REMOVABLE PROSTHODONTICS SECTION EDITORS

LOUIS BLATTERFEJN S. HOWARD PAYNE

The influences of fear, anxiety, and depression on the patient’s adaptive responses to complete dentures. Part I

Nathan Friedman, D.D.S.,* Howard M. Landesman, D.D.S., M.Ed.,*+ and Murray Wexler, Ph.D.*** University of Southern California, School of Dentistry, and School of Medicine, Los Angeles, Calif.

T he dentist, when fabricating complete dentures, is faced with the possibility that on their completion, the patient may not be able to adapt to them. A number of factors may be responsible for this. They are anatomic, physiologic, and psychologic. Of the psychologic factors, fear, anxiety, and depression can have significant effects on adaptability. For some patients, the recommendation that the loss of natural teeth is necessary can generate such emotional turmoil that a maladaptive response to the subsequent denture(s) could be the consequence.

REVIEW OF THE LITERATURE

Numbers of authors have considered the influence of emotional and psychologic factors on the patient’s satis- faction and ability to adapt to dentures. The literature tends to be general in nature and falls into three categories. The first category is concerned with the use of various personality testing devices.lm7 The second catego- ry addresses patient’s satisfaction or lack thereof with dentures.8-‘2 The third category deals with general psychologic considerations when treating the edentulous patient. 13-Z’ MouhonZ2 and Pittsz3 discuss psychologic problems in greater detail.

OBJECTIVES

Our purpose is to present the subject material in three separate articles. The first will consider in a detailed and specific manner the significance of tooth loss and the effects of such loss or threat of loss on people’s lives and how this ultimately may affect the patient’s ability to adapt to the edentulous state and the subsequent den- ture(s). Three classes of maladaptive responses to den- tures will be described. The second article will deal with clinical examples that identify the fear, anxiety, and depression expressed by the patient threatened with tooth loss and the expressions of these emotions after tooth loss and denture fabrication. The diagnoses for

*Clinical Professor and Chairman, Section of Behavioral Dentistry. **Professor, Department of Restorative Dentistry, Executive Associate

Dean. ***Professor, Department of Psychiatry and Behavioral Dentistry.

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maladaptability for each of these patients will be stated according to the classification system presented in the first article. The concluding article will deal with (1) the elements that make up the technique of managing the maladaptive denture patient-the behavior of the doctor; and (2) an interview designed to reduce the effects of anxiety and depression on the maladaptive patient and offer a solution to the problem.

BODY LOSS

Loss is a major event in everyone’s experience. Whereas the early portion of the life cycle is devoted to growth, strength, and activity, the latter segments are characterized, at first subtly and then with increasing momentum, by decline, decay, and death. Physical events abound to inform us that vigor, pleasure, and beauty are finite. Loss of teeth may play a preeminent role in reminding us that life is fragile and extinction assured.

The dentist is committed primarily to the preservation of healthy teeth. Once pathosis appears, the next task is to halt or slow the process in order to maintain maximal oral integrity. Failing that, replacement of teeth, the ultimate procedure being complete dentures, is the dentist’s final responsibility. It is at this point that the dentist often encounters puzzling, seemingly insoluble problems. The patient complains incessantly that, despite the dentist’s best efforts, “the denture just does not work.” The answer seems to be that despite the dentist’s technical skills, he has run “directly into the patient’s life.” Dentures are not just dentures to the patient. They are another sign that life is rapidly running its course.

Dentures have a variety of meanings to the recipients. The dentist may be unaware of the impact that dentures have on many patients because the “successful” denture wearer never complains of the “fit” and therefore has not fallen into the category of the difficult patient. Neverthe- less, the quality of life may be impaired in a variety of ways, but the dentist may never be privy to these circumstances.

A relatively small number of patients cannot adapt to complete dentures. Complaints that they do not fit, are

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the cause of burning of the palate and painful tissues and tongue, interfere with articulation of speech, and the like are generally only part of the clinical picture. Depres- sion, impaired concentration, social withdrawal, and even suicidal rumination may accompany the inability to accept the prostheses.

BODY IMAGE

Everyone has a normal amount of pride or narcissism (self-love) attached to one’s own body and organs. Although we accept the body as a matter of course, the several parts that comprise it each have a long develop- mental history, both physically and psychologically. For example, the amputation of a limb disrupts the internal body schema, resulting in both physical and emotional disorganization. The loss of a leg seriously interferes with body support and ambulation and thus requires the learning of a new set of responses to remain upright and move. But the loss of a limb has other meanings as well. The loss signals, at least temporarily, that not only physical but emotional supports have collapsed. The body image cannot accept the loss and disfigurement that is also reflected as a severe blow to one’s sense of wholeness, and self-esteem. This is especially true con- cerning visible parts of the body. Among these visible parts, the teeth play a dominant role. Consequently, most people resist change in their appearance. No prosthetic restoration, even if mechanically and estheti- cally perfect, can restore the person’s image of himself as a whole person with no parts missing. This is exempli- fied by one patient’s statement that, “. . . the denture fits, I am not suffering any physical pain but part of me is gone. These are not mine, they are a dead part of myself.”

For most people the first denture is an experience requiring adjustment to a major change in a major area of the body. Consequently, it is probable that patients approach major or total tooth loss with some anxiety and depression.

ANXIETY AND DEPRESSION

Anxiety is a response to the perception of danger, actual or anticipated. Its purpose is to alert individuals to danger to prepare them to cope with it. It becomes manifest when an individual perceives that his or her well being is threatened. As discussed, a major source of anxiety is alteration of body integrity and the way the body functions. Extensive changes in the oral cavity (loss of teeth and replacement with dentures) represents such a threat and therefore can trigger anxiety.

Depression is a response to loss, actual or threatened, real or fantasized. Feelings of sadness, helplessness, and hopelessness are the common accompaniments when significant losses are experienced, such as loss of loved one or loss of a body part. The impact is particularly

serious when it involves emotionally invested parts of the body such as the face (teeth), breasts, or genitals. For some patients, the teeth have become so invested with meaning that their loss is experienced as catastrophic. In this case, there is an emotional fight against losing teeth and, once the denture is in place, the struggle continues, making the denture psychologically unacceptable.

CLASSIFICATION OF RESPONSES

There are four specific ways in which people respond to the edentulous state and denture:

Adaptive

1. They face tooth loss with minimal trepidation, and accept the denture as an adequate substitute. In some instances, they may welcome tooth loss. The denture does not significantly impair the quality of their lives.

Maladaptive - Class 1

2. They view tooth loss as a serious impairment of the quality of their lives. They are not able to adapt to dentures emotionally (psychologically) but do adapt physically.

Maladaptive - Class 2

3. They are unable to adapt to denture(s) psychological- ly or physically. The edentulous state and the denture is a catastrophe. They are not able to accept the loss of teeth or the use of the denture(s) rationally. They are “difficult denture patients” who have frequent com- plaints requiring a disproportionate amount of atten- tion.

Maladaptive - Class 3

4. They cannot and do not wear the dentures and the dentist may never see them after the dentures are inserted. They become chronically depressed and isolate themselves from society. These “collapsed patients” are emotionally overwhelmed by the expe- rience. As these categories illustrate, the dentist’s clinical

responsibility involves an assessment of the psychologic factors that influence the patient’s responses to tooth loss and acceptance of dentures. Because dentures can have unforseen emotional consequences, it is essential to obtain a history to determine how the patient perceives the effects of dentures on his or her life.

Part II of this series illustrates, through the use of patient histories, how various individuals respond emo- tionally to the threat of tooth loss and edentulousness.

SUMMARY

‘. Loss and body image can result in anxiety, depression, or both and can affect a patient’s adaptive capacity to

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ADAPTIVE RESPONSES TO DENTURES. PART I

accept edentulism and complete dentures. A specific classification system has been presented to identify responses by individuals who are made edentulous. Three types of maladaptive responses are considered as probable consequences of fear, anxiety, and depression associated with tooth loss and complete dentures. In maladaptive class 1, the patient adapts physically but is maladaptive psychologically; thus suffering some impairment of the quality of life. In maladaptive class ‘2, the so-called “difficult patient” is maladaptive physically and psychologically and keeps the doctor involved tech- nically and emotionally for a protracted period of time. The maladaptive class 3 patient collapses with the loss of teeth. Physical and emotional maladaptibility is accom- panied by much suffering and social withdrawal.

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Refmnt requests to: DR. NATHAN FRIEDMAN

SCHOOL OF DENTISTRY, RWM 4202 UNIVERSITY PARK, MC-0641 UNIVERSITY OF SOUTHERN CALIFORNIA Los ANGELES, CA 90089-0641

Water sorption by denture acrylic resin and consequent changes in vertical dimensi.on

B. Ristic, B.D.S., M.Sc. (Dent.),* and L. Cam, B.D.S., M.Dent.** University of the Witwatersrand, School of Dentistry, Johannesburg, South Africa

S orption of water has been recognized as a problem in the dimensional stability of dentures. Denture base resins investigated in recent years have shown some

*Lecturer, Department of Prosthetic Dentistry. **Senior Lecturer, Department of Prosthetic Dentistry.

correlation between a high water uptake and clinical failures.’

Dental acrylic resins absorb water and expand slowly over a period of time. This expansion is a volumetric change and therefore is expressed in three dimensions. It has been shown that water molecules act according to the laws of diffusion.’ The diffusion presumably occurs

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