Psychological considerations for the orthognathic patient
- Understand the role of a clinical psychologist in an Orthognathic Service.
- Be able to explain the psychological impact of dentofacial anomalies.
- Be able to identify factors which may impact on patient satisfaction with treatment.
- Be able to identify psychological conditions which may not be helped by orthognathic treatment.
This chapter describes the role of a clinical psychologist, as an integral part of the multi-disciplinary team, in a dentofacial planning clinic. It covers:
- Psychological issues in facial appearance.
- Psychological assessment.
- Advice on the management of patients’ psychological issues.
- Identification of patients with psychological problems which impact treatment.
- Psychological therapeutic input within this setting.
1.1 Psychological issues associated with facial appearance
A person’s face is the most visible aspect of their appearance and is what other people focus on, during social interaction. Those with severe malocclusions may have been stared at, bullied, discriminated against most of their lives. Even when their condition may evoke a sympathetic response there may be an unintentional, negative non-verbal response from others which may be difficult for those people to suppress. As a result of these negative experiences, people with a facial deformity may go on to exhibit shyness and defensiveness in social situations, which compounds their social difficulties. Even those with more minor physical problems may be seen as less attractive, less socially competent and they may also have been subjected to teasing with resulting impact on their body image and self-esteem. MacGregor (1970) suggests that people with a minor anomaly such as “buck teeth” may evoke amusement, be a target of jokes and experience more actual direct comments about their appearance than those with more severe problems. Bull and Rumsey (1988) have conducted a number of experiments, in real life situations, which demonstrate the negative responses of others to a minor facial anomaly. Having an atypical facial appearance can therefore constitute a severe handicap in a wide range of situations and can affect social acceptance and social functioning in addition to the associated physical problems.
In addition to the objective features of the face, with its social implications, the psychological aspects of appearance also include the concept of body image. This is the person’s subjective representation of their bodily experience and appearance. Cash (2006) has described body image as a multi-dimensional construct, encompassing both an individual’s perception of and attitude towards their appearance. This involves their thoughts, feelings and behaviour in relation to their appearance. Their body image evaluation influences their level of satisfaction with appearance and will be influenced by cultural, ethnic and gender issues. The salience of attractive appearance, for that person, will also influence their associated distress with an objective or perceived anomaly. This helps explain why there is not a linear relationship between degrees of facial deformity and associated psychological disturbance.
Dental appearance plays an important part in body image assessment both in adolescence and adulthood. It is only one aspect of someone’s face but it can independently influence how attractive a person is perceived to be. Both the individual themselves and other people rate someone with severe malocclusion as less popular and less sociable. Cunningham et al. (2000) found that orthognathic patients had poorer body image and facial body image than a matched non-clinical control group. Those most dissatisfied with their dental appearance are reported to be firstly those having an extreme overjet, secondly, an extreme deep bite and thirdly, space abnormalities (Helm et al., 1985). Combined orthodontic and orthognathic surgical treatment is now more readily available and there is more awareness of it. The majority of people undergo such treatment in order to improve function, but it also has an impact on the aesthetic appearance of their face. Indeed many people presenting for treatment in clinics do not have a severe malformation and are seeking treatment primarily for aesthetic reasons. In this situation, surgery is being carried out with the objective of improving the individual’s body image. Even for those people who report a clear physical reason for undergoing orthognathic treatment, in a majority of cases, it is the aesthetic outcome from treatment that will determine their satisfaction with treatment.
Patients’ expectation of orthognathic treatment is that it will improve both physical problems and their appearance, with resulting improvement in their body image, self-esteem and social functioning. In some cases the change in appearance can be quite marked, whereas in others the changes may be more subtle. Patients have to adapt to the change in their appearance and to deal with the response of others, or conversely the lack of response, to these changes. Most patients cope well with the treatment process and are happy with the outcome; for a minority however, treatment appears to have some negative psychological effects. Equally, psychological factors have an impact on physical response to treatment and to patients’ level of satisfaction with it. There is therefore a complex interaction between oral functional and aesthetic factors in orthognathic treatment and between the physical and psychological aspects of treatment.
1.2 Psychological assessment
The psychological assessment takes place within the dentofacial planning clinic, before the patient is seen by the rest of the multi-disciplinary team. It is conducted in a one to one setting, in order to maximise the information obtained, as patients are much more likely to disclose information in that situation. The assessment does require a clinical psychologist with considerable experience of both psychological problems associated with appearance and also of the issues relating to the transitional period from late adolescence to adulthood (as the majority of patients seen are in this age group). It is a brief, focused psychological assessment covering the areas known to be relevant to patient satisfaction with the process and outcome of orthognathic treatment. The kind of information provided to the multi-disciplinary team includes:
- Patient’s perception of the presenting problem and associated functional impact.
- Patient’s motivation for and expectation of treatment.
- Patient’s current psychological status and early identification of those patients who may need psychological support during treatment.
- Identification of those whose perceived problem is unlikely to be resolved by treatment.
- Assessment of risk factors predicting dissatisfaction with treatment.
1.2.1 Patient perception of the presenting clinical problem
Assessment of the patient’s perception of the presenting clinical problem seeks to identify what exactly bothers them, how severe they perceive it to be and the impact it is having on their everyday life.
Patient’s view of the clinical problem
It is important, at this initial stage, to understand what the patient thinks about the referred problem because a patient’s perceived need for treatment may not always match the clinician’s view. They may have a relatively uninformed view of the problem or they may be quite knowledgeable. Initially they are asked, irrespective of what they have been told or heard or read, what exactly bothers them and why. A more structured format follows the initial open ended questions in order to cover the relevant areas.
Functional and aesthetic concerns
It is important to understand the relative importance of physical functional problems and aesthetic concerns for the patient, associated with the malocclusion they present with. Patients may find it easier to discuss the functional concerns but may feel that their aesthetic concerns will be considered to be less important by clinicians. Jensen (1978) maintains that the evidence suggests that many patients conceal their aesthetic motivation for surgery. It may therefore be necessary to encourage patients to describe the aesthetic aspect of their concern. The relative importance of the functional and aesthetic concern, for the patient, is important when decisions are being made to proceed with treatment. If for example, the patient is primarily interested in aesthetic change and the team concludes that there is little chance of noticeable aesthetic change or the possibility of a negative effect then clearly the patient’s concerns will not be met and they are likely to be dissatisfied with the outcome.
Perception of severity
The need to proceed with treatment is also influenced by the perceived severity of the problem both by the clinicians and the patient. The use of a Visual Analogue Scale, with defining markers at each pole, can be helpful in assessing the degree of concern a patient feels both about how severe they feel that the physical problem is and also the degree of distress they experience associated with the problem. There is no linear relationship between the degree of objective physical deformity and the severity of psychological disturbance associated with appearance reported by patients. So that someone presenting with marked facial problems may report little aesthetic concern, whereas others with some minor anomaly, which clinicians may consider to be within a normal range, may present with significant aesthetic concern. This latter group may require further more detailed assessment from a psychological perspective.
Not all patients who are offered surgery will accept this approach. In a study of patients with an equal objective need for surgery Bell et al. (1985) found that the patient’s own perception of their face was a more important determinant of whether or not they accepted treatment. In general, lay people are more likely to judge a face as normal compared to surgeons and orthodontists. The authors of the study suggest that the patient’s perception of their facial aesthetics should be of primary concern when alteration of facial aesthetics is being considered.
Impact on life
The reported impact that concern about appearance is having on the patient’s everyday life is also assessed. This may require careful assessment in order to gain a realistic picture and to avoid both under-reporting and over-reporting of associated difficulties. Information about the onset of their concern, when this happened and if there were any particular triggers for it. Occasionally, patients may be referred who have not been aware of problems with their facial appearance prior to initial referral, but when the problem has been identified and named, may begin to become more self-conscious about their appearance. Equally, there may be patients who have been concerned about their facial appearance from an early age and this may have had a significant impact on their social and emotional development. The reported impact of the perceived problem is therefore assessed both in the past and on their current functioning.
Patients are asked if they have consulted anyone else in the past about the problem or had any previous treatment for it. A more general assessment of their body image is also made, asking for example, if there are other aspects of their face or body that they dislike and have considered changing by surgery or some other means. A history of any previous cosmetic type procedures undergone is also noted and this should include cosmetic dentistry.
In addition to the patient’s description of the impact of their concern about their appearance, the psychologist will also observe their behaviour. For example, observing a patient automatically cover their mouth with their hand when smiling, gives important information about the behavioural aspects of their body image concern. Again, if a patient has problems establishing or maintaining eye contact then this may indicate a severe body image problem or a psychological condition such as social anxiety.
The assessment of the patient’s perception of the presenting clinical problem is important for the team discussion and comparisons made with the clinical view of the problem, in order to avoid problems associated with disproportionate concern about appearance and dissatisfaction ultimately with treatment outcome.
1.2.2 Patient expectation of treatment
A second main area of the psychological assessment involves looking at the patient’s expectation of treatment both from a physical and a psychological point of view. If patient’s expectations are vague or unrealistic, it may be possible to alter those views by giving them very clear information during the multi-disciplinary assessment, about what is possible from treatment. If their expectation about the effect that treatment will have on their lives is unrealistic, it may be possible to work with them psychologically in order to help them begin to make necessary changes in their lives, both prior to and following surgery, so that they can achieve a good outcome from treatment. If patients, however, continue to hold unrealistic views about what could be achieved both from a physical and a psychological point of view, despite input, then their expectations of surgery cannot be met and they are likely to be unhappy with the outcome from treatment.
1.2.3 Patient motivation for treatment
A third area of assessment is patient motivation both in relation to why they are seeking treatment and also to their likely adherence to what will be a long and demanding course of treatment. It is therefore important to establish if they have just agreed to be referred at the suggestion of their dental practitioner or another clinician and they are there unquestioningly. If this is the case, it is important to ask if they are keen to proceed once they have fully understood the nature of the clinical problem. This is particularly important if they are young or a vulnerable adult. If the referral was sought on their behalf primarily as a result of parental concern for example; it is important to establish whether they do actually share that concern and want to pursue treatment themselves. If they express a desire not to proceed, it is important to establish if this is because they have particular fears about the surgery (which may be inaccurate and change with reassurance) or do they simply have a different view from their parents. The maturity of this decision is also important to assess; for example to establish whether or not it is part of a more general oppositional stance with their parents or whether it is a considered view, taking into account the likely future impact of any facial anomaly they may have.
If the referral was primarily instigated by the patient themselves and is largely an aesthetic issue, the question of whether this is as a result of a sustained concern or one prompted by recent events (positive or negative) in the patient’s life, is an important area of assessment. The recent event may be a negative one such as a relationship breakdown and the concern about facial appearance may just be part of a resulting general negative evaluation of self. There may be a more complex issue underlying patient motivation for treatment such as gender dysphoria or ethnic identity difficulties which may influence an aesthetic dissatisfaction with facial appearance. The question of why exactly the patient is seeking surgery, at this particular time in their life, is an important one because if surgery is in response to a more sustained concern, then they are more likely to be satisfied with the outcome of treatment.
Sarwer (2002) has described the concept of internal and external motivation for treatment. Internal motivation is driven by factors within the individual, for example, a wish to improve appearance or increase self-esteem. External motivation he suggests is concerned with factors external to the individual such as a desire to please others or the notion that if they changed their appearance they will get promotion at work and so on. The importance of the division between internal and external motivation has some relevance for patient satisfaction with outcome from treatment because it is suggested that more internally motivated patients are more likely to be happy with the outcome from surgery.
The likely motivation of a patient to continue with treatment through a relatively long treatment programme is also an important issue to explore. Patients are required to make frequent clinic visits, to adhere to an excellent standard of oral hygiene and to cope with many months of the initial treatment probably worsening their facial appearance, during the orthodontic preparation. The issue of motivation is more pertinent if they have a history of avoiding treatment offered or of defaulting from treatment. We know that past behaviour is the best predictor of future behaviour and therefore people who have not continued treatment in the past are more at risk of defaulting again, compared to those with no such history. It is therefore important to find out what the cause of the previous failure to complete treatment and if it is likely to recur in their current life situation. The patient’s likely supportive network during treatment is ascertained, particularly for the immediate post-surgery period.
Motivation for treatment is affected both by the patient’s perception of the problem and its relative importance to them and they need to make a very clear decision to proceed with treatment. If patients seem ambivalent about proceeding or if their motivation is questionable, then a delay in starting treatment is indicated. Those requiring additional support to attend, such as those with mental health problems, can be identified and the necessary support arranged.
1.2.4 Patient’s psychological status
A psychological assessment, based on an expert knowledge of normal development, will also include taking a brief history of early childhood experience, their interpersonal relationships and of how they have functioned at school, work and in social settings. This will include some assessment of personality and the assessment of reported psychological difficulties currently or in the past.
A brief screening for a history of psychiatric illness is carried out and if such a history emerges then a more detailed assessment of current psychological status follows. This will include any history of alcohol or other substance abuse or of self-harm. If a significant psychological history emerges, a second assessment session may be required before the assessment is complete. This may include contacting the mental health professionals currently treating the patient, in order to obtain their opinion about any likely impact of the patient’s illness on orthognathic treatment.
Finally to complete the assessment, a brief assessment of how patients have coped with illness, surgery or trauma in the past is made. There is some discussion about the patient’s educational, work or family plans over the next two years because many patients seen in the dentofacial clinic are at a transitional stage of their lives and clearly this has to be taken into account when the treatment planning is being considered. An assessment of the social support available to them currently and any likely change to this, around the time of the surgery, is also carried out. The quality of social support has been found to be important for patient outcomes and it is important to try to identify patients who may need some additional support around the time of surgery.
1.2.5 Outcome from psychological assessment
At the end of the psychological assessment the psychologist has a discussion with the patient about relevant issues which have emerged during the assessment and informs them about issues which will be fed back to the rest of the clinical team. Some preparation for the rest of the assessment process is done, encouraging patients to ask questions or voice any concerns they may have during the process. If the patient indicates that they may have difficulty voicing their concerns they are reassured that they will have some help with that and they will also have a family member or partner or friend present with them. They are reminded that they have been referred for elective treatment and that they should only make the final decision to proceed, if treatment is recommended, after hearing all the risks and benefits of the treatment options. They are also reassured that they can take some time to make a decision as delay in starting treatment is better than withdrawing prematurely from treatment later.
Occasionally a recommendation will be made from the psychological assessment to delay the start of treatment because of the patient’s current life situation, psychological difficulties or current mental health problems. For example if someone is suffering from post-natal depression and struggling to cope with a new baby, then a period of delay before embarking on treatment may be better. Sometimes patients may have difficulty in expressing concern about the timing of treatment because they think they will not be offered it again or they feel guilty that they have taken up an appointment slot. Postponement of the decision-making process may also be recommended if it emerges that the patient is under pressure, for whatever reason, to make a decision and they are not sure about it. This is particularly important if they are young, perhaps over-compliant or vulnerable in some way.
On rare occasions, the psychologist may recommend that treatment is not offered at all because there are contra-indicators for surgery from a psychological perspective (Red Flags) and these will be detailed in a later section. In addition, there may be other occasions where significant issues are identified by the psychologist (Amber Flags), which will influence the discussion and decision about whether or not to offer orthognathic treatment to particular patients. This may be particularly relevant in situations where the physical indicators for treatment are slight and the desire for treatment is primarily an aesthetic one. In some cases, the psychologist may arrange to see them again, contact the relevant mental health services for more information if necessary and carry out a more detailed assessment. If the patient agrees to appropriate treatment for the psychological condition identified, then a referral to the appropriate services is made.
Immediate feedback from the psychological assessment is/>