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

SEMINAR BY
DR. SIDDHARTHA DHAR
Done under the guidance of
PROF. ASHIMA VALIATHAN
B.D.S ( Pb), D.D.S, M.S (USA)
DIRECTOR OF POSTGRADUATE STUDIES
PROFESSOR AND HEAD
DEPT. OF ORTHODONTICS AND DENTOFACIAL
ORTHOPAEDICS
MANIPAL COLLEGE OF DENTAL SCIENCES
MANIPAL.

 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 psychology
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
 Facial

 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 jobperformance 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 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

 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
 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

 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 selfconcept 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

 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 1014 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
 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.

 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,

 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 timewww.indiandentalacademy.com
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
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.

 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' selfimage 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
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.”

 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 selfefficacy.
 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 wellbeing in patients undergoing full fixed appliance

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 www.indiandentalacademy.com
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

 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 followup 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

 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' selfreported 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
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 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.


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



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 12year-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 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
• 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.

2.

3.

4.

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 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 fingersucking 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 facebow 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.

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.

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