Psychological treatment Jay




N. J.


timing of orthodontic









mproved cooperation from reluctant patients, so ardently coveted by all orthodontists, can be cultivated by various means. One simple method, coordination of clinical treatment with psychological readiness, has not been widely advocated. This article examines the proposition that prepubescent children are emotionally ripe for orthodontic therapy and, therefore, will carry out instructions more faithfully than adolescents. In order to test this hypothesis, a group of randomly selected orthodontists was surveyed. The questionnaires completed by the responders asked for a rating of patients’ behavior in several areas of treatment in which cooperation is crucial. In a previous article one of us has examined the theoretical psychological considerations which might account for a greater acceptance of treatment requirements by preadolescents than by teenagers.l To our knowledge, no previous study has investigated this possibility. The







While dental interest in motivational issues has quickened in recent years, efforts to address the cooperation problem in orthodontics remain scanty.2-4 Why should dentists in general and orthodontists in particular be hesitant to examine the behavioral implications of treatment problems? Perhaps the answer can be found in what Sherlock and Morris5 have described as a “common personality . . . in dentistry: cautious, orderly, persistent, conservative, and interested in the applied rather than the theoretical”-in short, the Freudian “anal character.” Crowdee summarized several studies of personality characteristics of dental students, reporting “The profession attracts a rather constricted type of individual and one who is rather compulsive, materialistically oriented, culturally restricted, and tradition-bound. Furthermore, there. is evidence that This



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MechalGcal means. If this trend discerned by Crowder toward diminished intellectual curiosity should continue during graduate training, orthodontists may tend even more than general dentists to seek mechanical solutions to psychological problems. Despairing of ever attaining adequate cooperation from his patients, Armstrong,7 for example, has discovered an engineering answer to what others might consider to be essentially a behavioral problem. Instead of convincing patients of the value of wearing headgear, he ties them in. Kelly8 entitled a presentation featuring this approach, “24 Hour Per Day Headgear, I Like It.” Armstrong feels that his patients like it, too. “Once the first visible progress is made (usually within 4 to 5 weeks), even the patient who exhibited strong initial resistance,” he says, “usually becomes an interested and motivated participant in treatment, for he can see for himself that his cooperation is producing results.” Whether this passive acquiescence in authoritarian manipulation can justly be described as “cooperation” is certainly a debatable point. It should be recalled that Korner and Reiderg found that a young patient’s ostensible agreement with similar tactics (in their study “hay rakes” were cemented in place) actually masked considerable latent resentment. One report of the Armstrong controlled force technique concedes that there is an important psychological component to the method. It relieves anxiety, the communication says, for the doctor.l’ Moclificatio?L or stimulation of behavior. Armstrong’s forthright approach, whatever its merits, stands in sharp distinction to traditional, usually haphazard, efforts by orthodontists to cajole their patients into cooperating. Most orthodontists would admit that they know less about and are less skillful in motivating their patients than in anything else they do. One way to remedy this deficiency might be to utilize operant conditioning methods which have already trained mute schizophrenics to speak and taught pigeons to operate torpedos.ll, I2 A technique which can accomplish that much might someday entice children into wearing rubber bands, brushing their teeth, and abandoning bubble gum. But that time has not yet arrived. No one has designed the proper schedule of reinforcement or the right system of rewards t.o shape the desired behavior. Preselection. A third method for obtaining an improved percentage of cooperative patients would be to preselect likely candidates and eliminate the unlikely ones in advance. Certain psychological tests have been proposed to this end, but they remain of dubious practical value.13 Even if they should ever be improved enough to be effective, the antidemocratic bias inherent in their use would make them unattractive to many practitioners. The partial method of preselection advocated here is much simpler and contains no such undesirable feature. To follow it, orthodontists would merely have to begin treatment on preadolescents whenever such a course was technically feasible. Young patients, our study suggests, will tend to be more cooperative in two key treatment areas than adolescents.

200 Some

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Am. J. Orthod. August 1977

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Tweed,14 among others, has advocated early commencement of orthodontic treatment for mechanical reasons that have nothing to do with psychology. He found serendipitously, however, that young people’s “cooperation in following instructions is, on the average, infinitely better” than that of “older patients entering the difficult age of adolescence.” Our agreement with this view is based on psychoanalytic theory. Briefly stated, the argument follows Freud’s concept of personality development. The early years of life, culminating in the Oedipal period at age 5, are inappropriate, psychologically, for orthodontic treatment or any other sustained endeavor, because internal conflicts arc so strong that they would interfere with a child’s willingness to cooperate. Of course, for most purposes, he is not dentally prepared for orthodntic treatment at this time anyway. At about the age of 12, however, when children are often quite ready physiologically for orthodontic therapy, the same Oedipal struggle is reawakened. This confrontation would again inhibit cooperation. Psychoanalytic theory suggests that between the ages of 5 and 12, the Oedipal conflict remains dormant. That is why a 6-year-old is interested in learning and ready for school. Similarly, the latency period, as the respite is known, ought to be a time when young patients would respond most favorably to the demands of orthodontic. care.‘” Some support for this contention can be found in the work of Campisi’” and Cavanaugh,l’ who studied cooperation at Loyola University by using a lie detector. They report that cooperation from all patients was poor, much less than the level anticipated by the staff or claimed by the patients. This was true even though patients in the Loyola clinic are subjectively preselected in an effort to weed out potential noncooperators. Cannon I8 did find that prepubescents were somewhat more cooperative than their older brothers and sisters. They “indicated a more favorable attitude for accepting social impediments” than older children. Objections

to ea’rly


Early treatment has been advocated previously by Tweed and others chiefly to simplify the mechanics of treatment. Despite Tweed’s enormous reputation and some obvious advantages to this approach, it has never achieved widespread acceptance. Certain objections to it have been raised. Practitioners have been urged to postpone headgear treatment, for example, until the onset of the adolescent growth spurt. But Haas lo has pointed out that the mixed-dentition period is a time of steady, if not spectacular, growth and that good results with cervical traction can routinely be anticipated in patients who have not yet reached the age of puberty. Sassouni’” advises that activators, too, should be employed during a time of maximum growth. This means that girls can be treated with it before the onset of puberty but that boys, who mature later, cannot. In the Bull technique, therapy cannot begin until the permanent second molars have fully erupted.21 Further, Begg”* is convinced that, as far as his technique is concerned, “conditions are more favorable for starting treatment at the onset of puberty instead of early in the mixed dentition.”

Psychological I. Members of age groups failing


Group Question

Elastics (a) Headgear(b) Removable (c) Appointments (a) Notice to cancel(b) On time(c) Oral hygiene3 Good patient (a) Accepts treatment(b) Breakage’ Appliance loss.5

No. excellent 21 19 13

Total Sample


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Per cent exceiIent






No. excellent

Total Sample

III Per cent excellent

46 28 15 120

58.69 61.85 86.66 44.16

7.1 1.9 1.8 10.3

142 54 36 157

54.22 35.18 50.00 65.64

17 8 8 22

30 18 16 38

56.66 44.44 50.00 51.89

58 61 64 69

50.00 77.91 53.10 72.46

.99 .99 .87 10.3

137 143 155 147

72.26 69.27 56.12 70.06

19 21 21 26

34 30 39 37

55.88 70.00 54.10 7mO


66 76

71.06 53.94

11.8 10.7

151 150

78.14 71.33

28 25

37 41

75.67 60.98










53 29 47 34

50 47

Each of these objections to early treatment has merit and deserves careful consideration, but each case should be judged individually. In making his diagnostic decision, the operator should ask himself if he is tailoring his treatment to fit his own needs or the demands of a particular technique instead of the needs of his patient. We agree with Tweed who cautioned orthodontists not to postpone treating young persons merely because they felt uncomfortable in dealing with them. Method

A questionnaire, based on a pretest in which eight orthodontists participated, was mailed to 100 practitioners randomly selected from the New Jersey section of the World Orthodontic Directory. Ten orthodontists responded in an acceptable manner. Each observer was asked to rate all patients seen on a single day with regard to various aspects of cooperation (Table I). Results

A total of 274 patients was rated on a l-through-5 scale in which 1 denoted excellent, 2 good, 3 fair, 4 poor, and 5 unsatisfactory. This pool was then grouped into three categories : I-prepubescent, up to 12 years; II-adolescent, 12 to 17 ; and III-17 and over. The number of responses varied from question to question, as observers did not score all subjects on every question. Patients in a fixedappliance phase of treatment, for example, could not be judged on willingness to wear removable devices. The answers were seen to cluster around the higher grades. Therefore, it wau decided simply to contrast score 1 (excellent) against all other categories. We do not know whether this possibly generous evaluation reflects an objective appraisal or stems from unwillingness on the observer’s part to deprecate his own powers of persuasion. We made the assumption that any tendency to view per-


Weiss and Eiser

Am. J. Orthod. August 1977

formance through rose-colored glasses would apply equally to all categories and would cancel itself out. A percentage was established in each age group of those perceived to be excellent cooperators. A chi-square test for significance was applied to the data, and the following results were obtained : Question 1. A. In the wearing of elastic bands, the three groups were perceived by the orthodontic observers to be virtually identical. The slightly higher percentage of Group I patients who wore rubber bands well was not statistically significant. B. Group I had a larger number of prepubescent patients deemed to be good wearers of extraoral appliances than the other groups. The difference was significant at the 5 per cent confidence level. C. Similarly, a true difference appeared between the groups with regard to wearing of other removable devices. The Group I patients were seen as excellent cooperators to a greater extent than other patients, a statistically significant difference at the 5 per cent level of confidence. Question 2. A. Adolescents were judged to keep their appointments well some 65 per cent of the time, adults were less reliable, and children much less SO. These differences were significant at the 5 per cent level. B. The same order of differences (adolescents best, adults next, and children last) also significant at the 5 per cent level, was observed with regard to giving sufficient notice of cancellation. C. A slightly higher percentage of children were perceived to arrive on time for their appointments, but the differences from the other groups was not significant. Question 3. About half of each group was thought to maintain excellent oral hygiene. There was no significant difference between the groups. Question 4. About 70 per cent of all patients were thought to tolerate the discomfort of orthodontic procedures well. There was no significant difference between groups. Question 5. Adolescents were seen as least likely to break appliances, adults as next most accident free, and children most likely to break appliances. The difference between groups was significant at the 5 per cent level of confidence. Question 6. According to our observers, roughly 80 per cent of all groups managed to hang onto removable appliances. There were no intergroup differences. Discussion

In two key areas, our hypothesis that young patients cooperate better than their elders was confirmed by the ten orthodontic observers. Children, according to these ratings, wear their extraoral devices and removable appliances better than older patients. The Loyola investigators speculated that headgear is worn reasonably well by children because it is so highly visible and thus subject to parental control. Children are at least as reliable as other groups of patients in the use of elastics, which, according to the Loyola polygraph records, is not very reliable at all. Our judges found the lowest age group least satisfactory in keeping appointments and in avoiding breakage of appliances.

Volunte Number

72 2







If the perception of our observers accurately reflects the true behavior of their patients, this study suggests that when headgear and activator treatment is indicated it should be started as early as possible. Our responders indicate that prepubescent patients are more willing to wear these devices than children who have begun to experience the stormy changes that accompany puberty. Not only does this approach harmonize with Tweed’s thinking, but it also dovetails with Harvold’s concept of activator therapy. Activators improve occlusion, HarvoldZ3 says, by adjusting the path of molar eruption. The best time for this intervention is during the mixed-dentition period, well before puberty. Summary

A questionnaire type of study was undertaken to test the hypothesis that prepubescent patients are more cooperative than adolescents. Older children were held to be psychologically resistant to the demands of orthodontic treatment bccause of their involvement in Oedipal conflicts, a normal but distracting aspect of “growing up.” Our observers found that patients under 12 were more cooperative than other age groups in the wearing of headgear and other removable devices. They were less cooperative in keeping appointments or in protecting appliances from breakage. The differences were significant at the 5 per cent level of confidence. If responders’ observations are an accurate index of true performance, the study suggests that, from a psychological standpoint, activator and headgear treatment should be begun sometime after age 6 and soon enough to be completed before the onset of puberty. Appreciation is expressed to the following orthodontists who participated in the survey: Jerome Alpart, Milton B. Asbell, Ronald R. Dalin, 5. D. Gosman, George Newman, F. James Obosky, Thomas A. Olivero, Carl M. Ostergaard, Helmer E. Pearson, and Donald ‘T. Rosenbloom. REFERENCES

1. Weiss, J. K.: L’Enfant, l’adolescent, et l’orthodontiste, Orthod. Fr. 41: 547554, measurements as a 2. Allan, T. K., and Hodgson, E. W.: The use of personality nant of patient cooperation in an orthodontic practice, AM. J. ORTHOD. 54: 1968. 3. Gabriel, H. F.: Motivation of the headgear patient, Angle Orthod. 38: 129-135, 4. Dongieux, G. L.: A study to determine if there is a relationship between treatment and patient attitude, unpublished MS thesis, Loyola University Dental School,

1970. determi433-439, 1968. success Chicago,


a dentist, Springfield, Ill., 1972, Charles C 5. Sherlock, B. J., and Morris, R. T.: Becoming Thomas Publisher. 6. Crowder, T. H., Jr.: The dental student and social responsibility: a review of the literature, Chicago, 1966, American Association of Dental Schools. and duration of extraoral force, 7. Armstrong, M. M.: Controlling the magnitude, direction, AM. J. ORTHOD. 50: 217-243,1971. 8. Kelly, J. E.: Twenty-four hour per day headgear, I like it, paper read before annual meetings of Eastern Association of Strang-Tweed Study Groups, New York, Dec. 10, 1972. aspects of disruption of thumbsucking by 9. Korner, A. P., and Reider, N.: Psychological means of a dental appliance, Angle Orthod. 25: 23-31, 1955. 10. Northwest Orthodontics, Inc., letter, April, 1973. and imitation to reinstate verbal behavior in 11. Sherman, 5. A.: Use of reinforcement mute psychotics, 12. Skinner, B. F.:

J. Abnorm. Pigeons in

Psychol. a pelican,

70: 155-164, 1965. Am. Psychol. 15:




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13. Miller, S. C., Thaller, J. L., and Soberman, A.: The use of the Minnesota Multiphasie Personality Inventory as a diagnostic aid in periodontal disease: A preliminary report, J. Periodontol. 27: 44-46, 1956. 14. Tweed, C. H.: Clinical orthodontics, St. Louis, 1966, The C. V. Mosby Company, vol. 1, p. 251. 15. Stone, L., and Church, J.: Childhood and adolescence, ed. 2, New York, 1968, Random House, p. 168. 16. Campisi, R. S.: A study of truthfulness in male orthodontic patients from the appraisal of certain autonomic responses to questions concerning cooperation, unpublished MS thesis, Loyola University Dental School, Chicago, 1963. 17. Cavanaugh, T. P., Jr.: A study of truthfulness in female orthodontic patients, unpublished MS thesis, Loyola University Dental School, Chicago, 1963. 18. Gannon, M. F.: Formation and administration of an attitude scale for orthodontic patients, unpublished MS thesis, Loyola University Dental School, Chicago, 1964. expansion: Just the beginning of dentofaeial orthopedics, AM. J. 19. Haas, A. J.: Palatal ORTHOD. 57: 219-255, 1970. 20. Sassouni, V.: Lecture notes, postgraduate course, University of Pittsburgh, 1973. 21. Bull, H. L.: Lecture notes, postgraduate course, Seton Hall College of Dentistry, Jersey City, N. J., 1957. 22. Begg, P. R.: Begg orthodontic theory and technique, Philadelphia, 1965, W. B. Saunders Company, pp. 75-76. Fairleigh Dickinson University, 23. Harvold, E. P.: Lecture notes, postgraduate course, Hackensack, N. J., 1974. 13’ Forest



Psychological timing of orthodontic treatment.

Psychological treatment Jay Weiss, A.B., Caldwell, N. J. D.M.D., timing of orthodontic M.A.,* and Harold M. Eiser, D.D.S., M.P.H. I mpr...
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