psyhologic preparation

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Psychologic Preparation of Denture Patients

Charles C. Swoope, James M. May – Clinical Dentistry – vol. 5

Denture patients are generally older individuals with a changing outlook on life.

This is due to many factors, including decreasing physical capabilities, changes inappearance, and increased incidence of generalized systemic disease. Feelings of

depression are common with changes in physical well – being. There is an increasing

tendency to feel they have outlived their usefulness. The incidence of emotionaldisturbance is quite high in the elderly population. Emotional preparation will always be

required as a part of prosthodontic treatment.

The prevalence of emotional disorders which create denture problems is not

known, but there is some information concerning emotional disturbances in the general population. Studies indicate that approximately 25% of the population have impaired

emotional stability, and the incidence of problems increases with advancing age. Health

surveys show an increased incidence of chronic disabilities of all types in studies of older

patient groups, and 8% to 10% of all persons reporting limited activity relate thislimitation to mental and nervous conditions. These findings indicate that denture –

wearing populations can be expected to contain significant numbers of patients with personality disorders.

There is little question that emotional problems can interfere with dental treatment

and patient adaptation to dentures. These disturbed patients create the greatestmanagement problems in the dental office in terms of dentist frustration and

nonproductive time. A cycle of fear and antagonism can develop rapidly between the

dentist and the patient. When the loss of confidence occurs, communication falters and a

brilliantly executed treatment can fail miserably. This problem is illustrated by thedenture that is technically adequate to the dentist but is unsatisfactory to the patient.

It is important to recognize that the attitude and behavior of the patient can affectthe dentist` s behavior. Dental patients are frequently nervous, ap0prehensive, andsuspicious. Nervous patients can cause the dentist to become nervous at the very time

there needs to be a calm person in control. It is easy to display patience and confidence in

the face of irresponsible statements and accusations.Emotional factors can play a significant role in the alteration of normal

physiologic processes. The relationship of emotional factors to dental disease is also

significant. Studies indicate a positive relationship between emotional factors and dental

caries, temporomandibular joint disease, and periodontal disease. Insecure person have poor tolerance for discomfort and will bear less injury; and persons in conflict may

release their frustration on a tangible focus such as the denture. The adaptive capability of

patients may be seriously impaired by their emotional state. Emotional stability is asignificant factor in patient satisfaction with dentures. There are to aid in predicting

problems, improving communication, and breaking a fear – antagonism syndrome. They

will be discussed later in this chapter.

Body Image

Over the years, we all form a concept of ourselves. We are accustomed to our

bodies and are comfortable with them. Even though our particular body may not be the

best one, we are used to it and have come to like it. It is important for the dentist to



realize that most prosthodontic care will make a change in the body image of the patient.

The result may be technically correct and a great improvement in the eyes of the dentist

but may be rejected by the patient.The loss of teeth and construction of a denture will certainly make a significant

change in the body image of the patient. Whether patients will adjust to the new situation

of dentures will depend on their emotional preparation. All patients will need time to getused to the idea of the change. Stable patients will need less preparation, consisting

mostly of an explanation of the procedures. Patients who are less stable need more

preparation because of their fears. The loss of the teeth as a body part may be threatening.The stress of this loss will produce anxiety and, in persons with personality disorders,

will result in symptoms. These symptoms provide the most difficult management

problems for the dentist since they are not related to technical deficiencies in the

dentures. Less stable patients need to discuss their fears, ask questions, be reassuredabout superstitions, and have more detailed explanations. The dentist can stimulate this

discussion by giving some examples of fears of the other patients and then asking how

this patient feels about the loss or change. The time spent in this emotional preparation is

essential to the success of treatment.The area of the face and mouth has great psychologic significance. Since the area

is emotionally charged, the response to change in the area may be exaggerated.Symptoms resulting from anxiety are most common in the face; these may range from

pain, bad taste, clenching, and grinding to a denture that does not fit. Symptoms of this

type are commonly produced by anxiety in persons with personality disorders when therehas been a change in body image. Patient responses may be inappropriate for the

procedure being performed. They are exaggerated because of the significance of the

mouth and the emotional state of the patient at that moment.

Significance of Tooth Loss

The decision to remove the teeth and construct replacement appliances is a very

serious event for a patient. There are many considerations in determining the need for

extraction, and they should be carefully weighed.It is imperative to predict what effect the loss of the teeth will have on the patient.

The dentist can easily predict and inform the patient of the obvious impairment of

masticatory function. However, it is more difficult to predict the psychologic effect of tooth loss; these psychologic limitations may result in failure adequately with the

dentures.

Nothing represents aging more dramatically than the loss of teeth. We tend to

associate the loss of teeth with relatives, acquaintances, or cartoon characters who wear inadequate dentures. The sunken face, closed vertical relation, unsupported lips,

prominent chin, clicking teeth, and poor speech are associated with growing old, changes

in appearance, and loss of reproduction. It is not surprising that patients fear the loss of teeth since to them it signifies a decrease in their worth as an individual.

Retaining the teeth may be symbolic of retaining youth in a distorted body image.

The patient may place the highest priority on saving the teeth and be willing to pursue avery involved treatment plan. The reaction to the suggestion of tooth removal may be

unusual and exaggerated. The dentist must make some assessment of the values and

emotional state of the patient to plan an effective treatment that has some chance of

actually being implemented.



For many people the construction of dentures is not a great emotional experience

because they may have encountered many problems with their natural dentition.

Receiving dentures may actually provide a relief from a long series of dental problems.The majority of patients are stable and adapt readily to wearing complete dentures. The

patient with emotional problems responds to this situation in an exaggerated,

inappropriate manner which interferes with the adjustment to wearing dentures. The needfor emotional preparation must be recognized and the preparation must be carefully

planned.

Classification of Patients

Many classifications have been suggested to aid the dentist in evaluation of

denture patients. The dentist is not trained in psychiatric techniques and may not be very

perceptive of patient attitudes and feelings. It is imperative, however, that some

psychologic assessment be made to arrive at a realistic prognosis. The importance of mental attitude in predicting problems, prognosis, limitations, and possibilities for

improvement cannot be overemphasized. Types of classification make it easier to discuss

groups of patients but are not particularly helpful in planning a course of treatment. It is

more meaningful to discuss patient behavior which interferes with treatment or interfereswith adaptation to appliances.

Patient Behavior which Interferes with Adaptation to Dentures

The following discussion will classify patients in terms of behavior which

interferes with dental treatment. General behavior patterns will be described and will be

followed by a description of possible patient responses in a dental situation. Thecategories are not mutually exclusive and there are overlaps between groups. Patient

behavior is a complex subject, but some categories are helpful, although they do not

occur in such simple and convenient forms. We are not particularly concerned with

specific classification of patients but are interested when significant improvement can be predicted.

Depression

This patient type is characterized by a decrease in self – esteem which results ingeneral inhibition of intellectual and motor function. They tend to feel helpless, hopeless,

and pessimistic, which leads to a progressive decrease of interest in the outside world.

There is an increased awareness of bodily functions and a frequent tendency towardhypochondriasis. Somatic complaints become an exaggerated focus of concern to gain

sympathy and support. The people around them tend to become tolerant and take care of

them. Depression usually is precipitated by a loss, eg, the death of a spouse. Age changes

such as loss of reproductive function, increasing wrinkles and gray hair, and loss of teethmay be important factors. We can characterize these patients by a loss of interest in

appearance, family, job, or food.

Depression takes varied forms in dental patients. Disturbances in food intake,gastrointestinal function, and elimination are frequent complaints. They relate these

problems to the denture in terms of poor mastication. Physical examination frequently

reveals no organic basis for basis for constipation, vomiting, or other vague GIcomplaints. An inadequate denture may be suggested as a contributory factor by the

examining physician, and improved digestive function may unfortunately become the

criterion for successful dentures. These patients require considerable supportive care in

the form of encouragement. They may form a dependent relationship with the dentist,



who is friendly and attentive, and may return on a periodic basis with trivial complaints.

Their family may have developed other interest, leaving the patient on the periphery of

family activities and feeling that he no longer fulfills his role in the home. Since thedenture is a very tangible object and may not be particularly comfortable, it is frequently

blamed for dryness of the mouth, decreased taste sensation, decreased appetite, and a

burning sensation in the palate.Dental management begins with careful history taking, including health

questionnaires (discussed later) such as the Cornell Medical Index. It may be desirable to

defer complex care until a more favorable time. A decision must be made for eachindividual, since new dentures may lift their mood. Management includes conservative

supportive care in the form of praise and encouragement. Since these patients commonly

return regularly for treatment, a definite period of postinsertion care should be included in

the original fee. Care is taken never to joke about “false teeth”. Concern must be focusedon replacement, not loss of teeth, so that the denture becomes an exchange and not a loss.

Organic Brain Syndrome

The basis for this classification is a diffuse permanent cerebral lesion caused by

aging, brain disease, or injuries. In a dental situation, this group is typified by the seniledenture patient. Since most denture patients are old, there is a prevalence of this condition

in prosthodontic practice. These patients exhibit disturbances in complex and abstractthinking, memory defects, disturbances in intellectual function and judgment, and

inability to learn new skills. Past personality disturbances may be emphasized or

exacerbated.These patients present characteristic problems in a dental situation. It is difficult

for them to follow instructions such as completing information sheets or questionnaires.

They may have difficulty remembering common items such as their address, telephone

number, physician` s name, and postinsertion instructions. Admitting they had forgottenwould be tantamount to admitting a decrease in mental competence; therefore, they may

deny what was said or think something else was said. These patients adhere to

accustomed practices and do not easily master new skills. Since adequate function withappliances is a learned skill, they frequently encounter difficulty and become

discouraged. Dissatisfaction with previous care is commonly expressed, even when the

dentures were technically adequate. They are inflexible in their judgment and may prematurely decide the new dentures are also inadequate. It is most difficult to reason

with them because they are unable to assimilate new facts and often become confused or

suspicious.

Successful management depends on a simple, well – structured program of treatment and instruction. It is not necessary or desirable to give long explanations of

procedures or rationale for treatment. Instructions for postinsertion care should be simple,

brief, and written. It is helpful to have a written statement of office policies regardingfees and methods of payment and postinsertion care included in the original fee. The

receptionist or dental assistant should always call to remind these patients of

appointments. Recall telephone contacts should be made after insertion, especially if scheduled postinsertion visits are missed. This is to insure that the dentures are being

used. An effective approach is to praise their adjustment, which induces a feeling of pride

in their progress by focusing on their attributes rather than on minor difficulties. Because

they are easily discouraged, this type of continued support is essential. Management is



characterized by simplicity, structured routine, and encouragement. Another member of

the family is brought into the room at the time instructions are given so that they can

assume the responsibility to remember the medicine, postinsertion care or cleansinginstructions.

Passive – Aggressive

This is a large group of dental patients whose behavior varies from passive toaggressive. Their underlying problem is unresolved dependency, and behavior may vary

from dependent to exaggerated independence. Their need to depend, be cared for, and be

dominated is an indication of their low self – esteem. When dependency needs are notsatisfied, they may react with hostile aggressive behavior. Behavior may become

aggressive, contrary, or authoritarian. Intimidating the dentist or others is an attempt to

elevate their precarious self – esteem. They may attempt to manipulate the dentist into the

position of an authoritarian manager to avoid responsibilities for decisions, and thedentist is often encouraged to make decisions in personal as well as dental matters. These

patients appear helpless by making statements indicating that the dentist is an expert and

they want to “ leave these decisions up to the doctor.” They seem incapable of decisive

action, even with strong encouragement. An example of this characteristic would be aninability to proceed with extractions, despite the recommendations of several dentists and

imminent pain.Inappropriate expressions of hostility in a dental situation may take many forms.

Patients may be passive or covert such as being late or breaking appointments.

Appointments may be extended by lengthy discussions or activities such as rinsing themouth, clearing the throat, or wiping the face with a tissue. Passive hostility may be

expressed by an inability to follow instructions. The unconscious need to remain

dependent on the dentist may prevent them from following postinsertion instructions.

These patients frequently involve the dentist in long discussions to prolong therelationship. These expressions of hostility are time – consuming and difficult to manage.

Dental management should be firm but attentive. The patient should be strongly

encouraged to make some decisions, eg, final selection of tooth form, after the dentist hasselected several molds that are suitable. Participation in decisions carries some

responsibility for the final result. Sharing in decisions may help to elevate their self –

esteem by implying that their opinion has value. This facilitates the treatment byminimizing the need for indirect expression of anger. Explicit instructions should be

given in writing for postinsertion care and should include items such as cleansers, oral

hygiene instructions, and leaving the dentures out of the mouth at night. There should be

a clear understanding of fees involved, the length of postinsertion care included under thefee, and whether there is a separate fee for relines. The use of a brief written report is

particularly helpful to prevent misunderstanding with this type of patient. The patient

should sign a statement in the chart that they have had the opportunity too see the teeth inwax at the clinical try – in and are satisfied with their appearance. Patients may criticize

the denture to prolong a dependent relationship, but usually they accept the denture in a

passive manner in order not to appear critical of the dentist. Therefore, any hesitation tosign such a statement is evidence of dissatisfaction, and another try – in appointment

should be scheduled. When these aspects of management are fitted to the emotional needs

of the patient, the treatment proceeds more smoothly.



Obsessive – Compulsive

The salient feature of this group is the attempt to control the environment around

them. They have a need for orderliness and perfection, with no tolerance for ambiguity.Activities such as dental treatment represent situations over which they have little control

and therefore produce anxiety. Symptoms are productive, since they can be used to

control people and circumstances. These patients are quite inflexible and pay attention to petty detail.

Behavior in a dental situation may be to demand perfection in esthetics and fit of

dental appliances. Dentures will be minutely examined for surface roughness, occlusaldiscrepancies, or other signs of imperfection. There is tendency to engage in “hair –

splitting” arguments, endless speculations and generalizations, and lengthy verbalization

without emotion. These patients are always able to find fault and seem to need a “one –

up” relationship over the dentist. There is a frequent preoccupation with fees and “gettingtheir money` s worth.” The need for orderliness and inflexibility may manifest itself in

many ways. This type of patient finds it difficult to change existing habits such as oral

hygiene and leaving the dentures out of mouth at night. Activities may be charted such as

past dental procedures and the dentist who performed them. These patients abhor anysuggestion of unhygienic action by the dentist or the staff such as dropping instruments

and re – using them or not washing their hands in the presence of the patient. They mayrequest that the towel and cup be changed to insure cleanliness. Their orderly, meticulous

nature may be reflected by their arrival time for appointments, compulsively early or

punctual. The dentist can expect to be chastised if late and to be reminded how early the patient came. The needs of these patients must be recognized to insure successful

treatment. Dental management consists of efforts to meet their needs for orderliness and

control which are balanced against the needs of the dentist, such as office routine and

efficiency. Every attempt should be made to be punctual with these patients. It is helpfulto place a clean cup after the patient has been seated and to wash the hands after entering

the room. The dentist should not be drawn into lengthy, minutely detailed discussions,

but spurious generalizations should not go unchallenged, since this would implyagreement.

Their need for perfection may result conflict with the dentist. Therefore, it is

helpful to involve patients in responsibility for the dentures by insisting that they participate and assist in various phases of the treatment. The dentist should resist feeling

defensive or antagonistic in the presence of critical requirements.

Additional time will be required to satisfy the requirements of these patients. An

increased number of postinsertion visits should be anticipated to correct minuteimperfections. Initial fee determination should be based on anticipated chair time. It is

not desirable to add additional fees at a later time, since this will intensify any patient –

dentist conflict. The dentist should be firm in the relationship with these patients and notacquiesce to unreasonable demands. A written policy statement should be prepared

regarding care of dentures, fees, method of payment, services, and length of care included

in the original fee.

Schizophrenia

There is generally accepted definition of this condition, although half of mental

hospital patients have this diagnosis. The prodromal symptoms are not distinctive; types

of behavior include hysterical, depressive, obsessive – compulsive, and hypochondriacal.



These patients can generally be categorized by inappropriate behavior, a private

language, and hallucinations or delusions. They show an inability to think abstractly;

thought processes are disordered; and preoccupation with religion or internationalconflicts is common. Disturbances occur in activity as well as thought. Severe symptoms

are easily diagnosed, but suggestive symptoms present greater difficulty. Treatment for

suggestive symptoms follows the appropriate form for the behavior present, such asdepression. Suicide may be a danger, particularly with heavy alcohol intake.

Dental behavior is a function of their psychopathology. Distortion of body image

may occur concerning the teeth, gingival, or facial appearance. They may feel that theteeth are causing disease or a change in appearance. Symbolism in speech, ideas, and

behavior is common, and the oral structures may have a special meaning which is

incomprehensible to the dentist. Social withdrawal makes it difficult for the dentist or

assistant to establish rapport. There is an increased sensitivity to sensory and emotionalstimuli, which may result in inappropriate responses to minor dental tasks. They may leap

out of the chair and leave the room or grasp the dentist` s hand. They are not “imagining”

pain but feel it with more intensity due to the state of their nervous system. Hallucination,

especially auditory, usually represents evil, e.g., enemy voices coming from the teeth.Olfactory or gustatory hallucinations may involve sudden horrible taste or odor attributed

to dentures. Language is primarily a means of self – expression for these patients not ameans of communication. It takes the form of lengthy, rambling, detailed, and difficult –

to – decipher speech patterns or written statements.

From a dental standpoint, the thought disorder must be considered in arrangingthe treatment. The dentist should avoid any display of instruments. It is important to

avoid casual conversation, instructions, or gestures to the assistant which might be

observed or misinterpreted. For example, an instruction to the assistant to “bring the

scalpel” might result in great anxiety during impression appointment. A more appropriatestatement within hearing of this patient would be, “Bring the number 25 so that I can trim

the impression tray.” The patient should be carefully observed to note signs of anxiety,

such as perspiration, muscular tension, or agitation.

Hysteria

Hysterical patients develop prominent somatic symptoms which lead them to seek

care. This is common in females who are physically oriented. Symptoms of hysteria arethought to be symbolic of underlying mental conflict, and this mechanism lessens

conscious anxiety. Stress situations which cause anxiety are converted into physical

symptoms with no anatomic pathologic change. Conversion refers to insecurity or anxiety

about a thought which is unacceptable, which is converted to physical symptoms. Agingis a common unacceptable event for these patients. The symptoms may be symbolic

representations of the thought. Pain is the most common, but blindness, anesthesia, and

paralysis also occur. Symptoms occur commonly in the face area, with anatomic findingswithin the normal range. Examples are pupillary response in a patient with blindness or

anesthesia which does not follow neurologic distribution. The symptoms usually involve

body parts under voluntary control and cannot be explained on a neurophysiologic basis.A distinguishing characteristic is that the symptoms have a purpose, generally avoidance

of a conflict.

Common dental findings are paresthesia; anesthesia or burning sensation in the

lips, tongue, and palate; and muscular tics involving the lips. They may have an



inordinate fear of needles, sharp instruments, and “drilling.” This acute fear may lead the

patient to resist insertion of any instruments. Other symptoms which may cause the

patient to come for evaluation include inability to swallow (dysphagia), dry mouth,excessive salivary flow (sialorrhea), or pain at a healed extraction site. They may feel that

past dental care such as a denture is responsible for the symptom. There may have been

an original organic etiology, but the physical symptom was useful and was perpetuated. Itmay be used to obtain sympathy, affection, or decreased responsibilities.

Occasionally these patients are docile throughout treatment and then become

hostile at the first visit following delivery. Hysterical symptoms may develop at this point. It is crucial that the dentist remain calm and sympathetic. Reassurance is important

since the patient needs this emotional support during the adjustment phase.

Dental management is aimed at excluding organic disease and reassurance about

symptoms which have anxiety as their etiology. No irreversible treatment of a destructivenature such as extraction should be performed. If organic disease such as neurologic

injury or hormonal deficiencies are not present, it is unlikely that dental treatment would

result in lasting improvement of symptoms. The patient should be reassured that no

disease process is present, e.g., patients who complain of burning sensations in the palatewhen the tissue appears normal. An effective approach is the suggestion that this

sensation may represent an idiosyncracy of their mouth and is something they will haveto tolerate. The suggestion should be made to examine their mouth on a periodic basis to

be certain that a pathologic condition does not evolve. The dentist and patient should be

pleased that no serious disease is present. Care should be taken to be attentive to their complaints, since indifference by the dentist may be interpreted as hostility. A brusque

impersonal approach may increase their fear, decrease communication, and lead to

antagonistic and uncooperative behavior. Effective management requires conservative

treatment and recognition of the patient` s anxiety. The dentist is usually able to helpthese patients by a good listener and providing some emotional support. It is very

important not to overtreat patients with facial symptoms, especially pain; for example,

teeth should not be extracted unless a definite pathologic etiology can be identified. In some instance it is not possible for the dentist to help the patient, but in all instances the

patient should not be harmed. Every attempt should be made to provide treatment which

is reversible. In the case of severe anxiety, evaluation by mental health personnel should be a prerequisite to dental treatment. Psychiatric treatment may include individual

psychotherapy and tranquilizing medication.

Paranoia

These patients are unable to trust and are characterized by suspicious, hostility,and rigidity. There is a constant feeling that others are discriminating against them or

taking advantage of them. They react with fear and anger, find fault with everyone, and

have special mistrust of any authority figure. Most of them are driving, ambitious,aggressive, hostile, and destructive. There is a tendency to criticize everyone around

them, but they are extremely sensitive to criticism. Criticism is interpreted as an attack,

and they respond with a counterattack. There is an inability to recognize their ownhostility and they project it onto others. Accusations against acquaintances sound like

descriptions of themselves, but they are not aware of this fact.

Gestures by others are interpreted as unfriendly, hostile, detrimental, and

humiliating. They cannot tell friends from foe and treat friends as if they were enemies by



constant testing and provoking. Their few friends finally withdraw, which reinforces their

mistrust and suspicion. The slightest rejection results in automatic anger, misread

motives, resentment, and thoughts of revenge. There is a constant search for hidden cluesand meanings. They feel they cannot depend on anyone but themselves.

Paranoid patients begin by commenting on the high level of competency of the

dentist and on the pleasant office. This is followed by a description of how poorly theywere treated previously. Later they begin to question the present treatment. The

appropriate response is not to overtreat by treating only obvious organic disease. Dental

treatment may be regarded as an attack, and they will view the dentist with distrust. Theyare very suspicious of past dentists and their motivation for rendering care. Past dental

care is blamed for all their problems. Verbal attacks are made on the dentist for supposed

rejection or personal slights, with responses excessive in proportion to the supposed

injustice. They commonly seek opportunity for lawsuits against the dentist.Patient wishes are expected to be known without being stated. This phenomenon

is common in the process of tooth selection, tooth position, removal of wrinkles, vertical

dimension, and fees. If instructions which affect the success of treatment are forgotten,

patients will deny receiving them and blame the dentist for any problems. Minute detailsout of context may be used to prove the dentist is at fault.

The dentist should be business – like and avoid excessive friendliness because thelatter might be viewed as having ulterior motives. Detailed records must be kept,

including handwritten lists of desired changes, signed statement of approval of esthetics,

and copies of instructions and financial arrangements. It is imperative to be scrupulouslyhonest at all times, since the patient will remember minute details. These patients are

difficult to treat because of their hostility and frequent recourse to revenge through

lawsuits.

Hypochrondriasis

This is a descriptive term, not a disease category. It is included as a separate

group since these patients present difficult diagnostic problems. Hypochondriasis is a

frequent overlay in various mental health disorders, especially depression. There ishabitual overconcern with health, with active searching for signs and symptoms. Diffuse

somatic complaints and physical symptoms with no demonstrable organic change are

common. An unrealistic assumption of illness leads to exaggeration and misinterpretationof normal body processes or insignificant symptoms. It is extremely difficult to convince

these patients that their assumptions are erroneous. They will seek many doctor` s

opinions and submit to lengthy and expensive diagnostic procedures. The behavior of

these patients varies from dependent to suspicious to hostile. These patients are difficultto influence, and there is little success in the use of persuasion or suggestion to gain

insight into psychologic mechanisms.

Evaluation of previous dental work may be requested. Suspicion that the dentist is protecting a colleague may result in abrupt termination. Denture symptoms are

exaggerated, and new symptoms appear as current ones are relieved. Pain complaints

may be vague and frequently described as burning sensations. Examination usuallyreveals an absence of inflammation. Numerous somatic complaints are readily elicited by

health questionnaires such as the Cornell Medical Index. The most common complaints

concerning prosthodontic care involve 1) pain, 2) cancer phobia, 3) vague GI complaints,

and 4) poor function. Some patients tend to form lasting attachments with the dentist and



return for many visits. Feelings of neglect are overcome by attention from the doctor.

They relate to particular hospitals or clinics and characteristic of these relationships are

statements like “my hospital” or “I have been coming here for 20 years.” The waitingroom and regular appointments become important social instruments in otherwise lonely

lives.

Dental management should generally be conservative. Reassurance is importantwhen cancer is feared and no organic change is visualized. Since therapy will not remove

symptoms, except as a transitory result of the treatment, patients must recognize that they

will have to tolerate the problem. The offer of regular examination to insure the absenceof disease is reassuring and tends to reduce their search for a “cure” that will not occur.

The dentist should be careful not to be over solicitous and to keep complaints in their

proper perspective. Firmness and positive statements are indicated when the patient` s

assumptions are incorrect. Care must be taken to prevent extensive periods of chair time being taken with lengthy and frequent visits. Long – term supportive care should be

anticipated and considered in fee determination.

Psychophysiologic Disorders

Emotional factors can play a significant role in the alteration of normal physiologic processes; examples of specific disorders include peptic ulcer, ulcerative

colitis, obesity, asthma, and gingivitis. Technically, bruxism is not a psychophysiologicdisorder, but it is a significant dental problem which involves an interaction of

psychologic factors and oral structures. It is detrimental to the teeth and the supporting

structures and may contribute to accelerated breakdown in the presence of dental diseasestates. Denture patients commonly exhibit bruxism, as evidenced by fractured denture

bases, chipped denture teeth, soreness of the ridge crest, and accelerated ridge resorption.

These patients should definitely be instructed to leave the dentures out of the mouth at

night.Management begins with the dentist having some familiarity with

psychophysiologic mechanisms. The specific problems are numerous with obscure

etiologies, and palliation may be all that is possible. Disease processes, e.g., periodontitis,which eventually occur or are made worse as a result of these disorders, must be treated.

Psychiatric assistance may be helpful with techniques such as insight oriented

psychotherapy, hypnosis, or tranquilizers.

Referral for Psychiatric Consultation

The preceding discussion has dealt identification of patients with emotional

problems or personality disorders. Management in a dental setting has been discussed

with the objective of care being provided by the general practitioner. The family dentistknows the patient well and has observed changes over time. The patient has confidence in

this dentist. It is important that the dentist be a good listener. In many instances patients

will feel much better after telling their problems to the dentist who did nothing more thanlisten sympathetically.

Occasionally, severe emotional disturbances that the dentist is not capable of

treating are recognized. There is an obligation to help the patient get to someone trainedin mental health problems. Helping the patient receive care includes helping him

recognize the need for care. The suggestion that a psychiatric consultation is required

must be handled with great tact. The response from the patient may be negative and

vigorous. Common responses are, “I` m not crazy,” or “there is nothing wrong with me.”



Most prosthodontic patients are older and psychiatric treatment in their opinion is a social

stigma. It is difficult for them to accept that they are contributing to the problem because

of their emotional instability. Careful preparation of the patient and tactful presentation of the suggestion will help prevent this type of negative response.

A useful approach is for the dentist to say that a careful examination has not

revealed any organic basis for the problem and that they both should be glad of this. Itcould have been something harmful or dangerous but instead is some particular

idiosyncracy of their tissues to appliances. They should be reassured that pathosis is not

present. A statement should then be made that the dentist has seen many patients withsimilar problems and that these patients had in common tension and stress. An

explanation is made that the body can respond in many ways to stress, such as in the

production of gastrointestinal disturbances. Most patients are not aware that stress can

also cause dental – facial problems such as a bad taste or facial pain.At this point, the dentist must be able to make a specific referral. The psychiatrist

must be one who is oriented to dental problems or who has worked with the dentist

previously. The dentist says to the patient, “I have a colleague who is very interested in

problems like yours. I want you to see this doctor so that we can both be helped to better understand your dental problems. I am very concerned about your problems and want to

help you overcome them. May I call now and arrange a visit for you?”

Identification of Potential Problems

Careful patient evaluation is important to arrive at a realistic prognosis. The

dentist is usually confident in nothing mechanical or technical problems, but it is verydifficult for most dentists to identify emotional problems which might interfere with

adaptation to dentures. The following methods can be used to help identify potential

problems.

Interview

The initial interview is a crucial time in establishing a positive relationship with

the patient. It is a time when the patient and the dentist evaluate each other. The patient

must decide if the dentist meets his or her needs and the dentist must determine what the patient wants. Four objectives for the interview ca be identified: 1) expectations or lack

of satisfaction with dentures, 2) health and patterns of daily living, 3) condition of oral

structures, and 4) technical adequacy of the present dentures.The importance of the interview cannot be overemphasized. The dentist must be

clearly aware of the problems and needs of the patient. The problems must be evaluated

to make some determination whether their basis is anatomic or psychologic. Are the

patient` s needs and expectations reasonable? Are they possible?For the dentist to answer these questions, good channels of communication must

be opened at the initial interview. Without a free flow of thoughts from the patient, the

dentist has little chance of formulating a realistic treatment plan which has some chanceof actually being performed.

Interviews can be very time – consuming if the dentist is not skilled in their use.

Unlike the psychiatrist who is trained in interview technique, the dentist has difficultymaking the interview effective and efficient. Dentist often become uncomfortable while

asking probing questions of an emotional nature since they have little previous

experience or training. As a result, few dentists set aside adequate office time to conduct

adequate interviews to provide information about patient wishes and feelings.



History

The general health experience of the patient is meaningful, but this discussion will

be confined to the dental history. The dental experience provides insight into the patient` s response to previous care. The amount, frequency, and nature of care indicate

the dental needs of the patient and patient and the priority given dental care. Have they

had dentures in 5 years or one denture for 25 years? Both of these situations could bedifficult, but for different reasons. Were new dentures frequently required for appearance,

facial wrinkles, comfort, or function? Why is care sought now? Are they in this office

because they recently moved to the area or because of dissatisfaction with the previousdentist?

A written denture history provided by the patient together with a list of

complaints and desired changes make meaningful discussion easier. It is sometimes

difficult for patients to verbalize their feelings in a dental setting.

Health Questionnaires

The use of these questionnaires has proved to be an effective and efficient method

to obtain past, present, and family health information. The Cornell Medical Index (CMI)

is a useful clinical tool and has a large section dealing with the emotional status of the patient. This aids the dentist in structuring the interview and history taking to concentrate

on pertinent areas. The CMI is a useful aid in dental practice to help predict potentialdenture problems and patient satisfaction. The validity of the CMI has been throughly

demonstrated. Large – scale tests on medical populations have shown the CMI to be

comprehensive (except in the areas of dental health and diet), efficient, and practical. Thevalidity has also been tested on a large group of denture patients and proved to be a

reliable prognostic device.

It is necessary to test all patients with the CMI to use it effectively. Unless this is

done, the dentist will not be perceptive enough to recognize a potential problem. Whenthe dentist already knows the patient will be difficult, the CMI is not needed to identify

the problem. It is an error to only administer the CMI when difficulties are suspected,

since the greatest value is to potential problems that are not anticipated. Thequestionnaire is not infallible, and a number of problems will go undetected; however

others which were unsuspected will be identified.

Attempts to reduce the size of the CMI have been unsuccessful. Helpful questionshave been extracted but do not appear to remain valid outside of the context of the larger

questionnaire. Extensive testing would required to test the validity of major

modifications.

There are critical levels of “yes” responses on the CMI. A total score of greater than 25 is important. This indicates significant systemi8c disease if the “yes” responses

are localized in one organ system or possible hypochondriasis if the “yes” responses are

scattered. The interview is then structured to follow directions suggested by patientanswers on the CMI. If systemic disease is present, is it a type that will affect the dental

treatment or prognosis. If the patient is overly concerned with trivial health problems,

difficulties with dentures can be anticipated. A score of 3 or more on the last page of theCMI indicates emotional disturbances which are significant enough to affect the course of

treatment. Sections on gastrointestinal disturbances, severe headaches, worry over illness,

and fatigue or exhaustion are meaningful and help structure interviews. Other significant



characteristics are unanswered questions, qualifying statements, and answering both

“yes” and “no”.

The following questions are examples of those used for emotional evaluation bythe Cornell Medical Index:

158. Do you usually feel unhappy and depressed? Yes No

159. Do you often cry? Yes No165. Does every little thing get on your nerves

and wear you out? Yes No

166. Are you considered a nervous person? Yes No180. Are you easily upset or irritated? Yes No

182. Do little annoyances get on your nerves

and make you angry? Yes No

185. Do you flare up in anger if you cant` thave what you want right away? Yes No

Responses to questions of this type give the dentist some insight into the emotional

stability of the patient and will help in predicting problems which may be encountered

during or after treatment.Dentists who have become skilled in the use of these questionnaires refuse to

evaluate their new patients without this information. Only in rare instance will patientsrefuse to answer the questionnaire if the need has been explained. Refusal to respond is

itself a prognostic sign of poor communication and cooperation between dentist and

patient.These questionnaires are easy to use obtain maximum information with minimal

chair time. Instruction manuals are available to aid the dentist in quickly becoming

proficient in their use. Since a health history is already part of most office routines, little

effort is required to institute the use of a more comprehensive questionnaire.

Use of Written Communication

Patients with emotional problems are frequently demanding and difficult to

manage successfully. Clear communication about what is desired or requested isessential. Patients are nervous and apprehensive, and the dental office may be a place of

anxiety for them. Important items are forgotten or misunderstood during periods of stress.

Written communication of various types is very helpful to document what was requested,what was possible, and what were the responsibilities of the dentist and the patient.

Patient – Written Statements

It is helpful for the patient to write statements which are then incorporated in the

chart. This helps prevent disagreement later about what was said. It may be difficult for patients to verbalize their wishes regarding changes, or they may forget to inform the

dentist about an important item. Written statements may relate to any area about which

the dentist is concerned.If nutritional deficiencies are suspected, a “Diet Diary” is kept for 5 days. All

food intake is recorded, including specific items and amount. The diet is then analyzed

for content and modifications are recommended.When there is dissatisfaction with existing appliances, a list should be made of all

problems, complaints, and desired changes. A chronologic denture history is helpful with

patients who have had numerous appliances. These hand written lists give the dentist a

greater insight into the difficulties of the patient, and the process of writing them tends to



give the patient a better understanding of problems and what can expected from new

dentures. The implication is that the dentist is interested in the problems of the patient

and is carefully investigating all aspects before proceeding.If esthetic considerations are a primary reason foe remake of an appliance,

particular care should be taken at the try – in. The dentist should carefully refer to the list

of desired changes written by the patient at the beginning of treatment. Changes are madeat the chair, in view of the patient, and the items is checked off the list. When a particular

request is not possible, it is discussed and explained why it cannot be done. The dentist

should offer to send the waxed trial dentures home with the patient for approval. Viewingin familiar surroundings, at leisure, may produce an additional written list of desired

changes. When the changes have been made and the patient is satisfied, the patient is

asked to sign a written statement of approval in the chart. This is not used as a legal

document since the responsibility will ultimately rest with the dentist if the patient is notsatisfied. There is a considerable psychologic impact in placing a signature. It designates

approval of the proceeding statement and is used for important documents. Patients with

emotional problems may have difficulty in reaching a decision or may be somewhat

erratic. They may state repeatedly that they are satisfied with the appearance but showhesitation in signing a statement of approval. Usually the pen stops short of the paper

while an inner debate takes place. An additional clinical try – in should always bescheduled when this occurs. The waxed denture is sent home and the patient is instructed

to make a written list of desired changes. The patient is encouraged to become a

participant in the treatment, assuming some responsibility for the result, not to be merelya recipient.

Treatment Plan Summary

The use of a written resume or summary is not new. They have been

recommended to describe the treatment to be performed and to clarify office policiessuch as fees and method of payment. The report is presented in a consultation

appointment using study casts and radiographs or by mail to reinforce the examination

discussion. It can be considered a consultation for the patient who has come for advice.The terminology must be easily understood and not obscured by technical jargon.

Under general findings the report should give an overview of the problems.

“Nervous problems,” bruxism, and specific areas of patient concern are carefullydocumented for the patient with emotional problems. Discussion continues for specific

areas such as radiographic findings and a description of each jaw. If the report is to be

discussed with the patient, radiographs and study casts are utilized to illustrate important

points. A series of recommendations is listed, representing a systematic approach totreatment. Items such as tissue conditioning, massage of the tissue, and use of a duplicate

denture are mentioned. The patient concludes that the dentist: 1) knows what to do and

2) has carefully planned the course of treatment. The fees are carefully stated, includingtotal amount, services included, and method of payment. A specific statement is made

about postinsertion care included in an initial fee. Emotional patients may give an

exaggerated response to institution of a fee for continuing supportive care if it was notdiscussed earlier.

psyhologic preparation

Documents