Condylar response to functional therapy with Twin-Block as shown by cone-beam computed tomography Ersin Yildirima; Seniz Karacayb; Mustafa Erkanb Angle Orthod. 2014;84:10181025.)

Rabab Khursheed Patient psychology

Contents IntroductionHealth psychologyPsychological 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 -Piagets theory -GenderMotivational factors in adults

Orthognathic surgery patients Pain perception and control Difficult patient Anxious patient Phobic patient Angry patient Using psychology to improve patient complianceConclusion

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

Health psychology Health psychology is the application of psychological theory and research to health, illness and health careit includes Doctor-patient relationshipUnderstanding of health informationBeliefs about illness effect of illness on patient

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

FACE Is the first thing anypne sees and employs in nonverbal communication 6

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.

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 maladjustmentRestriction of social activitiesAdverse occupational outcomes

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

Restriction of social activities : attractive individuals are believed to have more social appeal and attractiveness. It affects perception of social characteristics like perceived friendlinessPopularity among peersAcademic performance

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.

Psychological factors motivating patient to seek orthodontic treatmentMotivation 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 :AgeGenderSocio-economic set-up

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

The perception of attractive preference is gradually inculcated under the influence factors such as :Self and parental perception of malocclusionPeer pressure Severity of malocclusion Self-esteem Social class/cultural reasonsAffordability Availability of specialist orthodontic care

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 wouldnt bother about orthodontic treatment during childhood but would seek treatment when they grow up

Baldwin and barnes the mother is trhe mobilizing factor , in these cases the mother came from higher socio-economic backgrowun and may have had same problems before15

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.

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

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.

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.

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

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.

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 treatmentAnteriorly 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 irregular44% reported that the child had been teased in school

Self esteem Dentofacial deformities can constitute a source of emotional suffering , varying in degree from embarrassment to mental anguishEach 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.

When a childs insecurity becomes a serious problem is in school He then realizes the difference between him and others When the individual reaches adolecense , a sense of despair and negative ohilosphy of life , mixed with allnkinds of peculiar traits 25

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 individualsThey 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

Children are introverts

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Ericksons theory

195927

Piagets theory

Theory of cognitive development 28

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

Sharma lucknow thesis, 1972 , said females were more concerned and more concern was observed in higher socio-economic status

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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.

Psychological aspects of orthognathic surgeryCombined 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 %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

Psychological aspects of pain perception and controlOrthodontic 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 arent 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).

Difficult PatientsPatients 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 clingersEntitled demandersManipulative help-rejectersSelf-destructive deniers

New England journal of medicine 1978 39

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.

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

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.

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

Helping the Anxious PatientShow 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.

Helping the Phobic PatientRecognize that phobia is more than anxiety.Speak to the physician about pre-medication.Suggest behavior modification.Involve the phobic patients therapist or other supports.Schedule appointment to lessen stressors

Helping the Angry PatientDont delegate the angry patient to anyone else.Allow the patient to vent the angry feelings.Actively listen dont lead or second guess.Speak in a calm voice and slow your breathing.Use the words feel, felt, found.Avoid the urge to argue

Use of psychological principles to improve patient complianceMany 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 trainingSome important principles are: Progressions Backward chaining Reframing (symptom prescription, reverse psychology) Reinforcement theory Hypnosis Learning by doing

PROGRESSIONSProgression 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:

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.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.Next, show the patient how to insert the right end of the facebow into the right molar tube. Again, have the patient demonstrate.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 patients name frequently , ask for feedback of understanding 49

BACKWARD CHAININGEducational 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.

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 someones soup. They can continue to eat it, but they cant 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 THEORYPositive 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.

HYPNOSISHypnosis, 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 patients favorite summer vacation

While placing a band around the patients molar tooth, you paint a verbal picture of a scene from the patients vacation, describing in detail the ocean scene using words and language that embraces the patients 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 patients 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).

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 childs well-being.Do not criticize the childs 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.

Conclusion Starting from the reasons for demanding orthodontic treatment, to the patients 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

References Alex Jacobson. Angle orthodontist 1972Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod 1990;7:75-80.Reichmuth M, Greene KA, Orsini MG, Cisneros GJ, King GJ, Kiyak HA. Occlusal perceptions of children seeking orthodontic treatment: impact of ethnicity and socioeconomic status. Am J Orthod Dentofacial Orthop. 2005 128(5):575 -82. Bergius M, Berggren U, Kiliaridis S. Experience of pain during an orthodontic procedure. Eur J Oral Sci. 2002 Apr:110 (2):92-8. Rinchuse D, Rinchuse D. Orthodontics justified as a profession. Am J Orthod Dentofac Orthop 2002; 121: 93-95

Goldman SJ. Practical approaches to psychiatric issues in the Orthodontic Patient. Semin Orthod 2005; 10: 259-65.Cunningham S, Feinmann C, Horrocks E.N. Psychological problems following Orthognathic Surgery. JCO 1995; 29: 755-757.Portnoy S. Patient Co-operation-How can it be improved? Br J Orthod 1997: 340-342.