender
 Socio-economic set-up

13. The degree of psychological distress is not directly proportional to
the severity of the dentofacial anomaly. Hence a rotated lateral
incisor or a small median diastema may produce a more negative
body image in one person than a gross anomaly in another
Motivating factors differ in different age groups.a group which is of
utmost importance to a teen ager may not be all that significant for
an adult in seeking orthodontic treatment

14. The perception of attractive preference is gradually inculcated under the
influence factors such as :
• Self and parental perception of malocclusion
• Peer pressure
• Severity of malocclusion
• Self-esteem
• Social class/cultural reasons
• Affordability
• Availability of specialist orthodontic care

15. SELF AND PARENTAL PERCEPTION
• A child may be concerned and develops
anxiety for a minor tooth deviation while
others may not be concerned for major
irregularities. Such perception will depend on
parents perception of malocclusion
• Gosney(1986) in a study among British
children population referred to orthodontic
treatment observed that some were unaware
or relatively unconcerned about ab
pronounced malocclusion whereas others
showed a great concern over a relatively
mild irregularity
• The concept of self image varies with a ge
.some children wouldn’t bother about
orthodontic treatment during childhood but
would seek treatment when they grow up

16. • Helm and colleagues (AJO 1985) have found that overjet, extreme deep bite
and crowding are associated with the most unfavorable self-perceptions of
teeth, and the main reason to seek orthodontic treatment.

17. WHAT LEADS THE PARENTS TO SEEK THE
TREATMENT?
• The parents attempt to resolve problems of their own self-concepts by way
of identification with the child and his treatment
• Feeling of guilt about their own hereditary deformity among any of parents.
• View orthodontic treatment as a social status symbol.
• It has also been observed that children living with divorced mother who
often develop psychological shortcomings are often given orthodontic
treatment as a psychic gift in compensation for being deprived of father

19. PEER PRESSURE
• Children seek orthodontic advice on need for “braces” like their other
friends in school.
• There may be general problems in acceptance of braces in certain
population, where as it may be a “badge of honor” in others
Trulsson et al (JO 2002) interviewed 28 Swedish teenagers about
to start orthodontic treatment, in order to find out the factors
motivating them for treatment. Their results showed that the
decision to undergo treatment was based on a massive external
influence. This included the influence of peer group, as well as
the constant exposure to idealized beauty in the mass media.

20. The authors argued that youth without stable identities may find it difficult to resist the
influence of professionals, media and peer groups in their decision to have
orthodontic treatment
Shaw et al AJO 1981 , suggested that exposure and sight of appliance may
actually stimulate demand for similar object or treatments.

21. SOCIAL CLASS ,AVAILABILITY AND
AFFORDABILITY
• Certain health and cosmetic procedures are more valuable and popular in
social classes , which may also be indirectly influenced by affordability as
well as availability
• Ortho treatment may be considered as a symbol of prosperity .those not
having the appliance may feel they are being left out on something and
should have it

22. • Reichmuth et al. (AJODO 2005) assessed the effect of ethnic and
socioeconomic groups on demand for treatment .
• This study compared 3 groups of children who varied by location, payment
source, and ethnicity. The sample consisted of 150 children in the Bronx, NY,
and 100 in Seattle, Wash, who were undergoing or anticipating orthodontic
treatment in publicly funded dental clinics.
• Ethnic minorities comprised 69% and 92%, respectively, of these groups.
• The third group consisted of 84 children in Seattle, Anchorage (Alaska), and
Chicago who had sought treatment by private practitioners; ethnic minorities
comprised 22% of this group.

23. • Desire for treatment was higher among children in the publicly funded clinics
and among Black children than Whites or Asian Americans.
• Children in publicly funded clinics rated themselves as having worse
occlusions as determined by anterior crowding, overbite, overjet, diastema,
and open bite.
• This study showed that both socio-economic status and ethnicity play roles
in children's desire for treatment, self-assessed need, and judgments of
esthetics.
• A clinician's sensitivity to such differences can improve patient cooperation
with treatment.

24. SEVERITY OF MALOCCLUSION
• This is a major reason for seeking orthodontic treatment
• Large overjet, protruding teeth ,severely irregular teeth
• A child with severe malocclusion is more likely to seek treatment
• Anteriorly positioned teeth can cause teasing in school
Kilpelainen et al, angle orthod 1993 , did a study in Finland , parents of children
where asked about reasons to avail the treatment
Almost 85% expressed concern about their child's teeth being irregular
44% reported that the child had been teased in school

25. SELF ESTEEM
• Dentofacial deformities can constitute a source of emotional suffering ,
varying in degree from embarrassment to mental anguish
• Each individual has a conscious image of his/her own body , if that is not
personally pleasing the individual develops anxieties , which if un resolved
leads to mental illness
Roots et al, Am j orthod 1949 , consciousness of esthetic defect
Stated that the first and foremost effects of dentofacial deformity manifests as
inferiority complex , which is a painful emotional state characterized by
feelings of incompetence, inadequacies and depression in varying degrees.

26. • In a study by Secord and Backman , an attempt was made to determine
weather or not some dentofacial characteristics related to physical
attractiveness drew consistent stereotypic judgments about individuals
• They studied maxillary teeth protrusion , recession of the chin ,and alignment
of teeth
• It appeared that some personality characteristics are stereotyped because
of an individuals dental appearance

27. ERICKSON’S THEORY

28. PIAGET’S THEORY

29. GENDER
• Although the prevalence of malocclusion is equal among boys and girls ,
more girls seem to be seeking orthodontic treatment than boys.
• This sex steryotyping wherein the society has higher values and expectations
for females than males. It has also been found that females are more critical
of their dental apperence than males
Bergman and Eliasi studied psychological effects of malocclusion and the
attitudes and opinion about orthodontic treatment groups in Singapore and
Sweden, one of the significant conclusions was that features and facial
aesthetics are perceived differently by females and males

30. • Orthodontists are comparable to plastic surgeons who perform cosmetic
surgery, or dentists who do cosmetic dentistry; however, treating the teeth
and face is different from treating any other part of the body.
Moyers said:
“ Treatment of the face is more than moving teeth or cutting and rearranging
bones; it is even more than the sculpture of living tissues noted earlier, for it
often involves serious alterations in the personality and social interaction.”

31. PSYCHOLOGICAL ASPECTS OF
ORTHOGNATHIC SURGERY
• Combined orthodontic-orthognathic surgery is usually undertaken at
the request of the patient to improve esthetics or function.
• Several studies have reported a wide range of benefits from
orthognathic treatment, including psychosocial benefits such as
increased self esteem, as well as improvements in dental esthetics and
function.
• However, if patients embark upon treatment with unrealistic
expectations, they are more likely to be dissatisfied with the outcome
of care.

32. • It is vital that these patients are provided complete information on the
likely changes to be achieved, and that the patient be able to
articulate those issues they feel will be improved by orthognathic
treatment.
• Sarver D (AJODO 1998) showed the advantages of video-imaged
predictions in improving patient understanding of planned changes.
• Video-imaged predictions do not directly affect patients' treatment
decisions but may indirectly affect them by strengthening the patients'
self-image motivation and expectations and by confirming the
necessity of surgery as a treatment option.

33. • Video-imaging was ranked as the best information source when
compared to the other physical records presented in the video-
imaged group.
• Video-imaging influences patients by heightening their expectations
of improvement in self-image following treatment.
Post surgical considerations:
• Surgery produces sudden and sometimes dramatic changes, placing
immediate demands on patients' adaptive skills.
• A clinician who has any doubt about a patient's ability to adapt
should refer the patient for psychological assessment.

34. • Post-operative depression is common after any
surgical procedure, and the situation with
orthognathic surgery is exacerbated by difficulties
with speech and eating.
• Direct fixation, as opposed to wiring the jaws
together, appears to reduce the likelihood of
depression.
• Patients who exhibit symptoms of depression should
be taken seriously and offered counseling. Studies
have found occurrences of depression as long as
nine months after surgery, emphasizing the
importance of long-term support.
• Daily contacts with family and friends play an
important role in the post-operative phase.

35. • Overall, 92-100% of orthognathic surgery patients seem to
be satisfied with their results, although if satisfaction is
defined as "willingness to re-elect surgery", the rate drops to
84-92 %
• Cunningham et al,Eur J Orthod,2000, investigated
psychological profile of orthognathic patient prior to starting
treatment and compared it with controls.the orthognathic
patients displayed higher levels of anxiety and lower body
image

36. PSYCHOLOGICAL ASPECTS OF
PAIN PERCEPTION AND CONTROL
• Orthodontic appliances are uncomfortable and require a period of
physical and psychological adjustment.
• Patients must alter their diets and endure functional and esthetic
impairment.
• The most significant side effect however is the pain associated with
orthodontic appliances.
• Only 15% of the patients wearing intraoral elastics and headgear
among those interviewed by Egolf et al (AJODO 1990) agreed that
“braces aren’t painful.”

37. • Oliver and Knappman (BJO 1985) reported that 70% of the subjects in their
study had at least some degree of pain, regardless of the type of appliance
worn.
• Clinical experience and recent research data indicate that patients may
adapt to continuous pain and discomfort with the progression of treatment
as the sensations cease or at least disappear from their focus of attention.
• Individual psychological susceptibility is likely to be a significant factor for the
intensity of discomfort caused by physical effects of an appliance on oral
tissues.
• Pain experience, for instance, does not seem to be directly related to the
magnitude of force exerted by different arch wires and depends rather on
psychological well-being of the individual concerned. (Jones and Chan,
AJODO 1992)
• Psychological research has shown that experience of pain and discomfort is
influenced by personal values and expectations such as expectations of self-
efficacy and treatment outcome

38. • Of relevance to orthodontics are patients’ attitudes toward dental
esthetics, perceived severity of malocclusion, and expectations from
treatment in the sense of an anticipated orthodontic self-efficacy.
• Patients’ behavior during orthodontic treatment seems to be related
to perceived severity of malocclusion and to personal control
orientation (locus of control theory).

39. “DIFFICULT” PATIENTS
• Patients with no known psychopathology can still be difficult to manage,
exhibiting a number of different behaviours that are disruptive, hostile, or
otherwise difficult for the dentist to handle.
• According to Groves, they can be categorized into four distinctive types:
• Dependent clingers
• Entitled demanders
• Manipulative help-rejecters
• Self-destructive deniers

40. • Dependent clingers have needs for reassurance from
their caregiver that escalate.
• Patients are initially reasonable in their needs but
become progressively more helpless, ultimately
becoming totally dependent upon their doctors.
• These patients must be given appropriate limits with
realistic expectations.
• Clear verbal and written instructions can be helpful in
reinforcing the limits of patient access to the
professional staff.

41. • Entitled demanders are also needy but manifest it as
intimidation and attempts to induce guilt.
• They have a need to control the situation and often
make threats, either overt or implied, in order to get
what they want.
• Their aggressive behavior may be due to feelings of
dependency and fear of abandonment.
• These patients are best dealt with by validating anger
but redirecting the feelings of entitlement to realistic
expectations of good care.
• Again, limits must be placed so that office procedures
are not disrupted

42. • Manipulative help-rejecters focus on their symptoms but
are resigned toward failure. They seem satisfied with a lack
of improvement.
• Clearly, these patients who are difficult to treat must be
involved in all decisions and should have regular
appointments.
• They must either agree to all treatment or choose not to
proceed, the dentist does not have the responsibility for the
success of the treatment.

43. • Self-destructive deniers take pleasure in
defeating any attempts to help them.
• They do not seem to want to improve.
• These patients may be sufficiently depressed to
consider not rendering or limiting treatment

44. HELPING THE ANXIOUS PATIENT
• Show willingness to help calm worries over pain, loss of autonomy,
cost, or other concerns.
• Let the patient know that these concerns are normal and
understandable.

45. HELPING THE PHOBIC PATIENT
• Recognize that phobia is more than
anxiety.
• Speak to the physician about pre-
medication.
• Suggest behavior modification.
• Involve the phobic patient’s
therapist or other supports.
• Schedule appointment to lessen
stressors

46. HELPING THE ANGRY PATIENT
• Don’t delegate the angry patient to anyone
else.
• Allow the patient to vent the angry feelings.
• Actively listen –– don’t lead or second guess.
• Speak in a calm voice and slow your
breathing.
• Use the words feel, felt, found.
• Avoid the urge to argue

47. USE OF PSYCHOLOGICAL PRINCIPLES
TO IMPROVE PATIENT COMPLIANCE
• Many educational and psychological principles are adaptable to orthodontic practice.
• These educational-psychological principles can be used by the orthodontist as part of
patient treatment, patient management, or staff training
Some important principles are:
• Progressions
• Backward chaining
• Reframing (symptom prescription, reverse psychology)
• Reinforcement theory
• Hypnosis
• Learning by doing

48. PROGRESSIONS
• Progression learning involves segmenting the skill to be learned
into a number of simple and sequential component parts, or
progressive steps.
• Used when learning complex skills, including both cognitive and
psychomotor skills.
• For example, teaching a patient to insert a cervical headgear for
the first time could be sequenced into the following progression:

49. 1. Show the patient the headgear face-bow and explain the correct
orientation for insertion of the face-bow into the mouth. Have the patient
demonstrate this.
2. Show the patient how to place the face-bow inside his or her mouth with
no attempt to put it into the molar band tubes. Have the patient
demonstrate this.
3. Next, show the patient how to insert the right end of the facebow into the
right molar tube. Again, have the patient demonstrate.
4. Show and have the patient demonstrate how to insert the left side of the
facebow into the left molar tube.
5. Show the patient how to fasten the cervical strap around the back of neck;
have the patient demonstrate.
6. Show and have the patient demonstrate the steps for removal of the
headgear, and so on.

50. BACKWARD CHAINING
Educational principle that incorporates stages, or progressions, into
learning, only in reverse sequence.
The last steps in a sequence, from beginning to end, are taught first,
working backwards toward the first step in the progression.
Particularly useful in learning complicated psychomotor skills when
the last step is easier to learn than any of the beginning steps.
At times, it is only necessary to teach the last step first, then go to
the first and work forward.
Some activities in orthodontics that could be backward chained are
headgear placement, the use of intraoral elastics, placement (and
removal) of retainers, and activation of palatal expanders.

51. • The removal of the headgear is a much easier task than its insertion. The initial task
of removing the headgear is more success oriented than if the patient was first
asked to place the headgear.
• Similarly, patients first learn to remove elastics and retainers before they learn to
place them.
• Likewise, patients or parents are first asked to remove the activation key for a
palatal expander before they are asked to place and turn the key.
• In addition, the sequence of events in acquiring initial patient orthodontic records
could be backward chained starting with the one that is the easiest for the patient
and ending with the one that is the most difficult.
• The sequence might be: (1) photographs, (2) radiographs, and (3) impressions.
• The impressions are doubtless the hardest on the patient, with possible adverse
outcomes such as gagging and vomiting.
• In keeping with this logic, the lower impression might be taken first, before the
upper, because it is the least invasive.

52. REFRAMING (Symptom prescription or reverse psychology)
• Psychological technique in which a behavior that is considered undesirable
but pleasurable is made to appear, or reframed, as a duty, or vice versa.
• For example, reframing can be used for certain patients to help alleviate, or
lessen, a finger-sucking habit.
• The patient, perhaps an 8-year-old girl with a severe Angle Class II Division
1 malocclusion who still sucks her thumb, could be asked to actually
continue to suck her thumb
• Using this form of reverse psychology, the habit that you want to extinguish is
paradoxically prescribed.

53. • However, the catch to all this is to make the prescription a duty rather than a
pleasure.
• As described by Alfred Adler, “Therapy is like spitting in someone’s soup.
They can continue to eat it, but they can’t enjoy it.”
• One could ask the patient to not only continue to suck her thumb, but, for
every minute she sucks her thumb, she must suck all her other fingers as
well.

54. REINFORCEMENT THEORY
• Positive and negative reinforcement, and, to a limited degree, punishment,
can be used in orthodontics.
• The overriding principle of reinforcement theory is to give more praise than
criticism. It has been suggested that at least 3 words of praise be used for
every word of criticism (punishment).
• The orthodontist should look for appropriate behavior to positively reinforce.
• If you reinforce desired behavior and ignore undesirable behavior, eventually
the undesirable behavior become extinct.

55. HYPNOSIS
• Hypnosis, and other techniques closely associated with hypnosis, can be
used for fearful and apprehensive patients.
• Clinical situations in which hypnosis or a closely related technique could be
used are: impression making, bonding, debonding, and extraction of very
loose deciduous teeth.
• For an apprehensive patient about to receive braces, you may question the
patient about favorite hobbies, activities, sports, or vacations.
• You might then focus on a patient’s favorite summer vacation

56. • While placing a band around the patient’s molar tooth, you paint a verbal picture of a scene
from the patient’s vacation, describing in detail the ocean scene using words and language
that embraces the patient’s senses (sight, sound, smell, and touch).
• Patients have expressed fear, apprehension, and dislike for impressions.
• The following strategy can be used in conjunction with impression making.
• Make them aware of their breathing: tell them, particularly, to breath slowly by moving their
stomach in and out.
• This diaphragmatic breathing has been to produce a relaxing response, that is, a decrease
in metabolism, heart rate, blood pressure, breathing rate, and muscle tension.
• While the patient focuses on diaphragmatic breathing, insert the impression tray in the
patient’s mouth;
• One could also have the patient raise his or her legs and then arms.
• This technique helps keep the patient focused on something other than the unpleasant
procedure, the idea being that the patient cannot focus on 2 thoughts at one time (leg and
arm lifting and the impression material).

58. LEARNING BY DOING
There is a proverb that states:
I hear and I forget;
I see and I remember;
I do and I understand.
The more we can get our patients and our staff to do, rather than observe,
when we teach them new tasks, the faster they will learn.

59. S.Portnoy (BJO 1997) enumerated 8 important
factors to improve patient co-operation.
• Being polite, friendly and making the patient feel
welcome.
• Having a calm, confident manner.
• Giving information about the problem, the
treatment plan, and the procedures.
• Not using jargon.
• Pay attention to what the parent and child say.
• Reassure the child that you will do everything to
prevent pain.

60. • Express concern about the child’s well-being.
• Do not criticize the child’s tooth-brushing or oral hygiene.
(Encouragement is more effective than criticism.)
She also suggested the use of simple reward charts to help a child
stop thumb-sucking, or to encourage headgear wear. Praise and
appropriate rewards and are given when the child shows progress.

61. CONCLUSION
• Starting from the reasons for demanding orthodontic treatment, to the
patient’s attitude toward treatment, as well as elicitation of adequate
compliance, the underlying psychology is a key factor, which needs
to be understood and managed effectively.
• Only then can we as orthodontists truly give satisfaction to our
patients, and receive it in turn

62. REFERENCES
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63. • Goldman SJ. Practical approaches to psychiatric issues in the
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