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 in appearance, 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 emotional disturbance 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 this limitation 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 greatest management 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 the denture 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 affect the dentist` s behavior. Dental patients are frequently nervous, ap0prehensive, and suspicious. 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 a significant 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

There are many considerations in determining the need for extraction. The loss of teeth and construction of a denture will certainly make a significant change in the body image of the patient. The area of the face and mouth has great psychologic significance. Symptoms resulting from anxiety are most common in the face. 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 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. these may range from pain. Retaining the teeth may be symbolic of retaining youth in a distorted body image. in persons with personality disorders. or cartoon characters who wear inadequate dentures. and loss of reproduction. The result may be technically correct and a great improvement in the eyes of the dentist but may be rejected by the patient. All patients will need time to get used to the idea of the change. Significance of Tooth Loss The decision to remove the teeth and construct replacement appliances is a very serious event for a patient. be reassured about superstitions. They are exaggerated because of the significance of the mouth and the emotional state of the patient at that moment. . closed vertical relation. clenching. Since the area is emotionally charged. Stable patients will need less preparation. these psychologic limitations may result in failure adequately with the dentures. These symptoms provide the most difficult management problems for the dentist since they are not related to technical deficiencies in the dentures. will result in symptoms. acquaintances. We tend to associate the loss of teeth with relatives. The loss of the teeth as a body part may be threatening. bad taste. Nothing represents aging more dramatically than the loss of teeth. The time spent in this emotional preparation is essential to the success of treatment. However. and poor speech are associated with growing old. and grinding to a denture that does not fit. Symptoms of this type are commonly produced by anxiety in persons with personality disorders when there has been a change in body image. the response to change in the area may be exaggerated. 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.realize that most prosthodontic care will make a change in the body image of the patient. changes in appearance. ask questions. and they should be carefully weighed. Patient responses may be inappropriate for the procedure being performed. Less stable patients need to discuss their fears. Patients who are less stable need more preparation because of their fears. The patient may place the highest priority on saving the teeth and be willing to pursue a very involved treatment plan. it is more difficult to predict the psychologic effect of tooth loss. Whether patients will adjust to the new situation of dentures will depend on their emotional preparation. unsupported lips. consisting mostly of an explanation of the procedures. The sunken face. prominent chin. and have more detailed explanations. It is not surprising that patients fear the loss of teeth since to them it signifies a decrease in their worth as an individual. The stress of this loss will produce anxiety and. clicking teeth. The reaction to the suggestion of tooth removal may be unusual and exaggerated.

job. hopeless. They relate these problems to the denture in terms of poor mastication. however. and pessimistic. and loss of teeth may be important factors. They may form a dependent relationship with the dentist. An inadequate denture may be suggested as a contributory factor by the examining physician. or other vague GI complaints. gastrointestinal function. and elimination are frequent complaints. Depression takes varied forms in dental patients. . and possibilities for improvement cannot be overemphasized. but some categories are helpful. The patient with emotional problems responds to this situation in an exaggerated. or food. vomiting.For many people the construction of dentures is not a great emotional experience because they may have encountered many problems with their natural dentition. We are not particularly concerned with specific classification of patients but are interested when significant improvement can be predicted. Somatic complaints become an exaggerated focus of concern to gain sympathy and support. Disturbances in food intake. Depression usually is precipitated by a loss. eg. Types of classification make it easier to discuss groups of patients but are not particularly helpful in planning a course of treatment. They tend to feel helpless. The majority of patients are stable and adapt readily to wearing complete dentures. Physical examination frequently reveals no organic basis for basis for constipation. We can characterize these patients by a loss of interest in appearance. prognosis. Age changes such as loss of reproductive function. There is an increased awareness of bodily functions and a frequent tendency toward hypochondriasis. inappropriate manner which interferes with the adjustment to wearing dentures. family. The importance of mental attitude in predicting problems. Depression This patient type is characterized by a decrease in self – esteem which results in general inhibition of intellectual and motor function. The dentist is not trained in psychiatric techniques and may not be very perceptive of patient attitudes and feelings. The categories are not mutually exclusive and there are overlaps between groups. These patients require considerable supportive care in the form of encouragement. Patient behavior is a complex subject. Receiving dentures may actually provide a relief from a long series of dental problems. The need for emotional preparation must be recognized and the preparation must be carefully planned. increasing wrinkles and gray hair. General behavior patterns will be described and will be followed by a description of possible patient responses in a dental situation. that some psychologic assessment be made to arrive at a realistic prognosis. although they do not occur in such simple and convenient forms. which leads to a progressive decrease of interest in the outside world. The people around them tend to become tolerant and take care of them. limitations. Classification of Patients Many classifications have been suggested to aid the dentist in evaluation of denture patients. Patient Behavior which Interferes with Adaptation to Dentures The following discussion will classify patients in terms of behavior which interferes with dental treatment. the death of a spouse. and improved digestive function may unfortunately become the criterion for successful dentures. It is more meaningful to discuss patient behavior which interferes with treatment or interferes with adaptation to appliances. It is imperative.

or injuries. Organic Brain Syndrome The basis for this classification is a diffuse permanent cerebral lesion caused by aging. there is a prevalence of this condition in prosthodontic practice. They are inflexible in their judgment and may prematurely decide the new dentures are also inadequate. It is helpful to have a written statement of office policies regarding fees and methods of payment and postinsertion care included in the original fee. Since the denture is a very tangible object and may not be particularly comfortable. It may be desirable to defer complex care until a more favorable time. and inability to learn new skills. These patients present characteristic problems in a dental situation. Dissatisfaction with previous care is commonly expressed. they frequently encounter difficulty and become discouraged. leaving the patient on the periphery of family activities and feeling that he no longer fulfills his role in the home. Care is taken never to joke about “false teeth”. they may deny what was said or think something else was said. Successful management depends on a simple. These patients adhere to accustomed practices and do not easily master new skills. it is frequently blamed for dryness of the mouth. Dental management begins with careful history taking. not loss of teeth. The receptionist or dental assistant should always call to remind these patients of appointments. therefore. Concern must be focused on replacement. this group is typified by the senile denture patient. brain disease. memory defects. It is difficult for them to follow instructions such as completing information sheets or questionnaires. since new dentures may lift their mood. even when the dentures were technically adequate. Past personality disturbances may be emphasized or exacerbated. especially if scheduled postinsertion visits are missed. A decision must be made for each individual. including health questionnaires (discussed later) such as the Cornell Medical Index. and may return on a periodic basis with trivial complaints. physician` s name. They may have difficulty remembering common items such as their address. Management includes conservative supportive care in the form of praise and encouragement.who is friendly and attentive. telephone number. Admitting they had forgotten would be tantamount to admitting a decrease in mental competence. which induces a feeling of pride in their progress by focusing on their attributes rather than on minor difficulties. These patients exhibit disturbances in complex and abstract thinking. well – structured program of treatment and instruction. disturbances in intellectual function and judgment. and postinsertion instructions. Since adequate function with appliances is a learned skill. so that the denture becomes an exchange and not a loss. Since these patients commonly return regularly for treatment. This is to insure that the dentures are being used. Management is . An effective approach is to praise their adjustment. In a dental situation. this type of continued support is essential. It is most difficult to reason with them because they are unable to assimilate new facts and often become confused or suspicious. Their family may have developed other interest. It is not necessary or desirable to give long explanations of procedures or rationale for treatment. Recall telephone contacts should be made after insertion. Since most denture patients are old. Because they are easily discouraged. and a burning sensation in the palate. Instructions for postinsertion care should be simple. a definite period of postinsertion care should be included in the original fee. decreased taste sensation. decreased appetite. brief. and written.

any hesitation to sign such a statement is evidence of dissatisfaction. and be dominated is an indication of their low self – esteem. Their need to depend. and behavior may vary from dependent to exaggerated independence. after the dentist has selected several molds that are suitable.characterized by simplicity. Passive hostility may be expressed by an inability to follow instructions. This facilitates the treatment by minimizing the need for indirect expression of anger. These expressions of hostility are time – consuming and difficult to manage. Dental management should be firm but attentive. Behavior may become aggressive. the treatment proceeds more smoothly. even with strong encouragement. When dependency needs are not satisfied. the length of postinsertion care included under the fee. These patients frequently involve the dentist in long discussions to prolong the relationship. Patients may criticize the denture to prolong a dependent relationship. . An example of this characteristic would be an inability to proceed with extractions. they may react with hostile aggressive behavior. The unconscious need to remain dependent on the dentist may prevent them from following postinsertion instructions. Patients may be passive or covert such as being late or breaking appointments. postinsertion care or cleansing instructions. or authoritarian. 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. and encouragement. 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. Explicit instructions should be given in writing for postinsertion care and should include items such as cleansers. Their underlying problem is unresolved dependency. contrary. and the dentist is often encouraged to make decisions in personal as well as dental matters. There should be a clear understanding of fees involved.” They seem incapable of decisive action. The patient should sign a statement in the chart that they have had the opportunity too see the teeth in wax at the clinical try – in and are satisfied with their appearance. Inappropriate expressions of hostility in a dental situation may take many forms. The patient should be strongly encouraged to make some decisions. Appointments may be extended by lengthy discussions or activities such as rinsing the mouth. final selection of tooth form. Sharing in decisions may help to elevate their self – esteem by implying that their opinion has value. and another try – in appointment should be scheduled. When these aspects of management are fitted to the emotional needs of the patient. Therefore. structured routine. They may attempt to manipulate the dentist into the position of an authoritarian manager to avoid responsibilities for decisions. and leaving the dentures out of the mouth at night. oral hygiene instructions. clearing the throat. or wiping the face with a tissue. Participation in decisions carries some responsibility for the final result. eg. Intimidating the dentist or others is an attempt to elevate their precarious self – esteem. Passive – Aggressive This is a large group of dental patients whose behavior varies from passive to aggressive. but usually they accept the denture in a passive manner in order not to appear critical of the dentist. 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. be cared for. despite the recommendations of several dentists and imminent pain.

. such as office routine and efficiency. An increased number of postinsertion visits should be anticipated to correct minute imperfections. method of payment. These patients abhor any suggestion 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. and length of care included in the original fee. minutely detailed discussions. meticulous nature may be reflected by their arrival time for appointments. occlusal discrepancies. Symptoms are productive. They have a need for orderliness and perfection. Initial fee determination should be based on anticipated chair time. Their need for perfection may result conflict with the dentist. The dentist should be firm in the relationship with these patients and not acquiesce to unreasonable demands. since this will intensify any patient – dentist conflict. since they can be used to control people and circumstances. The dentist should resist feeling defensive or antagonistic in the presence of critical requirements. It is helpful to place a clean cup after the patient has been seated and to wash the hands after entering the room. compulsively early or punctual. with no tolerance for ambiguity. fees. Dental management consists of efforts to meet their needs for orderliness and control which are balanced against the needs of the dentist. Activities such as dental treatment represent situations over which they have little control and therefore produce anxiety. but spurious generalizations should not go unchallenged. There is tendency to engage in “hair – splitting” arguments. Dentures will be minutely examined for surface roughness. There is a frequent preoccupation with fees and “getting their money` s worth. Behavior in a dental situation may be to demand perfection in esthetics and fit of dental appliances. it is helpful to involve patients in responsibility for the dentures by insisting that they participate and assist in various phases of the treatment. This type of patient finds it difficult to change existing habits such as oral hygiene and leaving the dentures out of mouth at night. although half of mental hospital patients have this diagnosis. Schizophrenia There is generally accepted definition of this condition.” The need for orderliness and inflexibility may manifest itself in many ways. and hypochondriacal. It is not desirable to add additional fees at a later time. Therefore. Their orderly. obsessive – compulsive. and lengthy verbalization without emotion. Activities may be charted such as past dental procedures and the dentist who performed them.Obsessive – Compulsive The salient feature of this group is the attempt to control the environment around them. The dentist should not be drawn into lengthy. Every attempt should be made to be punctual with these patients. These patients are quite inflexible and pay attention to petty detail. or other signs of imperfection. depressive. The dentist can expect to be chastised if late and to be reminded how early the patient came. endless speculations and generalizations. Additional time will be required to satisfy the requirements of these patients. services. types of behavior include hysterical. since this would imply agreement. A written policy statement should be prepared regarding care of dentures. The needs of these patients must be recognized to insure successful treatment. The prodromal symptoms are not distinctive. They may request that the towel and cup be changed to insure cleanliness. These patients are always able to find fault and seem to need a “one – up” relationship over the dentist.

Distortion of body image may occur concerning the teeth. For example. They may feel that the teeth are causing disease or a change in appearance. generally avoidance of a conflict. and the oral structures may have a special meaning which is incomprehensible to the dentist. This is common in females who are physically oriented. Common dental findings are paresthesia. Language is primarily a means of self – expression for these patients not a means of communication. and difficult – to – decipher speech patterns or written statements. tongue.. and hallucinations or delusions. Examples are pupillary response in a patient with blindness or anesthesia which does not follow neurologic distribution. Symptoms occur commonly in the face area.g. Suicide may be a danger. thought processes are disordered. a private language. especially auditory. They may have an . There is an increased sensitivity to sensory and emotional stimuli. Hysteria Hysterical patients develop prominent somatic symptoms which lead them to seek care. instructions. From a dental standpoint. anesthesia. such as depression. and behavior is common. and preoccupation with religion or international conflicts is common. or agitation. particularly with heavy alcohol intake. which is converted to physical symptoms. ideas. Olfactory or gustatory hallucinations may involve sudden horrible taste or odor attributed to dentures. It takes the form of lengthy. Dental behavior is a function of their psychopathology. The symptoms may be symbolic representations of the thought. the thought disorder must be considered in arranging the treatment. and paralysis also occur. with anatomic findings within the normal range. but suggestive symptoms present greater difficulty. an instruction to the assistant to “bring the scalpel” might result in great anxiety during impression appointment. They show an inability to think abstractly. It is important to avoid casual conversation. or gestures to the assistant which might be observed or misinterpreted. muscular tension. and palate. Disturbances occur in activity as well as thought. Symbolism in speech. such as perspiration. gingival. Pain is the most common. detailed. rambling. which may result in inappropriate responses to minor dental tasks. Severe symptoms are easily diagnosed. usually represents evil. Symptoms of hysteria are thought to be symbolic of underlying mental conflict. Treatment for suggestive symptoms follows the appropriate form for the behavior present. enemy voices coming from the teeth. Social withdrawal makes it difficult for the dentist or assistant to establish rapport. They may leap out of the chair and leave the room or grasp the dentist` s hand.These patients can generally be categorized by inappropriate behavior. “Bring the number 25 so that I can trim the impression tray. A distinguishing characteristic is that the symptoms have a purpose. Aging is a common unacceptable event for these patients. and muscular tics involving the lips. The dentist should avoid any display of instruments. but blindness. They are not “imagining” pain but feel it with more intensity due to the state of their nervous system. Stress situations which cause anxiety are converted into physical symptoms with no anatomic pathologic change. and this mechanism lessens conscious anxiety. The symptoms usually involve body parts under voluntary control and cannot be explained on a neurophysiologic basis. Hallucination. Conversion refers to insecurity or anxiety about a thought which is unacceptable. A more appropriate statement within hearing of this patient would be. anesthesia or burning sensation in the lips.” The patient should be carefully observed to note signs of anxiety. e. or facial appearance.

especially pain. An effective approach is the suggestion that this sensation may represent an idiosyncracy of their mouth and is something they will have to tolerate. Other symptoms which may cause the patient to come for evaluation include inability to swallow (dysphagia). Hysterical symptoms may develop at this point. They cannot tell friends from foe and treat friends as if they were enemies by . but in all instances the patient should not be harmed.. The dentist is usually able to help these patients by a good listener and providing some emotional support.inordinate fear of needles. patients who complain of burning sensations in the palate when the tissue appears normal. Dental management is aimed at excluding organic disease and reassurance about symptoms which have anxiety as their etiology. aggressive. decrease communication. ambitious. There is a constant feeling that others are discriminating against them or taking advantage of them. Occasionally these patients are docile throughout treatment and then become hostile at the first visit following delivery. it is unlikely that dental treatment would result in lasting improvement of symptoms. Most of them are driving. hostile. In the case of severe anxiety. and have special mistrust of any authority figure. and lead to antagonistic and uncooperative behavior. since indifference by the dentist may be interpreted as hostility. and humiliating. Reassurance is important since the patient needs this emotional support during the adjustment phase. Care should be taken to be attentive to their complaints. and they respond with a counterattack. but they are extremely sensitive to criticism. The dentist and patient should be pleased that no serious disease is present. or decreased responsibilities. teeth should not be extracted unless a definite pathologic etiology can be identified. dry mouth. hostile. or pain at a healed extraction site. There may have been an original organic etiology. Criticism is interpreted as an attack. It may be used to obtain sympathy. The patient should be reassured that no disease process is present. detrimental. They may feel that past dental care such as a denture is responsible for the symptom. If organic disease such as neurologic injury or hormonal deficiencies are not present. evaluation by mental health personnel should be a prerequisite to dental treatment. The suggestion should be made to examine their mouth on a periodic basis to be certain that a pathologic condition does not evolve.g. for example. Effective management requires conservative treatment and recognition of the patient` s anxiety. It is crucial that the dentist remain calm and sympathetic. and rigidity. and destructive. affection. There is a tendency to criticize everyone around them. Psychiatric treatment may include individual psychotherapy and tranquilizing medication. Paranoia These patients are unable to trust and are characterized by suspicious. and “drilling. In some instance it is not possible for the dentist to help the patient. hostility. but the physical symptom was useful and was perpetuated. A brusque impersonal approach may increase their fear. Gestures by others are interpreted as unfriendly. They react with fear and anger. find fault with everyone. Every attempt should be made to provide treatment which is reversible. There is an inability to recognize their own hostility and they project it onto others. excessive salivary flow (sialorrhea).” This acute fear may lead the patient to resist insertion of any instruments. sharp instruments. It is very important not to overtreat patients with facial symptoms. e. Accusations against acquaintances sound like descriptions of themselves. No irreversible treatment of a destructive nature such as extraction should be performed. but they are not aware of this fact.

vertical dimension. Their few friends finally withdraw. with responses excessive in proportion to the supposed injustice. Suspicion that the dentist is protecting a colleague may result in abrupt termination. Evaluation of previous dental work may be requested. and copies of instructions and financial arrangements. not a disease category. Minute details out of context may be used to prove the dentist is at fault. This phenomenon is common in the process of tooth selection. and fees. It is imperative to be scrupulously honest at all times. Past dental care is blamed for all their problems. with active searching for signs and symptoms. Numerous somatic complaints are readily elicited by health questionnaires such as the Cornell Medical Index. This is followed by a description of how poorly they were treated previously. Later they begin to question the present treatment. and thoughts of revenge. They will seek many doctor` s opinions and submit to lengthy and expensive diagnostic procedures. Detailed records must be kept. These patients are difficult to influence. and 4) poor function. patients will deny receiving them and blame the dentist for any problems. Denture symptoms are exaggerated. The behavior of these patients varies from dependent to suspicious to hostile. which reinforces their mistrust and suspicion. and new symptoms appear as current ones are relieved. 3) vague GI complaints. since the patient will remember minute details. including handwritten lists of desired changes. Paranoid patients begin by commenting on the high level of competency of the dentist and on the pleasant office. They feel they cannot depend on anyone but themselves. It is extremely difficult to convince these patients that their assumptions are erroneous. especially depression. 2) cancer phobia. Hypochrondriasis This is a descriptive term. tooth position. Diffuse somatic complaints and physical symptoms with no demonstrable organic change are common. and they will view the dentist with distrust. There is a constant search for hidden clues and meanings. It is included as a separate group since these patients present difficult diagnostic problems. The dentist should be business – like and avoid excessive friendliness because the latter might be viewed as having ulterior motives. Examination usually reveals an absence of inflammation. Pain complaints may be vague and frequently described as burning sensations. The appropriate response is not to overtreat by treating only obvious organic disease. The slightest rejection results in automatic anger. An unrealistic assumption of illness leads to exaggeration and misinterpretation of normal body processes or insignificant symptoms. They are very suspicious of past dentists and their motivation for rendering care. Patient wishes are expected to be known without being stated.constant testing and provoking. Dental treatment may be regarded as an attack. The most common complaints concerning prosthodontic care involve 1) pain. There is habitual overconcern with health. and there is little success in the use of persuasion or suggestion to gain insight into psychologic mechanisms. resentment. removal of wrinkles. They commonly seek opportunity for lawsuits against the dentist. Hypochondriasis is a frequent overlay in various mental health disorders. If instructions which affect the success of treatment are forgotten. Some patients tend to form lasting attachments with the dentist and . misread motives. signed statement of approval of esthetics. These patients are difficult to treat because of their hostility and frequent recourse to revenge through lawsuits. Verbal attacks are made on the dentist for supposed rejection or personal slights.

e. Helping the patient receive care includes helping him recognize the need for care. except as a transitory result of the treatment. Psychophysiologic Disorders Emotional factors can play a significant role in the alteration of normal physiologic processes. as evidenced by fractured denture bases. Technically. but it is a significant dental problem which involves an interaction of psychologic factors and oral structures. In many instances patients will feel much better after telling their problems to the dentist who did nothing more than listen sympathetically. Management in a dental setting has been discussed with the objective of care being provided by the general practitioner.” . It is important that the dentist be a good listener. patients must recognize that they will have to tolerate the problem. The response from the patient may be negative and vigorous. Long – term supportive care should be anticipated and considered in fee determination. ulcerative colitis. must be treated. The dentist should be careful not to be over solicitous and to keep complaints in their proper perspective. It is detrimental to the teeth and the supporting structures and may contribute to accelerated breakdown in the presence of dental disease states. Occasionally. Denture patients commonly exhibit bruxism. Care must be taken to prevent extensive periods of chair time being taken with lengthy and frequent visits. There is an obligation to help the patient get to someone trained in mental health problems. bruxism is not a psychophysiologic disorder..” or “there is nothing wrong with me. asthma. The specific problems are numerous with obscure etiologies. and palliation may be all that is possible.” The waiting room and regular appointments become important social instruments in otherwise lonely lives. The patient has confidence in this dentist. The offer of regular examination to insure the absence of disease is reassuring and tends to reduce their search for a “cure” that will not occur. hypnosis. Common responses are. soreness of the ridge crest. 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.return for many visits. and accelerated ridge resorption. examples of specific disorders include peptic ulcer. Feelings of neglect are overcome by attention from the doctor. chipped denture teeth. Reassurance is important when cancer is feared and no organic change is visualized. Firmness and positive statements are indicated when the patient` s assumptions are incorrect. which eventually occur or are made worse as a result of these disorders.g. Management begins with the dentist having some familiarity with psychophysiologic mechanisms. Referral for Psychiatric Consultation The preceding discussion has dealt identification of patients with emotional problems or personality disorders. Since therapy will not remove symptoms. The family dentist knows the patient well and has observed changes over time. severe emotional disturbances that the dentist is not capable of treating are recognized. The suggestion that a psychiatric consultation is required must be handled with great tact. Disease processes. “I` m not crazy. Psychiatric assistance may be helpful with techniques such as insight oriented psychotherapy. Dental management should generally be conservative. periodontitis. or tranquilizers. These patients should definitely be instructed to leave the dentures out of the mouth at night. obesity. and gingivitis.

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. . such as in the production of gastrointestinal disturbances. The patient must decide if the dentist meets his or her needs and the dentist must determine what the patient wants.Most prosthodontic patients are older and psychiatric treatment in their opinion is a social stigma. “I have a colleague who is very interested in problems like yours. An explanation is made that the body can respond in many ways to stress. The following methods can be used to help identify potential problems. 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. A statement should then be made that the dentist has seen many patients with similar problems and that these patients had in common tension and stress. The dentist must be clearly aware of the problems and needs of the patient. It is difficult for them to accept that they are contributing to the problem because of their emotional instability. the dentist has little chance of formulating a realistic treatment plan which has some chance of actually being performed. 3) condition of oral structures. Interview The initial interview is a crucial time in establishing a positive relationship with the patient. 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. the dentist has difficulty making the interview effective and efficient. The dentist says to the patient. Four objectives for the interview ca be identified: 1) expectations or lack of satisfaction with dentures. Careful preparation of the patient and tactful presentation of the suggestion will help prevent this type of negative response. good channels of communication must be opened at the initial interview. I am very concerned about your problems and want to help you overcome them. Unlike the psychiatrist who is trained in interview technique. The dentist is usually confident in nothing mechanical or technical problems. At this point. 2) health and patterns of daily living. few dentists set aside adequate office time to conduct adequate interviews to provide information about patient wishes and feelings. the dentist must be able to make a specific referral. Without a free flow of thoughts from the patient. Most patients are not aware that stress can also cause dental – facial problems such as a bad taste or facial pain. It is a time when the patient and the dentist evaluate each other. Dentist often become uncomfortable while asking probing questions of an emotional nature since they have little previous experience or training. They should be reassured that pathosis is not present. The importance of the interview cannot be overemphasized. and 4) technical adequacy of the present dentures. I want you to see this doctor so that we can both be helped to better understand your dental problems. It could have been something harmful or dangerous but instead is some particular idiosyncracy of their tissues to appliances. Interviews can be very time – consuming if the dentist is not skilled in their use. The psychiatrist must be one who is oriented to dental problems or who has worked with the dentist previously. As a result. but it is very difficult for most dentists to identify emotional problems which might interfere with adaptation to dentures.

This aids the dentist in structuring the interview and history taking to concentrate on pertinent areas. and family health information. The questionnaire is not infallible. It is sometimes difficult for patients to verbalize their feelings in a dental setting. but for different reasons. A score of 3 or more on the last page of the CMI indicates emotional disturbances which are significant enough to affect the course of treatment. and fatigue or exhaustion are meaningful and help structure interviews. The interview is then structured to follow directions suggested by patient answers on the CMI. If the patient is overly concerned with trivial health problems. difficulties with dentures can be anticipated. A total score of greater than 25 is important. Extensive testing would required to test the validity of major modifications.History The general health experience of the patient is meaningful. The dental experience provides insight into the patient` s response to previous care. frequency. Other significant . comfort. The amount. worry over illness. is it a type that will affect the dental treatment or prognosis. Have they had dentures in 5 years or one denture for 25 years? Both of these situations could be difficult. however others which were unsuspected will be identified. Were new dentures frequently required for appearance. Helpful questions have been extracted but do not appear to remain valid outside of the context of the larger questionnaire. facial wrinkles. and practical. and nature of care indicate the dental needs of the patient and patient and the priority given dental care. The Cornell Medical Index (CMI) is a useful clinical tool and has a large section dealing with the emotional status of the patient. and a number of problems will go undetected. Sections on gastrointestinal disturbances. Attempts to reduce the size of the CMI have been unsuccessful. the dentist will not be perceptive enough to recognize a potential problem. the CMI is not needed to identify the problem. present. It is necessary to test all patients with the CMI to use it effectively. Large – scale tests on medical populations have shown the CMI to be comprehensive (except in the areas of dental health and diet). since the greatest value is to potential problems that are not anticipated. The validity has also been tested on a large group of denture patients and proved to be a reliable prognostic device. This indicates significant systemi8c disease if the “yes” responses are localized in one organ system or possible hypochondriasis if the “yes” responses are scattered. It is an error to only administer the CMI when difficulties are suspected. Health Questionnaires The use of these questionnaires has proved to be an effective and efficient method to obtain past. The validity of the CMI has been throughly demonstrated. efficient. When the dentist already knows the patient will be difficult. Unless this is done. 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 previous dentist? A written denture history provided by the patient together with a list of complaints and desired changes make meaningful discussion easier. but this discussion will be confined to the dental history. There are critical levels of “yes” responses on the CMI. severe headaches. The CMI is a useful aid in dental practice to help predict potential denture problems and patient satisfaction. If systemic disease is present.

Written communication of various types is very helpful to document what was requested. Only in rare instance will patients refuse to answer the questionnaire if the need has been explained. Written statements may relate to any area about which the dentist is concerned. a “Diet Diary” is kept for 5 days. what was possible. Use of Written Communication Patients with emotional problems are frequently demanding and difficult to manage successfully. Are you considered a nervous person? Yes No 180. A chronologic denture history is helpful with patients who have had numerous appliances. It may be difficult for patients to verbalize their wishes regarding changes. Do you usually feel unhappy and depressed? Yes No 159. and desired changes. Do you often cry? Yes No 165. Are you easily upset or irritated? Yes No 182. Do you flare up in anger if you cant` t have 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. The diet is then analyzed for content and modifications are recommended. The following questions are examples of those used for emotional evaluation by the Cornell Medical Index: 158. and the dental office may be a place of anxiety for them. These hand written lists give the dentist a greater insight into the difficulties of the patient. little effort is required to institute the use of a more comprehensive questionnaire. Dentists who have become skilled in the use of these questionnaires refuse to evaluate their new patients without this information. This helps prevent disagreement later about what was said. Refusal to respond is itself a prognostic sign of poor communication and cooperation between dentist and patient. Since a health history is already part of most office routines. qualifying statements. Clear communication about what is desired or requested is essential. or they may forget to inform the dentist about an important item. Patients are nervous and apprehensive. If nutritional deficiencies are suspected. When there is dissatisfaction with existing appliances. Do little annoyances get on your nerves and make you angry? Yes No 185. Patient – Written Statements It is helpful for the patient to write statements which are then incorporated in the chart. Does every little thing get on your nerves and wear you out? Yes No 166.characteristics are unanswered questions. All food intake is recorded. These questionnaires are easy to use obtain maximum information with minimal chair time. a list should be made of all problems. and answering both “yes” and “no”. and the process of writing them tends to . and what were the responsibilities of the dentist and the patient. Important items are forgotten or misunderstood during periods of stress. complaints. Instruction manuals are available to aid the dentist in quickly becoming proficient in their use. including specific items and amount.

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. If the report is to be discussed with the patient. The fees are carefully stated. The dentist should offer to send the waxed trial dentures home with the patient for approval. It designates approval of the proceeding statement and is used for important documents. in view of the patient. A specific statement is made about postinsertion care included in an initial fee.” bruxism. They have been recommended to describe the treatment to be performed and to clarify office policies such as fees and method of payment. the patient is asked to sign a written statement of approval in the chart. Items such as tissue conditioning. massage of the tissue. . services included. Usually the pen stops short of the paper while an inner debate takes place. A series of recommendations is listed.give the patient a better understanding of problems and what can expected from new dentures. “Nervous problems. radiographs and study casts are utilized to illustrate important points. This is not used as a legal document since the responsibility will ultimately rest with the dentist if the patient is not satisfied. including total amount. They may state repeatedly that they are satisfied with the appearance but show hesitation in signing a statement of approval. and specific areas of patient concern are carefully documented for the patient with emotional problems. The patient concludes that the dentist: 1) knows what to do and 2) has carefully planned the course of treatment. If esthetic considerations are a primary reason foe remake of an appliance. Patients with emotional problems may have difficulty in reaching a decision or may be somewhat erratic. Discussion continues for specific areas such as radiographic findings and a description of each jaw. Emotional patients may give an exaggerated response to institution of a fee for continuing supportive care if it was not discussed earlier. It can be considered a consultation for the patient who has come for advice. assuming some responsibility for the result. Treatment Plan Summary The use of a written resume or summary is not new. An additional clinical try – in should always be scheduled when this occurs. particular care should be taken at the try – in. and the items is checked off the list. Under general findings the report should give an overview of the problems. The terminology must be easily understood and not obscured by technical jargon. The dentist should carefully refer to the list of desired changes written by the patient at the beginning of treatment. and use of a duplicate denture are mentioned. There is a considerable psychologic impact in placing a signature. The implication is that the dentist is interested in the problems of the patient and is carefully investigating all aspects before proceeding. it is discussed and explained why it cannot be done. and method of payment. When a particular request is not possible. Viewing in familiar surroundings. not to be merely a recipient. at leisure. The report is presented in a consultation appointment using study casts and radiographs or by mail to reinforce the examination discussion. may produce an additional written list of desired changes. representing a systematic approach to treatment. When the changes have been made and the patient is satisfied. Changes are made at the chair.

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