Psychosocial factos /certified fixed orthodontic courses by Indian dental academy

PSYCHOSOCIAL FACTORS AND PATIENT COMPLIANCE

IN ORTHODONTICS.

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

SEMINAR BYDR. SIDDHARTHA DHAR

Done under the guidance ofPROF. ASHIMA VALIATHANB.D.S ( Pb), D.D.S, M.S (USA)

DIRECTOR OF POSTGRADUATE STUDIESPROFESSOR AND HEAD

DEPT. OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS

MANIPAL COLLEGE OF DENTAL SCIENCESMANIPAL.


Facial Esthetics and Human Psychology The Role of Teeth in Facial Appearance Orthodontics Justified as a Profession Factors affecting the demand for orthodontic treatment Psychological influences on the timing of orthodontic

treatment Psychological aspects of orthognathic surgery Psychological Aspects of Pain Perception and Control Measures of Patient Compliance Use of Psychological Principles to Improve Patient

Compliance.


Facial esthetics and human psychologyFacial esthetics and human psychology

Facial esthetics has been found to be a significant determinant of self and social perceptions and attributions.

These perceptions of facial esthetics influence psychological development from early childhood to adulthood.

The infant’s visual preference for human faces has been confirmed in many psychological studies.

By the age of 6 months, children can discriminate between familiar and unfamiliar faces.

By the age of 6 years, children have internalized cultural values of physical attractiveness.


By age 8 their criteria for attractiveness are the same as those of adults.

A teacher’s perceptions of a child’s attractiveness can influence the teacher’s expectations and evaluation of the child.

Children perceived as more attractive are not only more socially accepted by their peers, they are also believed to be more intelligent and to possess better social skills.

In addition, people perceived as attractive by their peers are considered more desirable as friends

Employees perceived as more attractive by their supervisors are given better job-performance ratings


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.


The Role of Teeth in Facial AppearanceThe Role of Teeth in Facial Appearance The appearance of the mouth and smile plays an important role in

judgments of facial attractiveness. Two national surveys showed most Americans believe dental

appearance is “very important” in social interactions, particularly in young people’s selection of dating partners.

Children of normal dental appearance are judged to be better looking, more desirable as friends, and more intelligent.

Children have reported that the appearance of their teeth is a common target of teasing. In particular, malocclusions in the anterior region are the most conspicuous and raise the child’s greatest concerns.


Helm and colleagues (AJO 1985) have found that overjet, extreme deep bite and crowding are associated with the most unfavorable self-perceptions of teeth.

Shaw (AJO 1981) has found that an overjet of 7 mm or more, anterior crowding and deep bite are associated with a child’s report of being teased.

Overjet has also been found to be the most significant predictor of the decision to seek orthodontic correction, especially in children referred for treatment by their parents.


Some researchers have examined laypersons’ evaluations of malocclusions in terms of attractiveness.

The following classes have been ranked from most to least attractive:

Class I > open bite > Class II > Class III, but patients with Class II malocclusion have been found to be significantly more motivated to seek treatment than Class III patients.

Malocclusions consisting of overjet, deep bite and overcrowding have been associated with the most negative self-evaluations among Danish adults


Research with Asian subjects has revealed a different pattern of perceived dental attractiveness of malocclusion types.A study in Singapore revealed that Class III malocclusion is ranked as more attractive than Class II.


Orthodontics justified as a profession

Scientific evidence that malocclusion per se is not associated with morbidity and mortality.

Malocclusion may not be associated with temporomandibular disease (TMD), and orthodontic treatment cannot lessen or prevent the future development of TMD.

Also, orthodontic treatment cannot routinely improve one’s periodontal health; in fact, orthodontic treatment has been associated with increased plaque retention, gingivitis, periodontitis, decalcification, dental caries, and root resorption.


Although we cannot easily justify routine orthodontic treatment from a physical dimension, we can justify it from a social and psychological dimension.

In the model of health represented by a triangle of mind, body, and spirit, orthodontic treatment most likely influences the mind and the spirit.


In this paradigm, sound mind, body, and spirit are all important elements of health.

If a person has only 1 or 2 of the 3 elements, he or she cannot experience total health.


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.”


By improving one’s physical attractiveness and social marketability, orthodontic treatment enhances one’s self-image and self-esteem.

In addition orthodontic treatment may offer a latent benefit of providing a model and an environment for the patient to experience success by his or her important participation with the doctor in achieving good dental results

E.g. wearing appliances, retainers, elastics, functional appliances, headgear, and oral hygiene compliance.

This model, or seed for success, may transfer to other endeavors in the patient’s journey through life.


As Plunkett (NZDJ 1997) has written: “ Psychological well-being is an intangible benefit to

society as a whole. Orthodontic treatment does not increase productivity in the way public health spending on, say, tuberculosis would.

Malocclusion can be regarded as a “health” problem because society perceives it as one.

Western society is very concerned with appearance, and orthodontics has become important to most people as they respond to peer pressure and strive to seek “normality” in society.

Morally, there must be some provision for orthodontic treatment for those people where it is shown that the treatment will improve their quality of life.”


Factors affecting the demand for Factors affecting the demand for orthodontic treatmentorthodontic treatment

The self-perception of dental esthetics has been suggested as the most common predictor of the seeking of treatment.

Perceived facial appearance has also been found to be an important predictor of the decision to undergo facial surgery for improvement of dental appearance.

Perceived need for treatment does not necessarily reflect an individual’s actual clinical need as assessed by an orthodontist.


Self-Concept and Appearance Self-concept is defined as the perception of one’s own

ability to master or deal effectively with the environment

The individual’s interactions with and responses from others may influence the development of self-concept.

Developmental psychologists generally agree that a child’s self-concept develops from the “reflected appraisal” that he or she receives from others.

In other words, self-concept is affected by the reactions of others toward the child.

Self-concept also depends on social comparisons and self-attributions by the child..



Researchers have consistently found that

Self-concept is related more to the individual’s perceptions of others’ evaluations than to objective evaluations by others.

Females have consistently been found to have more negative body image and self-concept scores.

This phenomenon begins in adolescence, when girls become more concerned about their physical appearance and weight.


Although pubertal changes increase the self-consciousness of boys and girls, the latter are more influenced by these rapid changes in their physical appearance, and they continue to attach more importance to these external characteristics into adulthood.


Parental concern most likely stems from the parents’ hope that the child will conform to their own and society’s ideals of facial attractiveness.

It has been suggested that parental influence based on dental aesthetics—not necessarily malocclusion severity— may be the main motivating factor for children to seek orthodontic treatment.

These findings are similar to those of Dann and colleagues:

“ The degree of malocclusion does not affect the decision to undergo treatment as much as the perceived esthetics of the malocclusion.”


The demand, or self-perception of need, for orthodontic treatment is greater in female subjects than in male subjects, among White subjects, in urban settings and among children of higher socioeconomic status.

In contrast, actual clinical need was found in these same studies to be greater for males and whites and equal across socioeconomic strata and in urban vs. rural settings.


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.

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.


Although overall self-concept has not been found to be altered by orthodontic treatment, some components of self-concept, perceptions of appearance by others (e.g., parents and peers), and body image have been found to improve after orthodontic treatment.

Dawoodbhoy and Valiathan ( KDJ 1994) reviewed the psychosocial implications of dentofacial deformities and concluded that the problems of the facially deformed lie squarely in the area of mental health.

In children with more conspicuous facial impairments such as cleft lip or palate, correction may result in improved school performance and social acceptance


In the USA, ethnic and economic differences have been suggested to affect occlusal perceptions in children seeking orthodontic treatment.

Overall it has been found that Whites have lower scores for body image and self-esteem compared to Black adolescents.

White children were more likely to associate physical attractiveness with self-esteem.

Holmes (BJO 1992) found that White children were more likely to perceive themselves as having unattractive dentitions and requiring orthodontic treatment than any other ethnic group.


However, there also seems to be a positive correlation between socio-economic status and self-esteem. Lower the economic status, lower the self esteem.

Gray and Anderson found that high school students from lower SES neighborhoods were more likely to have untreated malocclusions and to want straight teeth than children in higher SES areas.

Proffit et al (1998) found that only 5% of children from the lowest SES group received orthodontic care, compared to 10-15 % in intermediate SES group, and 30% in the highest SES group.


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.


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.


Marques et al (AJODO March 2006) studied the esthetic impact of malocclusion on the daily life of Brazilian school-children aged 10-14 years with no history of orthodontic treatment.

Self perception regarding dental esthetics was assessed with the oral aesthetic subjective impact scale (OASIS).

27 % of the children reported a negative impact on their daily lives because of malocclusions. Of these patients, 71% had not received treatment because of the cost.

As in previous studies, girls were more critical of and concerned with their dento-facial appearance. Also, children with low self esteem were more sensitive to the esthetic effects of malocclusion.


Psychological influences on timing of Psychological influences on timing of orthodontic treatmentorthodontic treatment

The decision of whether to treat a patient in childhood or adolescence raises several issues related to the developmental stages of preadolescence and adolescence.

One of these issues is the concern with adherence.

Treatment adherence is influenced by a child’s sex and age. In general, girls are more likely to adhere to treatment recommendations than boys. www.indiandentalacademy.com

Preadolescent children have been found to be more adherent to rules for the use of removable appliances than adolescents.

For this reason it has been suggested that treatment begin after age 6 and be completed before the onset of puberty.

Other predictors of greater adherence include high self-esteem, optimism regarding the future, and low social alienation.


Children experience major changes in these aspects of the self as they move from early childhood through the teen years.

According to Erikson’s theory of psychosocial development, the preadolescent experiences the stage of “industry vs. inferiority”.

Social and academic skills develop, children begin to compare their capabilities in these areas with peers, and they increasingly recognize that they can achieve competence through their own initiative.


The adolescent goes through a period of “identity vs. role confusion,” Erikson’s fifth stage of psychosocial development.

This is a period of role confusion for many adolescents as their physical selves mature into their future adult selves yet they are still treated as children.

The goal of this developmental stage is the search for identity, or “a feeling of being at home in one’s body, a sense of knowing where one is going, and an inner assuredness of anticipated recognition from those who count.”


Adolescence is often associated with increased self-consciousness, confusion about identity and acceptance by others, and concerns about recognition from adults and peers.

Younger children are influenced, greatly by their parents and other adults (e.g., teachers, health care providers).

As the child enters adolescence, however, peers assume a greater role in their lives, especially in terms of self-image.

Peers often serve as a standard of comparison and implicit or explicit critics of the adolescent’s appearance, dress, activities, and interests.


The increasing significance of peer acceptance for adolescents results in greater need for social comparison.

The increased focus on the self relative to his or her peers may help or hinder the child’s success with orthodontic interventions.

If the adolescent has significant concerns about the appearance of his or her teeth and has friends who are undergoing or have undergone orthodontics, they can serve as role models for the child. This role-modeling can result in greater cooperation with the treatment regimen.

If, however, the child is absorbed in other developmental tasks of adolescence, it may be the wrong time to initiate treatment.


Research by Peevers on children’s past, future, and current perspectives, and their perception of change vs. constancy in themselves, provides further evidence that adolescence is a time of identity confusion.

Adolescents focused on the “here and now” may have more difficulty with long-term adherence in the interests of future improvements in their oral function and appearance.

Also, the rejection of adult rules may manifest itself as non-compliance with doctor’s instructions and reluctance in maintaining oral hygiene.


Adolescents need to feel adult about their care. Orthodontists need to make them informed and involved consumers by actively including them in the process. The treatment plan and its details should be discussed with them.

Their concern with self image and identity could be used to motivate them.

Individualizing the patient and recognizing adolescent values and issues help to achieve better motivation


Psychological aspects of orthognathic Psychological aspects of orthognathic surgerysurgery

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.


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.


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.


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.


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 %


Psychological aspects of pain perception Psychological aspects of pain perception and controland 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.”


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


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).

Brown and Moerenhout (AJODO 1991) used a questionnaire study to assess age-related changes in psychological measurements of pain and well-being in patients undergoing full fixed appliance orthodontic treatment.


A longitudinal series of four questionnaires was used to obtain measurements of these factors after the separation phase of treatment, banding (2 to 7 days after separation), the first adjustment visit (3 to 4 weeks after placement of full fixed appliances), and the second adjustment visit (3-4 months after banding was completed).

The results suggest an interaction between the phases of treatment and reported pain and psychological well-being. Highest pain levels were seen just following banding.

There were significant differences in the response profiles of the adolescent age group (14-17 years) compared to the preadolescent (11- 13 years) and adult groups (18 years and older).


The profile comparisons indicated that the adolescent age group generally reported lower levels of psychological well-being and higher levels of pain during the phases of treatment examined.

Consistent with these results was the finding that the adolescents differed from the preadolescents and adults in the quality of the pain experience reported during treatment.

The results indicated an age difference in adjustment to fixed orthodontic therapy, which suggests that adolescents are more vulnerable to undesirable psychological effects of treatment.


Sergl et al (AJODO 1998) assessed pain and discomfort experienced by 84 patients undergoing orthodontic treatment, their attitude toward the treatment, and compliance, 7 days, 14 days, 6 weeks, 3 months, and 6 months after appliance insertion, using specially designed protocols, questionnaires, and rating scales.

Adaptation to pain and discomfort occurred during the first 3 to 5 days after placement of the appliance.

The severity of pain and discomfort experienced by the patients wearing functional or fixed appliances was significantly higher than by those treated with upper and/or lower removable plates.


Patients who had higher personal perception of the severity of their malocclusion and displayed attitudes characteristic for internal control orientation according to the so-called locus of control theory, seemed to adapt faster and have less pain.

The results of this study also indicated that acceptance of orthodontic appliances and treatment in general may be predicted by the amount of initial pain and discomfort experienced.


Bergius M, Berggren U, Kiliaridis S. (Eur J Oral Sci. 2002 ) investigated pain experiences during common orthodontic treatment.

55 patients (12-18 yr) starting treatment due to crowding were included. Molar elastic separators were inserted bilaterally, and telephone interviews were made during evenings for a week.

Pain intensity was assessed on a VAS scale, and pain medications were recorded.

48 patients (87%) reported pain the first evening. The highest intensity of pain was reached the day after placement of separators

At day 7, 42% of the patients still reported pain. Pain medication was used by 27% of the patients during the first 2 days, after which no patients used painkillers.


While motivational factors and reasons for seeking treatment did not influence pain assessments, patients taking pain medication made significantly higher pain ratings during the days medication was used.

Girls made significantly higher pain ratings during the later phase (day 3-7) of the follow-up week. Statistically significant relationships were found between 'late' VAS assessments and reported level of previous general pain experiences.

It was concluded that pain is common after a simple procedure such as placement of molar separators.


Firestone AR, Scheurer PA, Burgin WB. Eur J Orthod. 1999. investigated the relationship between

(i) the pain and its side effects, anticipated by patients before orthodontic therapy and

(ii) the reported pain and its effects after the placement of initial archwires.

Before treatment, 50 adolescent patients completed a questionnaire concerning their facial and dental appearance, and their expectations regarding pain, its influence on their daily lives, and changes in their facial and dental appearance as a result of orthodontic treatment.


In the week following insertion of the initial archwires the patients completed a series of eight questionnaires, where they reported the level of pain experienced and its influence on their daily lives.

In the week after arch wire insertion, the maximum pain levels reported did not differ statistically from the anticipated pain levels. Patients significantly under-estimated the changes they would have to make in their diet as a response to pain after archwire insertion.

Patients who anticipated a greater effect of pain on their leisure activities and those who had a history of frequent headaches reported higher levels of pain and more disruption of their daily lives as a result of pain.


This pattern of response is consistent with a medical model where anxious patients and those with a history of chronic pain reported more pain after surgery.


Bartlett BW, Firestone AR, Vig KW, Beck FM, Marucha PT. AJO-DO 2005 studied the influence of a structured telephone call on orthodontic pain and anxiety after orthodontic appliance placement

150 orthodontic patients were randomly assigned to 1 of 3 groups and matched for age, sex, and ethnicity.

The subjects completed baseline questionnaires to assess their levels of pain before orthodontic treatment.

After the initial arch-wires were placed, all subjects completed the pain questionnaire and state-anxiety inventory at the same time daily for 1 week.


One group also received a structured telephone call demonstrating care and reassurance; the second group received an attention-only telephone call, thanking them for participating in the study; the third group served as a control.

Although both telephone groups reported significantly less pain and state-anxiety than the control group, there was no difference between the 2 telephone groups

CONCLUSIONS: A telephone call from a health-care provider reduced patients' self-reported pain and anxiety; the content of the telephone call was not important.


Patrick J O’Connor (JCO 2000) surveyed 146 consecutive patients in a single orthodontic practice.. Depending on the patients’ stage of treatment, they were asked to respond in one of three categories:

Fears and apprehensions prior to treatment (10% of respondents)

Greatest dislikes during treatment (49%) Recommendations for orthodontists after

treatment (41%)





A QUESTIONNAIRE SURVEY ON “ATTITUDE OF A QUESTIONNAIRE SURVEY ON “ATTITUDE OF ORTHODONTIC TREATED PATIENTS”.ORTHODONTIC TREATED PATIENTS”.

Valiathan A et al (JPFA 2006, in Press) conducted a

questionnaire study among 72 patients who had completed orthodontic treatment with fixed appliances in both upper and lower arch at Manipal and Mangalore dental colleges (Manipal College of Dental Sciences).

Mean age of the sample was 22.35 + 3 years. Majority of the patients (63.9) % themselves felt that

they had crooked teeth. In the remaining patients crooked teeth were noticed

by others.


When it was enquired about difficult adjustment period 77.8% of the patients reported first four weeks as the most difficult where as 6.9% experienced entire treatment period difficult.

73.6% completed their treatment without any interruption. Reasons for interruption in the treatment varied and only 2 patients stated transfers of parent and guardian as the cause.

When asked about worst part about orthodontic treatment 38.9 % reported pain during initial treatment, 30.6% as problem in eating, 6.9% problem in speaking and 23.6% problem in tooth brushing.


77.8 % people reported that they got what they expected from the treatment.80.6% percent were satisfied from the treatment where as 19.4% reported dissatisfaction from the treatment.

When patients were asked whether they would recommend treatment to others people based on their own experiences, 63.9 % recommended, 20.8% said NO and 15.3% were unsure.

In conclusion, concern for appearance remains the major priority for orthodontic treatment, while pain remains a significant discouraging factor. Majority of patients would recommend it to others.


Measures of patient complianceMeasures of patient compliance

Although the knowledge and skills of the clinician remain significant, the cooperation of patients and that of the parents, in the case of children and adolescent patients, plays a major role in achieving the desired orthodontic results.

Patient cooperation is the single most important factor every orthodontist must contend with.


Major considerations are Regularity in keeping appointments Compliance in wearing rubber bands and

headgear or wearing removable appliances.

Refraining from chewing hard and tenacious substances that are likely to distort the arch wires and remove bonded brackets.

Maintenance of oral hygiene.


Laxity in following these instructions may lead not only to compromised treatment but also to slow progress of treatment, loss of chair time, and frustration.

There has been a wide variety of contradictory findings regarding predictors of patient compliance.

Allan and Hodgson ( AJO 1968) found that age was the single best predictor of patient cooperation, with the younger patients tending to be more cooperative.

Similarly, Weiss (AJO 1977) concluded that 12-year-old and younger patients were more cooperative than older patients.


Graber found that higher socioeconomic groups tend to cooperate more than lower socioeconomic groups.

However, Dorsey and Korabik (AJO 1977) found that lower middle class patients considered orthodontic treatment to be more important than the upper middle class patients.

Alley (1982) thought that regardless of socioeconomic status, facial appearance is probably the most important aspect of physical appearance that determines how others feel about us and how we feel about ourselves.


El-Mangoury (AJO 1981) indicated that orthodontic cooperation was predictable through psychologic testing. She devised three psychoorthodontic theories of motivation to provide a conceptual framework for the investigation of orthodontic cooperation.

Research from the Albino group (1982) suggests that two important aspects reflect the desire for orthodontic treatment: (1) the wish for treatment by the child and the parent, and (2) the concern about dental occlusion by the child and the parent.


Nanda and Kierl (AJODO 1992) conducted a prospective study of patient cooperation with orthodontic treatment on 100 adolescent patients.

Patient, parent, and orthodontist questionnaires were used at three stages of orthodontic treatment. The first was used at the initiation of treatment and the latter two at 6-month intervals.

Neither personality tests, the Orthodontic Attitude Survey, nor the patient's orientation toward peers proved to be significant predictors of patient cooperation.

One outstanding feature of this investigation was that the doctor-patient relationship had a positive impact on the cooperative behavior of the patients.


Bos, Hoogstraten, Birte Prahl-Andersen (AJODO 2003) also concluded that “ the assumption that patients’ personality characteristics alone enable us to predict their compliance to a clinically useful degree is no longer tenable.”

Agar et al (EJO 2005) used a questionnaire called the Child Behavior Checklist (CBCL) in order to detect psycho-social factors that might affect headgear compliance.They too could find no relation between child behavior pattern and headgear compliance.


Use of psychological principles to improve Use of psychological principles to improve patient compliance.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:Some important principles are:

• Progressions • Backward chaining • Shaping (close approximation) • Reframing (symptom prescription,

reverse psychology) • Reinforcement theory • Hypnosis • Kinesthesia • Learning by doing


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:


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.

Use the patient’s name frequently; it becomes a form of positive reinforcement. Also, ask the patient and parent to give you feedback about their understanding of the procedure being demonstrated.

Other patient procedures, or skills, that could be formulated into progressions are placement of retainers, activation of palatal expanders, and oral hygiene procedures etc.


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.


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.


SHAPING Shaping, or close approximation, is an operant conditioning

principle that involves reinforcing behavior that approaches the desired behavior.

Popularized by B. F. Skinner. The behavior that is reinforced is the closest approximation

of the ideal (or desired) behavior that the learner can make at that point in time.

As the learner’s skills and perceptions are further developed, the learner’s approximation comes closer to the desired response, and only the newest and best approximation is reinforced.

Thus, the learner’s behavior is “shaped” toward the desired response.


For example, if a patient is having trouble executing the desired technique in cleaning his or her teeth, shaping might be helpful.

During an office visit, when the patient is being instructed on tooth brushing, the patient’s closest (or best) approximation of the desired response should be reinforced.

Once the tooth-brushing technique has been practiced at home and the patient returns on the next office visit, a closer approximation- or even the desired response- is now reinforced.

The reinforcement may be as simple as a smile or a pat on the back or something as elaborate as a gift or a token.


Keep in mind that giving the patient a gift or other positive reinforcement is contingent upon performance of the desired behavior.


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.


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.


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.


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.


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).



KINESTHETIC LEARNING Sometimes called “muscle memory,” can be a

powerful teaching aid for learning a physical skill. Perhaps, when teaching a patient how to place

and remove a headgear, the orthodontist or staff member could have the patient hold onto the face-bow or onto the orthodontist’s hands while the face-bow is inserted and removed.

This may help certain patients who are having problems learning to place or remove a headgear when their manual dexterity is compromised.


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.


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.


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.


ConclusionConclusion

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.


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