B Shetty, P Mody, G Kumar, M Kumar
dental treatment, geriatric, psychological
B Shetty, P Mody, G Kumar, M Kumar. Psychological Aspects And Their Management During Dental Treatment In Geriatric Patients. The Internet Journal of Geriatrics and Gerontology. 2010 Volume 6 Number 2.
Life expectancy has increased worldwide, with India (having 8% who are senior citizens),Falling into the ‘‘Greying Country’’ category. It also leads to an increase in age related diseases and disabilities. In this scenario chronic disease play a significant role and dental diseases are the most prevalent chronic conditions. This ageing population constitutes a high-risk oral healthgroup, vis-à-vis impaired manual dexterity, cognitive deterioration and unmet treatment needs, which could be compounded by psychiatric morbidity. Authorities in dental medicine have long recognized a relationship between psychology and dentistry and have attempted to describe the factors that require consideration during the dental therapy. Theoretical approaches are now replaced by practical approach of patient management. Diagnosis and treatment planning for the elderly must include considerations of the biological, psychological, social and economic status of the patient in addition to the obvious dental problems. The aim of this article is to provide a review of the psychological and emotional factors involved in the dental treatment and the methods to develop a right dental attitude.
The world’s population is ageing rapidly and whilst increasing longevity is a positive development, it also leads to an increase in age-related diseases and disabilities.1 As the population attains an increasing life span, chronic diseases play a significant role and dental diseases are the most prevalent chronic condition. The dentist, therefore, has an essential role in maintaining and improving dental health as part of total heath care services available to the elderly.2
Authorities on dental medicine have long recognized a relationship between psychology and dentistry and have attempted to describe psychologic factors that require consideration in complete denture therapy. 3 Dental literatures that address the psychological problems confronting the dentist during complete denture fabrication have paralleled the burgeoning of psychologic theories throughout the last several decades. Psychoanalytic theories were the first formal concepts used to understand the behavior of dental patients.4 Although psychoanalytic theory provided the dentist with an enlightened view of the emotional problem s of patients, it failed to provide the practitioner with practical methods for the management of treatment problems. The dentist is best able to appreciate the importance of improved function and esthetic to the physical and mental health of the patient. Extensive training and experience is necessary to integrate the physical, social and psychologic changes that accompany the ageing process with the technical requirements for good patient care.5
Review of literature
Number of authors has considered the influence of emotional and psychologic factors on the patient’s satisfaction and ability to adapt the denture. one emotional problem often associate with ageing is depression.6 Klerman describes increased attention on depression by researchers and clinicians since the 1960s, which he referred to as the “age of melancholy.” He speculates that this depression milieu is precipitated by an increasing awareness of global events and doomsday prophecies concerning nuclear warfare, overpopulation.7
The following psychological disorders generally seen by dentist8
Anxiety: it 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. A major source of anxiety is alteration of body integrity and the way the body functions. Extensive change on oral cavity (loss of teeth and replacement with denture) represents such a threat and therefore can trigger anxiety.
Depression: It is a response to loss, actual or threatened, real or fantasized. Feeling of sadness, helplessness and hopelessness are the common accompaniments when significant loss is experienced, such as loss of loved one or loss of a body part. The impact is particularly serious when it is involved emotionally invested part of the body such as face (teeth), breast or genitals. For some patients, the teeth have become so invested with meaning that their loss is experienced as catastrophic.
Conversion Hysteria: By this means, people converts the anxiety from emotional conflicts into somatic symptoms such as pain, muscle weakness, or sensory disturbance, or they reproduce a symptom which they had at some time in the past.
Body image disturbance: The mouth is the most emotionally charged area of the body and therefore, frequently involved in body image disturbance. Any alteration to the patient’s mouth is a body change to which they must adapt. Until they do, anxiety will be present.
The main etiological factors discussed for the development of the psychological disturbances are9
Body loss: Loss is a major event in every ones experience whereas the early portion of the life cycle devoted to growth, strength, and activity, the latter segments are characterized, at first subtly and then with increasing momentum, by decline, decay, and death. Loss of teeth may play a preeminent role in reminding us that life is fragile and extinction assured. Dentures are not just denture to the patients; they are another sign that life is rapidly running its course. Loss of teeth and diseases associated with the supporting tissues may play a prominent role in reminding us that we are gradually getting old and that the quality of life may be affected with the development of anxiety and depression.
Body Image: Everyone has 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 developmental history, both physically and psychologically. 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 concerning visible part of the body. Among these visible parts, the teeth play a dominant role. Consequently, most people resist a change in their appearance. No prosthetic restoration, even if mechanically and esthetically perfect, can restore the person’s image of himself as a whole person with no part missing. This is exemplified by a 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.”
Factors that influence the patient’s response are10
Parental influences: The parental attitude toward body values is assumed by the children and this is obviously true regarding the value and appearance of the mouth. Patients who, as children, observe their parents undergoing dental treatment may become traumatically, conditioned by such observations.
Sibling's influence: The behavior of siblings also has a strong influence on the dental attitude developed by patients.
Peer group: A person is influenced to some extent by his peer group.
Symbolic significance: The more common symbolic significance of tooth loss is ageing, loss of femininity, loss of virility, loss of attractiveness and vitality and body degeneration.
Current life circumstances: Where one's life is already seriously disrupted, additional traumas such as tooth loss may impair the ability to cope and increase the probability of a maladaptive response.
Seven basic personality traits will be considered in the light of their influence on success in dentistry. Maximum benefits will he obtained only by Those who make an honest attempt to search for personal shortcomings, because of general failing to underestimate grossly personal weakness.11
A group of postgraduate students was asked by Cranes to select the dentist they considered best of those they had visited and write down the reasons for their choice. First on the list, when their answers had been tabulated was. “He was cheerful, friendly, and congenial.”
Courtesy, politeness, and accommodation cost not one cent, yet they may be sold. Some of the most successful dentists keep a card index system under which is listed personal information about each patient and his family. By the dentist’s being conversant with affairs that are of personal interest, each patient is made to feel that he occupies a position of special importance in the practice. The dentist who can make patients “feel at home” in his office will never be worried about future dental practice.
Be a good listener
“A bore is the fellow who keeps talking about himself when I want to talk about myself.”
Cultivate the habit of listening, not merely remaining silent while another speaks, but giving others their undivided attention. Too many people are so concerned about what they are going to say as soon as an opening presents itself that they do not really listen. listening is an art. Some individuals, without uttering a word, can be more flattering than most people.
If patients are encouraged to “think out loud” it gives the dentist an opportunity to size up each individual, to learn something of his likes, dislikes, prejudices, and to plan a presentation accordingly. If the dentist is to enjoy maximum success he must, of course, be a good conversationalist and an enthusiastic educator, but, first of all, he should be a good listener.
It must be remembered that force never won a permanent victory on the battlefield, and verbal force, which is just another way of describing arguing; there are times when one must fight for principles. One can convince few men and certainly no woman by arguing. Crane’ says, “Guide me deftly to the decision you want me to make--don’t crowd, don’t shove, just feed me ideas as fast as I can absorb them. If you can influence me to persuade myself, I will sign.”
In general, it can be said that criticism is futile because it aims a death blow at one’s self-respect by undermining the feeling OF personal worth. Criticism places people on the defense; it makes them appear foolish and silly. It usually opens up deep wounds that never heal, but fester down through the years. Yet it is possible to criticize and accomplish the proper results without offending. It merely requires a little tact. Hence an excellent policy to follow: compliment first, and then tactfully offer constructive criticism.
Don’t be egotistic
Individuals simply cannot wait for others to discover their good qualities; they extol their own virtues at every opportunity and, in so doing, arouse a feeling of antagonism among those with whom they come in contact. It is important to wait for the others o appreciate the effective dental service that you provide.
Remember name and faces
We can give people nourishment for their self-esteem by making it a point to remember their name. Anyone, who wishes, can improve his memory simply by listening attentively and concentrating on the name at the time of the introduction. Safer method is to place names of patients and their children on a card. together with any other information deemed worthwhile.
Be interested in others
Dentists in general become more interested in things than in people. The habit of being interested in others find that, without making any conscious, effort, without realizing exactly why, they hold in their hands the key, the open sesame to the hearts and minds of people.
Said Henry Ford: I am convinced by my own experience, and by that of others, that if there is one secret of success, it lies in the ability to get the other person’s point of view and see things from his angle as well as your own.”
These emotional elements make prosthodontia fascinating to those who enjoy the human side of dental practice. It is not merely the clever manipulation of compound, the skillful registering of mandibular movement, or the scientific control of materials. It represents a. chance to do something worthwhile for people at a time when things seem darkest. Patients fear the unknown. They fear the extractions, the waiting period, and, most of all, they are horror-stricken at what they have seen in the mouths of others. What an opportunity for the man who emotionally can exchange places with his patients and deal with their problems as he would have his own dealt with.
One businessman said : “I can’t bear to even think about losing my teeth ; it would he like dying a little.” Such is the attitude of most patients who view their loss of teeth as that critical period when a final transformation must be made from youth to old age.
Intellect versus Emotion
Rrownold” states: “While the two are closely related, there never was a man who was not more susceptible to an emotional appeal than an intellectual one. The appeal to the intellect makes us think, while an emotional appeal makes us feel.” The needs are there-one sees them everywhere, and if dentists are thoughtful enough and persistent enough in their search, they will uncover the motivating force that will make people want what they need.
Avoidance of technical terminology
All attempts to influence people will meet with failure unless the dentist uses terms the patient can understand. Technical words and phrases are all right for dental meetings but they should be carefully avoided when talking to patients. People hate to admit they do not understand so rather than ask for an explanation they reason it out their own way and often arrive at wrong conclusions. It is far better to use simple words and make certain that people understand. If the dentist’s presentation cannot easily be understood by the average eighth grader, he is talking over the heads of most patients. This always must be remembered. “The human mind defuses to accept that which it does not understand.”
There is a double rationale for the avoidance of technical terminology and the use of simple, concrete, comprehensible terms. The first reason is that language not comprehended by the patient compounds the “unknowns” within the unfamiliar situation and thus increases his anxiety. The second reason is that the normal anxiety of patients often causes impairment of concentration. Such impairment adversely affects patient comprehension and causes misinterpretations. It is important that misinterpretations be caught and corrected; one technique for accomplishing this is to have the patient repeat or summarize what you told him.12
Perhaps in speaking of dentures it would be better to use terms such as “wrinkle removers,” “an investment in youthfulness,” or “painless face lifting.” A re-establishment of normal facial contours could be called a “way to turn the calendar backwards.” It would be very enlightening if every dentist would make a recording of his presentations; then listen to a “play back” after the patients leave. Most everyone would be surprised, if not shocked, to hear what actually was said. It is a guaranteed method of arousing interest in a more careful selection of words and sentences.
The clever wife uses this idea very effectively when she decides it is time to purchase a new hat. Instead of making the fatal mistake of saying, “John, do you mind if I buy a new hat,” she brings home two hats and after a meal consisting of all John’s favorite dishes, she smiles sweetly and says, “John dear, I need your advice. Your taste in hats always has been excellent. Would you please tell me which of these two hats you think looks better on me?” It matters not how poor John answers the question, for anything he says will cost him exactly one new hat.
This idea, thoroughly understood and thoughtfully applied, will prove to be of great value in helping patients decide. Cases can be planned in two or more ways, hut instead of calling them “best,” “medium,” or “cheapest,” the dentist might meet with more success if he called his best plan the “ideal” plan, then offer a “compromise suggestion” and possibly an “alternate plan.” Then, after explaining the various methods, he can help the patient come to a decision which wills hr for his own best interest by asking, “Which case do you feel will best suit your needs?”
Psychologic conditioning is far from an exact science. The dentist cannot say, “Do this or do that, and we will build a satisfactory rapport.” A positive or negative rapport depends on how well the dentist’s own personality harmonizes or clashes with those of his patients. Rapport often depends on how well he conceals his own reactions when he thinks the patient is being unfair. It is sometimes difficult not to think a patient is being arbitrary, especially when the dentist has done everything in his power and, from his point of view, has obtained an excellent result.13
It is hoped that this paper will help stimulate more interest in the psychologic problems encountered in presenting denture service, a phase too long ignored. For many years, emphasis has been placed entirely on the development of technical proficiency, overlooking the cold fact that, in this streamlined atomic age, it is not enough to have become skilled in one’s chosen field. It is the responsibility of every dentist to conduct a never-ending search for improvements that will benefit his patients, and it is the function of organized dentistry to furnish such information through its meetings and publications. If the public is to enjoy the benefits of scientific research, if the dentist is to reap a just reward for honest service, organized dentistry must teach its members how to become as modern in dealing with patients’ minds as in the treatment of their mouths.