CHILD AND ADULT

PSYCHOLOGY AND
ITS CORRELATION
TO ORTHODONTICS

PRESENTED BY
Dr ASHWANI MOHAN
 INTRODUCTION
• Treatment goals of orthodontics depends on the
communication between the orthodontist and the
patient
• Psychological factors influence a patient
perception of malocclusion and treatment plan

• The cooperation of the patient depends on the doctor

patient rapport
• Psychological outcome of orthodontics:
Orthodontist → Attractive smile → positive self
image
• Orthodontics has benefits of well being and health, but
most important effect – makes patient feel better about
themselves
• Psychological outcome is as important as functional
and occlusal
• Face is the most important factor in physical appearance,
major motivation is to enhance the aesthetics of face
and dental.
• Dental anomalies- “general playground of
harassment” among children and associated with lower
attractiveness*
*Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of
dental features among school children. British Journal of Orthodontics. 1980 Apr
1;7(2):75-80.
 PSYCHOLOGY
• DEFINITION – the science dealing with human nature
and behaviour. It also includes understanding of the pattern
of mental processes and characteristics of an individual
• Also refers to application of such knowledge to various
spheres of human activity including issues related to
everyday life and treatment of mental health problems
• DEVELOPMENTAL PSYCHOLOGY – branch of psychology
concerned with physical, cognitive and social change
throughout the life span.
• Psychological development is a dynamic process
• Starts from birth in ascending order through various stages
that portray as behaviour
• Study of how individual grow and change through out life
PSYCHOLOGICAL IMPLICATIONS OF
MALOCCLUSION
Adverse effects of poor facial aesthetics, that motivates patient
to seek treatment
• Low self esteem – psychological handicap imposed
by anaesthetic dental appearance
• Restriction of social activities
• Adverse occupational outcomes
 CHILD PSYCHOLOGY
• Study of child behaviour including physical, cognitive,
motor, linguistic, perceptual, social and emotional
characteristics from birth through adolescence

• Proceed in a predictable, logical and sequential order

• Understanding the behaviour to specific group help the
dentist in knowledge of needs or fears of children
• Also help in assessing deviations from this processes
that might affect the treatment process
 Importance of child psychology
• To understand the child better
• To understand the psychological aspect of child
• To deliver proper services to the child and the parent
• To gain the confidence of the child
• To produce comfortable environment for the child and parent
during treatment
• To teach parent and child about importance of dental care
• For effective communication between the parent and child
with the doctor
• To develop treatment planning
 Values of knowing that
children develop
• All children cannot be expected to
differently
behave the same way
• Child may respond favourably, or
may respond with antagonism and
resentment to authorisation control –
child rearing must be individualised
• Not possible to predict how a person
would react to situations.
• Individuality
 THEORIES OF CHILD
PSYCHOLOGY
PSYCHODYNAMIC BEHAVIOR LEARNING

• Psychoanalytic theory • Classic conditioning by

by Sigmund Freud 1905 Ivan Pavlov 1927
• Hierarchy of needs by • Operant conditioning by
Abraham Maslow 1954 BF
• Psychosocial theory by Skinner 1938
Erick Erickson 1963 • Cognitive theory by
Jean Paiget 1952
• Social Learning theory
by
Albert Bandura 1963
 PSYCHOANALYTIC THEORY
• 2 primary ideas
1. Behaviour determined by childhood experiences
2. Personality development is the story of how to handle
antisocial impulses in socially acceptable ways
• Psychic triad
3. ID – basic drives, pleasure principle, instincts : life (Eros) and
death (Thanatos)
2. SUPEREGO - social conscience, judgements on individuals
actions: conscience and ego ideal
3. EGO – reality principle, controls id
EGO DEFENCES DISPLACEMENT
ANXIETY ↓
↓ REDIRECT IMPULSES
EGO MUST DEFEND ITSELF ↓ FROM
↓ REAL
UNCONSICOUSLY BLOCKS TARGET
IMP ↓ TO
ULSE INNOCENT PERSON
DENIAL – DISOWN THE PROJECTION
EXISTENCE OF UNWELCOME PROJECTS
REALITY INADEQUACY TO
REPRESSION – UNCONSCIOUS SOMEONE ELSE
FORGETTING
 REACTION FORMATION-
SUBLIMATION– REVERSAL OF BEHAVIOUR
SOCIALLY UNACCEPTABLE AS DICTATED BY
DRIVES UNCONSIOUS IMPULSE –
↓REDIRECT UNWANTED MOTIVE
SOCIALLY ACCEPTABLE CONTROLLED UNDER
DISGUISE
IDENTIFICATION – RATIONALISATION –
ASSUMPTION OF LOGICAL EXCUSE TO
QUALITY OF EXPLAIN BECAUSE THE
SOMEONEELSE TO REAL MOTIVE IS
VENT FRUSTRATION UNACCEPTABLE
OR CREATE FANTASY
 PSYCHOSEXUAL STAGES
• Satisfaction and problems in context of his own body
• Erogenous zones – stimulation results in pleasure
• Body – foci of interest
• 5 stages of development
1. ORAL STAGE 0-1year
 Mouth – gratification by stimulation of this area
 If satisfied – sense of trust optimistic outlook
 If not – uncertainty and pessimism
 Fixation – smoking, over eating, thumb sucking
 Personality traits – impatience, greediness,
dependence
2. ANAL STAGE 1- 3 yrs
 Gratification by elimination of faeces
 Acquisition of voluntary bowel and bladder control
 First encounter with rules and regulations
 When done successfully – independence and autonomy
 Gratification
o too little – orderliness, rigidity, hatred for waste, obstinate, stingy, punctual
o too much – untidiness, hot temper, destructiveness
3. PHALLIC STAGE – 3-6 yrs
 Interest in their own genitals
 Emerging interest in the parent of opposite sex -Oedepus complex –
boys
 Electra complex – girls
 Conflict-Homosexuality, authority problems, rejection of gender roles
4. LATENCY STAGE 7-12yrs
 Period of consolidation
 Tries to socialise
 Super ego become internalised
5. GENITAL STAGE >12yrs
 Appearance of mature heterosexual interest
 Competitiveness with parent of same sex
 extremities in emotional behaviour
 As result of disturbance– cannot reach maturity, cannot
shift
focus from his own body
PSYCHOSOCIAL THEORY – ERIC ERICKSON(1963)
• Internal psychological factors + external
social factor→ psychological development
• Progression through a series of
personality development changes
• Psychosocial developments proceeds by a series
of critical steps
• CRITICAL STEPS – turning points of moments of
decision between progress and regression,
integration and retardation
• Chronological age defers but the sequence
remains unaltered
1. Development of basic trust (birth -18months)
• Syndrome of maternal deprivation
• Bond with mother should be maintained to develop basic trust
• Separation anxiety
Dental consideration
• Treatment at early age, with parents
• At later stage – no sense of basic trust- uncooperative and
frightened
2. Development of autonomy – (18 mon to 3 yrs)
• Terrible twos, development of trust
• Failure to develop autonomy – shame, feeling of having ones own
short comings
Dental consideration - any simple procedure parent should
be present, may need behaviour management
3. Development of initiative
• Greater autonomy
• ↑ physical activity, curiosity, questioning
• Opposite – guilt

Dental consideration- usually first visit to the patients, curiosity

about everything, tolerate being separated from mother
4. Master of skills (7-11yrs)
• Learning rules of world by which it is organised
• ↑ peer influence
• Opposite - Sense of inferiority
Dental consideration – removable appliance wear depends on
how to please the dentist, peer group is supportive, whether desired
behaviour is reinforced by the dentist
5. Development of personal identity (12-17yrs)
• Peer group – model, partial withdrawal from family
• Motivation – internal and external
• Complex stage due to physical ability changes
Dental consideration- ortho treatment is done during this stage
• Management is difficult, as the parent authority is rejected
• Pursue only if the patient is interested
6. Development of intimacy (21 to 40yrs)
• Willingness to compromise
• Failure – isolation from others
Dental consideration- seek ortho treatment to enhance the aesthetics,
feel that change in appearance facilitate new relationships
• Change in appearance after treatment may effect the previously
established relationships
 7.Guidelines for next generation -(45 to 60
yrs) Establishment and guidelines to next
generation
Failure - Stagnation , indulgence and self
centred behaviour
8.Attainment of integrity (late adult)
combination of gratification and disappointment
Integrity – sense of satisfaction that a person feels
in satisfied life
Opposite – despair expressed as disgust and unhappiness, fear
of death,
Sense life has had with little purpose or meaning
 COGNITIVE DEVELOPMENT BY JEAN PAIGET (1952)
• Development of intelligence – phenomenon of biologic adaptation
• 2 complimentary processes
A) assimilation – child incorporates events within environment into
mental categories called cognitive structures
B)accommodation – changes cognitive structures to better
represent environment
• Intelligence is the interplay of assimilation and accommodation
• 4 stages:
1. Sensorimotor period (birth – 2yrs)
2. Pre operational period (2-7yrs)
3. Period of concrete operation (7 to puberty)
4. Period of formal operation (adolescence to childhood)
 Sensorimotor period (birth -
•2yrs)
Reflex activities to an individual who can develop
new behaviour to cope with new situations
• Foundation of language development
Pre operational periods (2-7 yrs)
• Form mental symbols
• Use language in way similar to adults
• Understand language in literal sense
• Egocentrism – incapable to assume other persons
views
• Animism – investing inanimate object with life
• Limited logical reasoning
Period of concrete operations (7 to puberty)
• Decreased animism
• Improved ability to reason but limited
• Ability to see others point
Period of formal operations (adolescence to
adulthood)
• Imaginary audience – others are concerned, as in
constantly on stage about being unable to respond
• Personal fable – feels he's unique, not subjected
to consequences
 CLASSICAL CONDITIONING – Ivan Pavlov
(1927)
• Learning by association
• Experiment on dog
• Conditioned stimulus is strengthened by reinforcement
• Extinction of conditioned behaviour if not reinforced
OPERANT CONDITIONING BF SKINNER
• Basic principle – consequences of behaviour is itself a
stimulus that can affect future behaviour––
• behaviour that led to pleasant
Positive consequence becomes more
reinforcement likely in future
• removal of unpleasant
Negative stimulus after a response
reinforcement • ↑ likely hood of response in
future
Omission • removal of pleasant
(timeout)
stimulus
• unpleasant stimulus
Punishm presented after a
response
ent
 SOCIAL LEARNING (modelling) – Albert Bandura
• Connection bridge between the cognitive learning and
behaviour theories (encompass attention, memory and
motivation)
• 2 stages
1. Acquisition of behaviour by observing it

2. Actual performance of that behaviour

• Types of learning
3. Inhibition – to learn not to do something that we already know,
because the model refrains from behaving that way or do
something else than what was intended to be done
4. Disinhibition – to learn to do a behaviour that is not acceptable
by the most, but because model does the same without being
punished
5. Facilitation – to promote to do something that not ordinarily does
because of insufficient motivation
Elements of observational
learning;
ATTENTION
RETENTION
PRODUCTION
MOTIVATION

Types of learning
1. Enactive learning – learning by doing
2. Vicarious learning - learning by observing others
• ORTHODONTICS- modern trend
3. Treatment in an open area with several treatment
stations
4. A great deal of Observational learning occurs
*Bandura A, Walters RH. Social learning theory.
HIERARCHY OF NEEDS – Abraham Maslow(1954)
 PRACTICAL PSYCHOLOGY
• Areas of behavioural research and application of
practical psychology to clinical practise of psychology
into 2 categories
1. Social psychology of orthodontics
2. Orthodontic motivational psychology
• New area → educational psychology to achieve
patient compliance
• The role of doctor as a teacher than a healer
• Social psychology of orthodontics involves
1. Why patients seek orthodontic care
2. Psychosocial outcomes of orthodontic therapy
3. Use of standardised psychological instruments to
assess prospective orthodontic patients
• Orthodontic motivational psychology
4. Motivating patients to follow doctors orders →
patient compliance
5. Standardise psychological instruments → to
predict patient compliance
 Social psychology of orthodontics
• WHY PATIENTS SEEK TREATMENT?
• Majority – their own initiative
• Most adolescence – “my mom thinks I need braces”
• Why do people want to look better???
• Facial appearance is a key determinant of whether or not a
person was believed to be attractive*
• Found that disfigured people: (significant skeletal discrepancy)
 Difficult time in school
 Less likely to do well in employment, politics or advertising
• Dento-facial appearance effect the overall quality of life
*Bull R, Rumsey N. The social psychology of facial appearance. Springer Science
& Business Media; 2012 Dec 6.
• Adams* suggested : developmental perspective for
examining social psychology of beauty
• 4 assumptions of relationship between outer attractiveness
and inner behavioural processes and outcomes extracted
1. Physical attractiveness stimulate expectation toward
one another
2. Attractiveness elicit social exchanges from others
3. Developmental outcome result from social exchanges,
consequences of reactions internalise differing social
images, self expectations, and inter personal styles
4. Greater experience with positive social interactions,
attractive people manifest confident interpersonal
behaviour
*Adams GR. Physical attractiveness, personality, and social reactions to
peer pressure. The Journal of psychology. 1977 Jul 1;96(2):287-96.
• Sincerity, intelligence, conscientiousness and good looks
were attributed to more correctly aligned teeth*
• Malocclusions are highly visible – interfere with
social interaction and acceptance
• Crooked teeth and skeletal disharmony – “cause teasing
of general playground harassment among
children and are associated with lower social
attractiveness**”

*Secord PF, Jourard SM. The appraisal of body-cathexis: body-cathexis and the
self. Journal of consulting psychology. 1953 Oct;17(5):343. used to persons with
more aligned teeth
** Phillips C, Bennett ME, Broder HL. Dentofacial disharmony: psychological
status of patients seeking treatment consultation. The Angle Orthodontist.
1998 Dec;68(6):547-56.
PSYCHOLOGICAL OUTCOME OF ORTHODONTIC TREATMENT
• Dann et al – children with serious malocclusions do not have
poor self concept or body images*
• Did not improve after orthodontic treatment
• Albino JE on contrary said children who received
orthodontic treatment felt better about their facial
appearance**
• Why the discrepancy?
Depends on the patients attitude before the treatment

*Dann IV C, Phillips C, Broder HL, Tulloch JC. Self-concept, Class II

malocclusion, and early treatment. The Angle orthodontist. 1995 Dec;65(6):411-
6.
**Albino JE, Lawrence SD, Tedesco LA. Psychological and social effects of
orthodontic treatment. Journal of behavioural medicine. 1994 Feb 1;17(1):81-98.
DEVELOPMENTAL PSYCHOLOGY OF ORTHODONTICS
• Shaw et al* – evaluated the risk/benefit for treatment
and outcome – 3 subgroups
1. Nicknames and teasing
2. Evaluated dental appearance and social attractiveness
3. Self esteem and popularity
• Conclusion – personal dissatisfaction with dental appearance
in adolescence persists till adulthood

* Shaw WC, O'brien KD, Richmond S, Brook P. Quality control in

orthodontics:
risk/benefit considerations. British dental journal. 1991 Jan 5;170(1):33.
Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic
treatment. American Journal of Orthodontics and Dentofacial Orthopedics.
1998 Jan 31;113(1):29-39.
 PATIENT COMPLIANCE
• Egolf and others*– compliant patient as one who practices
good oral hygiene, wears appliances as instructed without
abusing them, follows an appropriate diet and keeps
appointments.
• Success depends on patient compliance
• Compliance by patient helps achieve treatment objectives in
a
minimum treatment time
• Improved cooperation – reduces expenses
*Egolf RJ, BeGole EA, Upshaw HS. Factors associated with orthodontic
patient compliance with intraoral elastic and headgear wear. American Journal
of Orthodontics and Dentofacial Orthopedics. 1990 Apr 1;97(4):336-48.
• ADULTS
 care of their own
 have financial commitment
 have outcomes in mind
 Generally, not always
compliant
• ADOLESCENCE
 majority because of parents
 no financial commitment
 no specific outcomes
 Compliance can be difficult
UNDERSTANDING THE ADOLESCENT PATIENT
• Period between childhood and adulthood
• Their most important concern is appearance
• Capable of thinking hypothetical, applying logic and abstract
concepts
• Cognitive abilities can break down in emotional situations→
impulsive actions without considering the alternative
• Change of appearance – anxiety and self confidence
• Psychosocial changes shape their sense of self*
• Adolescent feels pressure to confront to norms and do so by
comparing themselves with others
• Peer group play a role in identity development
• * Petersen AC, Kuipers KS. Understanding adolescence: Adolescent development
and implications for the adolescent as a patient. Craniofacial growth
series. 1997;33:1-24.
MOTIVATING THE ADOLESCENT PATIENT
• Cooper and Shapiro* : Features of adolescent behaviour used
to ascertain certain behaviour are
1. Concerned with self image and identity → used for
motivation
2. Independence and autonomy → adult like status motivate them
3. Peer relationships are important → motivate behaviours that
meet social needs
• To accomplish motivation
4. Individualising patient
5. Recognising values and issues
6. Understand that they are not influenced by health specific goals
*Cooper ML, Shapiro CM. Motivations for health behaviours among
adolescents. Craniofacial growth series. 1997;33:25-46.
• Adverse effects of poor facial aesthetics, motivating a
patient to seek ortho treatment divided into:
1. Low esteem and maladjustment – motivation depends on
extend of deviation from social norms

2. Restriction of social activities – affect perception of

social characteristics like –
• Perceived friendliness
• Popularity among peers
• Academic performance
3. Adverse occupational outcome
PSYCHOLOGIC FACTORS MOTIVATING PT TO
SEEK ORTHO TREATMENT
• Motivation is dynamic and reciprocal interaction of triad
of three factors -
1. Personal factors
2. Behavioural factors
3. Environmental factors
• Degree of influence on patient motivation and
ortho treatment is governed by -
4. Age – different for adult and adolescent
5. Gender
6. Socioeconomic set up
 PATIENT PERCEPTION
• PERCEPTION OF ATTRACTIVE PREFERENCE UNDER
THE INFLUENCE FACTORS
1. Self and parenteral perception of malocclusion

• depend on parent → transferred to child

• Baldwin and Barner* – mother deciding member
 Attempts to resolve their own problems
 Feeling of guilt – hereditary
 As social status symbol
 Divorced mother – ortho treatment as a “psychic gift” in
compensation for deprived father
*Baldwin DC. Appearance and aesthetics in oral health. Community
dentistry and oral epidemiology. 1980 Aug 1;8(5):244-56.
2. Peer pressure - Braces – badge of honour, high socio economic
status – as symbol of prosperity
3. Severity of malocclusion
4. Self esteem
conscious of own appearance 2 aspects of dentofacial
(pleasing one) defects

↓IF NOT Individuals

attitude
Anxiety about himself towards Response of
defect others to disability
↓ if unresolved
Mental illness*
*Silverman S, Silverman SI, Silverman B, Garfinkel L. Self-image and its relation
to denture acceptance. The Journal of prosthetic dentistry. 1976 Feb 1;35(2):131-41.
• Secord and Backman* – psychological impact depends on
own reaction
• GENDER – sex stereotyping – girls ►boys
MOTIVATIONAL FACTORS IN ADULTS
1. Improve facial attractiveness
2. As referral from general dentist
3. Part of orthognathic surgery

*Secord PF, Backman CW. An interpersonal approach to personality. Progress in

experimental personality research. 1965;2:91-125.
 PERSONALITY TESTING Cucalon and smith
252 adolescent ortho pt,
1. Millon Adolescent Personality 11-17yrs
Inventory (MAPI) (Millon, Green
and Meagher, 1982) - to predict After 1 yr. of treatment – pt
compliance as GOOD,
behaviour of adolescent patient in FAIR OR POOR
orthodontic practice
2. Comprehensive personal
assessment system : self 3 questionaires given
report inventory Females more compliant
than men
3. The Adolescent Alienation No difference in age or race
Index Low esteem – low
compliance
4. The Home Index

Cucalon III A, Smith RJ. Relationship between compliance by

adolescent orthodontic patients and performance on psychological tests.
The Angle orthodontist. 1990 Jun;60(2):107-14.
ORTHODONTIST AND PATIENT COMMUNICATION
• Nanda and Kierl* : factors that affect patient compliance
1. Parent – child relationship
2. Psychosocial characteristics of parent and patient
3. Attitude toward opinions about ortho – parent and patient
4. Perceptions of child's degree of social compromise – parent and
child
5. Patient demographics
6. Parents and child's relationship with orthodontics
• Orthodontists behaviour influence:
7. Patient satisfaction
8. Cooperation
9. The orthodontist – pt relationship
*Nanda RS, Kierl MJ. Prediction of cooperation in orthodontic treatment. American
Journal of Orthodontics and Dentofacial Orthopedics. 1992 Jul 1;102(1):15-21.
• Sinha Nanda and Mc Neil * – concluded that the
orthodontist behaviour influences patient satisfaction, the
orthodontist patient relationship, and patient cooperation in
orthodontic treatment.
• Barsch et al** - doctor patient interaction is the best
predictor on how well a patient could be expected to comply
with the doctors instructions
• Good cooperation is by establishing good rapport with the
patient
*Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that
predict patient satisfaction, orthodontist-patient relationship, and patient
adherence in orthodontic treatment. American journal of orthodontics
and dentofacial orthopedics. 1996 Oct 1;110(4):370-7.
**Bartsch A, Witt E, Sahm G, Schneider S. Correlates of objective patient
compliance with removable appliance wear. American Journal of
Orthodontics and Dentofacial Orthopedics. 1993 Oct 1;104(4):378-86.
 EDUCATIONAL PSYCHOLOGY
• Experiential learning theory
• Learning styles inventory – Kolb
• 135 ortho pt to 4 learning styles
 Accommodator
 Diverger
 Assimilator
 Converger
• Divided to 2 dimensions
1. Prehension –
internalise information
2. Transformation –
change to
useful knowledge
Kolb DA. Experiential
learning: Experience as the
source of learning and
ACHIEVING PATIENT COMPLIANCE
1. Orthodontist - Information to educate about
malocclusion
2. Motivate by being straight forward and open
3. Patient need support from family and peer
4. Should not coerce compliance through brute force
5. Appreciate patient perspective
PATIENTS WITH PSYCHOLOGICAL DISORDERS
• Different and unanticipated behaviours are challenging
• Many patients re functioning within society with pre
existing psychological disorders
• An orthodontist should be able to assess the psychological status
of the patients
• Common psychological conditions are
1. ADHD attention deficit hyperactivity disorder
2. Obsessive compulsive disorder
3. Bipolar disorder
4. Body dysmorphic disorder
5. Depression
6. Panic disorder
ATTENTION DEFICIT HYPERACTIVITY DISORDER
• Inattention, impulsivity and hyperactivity
•Child trends of national health interview in
2013* 8.8% (3-17yr), 12% boys, 4% adults
ETIOLOGY – prenatal brain injury, hypoxia, trauma, food
allergies (aggravate)
MEDICATION
• Behavioural therapy
• Give short appointments
• Short clear instructions to be given
• Frequent prophylaxis
Castle L, Aubert RE, Verbrugge RR, Khalid M, Epstein RS. Trends in
medication treatment for ADHD. Journal of attention disorders. 2007
May;10(4):335-42.
OBSESSIVE COMPULSIVE DISORDER
• Intrusive thoughts and repetitive, compulsive behaviours
• 1-4% affected associated with eating disorders, autism, or
anxiety disorders*
ETIOLOGY – genetic
TREATMENT
• MILDER – cognitive behavioural therapy (CBT) – fear of
stimulus ► increased frequency and intensity
• SEVERE – selective serotonin reuptake inhibitors
(SSRIs), clomipramine (Anafranil), fluoxetine (Prozac),
Sertraline (Zoloft)
*Zohar AH. The epidemiology of obsessive-compulsive disorder in children and
adolescents. Child and adolescent psychiatric clinics of North America. 1999 Jul.
BODY DISMORPHIC DISORDER
• Intensely negative emotional response to a minimal or non
existent defect in the patients appearance
• Pt have obsessive concern on dentofacial appearance
• Multiple consultation about the perceived defect
• Emotional volatility

• 1% affected along with +OCD +depression

• Treatment – SSRI, CBT
• Physical improvement does NOT signify
psychological improvement
BIPOLAR DISORDER
• Manic depressive disorder
• 2 phases – depression and mania
• 1.6% - life time prevalence
• Onset – 15-24years
PATHOGENESIS – neurochemical abnormalities with an etiology +
genetics (25% risk of children getting affected)
TREATMENT – lithium, valporate, Carbamzepine
Antidepressants trigger mania – not given
FOR ORTHODONTICS – manifest as
• Poor oral hygiene
• Lack of compliance
• Apathy towards treatment
PANIC DISORDER
Diagnosed when patients experience sudden, recurrent
panic attacks consisting of heart palpitations, dizziness,
difficulty breathing, chest pains, and sweating that are
unrelated to any external event and are not due to any
medical condition
2% males and 5% females affected
ETIOLOGY – heritability 48%
Mutation in 13q with an organic defect in hippocampus and
amygdala, that portion of midbrain responsible for emotion and
memory with input from visual, auditory and somatosensory
systems
Amygdala misinterprets sensations → extreme reactions
TREATMENT – medication with CBT, SSRI
DEPRESSION
• Symptoms last for atleast 2 weeks
• Pervasive low mood
• Loss of interest in usual activities
• Weight gain or loss
• change in sleep pattern
• Loss of energy
• Persistent fatigue
• Current thoughts of death
• Diminished ability to enjoy life
• Normal depression – pt still can communicate and make their own
decisions and participate in their own care
• and pathologic depression – out of proportion to the
circumstances
ETIOLOGY - lack of stimulation of post synaptic neurons
in brain ↑in MAO (mono amine oxidase)≈↓ serotonin and
monoamines
TREATMENT
• Electroconvulsive therapy
• Hypnotherapy
• Meditation
• Diet therapy
• SSRI – Sertraline (Zoloft), Fluoxentine (Prozac), citalopram
(Celexa), Paroxetine (Paxil), MAO inhibitors, dopamine
reuptake inhibitors – Bupropion (Wellbutrin and Zyban)
• Non drug therapies – CBT, supportive therapy, Family therapy
ORTHODONTIST –
• should be attentive to patients who have dropped out
of their normal habits
• Report insomnia
• Abrupt deterioration in academics
• Signs of drug or alcohol abuse
• Change in their appearance
• Lack of interest in activities
EATING DISORDER
• Include anorexia nervosa or bulimia nervosa
• 2% females affected
• Fundamental defect lies in the distorted body image that leads
patients to control their weight by extreme dieting and vomiting
Oral manifestation –
• Dental erosions
• Extruding amalgams
• Dentinal hypersensitivity
• Salivary gland atrophy
• Chelosis
• TREATMENT – CBT – so that pt develop realistic ideas about
how much they should eat, about nutrition and their body
image, SSRI
PERSONALITY DISORDERS
• Classified as axis II disorders – disorders that involve
maladaptive behaviour and patterns of thinking that lead
to problems at home, school and work
• PD seen as
1. Narcissistic personality
2. Borderline personality
3. Antisocial personality
• Prevalence – 4.4% to 13%
• ETIOLOGY – environmental influences like prior abuse, poor
family support, family disruption, peer influences, and
biological causes
Narcissistic personality
• Believes they are special so entitled to special treatment
• Brittle self esteem
• Strong need for approval – manifested as arrogance
and demands special attention
• Patients are intolerant to minor complications and likely to
seek legal recourse

Borderline personality
• Prevalence 0.7% to 2%
• Erratic moods, impulsive and poorly controlled anger
• Begin treatment with extremely positive view point, but
changes to hatred and anger in response to complications
Antisocial personality
• Males: female – 5:1 ratio affected
• prevalence 2-3%
• Lying, theft, destructive behaviour, aggression to animals
and people, accompanied by lack of remorse
• Difficult to manage in an orthodontic office
• Handle these patient with even-handedness, not allowing
to disrupt the office procedure or abuse office personnel.
• Orthodontists should be beware of excessive dependent and
manipulative behaviour which can cause conflict among
office personnel
“DIFFICULT PATIENTS”
• According to Groves “difficult patients are typically
those who raise ‘difficult’ feelings within clinicians.
• 4 types
1. Dependent clingers
2. Entitled demanders
3. Manipulative help rejecters
4. Self destructive deniers
Dependent clingers
• Have needs for reassurance from their care givers that escalate
• Dependent on doctors
• Must be give appropriate limits with realistic expectations
• Clear verbal and written instructions to be given for reinforcing
the limits of the patient access to professional staff
Entitled demanders
• Needy but manifest it as intimidation and attempts to induce guilt
• Need to control situation and often make threats to get what
they want
• Aggressive behaviour due to dependency and fear of
abandonment
• Limits must be placed on the patient
Manipulative help rejecters
• Focus on their symptoms but are resigned toward failure
• Seem satisfied with lack of improvement
• Difficult to treat – must involve in all decision makings
and should have regular appointments
Self destructive deniers
• Take pleasure in defeating any attempts to help them
• Do not want to improve
• Sufficiently depressed to consider not rendering or
limiting treatment
ORTHODONTIST
• Should remain friendly, unemotional, professional all the
times
• Emotional outbursts should be responded to with
an acknowledgement of feelings but an expectation
of appropriate behaviour
• Non compliance must be countered with an
appropriate alternative treatment plan
• Must avoid being provoked and remain professional
and emotionally neutral while maintaining a correct
office atmosphere
PATIENTS HAVING ORTHOGNATHIC SURGERY
PSYCHOLOGICAL STATUS AND MOTIVATION
Ryan et al – 18 pts (18-40yrs)- impact of motivation
• Deformity affected in both practical and psychological aspect
• Low self esteem and embarrassment
• Coped by – avoiding social situations or continuing normal
activities while modifying their behaviour to minimise impact of
condition
Lee et al – effect on pts quality of life – 76pts - control group-
asymptomatic
1. Generic health third related
molar removal
– no – 3 questionnaire
difference significant difference
2. Generic oral health related
•3. Ryan
Condition specific quality of life
FS, Barnard M, Cunningham SJ. Impact of dentofacial deformity and motivation for treatment: a
qualitative study. American Journal of Orthodontics and Dentofacial Orthopedics. 2012 Jun 1;141(6):734-42.
• Lee S, McGrath C, Samman N. Quality of life in patients with dentofacial deformity: a comparison of
measurement approaches. International journal of oral and maxillofacial surgery. 2007 Jun 1;36(6):488-92.
De Avila et al* – 50pts – to determine if exhibited depression than
non surgical cases
• Modified QOL(quality of life) – (36q) how physical health influenced
patient life
• Beck Depression Inventory (21q) – how often something bothered the
patient
• 19 pts had depression
Yu et al**- - motivation of orthognathic surgery in Chinese patients – 210
pts – QOL questionnaire with oral health and self esteem measure
• Control – 219 who were not undergoing surgery
• Facial appearance improvement – #1 reason
• Men - #2 occlusion, #3 self confidence
• Women - #2 self confidence, #3 occlusion
**Yu D, Wang F, Wang X, Fang B, Shen SG. Presurgical motivations, self-esteem, and oral health
of orthognathic surgery patients. Journal of Craniofacial Surgery. 2013 May 1;24(3):743-7.
*de Ávila ÉD, de Molon RS, Loffredo LC, Massucato EM, Hochuli-Vieira E. Health-related quality
of life and depression in patients with dentofacial deformity. Oral and maxillofacial surgery. 2013 Sep
1;17(3):187-91.
EXPECTATIONS
• 4 categories*
1. Metamorphosizers – expectation of both physical and
psychological problems fully corrected by surgery. Likely to
be dissatisfied
2. Pragmatists – physical but no psychological change.
Lower satisfaction, as change may not be up to what
expected
3. Shedders – little physical change but profound
psychological
change, careful counselling to check true motivations
4. Evolvers – low expectation for both, dissatisfaction as
• More physical change than what the pt was ready for
• Postoperative course difficult o manage without
positive expectations for the patient
*Ritchie J, Lewis J, Nicholls CM, Ormston R, editors. Qualitative research practice: A
guide for social science students and researchers. Sage; 2013 Nov 1.
Bullen et al *– method of examining expectation – 85 pt –
pt profile altered with incremental movement of lips to form
13 photo sequence.
• Questionnaire

• 1 pt were asked how satisfied they were

• Asked to chose a profile that matched theirs – to compare
the real life and perceived profiles
• Younger pt – thought lips were more retruded than actual
• Older pt – more protrusive than actual
*Bullen RN, Kook YA, Kim K, Park JH. Self-perception of the facial profile: an aid in treatment
planning for orthognathic surgery. Journal of Oral and Maxillofacial Surgery. 2014 Apr 1;72(4):773-8.
SATISFACTION
Kiyat et al* – 74 orthognathic surgery patients (before surgery to 24
months post operatively)
• 1 and 4 mon – less pain, numbness, higher self esteem, more satisfied
• 9mon – see result as permanent
• 24months – satisfaction at highest level
Findlay et al* – 61 pts if surgery had influence on self esteem
• Questionnaire – extraversion/introversion status, general health,
feelings toward their bodies – 87% satisfied
Cunningham et al ***-83 pre op, 100 post op, determine self esteem and
level of post op satisfaction
• 95% satisfied
*Kiyak HA, West RA, Hohl T, McNeill RW. The psychological impact of orthognathic surgery: a 9-month follow-
up. American journal of orthodontics. 1982 May 1;81(5):404-12.
**Finlay PM, Moos SF, Atkinson JM. Orthognathic surgery: patient expectations; psychological profile and
satisfaction with outcome. British journal of oral and maxillofacial surgery. 1995 Feb 1;33(1):9-14.
***Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following orthognathic surgery.
British Journal of Oral and Maxillofacial Surgery. 1996 Jun 1;34(3):210-3.
 SUMMARY
Every patient had individual perceptions, desires, needs
and related behaviour
Clear communication is critical when discussing orthodontic
problems, proposed treatment and treatment alternatives
and expectations
Clinician must b familiar with the pt. medical ,
psychological history, needs, questions and perceptions
Patient must b given clear guidelines for office procedures
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