PROSTHODONTICS

1. PSYCHOLOGICALASPECT IN
COMPLETE DENTURE PATIENTS
Presented by:
Dr. Nonika Chahal
PG 2nd year

2. DEFINITIONS
Psychological means concerned with a person's mind(mental) and
thoughts(emotional) attitude rather than physical.
An Aspect of something is one of the parts of its character.

3. So, mental attitude is one of an important factor in planning the
treatment and improving its outcome.
According to literature various researchers have found
various classification of mental attitude of the elderly patient
for prosthodontic treatment.

4. 1. House classification
Dr Milus M. House in 1950 classified patient’s Psychology into four
types:
Type 1 : Philosophical mind
- reasonable,calm, and involved in the treatment procedure at every step.
- understand the treatment
- listen to the dentist’s advice and are willing to follow the instruction.

5. Type 2: Exacting mind
- disciplined, strict,may have precise demand and may ask for a
guarantee
- dentist may have to give a little more effort after which the patient
listens to him and follow his advice.
- if the patient had a previous denture which was dissatisfactory, then he
may doubt the present denture also.
But, once satisfied, he would be the dentist’s fan.
- prognosis is usually good

6. Type 3: Hysterical mind
- negative attitude
- poor oral health and lack of effort for maintaining oral health
- anxious and unstable emotionally
- do not have realistic expectation
- unreasonable complaints
- poor prognosis

7. Type 4: Indifferent mind
- not motivated for the treatment.
- disinterested in the treatment
- does not obey any advice of the dentist
- prognosis is doubtful

8. WHY THE HOUSE CLASSIFICATION
REQUIRES REEVALUATION
1. Some of the terminology is antiquated, falling out of use, or no
longer carries the same meaning within psychiatry. For instance, the
word hysterical has come to be regarded as derogatory and
judgmental. And today one might speak more of a narcissistic
patient.
2. House provided little attention to how the patient’s reactions and
behaviors are codetermined by the treatment and behavior of the
dentist.
Simon Gamer et al “M. M. House mental classification revisited: Intersection of particular patient types and particular dentist’s needs” J Prosthet Dent 2003;89:297-302

9. Stolorow and Atwood critiqued the idea that a patient can be viewed in
isolation from the effect of the psychoanalyst. They called this a
mistaken notion and an example of “the myth of the isolated mind.”
Thus the patient’s behavior is codetermined by the personality and
behavior of the psychoanalyst.

10. 2. Gamer’s Classification
Gamer et al. modified House’s classification in 2003, based on two factors, i.e:
patient’s engagement level to dentist and treatment procedure in a continum
from totally engaged (++++) to disengaged (+).
1. Ideal :
• Reasonably engaged i.e. (+ + +)
• Reasonably trusts the dentist i.e. (+ + +)
• May skeptically distrust also .
• Mature
• May ask questions and need satisfying answers for the same from the dentist
• May not be over suspicious or over accepting of the dentist’s opinions.
• Similar to Philosophical type of patient in House’s classification
Gamer S, Tuch R, Garcia LT. MM House mental classification revisited: intersection of particular patients type and particular dentist’s needs. J Prosthet Dent.
2003;89:297–302.

11. 2. Submitter:
• Highly engaged (+ + + +)
• trusts the treatment and the dentist(++++), considers the dentist as
ideal.
• Engages in the treatment completely

12. 3. Reluctant
• Engagement level is + +
• Trust for the treatment is ++
• skeptic

13. 4. Indifferent
• Engagement level is + i.e. minimum level of engagement.
• Trust for treatment is +; indifferent to the dentist’s instruction
• Similar to Indifferent type of patient in House’s classification

14. 5. Resistant
• Engaged with treatment but with an adverse mindset.
• Trust is very minimal or not there
• Question or doubt if they receive help from anyone in any situation
• Instead of acknowledging or accepting, they challenge the dentist.

17. 3. Classification II ( From Winkler S)
1. Cooperative
- may or may not recognize the need for dentures
- Open to suggestions
- After some effort by the dentist, these types of patients become cooperative.
M.M. House, The relationship of oral examination to dental diagnosis, The Journal of Prosthetic Dentistry, Volume 8, Issue 2, 1958,Pages 208-219.

18. 2. Apprehensive
- Unreasonable
- Acknowledge the need for dentures,
but give an illogical problem that
cannot be solved rationally.
a. Anxious
- Anxious and sometimes become
neurotic
- Focus on the uncertainties related to
dentures.
b. Frightened
- Fear the denture therapy
c. Obsessive or exacting
- Aware about their wants
- Exacting type
- May dictate the clinician regarding
the way to proceed.
d. Chronic complainers
- Dissatisfied with any kind of
treatment
- Find faults and problems in
everything
- Need appreciation, if they are willing
and cooperating for the treatment.
e. Self-conscious - Look-conscious
- Need to be re-assured and should be
acknowledged for their inputs in the
final result.

19. 3. Uncooperative
- Do not need dentures
- Not motivated
- Have a negative approach

20. 4. IPWCDO’s CLASSIFICATION
ADAPTIVE RESPONSE:
• Confidence in the dentist
• Previous favorable experiences
• Positive attitude
• Good physical health and coordination
• Realistic expectations
• Good learning capacity and cooperative
• Awareness to the limitations of a complete denture

21. MALADAPTIVE RESPONSE
• Lack of trust in the dentist
• Poor communication
• Previous negative experience
• Inadequate tissue tolerance and muscle coordination
• Disapproval to dentures by people who are important to the patient

22. 5. WINKLERS CLASSIFICATION (1977)
1. HARDY ELDERLY
- physically and psychologically maintained
- active in their professional life
- active socially
- adapt to changes and accept them
Winkler S. The geriatric complete denturepatient. Dent Clin N Am 1977;21:403-25.

23. 2. The Senile Aged Syndrome
- physically may be ill,disabled or aged
- psychologically and emotionally weak
- cannot cope with stress and vulnerable to ailments.

24. 3. The Satisfied Old Denture Wearer
- adapted well and happy with old dentures, even though they are faulty
- not motivated for treatment
- poor prognosis

25. 4. Geriatric Patient who doesn’t Want Denture
- long-standing edentulism, without any treatment
- no motivation for treatment and have a poor prognosis

26. 6. ALAN MACK’S CLASSIFICATION
Ectomorph -worrying types
Endomorph -Care free type
Mesomorph -Passive type

27. 7. BLUMS CLASSIFICATION(1960)
REASONABLE OR REALISTIC
UNREASONABLE OR UNREALISTIC

28. Need of Understanding Patient Psychology
• For the clinician to deliver good work and for the patient to adapt, there must exist a
good relationship between the patient and dentist. Then only the patient will accept
the treatment.
• There are many factors that play a role in satisfying the patient.
• Among these factors, the most important ones are:
 type of treatment selected,
psychology of patient,
perception of the patient towards the dentist and treatment selected,
the interaction between patient and dentist.
Sarangi D, Mental Attitude in Complete Denture Patients: A Review, Indian Journal of Forensic Medicine & Toxicology, October-December 2020,
Vol. 14, No. 4

29. • Patient satisfaction level may be increased if there is a good dentist-
patient relationship because the dentist understands the patient’s needs
and delivers as per the patient’s expectation whereas the patient builds
an acceptable and realistic result.

30. Prosthetic treatment plan considering the geriatric
psychology
1. The primary and best way to treat any psychological issue is
“Let’s Talk” in which effective communication, good rapport,
referral, counselling and peer influence all come in picture.
2. Proper time should be devoted to a thorough examination.
This builds the patient’s faith in the doctor.
Seth J, Aeran H, Sharma N. Geriatric psychology: A prosthodontist outlook- Let’s read the mind. Int J Oral Health Dent 2020;6(2):94-97.

31. 3. If the patient approaching is Anxious then
PreOperative : Effective communication, Explanation of procedures,
Making patient relax and oral sedation helps.
Operative time : Keep answering the patient’s questions, Reassurance is
big factor which play important role and effective local anaesthesia and
oral sedation helps and
Post- operatively: Explaining complications to the patient after
completing the treatment and instructing the patient to take analgesics
and adjunctive medications.

32. 4. If the patient approaching is Depressed then
Pre Operative: Consultation with physician, Examination of presence of
any signs like: Abrasion of teeth, gingival injury, xerostomia,
thrombocytopenia, leukopenia.
Operative: use of local anaesthesia but with precautions.
Post- Operative: Avoiding usage of sedatives or narcotics and
management of xerostomia if it is there.

33. 5. Any schizophrenic patient should always be accompanied by family
member.
Appointment should be schedule for morning session.
Confrontation and authoritative attitude on part of prosthodontist should
be avoided.

34. 6. Visits should be short with maximum amount of work completed
during scheduled time. Morning appointments are preferable as patient
has less tissue distortion in early morning. Geriatric patient should not
be promised too much. Treatment plan should be well explained and
discussed with patient’s family members before staring any dental
treatment.

35. Behavior shaping in completely edentulous
patients
Sudheer A, Reddy GV, Reddy G. Behavior Shaping of Complete Denture Patient: A Theoretical Approach. J Contemp Dent Pract 2012;13(2):246-250.

36. • Stage I
Pretreatment stage: In this stage, the patient has not yet approached the
dentist for treatment.
• Stage II
Treatment stage: This stage of behavior shaping deals with patient after
he enters the clinical setting.
• Stage III
Posttreatment stage: This stage involves dealing with patient after
treatment is completed.

37. Stage 1
Neutral:
• come from an uneducated background
• no history of previous exposure to dental treatment
• need a bit of motivation from dentist to understand the fact that
artificial teeth differ from their previous natural dentition and some
compromise can be needed on their part.

38. Behavior shaping in neutral patients:
Dental educational material, motivation, photographs, visual
aids.
Economic factor plays a minor role.

39. Unconditioned:
• usually from an educated background.
• little exposure to society.
• Take facts from news and other magazines or television.
• They have theoretical knowledge about the treatment involved but
have not come into contact with anyone who actually got the complete
denture fabricated. Hence, they will have a positive outlook.

40. Behavior shaping in unconditioned patients:
• Easy to motivate, telling them difference between fact and fiction of
the information they have already gathered.
• Economic factor plays a minor role.

41. Conditioned:
• more exposed socially to actual people than to electronic media regarding
dental matters.
• they rely more on gossip and personal experiences by their friends and
relatives.
• Their behavior in dental clinic depends on the experiences illustrated to them
by their peer group than on the actual skill of dentist.
• Also they are forced to undergo treatment by people near them but do not have
the interest to get the treatment on their own.
• They have a rigid mind and may remain uncooperative forever if not motivated
well.
• Economic factor plays a major role.

42. Behavior management in conditioned patients:
• Difficult to convince and time-consuming.
• Modeling is the best way to treat such patients. This is done by
showing video of another patient being treated so that the rigid mind
set changes to a more cooperative one.

43. Stage 2
Fear of unknown:
• The patient is new to the procedure and hence dentist should be careful
while informing the exact time to be taken for the procedure and the
steps involved.
• Sharp objects used to trim the excess impression elicit fear in the
patient.

44. Behavior management of fear of unknown:
• Proper education of patient prior to start of procedure, exactly
confining to the said timing for the procedure,
• Smooth and easy manipulation of material will go a long way in the
successful first appointment and removing the fear of unknown.

45. Trust vs mistrust:
An unsuccessful 1st appointment followed by a similar
2nd appointment will trigger another emotion in the
patient, called mistrust.

46. Behavior management of trust vs mistrust:
• Informing the patient about the duration of treatment, temperature
changes in the material being used for border molding, honestly
accepting any lapses in the procedure are the best ways to deal with
this stage.

47. Accommodation:
The next clinical step being jaw relation needs a lot of effort on the part
of patient to exactly follow the instructions of the dentist. It is a tiring
procedure for the patient.

48. Behavior shaping during accommodation:
• Properly guiding the patient during jaw relations is a test for
• the dentist to measure trust and cooperation
• developed between patient and dentist.
• If patient with good neuromuscular coordination follows the
instructions given by dentist to the word, the final treatment outcome
can be predicted with certainty as a success. If not, patient should not
be troubled much and teeth setting should be done according to
arbitrary settings to achieve moderate balancing.

49. Expectant:
• Try-in appointment is a time for rejoicing for any complete denture
patient. It gives the patient an opportunity to the patient to glimpse his
future denture.
• Trial denture elicits a mood of expectancy in the patient.

50. Behavior management of the expectations of
patient:
• It is natural for the patients to comment on the various aspects of trial
denture.
• Dentist should keep the pre extraction records of the patient ready in
order to give a comparative analysis.
• Failure to motivate and educate the patient during this stage will
inevitably fail the entire treatment.

51. Assimilation:
• Appointment for denture insertion will transpire to be a day where all
the feelings of patient assimilate together.
• Patient will judge the denture himself.
• The words of the dentist are compared with the deeds.

52. Behavior management during the process of
assimilation:
• Sometimes a patient who was well satisfied till try-in appointment will
suddenly start doubting the final denture’s efficiency.
• Such cases need to be handled carefully by explaining the various changes that
the denture undergoes during curing cycles and how the materials used in trial
denture and the final denture are different.
• Dentist will reap the rewards of his smooth handling of behavior of the patient,
or suffer the ignominy of failure to shape the patient’s behavior at this stage.

53. Stage 3
Indifferent:
• These patients will remain indifferent to the woes of their dentures and
rarely visit the dentist for recall checkups.
• In fact it will be a miracle if they wear the denture after they step out
of the clinic.
• Reason for this behavior is because, it was not the patient who
initiated the process, but rather it was at the behest of someone else
that he was forced to seek treatment.

54. Behavior shaping in indifferent patients:
• Deep seated insecure feeling or feeling of guilt and lack of purpose
need to be removed by appropriate counseling by a psychologist prior
to start of treatment and
• A sense of confidence need to be instilled during treatment by the
dentist.
• Such patients neither criticize the dentist nor admire his efforts.

55. Negative feeder:
• Inability to recognize any underlying medical or psychological
problem could lead to failure of denture service.
• In such cases it will be inevitable for the dentist to take blame in the
end inspite of his best efforts.
• This could be mainly because of the wrong start in the relation
between the dentist and patient or the failure of dentist to remove
doubts regarding denture service in patient’s mind.
• Such patients do a double damage of not only wasting dentist’s time,
but also destroy the image of dentist in society.

56. Behavior management of negative feeders:
• always advisable to take the opinion of psychologist prior to start of
treatment to such patients as they can be recognized easily during the
stage of case history recording.
• Such patients can be best handled by modeling, by showing examples
of people who are using dentures successfully.

57. Positive feeders:
• Considered as easiest patients to treat. They seldom question the
dentist regarding the treatment procedure and trust their dentist.
• Positive feeders will boost the confidence of dentist and help him to
attain perfection through experience.
• They also help to boost his image in the society.
• Require no behaviour shaping.

58. REFERENCES
1. Gamer S, Tuch R, Garcia LT. MM House mental classification
revisited: intersection of particular patients type and particular
dentist’s needs. J Prosthet Dent. 2003;89:297–302.
2. M.M. House, The relationship of oral examination to dental
diagnosis, The Journal of Prosthetic Dentistry, Volume 8, Issue 2,
1958,Pages 208-219.
3. Winkler S. The geriatric complete denturepatient. Dent Clin N Am
1977;21:403-25.
4. Sarangi D, Mental Attitude in Complete Denture Patients: A Review,
Indian Journal of Forensic Medicine & Toxicology, October-
December 2020, Vol. 14, No. 4

59. 5. Seth J, Aeran H, Sharma N. Geriatric psychology: A prosthodontist
outlook- Let’s read the mind. Int J Oral Health Dent 2020;6(2):94-97.
6. Sudheer A, Reddy GV, Reddy G. Behavior Shaping of Complete
Denture Patient: A Theoretical Approach. J Contemp Dent Pract
2012;13(2):246-250.

60. THANK YOU