Child & Adult Psychology in Orthodontics

CHILD AND ADULT PSYCHOLOGY
IN ORTHODONTICS
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education

 Contents.
 Introduction
 Definitions
 Importance of child psychology
 Theories of child psychology
 Emotional development
 Stages of Psychological growth and
development
 Psychological status of patients seeking
orthodontic treatmentwww.indiandentalacademy.com

Social psychology
Psychologic outcomes of orthodontic treatment
Social factors affecting self concept
Motivational Psychology
Orthodontist and patient communication
Problems of Orthodontists in treating adolescents
Psychosomatic considerations in orthodontics
Psychosocial implications of facial deformities
Psychosocial characteristics of patients with facial deformities
CONCLUSION

Introduction:
Psychological development is a dynamic process. Which
begins at birth and proceeds in an ascending order through a
series of sequential stages manifesting into various
characteristic behaviour,
These stages are governed by genetic, familial, cultural,
interpersonal and interpsychic factors.
The aim of this discussion is to understand the various aspects
of child and adult psychology applied to the dental
(orthodontic) situation for the successful management of the
child and adults.

Definition
Psychology – the science dealing with human nature,
function and phenomenon of his soul in the main.
Child psychology –the science that deals with the
mental power or an interaction between the conscious
and subconscious element in a child.
Emotion – An effective state of consciousness in
which joy, sorrow, fear, hate or the likes are
expressed.

Behaviour –is any change observed in the functioning of the
organism.
Behaviour management – means by which dental health team
effectively and efficiently performs treatment for a child and
simultaneously instill a positive dental attitude in the child
(Wright, 1975)

Importance of child psychology
 To understand the child better.
 To know psychological problem of child.
 To deliver dental services in a meaningful and effective
manner.
 To establish effective communication between the child and
parent.

 To gain confidence of the child and parent.
 To teach the child and parents importance of primary and
preventive care.
 To produce a comfortable environment for the dental team to
work on the patient.

Theories of child psychology
Psychodynamic
theories
Psychoanalytical theory
Psychosocial theory
Cognitive theory
Behavioural learning
theories
Hierachy of needs
Social learning theory
Classical conditioning
Operant conditioning

Psychoanalytical theory
Sigmond freud – 1905
Freud thought the personality to originate from
biological root manly sexual insticts was the
most important.
He compare the human mind to an iceberg.
Conscious experience
The unconscious store of impulses

Id : Basic structure of personality
Serves as a reservoir of instincts or their
mental representative
It is present at birth Governed by pleasure
principle.
Exm; The need to eat, eliminate the wastes and
to avoid pain etc,.
According to SIGMOUND FREUD personality composed of
three major system.

Ego : Develops out of Id in the 2nd to 6th month of life
Governed by reality principle
Concerned with memory and judgment
Modifies or controls id impules on realistic level
Exa; children learn that hunger must wait until some one provides
food.
Super ego :It is the prohibition learned from environment
It acts as a censor of acceptability of thoughts, feelings
and behavior.
Exm; the patient may deny the anxiety associated with the necessary
dental treatment. www.indiandentalacademy.com

An Individual goes through five stages prior to
adulthood:
– Oral
– Anal
– Phallic
– Latency
– Genital

Oral stage (0-1 year)
The oral region (mouth, lips and tongue) is the main
source of satisfaction or pleasure.
Adequate and regular feeding is of prime importance
to the infant.
Incomplete resolution of the oral stage is said to
provide the basis for the psychopathology of
addictive behaviour such as overeating, smoking or
drinking.
Oral dependency in the form of digit sucking habit is
an example of this seen in older individualwww.indiandentalacademy.com

The responsibility of the mother during this stage
is crucial.
She has to take care of the baby addressing all its
needs.

Anal stage (2-3 years)
The main feature of this stage is the child‟s acquisition of
voluntary bowel and bladder control.
The child derives enjoyment and pleasure from increasing
control over bodily functions as well as from his
developing autonomy.
Toilet training is seen as the first and also as the prototype
of co-operative activity between the child and the parent.

Phallic stage (3-5 years)
The child becomes increasingly aware of his/her genitals,
the enjoyment to be derived from them and the
differences between the sexes.
Freud developed these ideas most clearly for boys and
coined the term Oedipus complex to describe the
conflictual situation arising between the boy and his
parents during this phase.

The boy becomes attached to his mother, leading to
rivalry with the father for the affection of the mother; the
boy also recognizes that his father is powerful and would
be likely to punish him severely if he pursues the rivalry
too far.
The resolution of the crisis for the boy is to 'identify' with
his father and use him as a role model, so that he can
hopefully not only reduce the risk of retaliation but also
increase his own power by emulating his father.

Similar explanations are applied for the girls' sexual
conflict, for which the term Electra complex is used.
The unsatisfactory resolution of the Oedipus conflict
manifests itself in later life as sexual conflicts concerning
sexual role and identity and also the inability to form
intimate sexual relationships.

Latency stage (6-11 years)
This period is so called because of its relative tranquility
compared with the emotionally stormy periods of the phallic
and genital periods.
Sexual feelings subside after the resolution of the oedipal crisis.
The child focuses his attention on the same-sex parent, leading
to increased identification with and role-modeling on this
parent.

Similarly, peer group relationships are predominantly
with the same sex.
The exposure to stress and anxiety is essential for the
child's well-being, as it provides the child with the
opportunity to learn to cope with unpleasant or distressing
feelings.

Genital stage (12-18 years)
The endocrinological and physiological changes occurring at
puberty rekindle the individual's interest in sexual matters and
heterosexual relationships.
A good outcome of this stage is dependent on how well or
otherwise the individual has dealt with earlier stages.
Two stages, the oral and the phallic, are particularly crucial.
Poor resolution of the oral phase may preclude the foundation
of close, trusting relationships with the opposite sex,
whilst unresolved phallic conflicts may lead to confusion over
sexual role and behavior.

Basic trust v/s Basic mistrust
Autonomy v/s Shame and doubt
Initiative v/s Guilt
Industry v/s Inferiority
Identity v/s Role confusion
Generativity v/s Stagnation
Intimacy v/s Isolation
Integrity v/s Despire
Erikson‟s 8 stages of emotional development
0-18m
18m-3y
3-6y
7-11y
12-17y
Psychosocial theory
Child's development covering the entire span of life cycle from infancy to
childhood through old age

1} BASIC TRUST VS MISTRUST
•Birth to 18 mon
•Infant depends on others for his basic needs
•Successful development of trust depends on caring mother who meets
both the physiologic and emotional needs of an infant.
•Infact physical growth can be retarded if the child receives inadequate
maternal support. The syndrome of „Maternal deprivation’ such infant
fail to gain weight and are retarded in their physical as well as emotional
growth.

Dental consideration
If it is necessary to provide dental treatment at an early
age, it usually is preferable to do so with the parent
present, and if possible, while the child is being held by
one of the parents present.
At later stages, a child who never developed a sense of
basic trust will be an extremely frightened and unco-
operative patient who needs special effort to establish
rapport and trust with the dentist.

2} AUTONOMY VS SHAME, DOUBT
18 m to 3 YRS
Child moves away from mother to develop sense of individual identity or
autonomy.
Children around the age of 2 are said to be undergoing the “terrible twos’
because of their un co-operative behaviour.
Their self-control and self-confidence begins to develop at this stage
Failure leads to shame or doubt

At this age for any simple procedures parents should be
present and for complex dental treatment of children at
this stages it may require extraordinary behaviour
management procedures like sedation or general
anesthesia.

3} INITIATIVE VS GUILT:
• 3 to 6 yrs
• At this stage child wants to take part in many activities,
ask more questions
• A major task for parents and teachers at this stage is to
channel the activity into manageable tasks so that the
child is able to succeed.
• If child is made to feel that a certain activity is bad, that
play is silly and stupid then the child may develop sense
of guilt

For most children the first visit to the dentist comes
during this stage of Initiative. A child at this stage will be
intensely curious about the dentists office and eager to
learn about the things found there. After initial
experience, a child at this stage can usually tolerate being
separated from the mother for treatment so that
independence rather than dependence is reinforced.

4} INDUSTRY OR MASTERY VS INFERIORITY:
• 7 TO 11 YRS
• Child acquires academic and social skills } preparation to enter
competitive world.
• Sense of inferiority crops when child compares academically,
socially and physically and finds that someone else can do things
better than him/her.

Orthodontic treatment in this age group involves wearing
of removable appliances. Whether a child will do so is
mainly determined whether he or she understands what is
needed to please the dentists and parents, whether the
peer group is supportive and whether the desired
behaviour is reinforced by the dentist. Children at this
stage are motivated by improved acceptance from the
peer group.

5} IDENTITY VS ROLE OF CONFUSION:
• 12 to 18yrs
• Adolescence, a period of intense physical development, is also the
stage in psychosocial development in which a unique personal
identity is acquired.
• It is extremely complex stage because of physical ability changes,
academic responsibilities increase and career possibilities begin to
be defined.
• Failure to solve this conflict leads to confusion

Orthodontic consideration
Most orthodontic treatment is carried out during this period
and behavioural management of adolescents can be
extremely challenging since parental authority is rejected, a
poor psychological situation is created by orthodontic
treatment if it is carried out primarily because the parents
want it, not the child.
At this stage, orthodontic treatment should be instituted
only if the patient wants it, not just to please the parents.

6} INTIMACY VS ISOLATION:
21 to 40 yrs
The adult realizes the need for one truly intimate
relationship with others.
Successful development of intimacy depends on a
willingness to compromise and even to sacrifice to
maintain relationship.
Failure leads to isolation

Orthodontic consideration
At this stage they seek orthodontic care. often,
these individuals are seeking to correct dental
appearance they perceive as flawed. They may
feel that a change in their appearance will
facilitate attainment of intimate relationships.
A new look resulting from orthodontic treatment
may interfere with previously established
relationships.

7} GENERATIVITY VS STAGNATION
• 45 to 60 yrs
• Major responsibility of an adult is to guide next generation
• Guidance should not be only to one‟s own children but also
by supporting the network of social services needed to
ensure the next generation‟s success.

8} INTEGRITY VS DESPAIR:
over 65 yrs
Final stage in psychosocial devlp
Integrity – sense of satisfaction that a person
feels, in a productive life lived
Despair – sense that life has had little purpose or
meaning,
It is expressed as disgust and unhappines on a
broad scale

Cognitive theory
 Jean piaget in 1952
 Based on how children and adolescents
think and acquire knowledge
 Environment does not shape child
behavior but the child and adult actively
seek to understand the environment

Adaptation occurs through two processes
Assimilation:
Accommodation:

 Assimilation: From the beginning, a child incorporates
or assimilates events within the environment into
mental categories called cognitive structures.
 Accommodation: Accommodation occurs when the
child change his or her cognitive structure to better
represent the environment

The sequence of development has been categorized into 4 major stages
1)Sensoriomotor stage (0 to 2 yrs)
2)Pre –operational stage (2 to 6 yrs)
3)Concrete operational stage (6 to 12 yrs)
4)Formal operation stage (11 to 15 yrs)

 1}Sensorimotor stage:
 Birth to 18mon.
 Every child is born with certain Strategies for
interacting with the environment.
 Beginning of thinking process.
 Not yet have capacity to represent objects or people.

2} Pre-operational stage:
Because children above the age of 2 begin to use language in ways
similar to adults,
It appears that their thought processes are more like those of adults.
A general feature of thought processes and language during the
preoperational period is egocentrism, meaning that the child is
incapable of assuming another person‟s point of view.
At this stage, capabilities for logical reasoning are limited and
the child thought processes are dominated by the immediate
sensory impressions

 3} Concrete operational stage:
 7 to 12 years
 By this stage egocentrism and animism
declines.
 Thinking process becomes logical
 Able to use complex mental operations
 Able to understand the others point of view

 4} Formal operational stage:
 12 to18 years
 Child‟s thought process is similar to adult.
 Adolescents assume that others are concerned with their actions and
feeling. They feel as though they are constantly being observed and
criticized by those around them. This phenomenon has been called
the “Imaginary Audience” by Elkind.
 This has powerful influence on young adolescents making them
quiet self-conscious and susceptible to peer influence.

LEARNING & DEVELOPMENT OF BEHAVIOUR:
Psychologists generally consider that there are 3 distinct mechanisms by
which behavioural responses are learned.
•Classical conditioning
•Operant conditioning
•Observational learning

CLASSICAL CONDITIONING:
This was first described by the Russian Physiologist Ivan
Pavlov who discovered in 19th century during his studies of
reflexes that apparently unassociated stimuli could produce
reflexive behaviour.

Pavlov‟s classical dog experiments involved the presentation of
food to a hungry animal along with some other stimulus like
ringing of a bell. The sight and sound of food normally elicit
salivation by a reflex mechanism. If a bell is rung each time
food is presented the conditioning stimulus of the ringing bell
will became associated with the food presentation stimulus and
in a short time ringing of a bell itself will elicit salivation.

Classical conditioning occurs readily with young children and
has a considerable impact on a young child‟s behaviour on the
first visit to the dental office. By the time the child is brought
to the dental office he or she might have many experiences
with pediatricians and medical personnel when a child
experiences pain, the reflex reaction produced is crying and
withdrawal.
According to Pavlov the infliction of pain is an unconditioned
stimulus. If the unconditioned stimulus of white coats a child
may cry and withdraw immediately at the first sight of white
coated dentists.

The association between a conditioned and an unconditioned stimulus
is strengthened or reinforced every time they occur together
Every time they occur, the association between a conditioned and
unconditioned stimulus is strengthened.

OPERANT CONDITIONING:
According to behavioural theorists B.F.Skinner this operant
conditioning is viewed conceptually as a significant extension of
classical conditioning.
Operant conditioning differs from classical conditioning in that the
consequence of behaviour is considered as a stimulus for future
behaviour.
This means that the consequence of any particular response will
affect the probability of that response occurring again in a similar
situation. www.indiandentalacademy.com

Skinner described 4 basic types of operant conditioning
distinguished by the nature of the consequence

Positive reinforcement: -If a pleasant consequence follows a response,
the response has been positively reinforced, and the behaviour that lead to this
pleasant consequence becomes more likely in the future.
eg:- If a child is given a reward for such as a toy for behaving well during her
first dental visit, she is more likely to behave well during future dental visits her
behaviour was positively reinforced.
Negative reinforcement:- involves the withdrawal of an unpleasant
stimulus after a response.
eg:- a child who views a visit to the dental clinic as an unpleasant experience
may throw a temper tantrum at the prospect of having to go there. If this
behaviour (response) succeeds in allowing the child to escape the visit to the
clinic, the behaviour has been negatively reinforced and is more likely to occur
the next time a visit to the clinic is proposed.

Omission or Time out: - Involves removal of a pleasant stimulus after
a particular response.
Eg:- If a child who throws a his favorite toy taken away for a short time as a
consequence of this behavior, probability of similar misbehavior is
decreased.
Punishment:- This occurs when an unpleasant stimulus is presented after
a response. This also decreases the probability that the behavior that
prompted punishment will occur in the future.

Simply praising a child for desirable behaviour produces positive
reinforcement and additional positive reinforcement can be achieved by
presenting some reward.
The other two types of operant condition omission and punishment
should be used with caution in the dental office since a positive stimulus
is removed in omission, the child may react with anger or frustration.
When punishment is used, both fear and anger sometimes results. Infact
punishment can lead to a classically conditioned fear response.

OBSERVATIONAL LEARNING (Modelling):-
This behaviour is acquired through imitation of behaviour observed in a social context.
There are 2 distinct stages in observational learning.
Acquisition of the behaviour by observing it. Children are capable of acquiring almost
any behaviour that they observe and that is not too difficult for them to perform at
their level of psychical development.
Actual performance of the behaviour Whether a child will actually perform an
acquired behaviour depends on several factors like characteristics of role model. If the
model is liked or respected the child is more likely to imitate them eg:- for adolescents
the peer group are the major source of role models.

Observational learning can be used to advantage in the design of
treatment areas. At one time, it was routine for dentists to provide
small private cubicles in which all patients, children and adults,
were treated. the modern treatment particularly in treatment of
children and adolescent is to carry out dental treatment in open
areas with several treatment stations.

Stages of Psychological growth and development
Infant (first year of life)
Toddler (second year of life)
Preschool child (3rd to 6th year of life)
School age child (6th year to puberty)
Adolescent (12th to 18 years of life)
Early adolescent
Middle adolescent
Late adolescent www.indiandentalacademy.com

Infant:
Human infant is totally dependent upon another person for survival
during a significant period of early childhood. This dependency exceeds
the simple physical care of feeding and cleansing and emotional needs.
By 4-6 weeks the child acknowledges someone outside himself by social
smile. This is one of the first social interactions in which the child
participates. Psychoanalysts describe the early interdependency of
mother and child as a symbiotic relationship.

Toddler (2nd year of life):
It is usually, called as the “terrible two’s” because of the negativism,
anger, temper-tantrums are characteristics of this period.
These behaviors represent the child‟s desire to control when faced with
restrictions set by adults. Language skills develop rapidly so that by 18
months the child can understand and follow simple directions.

Preschool child (3-6 years of life):
Language skills develop and allows for meaningful
conversation. Playing becomes a major preoccupation and it
serves a necessary function in maturation of the child.
The child often thinks that every thing is a magic i.e events
are reversible.

School age child (6th year of life to puberty):
At school age child is required to leave the home to enter the school. The
child is expected to give up certain idiosyncrasies developed in the home
to live in less co-operative society.
This is a major step in the separation – individualization. school phobia
develops due to increased separation anxiety to cope up with this anxiety
child gains support from the peer group.
The child from 6-12 years is perceived as a untroubled individual who is
acquiring new knowledge in school and actively engaged in play with
friends

Adolescent age (12th-18 years of life):
Adolescence is a psychological state of development in puberty which
is a physical state. The beginning of adolescence coincides with the
onset of puberty but ends with the accomplishment and completion of
the developmental tasks of this age period. The longer the period of
dependency exists, the longer is the state of adolescence.
It is sub-divided into 3 stages:
Early adolescence:
Middle adolescence:
Late adolescence:

Early adolescence:
This period begins with the pubertal growth spurt and continues for 12-
18 months corresponding approximately to 12-14 in girls and 13-15 in
boys
Middle adolescence:
This period is from 14-16 years. It is the middle point of teenage
development with the surging drive forward toward adulthood with all
its responsibilities but with the regressive pull backward towards his
security and known comfort of childhood.
Late adolescence:
This is the final stage of transition to adulthood. Two major tasks to be
achieved during this stage are ego identity and the capacity for intimate
relationships. He must develop as self sufficient individual independent
of his family and capable of filling his role as a person in society.

Psychological status of patients seeking orthodontic treatment
Psychological and behavioural sciences play an important role and it
had been in research and in clinical practice.
Numerous studies have showed that psychological outcomes of
orthodontics on the patients self image are positive.
The areas of behavioural research and the application of practical
psychology to the clinical practice of orthodontics can be divided
into 2 broad categories.
1. Social psychology
2. Motivational psychology

Social psychology
Encompasses divergent fields like
Why patients seek orthodontic treatment?
Use of standardized psychological instruments to assess
prospective orthodontic patients.

Why patients seek orthodontic treatment?
Majority of orthodontic patients who seeks care under their own
initiative (ie)
Adult patients do so to improve their facial appearance.
Most adolescents on the other hand seek care because their parents
wants them to look better.
so the answer to why patients seek orthodontic treatment was to improve
their facial appearance,
Many patients seek orthodontic treatment to improve the quality of life
because it has a significant effect on their overall quality of life.
william R Proffit, DDS, PHD text book of contemporery orthodontics 4rt Editionwww.indiandentalacademy.com

Phillips C, Bennett ME, Broder HL: Dentofacial disharmony: psychological status
of patient seeking treatment conclusion, Angle Orthod 68(6):547-556, 1998.
Adolescents with significant dento facial disharmonies are frequently
considered to be at risk for negative self-esteem and social
maladjustment.
According to studies done by Philip dentofacial anomalies such as
crooked teeth and skeletal disharmonies, have been reported as the
cause of teasing and general playground harassment among children
and are associated with lowered social attractiveness.

Psychologic outcomes of orthodontic treatment
Dentofacial esthetics plays an important role in a child‟s self
concept. According to the studies done by Dann et al,
Children with serious malocclusions did not necessarily have poor
self-concept and they also noted that the patients self concept did
not improve significantly with orthodontic treatment.
Dann C et al : self concept Class II malocclusion, and early treatment , Angle
orthod 65(6) : 411-416, 1995. www.indiandentalacademy.com

But contrary to Dann et al, Albino showed the psychological and social
effects of orthodontic treatment.
He investigated the hypothesis that dentofacial disharmonies may have
important social and significant psychological effect on the patient and
found that parent, peer and self reported evaluations of dentofacial
specific self image improved significantly after the patient received
orthodontic treatment .
(ie) children who received orthodontic treatment felt better about their
facial appearance after braces than they did before them.
Albino JE psychological reasons for orthodontic treatment explored, J Am Dent
Assoc 98 : 1002- 1003 , 1979 www.indiandentalacademy.com

According to the studies done by Varela psychological outcomes of
orthodontic treatment differ for adult and adolescent patients with the
aid of standardized psychological tests.
These researchers found a significantly positive effect of orthodontic
treatment on adult paitents self-concept and after treatment these adult
patients felt better about themselves, regardless of their state of mind at
the outset of treatment.
Varela M, Garcia-Camba JE: impact of orthodontics on the psychologic profile of
adult patients: a prospective study, Am J Orthop 108 (2):142-148,1995.www.indiandentalacademy.com

Social factors affecting self concept.( from Tung AW,
Kiyak HA: Am J Orthod Dentofacial Orthop 113 (1):29-39,
1998)
Social factors affecting self-concept:
age Influences
Young child parent
Teachers
Preadolescent peers
Perceived attractions
Perceived competence
Self-concept
Adolescent peers
Adults Achievements
Social roles

preadolescent children are at a stage of developing a sense of
selfconfidence and competence. They are aware of their own physical
appearance and that of their peers. They can accurately describe their
own facial features
Another strength of this stage of development is that these children are
more focused on the future, less concerned about peer approval than
are adolescents. They generally are still seeking the approval of
significant adult role models (e.g., parents, health care providers);
Alice W. Tung, BS,a and H. Asuman Kiyak, MA, PhDb
Seattle, Washwww.indiandentalacademy.com

Their research also suggests that there may be racial differences in the
psychological influences of orthodontics.
They state “although white and minority children were similar in their
self rating and expectations for orthodontics, the former were more
critical in their esthetic judgments”. They rated faces with crowded teeth,
diastema, and overbite more negatively than did ethnic minorities.

Motivational Psychology
The success of orthodontic therapy frequently depends on patient
compliance. Headgear effects, functional appliances treatment, oral
hygiene and keeping appointments are all dependant on the patient
complying with the doctors instructions.
Egolf described a compliant patient as one who practices good oral
hygiene, wears appliances as instructed without abusing them, follows
an appropriate diet and keeps appointments.
Adults are generally compliant patients but adolescents are generally in
the orthodontist‟s office because a parent has brought them there and
their goals for treatment are frequently nonspecific
Eglof RJ, BeGole EA, Upshaw HS : Factors associated with orthodontic patient compliance
with intra oral elastic and head gear wear Am J orthod Dentofacial orthop 97:336-348,1990.www.indiandentalacademy.com

Southard et al pointed out that the assurance of good compliance can
be difficult in the case of adolescent.
Compliance by the patient helps achieve the treatment objectives in
minimum treatment objectives in a minimum treatment time and
improved co-operation by the patient can also reduce expenses of
orthodontic treatment
Southard KA et al : Application of the millon adolescent personality inventory in
evaluating orthodontic compliance, Am J Orthod Dentofacial Orthop 100:553-
561,1991.

According to Nanda, Sinha, the efficiency of care and improved oral
hygiene can decrease damage to the periodontal tissues and limit the
effects of enamel decalcification and caries.
Sinha PK , Nanda RS, McNeil DW : Perceived orthodontist behaviors that patient
satisfaction orthodontist patient relationship, and patient compliance in orthodontic
treatment, Am J Orthod Dentofacial Orthop 100: 370-377,1996.

Motivating the adolescent patient:
First- As adolescents are mainly concerned with self-image and
identity which can be used for motivating them.
Secondly independence and autonomy are important to adolescent;
therefore achieving an adult like status could motivate the adolescent.
Third, peer relationships are important, so this feature may motivate
behaviors that meet social needs. But most successful motivation can
be accomplished by individualizing the patient and recognizing
adolescent values and issues

Personality testing and compliance:
Southard et al examined the feasibility of using a commercially available
Adolescent Personality Test, the Million Adolescent Personality
Inventory (MAPI), to predict the behavior of adolescent patient to
orthodontic practice.
The results of MAPI were then correlated to the results of an ordinary
assessment of the patients compliance, over 2 years of orthodontic
treatment. Finally authors concluded that the MAPI is a useful
instrument for predicting adolescent orhthodontic patient compliance
behavior.

Orthodontist and patient communication:
Nanda et al conducted an extensive prospective study of patient
compliance by investigating numerous variables that had been suggested
to affect patient compliance. The variables they looked at included
parent-child relationship
Psychosocial characteristics of the patient
patient attitude and opinion about orthodontics
parents attitude and opinion about orthodontics
parents perceptions of the child‟s degree of social compromise
Parent and child relationship with orthodontist.
Of all these possible predictors of compliance the authors found that the
variables assessing the orthodontist‟s perception of the doctor-patient
relationship had the strongest association with patient‟s compliance.

If the doctor wants good co-operation from a patient,
the most important factor in obtaining it is the establishment of good
rapport with the patient.

Achieving patient compliance:
White proposed a new way to look at motivation for the typical
orthodontic patient. He believed that positive reinforcement for
good behavior is a key to conditioning patients to co-operation
Rosen suggests that the orthodontists should first provide the
patient with the information necessary to educate them about their
malocclusion.
Next, the orthodontist should motivate the patient by being open
and straight forward and by building a relationship of mutual
respect.
Third, patients need support from family and peers to be
compliant.

Problems of Orthodontists in treating adolescents
Adolescence:- has been defined as “the period extending from the time
of puberty to the attainment of complete maturity. With individual
variations it begins at about 10 in girls and 12 in boys.
They are in a constant state of transition.
It encompasses an extensive period of physical and psychological
growth.
Onset can be determined by observation of physical changes.
Modification of the psychological structure take place at the same time
as physical changes but there no accurate measuring techniques for
determining psychological growth patters.

It terminates physically at about the age of 20 with the establishment
of mature body structures.
Adolescence is a period of stress and strain for the maturing person.
It involves complex changes in body structure and functions and
accompanying changes in emotional maturation and mental
expansions.
Recognizing the strength of the adolescent social drives one can
understand the effect that orthodontic appliances may have on the
patient in his trying period.

As a result of the application of braces their appearance which vitally
affects their standing with their group is altered. Furthermore, the
adolescent may associated the wearing of an appliance with being a
child.
Hence it represents regression, which is frustrating to a young person
who is attempting to establish himself as an adult.

Problems arising in consultation
Resistance to treatment –forcefully brought by parents
Reactions to retarded growth.
Exaggerated sensitivity to pain.

Adolescent rebellion:-
In any specific age group, adolescents show wide variation with
respect to
Physical development,
Emotional maturity, and
Social experiences.
Therefore, no general set of suggestions is applicable for
handling patients as a group.

It is important to establish a rapport with adolescents which makes
it possible for them to have the freedom that they need and yet
assures their acceptance of guidance and restrictions.
Early in the course of treatment we should attempt to learn some
things of each patient as a person rather than merely to categorize
the malocclusion.
Patients should be encouraged to share their feeling about
concerning orthodontics. Negative feelings, should be accepted in
a sincere manner rather than to suppress his dissentient feelings.

Psychosomatic considerations in orthodontics
– Arthur Ash
The prime considerations of the orthodontist is the establishment of an
adequate and healthy occlusion in making his diagnosis he has come to
realize more and more the necessity for evaluating the biologic and
physiologic totality of the patient.
In short the orthodontist has attempted to keep pace with the advance of
medical knowledge (ie) current concept of psychosomatic medicine
should be evaluated as to its application to orthodontics.
Emotional factors play a major role in the course and outcome of
orthodontic treatment. The connection between the underlying emotion
and its effect upon occlusion are evident, as in habit formation. Thumb
and finger sucking are generally attributed to a child‟s need for security
and affection.

Psychosocial implications of facial deformities
H. Kiyak
Meanings of the Face
The face is the area of one‟s body that produces the greatest concern
regarding physical attractiveness; it is the individual‟s focal point and
the source of vocal and emotional communications with others
Berscheid et al in a survey of over 1000 adults found that people who
were satisfied with their facial features expressed greater self-
confidence.
The greatest dissatisfaction for subjects in their large sample was the
appearance of their teeth

Attractive adults & children are evaluated as more successful and more
intelligent than are unattractive persons and are viewed as more socially
skilled
Adams G: physical attractiveness, personality ,and social reaction to peer pressure
J Psych 96:287-296,1977

Psychosocial characteristics of patients with facial deformities
Children with craniofacial anomalies are more introverted, neurotic and
demonstrate poor self-concept
Strauss et al
Children with Down’s syndrome were rated as being less
intelligent, less attractive, and less socially acceptable.
Postoperative ratings of these same children were significantly
more positive in all three domains

A seriously handicapping orthodontic condition is the one that
“severely compromises a person‟s physical or emotional health” –
AL Morris et al
Physical compromise – serious problems with breathing, speaking, or
eating, especially if accompanied by tissue destruction
Emotional health – includes other‟s reactions to the individual in a way
that influences self-esteem
Research in the areas of self-esteem and attractiveness indicates that
the face is a major source of one‟s psychological identity

Orthognathic surgery differs from surgery for congenital anomalies (in
that the changes in appearance are less dramatic and improvements in
occlusion, mastication, speech, and TM joint function are likely to be
major reasons for treatment) – but patients undergoing this surgeries
also expect esthetic changes. They must adapt not only to changes in
their oral function, but also to changes in their perceived appearance and
interactions with others

CONCLUSION
Psychology and Behavioural sciences have been an integral part of
orthodontics both in research and in clinical practice since the early
days of this century. Through out the course of orthodontic treatment,
the orthodontist should keep in mind the fact that the psychological
outcomes of treatment are as important as the occlusal and functional
outcomes of treatment.
In broad terms, straight teeth make for more attractive smiles. More
attractive smiles make for more positive self-image.

References
William r. proffit, raymond p. white, david m. Sarver.
Contemporary treatment of dentofacial deformity, Mosby,
London.
Vanserdall RL ,Musich DR. Adult Orthodontics: Diagnosis
and Treatment in Graber TM Vanarsdall RL.
Orthodontics . Current principles and pratice 2 nd ed
.C.V.Mosby . St Louis 1994.pp 750-836
Shobha Tandon : Text book of pedodontics.

Park and park ; Text book of preventive and community dentistry.
Samir E. bishara, text book of orthodontics.
Phillips C, Bennett ME, Broder HL. Dentofacial dishar-mony;
psychological status of patients seeking treatment consultation.
Angle Orthod 1998; 68: 547-56.
Adams G: Physical attractiveness, personality, and social reactions
to peer pressure, J Psych 96; 287-296,1977.
Dann C et al Self concept, Class II malocclusion , and early
treatment, Angle orthod 65(6):411-416,1995.

Tung AW, Kiyak HA: psychological influences on the timing of
orthodontic treatment, Am J Orthod Dentofacial Orthopedics
97:336-348, 1990.
Egolf RJ, BeGole EA, Upshaw HS: Factors associated with
orthodontic patient compliance with intraoral elastic and head
gear wear, Am J Orhod dentofacial Othop 97:336-348, 1990.
Sinha PK, Nanda RS, McNeil DW: Perceived orthodontist
behaviors that predict patient satisfaction, orthodontist patient
relationship, and patient compliance in orthodontic treatment,
Am J Orthod Dentofacial Orthop 100:370-377,1996.

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