By Dr.

Nilofer Vevai PG Student VYDEHI INSTITUTE OF DENTAL SCIENCES

Content

Introduction & Definitions. Child Psychology Theories. Diagnosing Of Psychological Readiness. Psychological Implications Of Malocclusions. Psyche during Treatment. Psychology Of Retentive Phase. Psychology Of Habits. Motivating Factors For Treatment. Psychometrics. Psychology Of Removable Appliance Wear. Psychology Of Cleft lip Cleft palate. Psychology Of Adult Orthodontics. Head Gear Use Psychology . Psychology Of Orthognathic Surgery. Application.

 Psychology is an academic and applied discipline that involves the scientific study of

human or animal mental functions and behaviors.

It also can be defined as the study of behaviors & of function & processes of mind , especially as related to social & physical environment

 Psychologists are classified as social or behavioral scientists. Psychological spectrum include

perception, cognition, attention , emotion , motivation, brain functioning, personality, behavior and interpersonal relationships.

 Clinical psychology is application of behavioral science

to day to day behavior with objective of modifying that behavior in direction more acceptable to individual & to society in which he or she functions

 Psychiatry : is defined as branch of medical science that deals with causes , treatment & prevention of

mental , emotional & behavioral disorders.

 Orthopsychiatry : is defined as branch of Psychiatry that specializes in correcting incipient mental &

behavioral disorders in children & in developing techniques to promote mental health & emotional growth & development.

Psychologic growth & development generally progressed in relatively predictable, logical, step like sequential order. These processes are influenced by genetic, familial-cultural, interpersonal, & intrapsychic factors.


1. 2. 3. 4. 5. 6. 7.

The major schools of thought that will be discussed: Classical Conditioning. Operant Conditioning Modeling Psychoanalytical theory Psychosocial theory Cognitive theory Social learning theory.

Classical Conditioning
Dr. Ivan Pavlov
Dog Experiment.

Perception of people in white coats as fear conditioned to

pain. To counteract this treatment with involving painful procedures avoided in the first appoinment.. To cause a phenomenon known as extinction of the conditioned behaviour. Generalization vs discrimination.

Operant Conditioning
B.F Skinner. In Classical conditioning a stimulus becomes a

response in Operant conditioning the response becomes a further stimulus. Response Favourable /desired reaction acts as a reinforcement. Response Unfavorable consequence likely to be diminished. Positive reinforcement. Negative reinforcement. Omission. Punishment

Modeling
a.k.a Observational Learning.
Two distinct stages:

Acquisition. Performance.

Psychoanalytic Theory
Given by Sigmund Freud. Birth of a baby results in change in environment. The cutting of the umbilical cord causes damming up of energies inside the baby who wants an

independent existence .

Ref: Child Psychology :Dr. Alan Dsouza

 It has a feeling of being great basically is a narcissiit experiences light, pain temperature all new sensationshowever the feeling of independence soon leads to the realization of a need to survive and of being dependent on the Mother.
It cannot survive if the mother is taken away from him.

 Freud gave 3 Principles Id Ego Superego.

He believe Id represented unregulated instinctual drives & energies striving to meet

bodily needs & desires & are regulated by pleasure principal. These sexual & aggressive drives , necessary for survival of species through procreation & self defense, are tempered by Ego & Superego.

 EGO described as that part of self which is concerned with overall functioning & organization of personality through egos capacity to test reality, the utilization of ego defense mechanisms & of other ego functions such as memory, language, intelligence & creativity.

 Thus, ego is concerned with maintaining state in which an adequate expression of id drives & satisfactions can occur within the constraints of reality & demands of superego.

 SUPEREGO: likened to social conscience. Is derived in part from familial cultural restrictions placed upon growing child.
Its functions were derived from struggle over strong feelings of child b/w age of 41/2 to 7yrs for parent of opposite sex. This time of development called oedipal period.

 Superego stems from internalization of feelings of good & bad , reward & punishment of both parents.

Superego formation continues during school age &

in fact, throughout life.

 Upon basic constructs of id , ego & superego , Freud defined 5 phases of psychosocial

development based on theory of energies or drives.

Freud based his understanding of development as

occurring in 5 stages linked to pleasurable erotic body zones: The Oral Phase . The Anal Phase . The Phallic-oedipal Phase . The Latency Phase. The Genital Phase.

 The Oral Phase :

The Babys main interest is centered around the mouth. Lasts till 18 months. Experiences pleasure when the hunger needs are satisfied. Irritable when his demands are not met Attitude of the mother towards the child at this stage determines the childs psyche throughout life.

 A warm and loving relationship between the mother and child in this period results in the child being able to maintain lifelong relationships in a similar manner.

 The Anal Phase

The main interests of the baby are located along the Anal zone. Extends from 18 to 36 months. The mother makes best efforts to teach babies toilet training with varying resistance. If the baby is fixated at an earlier stage this is generally encountered with increased resistance. The child here finds a way to exert power over his parents due to the retaining or excretion of faeces

The act of defecation is imbued with a sense of omnipotence and independence and the faeces are libidinised with pleasure.
The child develops a love hate relation with his

parents.

 The fixation at this stage leads to anal traits like

regularity, punctuality, automatic obedience , orderliness, cleanliness, jealousy , lack of trust, and a tendency to hoard and miserliness.
Certain Psychiatric disorders can show an anal

fixation such as OCD, Paranoid Schizophrenia etc.

 The Urethral Stage

Pleasure derives from the Transition from Anal stage. Shame on loss of Urethral control occurs and Ego and Superego set in more strongly..

 The Phallic-oedipal Phase

Seen around 3 yrs of age. The childs interest is around the genital organs. The oedipus and electra complex observed herein wherein the boy is strongly attached to mother and v/v Resolves when the boy identifies with the father and girl with mother . Else continues in to adulthood with boy clinging to the mom and girls to their fathers. Freud called this the Oedipus Complex. Electra Complex by others.

 The Latency Phase

At around age 5-6 years upto 12 years. Development of a sense of industry and capacity. Skills are broadened here.

 The Genital Phase:

This begins at around 11-13 years of age. Mature adult identity achieved. Separation of dependence from the parents.

Psychosocial Theory
Given by Erik Erickson.
His theory postulates that society responds to childs basic needs or developmental tasks in each specific period of life & states that in doing so society assures not only childs healthy growth but also passage & survival of societys own culture &

traditions. Each developmental stage represents a psychosocial crisis.

 He gave 8 stages of emotional development.

0-1 yrs

TRUST VS MISTRUST

2-3 yrs

AUTONOMY VS SHAME DOUBT

3-5 yrs

INITIATIVE VS GUILT

6-12 yrs

INDUSTRY VS INFERIORITY

13-18 yrs

IDENTITY VS ROLE CONFUSION

19-25 yrs

INTIMACY VS ISOLATION

26-40 yrs

GENERATIVITY VS STAGNATION

42 yrs+

EGO INTEGRITY VS DESPAIR

 Development of basic trust (birth to 18 months)strong bond & trust develops b/w child & mother depending on care & love he receives from her.

Inability to achieve this leads to development of mistrust. Separation anxiety seen during this phase. So child parents must be present during treatment.

 Development of autonomy (18months to 3yrs)(Corresponds to anal stage.) Development of independence from the mother. Referred to popularly as the terrible twos

Viewed as time of gaining mastery over issues of self-control far beyond bowel & bladder control. Successful outcome leads to sense of autonomy , whereas failure leads to sense of shame & doubt.

 Development of initiative(3 to 6yrs)-

Corresponds to phallic stage. Child deals with issues of curiosity about anatomic differences b/w sexes, body integrity & gender identity. The successful resolution leads to sense of initiative, whereas inability to accomplish these leads to sense of guilt. Child is extremely curious about dentists office & eager to learn things found there.

Mastery of skills (7 to 11 yrs) (latency stage) Child acquires industriousness & begins the preparation for entrance into competitive world. Influence of peer group increases & of parents decreases. Inability to measure up to peer group predisposes towards personality characteristics of inadequacy, inferiority & uselessness. Orthodontic treatment usually begins at this stage. Cooperation with treatment can be obtained. Faithful wearing of removable appliances seen.

Develop of personal identity(12-17 yrs) (genital phase)Unique personal identity achieved. Members of peer group becomes important role models. Most orthodontic treatment carried during adolescent years can be extremely challenging. Since parental authority is rejected, a poor Psychologic situation is created if orthodontic treatment is done because parents want it, not child. At this stage, orthodontic treatment should be instituted only if patients want it. Emphasis on treatment for the patient and not to the patient.

Develop of intimacy (young adult)Attainment of intimate relationships with others. Success leads to establishment of affiliations & partnerships & failure leads to isolation. People receiving orthodontic treatment during this stage thinks change in their appearance might facilitate intimate relationships.

Guidance of next generation (adult)

Attainment of integrity (late adult)

Cognitive Theory
Jean Piaget is the worlds leading theorist in the field of cognitive development of children. Although Piaget does not place much emphasis on the influence of psychosocial & psychosexual

factors, he does hold that childhood development proceeds from an egocentric position through a predictable, step like, consistent expansion & incorporation of learned experiences.

 In this sense his theory is consistent with those of Freud & Erickson, that the child is an active participant with the environment in the constant incorporation & reorganization of data.
Adaptation occurs throu 2 commplementary processesassimilation & accomodation.

Piaget delineated four major periods of cognitive growth, each characterized by distinct types of thinking & which child successfully relies more upon internal stimuli & symbolic thought & less upon external stimulation. Each stage follows in an orderly, predictable fashion but with relatively wide variation for each child.

 Stages are : Sensorimotor period (birth to 18 months) Preoperational period

Preconceptual period (18months to 4yrs) Intuitive period (4 to 7 yrs) Period of concrete operation (7 to 12yrs) Period of formal operation (12 to 18 yrs)

 SENSORIMOTOR PERIOD-

Infant responds in a relatively undifferentiated reflexive pattern. Is egocentric, pleasure seeking orientation is gradually organized by coordinating & storing information gained from various sense organs. Thus, infant learns to integrate sensory modalities. Piaget describes this behavior as genuinely adaptive & intelligent at behavioral level, but totally concrete & not accompanied by cognitive awareness of casualty or of outcome of action.

PREOPERATIONAL PERIODTransitional period from Sensorimotor period to period of concrete operations where concepts of time, space, no. & logical ordering are acquired. The child understands the world throu the 5 senses.
Egocentricism. Animism. Lives in the present. Is dominated by how things look

feel taste and sound.

CONCRETE OPERATION PERIOD Corresponds to school years.

He develops ability to classify objects according to

attributes of size, shape, color & consistency & acquires concept of time, space, no. & logic. In addition, capacity to compare & classify equips child to understand & tolerate various points of view of peers & parents which often conflict with his own. The glass experiment shown practically may give correct answers. Childs thinking still held to concrete ideas. Hence things must be explained practically.

FORMAL OPERATIONSOccurs during adolescence. Thinks he/she is the center of attention throughout. This phenomenon termed as imaginary audience. By Elkind. Susceptible to peer pressure and extremely self conscious. Often come to us with requests about the type of braces they should get. Elkinds second phenomenon personal fable. Both help as well as could lead to risk taking behaviour and affects Orthodontics as well.

Social Learning Theory

Theory based on stimulus response and psychoanalytic principles Behavior is learnt by reinforcement Attention seeking behavior is normal in mother child relation Most persons behaviors are learned from other people Learned behavior can be maintained or changed.

 In This There Is Learning through

Modeling Attention Retention Reproduction Motivation

Attitude towards peers Family relations

Parent expectations

Attitude towards family

Physical state

Self concept

Family economic problems

biological development Opinion Of peers Religious affiliations School demands, Opportunities Impact of t.v. ,radio

The application of the understanding of Psychologic growth & development of children to the practice of orthodontics

The understanding of Psychologic growth & development is applied to identify the time of psychological readiness of child for orthodontic treatment. The early yrs of life culminating in oedipal period at age 5, are inappropriate , psychologically, for orthodontic treatment or any other sustained endeavor. Not mentally prepared for any form of treatment.

 At about age of 12, however, when children are often quite ready physiologically for orthodontic therapy, same oedipal struggle is reawakened.
This confrontation would again inhibit cooperation. Psychoanalytic theory suggests that b/w ages of 5 & 12, oedipal conflict remains dormant. That is why 6yr old is interested in learning & ready for school.

 Similarly latency period, (known as respite period), ought to be time when young patients

would respond most favorably to demands of orthodontic care

 Orthodontists treat dentofacial deformities that interfere with well being of patient by their adverse

effect on esthetics[Soft tissue Paradigm]. Most of orthodontic treatment with primary objective of improvement in facial appearance which may have an effect on their overall personality. Hence a concept of self body image is totally involved.

 Graber said that this impact was illustrated when one sees

few of shy, self conscious, withdrawn or overly demonstrative youngster with protruding upper incisors & adenoid faces.
Malocclusion being an easily recognized physical defect

constitutes major cause of abuse & may lead to humiliation in overly sensitive individual.
One of most traumatic experience in childhood &

adolescence is knowledge or feeling that one is different from peers.

Consciousness Of Body Defect

It is obvious that dentofacial deformities can constitute source of emotional suffering, varying in degree from embarrassment to mental anguish. In order to understand better this somatopsychic factor one must consider concept of body image.

 Each individual develops a conscious image of his own appearance, which is usually a pleasing one. When it is not personally pleasing, individual develops anxieties about himself, which, if unresolved, may lead to mental illness.

2 aspects have to be considered in relation to dentofacial defects-

1st is individuals attitude towards his bodyAn attitude resulting from his own reaction to defect what he perceives others reactions to be. Child who is teased about his defect will tend to have body image different from that of a person without a dentofacial defect.

2nd aspect is others response to disabilityThis involves degree to which ones relationship with others is altered because of how they respond to defect with lack of acceptance, from mild amusement to horror.

 Roots states that the first & foremost psychological

effect of dentofacial deformity manifests itself as inferiority complex.

Sense of inferiority is a complex, painful, emotional

state characterized by feeling of incompetence, inadequacy & depression in varying degrees.

 On basis of studies by Baldwin & Barness & by Lewit & Virolainen it appeared that primary psychological impact of malocclusion doesnt

result from response of others to dentofacial irregularity but from individuals own reaction to deformity.

These children often lack love & attention from their parents & as a result are frustrated & depressed. This may lead to a tendency to be introvert.

 Self & concept changes in orthodontic patients during initial treatment a study published in AJO DO Vol 72

77 Caucasian pts were given Tennessee self concept scale before extraction or banding of teeth & then retested 7 months after banding. Results
Initial level of self concept of these pts was found to be significantly lower than that of normative

sample

 Significant increase in self concept b/w initial testing & readministration.

There were similar increases in self concept, regardless of whether the pts initial self concept had been low or high. The Increases occurred even though actual physical appearance of many pts was worse during initial phase of treatment becoz of appliances & spaces caused by extraction.

 Could depend on whether the patient is internally

motivated.
Peer pressure influnce. Aim to be One among the crowd.

 Varying amount of relapse continues to occur post treatment.

This should be clearly explained to the patient to improve his cooperation in retention phase . Often the adolescent patient is tired of 2-2.5 years

of treatment and if the retainer design is slightly uncomfortable to him ,he may totally stop its wear on personal decision or peer influence.

 Certain habit which were controlled during treatment phase may come back so appliance

design should incorporate special design.

Oral hygiene neglect is common in adolescents so

recalls should be timed so as to evaluate oral hygiene maintenance.

 Habit is a psychological matter- the tendency of nerve

impulses to follow old, well-worn paths. Swift

The principal of association has a great bearing on

habits of all forms of life & we see it taking shape even in infants.

 When an infant sees its mother or is shown a bottle, its

sense of sight immediately stimulates hunger sense. It is an association b/w the cells which control sight & cells which control hunger. This association or grouping of neurons leaves its impression in substance of brain. And when same stimulation is applied at a future time, group will respond exactly the same as in original response. If this group is stimulated often enough, the repetition soon has path worn in structure of brain of such depth that it becomes very easy for impulses to travel along it & as a result habit is formed.

Thumb /Finger Sucking

Observation and clinical studies have demonstrated that the primary cause of finger sucking is insufficient sucking at breast or bottle.

Statistical evidence demonstrated that the % of finger sucking problems is also consistent with the sucking-time, rising as high as 40 percent in infants fed at 4 hrs intervals to as low as 6 % in unscheduled feeders.

The conclusion that sucking time is primary factor in etiology of finger sucking was aided by following observations
There was not 1 instance of finger sucking in case of children who need pacifiers.

a)

b) In several cases of children with rickets, whose feeding histories showed sufficient sucking time, habit didn't develop, thus ruling out nutritional

factor as a primary cause.

c)

In an experiment with an infant of 8 months whose thumb sucking started from glass was substituted for bottle & started again by return of glass.

 2 main schools of thought prevail-

Psychoanalysts regard habit as symptom of emotional disturbance.

Behaviorists view act as simple learned habit with no underlying neurosis.

 Psychoanalysts believe that sucking in infancy ( birth to 2yrs) is part of normal behavior pattern which satisfies 2 needs, that of taking food & of oral gratification. Very frequently nutritional requirements of infants are amply catered to but actual sucking need has

not been satisfied. This could be caused by bountiful mothers or by feeding bottles with large apertures, causing child to gulp food rather than working for it by sucking action.

 Having not satisfied emotional needs, infant fulfills sucking requirement with readily available

thumb or finger.
Sucking need vary from 2hrs in some infants to

few min. in others. Sucking reaches its max. intensity at 4 months & tends to wane at different ages in different individuals usually toward later half of 1st yr.

 Therefore to wean child abruptly or to change

from liquid to solid diet before age of 4months may cause child to suck on any object usually thumb, to satisfy his emotional need. Dummy sucking is in majority.

Thumb Sucking At Different Ages

In the preschool child (2 to 5yrs) mild sucking before retiring or when fatigued is normal. In most instances, children who indulge in habit at this age are those who have continued to do so from infancy.
In instances where habit is initiated in the

preschool yrs, cause is generally emotional. Sucking at this age may appear during times of stress.

 Thumb sucking in the school child (6 to 12yrs) is usually manifestation of general emotional &

social immaturity..Most have continued these habit patterns from infancy.

 A group. of thumb suckers worthy of mention are constitutional thumb suckers Oral types who are either constitutionally

based or who have suffered such severe deprivation in their 1st few yrs of life that they have continued their oral traits. These habits are extremely difficult to break. Offer a very poor prognosis. Heredity appears to play an imp. role in such persons.

Dunlop beta-hypothesis According to psychologists no treatment till patient is in preadolescence &(or) adolescence. Best dental appliance in view of psychological stability is removable appliance where patient can help himself by removing appliance to suck thumb when sucking urge overwhelms his ability to overcome it.

1. Child psychology. 2. Psychology of parents/guardian. Jarabak cited 5 stimuli that they cause patient to desire orthodontic treatment. These are: Social acceptance. Fear. Intellectual acceptance. Personal pride. Biological benefits.
3.

Parent Determinants
Baldwin & Barness observed that the mother is usually the mobilizing, deciding & determining

member of the family in terms of the decision for treatment. The following factors among parents were found responsible for bringing children for orthodontic treatment: Parents attempt to resolve problems of their own self concepts by way of identifications with child & his treatment. Feeling of guilt about their own hereditary deformity . View of orthodontic treatment as a social symbol.

 Social & psychological motivations for orthodontic patients - AJO 1977 ; 72 : 460

A questionnaire survey of factors which motivated people to seek orthodontic treatment was taken of 3 samples of orthodontic patients & their parents:

 Results : Patients predominantly females. Decision made by mother generally. Treatment was seen more important by parents than child. Most important motivation for treatment was improvement of appearance. Lower middle class considered orthodontic treatment to be more important than upper

middle class. Lower middle class tended to be more child oriented & to have better relationships with their children.

 Investigation into some of factors influencing the desire for

ortho treatment BJO 1986 : 13 ; 87-94

Results : More attention should be given to particular occlusal

and esthetic deviations which are causing concern to the patient For majority of patients the provision of orthodontic care was dictated largely by esthetics and general dental practitioner exert an appreciable influence on patient acceptance of treatment

Psychometrics
Patient compliance is critical factor in efficacy of

orthodontic treatment. Major treatment decisions hinges on expected level of compliance & poor cooperation usually prevents orthodontist from realizing optimal treatment results.

Factors Affecting Compliance

Factors included not only personality traits dealing with locus of control & stoicism but also feelings toward pain & interference in oral activities, health awareness & perceived need for ortho treatment.
Others have found significant correlations b/w specific traits & ortho cooperation such as relationship with parents, school cooperation, relationship with authority age of patient, sociologic classifications & gender of patient.

The Million Adolescent Personality Inventory

The test (inventory) is composed of scales that are used to measure a particular characteristic. The greater the score on a particular scale, the greater probability that person possesses characteristic measured.

Scale category Personality style

No. of scales Measured characteristic Expression of 8 each Personality style

Scale names
Introversive, inhibited, cooperative, sociable, confident, forceful, sensitive

Expressed concern

Feelings & attitudes about issues concerning adolescents

Self-concept, personal esteem, body comfort, sexual acceptance, peer security, academic confidence

Behavioral 4 correlate

Behavior associated with adolescence

Impulse control, societal conformity, scholastic achievement, Attendance Consistency.

 The eight personality styles contained in MAPI are derived from a two-dimensional theoretical matrix.
The1st dimension pertains to primary source from which adolescents gain either positive or negative reinforcements. Persons who experience few rewards or little satisfaction from self or others are referred to as detached types.
Those who measure their satisfaction by how others react are

identified as dependent.

If gratification is determined primarily by ones own values and

desires without reference to concerns of others, person is described as having an independent personality style.

 Ambivalent personalities are those who suffer conflict over

whether to be guided by others or by their own desires.

2nd dimension reflects coping behavior used by adolescents to maximize rewards & minimize pain. This dimension is described as either an active or passive pattern.
Persons of active pattern lifes events to achieve

gratification & avoid discomfort. Those of passive type seem apathetic, restrained & content to allow events to take their own course without personal control.

 8 expressed concerns scales measure the intensity of feelings & attitudes that the adolescent may experience about issues that tend to concern most

adolescents. The expressed concerns scales focus only on voiced concerns & not on observable behavior. 4 behavior correlates scales measure intensity of behavioral problems associated with adolescents.

 MAPI in evaluation of orthodontic compliance

Poor patient compliance is well-documented problem in health care, with reported rates of noncompliance ranging from 15% to 93%. Unfortunately, the specialty of orthodontists is not exempt from this dilemma.

 Patient non-compliance may result in Extended duration of treatment

Inability to incorporate the most ideal

mechanics into the treatment regimen Destruction of teeth & periodontium Need for extraction of additional teeth Collapse of a corrected malocclusion after treatment Frustrated patients & additional stress for orthodontists & staff.

Miller & Larson have also indicated that more difficult ortho patients are those who are seeing a psychologist. The scale sensitive most likely is best indicator of psychological problems that have negative impact in our clinic.

Psychology Of Removable Appliance Wear..

Patient cooperation in treatment with removable appliances:
The uncooperative patient is labeled as having a poor or defiant attitude toward orthodontic treatments.

Inability to adhere to prescribed removable appliance wear schedules will result in either slow treatment response or no response at all.

 Lack of adequate patient compliance is not only a treatment response problem but can be a source of frustration & anxiety for orthodontist. Demographic factors & other variables related to

patient adherence to treatment regimes has led to identification of following reliable predictors. Demographic patterns:
Age, sex, socioeconomic status Education, race, religion, marital status.

Illness variables:
Severity of symptoms Duration of illness Resulting disability

Psychologic aspects of cleft lip & palate

Stigma experienced by CLP patients
A negative response from outsiders, actual or perceived

may adversely affect self image.

Social interactions an imperfect image may initiate

overt teasing ,unfavorable responses may be interpreted as a form of social unacceptability.

Speech - less significant than appearance in

contributing to low self esteem

 56%of the patients with clefts have problems warranting a psychosocial referral.

The incidence increases with age .

Problems are more frequently found in males

(69%) than females (42%) .

Suicide rate in adult individuals with cleft is twice that of normal population .

Treatment
Enhancement of patients self esteem and parental acceptance of their cleft are important goals for craniofacial team Surgical procedures are less traumatic if performed at an early age Detailed case discussion between different specialists within the team to avoid conflict in between treatment and informing the family about the plan Show empathy & support to the family & patient Easy instructions and comfortable appliance

Psychology of Adult Orthodontics

Major motivation in children & adolescents is the parents desire for treatment, adults in contrast seek treatment because they themselves want something .
They may have a hidden set of motivations. Some times the treatment is sought as a last ditch effort to improve personal appearance to deal with series of complicated social problems.

 It takes a good deal of ego strength to seek orthodontic treatment, Patients who are internally

motivated rather than externally respond better to treatment. Patients unrealistic expectations should be identified early, if patient thinks that the appearance or function of teeth is creating a severe problem ,while an objective assessment simply does not corroborate that ,orthodontic treatment should be approached with caution.

 Adolescents passive acceptance of what is being done is rarely found in adults.

The fact that adult can be counted on to be interested in the treatment does not automatically translate into compliance with instructions.
Unless adult patients understand why they have been asked to do things ,they may choose not to do them from an active decision not to cooperate.

 Adults as a rule are less tolerant of discomfort and

more likely to complain about pain after adjustments and about difficulties in speech , eating ,tissue adaptation. Additional chair time to meet these demands should be anticipated. If the expectations of both doctor & patient are realistic, comprehensive treatment of adults can be rewarding experience for both. Esthetics is very imp. for them.

Psychology of use of a head gear.

Gabriels study Majority said that they wore the head gear as instructed. With time the no. of patients wearing head gear as per instructions considerably decreased. But when they knew that treatment was soon to be completed the no. again increased.

 In most female patients hairstyling was a major consideration in not wearing head gear.

Cheek depression, also at top of head were the other major limiting factors in females. These adverse effects were thought to be permanent.
Most patients both male and female said that they

were embarrassed of wearing headgear in the public

Gabriel has also proved that public embarrassed is the single most main limiting factor in use of headgear

1.

It limited use of headgear: In period of wearing time of headgear, 2. The time per day of wearing headgear 3. The time of the day

 Reasons for tolerating a headgear :

1. As sense of duty 2. The parents insisted

3. The orthodontists insisted

 Gabriel has shown that use of headgear can be increased effectively by the following patient

communications techniques : The importance of headgear use must be repeatedly stressed & explain to the patient as well to the parent. The progress in treatment s/b discussed with patients mainly to involve him in treatment process. Decrease in expense & duration of the treatment have not been proved as positive motivating factors, so shouldnt be used. The possibility of increased or better quality of the treatment with headgear use has to be emphasized.

Frequent reminders on how to use headgear & why to use it should be sent to patients & to parents. Popular misconceptions of the use of headgear like cheek depressions have to be removed. Preparing patients for anticipated embarrassments resulting from appliances.

Implications for clinician

Allow patients to ask questions & encourage them to

discuss.
Providing patients with background on the philosophy

of your health team facilities, compliance with OSHA regulations.

 Informing the patient about what can & cannot be achieved ,use of visual aids helps most patients , whenever possible patients s/b allowed to speak with others who have had such care.

Screening patients for psychological distress using standardized questionnaires with mental /health questionnaires for patient to complete.
Discussing the patients history of present concern is critical in understanding the patients expectations .

 If patient is unable to answer ,it is a red flag that should be addressed or at least noted ,if patients

motivations are totally others directed then adherence can be problematic.

Checking patient understanding is essential. The medical history form should query about obsessive thoughts & rituals ,history of depression ,anxiety , reasons for visit to mental health practitioner

Psychology of orthognathic surgery

Unlike conventional orthodontic treatment which produces gradual change in facial features, orthognathic surgery results in often dramatic modifications. The patient unconsciously adapts to the physiognomic changes during ortho treatment & slowly integrates these changes into his/her self concepts.
Orthognathic surgery on other hand requires rapid integration of ones new facial features into self concept thereby placing immediate demands on patients adaptational skills.

Presurgical concerns & motivation

Evaluate patient's personality characteristics & Psychologic

stability in detail.

Acc. To survey done by Laufer & associates the primary

reason for seeking surgery are esthetics 56% mastication 32% family pressure 8% speech problems 8%.

Another study by Wictorin & others found out that 76%

have the functional rationale & 67% cosmetic rationale.

Post surgical psychological outcomes

Post surgical dissatisfactions with surgical treatment may not be related to surgeons skill but to communication gap b/w surgeon & patient. Those patients with primarily esthetic motivation have less initial reticence towards having orthognathic surgery & less difficulty adjusting to new appearance than those with strong functional incentives.
Younger patients & those with strong cosmetic motivation are less concerned about surgical risks.

 These results point to the potentially significant impact that orthognathic surgery can have on patients emotional well being. The anticipation of surgery results in considerable tension & anxiety. The days immediately following surgery are characterized by fatigue, loss of vigor, moderate levels of tension & anxiety & some depression.
6 months after surgery, their mood scores improve significantly, even beyond the presumably normal mood scores reported by persons who dont undergo surgery.

 It is note worthy that anger hostility reaches its lowest

level at the immediate post surgical stage but peaks 4 to 6wks later. This is accompanied by continued tension & anxiety & mild depression during the stages immediately & 4 to 6wks after surgery. ortho treatment without surgery may be a stressful event for persons who have initially considered surgical orthodontics, as revealed by their significant shifts in mood scores across time. The impact of long term orthodontic treatment appears to be one of heightened tension & frustration in the later stages. Although emotional status improves after treatment ends, the patient must be forewarned of these potential problems before treatment begins.

Their findings suggest that undergoing conventional

Application of behavioral model

Treatment behaviors must be clearly defined. Should be direct presentation of information to pt.
The events to use as reinforces can be identified by

conducting an assessment of patients high priority & high frequency behavior

 Next step in our intervention involves development of a reliable observation system. The purpose of this step is to ensure that behavior is performed before reward is given. It also allows the

child to receive performance feedback. Target behaviors have been selected, rewards identified & a monitoring system developed.

Once rewards are selected & observational system is developed, a reinforcement schedule is created. As the child demonstrated the ability to meet this requirement consistently, the response-reinforces ratio is adjusted so higher performance levels are required in order to obtain rewards.

 A vastly different topic with a wide scope. It is very

important for any doctor to master this as it can be a useful tool for the handling of various patients.
Especially in our field where the initial concern of the

patient is to look good which is a major psychological concern for the patient and one of the most common factors for motivation.

References
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Pedodontics Andlaw, Rock. Oral Psychophysiology - IIana Eli. Dental care for Handicapped Patients Bruce Hunter. The Psychology of Dental care G.G Kent, A.S. Blinkhorn. Developmental Psychology a life-span approach Hurlock. Dentistry for the Child and Adolescent Mc.Donald Avery. Textbook of Pedodontics Shobha Tandon Child Psychology Thompson.

 Concise Medical Psysiology Chaudhuri. Textbook of Medical Physiology Guyton Hall. Contemporary treatment of Dentofacial deformity

Proffit, white, Sarver. Albert H Owen III. Clinical Motivation of the Functional Jaw Orthopedic Patient. J.clin. orthod; 1983 Mar (192 198) Larry W.White. Behavior Modification of Orthodontic Patients. J.Clin. Orthod; 1974 Sep (501-505) R.G. Alexander. The Vari-Simplex Discipline: Part 5 Practice Management. J. Clin.Orthod; 1983 Oct (680687) Melvin Mayerson. Management and Marketing: Creating the compliant patient. J. Clin. Orthod; 1996 Sep (493-497)

 Melvin Mayerson, Larry W. White. A New Paradigm of

Motivation. J. Clin. Orthod. 1996 June (337-341) T.Mehara, R.S.Nanda, P.K.Sinha. Orthodontists Assessment and Management of Patient Compliance. Angle Orthod; 1998;2; (115122) D.D.Richter, R.S.Nanda, P.K.Sinha, D.W.Smith. Effect of Behavior Modification on Patient Compliance in Orthodontics Child Psychology Dr Alan Desouza Pediatric Dentistry Pinkham, Cassamasimo Self & concept changes in orthodontic patients during initial treatment AJO DO Vol 72. Social & psychological motivations for orthodontic patients. AJO 1977 ; 72 : 460.

Investigation into some of factors influencing the desire for

ortho treatment BJO 1986 : 13 ; 87-94