Social psychology of orthodontics /certified fixed orthodontic courses by Indian dental academy

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Social psychology
• It is the scientific study of the way in which
people’s thoughts, feelings and
behaviours are influenced by the real or
imagined presence of other people


Social Psychology-of orthodontics
Q1. Why do patients seek orthodontic care?
Primary cause-Improve appearance –Social psychology of
personal appearance-Landmark book (Bull &
Ramsay)-1960s-70s
Key points of the book
1. Facial appearance- most important determinant of a
persons attractiveness
2. Have more difficult time in school
3. Disfigured people- less likely to do well in –
employment, politics.
A person’s Dentofacial deformity – can have significant
effect on overall quality of life

• Adams examined the social psychology of
beauty-and concluded that physical
attractiveness appears to elicit different
social exchanges
• As a consequence of receiving a constant
positive or negative social reaction –
different interpersonal styles develop
• In short- attractiveness has a lot to do with
a person’s self confidence

• Appearance also has a lot to do with the way people are
perceived
• Secourd & Jourard-evaluated the importance of
dentofacial appearance as determinants of personality
traits compared to all other body clues
• They found- correctly aligned teeth- reflects- sincerity,
intelligence, conscientiousness & god looks
• Crooked teeth-????? (Bishara)
• Klima,Witterman & McIver-on the basis of facial
appearance- personal attributes such as –good, worth ect
is set
• Bennett, Broder,& Phillips-dentofacial deformities-cause
of teasing & harassment –associated with lowered social
attractiveness

• Table 3-1- Proffit,White & Sarver


• Leslie Zebrowitz calls the preferential
reaction to & treatment of people with
attractive faces as the “attractiveness
halo”


• Social Psychological impact –
• 1.Parent- Child interaction
– Langlois showed that even mothers were more affectionate &
playful with their babies when they had more attractive faces
– Other studies also showed similar results- and mothers also
tended to behave less positively when their children had
craniofacial abnormalities such as cleft lip & palate(Field &
Vega-Lahr)
– Parke et al- Fathers also showed a positive correlation between
attractiveness & affectionate behaviour
– Harsher punishments to less attractive children was also found
among both parents


2.Teacher-student interaction
• The Halo extends from the home to school
• Clifford & Walster-asked teachers to estimate IQ based on
photographs, report card& attendance percentage
• The child’s attractiveness had a large effect on the
teachers expectation as to have a higher IQ
• “Pygmalion effect”-A study was conducted to check this
phenomenon
• It was found that-the teachers expectations did in fact
influence the students’ actual increase in IQ
• Zebrowitz-Host of supportive behaviour by the teacher to a
student causes this difference

• White et at showed that-attitude of the
teachers are also influential in the opinions
that students form of their peers
• The same is true the other way round as
well-Klein showed that-Students preferred
teachers with a more attractive face as
they felt he/she to be more smarter


3.Occupational outcomes• Meta analysis by Hosoda et al-attractive
individuals fare better than their less attractive
counterparts in terms of perceived job
qualification & success, hiring decisions etc
• Study by Frieze et al-the MBA graduates found
facial attractiveness correlated with benefits they
obtained- such as higher salary.


• In 1990s –evolution in the understanding of the interplay
of psychological factors & dentofacial deformity
• Shaw et al-discussed the benefit of “social psychological
well being” in terms of 3 subgroups
1. Nicknames & teasing
2.Dental appearance & social attractiveness
3.Self-esteem & popularity
They concluded- dental conditions did effect certain
characteristics such as popularity & intelligence & also
that personal dissatisfaction felt in childhood can remain
for a lifetime.

What is attractive?
• “Tis not a lip or eye, we beauty call, but the joint force and full
result of all”
Is there a universal agreement on the concept of facial
attractiveness or is it only in the eye of the beholder
Current research shows- cross cultural agreement about
who/what is attractive
Langlois et at- found correlation as high asr=0.85-0.94
Even infants respond to attractiveness- one method to evaluate
the infants’ respose- ‘Gaze time’
When presented simultaneously with 2 photographs- the infants
tend to gaze longer at the face previously rated more attractive
(by adults)
Langlois- experimented with infants who had a attractive or non
attractive caretaker( Mask was put)- found more avoidance
behaviour when the non attractive mask was put.
Above studies show-innate sense of attractiveness is present at
birth though later influences of culture & environment are also a
great influence

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Facial attractiveness has been postulated to consist of
the following (in combination or alone)“Averageness”
Symmetry
Neonate-like features (baby face)
Secondary-sexual charecteristics
Youthfulness
Familiarity
Straight profiles
Facial expression- esp. smiling

1. “Averageness”- Sir Francis Galton’s serendipitous
experiment with composite faces lead to the
“averageness” hypothesis-i.e.-composites were more
attractive than individual faces singly
Langlois et al – found that the composites formed by
computerized averaging of multiple faces more
attractive
The term “Averageness” does not denote mid-level
attractiveness but indicates a representation of facial
features closer to the population mean( attempts to
bring the patients’ ceph readings close to that of the
average reflects the clinical predilection to accept
averageness as attractive

• Why is it attractive?
1.Preference for prototypes-on an evolutionary
scale-face closer to representing population
average recognized more easily as the member
of the same species
2. Averageness-appears more familiar-makes
faces familiar even when never seen before
3.Mate selection-Averageness equates with good
genes

2. Symmetry-Has a positive correlation with attractiveness
Mealy et al- Twin study- monozygotic twins though
genetically identical due to developmental differences
phenotypic expression diffres
The facially symmetrical twin within each of the 34 pairs
was consistently rated more attractive
Potential critique of the Averageness hypothesis- average
faces are more symmetrical- therefore more attractive
Current research by –Rhodes et al & Rubenstein et al –are
contradictory thus concluding that both are equally
important

• Why is symmetry important?
• Signals Genetic fitness/& or good health
• A variety of psychological & physical
abnormalities area associated with facial
anomalies- such as cretinism-receding
chin associated with impaired brain
fetal alcohol syndrome- midface deficiency,
schizophrenia-crooked smile

3.Babyfaceness-include characteristics such as- large
forehead, lower set but large eyes, nose & mouth,
smaller, shorter, more recessive chin, fuller lips, small
nose and round less angular face
• This has been found to be more attractive particularly in
females and in males its more curvilinear( increasing to a
point then decreasing)
• Baby faced adults- perceived to be more honest, warm,
approachable ,friendly, naïve & submissive
• However certain mature characteristics-such as high
cheek bones in women & larger chins in males is found
attractive

• Why is baby face attractive?
• They have a natural appeal to the adults-elicit
affection & sympathy & care
• On a evolutionary analysis- ‘cute’ children have
a better survival rate
• Baby faced females-associated with
youthfulness-associated with fertility
• Male faces- which are to acertain extent
“feminized’ are preferred by females as partners
as they are thought to make better parents

4. Profile considerations- from Angle through
Tweed to Mclaughlin –expounded preference for
Class I profile
Psychological research has mostly been based on
frontal assessments- several studies validate the
hypothesis that straight profile is more attractive
Lucker et al -showed photographs of 10-14 yr olds
to their peers- found that the children could find
‘something wrong’ when the profile was
retrognathic or prognathic

• Why is straight profile attractive?
• Evolutionary advantage-appropriate
masticatory function is hypothesizedenhanced survival


5. Expressiveness-certain features which gives cues to
perceivers to infer certain characteristics
Raised eyebrows-convey openness, interest ,nondominance
Fuller lips- babyfaceness
Smiling- conveys friendliness, social supportiveness
Cunningham et al- expressive features are particularly
attractive in women
Smiling- increases attractiveness in males along with other
masculine features- thick eyebrows, large chin


• Expressiveness: The smile
• It is a very important positive social behaviour for human
beings
• Such positive facial expresiion increase the rating of
attractiveness- it also elicits more positive person
perceptions
• The Duchenne or the ‘felt smile’-involves the use of both
the muscles of the mouth & eye
• The social smile –involves the mouth only
• The former type of smiles are deemed to be more
genuine
• Attractive & smiling faces make us feel goodpleasurable regions of the brain is stimulated

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Various influences in seeking
treatment
Patient perception & reaction of others to a
disharmony varies1. Ethnic group variation-e.g. In a population where
mandibular prognathism is common – its not
noticed as a severe deformity
2. Cultural background- Africans’ concept of
beauty- such as enlarged lips & pointed teeth
may not be acceptable to the rest of the world
3. Gender differences- generally considered more
important in females
4. Social setting- Higher socio-economic statusmore important to be attractive

• 5.Extent of the problem –McGregor et al foundeasier to live with a severe problem than a mild one
• Severe problem- reaction is predictable &
consistent
• 6. Patients reactions to their own condition- a
severe deformity may not be affecting an individual
and vice-versa- mild problem could cause severe
anxiety
• 7.Patients’ reactions –to the way they are
perceived• Some people handling teasing better than others.
How a person responds depends on complex
interplay of behaviours, attitudes & beliefs

Psychological Outcomes of
Treatment
• Dann et al – all children with serious malocclusion did not
necessary have poor self concept/esteem or poor body
image
• And post orthodontic treatment there was no significant
improvement
• Conversely Albino et al found that dental disharmonies do
have social consequences & significant psychological
effects
• He also reported significant improvement in the dentofacial
specific self-image scores (by patient, peer & parent) after
orthodontic treatment
• Though he also reported that there was no improvement in
social competency or social goals
•

• Why the difference between the 2 studies• Answer lies in the patients’ attitude before
the treatment started
• If the patient feels bad at the outset of
treatment the treatment causes a greater
change in the patients self-esteem.
• worse it is at the beginning, more is the
change perceived
•

• Varela & Garcia- Camba –evaluated the
extent to which orthodontic treatment
effects the perception of self-esteem &
image in adults
• They found – orthodontic treatment does
have a significant positive effect in adults
regardless of their state of mind at the
outset of treatment

How important is it to give the
orthodontic treatment at the right time?
•

Shaw et al- evaluated the risk/ benefit appraisal for
orthodontic treatment
•
They divided the socio-psychological well being into 3 sub
groups
1. Dental abnormalities that cause a obvious dentofacial
deviation –leads to hurtful mockery by the peers – the
contribution of orthodontic treatment at such a stage
should not be underestimated
2. Dental appearance & social attractiveness-change in the
appearance causes a change in the social class &
popularity
3. Self esteem & popularity
They concluded that if personal dissatisfaction is felt in
childhood- if not treated may remain for a lifetime

• Tung & Kiyak• They also concluded that the developing
child’s psychologic well-being may be an
indication for early orthodontic treatment
• They also found racial differences – White
children are far more critical in their
esthetic judgments- thus require early
care & attention
• Fig-25.1- pg 457-bishara

Understanding the Adolescent
patient
• Period between childhood & adulthood
• Period of immense-Physical &
psychological changes
• One of the most important factors for peer
acceptability-Facial appearance
• Changes in appearance at this point of
time-contributes to anxiety on one hand or
positive self confidence in the other

• Physical changes in adolescence- stessful
• The timing & tempo of puberty have
serious effects such as succumbing to
eating disorders in females as they gain
weight during puberty
• Cognitively- adolescents can apply logic &
abstract concepts but at the same time be
impulsive without thinking about
alternatives or consequences

• Difficult stage for the orthodontist• As the patient may not be internally
motivated
• Achieving total patient compliance


• Patient Compliance• Main requirements of an orthodontist are1.Maintain oral hygiene
2.Less breakage of the appliance- proper
maintenance & diet
3.Maintaines appointments
4.Regulaly wears functional /orthopedic
appliance

• Adults- generally seek care on their own &
also have financial commitment- usually
compliant
• Adolescent- compliance is more difficult
• May be taking treatment due to the parent
• No financial commitment
• Does not have a clear picture of the result

• Personality testing & compliance-is it possible to test the
patients compliance levels before the start of the
treatment so that appropriate changes can be made in
the treatment plan
• More than 80% of the orthodontists do not have a
specific method for assessing compliance
• Southard et al- examined a commercially available
personality tester called-MAPI-Million Adolescent
Personality Inventory
• The results were correlated to an ordinal assessment of
the patient’s compliance over a period of 2 years
• They concluded that-MAPI could be a useful instrument
in assessing adolescent compliance

• Calcalon & Smith-studied 252 patients between 11-17
years using 3 questionnaires
• Comprehensive personal assessment system
• Adolescent alienation index
• Home index
• They found• Females more compliant
• Low compliance in patients with low self-esteem
• Females higher socioeconomic backgrounds- more
compliant
•

Motivational psychology
• Motivating an adolescent patient-Cooper &
Shapiro-pitted health specific motivation
against the non health related issues for
motivation
• He found that- adolescents were more
concerned with• Self image & identity
• Independence & autonomy
• Peer relationships

• They concluded that• Taking time to identify the patient
concerns & treating them as responsible
individuals is important
• And orthodontist should understand that
adolescents are not motivated by strong
health specific goals projected to them but
rather by the peer group influences

•

White –many orthodontists believe in positive reinforcement-key to
motivation
• Reward system – extensively used
But White found that – compliance was unpredictable in his practice
There seemed to be some influence of their personality beyond the
positive & negative reinforces
He said compliance more related to Sensitivity threshold relates to
the patients pain tolerance
Chase & Thomas said- Sensitivity threshold – unchangeable
characteristic of the patients genetically determined personality
Then –How do you make the patient more complaint?


Then –How do you make the patient more
complaint?
1. Reduce discomfort by prescribing soft
tooth brushes
2. Simplest appliance – low magnitude of
forces
3. Prescribe analgesics
4. Lessen treatment time

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Rosen –proposed patient oriented approach
A individualized compliance plan has to be
devised
The orthodontist first provides patient
necessary information to educate them
Motivates the patient – through an open &
straight forward method- build mutual respect
Family & peer support to be encouraged
Should appreciate the patients perspective –
work together to overcome barriers
pic

• Orthodontist- patient communication-one of the
most profound effects on patient compliance
• Klages,Sergl & Burucker studied the doctor–
patient communication by audiotaping the
conversation
• Found strong correlation between clinician’s
encouraging behaviour & patient compliance
• Barsch et al found –doctor- patient interaction
was the best predictor of how well a patient
could be expected to comply

•

Nanda & Kierl-found certain variables to affect the
patients’ compliance
1. Parent- child relationship
2. Psychosocial characteristics of the parent &
patient
3. Patient & parents opinion about orthodontics
4. Patient & parents perception of the degree of
social compromise
5. Patient demographics
6. Parent & child’s relationship with the orthodontist
Authors found that the doctor- patient relationship,
strongest association with patient compliance

Adult psychology- orthodontic
perspective
• Main motivation for adults-improve facial
appearance
• Less than half- want to improve jaw
function
• 1/3rd – want to improve pain & discomfort
The type of the problem & how the problem
is perceived is also a important
determinant

• Patients own reason for seeking treatment
may differ from their perception of why the
treatment was recommended
• Because in general – doctors place less
emphasis on esthetic reasons for seeking
treatment & patients are unwilling to admit
to severe psychological problems
• The orthodontist must evaluate the
psychological distress of the patient

• Certain indices are used-GSI-Global severity index can help
us achieve “positive diagnosis”- identify subjects with
sufficiently pronounced distress
• GSI represents a composite of dimensions & is the single
most sensitive indication of in the SCL-90-R of
psychological distress
• RCT by Hatch et al- should 22% of the patients had
sufficient distress for a positive diagnosis
• 20% -North Carolina study
• Patients scores- far outside normal range will benefit from
face to face evaluation with mental health professional
• Orthodontists who identify any kind of strange of difficult
behaviour (Red Flag) – should immediately refer to a Mental
health professional

• Acceptance Vs Rejection of treatment• What is the motive behind a patient
accepting/rejecting a surgical treatment plan?
• Kiyak et al- developed a measure of the patient
expectancies based on SEU( subjective
expected utility) theory
• Theory assumes that – individuals likelihood of
choosing a particular behaviour is determined by
the weight he/she attributes to values associated
with that behaviour

• On an 18 point scale-5 items were found to be
the determining factors(80%)
• Cost, Family or Friends’ advice, advice of dental
professional, appearance of teeth & appearance
of profile
• Patients who agreed for treatment-found coat
manageable & had support of family & friends
• Cost was a major factor- for those who refused


• Second major decision-Surgery Vs
Camouflage
• The decision is influenced by almost the
same factors as above but ranking &
relative importance is different
• Table 3-2


• Cost remains the single biggest influence• Surgery patient has to think of 4 major costs
1.Associated orthodontic treatment
2.surgeon’s fee
3.Hospital bill
4.Loss of productive income & time
Lack of insurance –major obstacle
BUT- whether you can afford something is affected by how
badly you want it, so it ultimately depends on the patient
If there is an insurance cover- then the 2nd most important
factor – opinions of family & friends


• The patients who chose surgery- felt more
negative about their mouth, chin or profile
whereas those who chose camouflage felt
more negative about their teeth
• Other studies showed- Quality of life
issues are strong underlying motivators for
surgery
• More than 50% of them felt socially
disadvantaged & had self image issues

• Role of an orthodontist• Should learn to obtain sensitive information
without giving offense
• Best way to explain-Emphasize on the stress
involved• Due to change in facial appearance
• Due to stress of the treatment itself- esp.
surgery
• Emphasize the need for good stress
management & need to understand the whole
patient

• As the patient ‘opens up’ one must assess
the individual’s practical &emotional
readiness for treatment
• One may use various techniques to gather
information such as-silence & open ended
questions


• One must also evaluate the patients expectations out of
the treatment
• They can vary from-realistic to impossible to satisfy
category
• If the patient has extraordinary expectations- then will
end being bitterly disappointed when they are not met
• The categories for unrealistic expectations1.Improvement in appearance- unattractive to extremely
beautiful
2.Broader quality of life- get promotions or improve a failing
marriage
3.Function- surgery may not improve TMJ problems
drastically or predictably

• Evaluate coping skills• It is very important to know if the patient can
cope up with the stress of a
-protracted treatment time
-stress of the surgery itself
The orthodontist can judge this by finding out how
the patient copes with other challenges in life
Are the actions adaptive?- such as seeking
support from family or maladaptive- using
alcohol or drugs

• It is also important to focus on the social
support of the of the patient
• Find out who are the persons & how well
will they support the patient in all stages of
treatment emotionally
• They should be urged to attend the
sessions where treatment plan is reviewed


• Preparing patients for surgery1.Involve the patient as much as possible during decision
making
2.Should present simulations of various treatment results
3.Appropriate cautions –and risk involved should be
properly explained
4. As the surgery approaches – more detailed information
about the surgery & its after effects should be discussed
The amount of information – varies depending on the
nature of the patient


• Box 3-2


• Treatment refusal & delay• Treatment may have to be refused due to the
patient’s psychological condition or social
situation
• Eg.-unrealistic expectations or improper social
support (abusive partner)
• Very sensitive area for the orthodontist• The practitioner should be confident & clear
about his decision but at the same time have
empathy for the patient

• Orthodontist should learn to refer the patient to a
mental health practitioner with ease
• Can also have collaboration with one or two
therapists- who can if possible come to the
orthodontists office & even be a part of the
discussion as the patient will feel more
comfortable & the therapists will be able to
understand the complexity of the problem


Response of treatment
• Three ways to evaluate the treatment
outcome1.Measure the physical dimensions
2.Evaluate function
3.Questionnaires-asking the patient how
they feel
The physical measurement is the most
direct-the latter two varying from patient to
patient

• Functional outcomes• Short term effectsMulticentre RCTs (Hatch et al) show that patient are more
comfortable when they have shorter hospital stay & RIF
is used
But a study by Neuwirth shows that only half the patients
felt that they have achieved normal levels of activity 4
weeks post-surgery & 70% felt the same at 6weeks
At least 1/3rd of the patients felt that they experienced
unexpected difficulty in the post operative period


• Perception of dental occlusion &
masticatory ability• As the patient expect- they almost always
get improvement in occlusion &
masticatory ability
• Table-3.4


• To measure improvements in facial
movements- new approach (Trotman &
co-workers)
• 3-D video-based motion analysis is used
to quantify movements of the peri-oral
region
• pic


• Oral sensation• All patients have a period of numbness
after mandibular surgery –due to the
traumatized IAN
• Sensation should return in a few weeks
• But UNC trial showed-almost 3/4ths of the
patients reported altered sensation even 2
years after surgery
• Fig 3.10

• Speech• Great fear in the patient- but very rare
• UNC trial- 15% reported difficulty in speech-4 weeks
post surgery & after 2 years- only 5%
• TMJ• About 20-30% of the patients seek orthodontic treatment
to alleviate TM pain
• Literature reports shows only certain types of
malocclusion show a higher prevalence of TMD
• Nemeth et al-in a multicentre RCT showed shoed that
patients with MMF rather than RIF showed improvement
in TMD 2 yrs post surgery

• Satisfaction with treatment• UNC study showed 82% of patients being happy with the
results 4-6 weeks after surgery
• 90% after 2 years
• There of course was reported dissatisfaction with
specific aspects of the treatment in 5-40%
• Females with neurotic tendency & introvert malesshowed more pain post-surgery-Kiyak et al
• Scott et al showed- older patients & those with a positive
attitude towards their esthetic impovement- were more
satisfied

• Psychosocial assessment & consideration
immediate post surgery
• Box 3-3


• How does it help improve the social environment of the
patient?
• UNC study- most patients were happy with the esthetic
results of the treatment even 2 years post surgically
• 1/4th – said that they were receiving more positive
comments & first time reaction of people was better
• Kiyak’s study showed a slightly different pattern• There is an dip in the self esteem at 9 months post
surgery with higher scores at 24 months
• This could be due the result of prolongation of the
orthodontic treatment post surgically

• Self-image• Kiyak et al compared 3 sets of patients1.Those who refused treatment
2.Those who opted for camouflage
3.Those who opted for surgery
The scores were given by the patient -for
facial body image
Fig 3-13

• Similar effect seen when profile
assessments of treated & untreated
patients were compared
• The camouflage patients rated themselves
as normal whereas the untreated patients
were aware that they were outside normal
range


• HRQOL-health related quality of life
• This is a new paradigm in area of health care
• Medical care has shifted from-disease prevention
paradigm to quality of life paradigm
• The high levels of satisfaction with orthodontic treatment
shows that there has been an increase in the quality of
life
• The HRQOL – has shown an improvement across
health, emotional behaviour & psychosocial dimensions
• To obtain insurance coverage-clinicians & patients
should be able to demonstrate benefits that improve
HRQOL

Psychological issues in cleft lip & palateThe social & emotional adjustment of a child
is also a developmental process
Various factors –
Parental functioning
Child functioning
Societal acceptance

• Parental influence• Birth of a child with CLCP-traumatic experience for the
child
• First few months very difficult for the parents
• Parental success to cope at his this time depends onmental health of the parents
• Parents –reporting high levels of stress – more
adjustment problems to the children
• Mothers who believe that they can meet the child’s
needs & take satisfaction in their role as parents- child
learns better emotional self regulation

• Child’s characteristics- can also be
controlled by the inherent temperament
• Hart et al-Classified
• 1.resilient child
• 2.overcontrolled-shy & co-operative
• 3.Uncontrolled- uncooperative & has
difficulty with social relationships

• Most obviously the children with CLCP are
viewed negatively or have a difficult time
socially-testing the resilience of the child much
more
• This is largely due to the appearance and also a
slightly below average cognitive skills
• CLCP patients- demonstrate intellectual
development within the broad range of normal
although 3-5 points lower
• The Verbal fluency was significantly less
developed

• Bottom line- The orthodontist must
understand the emotional &
developmental psychology as well as
social implications of dentofacial deformity
• Building a rapport with the patient &
communicating with them through out the
treatment – is the key to successful
orthodontics- as one must keep both the
dental & the mental factors of the patient

Thank you
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Social psychology of orthodontics /certified fixed orthodontic courses by Indian dental academy

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