Evolution of the Temperament Theory and Mental Attitude

in Complete Denture Prosthodontics: From Hippocrates

to M.M. House
Charles J. Goodacre , DDS, MSD1 & W. Patrick Naylor , DDS, MPH, MS2
1
Advanced Education Program in Implant Dentistry, Loma Linda University School of Dentistry, Loma Linda, CA
2
Advanced Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, CA

Keywords
Complete dentures; temperament;
personality; mental attitude; tooth selection.
Correspondence
Dr. Charles J. Goodacre, Advanced Education
Program in Implant Dentistry, Loma Linda
University School of Dentistry, Loma Linda,
CA 92350. Email: cgoodacre@llu.edu1
Conflict of interest: The authors deny any
conflicts of interest in regards to this study.
Accepted June 17, 2020
doi: 10.1111/jopr.13215
Abstract
Some 2,500 years ago Hippocrates developed the “Temperament Theory” of the four
humors (fluids) he identified as blood, phlegm, yellow bile, and black bile which then
led to the ancient medical concept known as "humorism.” In Greco-Roman medicine,
these humors were believed to be the influencers of an individual’s relative wellness
or ill-health, served as a means to classify illnesses, and subsequently guided medi-
cal diagnosis and treatment. Centuries later modifications to Hippocrates’ hypothesis
were suggested for use in dentistry when selecting denture teeth and later as a means
to classify the mental status and personality of complete denture patients. This paper
examines the historic transition of the terminology, characteristics, and thinking be-
hind the four humors with mention of key thinkers in this journey. Of particular note
is the evolution in the application of this theory from its suggested use in medicine,
proposed by Hippocrates, to the descriptions of mental attitudes and personalities of
complete denture patients first described by Neil and subsequently popularized by M.
M. House.

The long and journeyed history of complete denture
prosthodontics is not only complex but rich with novel thinking
and techniques, yet grounded in concepts and principles, both
empirical and evidenced-based that have been documented in
the dental literature to varying degrees over the course of cen-
turies. Many of the beliefs espoused by renowned thinkers and
clinicians from long ago survive to this day, some have been re-
vised to keep abreast of the language of the times, while others
have simply been abandoned, perhaps lost to history, or seldom
mentioned in contemporary dental literature for any number of
reasons.
One novel philosophical concept that was in favor centuries
ago, but is seldom mentioned today, is the call to categorize
patients according to their human qualities and the subsequent
behavioral characteristics they are likely to exhibit. This idea
is far from new and was promoted some 2,500 years ago by
the Greek physician, Hippocrates (BC 460 to BC 370).1-5 This
renowned medical practitioner, scholar, and teacher is consid-
ered the father of Western medicine and recognized as hav-
ing established the medical profession as a distinct discipline.
Among his many contributions was the famous Hippocratic
Oath. Even today, variations of the original oath of ethics
written by Hippocrates are sworn to and held sacred by new
physicians with the aim to guide their conduct and patient
management.
Hippocrates and the temperament
theory
Hippocrates also is credited with conceiving what was referred
to as the “Temperament Theory,” a 5th century BC concept
rooted in his own observations of differences in human bodily
actions, functions, and illnesses based on fluids (called “hu-
mors”) believed to exist in the human body.1-5 This theory led
to the ancient medical concept known as ‘humorism.” In the
application of this theory, Hippocrates sought to identify and
describe several temperaments with distinguishing physical,
emotional, and bodily characteristics that he believed were ge-
netically determined and ascribed to a patient’s health and col-
lectively lead to the formation of one’s temperament.1-5 He also
believed that illnesses could be classified and, therefore, cer-
tain human moods, emotions, and variations in behavior could
be attributed to the relative proportions of these fluids.1-4 Hip-
pocrates referred to the four humors as part of medieval science
and medicine, and he designated them as blood, phlegm, yel-
low bile, and black bile.1,2,4-6 Good health was attained when
all four were in balance. In contrast, diseases and the adverse
conditions that arose were attributed to either an excess or a
deficiency in one or more of these key humors.
The Greek physician Galen7 (BC130 to BC 210), who rose
to fame in the Roman Empire, was said to be a supporter of

594 Journal of Prosthodontics 29 (2020) 594–598 © 2020 by the American College of Prosthodontists
Goodacre and Naylor
the theory behind bodily humors, but he played a larger role
by perpetuating Hippocratic medicine. In fact, during medieval
times, most ideas about medicine were based on the beliefs
of both Hippocrates and Galen. In regard to the temperament
theory, it was Galen who added names to describe the per-
sonalities present in people in whom there was an imbalance
of the humors. Distinctions among the different temperaments
were said to be responsible for the characteristics of four cor-
responding personality types.5 Furthermore, variations of tem-
peraments were possible with some 12 combinations of mixed
temperaments with one likely to predominate.4 For example,
individuals in whom the blood predominated were believed to
have sanguine temperaments and those where phlegm predom-
inated were phlegmatic.7 When yellow bile predominated, a
person was described as being choleric, and when black bile
predominated that individual was said to be melancholic.7
Application of the temperament theory
to dentistry
Fast forward to the 19th century and J.W. White published
an editorial in Dental Cosmos in 1884 pertaining to applica-
tions of the temperament theory in dentistry for tooth selec-
tion and the improvement of denture esthetics in the treatment
of edentulous patients.4,8 White ascribed “cases of incongru-
ous artificial dentures” not to “carelessness or indifference of
the dentist” but to “a failure to recognize the requirements
of temperament.”8 The incongruities he observed in complete
dentures included what he described, in the terminology of the
time, as the “massive tooth of the bilious temperament” and the
“long, narrow teeth of the nervous temperament.”8 White also
made reference to the “pearl-blue color belonging to the ner-
vous temperament” and “the bronze-yellow color never seen in
the mouths of any but those of a bilious temperament.”8
More than a decade after White’s editorial,8 Alton Howard
Thompson wrote a book chapter entitled “The Temperament
and the Temperamental Characteristics of the Teeth in Relation
to Dental Prosthesis” that appeared in Dr. Charles Essig’s 1896
text, The American Textbook of Prosthetic Dentistry.1 It was
Thompson’s belief that Hippocrates’ temperament theory and
later classification systems influenced the development of sim-
ilar thinking about denture tooth selection during his era. He
also described a temperament classification system attributed
to a physician named Dr. Johann Gaspar Spurzheim in which
patients were categorized as lymphatic, sanguine, bilious, or
nervous.1,2 Thompson’s chapter even included elaborate tables
in which he offered physical characteristics for each of the four
temperaments in relation to differences in patient stature, os-
seous development, muscular development, body contour, cir-
culation, facial features, skin and complexion, hair, and eyes.
Thompson1 stated that Dr. D. H. Jacque “amplified” the indi-
cations described by Spurzheim, and he included a table la-
beled “Dr. Jacque’s Anatomical Classification of the Tempera-
ments.” One of the tables attributed to Thompson himself was
entitled “The Temperamental Characteristics of the Teeth” in
which he listed differences in the four temperaments (lym-
phatic, sanguine, bilious, and nervous) as they related to den-
tal characteristics.1 Thompson1 ended his 1896 narrative on
temperaments with a statement attributed to White from 1884:
Journal of Prosthodontics 29 (2020) 594–598 © 2020 by the American College of Prosthodontists
History of Temperament Theory and Mental Attitude in Denture Patients
“A knowledge of the distinguishing characteristics of the vari-
ous temperaments and the style of teeth which conform to na-
ture’s type in the physical organization marks the difference be-
tween the dental mechanic and the dental artist.”8 In the 1913
fourth edition of this textbook Thompson and co-author Dr.
C. R. Turner described how these four temperaments related
to complete dentures in terms of tooth size, shape, color, tex-
ture, enamel, cusps, arrangement, articulation, arch form, vault
form, gingival color, rugae size, and even rugae number.2 Ac-
cording to Sellen et al.4 “Prior to approximately 1915, the tem-
perament theory was used extensively in medicine to classify
illnesses and later in dentistry to aid in the selection of artificial
teeth.”
Classification systems based on Thompson’s temperaments
in dentistry and the ideas of Thompson and Turner2 continued
to be discussed after the publication of their writings. But in the
years that followed the conversation shifted from the relation-
ship between patient temperaments and the technical aspects of
complete denture fabrication mentioned earlier to that of a den-
ture patient’s mental attitude (or personality) and relationship
with the treating dentist.9-11 In fact, a 1930 textbook entitled
Prosthetic Dentistry by Ira Nichols contained a chapter writ-
ten by W. M. Randall9 entitled “History, Examination, Diag-
nosis, and Prognosis for Full Denture Service.” Randall wrote
about the importance of obtaining a comprehensive patient his-
tory, and he listed the required components to be identified in
that history. He even included a section related to categoriz-
ing a patient’s “temperament” as lymphatic, sanguine, bilious,
or nervous, using the very same designations Thompson de-
scribed more than three decades earlier.1,2,9 Randall was of the
opinion that “personal qualities and characteristics of personal-
ity” actually predetermine “the ease or difficulty to be expected
in satisfying and pleasing the patient in the relative functions
of esthetics, phonetics, and mastication to be expected in full
denture service."9 Later in that same chapter, he discussed clas-
sifying the mental attitude of complete denture patients using
the following four new terms: receptive, passive, exacting, and
antagonistic.9
Receptive patients were described as being “alert to advice
and having full confidence in the dentist’s ability to render the
best service under existing conditions.”9
Passive patients were identified as being “quite indifferent to
the technical details and principally interested in the end-result
with especial interest in the utility and service to be obtained.”9
Exacting patients were described as individuals who lay
“great store in appearances” and frequently expect, and some-
times, even insist upon “certain things being done by the dentist
that are contrary to fundamental dental principles essential to
the efficiency, retention, and stability of complete dentures.”9
Antagonistic patients were said to be those individuals who
lack confidence in their ability “to wear new dentures when
finished and in the dentist’s ability to construct something they
will want to wear.”9 They also are believed to be unwilling to
make the best of an unfortunate condition and are “unwilling
to fully cooperate with the dentist in learning to wear artificial
dentures when finished.”9
History provides some additional insight into how the “Tem-
perament Theory” Hippocrates developed in the course of his
practice and teaching of ancient medicine evolved into an
595
History of Temperament Theory and Mental Attitude in Denture Patients
Figure 1 The four categories of complete denture patients in the House mental classification.
association with complete denture prosthodontics.1-11 It is
noteworthy how the thinking behind the four humors Hip-
pocrates spoke of in the time of Socrates and Plato may have
led to the four categories of mental attitude (temperament or
personality) of denture patients described by Neil10 in 1932
and later discussed by M. M. House11 in a 1950 booklet based
on notes from a study club supervised by House. Both Neil
and House used the terms philosophical, exacting, hysteri-
cal, and indifferent in their “mental classification” of denture
patients.10,11 In a 2005 publication, Winkler12 clarified that the
well-known House classification “was based on how patients
react to the thought of becoming edentulous and how they
adapt to complete dentures.” Winkler12 added that the intro-
duction of the four named categories of complete denture pa-
tients was attributed to Dr. M. M. House, and he called into
question “the origin of this classification system.” He stated
that he was unable to “find any publication by House that de-
scribes a classification system for complete denture patients.”12
However, he noted that in 1932 Dr. Ewell Neil10 published
“a small text entitled Full Denture Practice” in which he
described the same four categories of a “mental classifica-
tion of denture patients” that have been “credited to House,”
namely hysterical, exacting or hypercritical, indifferent, and
philosophical.11 Winkler also pointed out that it was “not
known whether House credited Neil for his original description
of the mental classification of denture patients during his many
lectures, seminars, and continuing education courses.”12 But he
mentioned that “House expanded and popularized the system
which was originally introduced to the profession in 1932 by
Neil.”12
Consequently, it is Neil who should be recognized as the de-
veloper of this mental classification system for complete den-
ture patients. Yet in all fairness, crediting House, rather than
Neil, likely ensued for two reasons. The first reason being that
members of the dental profession seemingly were unfamiliar
with the contents of Neil’s now classic 1932 textbook.10 The
second reason being that House’s body of work has been more
widely read, presented, and followed even to this day.11 Attri-
butions aside, House did popularize this classification system
among those providing prosthodontic care, and he even com-
missioned an artist to create images depicting the four different
mental attitudes (Fig 1).
596 Journal of Prosthodontics 29 (2020) 594–598 © 2020 by the American College of Prosthodontists
Goodacre and Naylor
The Neil mental classification of
complete denture patients
Ewell Neil10 named the different mental categories and de-
scribed the characteristics and behavior of denture patients in
each of the categories in his mental classifications as follows:
The exacting (or hypercritical) mind
These patients often want dentures that are “so perfect as to
defy detection” by friends.10 It is even possible they will tell
you their natural teeth were “small and white.”10 They ex-
pect you to provide them with the last word in esthetics but
insist on “bossing the job.”10 Exacting patients also tend to
be unreasonable in their expectations and ”change their minds
and their statements as often as a chameleon will change his
color.“10 Consequently, it is ill advised to finalize the complete
dentures for exacting patients until their family members have
attended an appointment and expressed their approval of the
shade (color), mould, size, and the arrangement of the artificial
teeth “while they are in wax.”10 Neil concluded his descrip-
tion of exacting patients with the following sentences: ”Even
after the family has been pleased some friend will remark to
the patient upon seeing them the first time after the new teeth
are received, What on earth has happened to you? Your only
salvation in such cases is to get your check when the case is
delivered."10
The hysterical mind
Patients in this category are those who tend to present “with
a very positive and predetermined opinion as to their lack of
ability to wear artificial teeth.”10 They may even “announce
upon entering the dental office” that they know they “will never
be able to wear artificial teeth.”10 An hysterical “patient fre-
quently returns the dentures, refusing to accept them and pay
for them.”10 They even may arrange appointments with mul-
tiple dentists and repeat this behavior. “Over a period of sev-
eral years, they will have ‘made the rounds’ and had some-
times as many as a dozen sets of teeth made, some of which
were undoubtedly as good as was possible to produce in this
case.”10 Despite positive outcomes, none of the prostheses
are considered adequate by someone believed to fall into the
Goodacre and Naylor
hysterical mind category. However, over the course of these
multiple treatment encounters, such individuals will have ac-
quired “quite a bit of denture experience.”10 Eventually these
patients will accept prostheses that “finally fit” but actually
may be “inferior to others” that were “condemned” doing “a
great injustice” to the other clinicians who had, in fact, pro-
vided quality complete denture treatment.10
The indifferent mind
Indifferent patients usually can be found among the older seg-
ment of the patient population, and these individuals are rec-
ognized as those who have “lost interest in social and busi-
ness affairs.”10 As a rule, “They are perfectly contented with-
out teeth and do not even want to be bothered with artificial
substitutes.”10 But a son, daughter, or spouse may have de-
cided they would look better with teeth. So, they are taken to
the dentist against their will to have complete dentures made,
and present themselves in the dental office as “an unwilling
patient.” They tend to show little interest in their care as their
appointments progress, and everything done for them in the
course of treatment “is all right.”10 A family member very
well may make all the critical decisions relative to the “size,
mold, and color” of the denture teeth. But upon completion
of treatment, these patients may never wear the new prosthe-
ses, because they did not want dentures in the first place. Con-
sequently, when it is apparent the new dentures are not be-
ing worn, expect that family member to “find some fault with
your work.” Unfortunately, even indifferent patients who do
wear their dentures quite often do not wear them long enough
to even allow the dentist to make appropriate postoperative
adjustments. As a result, the prostheses irritate the patients’
mouth, sore spots develop, and patient complaints soon follow.
Of course, patients with an indifferent mind and their family
members will contend the dentist is to blame for the mouth
soreness and the fact that the dentures are not being worn.10
The philosophical mind
Patients in this mental category have confidence in the den-
tist’s abilities, actually seek denture treatment (“artificial sub-
stitutes”), and are prepared to “give the dentist the finest
cooperation.”10 Moreover, they do not consider the loss of their
teeth as the greatest misfortune that could befall them. So, in-
dividuals with a philosophical mind may even “wear a misfit
and put up with discomfort rather than return for adjustments,
feeling that they can adjust themselves to the condition.”10.
The House mental classification of
complete denture patients
M. M. House11 applied the same names as the Neil10 mental
categories: philosophical, exacting, hysterical, and indifferent.
He also offered his own abbreviated descriptions of the char-
acteristics and behavior of patients in each of the four classifi-
cations of complete denture patients published in a study club
booklet.11 It should be noted that the original order in which
Neil presented the four categories differed from the order fol-
lowed by House in his 1950 publication.10,11 Neil also referred
to each type of patient using the definite article “the” as in “the
Journal of Prosthodontics 29 (2020) 594–598 © 2020 by the American College of Prosthodontists
History of Temperament Theory and Mental Attitude in Denture Patients
hysterical mind,” “the exacting mind,” etc., whereas House did
not. And except for the indifferent patient, the descriptions pro-
vided by House11 differentiated between those patients with no
prior experience with complete dentures (the “a” description)
versus those individuals who either wear dentures or had den-
tures made but currently do not wear them (the “b” description
in each category).
Philosophical mind
These are said to be good, rational, and sensible patients who
are “of a well-balanced mental type” and “have had no ex-
perience with wearing artificial dentures.”11 Or, they may be
those individuals “who have worn dentures satisfactorily in the
past, are in good health and of a well-balanced type.” Further-
more, patients of a philosophical mind understand they may
need subsequent dental treatment in the future.11
Exacting mind
These individuals may be in “ill health” yet they are “seriously
concerned about the appearance and efficiency of artificial den-
tures and, therefore, are reluctant to accept the advice of their
physician and dentist and are unwilling to submit to the re-
moval of their natural teeth.”11 Those exacting patients already
wearing unsatisfactory complete dentures will doubt “the abil-
ity of the dentist to render a service that will be satisfactory,”
and they may even insist on a “written guarantee or expect the
dentist to make repeated attempts without an additional fee.”11
Hysterical mind
Patients in this category would include those in poor health
“with long neglected pathological mouth conditions who dread
dental service” and have their teeth removed only as “a last
resort.”11 They have even convinced themselves that they
“never can wear artificial dentures.”11 Those individuals who
previously tried to wear completed dentures but “failed” in
their efforts may have become “thoroughly discouraged” about
future denture treatment. They tend to be “of a highly nervous
temperament, very exacting, and will demand” that their pros-
theses be both efficient and have an appearance equivalent to
“the most perfect natural dentures.”11
Indifferent mind
Those denture patients said to have an indifferent mind are “un-
concerned regarding their appearance and feel very little or no
necessity for mastication.”11 Furthermore, they “will inconve-
nience themselves very little to become accustomed to the use
of dentures.”11
Summary
As mentioned previously, it is important to acknowledge Neil
as being first to name and publish his descriptions of the
four categories of a mental classification for complete den-
ture patients.10 But House also should be credited for the
wider dissemination of this information.11 Consequently, in fu-
ture reports about these concepts, it may be more appropri-
ate to use the designation “Neil-House Mental Classification
597
History of Temperament Theory and Mental Attitude in Denture Patients
System” when discussing the terms philosophical, exacting,
hysterical, and indifferent in reference to the mental condition
of complete denture patients.
Lastly, M. M. DeVan13 may have expressed it best when he
wrote that “For denture ventures to be successful, minds as
well as mouths must be individually understood and treated.”13
He added that it is important for dentists to “meet the minds of
the patient” before meeting “the mouth of the patient.”13 While
the labels and clinical implications associated with the four
temperaments have evolved since the 5th century, just as the
Glossary of Prosthodontic Terms has changed with the times,
an assessment and appreciation of the personality (mental tem-
perament) of present day complete denture patients may very
well be worthy of consideration and should not be overlooked
in our efforts to achieve successful clinical outcomes. For even
in this age of digital (CAD/CAM fabricated) complete den-
tures it remains worthwhile to assess the expectations and be-
haviors of patients prior to commencing treatment, particularly
in the event the mental characteristics identified by Neil10 and
House11 harken what is to come.
Disclosure
The authors have co-authored a digital education resource by
eHuman.com that contains some of the information appearing
in this publication.
References
1. Thompson AH: The temperaments and the temperamental
characteristics of the teeth in relation to dental prosthesis. In
598 Journal of Prosthodontics 29 (2020) 594–598 © 2020 by the American College of Prosthodontists
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Essig CJ (ed): The American Text-Book of Prosthetic Dentistry,
In Contributions by Eminent Authorities. Philadelphia, Lea
Brothers & Co., 1896. pp 578-587
2. Thompson AH, Turner CR: The human dental mechanism as
modified by temperament, age, and use. In Turner CR (ed): The
American Text-Book of Prosthetic Dentistry, Contributions by
Eminent Authorities (ed 4). Philadelphia, Lea & Febiger, 1913.
pp 255-265
3. www.psychology.jank.org>pages>Temperament. Accessed
5/19/2020.
4. Sellen PN, Jagger DC, Harrison A: Methods used to select
artificial anterior teeth for the edentulous patient: a historical
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5. http://en.wikipedia.org/wiki/Four_temperaments. Accessed
6/01/2020
6. http://en.wikipedia.org/wiki/Humorism. Accessed 6/06/2020
7. http://en.wikipedia.org/wiki/Galen. Accessed 5/19/2020
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Cosmos 1884;26:113-115
9. Randall WM: History, Examination, diagnosis, and prognosis
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10. Neil E: Full Denture Practice. Nashville, Tennessee, Marshall &
Bruce Co., 1932
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Quesnell AJ, Rogers RM (eds): Classic Prosthodontic Articles:
A Collector’s Item (Vol III). Chicago, American College of
Prosthodontists; 1978. pp. 2-24
12. Winkler S: House mental classification system of denture
patients: the contribution of Milus M. House. J Oral Implantol
2005;31:301-303
13. DeVan MM: Methods of procedure in a diagnostic service to the
edentulous patient. J Am Dent Assoc 1942;29:1981-1990