Evaluation of mental attitude of patient

Presented By – Dr.Piyali Bhattacharya
1st year PGT
Dept. of Prosthodontics
HIDSAR


Jamieson stated that “fitting the
personality of the aged patient is
often more difficult than fitting the
denture to the mouth”.

Etiology for development of psychological and emotional disturbances :
Body loss
Body image
Emotional aspects of tooth loss
Psychological and emotional disorders usually seen by the dentist :
1.Anxiety:
2.Depression: often disguised as a somatic complaint such as pain, bad taste or
an inability to adjust to dental treatment.
3.Conversion hysteria
4.Body image disturbance:
Gerodontology Review article
Geriatric patient – psychological and emotional considerations during dental treatment
Introduction

Factors that influence the patient’s response :
• Parental influence
• Sibling’s influence
• Peer group
• Symbolic significance
• Current life circumstances
Gerodontology
Review article
Geriatric patient – psychological and emotional considerations during dental treatment

Factors that a dentist must keep in mind before
examining the patient:
1. Sex
2. Skin complexion
3. Occupation
4. Gait of the patient
5. Medical History

Sex :
Male patients focuses more on function
Female patients Focus on aesthetics

Anxiety for Dental treatment on the basis of sex of
the patient:
Women rate higher in Dental anxiety scale, self
rating depression compared to males
The Journal of Contemporary Dental Practice, Volume 6, No. 1, February 15, 2005

Skin complexion :
It is suggested that the hue of artificial teeth should
harmonize with the patient’s complexion
(Boucher et al, 1975; Winkler, 1979); Bates et al,
1991). These authors also advocated the use of the
colour of the facial skin as one basic guide in selecting
colour for artificial teeth in Caucasians.
as a person ages, the shade of the teeth becomes darker .
However the skin complexion may or may not match with
colour of natural teeth.
It is rather an individual judgement
Afr. J. Biomed. Res. 13 (January 2010) 9 - 14

Occupation:
People working in the field of media or public
figures have a higher aesthetic and functional
demands compared to other patients.

Gait of the patient:
1.The change in mandibular position inclines to cause instability in gait of
the patient.
2. The Parkinson disease is progressive neurological disorder with resting
tremor, bradykinesia , akinesia, and postural instability.
The psychological components of disease -depression, anxiety, and
cognitive deficiency.
Poor oral hygiene, increased susceptibility for dental caries, and
periodontal diseases predispose them to early edentulism .
The short, mid-morning appointments are ideal for the patient. The tremors
are less in morning and drug is most effective 60– 90 minutes after its intake
The communication with the patient is improved by using closed-ended
questions and allowing adequate time for the patient to respond. Effective
communication is important to motivate the patient for treatment rigors and
future effective utilization of denture. The slow raising of the dental chair
for upright position is recommended to prevent the orthostatic hypotension
J Med Dent Sci 2001 ; 48: 131-136
Case Reports in Dentistry
Volume 2015, Article ID 352878, 5 pages
Clinical Strategies for Complete Denture Rehabilitation in a Patient with Parkinson Disease andReduced Neuromuscular Control

In patients with heart-attack or brain-stroke, the gait changes
Also in Alzheimer's disease the gait of the patient changes ,
the gait velocity becomes slower, their cognitive capacity
becomes less as they tend to forget the daily routine
Xerostomia is a common side-effect of the AD patient as well
(because of the AD drugs )

Significance of medical history of patients:
Diabetic patients, hypertensive patients and patients with history of
cardiovascular stroke or brain stroke tend to have higher level of
anxiety, depression and overall negative attitude compared to
normal counterpart.
Also, abnormal gait seen in diabetes patients (high step/foot drop)
Post-Stroke patients Hemiperetic gait
Cancer patients who have undergone radiation therapy or,
maxillectomy or hemimandibulectomy feels rejected socially and
those terminally ill, have higher level of anxiety, depression and
high desire to hasten death.


 The House classification system is
described in detail in a chapter by S.
Howard Payne in John J. Sharry's textbook
Complete Denture Prosthodontics. Payne
attributes the classification to unpublished
notes of "Study Club No. 1" on "Full
Denture Technique" in 1937.
HOUSE MENTAL CLASSIFICATION SYSTEM OF DENTURE PATIENTS: THE CONTRIBUTION OF MILUS M. HOUSE
Sheldon Winkler, DDS

Rahn and Heartwell list the classification in their textbook and footnote the
narrative with ‘‘Lecture by M. M.House.’’ Craddock mentions the classification
system in his textbook but provides no reference. Landa briefly mentions the
classification system in his textbook but does not credit anyone with its origin.
In an article published in 2003 in the Journal of Prosthetic Dentistry,Gamer et al
credit Dr House with devising the classification system in 1950. Their reference
is from Classic Prosthodontic Articles, volumeIII, published by the American
College of Prosthodontists.
In 1932 Dr Ewell Neil wrote a small text entitled Full Denture Practice. Neil
described the system initially in his textbook Full Denture Practice, which was
published in 1932. Dr Neil began his book with a mental classification of denture
patients, similar to that credited to House. Neil writes,‘‘The patient’s mental
attitude may be classed under one of four possible groups, viz., hysterical;
exacting or hypercritical; indifferent; and philosophical.’’ Neil then describes
representative patients in each of these groups.
HOUSE MENTAL CLASSIFICATION SYSTEM OF DENTURE PATIENTS: THE CONTRIBUTION OF MILUS M.
HOUSE

It is 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
There is no doubt that House expanded and popularized the
system, which was originally introduced to the profession in
1932 by Neil.
HOUSE MENTAL CLASSIFICATION SYSTEM OF DENTURE PATIENTS: THE CONTRIBUTION OF MILUS M. HOUSE


House Classification (1950)
1) Philosophical patient:
Best mental attitude for denture acceptance
Rationale, sensible, calm and composed in different situations.
His motivation is generalized, as he considers dentures for the
maintenance of health and appearance and feels that having teeth
replaced is a normal acceptable procedure. These patients are
willing to rely on the dentist’s advice for diagnosis and treatment.
Philosophical patients will follow the dentist’s advice when
advised to replace their dentures.
IJOCR Apr - Jun 2015; Volume 3 Issue 8
DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE PATIENTS BASED ON MENTAL ATTITUDE: A
REVIEW

2) Exacting:
The exacting patient may have all of good attributes of the
philosophical patients; however he may require extreme care,
effort and patience on the part of dentist.
Patient is methodical, precise, and accurate and at times makes
severe demands.
Above average in intelligence often dissatisfied with past
treatment, Doubt the dentist’s ability to make dentures that
would satisfy their esthetic and functional needs and often
want written guarantees or remakes at no additional charge.
Careful observation and listening will reveal that the big
mistakes had been the result of doctor trying to follow the
directions of the patient.
DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE PATIENTS BASED ON MENTAL
ATTITUDE: A REVIEW

A firm control of these patients is essential. They must not be
allowed to even think that they are directing the treatment. The
dentist must be the doctor who directs all treatment and
decisions. These patients can be traumatic in a dental practice if
they are not properly controlled.
Medical consultation is always advisable for these patients before
treatment is started.
Once satisfied an exacting patient may become the greatest
supporter.
RRJDS | Volume 1 | Issue 3 | October-December, 2013
Mental Attitude and Psychological Adaptive Response in Complete Edentulous Patients

3) Hysterical:
Emotionally unstable, excitable and excessively apprehensive.
submit to treatment as a last resort,
negative attitude, are often in poor health, are poorly adjusted,
often appear exacting but with unfounded complaints,
have failed at past attempts to wear dentures,
unrealistic expectations.
They expect the prosthesis to look and function like natural
teeth.
Prognosis is poor for these patients.
ATTITUDE: A REVIEW

4) Indifferent:
Presents a questionable or unfavorable prognosis.
evidences little concern;
apathetic and uninterested and lacks motivation.
manages to survive without wearing dentures.
pays no attention to instructions, will not co-operate, and is prone to
blame the dentist for poor dental health.
REVIEW

There are two groups of patients that require special psychologic
evaluation:
1. those at the climacteric age.
2. geriatric patients. These patients are undergoing glandular
changes, and as a result, they may also experience changes in
behavior as well as physiologic changes.
Psychologic considerations in complete denture prosthodontics Charles M. Heartwell, Jr., D.D.S.
J.Pros.Dent, July 1970

Pitfalls in House classification:
House provided little attention to how the patient’s
reactions and behaviors are codetermined by the
treatment and behavior of the dentist.
DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE PATIENTS BASED ON MENTAL ATTITUDE:
A REVIEW

WINKLERS CLASSIFICATION:
1. The Hardy elderly:
These are individuals who are well-preserved physically and
psychologically, are active in their professional and social
lives and quickly adapt to their age
2. The Senile aged syndrome: These are individuals who are
disadvantaged emotionally and physically and may be
described as handicapped, chronically ill, disabled, infirm
and truly aged. They cannot handle daily stresses and are
susceptible to disease.
DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE PATIENTS BASED ON MENTAL ATTITUDE: A REVIEW

3. The Satisfied old denture wearer: These patients are satisfied
with their old dentures in spite of severe problems. They have
learned to live with them and are happy with them.
4. The Geriatric patient who does not want dentures: An
elderly person who has been without teeth for many years and
has no desire for complete dentures and lacks motivation.
The last two categories of patients lack motivation and have a
poor prognosis if forced into undergoing treatment.
DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE PATIENTS BASED ON MENTAL ATTITUDE: A REVIEW

IDEAL PATIENT
The ‘ideal’ geriatric denture patient O’Shea characterized the ideal
dental patient as compliant, sophisticated and responsive.
Winkler described four traits that characterize the ideal patient’s
response:
1. realizes the need for the prosthetic treatment,
2. wants the dentures,
3. accepts the dentures and
4. attempts to learn to use the dentures.
It is evident from the various classifications that a so-called ideal
psychological profile, though rare, is often desired by most dentists
as it provides the greatest chance of success.
REVIEW

the definition of the term ‘ideal’ may be relative, but it does
provide a standard to refer to.
Simon Gamer et al. in 2003 presented an expansion of the House
classification to include the behavior of the dentist as a co-
determiner of the patient’s behaviour.
ATTITUDE: A REVIEW

The Gamer classification:
based on 2 factors
1. The level of patient engagement with the dentist and
treatment process exists along a continuum from
completely over involved (+ + + +) to disengaged (+).
2. The level of the patient’s willingness to submit (trust) also
exists along a continuum from willingness to submit to the
dentist’s recommendations without a second thought (+
+ + +) to intense reluctance to do anything the dentist
recommends (+).

1.The Ideal patient
which corresponds to House’s philosophical mind, is reasonably
engaged (+ + +) and reasonably willing to submit (trust) (+ + +) to
the dentist. This type of patient is not ranked + + + + in either
category, because these patients are considered mature with a
healthy life balance.
The ideal patient has a healthy level of distrust. Any reasonable
patient should have some skepticism; they should permit
themselves to have questions and doubts. Patients deserve
explanations for professional dental treatment to understand the
situation and arrive at a decision regarding treatment.
Therefore the ideal patient tends to be neither overly suspicious
nor blindly accepting of the dentist’s recommendations.

2.The Submitter patient
+ + + + on engagement and ++++ on willingness to submit (trust).
lack discrimination and tend to idealize the dentist which results in
a high degree of engagement and utter surrender.
This renders the submitter incapable of providing genuine
informed consent because he/she has surrendered the use of
critical faculties and therefore cannot be an active partner in
the treatment.

3. The Resistant patient
corresponds to House’s exacting mind and Boucher’s critical
patient.
Resistant patients are skeptical of the dentist as a person and
of being helped by anyone under any circumstance.
The resistant patient is, paradoxically, very engaged with the
dentist but in an adversarial way.
Rather than being dependent, they challenge the dentist. And,
like the indifferent patient, there is no trust.

4. The Reluctant patient rates + + on engagement and ++ on
willingness to submit. He is often leery of the dentist and skeptical
of the treatment plan.
5.The Indifferent patient, who corresponds to House’s
indifferent mind, rates + on engagement and + on
willingness to submit (trust).
Usually forced to see the dentist by a concerned family
member or friend, the indifferent patient is minimally
engaged and indifferent to the dentist to the extent that
willingness to submit (trust) is not an issue.

Wright’s classification:
1. Cooperative
They may or may not recognize the need for dentures but they are
open-minded and are amenable to suggestion. Procedures can be
explained with very little effort and they become fully cooperative.
2. Apprehensive
Even though these patients realize the need for dentures they
have some irritational problem which cannot be overcome by
ordinary explanation.
They are of different types:

a. Anxious
The patients are anxious and upset about the uncertainties of
wearing dentures. They often put themselves into a neurotic state.
b. Frightened
They will have unwanted fear about the dentures.
c. Obsessive or exacting
They are naturally of an exacting nature. They state their
wants and are inclined to tell the dentist how to proceed.
They must be handled firmly and tactfully.

d. Chronic complainers
They are a group of people who are habitually fault finding
and dissatisfied. Appreciating the corporation and
incorporating as many of their ideas as possible with good
denture construction is the best way to handle them.
e. Self-conscious
The apprehension here centers chiefly on appearance. It is
wise to give overt reassurance to the self-conscious patient
and permit participation as far as feasible in order to
establish some responsibility in the result.

3. Uncooperative
They do not feel a need for dentures though the need exists.
Their general attitude is negative. They constitute an
extremely different group of potential denture members.

Sharry's classification
TOLBUDS: Patients who could tolerate prosthesis backwards,
upside down or sideways.
TOLAD: Patients who could tolerate prosthesis with some degree of
adjustment.
TOLN: Patients who could tolerate nothing.
Blum classification
Reasonable
Unreasonable.
Bandodkar, et al.: Psychological considerations for denture patients

A. Unreasonable expectation towards the doctor and towards
medical science with regard to the quickness and certainty of the
treatment.
B. Unreasonable expectation about the fee and a basic unwillingness
to pay unless completely satisfactory results are obtained.
C. Unreasonable beliefs about the general incompetence or
unpleasant and untrustworthy nature of the physician in general

Alex Koper described the "Difficult Denture Bird" as a problem
denture patient with much experience as a recipient of various
kinds of dental therapy.
The problem denture patients are individuals who complain,
have pain and are hostile, tense, anxious and unhappy people.
They often exhibit regressive behavior and transfer many of their
fears and frustrations to the mouth and face and endow their
dentist with all sorts of unrealistic fantasies: he / she is an angel,
a devil, a magician; he can be kind or cruel.

Shaking hands with a
patient is an informative
process
The manner in which the patient
opens his mouth also tells about
his mental attitude.
Left: The show-off center: The
cooperative patient. Right:
The uninterested and
uncooperative patient

Seven basic personality traits have been considered by Bliss CH that are
important in successful treatment. Maximum benefits will be obtained
only by those who make an honest attempt to search for and address
personal shortcomings.
1. Be agreeable.
2. Be a good listener.
3. Avoid arguments.
4. Criticize tactfully.
5. Don't be egoistic.
6. Remember names and faces.
7. Be interested in others.

The Psychosomatic Component in Prosthodontics
The link between the mind and the body in psychosomatic disorders can be
observed in the visceral systems as a function of the changes in the emotional
state of the patient.
Emotional conflict brings on anxiety, which results in physiologic symptoms,
psychological symptoms or both.
These phenomena are illustrated as:
The most common disorders, which affect prosthodontic treatment are:
(1) circulatory disturbances, hypertension, vasomotor instability and cardiac
disease
(2) respiratory disorders shortness of breath or difficulty in breathing, asthmatic
attack

(3) gastrointestinal disorders. An increase in the bacterial flora of the
mouth:
Poor hygiene frequently is associated with psychoneuroses and causes
interference with circulation and antibody formation in the saliva. Faulty diet
is frequently nondetergent in character and coupled with poor masticatory
efficiencies and promotes and hastens bacterial growth.
Patients who are in a depressed state do not maintain good oral hygiene and
they may allow masses of debris to accumulate in the buccal folds and on
denture surfaces.
Oral hygiene instructions will improve the oral health status and. indirectly,
quality of life and psychological well-being.

Whitehead et al. suggested that psychosomatic symptoms can be divided into:
I) Those associated with abnormal physical changes in organs innervated
by the autonomic nervous system (for example, peptic and duodenal
ulcers and hypertension).
II ) Those influenced by environmental events that possess psychological
significance (for example; musculoskeletal or sensory anomalies and
hypochondriacal complaints such as chronic pain syndrome).

three principal etiologic categories of psychosomatic symptoms were:
Pathological conditions associated with environmental stressors of a general nature
1.Temporomandibular joint (TMJ) dysfunction may be a pathologic condition
associated with environmental learning. Treatment of stress reactions requires
modulation of the effects of stress and includes relaxation, cognitive restructuring
and environmental modification.
2.Conditions that arise as a result of classic conditioning. The gag reflex may arise
from classic conditioning. Classically conditioned symptoms are usually treated by
extinction procedures such as desensitization and flooding.
3.Operantly conditioned symptoms-Denture intolerance may be an operantly
conditioned symptom. Operantly conditioned symptoms are alleviated by
discontinuing the reinforcement that maintains them.

The international prosthodontic workshop identified the following factors which
produce an adaptive or maladaptive response.
1. The acceptance of the doctor and confidence in the doctor, which could be
described as trust.
2. Previous favourable experiences with authority figures.
3. The capacity to cope favourably with change. Positive attitude increases this
capacity
4. Favourable physical conditions: youth and general health were factors which
produces an adaptive response to complete denture
5. Realistic expectation of the patient.
6. Good learning capacity.
7. The desire of the patient to please the doctor.
8. Recognition by both doctor and the patient that there are varying degrees of
success and acceptance of a less than ideal result by the patient and the doctor.
9. Recognition by the patient of the limitation and facts of success of complete
denture treatment Good physical coordination on the part of the patient.
10. The patient should be aware of the active role he must play in the cooperative
treatment effort
Mental Attitude and Psychological Adaptive Response in Complete Edentulous Patients.
Research and Reviews: Journal of Dental Sciences

Factors which produce a maladaptive response to edentulous treatment
1. Lack of trust in the dentist.
2. Poor communication between the dentist and his patient .
3. Negative previous experience, such as unfavourable experience with
other dentist.
4. Unrealistic expectation of the denture patient.
5. Resistance to change arising from severe anxiety or depression or
hopelessness.
6. Low tolerance for anxiety or pain.
7. A high level of anxiety on the part of the patient .
8. Inadequate tissue tolerance.
9. Muscle in coordination
10. Chronic dissatisfaction
Mental Attitude and Psychological Adaptive Response in Complete Edentulous Patients.
Research and Reviews: Journal of Dental Sciences

1.Gerodontology Review article
Geriatric patient – psychological and emotional considerations during dental
treatment
2. Prosthodontic treatment for edentulous patients,Zarb.Bolender
2. The Journal of Contemporary Dental Practice, Volume 6, No. 1, February 15, 2005
3. Afr. J. Biomed. Res. 13 (January 2010) 9 - 14
4. J Med Dent Sci 2001 ; 48: 131-136
5. Case Reports in Dentistry,Volume 2015, Article ID 352878, 5 pages
Clinical Strategies for Complete Denture Rehabilitation in a Patient with Parkinson
Disease andReduced Neuromuscular Control
6. HOUSE MENTAL CLASSIFICATION SYSTEM OF DENTURE PATIENTS:
THE CONTRIBUTION OF MILUS M. HOUSE, Sheldon Winkler, DDS
7. IJOCR Apr - Jun 2015; Volume 3 Issue 8
DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE PATIENTS
BASED ON MENTAL ATTITUDE: A REVIEW
8. RRJDS | Volume 1 | Issue 3 | October-December, 2013,
Mental Attitude and Psychological Adaptive Response in Complete Edentulous
Patients
9. Psychologic considerations in complete denture prosthodontics Charles M.
Heartwell, Jr., D.D.S., J.Pros.Dent, July 1970
10. Bandodkar, et al.: Psychological considerations for denture patients

Evaluation of mental attitude of patient

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