THE BOLD AND THE BEAUTIFUL!!! The influence of dental malocclusion and orthodontic problems on 'Social Phobia (Shyness)' and 'Self-Esteem'

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1 THIS PAPER WAS PRESENTED AS A RESEARCH PAPER AT THE 36th 1.0.c. & ASIAN ORTHODONTIC CONGRESS, COCHIN, THE BOLD AND THE BEAUTIFUL!!! The influence of dental malocclusion and orthodontic problems on 'Social Phobia (Shyness)' and 'Self-Esteem' Abstract: Author's Name: VALID NIKHILESH, R., M.D.S., Fellow-WFO, PFA, PG.Cert-Lingual Orthodontics, Aligner Therapy. Consu Itant Orthodontist CAD, Breach Candy Hospital, Mumbai. ROY, E.T., M.D.S., D.I.B.O. Professor Dept. of Orthodontics, 8apuji Dental College, Davangere. D'SOUZA LANey, M.A., Ph.D. Professor, Dept. of Psychology, Maharaja's Co llege, Mysore. SIMHA ASHOK, M.D.S., M.Orth. R.C.S. Former Reader Dept. of Orthodontics, JSS Dental College & Hospital, Mysore. Address for Correspondence: Dr. NIKHILESH R. VAID Ground Floor, Mani Mount, 24 Altamount Road, Mumbai - 10, India. Tel No.: The study reports the influence of dental malocclusion and orthodontic problems on 'Social Phobia (Shyness)' and 'Self-Esteem' of male and female subjects. A total of 240 subjects (120 male and 120 females) were selected for the study having orthodontic problems (age years) and were divided into 6 groups (one control and five experimental groups), based on the severity and the effect of malocclusion on facial appearance. Coppersmith's Self-esteem scales (1986) and Crozier's Shyness scales (1995) were employed to find out the level of self-perception and social phobia influencing social conduct. Results revealed that orthodontic problems had a significant influence over subjects' social phobia and self-esteem. Higher the degree of dental malocclusion, more was the social phobia and lesser the self-esteem. In essence, the BEAUTIFUL, were indeed BOLD in their social conduct and vice-versa. The study comprehensively indicates that orthodontic therapy not only influences the appearance of a person, but also manifests changes in his personality, that are positive. Abbreviated Title: The Bold and the Beautiful Key words : Psychology, Self-Esteem, Social Phobia, Shyness, Orthodontic Treatment ~ 32

2 I;,...~ --===---=~ ---- INTRODUCTION The mechanical aspects of orthodontics are the subjects of most concern, in an orthodontist's early career. Appliance types, mechanics and techniques exemplify their existence in such magnamous fashions, that other aspects of orthodontic care are often overlooked. Though every mechanotherapy is directed at the dentition, it is imperative to recognize that every dentition is within a face, and every face within a person! Persons are distinctive creatures with beliefs and desires, moods and emotions, intentions and projects. The window that showcases every intricacy of personhood with expressive variability, depth, salience, and immediacy is the living human face. In myriad complexes and subtle ways, faces push and pull us. They attract, repel, motivate and captivate us with a force-and yet also, with a delicacy of a nuance-are impossible to ignore. The field of clinical psychology has provided increasing evidence that facial attractiveness is an important variable in the formation of "First Impressions", and that dentofacial disharmonies predispose individuals to socio-cultural precepts or stereotyping1. Cartoonists typically use protruding upper incisors and long facial heights to depict individuals of low intellect, and the caricature of a witch features a deficient upper jaw and a protruding chin. While the Bold are the Beautiful, unattractive people are perceived as less socially competent, popular and friendly. Social stereotyping based on facial appearance, disproportionately affects young adults and adolescents, and can be a major factor in determining their interpersonal relationships and selfesteem. Shaw 2 3 stated that unattractive physical appearance might evoke an unfavourable social response, whereas well-aligned teeth and a pleasing smile carry a positive status at all social levels. Chaturvedi et a1 4, studied the correlation of orthodontic problems to self-concept, and concluded that an increase in the degree of orthodontic problems, proportionately causes a deterioration of the persons self-concept. From the patient's perspective, Burden and PineS, revealed that the main reason for people to seek orthodontic treatment, is to minimize psycho-social problems related to their dentofacial appearance. In the light of the above research, it would be fair to state, that in the vast majority of the patients, the health gain is primarily psycho-social in nature and cannot be comprehensively represented in terms of reduction in the prevalence of dental disease or a diminution in susceptibilityg. Social Phobia (Shyness) and Self-Esteem are major determinants of psychosocial health. Doubts about one's ability to contribute effectively to social encounters and the belief that others will negatively evaluate one's action/behavior may contribute to the withdrawal behavior and social anxieties that characterize Shyness 7 When people withdraw from daily life experiences, in order to avoid the social interactions they dread, they suffer from an anxiety disorder called the Social Phobia or Shyness 8 A person's Self-Esteem is a judgement of worthiness that is expressed by the attitudes he or she holds towards the self. It is a subjective experience conveyed to others by verbal reports and other overt behavior9. The importance of psychological attributes to orthodontic problems and practice has been reported extensively, but studies carried out on Indian populations are scarce. Though, self-esteem have been the focus of attention of previous investigators, Social Phobia (Shyness) in individuals with malocclusion is an unprobed entity. With these parameters in contention, the present study was envisaged. MATERIALS AN D METHODS Subjects The subjects consisted of 6 groups of 40 people each (20 Male and 20 Female). Their age varied from 18 to 23 years with the mean age of years. The subjects were assigned to different groups based on the severity of dente-facial malocclusion as described below: Group A " Normal Controls: People with normal or near normal occlusion with well-aligned arches and an aesthetic profile. Group B,' People with mild to moderate malocclusion, acceptable profile and alignment; requiring no or minimal orthodontic intervention. Group C: People with moderate to severe malocclusion, affecting facial profile and appearance, definitely requiring clinical intervention. Group 0 " People with extremely severe malocclusion, with profound distortion of facial appearance, requiring orthogenetic surgeries for correction Group E " Patients undergoing orthodontic treatment. Patients who were mid-treatment, with a sufficient degree of correction of the malocclusion completed Group F " Patients who have undergone comprehensive fixed orthodontic treatment and are, at least 6 months in retention phase. 33

3 Selection of the Subjects Four hundred and three (403) people were surveyed for establishing a relationship between dental malocclusion, Social Phobia (Shyness) and Self-Esteem. The demographic information (age, sex, diet, income, ethnic background) and subjects knowledge and perception of his/her orthodontic condition were also elicited. A panel of 5 orthodontists and 5 psychologists randomly selected the subjects for the study. From amongst the surveyed population, subjects with grossly destructed teeth, prosthesis in the mouth, severe periodontal conditions, developmental anomalies, syndromes affecting the jaws, severe psychological depression, having undergone the psychological tests earlier and have undergone partial orthodontic treatment and discontinued it: were excluded from the study. The psychologists were blinded to the assignment of groups based on severity of malocclusion, and the orthodontists were blinded with respect to the psychological status. The subjects were blinded to both aspects of the study. The panel of orthodontists conducted a thorough general, extra oral and intra oral exa mination before assigning the subjects to specific groups. The psychologists' administered Shyness and Self-Esteem questionnaires in batches of 5 subject each. Any ambiguity on the questionnaires was clarified to th e subjects in local; languages. Research Tools 1. Shyness Questionnaire Thi s questionnaire was developed by Crozier (1995)7 at the University College of Cardiff. It consists of 26 items and requires the subject to indicate his/her response by ticking 'YES', 'NO' or DON'T KNOW'. The items of the questionnaire are based on situations or interactions like performing in front of the class, being made fun of, being told off, having one's photograph taken, novel situations involving teachers, schoolfriends interaction and so on. Of the 26 items, shyness is indicated by a 'YES' response for 21 items and a " NO" reponse for 5 items. 2. Self-Esteem Questionnaire To find out the level of self-esteem in subjects, the inventory developed by Stanley Coopersmith (1986)9 was employed. This consists of 25 items, both negative (17) and positive items (8), where the subject has to read the statement and he/she has to tick mark the answer in one of the boxes mentioned as "like me" or " unlike me". On completion of the study, each subject was informed, counseled, about hislher malocclusion and psychological status and motivated to seek clinical intervention if required. The data was then coded, scored according to the norms provided and statistically analyzed. RESULTS AND OBSERVATIONS The Statistical tests employed were the Two-way Analysis of Variance and the Duncan's Multiple Range Test., Sex and Shyness Between vari'ous malocclusin groups, a significant difference was found in their mean shyness scores (F=26.675; p<o.ooo). The respective mean shyness values for groups A,B,C,D, E and F were , 24.28, 33.45,20.20 and Further DMRT (Duncan's Multiple Range Test) revealed that Group D (Severe dental malocclusion group) differed significantly from other groups. Likewise groups F (undergoing treatment group) was found to have the least shyness, differing significantly from all other groups. However, no difference in the shyness scores was found between group A and E (normal controls and undergoing treatment group). In general, we can say that as severity of dental malocclusion increased, shyness scores also increased linearly. Female subjects (mean 24.08) were found to have a significantly (F=6. 780; p<0.010) higher shyness score compared to male subjects (21.70). The interaction effect between groups and sex was found to be non-significant (F=1. 433; p<0.213) indicating that the pattern of shyness is same amongst male and female subjects irrespective of the group they belong to., Sex and Self-Esteem As in the case of Shyness, in the Self-Esteem scores also, various malocclusion groups differed significantly (F=34.684; p<o.ooo). The respective mean self-esteem scores for groups A, B, C, D, E and F were 16.40, 12.82, , , and F u rt her D M R T (Duncan's Multiple Range Test) revealed that Group D (Severe dental malocclusion group) differed significantly from other groups having least self-esteem. Likewise group F (completed treatment group) had the highest self-esteem scores, differing significantly from all other groups. No difference was found between groups, B, C and E. However, males and females had almost the same level of Self-Esteem scores, which contributed for the non-significant difference (F=1.727; p<o.190). The interaction effect between groups and sex was found to be non- significant (F=1.433; p<o.21 3) indicating that the pattern of self-esteem is same among male and female subjects irrespective of the group they belong to. 34

4 Table Mean Shyness and Self-Esteem scores of male and female subjects belonging to various groups tested in the study Factor Male Sex Female Overall Group A Group B Group C Shyness Group D Group E Group F OVERALL Group A Group B Group C Self-Esteem Group D Group E Group F OVERALL A B C D E F A B C D E F Fig. 1 : Mean Shyness scores of various groups Fig. 2 : Mean Self-Esteem scores of various groups 35

5 A BCD E F ClShyness Se/f-Ellteem Shyness Self Esteem OMs/e Fems/e Fig. 3 : A comparative figure of Shyness and Self-Esteem scores across groups DISCUSSION Orthodontic literature on psychological aspects of physical appearances, has comprehensively concluded that a large number of individuals with dentofacial disharmonies, experience levels of psychological aberrations that might warrant clinical interventionl The results of the present study vehemently augur in favour of a definitive correlation between the severity of malocclusion and the psychologica l of a subject. In Group 0 (People with extremely severe malocclusion) subjects scored extremely high on the social phobia (Shyness) scales (33.45) and extremely poorly on the self-esteem scales (1 0.85). This establishes the fact that severe dentofacial distortions are associated with a "social handicap", that alters the psychology of an individual. Subjects in Group B and (People with mild to moderate! Moderate to severe malocclusion) also demonstrated more shyness and less Self Esteem with respect to the ontrol group. Subjects in Group E (Mid treatment) have shown low scores on the shyness scale (20.18) with respect to people in Group, B, C and 0 a higher score of self esteem (12.50) on the scale with respect to other experimental groups. This indicates a positive influence of orthodontic treatment on the personality. However" when compared to the control group, the shyness score was comparable, but the self-esteem score was less. This may be due to the concept of physical inadequacy and its consciousness imposed on the subjects due to the orthodontic appliance, affecting self-esteem. Fig. 4 : Comparative scores of male and female subjects on the Shyness and Self-Esteem scales Females had higher shyness and a comparable selfesteem in all groups of subjects studied, with respect to males. This may corroborate the findings of Klima et at (1979)10 and Chaturvedi et al (2004)4. This may be attributed to a greater consciousness and scrutiny, females are subjected to as regards physical appearance, when compared to males of the age groups evaluated. Another finding of significance was that low self-esteem and high shyness scores were obtained in patients with Class III malocclusion, as compared to Class II and Class I malocclusion. However, because of the magnitude of deference and uneven distribution of subjects into groups, based on this type of malocclusion in the present study, the psychological impact of this form of malocclusion, warrants further study. The most alarming findings were the extremely low shyness (17.00) and extremely high self-esteem scores (19.35) in Group F (patients who had undergone complete orthodontic treatment,), with respect to the control group (Group A) where the scores were and respectively. Though the patients for the tests were evaluated, at least 6 months after debonding (to eliminate any bias resulting from the euphoria associated with the debonding appointment) the scores obtained, point to psychological change being an important sequela of authentic treatment. These findings are in agreement with Hunt et at (2001 )13 who describes an increase in self concept, self confidence and physical attractiveness as being the top most benefits of orthodontic treatment. Further longitudinal research and interaction amongst orthodontists, psychologists and facial surgeons is 36

6 requires to probe into depths of not only the personality; but also the reflection of these entities, on the most sensitive part of the human body, "the Face". The results of the present study, clearly implicate the importance of the fact that "Treatment of the face is more than the sculpture of living tissues, for it involves serious alterations in personality and social interactions. It is our obligations, as professionals who serve individuals - to serve them completely in all their needs, physical, social emotional and intellectual. We cannot do more - we dare not do less!!! CONCLUSION The following conclusions can be made from the present study; Experimental groups differ Significantly in self esteem and social phobia (shyness) with respect to the control group, which underlines the effect of malocclusion on psychological well being. Self esteem and shyness scores were inversely proportional in most groups, reiterating an established psychological principle. Group 0 (People with extremely severe malocclusion) had the most degraded Self Esteem and maximum shyness; demonstrating negative psychological traits as a sequelae of distorted dentofacial appearance. Band C and less Self Esteem and more Shyness compared to the control group (people with normal occlusion), indicating that the " Beautiful" were indeed "Bold" and vice versa in their social conduct. Group E (Mid treatment subjects) showed higher Self Esteem and lesser Shyness with respect to people with degrees of malocclusion, indicating a possible positive effect of orthodontic mechanotherapy on their social outbook. Females showed a tendency for more shyness but a comparable Self-Esteem with respect to males in all groups tested. Group F (Subject who had undergone orthodontic treatment) showed the highest self-esteem and lowest shyness scores from amongst all groups evaluated. These findings would serve to offer a lot of food for thought! As we dedicate ourselves to provide quality orthodontic services to our patients, the mantra of the contemporary orthodontist should be - "We change personalities, We also straighten teeth". REFERENCES 1. Philips C, Bennet E. & Broder H. " Dentofacial disharmony; psychological status of patients seeking treatment consultation". Angle Orthod. 1998; 68(6) : Shaw W.C, Rees G., Dawe M. & Charles CR. "The influence of dentofacial appearance on the social attractiveness of young adults". Am.J. Orthod., 1985; 87 : Shaw W.C, Richmond S., O ' Brien K.D., P. & Stephens CD. " Quality control in Orthodontics: Indices of treatment need and treatment standards", British Dent. J.; 1991 ; 170: Chaturvedi T.P., Arshad S. & Alvi H.A. " A study of physical 'self-concept' of patients having dental malocclusion and orthodontic problems".j. Ind. Orthod. Soc.; 2000; 33: Burden D. & Pine C. " Self perception of maloccusion among adolescents". Community Dent. Health; 1995; 12 : Proffit W. & Fields H. "Contemporary Orthodontics". 2000; Mosbly, London; Crozier W.R. "Shyness and Self-esteem". British J. of Edu Psych; 1995; 65 : D'Souza L., Urs G.B. & James M.S. "Assessment of shyness: Its influence on the personality and acaden ic ach ievement of High school students". Ind. J. Clin. Psych. 2000; 27 : Coopersmith S. " Self-esteem Inventory and Manual". 1986, California; Consulting Psychologists Press, Inc. 10. Klima R.J., Wittermann J.K. & Mc Iver J.E. " Body image, Self-concept and the orthodontic patient". Am. J. Orthod; 1979; 75(5); Tung A.W & Kiyak H.A "Psychological influences on the timing of orthodontic treatment". Am.J. Orthod. Dentofac. Orthop. 1998; 113 : Birkeland K., Boe O.E. & Wistn P.J. "Relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups - A longitudinal study". Eur. J. Orthod. 2000; Hunt 0., P., Johnson C, Stevenson M. & Burden D. "Professional perception of the benefits of orthodontic treatment". Eur. J. Orthod; 2001 ; Cucalon A. & Smith R,J. " Relationship between compl iance by adolescent orthodontic patients and performance on psychological tests." Angle Orthod., 1990; 60 (2) Moyers R.E. "Evolution ofthe concepts of the Face". Esthetics and the treatment of facial form". 1993; 28; Cranofac. Growth Series;