RELEVANCE OF CHILD AND ADULT PSYCHOLOGY IN ORTHODONTICS

1. CHILD AND ADULT
PSYCHOLOGY AND
ITS CORRELATION
TO ORTHODONTICS
PRESENTED BY
Dr ASHWANI MOHAN

2. INTRODUCTION
• Treatment goals of orthodontics depends on the
communication between the orthodontist and the patient
• Psychological factors influence a patient perception of
malocclusion and treatment plan
• The cooperation of the patient depends on the doctor patient
rapport
• Psychological outcome of orthodontics:
Orthodontist → Attractive smile → positive self image

3. • Orthodontics has benefits of well being and health, but most
important effect – makes patient feel better about
themselves
• Psychological outcome is as important as functional and
occlusal
• Face is the most important factor in physical appearance,
major motivation is to enhance the aesthetics of face and
dental.
• Dental anomalies- “general playground of harassment”
among children and associated with lower attractiveness*
*Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of
dental features among school children. British Journal of Orthodontics. 1980 Apr
1;7(2):75-80.

4. PSYCHOLOGY
• DEFINITION – the science dealing with human nature and
behaviour. It also includes understanding of the pattern of
mental processes and characteristics of an individual
• Also refers to application of such knowledge to various
spheres of human activity including issues related to everyday
life and treatment of mental health problems
• DEVELOPMENTAL PSYCHOLOGY – branch of psychology
concerned with physical, cognitive and social change throughout
the life span.

5. • Psychological development is a dynamic process
• Starts from birth in ascending order through various stages that
portray as behaviour
• Study of how individual grow and change through out life
PSYCHOLOGICAL IMPLICATIONS OF
MALOCCLUSION
Adverse effects of poor facial aesthetics, that motivates patient to
seek treatment
• Low self esteem – psychological handicap imposed by
anaesthetic dental appearance
• Restriction of social activities
• Adverse occupational outcomes

6. CHILD PSYCHOLOGY
• Study of child behaviour including physical, cognitive,
motor, linguistic, perceptual, social and emotional
characteristics from birth through adolescence
• Proceed in a predictable, logical and sequential order
• Understanding the behaviour to specific group help the dentist
in knowledge of needs or fears of children
• Also help in assessing deviations from this processes that
might affect the treatment process

7. Importance of child psychology
• To understand the child better
• To understand the psychological aspect of child
• To deliver proper services to the child and the parent
• To gain the confidence of the child
• To produce comfortable environment for the child and parent
during treatment
• To teach parent and child about importance of dental care
• For effective communication between the parent and child with
the doctor
• To develop treatment planning

8. Values of knowing that children
develop differently
• All children cannot be expected to behave
the same way
• Child may respond favourably, or may
respond with antagonism and
resentment to authorisation control –
child rearing must be individualised
• Not possible to predict how a person
would react to situations.
• Individuality

9. THEORIES OF CHILD PSYCHOLOGY
PSYCHODYNAMIC
• Psychoanalytic theory by
Sigmund Freud 1905
• Hierarchy of needs by
Abraham Maslow 1954
• Psychosocial theory by Erick
Erickson 1963
BEHAVIOR LEARNING
• Classic conditioning by Ivan
Pavlov 1927
• Operant conditioning by BF
Skinner 1938
• Cognitive theory by Jean
Paiget 1952
• Social Learning theory by
Albert Bandura 1963

10. PSYCHOANALYTIC THEORY
• 2 primary ideas
1. Behaviour determined by childhood experiences
2. Personality development is the story of how to handle antisocial
impulses in socially acceptable ways
• Psychic triad
1. ID – basic drives, pleasure principle, instincts : life (Eros) and
death (Thanatos)
2. SUPEREGO - social conscience, judgements on individuals
actions: conscience and ego ideal
3. EGO – reality principle, controls id

12. DISPLACEMENT
↓
REDIRECT IMPULSES
↓ FROM
REAL TARGET
↓ TO
INNOCENT PERSON
PROJECTION
PROJECTS
INADEQUACY TO
SOMEONE ELSE
EGO DEFENCES
ANXIETY
↓
EGO MUST DEFEND ITSELF
↓
UNCONSICOUSLY BLOCKS
IMPULSE
DENIAL – DISOWN THE
EXISTENCE OF UNWELCOME
REALITY
REPRESSION – UNCONSCIOUS
FORGETTING

13. SUBLIMATION–
SOCIALLY UNACCEPTABLE
DRIVES
↓REDIRECT
SOCIALLY ACCEPTABLE
REACTION FORMATION-
REVERSAL OF BEHAVIOUR
AS DICTATED BY
UNCONSIOUS IMPULSE –
UNWANTED MOTIVE
CONTROLLED UNDER
DISGUISE
IDENTIFICATION –
ASSUMPTION OF
QUALITY OF
SOMEONEELSE TO
VENT FRUSTRATION OR
CREATE FANTASY
RATIONALISATION –
LOGICAL EXCUSE TO
EXPLAIN BECAUSE THE
REAL MOTIVE IS
UNACCEPTABLE

14. PSYCHOSEXUAL STAGES
• Satisfaction and problems in context of his own body
• Erogenous zones – stimulation results in pleasure
• Body – foci of interest
• 5 stages of development
1. ORAL STAGE 0-1year
Mouth – gratification by stimulation of this area
If satisfied – sense of trust optimistic outlook
If not – uncertainty and pessimism
Fixation – smoking, over eating, thumb sucking
Personality traits – impatience, greediness, dependence

15. 2. ANAL STAGE 1- 3 yrs
Gratification by elimination of faeces
Acquisition of voluntary bowel and bladder control
First encounter with rules and regulations
When done successfully – independence and autonomy
Gratification
o too little – orderliness, rigidity, hatred for waste, obstinate, stingy, punctual
o too much – untidiness, hot temper, destructiveness
3. PHALLIC STAGE – 3-6 yrs
Interest in their own genitals
Emerging interest in the parent of opposite sex -Oedepus complex – boys
Electra complex – girls
Conflict-Homosexuality, authority problems, rejection of gender roles

16. 4. LATENCY STAGE 7-12yrs
Period of consolidation
Tries to socialise
Super ego become internalised
5. GENITAL STAGE >12yrs
Appearance of mature heterosexual interest
Competitiveness with parent of same sex
extremities in emotional behaviour
As result of disturbance– cannot reach maturity, cannot shift
focus from his own body

17. PSYCHOSOCIAL THEORY – ERIC ERICKSON(1963)
• Internal psychological factors + external social
factor→ psychological development
• Progression through a series of personality
development changes
• Psychosocial developments proceeds by a series of
critical steps
• CRITICAL STEPS – turning points of moments of
decision between progress and regression, integration
and retardation
• Chronological age defers but the sequence remains
unaltered

19. 1. Development of basic trust (birth -18months)
• Syndrome of maternal deprivation
• Bond with mother should be maintained to develop basic trust
• Separation anxiety
Dental consideration
• Treatment at early age, with parents
• At later stage – no sense of basic trust- uncooperative and
frightened
2. Development of autonomy – (18 mon to 3 yrs)
• Terrible twos, development of trust
• Failure to develop autonomy – shame, feeling of having ones own
short comings
Dental consideration - any simple procedure parent should be
present, may need behaviour management

20. 3. Development of initiative
• Greater autonomy
• ↑ physical activity, curiosity, questioning
• Opposite – guilt
Dental consideration- usually first visit to the patients, curiosity
about everything, tolerate being separated from mother
4. Master of skills (7-11yrs)
• Learning rules of world by which it is organised
• ↑ peer influence
• Opposite - Sense of inferiority
Dental consideration – removable appliance wear depends on
how to please the dentist, peer group is supportive, whether desired
behaviour is reinforced by the dentist

21. 5. Development of personal identity (12-17yrs)
• Peer group – model, partial withdrawal from family
• Motivation – internal and external
• Complex stage due to physical ability changes
Dental consideration- ortho treatment is done during this stage
• Management is difficult, as the parent authority is rejected
• Pursue only if the patient is interested
6. Development of intimacy (21 to 40yrs)
• Willingness to compromise
• Failure – isolation from others
Dental consideration- seek ortho treatment to enhance the aesthetics,
feel that change in appearance facilitate new relationships
• Change in appearance after treatment may effect the previously
established relationships

22. 7. Guidelines for next generation -(45 to 60 yrs)
Establishment and guidelines to next generation
Failure - Stagnation , indulgence and self centred behaviour
8. Attainment of integrity (late adult)
combination of gratification and disappointment
Integrity – sense of satisfaction that a person feels in satisfied life
Opposite – despair expressed as disgust and unhappiness, fear of
death,
Sense life has had with little purpose or meaning

23. COGNITIVE DEVELOPMENT BY JEAN PAIGET (1952)
• Development of intelligence – phenomenon of biologic adaptation
• 2 complimentary processes
A) assimilation – child incorporates events within environment into
mental categories called cognitive structures
B) accommodation – changes cognitive structures to better represent
environment
• Intelligence is the interplay of assimilation and accommodation
• 4 stages:
1. Sensorimotor period (birth – 2yrs)
2. Pre operational period (2-7yrs)
3. Period of concrete operation (7 to puberty)
4. Period of formal operation (adolescence to childhood)

24. Sensorimotor period (birth - 2yrs)
• Reflex activities to an individual who can develop new
behaviour to cope with new situations
• Foundation of language development
Pre operational periods (2-7 yrs)
• Form mental symbols
• Use language in way similar to adults
• Understand language in literal sense
• Egocentrism – incapable to assume other persons views
• Animism – investing inanimate object with life
• Limited logical reasoning

25. Period of concrete operations (7 to puberty)
• Decreased animism
• Improved ability to reason but limited
• Ability to see others point
Period of formal operations (adolescence to adulthood)
• Imaginary audience – others are concerned, as in
constantly on stage about being unable to respond
• Personal fable – feels he's unique, not subjected to
consequences

26. CLASSICAL CONDITIONING – Ivan Pavlov (1927)
• Learning by association
• Experiment on dog
• Conditioned stimulus is strengthened by reinforcement
• Extinction of conditioned behaviour if not reinforced

28. OPERANT CONDITIONING BF SKINNER
• Basic principle – consequences of behaviour is itself a stimulus
that can affect future behaviour––
• unpleasant stimulus presented
after a responsePunishment
• behaviour that led to pleasant
consequence becomes more likely
in future
Positive
reinforcement
• removal of unpleasant stimulus
after a response
• ↑ likely hood of response in
future
Negative
reinforcement
• removal of pleasant stimulus
Omission
(timeout)

29. SOCIAL LEARNING (modelling) – Albert Bandura
• Connection bridge between the cognitive learning and behaviour
theories (encompass attention, memory and motivation)
• 2 stages
1. Acquisition of behaviour by observing it
2. Actual performance of that behaviour
• Types of learning
1. Inhibition – to learn not to do something that we already know,
because the model refrains from behaving that way or do something
else than what was intended to be done
2. Disinhibition – to learn to do a behaviour that is not acceptable by
the most, but because model does the same without being punished
3. Facilitation – to promote to do something that not ordinarily does
because of insufficient motivation

30. Elements of observational learning;
Types of learning
1. Enactive learning – learning by doing
2. Vicarious learning - learning by observing others
• ORTHODONTICS- modern trend
1. Treatment in an open area with several treatment stations
2. A great deal of Observational learning occurs
*Bandura A, Walters RH. Social learning theory.
ATTENTION
RETENTION
PRODUCTION
MOTIVATION

31. HIERARCHY OF NEEDS – Abraham Maslow(1954)

32. • Areas of behavioural research and application of practical
psychology to clinical practise of psychology into 2
categories
1. Social psychology of orthodontics
2. Orthodontic motivational psychology
• New area → educational psychology to achieve patient
compliance
• The role of doctor as a teacher than a healer
PRACTICAL PSYCHOLOGY

33. • Social psychology of orthodontics involves
1. Why patients seek orthodontic care
2. Psychosocial outcomes of orthodontic therapy
3. Use of standardised psychological instruments to assess
prospective orthodontic patients
• Orthodontic motivational psychology
1. Motivating patients to follow doctors orders → patient
compliance
2. Standardise psychological instruments → to predict
patient compliance

34. Social psychology of orthodontics
• WHY PATIENTS SEEK TREATMENT?
• Majority – their own initiative
• Most adolescence – “my mom thinks I need braces”
• Why do people want to look better???
• Facial appearance is a key determinant of whether or not a person
was believed to be attractive*
• Found that disfigured people: (significant skeletal discrepancy)
Difficult time in school
Less likely to do well in employment, politics or advertising
• Dento-facial appearance effect the overall quality of life
*Bull R, Rumsey N. The social psychology of facial appearance. Springer Science &
Business Media; 2012 Dec 6.

35. • Adams* suggested : developmental perspective for examining
social psychology of beauty
• 4 assumptions of relationship between outer attractiveness and
inner behavioural processes and outcomes extracted
1. Physical attractiveness stimulate expectation toward one
another
2. Attractiveness elicit social exchanges from others
3. Developmental outcome result from social exchanges,
consequences of reactions internalise differing social images,
self expectations, and inter personal styles
4. Greater experience with positive social interactions, attractive
people manifest confident interpersonal behaviour
*Adams GR. Physical attractiveness, personality, and social reactions to peer
pressure. The Journal of psychology. 1977 Jul 1;96(2):287-96.

36. • Sincerity, intelligence, conscientiousness and good looks were
attributed to more correctly aligned teeth*
• Malocclusions are highly visible – interfere with social
interaction and acceptance
• Crooked teeth and skeletal disharmony – “cause teasing of
general playground harassment among children and are
associated with lower social attractiveness**”
*Secord PF, Jourard SM. The appraisal of body-cathexis: body-cathexis and the
self. Journal of consulting psychology. 1953 Oct;17(5):343. used to persons with
more aligned teeth
** Phillips C, Bennett ME, Broder HL. Dentofacial disharmony: psychological
status of patients seeking treatment consultation. The Angle Orthodontist. 1998
Dec;68(6):547-56.

37. PSYCHOLOGICAL OUTCOME OF ORTHODONTIC TREATMENT
• Dann et al – children with serious malocclusions do not have poor
self concept or body images*
• Did not improve after orthodontic treatment
• Albino JE on contrary said children who received orthodontic
treatment felt better about their facial appearance**
• Why the discrepancy?
Depends on the patients attitude before the treatment
*Dann IV C, Phillips C, Broder HL, Tulloch JC. Self-concept, Class II
malocclusion, and early treatment. The Angle orthodontist. 1995 Dec;65(6):411-6.
**Albino JE, Lawrence SD, Tedesco LA. Psychological and social effects of
orthodontic treatment. Journal of behavioural medicine. 1994 Feb 1;17(1):81-98.

38. DEVELOPMENTAL PSYCHOLOGY OF ORTHODONTICS
• Shaw et al* – evaluated the risk/benefit for treatment and
outcome – 3 subgroups
1. Nicknames and teasing
2. Evaluated dental appearance and social attractiveness
3. Self esteem and popularity
• Conclusion – personal dissatisfaction with dental appearance in
adolescence persists till adulthood
* Shaw WC, O'brien KD, Richmond S, Brook P. Quality control in orthodontics:
risk/benefit considerations. British dental journal. 1991 Jan 5;170(1):33.

39. Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic
treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 1998
Jan 31;113(1):29-39.

40. PATIENT COMPLIANCE
• Egolf and others*– compliant patient as one who practices
good oral hygiene, wears appliances as instructed without
abusing them, follows an appropriate diet and keeps
appointments.
• Success depends on patient compliance
• Compliance by patient helps achieve treatment objectives in a
minimum treatment time
• Improved cooperation – reduces expenses
*Egolf RJ, BeGole EA, Upshaw HS. Factors associated with orthodontic patient
compliance with intraoral elastic and headgear wear. American Journal of
Orthodontics and Dentofacial Orthopedics. 1990 Apr 1;97(4):336-48.

41. • ADULTS
 care of their own
 have financial commitment
have outcomes in mind
Generally, not always compliant
• ADOLESCENCE
majority because of parents
no financial commitment
no specific outcomes
Compliance can be difficult

42. UNDERSTANDING THE ADOLESCENT PATIENT
• Period between childhood and adulthood
• Their most important concern is appearance
• Capable of thinking hypothetical, applying logic and abstract concepts
• Cognitive abilities can break down in emotional situations→ impulsive
actions without considering the alternative
• Change of appearance – anxiety and self confidence
• Psychosocial changes shape their sense of self*
• Adolescent feels pressure to confront to norms and do so by
comparing themselves with others
• Peer group play a role in identity development
• * Petersen AC, Kuipers KS. Understanding adolescence: Adolescent development
and implications for the adolescent as a patient. Craniofacial growth series.
1997;33:1-24.

43. MOTIVATING THE ADOLESCENT PATIENT
• Cooper and Shapiro* : Features of adolescent behaviour used to
ascertain certain behaviour are
1. Concerned with self image and identity → used for motivation
2. Independence and autonomy → adult like status motivate them
3. Peer relationships are important → motivate behaviours that meet
social needs
• To accomplish motivation
1. Individualising patient
2. Recognising values and issues
3. Understand that they are not influenced by health specific goals
*Cooper ML, Shapiro CM. Motivations for health behaviours among adolescents.
Craniofacial growth series. 1997;33:25-46.

44. • Adverse effects of poor facial aesthetics, motivating a patient
to seek ortho treatment divided into:
1. Low esteem and maladjustment – motivation depends on
extend of deviation from social norms
2. Restriction of social activities – affect perception of social
characteristics like –
• Perceived friendliness
• Popularity among peers
• Academic performance
3. Adverse occupational outcome

45. PSYCHOLOGIC FACTORS MOTIVATING PT TO
SEEK ORTHO TREATMENT
• Motivation is dynamic and reciprocal interaction of triad of
three factors -
1. Personal factors
2. Behavioural factors
3. Environmental factors
• Degree of influence on patient motivation and ortho
treatment is governed by -
1. Age – different for adult and adolescent
2. Gender
3. Socioeconomic set up

46. • PERCEPTION OF ATTRACTIVE PREFERENCE UNDER
THE INFLUENCE FACTORS
1. Self and parenteral perception of malocclusion
• depend on parent → transferred to child
• Baldwin and Barner* – mother deciding member
Attempts to resolve their own problems
Feeling of guilt – hereditary
As social status symbol
Divorced mother – ortho treatment as a “psychic gift” in
compensation for deprived father
*Baldwin DC. Appearance and aesthetics in oral health. Community dentistry
and oral epidemiology. 1980 Aug 1;8(5):244-56.
PATIENT PERCEPTION

47. 2. Peer pressure - Braces – badge of honour, high socio economic status
– as symbol of prosperity
3. Severity of malocclusion
4. Self esteem
conscious of own appearance 2 aspects of dentofacial defects
(pleasing one)
↓IF NOT
Anxiety about himself
↓ if unresolved
Mental illness*
*Silverman S, Silverman SI, Silverman B, Garfinkel L. Self-image and its relation to
denture acceptance. The Journal of prosthetic dentistry. 1976 Feb 1;35(2):131-41.
Individuals
attitude
towards defect Response of
others to disability

48. • Secord and Backman* – psychological impact depends on own
reaction
• GENDER – sex stereotyping – girls ►boys
MOTIVATIONAL FACTORS IN ADULTS
1. Improve facial attractiveness
2. As referral from general dentist
3. Part of orthognathic surgery
*Secord PF, Backman CW. An interpersonal approach to personality. Progress in
experimental personality research. 1965;2:91-125.

49. PERSONALITY TESTING
1. Millon Adolescent Personality
Inventory (MAPI) (Millon, Green
and Meagher, 1982) - to predict
behaviour of adolescent patient in
orthodontic practice
2. Comprehensive personal
assessment system : self report
inventory
3. The Adolescent Alienation Index
4. The Home Index
Cucalon and smith
252 adolescent ortho pt,
11-17yrs
After 1 yr. of treatment – pt
compliance as GOOD,
FAIR OR POOR
3 questionaires given
Females more compliant
than men
No difference in age or race
Low esteem – low
compliance
Cucalon III A, Smith RJ. Relationship between compliance by adolescent
orthodontic patients and performance on psychological tests. The Angle
orthodontist. 1990 Jun;60(2):107-14.

50. ORTHODONTIST AND PATIENT COMMUNICATION
• Nanda and Kierl* : factors that affect patient compliance
1. Parent – child relationship
2. Psychosocial characteristics of parent and patient
3. Attitude toward opinions about ortho – parent and patient
4. Perceptions of child's degree of social compromise – parent and child
5. Patient demographics
6. Parents and child's relationship with orthodontics
• Orthodontists behaviour influence:
1. Patient satisfaction
2. Cooperation
3. The orthodontist – pt relationship
*Nanda RS, Kierl MJ. Prediction of cooperation in orthodontic treatment. American
Journal of Orthodontics and Dentofacial Orthopedics. 1992 Jul 1;102(1):15-21.

51. • Sinha Nanda and Mc Neil * – concluded that the orthodontist
behaviour influences patient satisfaction, the orthodontist
patient relationship, and patient cooperation in orthodontic
treatment.
• Barsch et al** - doctor patient interaction is the best predictor
on how well a patient could be expected to comply with the
doctors instructions
• Good cooperation is by establishing good rapport with the
patient
*Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that
predict patient satisfaction, orthodontist-patient relationship, and patient
adherence in orthodontic treatment. American journal of orthodontics and
dentofacial orthopedics. 1996 Oct 1;110(4):370-7.
**Bartsch A, Witt E, Sahm G, Schneider S. Correlates of objective patient
compliance with removable appliance wear. American Journal of Orthodontics
and Dentofacial Orthopedics. 1993 Oct 1;104(4):378-86.

52. EDUCATIONAL PSYCHOLOGY
• Experiential learning theory
• Learning styles inventory – Kolb
• 135 ortho pt to 4 learning styles
 Accommodator
Diverger
Assimilator
Converger
• Divided to 2 dimensions
1. Prehension – internalise
information
2. Transformation – change to
useful knowledge
Kolb DA. Experiential learning: Experience as the source of learning and development.
FT press; 1984 Dec .0

53. ACHIEVING PATIENT COMPLIANCE
1. Orthodontist - Information to educate about malocclusion
2. Motivate by being straight forward and open
3. Patient need support from family and peer
4. Should not coerce compliance through brute force
5. Appreciate patient perspective

54. PATIENTS WITH PSYCHOLOGICAL DISORDERS
• Different and unanticipated behaviours are challenging
• Many patients re functioning within society with pre existing
psychological disorders
• An orthodontist should be able to assess the psychological status of
the patients
• Common psychological conditions are
1. ADHD attention deficit hyperactivity disorder
2. Obsessive compulsive disorder
3. Bipolar disorder
4. Body dysmorphic disorder
5. Depression
6. Panic disorder

55. ATTENTION DEFICIT HYPERACTIVITY DISORDER
• Inattention, impulsivity and hyperactivity
• Child trends of national health interview in 2013*
8.8% (3-17yr), 12% boys, 4% adults
ETIOLOGY – prenatal brain injury, hypoxia, trauma, food allergies
(aggravate)
MEDICATION
• Behavioural therapy
• Give short appointments
• Short clear instructions to be given
• Frequent prophylaxis
Castle L, Aubert RE, Verbrugge RR, Khalid M, Epstein RS. Trends in medication
treatment for ADHD. Journal of attention disorders. 2007 May;10(4):335-42.

56. OBSESSIVE COMPULSIVE DISORDER
• Intrusive thoughts and repetitive, compulsive behaviours
• 1-4% affected associated with eating disorders, autism, or
anxiety disorders*
ETIOLOGY – genetic
TREATMENT
• MILDER – cognitive behavioural therapy (CBT) – fear of
stimulus ► increased frequency and intensity
• SEVERE – selective serotonin reuptake inhibitors (SSRIs),
clomipramine (Anafranil), fluoxetine (Prozac), Sertraline
(Zoloft)
*Zohar AH. The epidemiology of obsessive-compulsive disorder in children and
adolescents. Child and adolescent psychiatric clinics of North America. 1999 Jul.

57. BODY DISMORPHIC DISORDER
• Intensely negative emotional response to a minimal or non existent
defect in the patients appearance
• Pt have obsessive concern on dentofacial appearance
• Multiple consultation about the perceived defect
• Emotional volatility
• 1% affected along with +OCD +depression
• Treatment – SSRI, CBT
• Physical improvement does NOT signify psychological
improvement

58. BIPOLAR DISORDER
• Manic depressive disorder
• 2 phases – depression and mania
• 1.6% - life time prevalence
• Onset – 15-24years
PATHOGENESIS – neurochemical abnormalities with an etiology +
genetics (25% risk of children getting affected)
TREATMENT – lithium, valporate, Carbamzepine
Antidepressants trigger mania – not given
FOR ORTHODONTICS – manifest as
• Poor oral hygiene
• Lack of compliance
• Apathy towards treatment

59. PANIC DISORDER
Diagnosed when patients experience sudden, recurrent panic
attacks consisting of heart palpitations, dizziness, difficulty
breathing, chest pains, and sweating that are unrelated to any
external event and are not due to any medical condition
2% males and 5% females affected
ETIOLOGY – heritability 48%
Mutation in 13q with an organic defect in hippocampus and
amygdala, that portion of midbrain responsible for emotion and
memory with input from visual, auditory and somatosensory
systems
Amygdala misinterprets sensations → extreme reactions
TREATMENT – medication with CBT, SSRI

60. DEPRESSION
• Symptoms last for atleast 2 weeks
• Pervasive low mood
• Loss of interest in usual activities
• Weight gain or loss
• change in sleep pattern
• Loss of energy
• Persistent fatigue
• Current thoughts of death
• Diminished ability to enjoy life
• Normal depression – pt still can communicate and make their own
decisions and participate in their own care
• and pathologic depression – out of proportion to the circumstances

61. ETIOLOGY - lack of stimulation of post synaptic neurons in
brain ↑in MAO (mono amine oxidase)≈↓ serotonin and
monoamines
TREATMENT
• Electroconvulsive therapy
• Hypnotherapy
• Meditation
• Diet therapy
• SSRI – Sertraline (Zoloft), Fluoxentine (Prozac), citalopram
(Celexa), Paroxetine (Paxil), MAO inhibitors, dopamine reuptake
inhibitors – Bupropion (Wellbutrin and Zyban)
• Non drug therapies – CBT, supportive therapy, Family therapy

62. ORTHODONTIST –
• should be attentive to patients who have dropped out of
their normal habits
• Report insomnia
• Abrupt deterioration in academics
• Signs of drug or alcohol abuse
• Change in their appearance
• Lack of interest in activities

63. EATING DISORDER
• Include anorexia nervosa or bulimia nervosa
• 2% females affected
• Fundamental defect lies in the distorted body image that leads
patients to control their weight by extreme dieting and vomiting
Oral manifestation –
• Dental erosions
• Extruding amalgams
• Dentinal hypersensitivity
• Salivary gland atrophy
• Chelosis
• TREATMENT – CBT – so that pt develop realistic ideas about
how much they should eat, about nutrition and their body image,
SSRI

64. PERSONALITY DISORDERS
• Classified as axis II disorders – disorders that involve
maladaptive behaviour and patterns of thinking that lead to
problems at home, school and work
• PD seen as
1. Narcissistic personality
2. Borderline personality
3. Antisocial personality
• Prevalence – 4.4% to 13%
• ETIOLOGY – environmental influences like prior abuse, poor
family support, family disruption, peer influences, and biological
causes

65. Narcissistic personality
• Believes they are special so entitled to special treatment
• Brittle self esteem
• Strong need for approval – manifested as arrogance and
demands special attention
• Patients are intolerant to minor complications and likely to seek
legal recourse
Borderline personality
• Prevalence 0.7% to 2%
• Erratic moods, impulsive and poorly controlled anger
• Begin treatment with extremely positive view point, but changes
to hatred and anger in response to complications

66. Antisocial personality
• Males: female – 5:1 ratio affected
• prevalence 2-3%
• Lying, theft, destructive behaviour, aggression to animals and
people, accompanied by lack of remorse
• Difficult to manage in an orthodontic office
• Handle these patient with even-handedness, not allowing to
disrupt the office procedure or abuse office personnel.
• Orthodontists should be beware of excessive dependent and
manipulative behaviour which can cause conflict among office
personnel

67. “DIFFICULT PATIENTS”
• According to Groves “difficult patients are typically those
who raise ‘difficult’ feelings within clinicians.
• 4 types
1. Dependent clingers
2. Entitled demanders
3. Manipulative help rejecters
4. Self destructive deniers

68. Dependent clingers
• Have needs for reassurance from their care givers that escalate
• Dependent on doctors
• Must be give appropriate limits with realistic expectations
• Clear verbal and written instructions to be given for reinforcing the
limits of the patient access to professional staff
Entitled demanders
• Needy but manifest it as intimidation and attempts to induce guilt
• Need to control situation and often make threats to get what they
want
• Aggressive behaviour due to dependency and fear of abandonment
• Limits must be placed on the patient

69. Manipulative help rejecters
• Focus on their symptoms but are resigned toward failure
• Seem satisfied with lack of improvement
• Difficult to treat – must involve in all decision makings and
should have regular appointments
Self destructive deniers
• Take pleasure in defeating any attempts to help them
• Do not want to improve
• Sufficiently depressed to consider not rendering or limiting
treatment

70. ORTHODONTIST
• Should remain friendly, unemotional, professional all the times
• Emotional outbursts should be responded to with an
acknowledgement of feelings but an expectation of
appropriate behaviour
• Non compliance must be countered with an appropriate
alternative treatment plan
• Must avoid being provoked and remain professional and
emotionally neutral while maintaining a correct office
atmosphere

71. PATIENTS HAVING ORTHOGNATHIC SURGERY
PSYCHOLOGICAL STATUS AND MOTIVATION
Ryan et al – 18 pts (18-40yrs)- impact of motivation
• Deformity affected in both practical and psychological aspect
• Low self esteem and embarrassment
• Coped by – avoiding social situations or continuing normal activities
while modifying their behaviour to minimise impact of condition
Lee et al – effect on pts quality of life – 76pts - control group-
asymptomatic third molar removal – 3 questionnaire
1. Generic health related – no difference
2. Generic oral health related significant difference
3. Condition specific quality of life
• Ryan FS, Barnard M, Cunningham SJ. Impact of dentofacial deformity and motivation for treatment: a
qualitative study. American Journal of Orthodontics and Dentofacial Orthopedics. 2012 Jun 1;141(6):734-42.
• Lee S, McGrath C, Samman N. Quality of life in patients with dentofacial deformity: a comparison of
measurement approaches. International journal of oral and maxillofacial surgery. 2007 Jun 1;36(6):488-92.

72. De Avila et al* – 50pts – to determine if exhibited depression than non
surgical cases
• Modified QOL(quality of life) – (36q) how physical health influenced patient
life
• Beck Depression Inventory (21q) – how often something bothered the
patient
• 19 pts had depression
Yu et al**- - motivation of orthognathic surgery in Chinese patients – 210 pts
– QOL questionnaire with oral health and self esteem measure
• Control – 219 who were not undergoing surgery
• Facial appearance improvement – #1 reason
• Men - #2 occlusion, #3 self confidence
• Women - #2 self confidence, #3 occlusion
**Yu D, Wang F, Wang X, Fang B, Shen SG. Presurgical motivations, self-esteem, and oral health
of orthognathic surgery patients. Journal of Craniofacial Surgery. 2013 May 1;24(3):743-7.
*de Ávila ÉD, de Molon RS, Loffredo LC, Massucato EM, Hochuli-Vieira E. Health-related quality of
life and depression in patients with dentofacial deformity. Oral and maxillofacial surgery. 2013 Sep
1;17(3):187-91.

73. EXPECTATIONS
• 4 categories*
1. Metamorphosizers – expectation of both physical and
psychological problems fully corrected by surgery. Likely to be
dissatisfied
2. Pragmatists – physical but no psychological change. Lower
satisfaction, as change may not be up to what expected
3. Shedders – little physical change but profound psychological
change, careful counselling to check true motivations
4. Evolvers – low expectation for both, dissatisfaction as
• More physical change than what the pt was ready for
• Postoperative course difficult o manage without positive
expectations for the patient
*Ritchie J, Lewis J, Nicholls CM, Ormston R, editors. Qualitative research practice: A
guide for social science students and researchers. Sage; 2013 Nov 1.

74. Bullen et al *– method of examining expectation – 85 pt – pt
profile altered with incremental movement of lips to form 13
photo sequence.
• Questionnaire
• 1 pt were asked how satisfied they were
• Asked to chose a profile that matched theirs – to compare the
real life and perceived profiles
• Younger pt – thought lips were more retruded than actual
• Older pt – more protrusive than actual
*Bullen RN, Kook YA, Kim K, Park JH. Self-perception of the facial profile: an aid in treatment
planning for orthognathic surgery. Journal of Oral and Maxillofacial Surgery. 2014 Apr 1;72(4):773-8.

75. SATISFACTION
Kiyat et al* – 74 orthognathic surgery patients (before surgery to 24 months
post operatively)
• 1 and 4 mon – less pain, numbness, higher self esteem, more satisfied
• 9mon – see result as permanent
• 24months – satisfaction at highest level
Findlay et al* – 61 pts if surgery had influence on self esteem
• Questionnaire – extraversion/introversion status, general health, feelings
toward their bodies – 87% satisfied
Cunningham et al ***-83 pre op, 100 post op, determine self esteem and level
of post op satisfaction
• 95% satisfied
*Kiyak HA, West RA, Hohl T, McNeill RW. The psychological impact of orthognathic surgery: a 9-month follow-
up. American journal of orthodontics. 1982 May 1;81(5):404-12.
**Finlay PM, Moos SF, Atkinson JM. Orthognathic surgery: patient expectations; psychological profile and
satisfaction with outcome. British journal of oral and maxillofacial surgery. 1995 Feb 1;33(1):9-14.
***Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following orthognathic surgery.
British Journal of Oral and Maxillofacial Surgery. 1996 Jun 1;34(3):210-3.

76. SUMMARY
Every patient had individual perceptions, desires, needs and
related behaviour
Clear communication is critical when discussing orthodontic
problems, proposed treatment and treatment alternatives and
expectations
Clinician must b familiar with the pt. medical , psychological
history, needs, questions and perceptions
Patient must b given clear guidelines for office procedures

77. REFERENCES
1. Contemporary orthodontics - William R Proffit
2. Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the
salience of dental features among school children. British Journal of
Orthodontics. 1980 Apr 1;7(2):75-80.
3. Orthodontics current principles and techniques – Graber Vandarshall
4. Textbook of orthodontics – Bishara
5. Bull R, Rumsey N. The social psychology of facial appearance. Springer
Science & Business Media; 2012 Dec 6.
6. Textbook of pedodontics – Shobha Tandon
7. Secord PF, Jourard SM. The appraisal of body-cathexis: body-cathexis and the
self. Journal of consulting psychology. 1953 Oct;17(5):343. uted to persons
with more aligned teeth
8. Phillips C, Bennett ME, Broder HL. Dentofacial disharmony: psychological
status of patients seeking treatment consultation. The Angle Orthodontist.
1998 Dec;68(6):547-56.
9. Adams GR. Physical attractiveness, personality, and social reactions to peer
pressure. The Journal of psychology. 1977 Jul 1;96(2):287-96

78. 10. Dann IV C, Phillips C, Broder HL, Tulloch JC. Self-concept, Class II malocclusion,
and early treatment. The Angle orthodontist. 1995 Dec;65(6):411-6.
11. Albino JE, Lawrence SD, Tedesco LA. Psychological and social effects of orthodontic
treatment. Journal of behavioral medicine. 1994 Feb 1;17(1):81-98
12. Shaw WC, Richmond S, O'brien KD, Brook P, Stephens CD. Quality control in
orthodontics: indices of treatment need and treatment standards. British Dental Journal.
1991 Feb 9;170(3):107.
13. Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic
treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 1998 Jan
31;113(1):29-39.
14. Cooper ML, Shapiro CM. Motivations for health behaviours among adolescents.
Craniofacial growth series. 1997;33:25-46.
15. Bandura A, Walters RH. Social learning theory.
16. Egolf RJ, BeGole EA, Upshaw HS. Factors associated with orthodontic patient
compliance with intraoral elastic and headgear wear. American Journal of Orthodontics
and Dentofacial Orthopedics. 1990 Apr 1;97(4):336-48.
17 Secord PF, Backman CW. An interpersonal approach to personality. Progress in
experimental personality research. 1965;2:91-125.

79. 18 Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that predict
patient satisfaction, orthodontist-patient relationship, and patient adherence in
orthodontic treatment. American journal of orthodontics and dentofacial orthopedics.
1996 Oct 1;110(4):370-7.
19 Bartsch A, Witt E, Sahm G, Schneider S. Correlates of objective patient
compliance with removable appliance wear. American Journal of Orthodontics and
Dentofacial Orthopedics. 1993 Oct 1;104(4):378-86.
20 Orthodontics – diagnosis and management of malocclusion and dentofacial
deformities – Kharbanda