psychological aspects of orthodontics

7/29/2019 Psychological Aspects of Orthodontics

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Click to edit Master subtitle style3/24/13

Psychological aspects

of Orthodontics

Dr.M.Saud


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Every patient is different & each patient respondsdifferently to Ortho.

Good communication b/w orthodontist & Pt is

essential in achieving treatment goals also

important for encouraging co-operation, Ptsatisfaction & Medico-logical purposes.

Research has shown that the PTs dont always

understand or remember what they have toldabout their malocclusion or Ortho treatment.


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Patient perceptions

There are several research approaches that can givesome insight of as to how Pts see malocclusion & helporthodontist to assess how their Pt will likely to react.

Show patient profile alter one aspect in successive

photo/silhuettes ask patient which profile is mostlikely theirs?

Perceptometric technique developed by Gidden etal enables the clinicians to determine the range ofwhat patient consider accepted.


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Studies regarding patient perceptions on Facialesthetics.

Kitay et al Ortho Pt are less tolerantofvariations in their profiles than are non-orthodontic 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>oralsur eon>si nificant


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Hier at al compared the preferences of lipposition in ortho patient & untreated subjects.

Result:- untreated subjects prefer fuller lips.

Miner er al compared self perception ofpediatric pateint & perception of their mother &their orthodontist.

Result:-both patient and mother over estimate

the protrusiness

of child.

:- both prefer a more protrusive profile

:- Mothers had smallest tolerance for change in


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Mejia-maidl et al Mexican- American prefer lessprotrusive lips than whites.

Park et al Korean Americans prefer a moreprotrusive nose for females and retrusive chin formales.


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Attention-dificit/Hyperactivity Disorder

C/F:- inattention, impulsivity , hypereactivity.

Incidence:- 4%

Etiology:- precise etiology is unknown- considerto be genetic (more likely a combination of genes

is responsible) prenatal brain injury i.e. due to hypoxia ortrauma.

food allergies & food additives are possible

aggrevating factors.


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Orthodontic management

Give short, clear & written instructions orreminders.

Reward therapy for successful compliance

Dental prophylaxis/improved oral hygiene.

Avoid Rx plans that require high degree of patientcompliances.

Breaks during prolonged procedures.


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Obsessive-Compulsive Disorder

C/F:- intrusive thoughts & repetitive, compulsivebehavior.

:- often associated & eating disorders , autism

and anxiety.

INCIDENCE:- 1-4% of population


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Etiology:-

Consider genetic, however specific genes are notidentified.

Clinical variability suggests a heterogeneous etiologyand the possibility of gene -to- gene and gene-toenvironmental interaction.

TREATMENT:- Milder case:=> cognitive behaviortherapy.

severe case SSRIs

S/E xerostomia


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Body Dysmorphic Disorders

C/F:- an intensively negative response to aminimal or non-existing defect in patientappearance- excessive concern about theirappearance.

multiple consultation-emotional volatility

related stress disorders and become sociallyisolated.

may co-exist with other disorders i-edepression and OCD


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Incidence:- approx. 1% of population

Diagnosis is difficult and misleading

Treatment :-

SSRIs+CBT using photographic images of pts ownface as a reality check :- reconstruct pt faulty beliefsregarding defect.

to reduce social avoidance & repititive behaviour

Dissatisfied Pts may become violant towardsthemselves or attempt sucide.


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Orthodontic management

Set the limits of therapeutic intervention

Pt should be given realistic option with definiteend points.

Written consent regarding Rx options, final Rxplan , along with possible obstacles to idealresults

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 andmania. That interface along with normal life

Prevalence:- life time prevalence is 1.6% withmajority 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 ordepression.

Drugs can provide xerostomia


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Panic attacks

C/F:- sudden recurrent attacks consisting of heartpalpitation dizziness, chest pain, difficulty inbreathing and sweating

Unrelated to any external event or medicalcondition.

Concurrent depression patient are socially orvocationally impaired.

INCIDENCE; 2% male and 5% female are affectedin their young adult life


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Etiology

Genetic susceptibility combined along withenvironmental stresses heritability is estimatedto be 48%

Mutation in 13q, with an organic defect inamygdale 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 withcheilosis


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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 andtheir own body image SSRI,s can also help.


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Normal or situation depression naturalresponse to trauma or illness

Clinical depression:-

related to underlying endogenous factor

Pathologic depression:-

symptoms that are out of proportion of the

circumstances


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Depression

Most common psychiatric problem affecting anestimated 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:- lowmood, 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 toenjoy life


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Etiology :

Lack of stimulation of post synaptic neurons inthe brain.

Increase MAO-A decreases serotonin and othermonoamine concentration.

There may be genetic component.


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Management :

Orthodontist must be particularly attentive tothese patients

Drugs :- SSRI, MAO inhibitors, Dopamine reuptakeinhibitors.

Psychotherapy.

Electroconvulsive therapy.

Hypnotherapy, meditation.

Diet therapy.

Hospitalization if suicide is a possibility.

CBT.


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Supportive therapy patient may discuss theirproblems with others who can share strategiesfor coping with their illness.

Family therapy entire family learns how to undopatterns 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 maladaptivebehavior and pattern of thinking leads toproblems at home, office and schools.

Prevelance:

4.4-13% in USA.

Etiology:

Environmental causes prior abuse , poor familysupport, family disruption and peer influences.

Biological causes .


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Narcissistic personality :

Patient believe that he/she is special andtherefore entitled to special treatment.

Brittle, self-esteem and strong need for approval.

more intolerance to minor complications seeklegal recourse.


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Border-line personality disorders :

Erratic moods, impulsivity andpoorly controlled anger.

Unstable relationship andchronic interpersonalproblems.

Begin treatment with anextremely positive view of theorthodontist but withtreatment quickly changes tohatred and anger in responseto complications.


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Anti-social personality disorder

Male to Female ratio

4 or5 : 1

Prevalence

2-3%

q Exhibits unacceptablebehavior that is lying, theft,destructive behavior andaggression to people andanimals.


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Management :

Very difficult to manage.

Staff members need to handle these patientswith even handedness.

If necessary discontinue treatment and dismisspatient.


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Difficult Patients :

According to Graves,categorized into 4 types :

1. Dependant clingers :

. Have need for reassurancefrom their caregivers.

. Initially responsible in theirneeds. Progressively becometotally dependant of doctor.


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They must be given appropriate limitswith realistic expectations.

Clear verbal and written instructionshelpful in reinforcing the limits of patientaccess to the professional staff.


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2. Entitled Demanders:

Needy but manifest it as intimidation ( tofrighten, by threatening violence) and attemptsto induce guilty.

Often makes threats in order to get what theywant.

Best dealt with by validating anger but

redirecting the feeling of entitlement to realisticexpectations of good care

Limits must be placed so office procedure are notdisturbed.


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3. Manipulative help rejectors :

focus on their symptoms but are resignedtowards failure.

They seem satisfied with the lack ofimprovement.

Must be involved in all decisions and should haveregular appointments.

They must agree to the treatment or not toprocess, so orthodontists must not take anyresponsibility of failure or success of treatment.


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4. self destructive deniers:

Take pleasure in defeating in any attempt to helpthem.

May be sufficiently depressed enough to considernot rendering or limiting treatment.


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Patient with craniofacial deformities

Studies have shown that these patients are moreanxious, more introverted have a poorer selfconcept, inhibited personality disorder, low selfesteem , impaired peer relationship and greater

dependence on significant adults. Also they have greater dissatisfaction with their

facial appearance , a significant lower selfesteem and lower quality of life.

Many of them felt that they are discriminated dueto facial deformity.


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Pertschuk & whitaker compared a group of 43patients with craniofacial anomalies with normalchildren (age 6-13 years).

Results :

craniofacial patient were more anxiousintroverted in power and poorer self concept, theydont know what to change with treatment.

16 to 18 months after surgery decrease inanxiety but more negative social interactions.


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Pillemer & cook evaluated 25 patients (age 6-16 years) 1 year after craniofacial surgery.

Results :

children still exhibit an inhibited personalitystyle, no self esteem , impaired peer relationshipand greater dependence on significant adults.


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Sarwer et al examined 24 patients (adults) withcraniofacial anomalies.

Results :

greater dissatisfaction with their facialappearance, significant lower self esteem andsignificant 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 individualshave about themselves.

It includes general and specific judgment aboutones self worth, a personal evaluation of onescapabilities and internalization of others reactionsto ones self and behaviors.

psychological aspects of orthodontics

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