Kiyak HA, McNeill RW, West RA Predicting psychologic responses to orthognathic surgery. J Oral Maxillofac Surg. 1982; 40:150-155
Cadogan J, Bennun I. Face value: an exploration of the psychological impact of orthognathic surgery. Br J Oral Maxillofac Surg. 2011; 49:376-380 https://doi.org/10.1016/j.bjoms.2010.07.006
Cunningham SJ, Gilthorpe MS, Hunt NP. Are orthognathic patients different?. Eur J Orthod. 2000; 22:195-202
Hammond V. Longitudinal involvement of the psychologist in services for people born with a cleft lip and/or palate: CLP series part 3. Orthod Update. 2012; 5:78-81
Morris DO. Improving standards in orthognathic care: the bigger picture (a national and international perspective). J Orthod. 2006; 33:(3)149-51 https://doi.org/10.1179/146531205225021669
In: Ayoub A, Khambay B, Benington P (eds). Oxford: Wiley Blackwell; 2014
Barkham M, Mellor-Clark J, Connell J Clinical outcomes in routine evaluation (CORE). The CORE measures and system: measuring, monitoring and managing quality evaluation in the psychological therapies. In: Barkham M, Hardy GE, Mellor-Clark J (eds). Chichester, UK: John Wiley; 2010
Carr T, Harris D, James C. The Derriford Appearance Scale (DAS-59): a new scale to measure individual responses to living with problems of appearance. Br J Health Psychol. 2000; 5:201-215
Carr T, Moss T, Harris D. The DAS24: a short form of the Derriford Appearance Scale DAS59 to measure individual responses to living with problems of appearance. Br J Health Psychol. 2005; 10:285-298
Clinical Psychology and its role in the Orthognathic Surgical Pathway Matoula Taloumtzi Charlotte Priestley Michael Millwaters Dental Update 2024 14:4, 707-709.
Authors
MatoulaTaloumtzi
DDS, MSc, MJDF
Clinical Fellow in Oral and Maxillofacial Surgery, The Royal London Hospital
Orthognathic surgery is a major elective procedure that can pose a significant amount of psychological distress to patients before, during and after surgery. These patients tend to have higher levels of state anxiety and a poor (facial) body image of themselves. Patients less satisfied by their outcomes tend to have had particularly high expectations of surgery beforehand. Therefore, it is important to ensure that there are effective and supportive psychology services in place. Here, we assess the utility and the role of clinical psychology in modern, holistic orthognathic surgery and the tools used to assess patients for further psychological intervention.
CPD/Clinical Relevance: Clinicians should be aware of the services available to patients who are transitioning through the orthognathic surgery pathway.
Article
Orthognathic surgery is a major elective procedure that can place a significant amount of psychological distress on patients before, during and after their surgery. It requires patients to adapt quickly to their new facial features, which can be very challenging for some individuals.1 Patients often describe unpleasant experiences related to their post-surgical appearances. They may have difficulties in adjusting to their new facial image and the differences that these changes make to their overall body image.2
Orthognathic patients have also been shown to have poorer facial body image and higher levels of state anxiety (ie a temporary emotional state that arises from a particular situation, this differs from trait anxiety which can be described as a consistent personality attribute).3 It has been shown that those with particularly high expectations of surgery are less satisfied by post-surgical outcomes.2 Therefore, it is important to ensure that effective supportive mechanisms, such as psychology services, are in place for all patients.
Here, we discuss the role of clinical psychology in the modern, holistic orthognathic pathway and the tools used to assess patients for further psychological intervention. We also discuss our research on the effectiveness of clinical psychology tools in determining whether patients require further intervention.
Clinical psychology
Clinical psychology is a branch of psychology that assesses, identifies and treats a wide range of mental and physical health problems, including addiction, anxiety, depression, learning difficulties and relationship difficulties. It is one of the largest subfields within the discipline.4 Clinical psychology is principally distinguished from other psychological, or helping, professions by its clinical foundation. It tends to use the results of research on human behaviour to assess, understand and help individuals.5
Clinical psychologists have the skills and experience to assess patients for a variety of mental health, social and emotional problems. They can determine the appropriate assessment tools to thoroughly evaluate the subtleties of each person's individual situation. For example, assessment domains that are particularly important in the area of anxiety disorders may differ from domains assessed among individuals with depression or personality disorders.6 Therefore, their role cannot simply be replaced by clinicians who are unfamiliar with the broad spectrum of psychological disorders and assessments.
Clinical psychology services are commonly employed within dentistry. Such services can help patients cope with the anxiety/phobia associated with their dental visit. Clinical psychologists work with patients, over a number of visits, to help them change how they think and feel about visiting the dentist.7 Although clinical psychology services are not commonly used during orthodontic treatments, they can be useful in complex cases that demand a multidisciplinary approach. For example, various regional cleft lip and palate services in the UK may include clinical psychologists as an established member of their multidisciplinary team (MDT).8
It has become apparent that clinical psychologists have the potential to make significant contributions within the orthognathic pathway. Clinical psychologists undergo training placements, and have experience of working in a variety of settings and with a wide range of mental health difficulties. The knowledge and skills they develop as a consequence can be applied to different contexts. Often, those working in similar dental or orthognathic services may have specialized in the field of clinical health psychology, meaning that they will have experience of providing psychological services within physical health settings and understand the psychological complexities that may arise within these contexts. They will spend time with the MDT learning about the treatment and surgical procedures, and draw upon the research in the area and from similar areas (such as with other elective surgeries and appearance-altering procedures), to develop an understanding of the patient group and their potential needs. In recent times, clinical psychologists have been integrated into the orthognathic MDT in various secondary care units across the UK. Their primary role is to support the MDT to develop skills in identifying and discussing psychological/mood issues. Their experience of psychological problems associated with appearance-related distress, and issues associated with the transitional period from late adolescence to adulthood, reinforces their usefulness in an orthognathic MDT because the majority of orthognathic patients belong to this age group.
They aim to provide a psychological pathway of care for patients undergoing orthognathic surgery, from their first pre-operative consultation right through to their post-operative follow-up. Their role, among others, may involve assessing body image and appearance concerns, patients' expectations and understanding of surgery, as well as any mental health concerns that may impact on the treatment processes.9 They also assess a patient's suitability for surgery by recognizing those patients who would not benefit from surgery, such as those with unrealistic expectations. They can also support patients during decision-making and provide psychological interventions.10
Where necessary, they provide tailored support to patients and their families prior to, during and after orthognathic surgery. They aim to improve psychosocial outcomes for patients through promoting adherence to treatment and assisting patients to adjust to their post-operative appearance. Orthognathic clinical psychologists are also involved in audit, research and teaching/training regarding psychological concepts.
Psychological assessment
The psychological screening assessment takes place within the joint orthodontic–orthognathic clinic, preferably before the patient is seen by other members of the MDT. It is carried out in a one-to-one setting to create a comfortable environment where patients are likely to disclose the maximum amount of information. It is brief and focused on aiming to cover areas relevant to patient satisfaction both with the process and the outcome of orthognathic treatment. Assessment and interventions in orthognathic clinical psychology are based upon research, evidence and NICE guidance. In areas where the literature is in its infancy or is sparse, clinical psychologists can draw on similar areas, such as from the field of plastic surgery and other elective surgeries.
During the assessment, the clinical psychologist collects information on the patient such as sex, occupation, education and cultural identity. Important psychological information which can be determined and presented to the MDT is summarized in Table 1.11
Information determined during psychological assessment
Patient's perception of the presenting problem and any functional and psycho-social impact
Patient's motivation for, and expectation of, treatment. Identification of those whose perceived problem is unlikely to be resolved by treatment
Patient's psychological status and early identification of those patients who may need psychological support during treatment
Assessment of risk factors predicting dissatisfaction with treatment. For example, body dysmorphic disorder or having very high expectations regarding the psycho-social outcomes of treatment
Study
In our department, clinical psychologists have been part of our team for 15 months. They are a dedicated team of two clinical psychologists, both working part-time (0.8 FTE and 0.6 FTE). The specific points in the OGS MDT pathway at which they have direct patient input are when the patient is seen for the first time at the combined clinic, and they will review patients prior to and after surgery. Patients can be referred to psychology at any point throughout their patient journey.
Two psychological assessment tools have been used at the initial assessment prior to further psychological assessment, can be used as a post psychological intervention measure (if the measures are relevant to the work) and at the end of treatment.
This study is a prospective service review using a convenience sample. The sample included all the patients who presented for the Barts Health NHS Trust orthognathic MDTs at The Royal London and Whipps Cross hospitals from October 2018 to December 2018.
Aim
The primary aim was to assess the utility and effectiveness of psychological assessment tools in determining which orthognathic patients would benefit from a referral for further psychology services or whether a more in-depth psychological assessment from a clinical psychologist was indicated.
Method
In total, 77 pre-surgical orthognathic patients who attended the Barts Health NHS Trust Orthognathic MDT were assessed by a clinical psychologist at a one-to-one session during their first visit to the MDT. In addition, two psychological screening tools were used.
Psychological assessment tools
The Clinical Outcomes in Routine Evaluation-10 (CORE-10) tool was developed as a shorter and easier-to-use version of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) tool to help identify psychological distress and evaluate the effectiveness of psychological interventions.12 Patients were given a questionnaire with 10 questions about how they were feeling over the past week, each with five possible answers. Each answer is marked with a number from 0 to 4. The sum of all answers gives a total score from 0 to 40. The CORE-10 estimates a patient's level of psychological distress and gives an indication of their mental health. The clinical cut-off score for general psychological distress is 11. For depression, the cut-off score for the CORE-10 is 13.12
The Derriford Appearance Scale 24 (DAS-24) was also developed as a shorter and easier-to-use version of the comprehensive DAS-59 evaluation, and it measures distress and dysfunction associated with appearance.13 It identifies the body part or parts about which the respondent may be self-conscious. Questions measure the intensity of emotional responses, such as the amount of distress when looking at oneself in the mirror and the frequency of behaviours that can be indicative of a self-conscious response, such as avoiding leaving the house. Each of the 24 items has response categories that are scored from 0 to 4. The response category indicating more distress scores the highest. The scores are summed to provide a total score from 11 to 96. There is no threshold or cut off point to indicate who has problems at a higher level than normal.14
Statistical analysis
A chi-squared test was used to assess the relationship between a CORE-10 greater than 11, indicative of psychological distress, and a CORE-10 greater than 13, indicative of depression, and a referral for further psychological services. The chi-squared test was also used to check the relationship of an increased DAS-24 and the offer for further psychological input. Adjustments were made for the age and gender of the patients.
Results
In total, 77 patients were assessed by a clinical psychologist at the orthognathic surgery MDT. The sample had a mean age of 21.8 years (SD 8.73) and an age range of 14–54 years. Two-thirds of the sample population were female. Of the 77 patients, 19 were offered further psychology assessment. The mean CORE-10 for females was 8.14 (SD 7.3) and males 6.9 (SD 7.1). The mean DAS-24 for females was 35.3 (SD 13.2) and males 33 (SD 12.8).
A CORE-10 >11, indicating general psychological distress, was not found to be a significant factor to determine referral for further psychology assessment (P=0.090). Seven out of 13 patients who obtained a CORE-10 greater than 11 did not get an onward referral. When we tested for the subsample who had a CORE-10 score >13, which indicates depression, we found that such a score had a statistically significant association with the offer of further psychology services (P=0.012).
The level of distress and dysfunction for problems with appearance (DAS-24 score) was shown to have a statistically significant association with further psychology intervention, with patients with higher levels of distress being more frequently referred (P=0.009). The association, however, became insignificant after adjustment for patients' age and gender (P=0.063).
When the offer for psychology services was checked against the age of the patient, the association was significant, with older patients being less likely to be referred for such services (P=0.0490). Men and women had similar chances of being offered further psychology input.
Discussion
In evidence-based psychological assessment, research and theory are used to guide the specific theoretical concepts to be evaluated for a particular assessment purpose, the exact methods and measures to be used and the way the assessment should be conducted. This means that even when data from psychometrically strong measures are available, the assessment process is an iterative, decision-making task for the psychologist. New data, even if they are incomplete or inconsistent, should be integrated in each iteration, and new hypotheses should be tested considering potential bias, as well as the impact the assessment may have on clinical outcomes for the assessed person.15
In other words, psychological assessments require the skill and knowledge of the clinical psychologist to understand and interpret the information taken from an assessment and determine those who require further assessment and intervention. This is evident from the above research as 77 patients were assessed by the clinical psychologist, with only 19 patients referred for further psychological intervention. However, when we look at the distribution of the CORE-10 scores, there is variation among the scores provided and those who had further assessment. Seven patients who obtained a CORE-10 greater than 11 did not get an onward referral, therefore, reinforcing the point that despite assessments being based on a strong evidence base, there is an element of experience and skill required from the clinical psychologist to interpret the data.
Clinical psychologists collect assessment data from various sources, such as interviews, observations, questionnaires, tests and medical records. They normally use multiple assessment sources to cross-validate their assessment. A similar approach was taken to validate the assessment methods used in the above research.
The mean DAS-24 for females was 35.3 (SD 13.2) and male 33 (SD 12.8). When compared to previously published data for general population of 37.09 (SD 15.13) and 29.04 (SD 12.1),14 the DAS-24 from our female sample appear lower (Figure 1). Various reasons for the low DAS-24 may indicate that patients are under reporting, have an inability to verbalize their concerns or that the questionnaires are unable to identify appearance-related distress, strengthening the need for a multifactorial approach to psychological assessments.
Figure 1. Comparison of mean DAS-24 relative to the general population.14 M: male, F: female.Figure 2. Comparison of mean CORE-10 relative to the general population.12 M: male; F: female.
Assessments by clinical psychologists are important in determining the suitability of patients for further psychological assessment and intervention. Psychological screening tools appear to be useful aids in identifying and deciding which orthognathic patients should be offered further psychology assessments. The CORE-10 was particularly useful when a score >13 was recorded because this was a robust predictor of offer for such services, in agreement with the clinical psychologist's interview outcome. However, interpretation and assessments by clinical psychologists appear necessary in determining the suitability for an onward psychological referral.
Conclusion
The CORE-10 and DAS-24 are useful screening tools; however, interpretation and individual assessments by clinical psychologists also have an impact in determining the suitability for an onward psychological referral. It is clear that clinical psychologists are important members of modern, holistic, orthognathic MDT teams.
