Psychological aspects of Orthodontics

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Dr.M.Saud Click to edit Master subtitle style

Every patient is different & each patient responds differently to Ortho. Good communication b/w orthodontist & Pt is essential in achieving treatment goalsalso important for encouraging co-operation, Pt satisfaction & Medico-logical purposes. Research has shown that the PTs dont always understand or remember what they have told about their malocclusion or Ortho treatment.

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Patient perceptions

There are several research approaches that can give some insight of as to how Pts see malocclusion & help orthodontist to assess how their Pt will likely to react. Show patient profile alter one aspect in successive photo/silhuettes ask patient which profile is most likely theirs? Perceptometric technique developed by Gidden et al enables the clinicians to determine the range of what patient consider accepted.

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Studies regarding patient perceptions on Facial esthetics. Kitay et al Ortho Pt are less tolerant of variations in their profiles than are nonorthodontic Pt. Arpino et al compared zone of acceptability(ZA) of profiles selected for orthognathic surgery Pts, their significant others oral surgeon & orthodontist.

result :- ZA was smallest for pt>oral 3/24/13 surgeon>significant

Hier at al compared the preferences of lip position in ortho patient & untreated subjects. Result:- untreated subjects prefer fuller lips. Miner er al compared self perception of pediatric pateint & perception of their mother & their orthodontist.

Result:-both patient and mother over estimate the protrusiness of child. :- both prefer a more protrusive profile
3/24/13 :- Mothers had smallest tolerance for change in

Mejia-maidl et al Mexican- American prefer less protrusive lips than whites. Park et al Korean Americans prefer a more protrusive nose for females and retrusive chin for males.

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Attention-dificit/Hyperactivity Disorder

C/F:- inattention, impulsivity , hypereactivity. Incidence:- <18years 5% while in adults >4% Etiology:- precise etiology is unknown- consider to be genetic (more likely a combination of genes is responsible)

prenatal brain injury i.e. due to hypoxia or trauma. food allergies & food additives are possible 3/24/13 aggrevating factors.

Orthodontic related problems

Trouble sitting still during procedures Poor oral hygiene and poor compliance ( wearing elastics)

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Orthodontic management

Give short, clear & written instructions or reminders. Reward therapy for successful compliance Dental prophylaxis/improved oral hygiene. Avoid Rx plans that require high degree of patient compliances. Breaks during prolonged procedures.

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Obsessive-Compulsive Disorder

C/F:- intrusive thoughts & repetitive, compulsive behavior. :- often associated & eating disorders , autism and anxiety.

INCIDENCE:- 1-4% of population

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Etiology:

Consider genetic, however specific genes are not identified.

Clinical variability suggests a heterogeneous etiology and the possibility of gene -to- gene and gene-to environmental interaction.

TREATMENT:- Milder case:=> cognitive behavior therapy. severe case SSRIs S/E xerostomia
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Body Dysmorphic Disorders

C/F:- an intensively negative response to a minimal or non-existing defect in patient appearance- excessive concern about their appearance. multiple consultation-emotional volatility related stress disorders and become socially isolated. may co-exist with other disorders i-e depression and OCD

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Incidence:- approx. 1% of population Diagnosis is difficult and misleading Treatment :

SSRIs+CBT using photographic images of pts own face as a reality check :- reconstruct pt faulty beliefs regarding defect. to reduce social avoidance & repititive behaviour Dissatisfied Pts may become violant towards themselves or attempt sucide.
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Orthodontic management

Set the limits of therapeutic intervention Pt should be given realistic option with definite end points. Written consent regarding Rx options, final Rx plan , along with possible obstacles to ideal results Rx should be stopped or Pt refered other health profession in case of uncooperation.

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Bipolar disorders

C/F:- consist of two phasesdepression and mania. That interface along with normal life Prevalence:- life time prevalence is 1.6% with majority between 15-24 years can be associated with other disorders 50% of patient abuse illegal substances 25-50% attempt suicide 10-15 % successful
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Pathogenesis Partially genetic # one parent affected 25% chance # both parents affected 50-75% # identical twins 70% Neuro chemical abnormalities

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TREATMENT:- mood stabilizers;lithium valproate carbamazepine Drugs that calm agitation. chlorpromazine olazepine

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Ortho related problems Poor hygiene & poor compliance General apathy toward Rx

Ortho-management:

difficult to manage during period of mania or depression. Drugs can provide xerostomia

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Panic attacks

C/F:- sudden recurrent attacks consisting of heart palpitation dizziness, chest pain, difficulty in breathing and sweating Unrelated to any external event or medical condition. Concurrent depression patient are socially or vocationally impaired. INCIDENCE; 2% male and 5% female are affected in their young adult life
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Etiology Genetic susceptibility combined along with environmental stresses heritability is estimated to be 48% Mutation in 13q, with an organic defect in amygdale and hippocampus. TREATMENT:- medication alone or in combination with CBT

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Eating disorders

Includes anorexia nervosa or bulimia nervosa Affects up to 2% of adolescent/ young females Patient has distorted body image so they control their weight by extreme dieting or vomiting severe metabolic disturbance death. Oral manifestations bulimia dental erosions, dental hypersensitivity, slivery glands hypertrophy- both may be associated along with cheilosis

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TREATMENT:-

Should be addressed directly CBT patient can develop realistic ideas how much they should eat what is a good nutrition and their own body image SSRI,s can also help.

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Normal or situation depression natural response to trauma or illness Clinical depression:Pathologic depression:-

related to underlying endogenous factor

symptoms that are out of proportion of the circumstances

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Depression

Most common psychiatric problem affecting an estimated 20% of population course variable may affect a patient once or reoccur: can appear gradually or suddenly:may last for months or life time high risk of suicide : high mortality rate i.e. accident, trauma.

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C/F: symptom lasting for at least 2 weeks:- low mood, loss of interest in usual activities Significantly(5%) weight gain or loss Change in sleep patterns Loss of energy, persistent fatigue recurrent thoughts of death. Diminished ability to enjoy life

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Etiology :

Lack of stimulation of post synaptic neurons in the brain. Increase MAO-A decreases serotonin and other monoamine concentration. There may be genetic component.

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Management :

Orthodontist must be particularly attentive to these patients Drugs :- SSRI, MAO inhibitors, Dopamine reuptake inhibitors. Psychotherapy. Electroconvulsive therapy. Hypnotherapy, meditation. Diet therapy. Hospitalization if suicide is a possibility. CBT.
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Supportive therapy patient may discuss their problems with others who can share strategies for coping with their illness. Family therapy entire family learns how to undo patterns of destructive behavior.

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Axis 1 disorders depression, BDD , OCD predominantly related to mood. Axis 2 disorders personality disorders maladaptive behaviors and pattern of thinking

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Personality disorders :

Axis 2 disorders that involve maladaptive behavior and pattern of thinking leads to problems at home, office and schools. Prevelance: 4.4-13% in USA. Etiology: Environmental causes prior abuse , poor family support, family disruption and peer influences. Biological causes .
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Narcissistic personality :

Patient believe that he/she is special and therefore entitled to special treatment. Brittle, self-esteem and strong need for approval. more intolerance to minor complications seek legal recourse.

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Border-line personality disorders :

Erratic moods, impulsivity and poorly controlled anger. Unstable relationship and chronic interpersonal problems. Begin treatment with an extremely positive view of the orthodontist but with treatment quickly changes to hatred and anger in response to complications.
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Anti-social personality disorder

Male to Female ratio 4 or5 : 1 Prevalence 2-3% Exhibits unacceptable behavior that is lying, theft, destructive behavior and aggression to people and animals.
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Management :

Very difficult to manage. Staff members need to handle these patients with even handedness. If necessary discontinue treatment and dismiss patient.

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Difficult Patients :

According to Graves, categorized into 4 types :

1. .

Dependant clingers : Have need for reassurance from their caregivers. Initially responsible in their needs. Progressively become totally dependant of doctor.
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They must be given appropriate limits with realistic expectations. Clear verbal and written instructions helpful in reinforcing the limits of patient access to the professional staff.

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2. Entitled Demanders: Needy but manifest it as intimidation ( to frighten, by threatening violence) and attempts to induce guilty. Often makes threats in order to get what they want. Best dealt with by validating anger but redirecting the feeling of entitlement to realistic expectations of good care Limits must be placed so office procedure are not disturbed.
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3. Manipulative help rejectors : focus on their symptoms but are resigned towards failure. They seem satisfied with the lack of improvement. Must be involved in all decisions and should have regular appointments. They must agree to the treatment or not to process, so orthodontists must not take any responsibility of failure or success of treatment.
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4. self destructive deniers: Take pleasure in defeating in any attempt to help them. May be sufficiently depressed enough to consider not rendering or limiting treatment.

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Patient with craniofacial deformities

Studies have shown that these patients are more anxious, more introverted have a poorer self concept, inhibited personality disorder, low self esteem , impaired peer relationship and greater dependence on significant adults. Also they have greater dissatisfaction with their facial appearance , a significant lower self esteem and lower quality of life. Many of them felt that they are discriminated due to facial deformity.
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Pertschuk & whitaker compared a group of 43 patients with craniofacial anomalies with normal children (age 6-13 years). Results :

craniofacial patient were more anxious introverted in power and poorer self concept, they dont know what to change with treatment. 16 to 18 months after surgery decrease in anxiety but more negative social interactions.

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Pillemer & cook evaluated 25 patients (age 616 years) 1 year after craniofacial surgery. Results :

children still exhibit an inhibited personality style, no self esteem , impaired peer relationship and greater dependence on significant adults.

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Sarwer et al examined 24 patients (adults) with craniofacial anomalies. Results : greater dissatisfaction with their facial appearance, significant lower self esteem and significant lower quality of life. 38% reported that they felt discriminated against on other bases of their facial deformity.

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THANX

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Cleft lip & palate :

Kapp-simon Self concept a complex summary of the multiple perceptions individuals have about themselves. It includes general and specific judgment about ones self worth, a personal evaluation of ones capabilities and internalization of others reactions to ones self and behaviors.

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