A New Paradigm of Motivation

The subject of this year's Moyers Symposium at the University of Michigan was "Creating the Compliant Patient". Two of the speakers listed on the program were Dr. Richard "Wick" Alexander, whose topic was "Creating the Compliant Orthodontic Patient", and Dr. Larry White, who was to discuss "The Management of the Non-Compliant Patient".

At first, it appeared to me as if they were going to speak about two sides of the same coin. Upon closer scrutiny, however, I realized that both clinicians were trying to devise methods for making a more positive patient. Dr. Alexander?s talk will appear in a future column.

Dr. White's methods of improving compliance, as presented in this month's article, are based on solid psy chological principles. Drawing on behaviorism, he cautions us to "increase positive reinforcements while limiting negative ones". The most interesting part of his article to me is his practical approach to the elimination of these negative factors in everyday practice. Any method, no matter how well based in medical science, must apply to routine clinical procedures.

Orthodontists have long wished for some method that would reliably predict which patients will be easy to manage and which will not. About 20 years ago, my office worked with a psychologist to develop a test containing more than 200 questions. I would like to be able to tell you that it was successful, but it proved much too long and cumbersome and was soon discarded. In contrast, Dr. White describes behavioral patterns that can predict compliance or non-compliance. His approach can help minimize treatment time, increase profitability, and reduce stress in our practices.

A New Paradigm of Motivation

The primary motivational techniques orthodontists use for encouraging patients to assist in their treatments belong to one of three main psychological disciplines:

Without thinking about it, most orthodontists will use one or more of these techniques as they work with patients. Usually they simply imitate their own parents, teachers, or coaches and apply whatever techniques they learned while observing these role models.

It is easy to see why orthodontic patient motivation remains such a haphazard affair and bears such little fruit. I will not linger on psychoanalytical techniques, because I have no expertise in this field and it holds little promise for orthodontists and their patients. Likewise, I have little to say regarding humanism, because although familiar with the concept, I think it has poor long-range motivating ability.

I have developed a rather complete motivational system for orthodontists and their patients that blends behaviorism with genetic temperament inheritance. I feel this enlists the use of the personality features we cannot alter, while implementing effective measures to control the plastic traits of human nature. Much of this new paradigm of motivation depends upon reducing the discomfort delivered to patients, and I will outline some of the methods I routinely use.

Behaviorism

The underlying basis of behaviorism is that consequences dictate behavior. There are three broad categories of consequences: positive reinforcers, negative reinforcers, and punishment.

Punishment can only extinguish behaviors, not teach them, so it has limited use in orthodontics. Punishment must be severe to be effective, and it often results in counterproductive behavior such as resent ment, aggression, emotional arousal, or avoidance.

When orthodontists want to increase patient compliance, they should increase positive reinforcements while limiting negative ones such as pain, fear, frustration, and humiliation. Orthodontists can also improve compliance by providing patients with feedback that is immediate, accurate, and specific. I cannot overemphasize the importance of delivering immediate consequences for behaviors, since learning is much faster and easier when there is a close approximation of the behavior and its consequence.

A "token" economy that rewards patients with points or tokens that they can trade in for T-shirts, badges, or tote bags has proven effective in improving the compliance of some patients.1 Some of my patients remained unaffected by the token economy, however, and this resistance to change led me to the discovery that poorly compliant orthodontic patients have a low sensory tolerance for pain.2 When their toothbrushing pressures were measured with a highly sensitive strain gauge, they were found to use four and a half times less brushing force than compliant patients did.

Do not expect patients to do things for the benefit of others. Most people, except for the deranged and totally altruistic, do things that benefit themselves. So when people have the skill but not the will to do something, look for the following conditions3:

Low Sensitivity Threshold

The discovery of low pain tolerance in non-compliant patients coincided with a study by Alexander and Chase, which suggested that there are at least nine congenital temperaments that make children easy or difficult to manage4 (Fig. A).

The most important of these personality features to orthodontists is the sensitivity threshold. People with an inherited low sensitivity threshold have diminished tolerances for all the senses. That is, what might be an acceptable tactile stimulation for a person with ordinary sensitivity will be painful for a person with a low sensitivity threshold.

These people do not tolerate items such as wool sweaters, shirt labels, new shoes, or tight clothes. They are highly selective about the foods they eat--their foods must have the right texture. And they show an unusually high social sensitivity, perceiving insults where none are intended. Bright lights and loud or repetitive noises irritate them greatly, so it should come as no surprise to orthodontists that they show little inclination to tolerate the demands, discomfort, and inconvenience of orthodontic therapy.

Many of their broken brackets and bands result from when they touch, tug on, and damage the appliances that are discomforting them. They will then show their true creativity and do whatever is necessary to diminish the pain and release their teeth from the traps that hold them. They will break the offending brackets by biting on a pencil, pen, or block of ice. Some have even removed their brackets with toenail clippers or wire cutters.

The immediate positive reinforcement they receive from the release of pressure teaches them to repeat this behavior whenever they hurt again. So orthodontists can begin to understand why these patients pose such challenges.

Dental Behaviors of the Difficult Child

Heightened sensitivity to taste, touch, smell, and aural and visual stimuli explains why some patients are so resistant to orthodontists' appeals and encouragements. It also explains many of the behaviors associated with non-compliant orthodontic patients, such as poor oral hygiene, chronic complaining, easily fatigued jaw muscles, inability to open their mouths wide, copious salivation, frequently broken appliances, refusal to use permissive appliances, easily provoked gag reflexes, chronic mouth ulcers, TMD symptoms, and frequent missed appointments.

Rather than considering these patients as having character defects or poor attitudes, orthodontists should view them as "turtles without shells". And rather than trying to change what is probably unchangeable, it might be better to identify these low-sensitivity-threshold patients and design their therapies so they can cooperate enough to achieve acceptable results.

Knowing beforehand what patients may do can prepare orthodontists for these events. For instance, parents and patients may believe that chronic intraoral ulcers result from their orthodontic appointments, which encourages them to accuse their doctors of infecting them with nonsterile instruments or of some other precipitating behavior. Orthodontists need to know what lies behind these ulcerations so they can explain the etiology in a convincing manner. Whether or not the patients and parents are persuaded, orthodontists will also need an effective remedy for the ulcerated tissues. The following prescription has served me well for many years (Fig. B).

Label: Rinse with 1 tablespoon of liquid for 10-15 minutes Q.I.D. and spit out.

(Patients can receive a systemic dosage by swallowing the liquid, but the Benadryl will cause drowsiness and thus should be taken this way only at bedtime.)

A good method of controlling the gag reflex of sensitive patients during impression taking enlists what psychologists call "incompatible behaviors". Patients find it almost impossible to gag with their eyes open. I usually have susceptible patients stare directly at my nose while I take the impression, and I also have them raise the left leg as a diversion (Fig. 1). The fatigue of holding the leg aloft preoccupies them and prevents any mental rehearsal of previous gagging episodes. This technique does not eliminate all nausea during impression taking, but it dramatically reduces severe gagging.

Sensitive patients frequently develop TMD symptoms during or following orthodontic treatment, and the orthodontist makes a convenient target should patients or parents want to place blame. Unfortunately, they often receive reinforcement from other professionals regarding the orthodontist's culpability. I wouldn't say that orthodontic treatment could never be responsible for TMD, but such etiology is neither frequent nor common, and orthodontists need to convince patients and their families of this.

In my experience, many adolescent TMD patients have painful masseter and temporalis muscles as a result of chronic gum chewing, bruxism, or hyperextended mouth opening from dental procedures. The subsequent chronic contraction of the masseter muscles will limit mouth opening and cause pain that frequently refers to the ear and the TMJ. The orthodontist should help the patient understand how these muscles and the TMJ cannot hurt without excessive pressure from the teeth being together too much. Humans were not made to clench their teeth most of the time. In fact, as every dentist knows, the normal tendency is to separate the teeth 2-3mm in a physiological rest position.

When patients have chronically tight occlusion, they also tend to develop joint noises from squeezing out the synovial fluid in the TMJ. Once heavy occlusal pressure distorts the quantity and quality of the synovial fluid, normal joint lubrication does not occur, and minor anatomical discrepancies, which normally would go unnoticed, will cause interferences that the muscles must overcome with an extra burst of force. When this muscular energy succeeds in overcoming the obstacle, a snap or pop is heard in the joint.

Not all joint noises result from this scenario, but many do in adolescents and young adults. Patients need to understand how this happens and what they and orthodontists must do to restore their TMJ health.5 The following is not an exhaustive list, but it is a good start toward relieving patient discomfort:

Tame the Pain

Orthodontic therapy, by its biological nature, involves some discomfort, but if orthodontists hope to enlist more patient cooperation, they must devise strategies that tame the pain. The following represent some reasonable objectives for limiting patient discomfort and enlisting more help from patients during their treatments7:

Oral Hygiene for Orthodontic Patients

Reluctance to practice good oral hygiene has unusually serious consequences for orthodontic patients. When tissues are inflamed, they exhibit a special sensitivity to discomfort, and it then takes much less stimulus to evoke a painful response.8 With orthodontic patients, this causes a vicious cycle of reinforcing events that defy correction without aggressive therapy. Inflam mation causes neglect, which leads to a greater accumulation of plaque, which leads to an even lower tolerance, which leads to more inflammation (Fig. 2).

Patients with poor oral hygiene often reach such a point of gingival inflammation that orthodontic treatment must stop so that special periodontal therapy can restore the patient's gingival health. Before patients get to this point, orthodontists should exercise an aggressive remedial strategy that includes:

I can only guess why so many negligent patients seem to come from dysfunctional families. Perhaps it is genetic, cultural, or a combination of both, but orthodontists need to involve the parents of these patients and keep them informed of progress or problems. Failure to do so invites misunderstanding and resentment--usually at the end of treatment.

To avoid such unhappy events, I invite parents into the clinic at each appointment to show them poor oral hygiene, highlighted by plaque staining (Fig. 3), explain what has been done, and describe what I expect to happen from that day's treatment. The parent's presence is acknowledged by making a blue line across the treatment chart with a highlighting marker.

When a patient's chart shows no blue marks, I make a special effort to talk with the parents on the phone and encourage them to visit the office. With such parents, you must inform as you perform. Otherwise, they will have the convenient excuse of "professional negligence to disclose" to intimidate you legally.

My experience indicates that if patients will practice good oral hygiene, they will do just about any other task you give them. Certainly, there are exceptions to this general statement, but not many. On the other hand, if patients will not brush well, they will hardly ever perform any other duty that will aid their orthodontic treatment.

Good oral hygiene may seem secondary to orthodontic diagnosis and treatment, but it is not. Without it, we compromise the entire treatment.

Editors' Note: We would like to thank the Center for Human Growth and Development at the University of Michigan for allowing us to publish this slightly condensed version of Dr. White's material in advance of the Craniofacial Growth Series monograph on the Moyers Symposium.