REMOVABLE PROSTHODONTICS SECTION EDITORS

LOUIS BLATTERFEIN S. HOWARD PAYNE

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

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.

n L/entists are in significant agreement that success or failure in fab.ricating dentures is predicated on the patient’s attitude toward the prosthesis. In the first article,’ the authors noted that the body schema (the psychologic image of the physical self) is heavily invested with emotional meaning. Significant changes in body image result in. varying degrees of emotional instability that affect adaptive competence. Given time, most people can absorb the trauma involved in body changes and develop new adaptations to change circumstance. Never- theless, there is a group of patients who are more emotionally fragile and who find that they cannot adjust to the physical change. The loss of teeth, despite an excellent prosthetic replacement, is an obstacle they cannot surmount. Examples of preedentulous and eden- tulous patients who responded to such loss are presented in the second a.rticle of this series.2

Part III identifies and discusses the technique of managing the maladaptive denture patient. The critical elements are (1) the behavior of the doctor--the most significant therapeutic part of altering maladaptiveness; and (2) the iatrosedative interview.

THE DOCTOR’S BEHAVIOR

For the maladaptive denture patient, the sense of loss and the prospect of a life of discomfort and discontent are powerful feelings that create a sense of hopelessness. The doctor, on whom the patient is dependent to make a significant change in his or her life, becomes an impor- tant figure.3 The patient must have an alliance with the doctor to cross over to adaptability. Consequently, there are strong feelings associated with such a doctor. They will be powerfully positive or negative dependent on the doctor’s behavior and attitude. Those feelings will become “incorporated” into the denture. If the patient distrusts and resents that behavior and attitude, the resulting denture will be “contaminated” by those feel- ings. The consequence is rejection of the denture as well as the doctor. On the other hand, if a warm trusting

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

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

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relationship is created by the doctor, the good will becomes embedded in the denture, resulting in patient acceptance of it along with acceptance of the doctor. Trust and a warm relationship will override the mechanical and psychological factors that ordinarily create a maladaptive response to the prosthesis. The first few minutes of an interaction are critical in creating trust.4 A warm relationship should be generated at the greeting before the initial interview starts. This is accomplished by empathic nonverbal and verbal commu- nications, a skill some doctors have intuitively and others have acquired in learning the role of a doctor and dedicating themselves to mastering it.

Bowlby’ research demonstrated that attachment behavior is among the instinctive responses that appear at birth. This response is biologically preset and there- fore not dependent on prior learning. Attachment behav- ior is defined as “seeking and maintaining proximity to another individual.” Attachment behavior is one set of instinctive responses that operates in the service of species survival. For the remainder of one’s life, seeking and maintaining proximity to another individual will be a matter of central importance to existence.

All relationships of consequence include attachment behavior and trust if they are to effectively survive. When patients require the help of caretakers (such as a dentist or physician) to care for their most prized possession (effective physical functioning), attachment and trust needs are activated. How the clinician recog- nizes and responds to such needs can make a crucial difference in outcome.

When a denture is prescribed, the patient may view the prosthesis with some degree of alarm and, for some, the prescription is viewed as the ultimate disaster. Hopefully, latent attachment behaviors are stimulated as the patient looks for a caretaker who is confident, caring, sensitive, and supportive. The dentist who can satisfy these attachment behaviors is likely to have a consider- able advantage in preparing a denture that is acceptable to the patient, both physically and emotionally.

THE IATROSEDATIVE INTERVIEW

The iatrosedative interview is designed to help the dentist mobilize her or his resources so that they operate

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in the most efficient way to create the climate of involvement and trust indispensable to altering mal- adaptiveness.

The iatrosedative model is a systematic, pragmatic “chairside” interaction used to reduce or eliminate most of the dental fears encountered in practice.6-7 The definition of iatrosedation is “making calm by the doctor’s behavior.” The word was created by combining “iatro” (doctor) with “sedation” (the a& of making calm). The goal of iatrosedation is to create a relearning experience wherein the feelings originally learned will be unlearned and a new set of feelings generated as a consequence of the interaction between the present doctor and his patient. The iatrosedative interview is composed of four parts: (1) recognizing and acknowledg- ing the problem, (2) exploring and identifying the problem, (3) interpreting and explaining the problem, and (4) offering a solution to the problem.

Recognizing and acknowledging the problem

The following example started as an open-ended initial interview. The patient immediately indicated that emotional factors were an important component of her request for a new denture. The doctor recognized this and acknowledged it by shifting into an iatrosedative interview. Had he re$ponded to the patient’s opening statement by saying, “Well, what’s the problem with your denture,” this would indicate nonacknowledgment and the desire to move the interview into the technical- anatomic arena.

Example. A 57-year-old woman has an appointment to see a dentist concerning her inability to adapt to dentures. Other than this information, he knows virtual- ly nothing about this patient. When he enters the operatory, his first impression is of an attractive, petite woman who seems younger than her stated age. She is seated, her face is expressionless, and the doctor infers that she is anxious or depressed. He begins with a greeting and some brief pleasantries, then continues:

Doctor: What kind of difficulties are you having?

This type of opening permits the patient to tell her story in the way she wishes. An open-ended question often elicits the patient’s dominant concern.

Patient: I am awfully unhappy. (Pauses.) Doctor: Unhappy?

The patient chooses to convey her emotional uneasiness as a primary complaint. The doctor repeats the signifi- cant word, indicating to the patient that he wishes to hear more. This also conveys to the patient his willing- ness to consider psychologic factors as well as physical ones. This is a first step toward developing a strong working relationship.

Patient: I have grown into an old woman long before my time. The day they removed my teeth I felt I had aged 20 years.

The patient is defining one potentially major factor in her maladaptive response to dentures. There may be others but she has provided the doctor with an important diagnostic clue.

Doctor: That feeling must be quite distressing. However, you do not give the appearance of an old woman.

The doctor again recognizes the emotional issues and indicates his acknowledgment by providing some support in making a realistic appraisal of her appearance. To go beyond this limited observation may make the patient feel that the doctor is tfying to make her feel better but is in reality insincere. He will continue to explore the emotional factors.

Exploring the problem

Patient: Yes, everyone tells me that but that’s not how I feel.

(She smiles for the first time.) And that’s what counts. The doctor’s observation has been validated, but she emphasizes that the only thing that matters is how she feels. Again, she underscores the importance of her inner state. The smile signals that her earlier tension is probably receding and the doctor’s style of communica- tion is beginning to have an effect.

Doctor: I agree with you. In the end, it is only how we feel that really matters. (He waits to see if the patient will respond to this remark. She does not.) But aside from the fact that the loss of teeth and the denture makes you feel like an old woman, how are you having difficuliy with the denture?

The doctor agrees with this very realistic assessment by the patient, that is, the nature of one’s feelings. No matter how fine the prosthesis, all is for naught if the patient feels miserable. He pauses to see whether the patient wants to add anything more to this point. Since she does not, he now shifts his focus from the generalized emotional state to ask what specific complaints there are. This will lead shortly to an interruption to evaluate the oral condition and the dentures.

Patient: I find it very uncomfortable. It slips. I have a burning sensation. My food seems tasteless. But I wear the denture all the time in spite of the discomfort because I’m shocked by how I look without it.

She mentions physical difficulties but indicates that the discomfort is overriden by the dread of appearing aged. Even when she is talking about physical factors, the pull is always back to emotional distress.

Doctor: I see. Your emotional discomfort is even greater than your physical discomfort. But can you give me more details about the physical difficulties?

The doctor makes explicit what is implicit in the patient’s observations. This is another way of indicating to the patient that she has been heard and understood. Because the doctor needs more information about physi- cal difficulties, he shifts back to this area.

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Patient: The denture seems to move in my mouth. When I chew, it seems to slip from side to side. The only time it doesn’t is if I eat soft foods. But my gums seem to be sore all the time. Seems like a burning sensation. Spicy foods make it much worse. I have given up all alcohol because it now seems to burn my mouth.

The physical symptoms that accompany the emotional ones have now been clarified. In a brief period of time the doctor has acquired some knowledge of the patient’s emotional and physical symptoms. This seems an appro- priate time ‘to gather information about previous attempts to fabricate dentures.

Doctor: As I understand it, you’ve had several other dentures made. Patient: Yes, none of them worked. Dr. L did two, and Dr. Y did the other two. Each one didn’t work and I don’t know why. To be honest, doctor, I really don’t know why I came to see you. ‘If two perfectly competent specialists could not make one denture that I could wear comfortably, I really don’t know what I could expect from you.

During the early part of the interview the patient appeared tense and anxious. Her emotional state has shifted to a more aggressive position in which the edge of sarcasm and challenge can be detected in both the tone of her voice and her words. The doctor has two possible responses. The first is to simply ask her why she requested a consultation despite her pessimism. A second possibility is to pick up on her thinly veiled anger. For the moment, the doctor chooses the first maneuver. However, he will keep in mind the anger and the challenge for another point in the interview.

Patient: Well, I haven’t given up. Somehow I have the feeling that someone must have the answer to my problem. (Long pause.) You can help.

Her pessimism is not total. But the doctor must be cautious. What happened with the previous “very com- petent dentists” who she says failed her could also be the fate of this doctor.

Doctor: You are riot very happy with the previous dentists you went to?

As noted earlier, her manner indicated anger at the previous practitioners. Is there something of consequence he can learn from her past encounters? The dentist puts the question directly to the patient in looking for the doctor-behavior link to maladaptiveness.

Patient: Each one was quite confident that he could make a denture that I would be happy with. I remember telling them that I hated wearing a denture but they just said that they could make one that would fit.

The statement is at the crux of the matter, because the previous dentists and this patient were talking at differ- ent levels. In each instance, the dentist was focused on fit, but she was talking about emotional fit.

Doctor: You were talking about your emotional distress mostly,

The doctor explicitly interprets what the patient has been telling him. At this point he realizes that if there is

any chance of success, he must hear both levels and set up a treatment plan that incorporates both aspects.

Patient: Exactly. I must say, doctor, I am somewhat encouraged because you seem to appreciate what I’m going through.

This is a positive movement in cementing a relationship. The doctor is now fully aware that attention to the psychological factors will be important because emotion- al concerns will always be present. This is an appropri- ate time to interrupt the interview and examine the dentures in the mouth to determine whether the burning and soreness of the tissues are related to any pathosis such as lesions or inflammation, whether there are any problems with inadequate ridges, and whether the denture is well fabricated. If all of these factors are within a satisfactory range, the question of nonaccep- tance maladaptiveness arises. (The oral examination revealed that the patient was wearing mandibular and maxillary dentures. The ridges were more than adequate in size and shape and the dentures were well fabricated and adapted. No lesions were visible and the mucosa was free of inflammation. The tentative diagnosis was “mal- adaptive class 2, unable to adapt psychologically and physically.2)

Part of the exploration of the problem was stated in the above portion of the interview. Some of the feelings were revealed and the previous doctors’ behaviors seemed to have been limited to technical aspects of the problem. It is probable that some of the patient’s hostility may be related to these experiences. Further exploration is necessary to determine whether previous learning has conditioned the patient and, if so, how the recommendation of total tooth loss and complete den- tures affected her. In addition, what were her feelings when the teeth were extracted and the dentures placed?

Doctor: You mentioned that you hate wearing dentures. Before we talk more about that I’d like to ask if your parents or grandparents had

dentures. Patient; Yes, my mother did and she suffered so with them. I remember as a child that she was unable to wear them and had several sets made. She was unable to eat with them and I was frightened because I thought that this might happen to me. I am so much like my mother. Doctor: That must have been terrifying to you as a child. Did you ever get used to the idea?

The doctor makes an understanding statement and follows it with a facilitative question to get more information about her feelings.

Patient: No, no, I never did. I’ve never forgotten the first time I saw my mother with her dentures out. Her face fell in-it was so shrunken that I panicked. And when the doctor told me that I had to have my teeth pulled, that horrible image flashed through my mind.

Doctor: Did you tell the doctor how you felt? Patient: Yes, I did, but he didn’t seem to care too much and repeatedly said that I would get used to it and get along just fine. Doctor: How did that make you feel?

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Patient: It made me angry and frightened me even more than I was.

This example represented the most common basis for maladaptiveness as a result of depression and anxiety related to toothlessness and dentures.

Examples of other origins were given in the second article of this series by preedentulous and edentulous patients. Their expressions cover most of the feelings of fear, anxiety, and depression associated with the antici- pation of complete dentures or their acquisition. The preedentulous patients’ varied responses to the threat of complete tooth loss serve to make us aware of the feelings that may be expressed if the edentulous maladaptive denture patient is carried back, through questioning, to the preedentulous state. Whatever feelings are expressed-the depression and fears of aging, loss of body integrity, femininity, masculinity, youthfulness, or beauty-may be the core around which the explanatory and interpretive segment of the interview will be built. The responses to the questions about the feelings associated with the doctors’ behaviors will provide insight as to the probable effect on adaptiveness and will also be used in the explanatory interpretive phase of the interview.

Interpreting and explaining the problem

There is more than one way to use the information garnered by the exploration of the feelings and events preceding and following the advents of tooth loss and replacement by artificial substitutes. The doctor’s style will determine this. The iatrosedative model is a vehicle to create mutual involvement by a combination of expressions of feelings of confidence and trust by both parties, the inclusion of the patient as participating in achieving success, and using the acquired information to suggest that feelings may affect success or failure in adapting to dentures. The sincerity of the tone the doctor brings to the situation probably will have a profound effect on the patient.

Doctor: I feel that you have suffered a great deal at the loss of your teeth. It was a terrible blow and it seems as if you have never really gotten over it. You were frightened as a child when your mother lost her beautiful teeth and her face sunk in, making her look very old suddenly. You learned to fear dentures because of this and because of this fear, you fought to avoid losing your teeth. Unfortunately you did lose them. The dentures are a constant reminder of that loss and your feelings may have an affect on your being able to accept them. You may have learned to fear having dentures because of your mother’s unhappy experience. This may have set the stage for your not being able to accept dentures for yourself. What do you think? Does this make sense to you? Patient: Yes, that sounds possible. Doctor: I want you to know your feelings can change and with that change we can expect you to be able to wear the dentures with comfort. Your gums, although tender, are healthy. They are not infected, but the stress of your unhappiness with the dentures can and does affect the way your gums tolerate the pressure of the dentures. With your new dentures and a new set of feelings it is likely that you will not have the soreness you have now. Let’s talk about what we can do.

Offering a solution to the problem

Doctor: We will work together in making new dentures and I am quite confident that, as we work things out together, your ,feelings about yourself and your dentures will change so that you will be able to live with them comfortably. It is going to take time to fabricate well-fitting dentures for you. It may take as long as 3 to 4 months. Patient: Doctor, why so long? Doctor: It takes time to make dentures that are well-fitting, dentures that you will be able to function with properly, and I want you to know that the day I place the dentures in your mouth is in essence the first day of treatment. From that time on I will be available to help make you comfortable. Patient: I really appreciate that, Doctor. The other doctors were so impatient with me and didn’t seem to realize that I was suffering so much emotionally. I feel hopeful and would like us to start.

The patient is grateful that the dentist is willing to spend the necessary time to make a good set of dentures. The great advantage is that the patient will get involved with the dentist as the helping, understanding, and supportive figure, realizing that the dentist is extremely concerned about her long-term well being. She also realizes that this dentist is maintaining an open-door policy. This continues the building process toward an ever more positive trusting relationship.

Doctor: Good. I am glad you feel optimistic about our working together. Let’s set’up an appointment to start treatment. I would like you to bring some photographs of you when you had your natural (own) teeth. They will be of great help to both of us in determining what your teeth looked like before, and also help us in determining how to arrange the new teeth. Patient: I’ll start looking for them. I think I have wedding pictures when I had a big smile on my face.

The patient is now involved in the fabrication of the new dentures, which adds another increment of relationship building. If after a considerable amount of treatment it becomes apparent that the patient’s adaptive ability is not increasing sufficiently, it would be in her best interest and the dentist’s to address the issue. The timing is important here. This is a difficult issue. Most patients reject the initial recommendation of dealing directly with the emotional aspects of the problem. Nevertheless, with an understanding approach, coupled with a strong relationship such as exists with this patient, an initial rejection may change to acceptance.

Doctor: I am very concerned about our progress at this point. We have done everything that we can together and things are not going as well for you as they should. My experience has been that most patients would be able to manage these dentures. I am quite confident that the stress you have undergone in losing your teeth and struggling with the dentures is still affecting you. Therefore I think we should bring someone in to help us with those stress factors. Patient: No, I don’t think I want to do this. I don’t think I am emotionally disturbed. Doctor: I did not mean to imply that you were an emotionally disturbed individual. We all have specific areas in our lives which are upsetting and for many people, accepting dentures is very difficult. I need to discuss this with you at this point because without solving this emotional aspect, we chance failure again and you may be spending time, effort, and money unnecessarily. What I would like you to do is

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think about it, because I sincerely believe it would be in your best interest. Perhaps share these thoughts with someone who is particular- ly close to you an(l whose opinion you value. Call me next week and let us discuss this ov’er the phone. One last point: next week you may still be opposed to my suggestion; however, in four or six months you may feel differently about it and want to explore my suggestion further. If that happens, feel free to call me and I’ll be happy to help you in any way I can.

nicators in the areas of physical and anatomic problems, but reticent when the issues are emotional.

Most dentists are taught to provide quick solutions to problems. This philosophy cannot be applied to treating behavioral problems. Some problems require “patience with patients.”

There is a small percentage of patients who cannot adapt because they need their symptoms. Patients main- tain symptoms for a variety of reasons. The symptoms may represent a way of rationalizing other problems, manipulating people, and may be an exhibitionistic attempt to draw sympathy from other people. These symptoms may be absolutely necessary in order to maintain a precarious psychological equilibrium. If the patient cannot relinquish such symptoms, the dentist will fail.8

SUMMARY

The iatrosedative interview is an effective method of helping patients who are unable to adapt to dentures because of fear, anxiety, and depression. It creates an indispensable trusting relationship in the process of determining the factors responsible for the maladaptive- ness and offers a solution to the problem.

REFERENCES

1.

DISCUSSION 2.

The behavior of the dentist is the most significant part in minimizing the maladaptive response. The dentist must develop .a new point of view in treating these kinds of patients. It is important to realize that the maladaptive patient who seeks technical advice relative to the pros- thesis from many dentists is in essence seeking emotional solutions.

3.

4.

5.

However, the dentist cannot conclude that the patient is “neurotic” and beyond his or her capacity to help. The doctor who shuts off the patient’s desire to share his or her fears about wearing a denture is putting obstacles in the path to achieving a successful outcome. It is not the denture that is the problem; it is the patient’s feelings about that particular denture.

6.

7.

8.

A major aspect of the solution is the dentist’s ability to first listen and gather information and then communi- cate effectively. In general, dentists are excellent commu-

Reprint requests to: DR. NATHAN FRIEDMAN

SCHOLL OF DENTISTRY, RWM 4202

UNIVERSITY PARK, MC-0641 UNIVERSITY OF SOUTHERN CALIFORNIA

Los ANGELES, CA 90089-0641

Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety, and depression on the patient’s adaptive response to complete dentures. Part I. J PROSTHET DENT 1987;58:687-9.

Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety, and depression on the patient’s adaptive response to complete dentures. Part II. J PROSTHET DENT 1988;59:45-8.

Egbert L, Battit G, Turndoff H, Beecher H: Value of the preoperative visit by an anesthestist. JAMA 1963;195:553. Zunin L. Contact: The first four minutes. New York: Ballantine Books, Inc, 1972. Bowlby J. Attachment and loss.Vol 1. New York: Basic Books, Inc, 1979;194. McCarthy FM. Emergencies in dental practices. 3rd ed. Phila- delphia: WB Saunders Co, 1979;236-5. Friedman N. Iatrosedation: the treatment of fear in the dental patient. J DENT EDUC 1983;47:91-5.

Pitts WC. Difficult dentures patients: observation and hypothe- sis. J PROSTHET DENT 1985;53:532-4.

Wear characteristics of high-strength denture teeth

J. A. von Fraunhofer, M.Sc., Ph.D.,* R. Razavi, B.S.,** and Z. Khan, D.D.S.*** University of Louisville, School of Dentistry, Louisville, Ky.

T he wear characteristics of monoplane and anatomic teeth were investigated in previous studies.‘s2 There appears to be no statistically significant difference in the

*Professor of Biomaterials Science. **Third-year dental student. ***Associate Professor and Director of Postgraduate Prosthodontics.

wear resistance of acrylic resin monoplane and anatomic denture teeth tested under comparable regimens. Fur- ther, despite claims of greater wear resistance for differ- ent products, the improved wear characteristics of acrylic resin anatomic denture teeth produced by three different manufacturers were judged to be clinically insignificant.2 Now, a modified high-strength resin tooth has been

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