THIS PAPER WAS PRESENTED AS A RESEARCH PAPER AT THE 36th 1.0.c.

&
ASIAN ORTHODONTIC CONGRESS, COCHIN, 2001.
THE BOLD AND THE BEAUTIFUL!!!
The influence of dental malocclusion and orthodontic problems on
'Social Phobia (Shyness)' and 'Self-Esteem'
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 Coll ege, 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, Indi a.
Tel No.: 91 - 9820644222
Abstract: 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 15-25 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
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 self-
esteem.
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
33
I ; . . . ~
- - = = = - - - = ~
----
----
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 20.28 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.
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
eli cited.
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
di scontinued 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
examination 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
the 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, school-
friends interaction and so on. Of the 26 items, shyness
is indi cated 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" .
34
On completion of the study, each subject was informed,
counseled, about hislher malocclusion and psychologi cal
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.
Groups, 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 20.8321 .62,
24.28, 33.45,20.20 and 17.00 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 control s
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-signifi cant
(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.
Groups, 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,
1 2 . 95, 1 1 . 05, 1 2 . 5 0 and 1 9.3 5 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, whi ch
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.
Table
Mean Shyness and Self-Esteem scores of male and female subjects belonging to various groups tested in the study
Factor
Shyness
Self-Esteem
35
30
25
20
15
10
A
Groups
Group A
Group B
Group C
Group D
Group E
Group F
OVERALL
Group A
Group B
Group C
Group D
Group E
Group F
OVERALL
B C D
Groups
Male
19.40
22.60
21.25
32.75
18.20
16.00
21.70
16.60
12.00
12.60
11 .15
12.40
18.65
13.90
E F
Fig. 1 : Mean Shyness scores of
various groups
Sex
35
Overall
Female
22.25 20.83
20.65 24.62
27.30 24.28
34.15 33.45
22.15 20.18
18.00 17.00
24.08 22.89
16.20 16.40
13.65 12.82
13.30 12.95
10.95 10.85
12.60 12.50
20.05 19.35
14.46 14.13
A B C D E F
Groups
Fig. 2 : Mean Self-Esteem scores of
various groups
35
30
25
20
15
10
A BCD
Groups
E F
ClShyness
Se/f-Ellteem
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 .4.10.11 .12. The results of the present study
vehemently augur in favour of a definitive correlation
between the severity of malocclusion and the
psychological 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 (Mi d 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.
36
Shyness
Self
Esteem
13.9
14.46
24.08
OMs/e
Fems/e
Fig. 4 : Comparative scores of male and
female subjects on the Shyness and
Self-Esteem scales
Females had higher shyness and a comparable self-
esteem 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 20.83
and 16.40 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 )1 3 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
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.
Groups 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" .
37
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