Understanding the Psychology of Geriatric Edentulous Patients

Rev iew ar t i c l e

Understanding the psychology of geriatric edentulous patients

Ashwin R. Mysore and Meena A. ArasDepartment of Prosthodontics, Goa dental college and hospital, Bambolim, Goa, India

doi: 10.1111/j.1741-2358.2011.00496.x

Understanding the psychology of geriatric edentulous patients

Objective: This article focuses on understanding our older patients who require complete prosthodontic

care. By breaking down the patient psychology to its component parts, it is easier to obtain a clear picture of

this special cohort of patients. Considering the increase in number of geriatric edentulous patients, this

knowledge will help the dentist serve the geriatric population better.

Background: The role of psychology and personality in complete denture treatment is well documented.

The geriatric patient who needs complete dentures has a psychological aspect that needs consideration.

Although significant, these aspects may sometimes be ignored or considered irrelevant.

Materials and methods: A review of relevant literature was carried out to obtain data on the psychology

and personality of geriatric, complete denture patients and their behavioural changes. The obtained data

was filtered and condensed to provide a short but comprehensive look at the geriatric edentulous patient’s

psychology.

Conclusion: When handling geriatric edentulous patients, the dentist must be confident of addressing

and managing the psychology of these patients. A thorough understanding of the geriatric mental state

thus becomes important and significant for the clinician.

Keywords: geriatric patients, geriatric psychology, complete denture patients.

Accepted 28 November 2010

Introduction

Today, the geriatric population is on the rise

because of an increase in the quality and avail-

ability of medical facilities, introduction of new

drugs and disease control combined with better

nutrition and improved hygiene. This implies that a

greater number of geriatric patients will seek dental

care including complete prosthodontic care. The

success of complete dentures is related to technical

procedures, functional factors, aesthetics, biological

determinants and psychological factors. The

psychological factors include preparedness of the

patient, attitude towards dentures, relation and

attitude towards dentist, ability and intelligence to

learn use of dentures and the patient’s personality.1

The relationship between psychology of the

patient, personality, the dentist patient interaction

and denture treatment is well recognised.1–7

We have tended to stereotype the aged as senile,

financially and emotionally dependent, useless

and ill. Their wisdom, experience and accrued

expertise are constantly being misused, wasted or

ignored.8

For the population over 65 years of age, Birren

identifies five sources of frustration that are age-

related: (i) an age status system that idealises

youth, (ii) pressures of time and money that leads

us to a restriction of former interests, (iii) physio-

logical changes that demand or usurp attention,

(iv) technological changes that increasingly outdate

the skills of ageing persons and (v) with age, indi-

viduals become more ‘locked in’, being less able to

move out of a frustrating situation.9

The earlier the signs of frustration are detected

and correlated to the source(s) the better are the

chances of understanding the patient’s psycholog-

ical make-up and delivering better care.

What to expect?

Jamieson10 wrote that ‘fitting the personality of the

aged patient is often more difficult than fitting the

denture to the mouth’. The geriatric patient seeking

� 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e23–e27 e23

complete denture treatment is classified in many

ways by various researchers. The numerous classi-

fications available in literature highlight the depth

of study of the psychology of the geriatric denture

patient and an effort to understand it to in turn

provide better care for the geriatric denture patient.

It also reflects the variety and wide variation that is

observed in the mental make-up of the geriatric

patient.

Ettinger and Beck11 divided geriatric patients

functionally into (i) functionally independent el-

derly: live in the community unassisted (ii) frail

elderly: have lost some of their independence, but

still live in the community with the help of support

services and (iii) functionally dependent elderly:

unable to live independently in the community.

Years ago, House classified patients into four types:

philosophical mind, exacting mind, hysterical mind

and indifferent mind.12 Patients with an exacting

mind, hysterical mind or indifferent mind were

believed to exhibit less than ideal adaptability to

edentulism and denture use. More recently, Gamer

et al.13 suggested a re-evaluation of the House’s

classification because of the following reasons (i)

the classification uses antiquated terminology (ii) it

considers the patient in isolation. The new system

classifies the patients into ideal, submitter, reluc-

tant, indifferent or resistant. This system, in addi-

tion to the patient, takes into consideration the

dentist and the interaction between the dentist and

the patient.

Winkler8 also mentioned the following catego-

ries of patients.

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 changes.

2. The senile aged syndrome: these are individuals

who are disadvantaged emotionally and physi-

cally and may be described as handicapped,

chronically ill, disabled, infirm and truly aged.

They cannot handle daily stresses and are sus-

ceptible to disease.

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 den-

tures: 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 motiva-

tion and have a poor prognosis if forced into

undergoing treatment.

The ‘ideal’ geriatric denture patient

O’Shea et al.14 characterised the ideal dental patient

as compliant, sophisticated and responsive. Win-

kler15 described four traits that characterise the

ideal patient’s response: realises the need for the

prosthetic treatment, wants the dentures, accepts

the dentures and attempts to learn to use the

dentures. It is evident from the various classifica-

tions13–15 that a so-called ideal psychological pro-

file, though rare, is often desired by most dentists as

it provides the greatest chance of success. Strictly

speaking, the definition of the term ‘ideal’ may be

relative, but it does provide a standard to refer to.

Understanding the aged

No matter how the patients are classified, the

characteristic they all have in common is tooth loss.

Tooth loss brings about considerable changes in the

psychology of patients. Psychological assessment of

the patient becomes essential because the success of

the treatment depends on the expectations and the

self-concept of the patient.16 According to a study

conducted by J. Fiske et al., 17 the emotional effects

related to tooth loss ran parallel with the five stages

of bereavement, i.e. denial, anger, depression,

bargaining and acceptance. In patients who had

failed to reach the final stage of bereavement, the

following emotional responses were noted:

• lack of acceptance;

• diminished self-confidence;

• difficulty in adjusting to a change in appearance

and self-image;

• treating the subject of tooth loss as a taboo topic;

• secrecy or an attempt to hide the edentulousness;

• prosthodontic privacy or a fear of removing the

dentures;

• behaviour change;

• feeling of having aged prematurely;

• lack of preparation to face the tooth loss.

Handy proposed that, like losing a body part,

tooth loss too can affect the personality or psyche

and that it may be a response to the extractions

and/or denture construction and not an inherent

flaw in the psychological make-up of the patient.17

Tooth loss and its acceptance are one of the major

factors determining the psychology of geriatric

complete denture patients. Another important

factor is the inherent differences between young

and old patients. Older patients are behaviourally

different when compared to younger patients. They

are more sceptical, demanding and at times quite a

challenge to handle.

� 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e23–e27

e24 A. R. Mysore, M. A. Aras

Heartwell18 states that aged patients rarely ex-

pect to see with an artificial eye or to have natural

use of an artificial hand or leg, yet they frequently

expect artificial teeth to duplicate natural teeth in

form and function. Many of them have a tendency

to exaggerate their problems, and such situations

require the dentist to have a lot of patience and

understanding. Winkler8 states that geriatric pa-

tients remember all the claims made by the dentist

and if the prosthesis is not exactly as it was

described, they will invariably complain. Elderly

people develop fixed habits and ideas and do not

adapt readily to change in their mode of life. They

tend to endure increasing physical discomfort rather

than to make an effort to see a doctor for the early

treatment of an ailment that may become serious.10

At the other end of the spectrum, Winkler8 and

Iacopino19 separately mention the routine of the

geriatric patient who visits a sympathetic or

comforting dentist for reassurance. They also believe

that working briskly and being overly efficient is

construed as indifference by the geriatric patient.

Most geriatric patients come from an age where

speaking up is considered ungrateful and critical,

and an expression of emotions is considered as a

sign of poor self-control. Most patients are not

familiar with the concept of preventive treatment,

being used to curative treatment only. Lower

educational achievement is also a factor that

inhibits effective communication. Patients’ atti-

tudes are influenced by prior dental experience, the

importance of dentistry (from the patient’s point of

view) and dental awareness.20

Researchers have shown that older people take

more time to process new information, and they

need a slower pace of instruction and more time to

process new information. Another deterrent to

successful communication with older patients is the

normal, age-related decline in sensory processes. As

patients get older, they cannot see, hear, touch,

taste or smell as well as they did when they were

young. Depressed patients and those suffering from

hypochondria focus on the body; thus, they will be

more likely to respond to, or report as, pain even

minor non-pain sensations such as vibration.16 In

explaining the psychology of the dentally phobic

geriatric patient, Epstein20 states that the oral cav-

ity is often experienced by the patient as the point

wherein the dentist ‘trespasses’ into the patient’s

body.

Influence of personality

A correlation between the personality of a patient

and the denture acceptance exists.1,7 Ozdemir

et al.6 compared the denture satisfaction in type A

and type B personalities. Type A personalities lead

high stress lives, whereas type B personalities are

relaxed and stress free. Type AB personalities are

located between these two extreme groups.

Patients with personality Type A exhibited the

lowest levels of satisfaction with their dentures

with regard to aesthetics, speaking ability and

masticatory function.

Patient behaviour towards the dentist

Lefer et al.,3 commenting on the dynamics of the

dentist patient interaction, predict one of two

patient behaviour patterns. The patient may have

the expectation that the dentist will take care of

him and be gentle if he defers all decisions to the

dentist. At the other end of the spectrum, a patient

may feel that submission to an authority figure is a

sign of weakness. As a result, he may resist anyone

who displays authority. In a study conducted on

the dentist patient interaction, Hirsch et al.21 found

that patients treated by high authoritarian dentists

were less satisfied than those treated by low

authoritarian dentists.

The geriatric patient’s response to form and function of

dentures

Pan et al.22 when evaluating sex-related differences

in patient behaviour to complete dentures found

that elderly females are less satisfied with con-

ventional dentures than elderly males with regard

to aesthetics and ability to chew. This result is

partly supported by a previous study by Langer

et al.2 who found that more women complained

about the appearance of their dentures, while

more men had objections regarding mastication.

Waliszewski et al.23 evaluated preference of tooth

arrangement (aesthetics) among edentulous

patients using three types of set-ups, i.e. natural,

supernormal and denture look. The natural look

was a standard tooth arrangement, while the

supernormal and denture look were with larger

and smaller moulds of teeth, respectively. The

results showed that a natural look was chosen by

55% of the patients, whereas the other 45% chose

set-ups that were marked deviations from the

anatomical averages (either supernormal or den-

ture look).

Adaptation to dentures

The acceptance of dentures is usually unrelated to

the technical quality of the prosthesis2,17,19,24,25 All


Understanding the psychology of geriatric edentulous patients e25

or most of the above factors contribute to the

patient’s acceptance of the dentures.

According to Anderson,26 the popular belief

that patients adapt better to duplicated dentures

than new ones is unfounded. In comparing the

better technique for denture construction, Ellis

et al. 27 made the following observations: (i) after

delivery, the edentulous patients who received

complete dentures using either conventional or

duplication techniques showed similar improve-

ments in terms of overall patient satisfaction and

oral health-related quality of life and (ii) Patients’

reported satisfaction with their dentures and the

impact dentures had on their quality of life might

not be useful measures for determining the most

appropriate technique for providing new den-

tures.

A study by Fiske et al.28 investigated the role of a

self-help group in helping denture wearers with

long-standing problems. During the course of the

investigation, the following observations were

made: sharing problems helped people to accept

and cope with them. Patients included foods they

previously did not attempt to eat, and they com-

municated their problems better than before. It was

also found that the responsibility for successful

denture wearing was placed totally with the den-

tist, and most patients thought that there was

nothing they could do to contribute to successful

denture wearing. The patients suggested that the

dentists listen more and explain everything

including potential denture problems.

Conclusion

Knowledge of patient psychology helps us in

understanding the mental status of a patient who

has suffered tooth loss and is in need of treat-

ment. Knowing what to expect when treating a

geriatric edentulous patient puts the dentist at a

distinct advantage as a treatment plan can be

formulated accordingly. This will facilitate an

improved approach towards the patient and will

help in more appropriate management of the

patient, both psychologically and prosthodontic-

ally.

References

1. Seifert I, Langer A, Michmann J. Evaluation of

psychologic factors in geriatric denture patients.

J Prosthet Dent 1962; 12: 517–523.

2. Langer A, Michman J, Seifert I. Factors influenc-

ing satisfaction with complete dentures in geriatric

patients. J Prosthet Dent 1961; 11: 1019–1031.

3. Lefer L, Pleasure MA, Rosenthal L. A psychiatric

approach to the denture patient. J Psychosom Res 1962;

6: 199–207.

4. al Quran F, Clifford T, Cooper C, Lamey PJ.

Influence of psychological factors on the accep-

tance of complete dentures. Gerodontology 2001; 18:

35–40.

5. Patil MS, Patil SB. Geriatric patient- psychological

and emotional considerations during dental treat-

ment. Gerodontology 2009; 26: 72–77.

6. Ozdemir AK, Ozdemir HD, Polat NT, Turgut M,

Sezer H. The effect of personality type on denture

satisfaction. Int J Prosthodont 2006; 19: 364–370.

7. Sheiham A, Steele JG, Marcenes W, Finch S,

Walls AW. The impact of oral health on stated ability

to eat certain foods; findings from the national diet

and nutrition survey of older people in Great Britain.

Gerodontology 1999; 16: 11–20.

8. Winkler S. The geriatric complete denture patient.

Dent Clin N Am 1977; 21: 403–425.

9. Fishman SK. Health professionals’ attitudes toward

older people. Dent Clin N Am 1989; 33: 7–10.

10. Jamieson CN. Geriatrics and the denture patient. J

Prosthet Dent 1958; 8: 8–13.

11. Ettinger RL, Beck JD. Geriatric dental curriculum

and the needs of the elderly. Spec Care Dent 1984; 4:

207–213.

12. Hickey J, Zarb GA. Boucher’s Prosthodontic Treat-

ment for Edentulous Patients. USA: C V Mosby & Co,

1980.

13. Gamer S, Tuch R, Garcia LT. M.M. House mental

classification revisited: intersection of particular

patient types and particular dentist’s needs. J Prosthet

Dent 2003; 89: 297–302.

14. O’Shea RM, Corah NL, Ayer WA. Dentists’ per-

ceptions of the ‘good’ adult patient: an exploratory

study. J Am Dent Assoc 1983; 106: 813–816.

15. Winkler S. Psychological aspects of treating com-

plete denture patients: their relation to prosth-

odontic success. J Geriatr Psychiatry Neurol 1989; 2:

48–51.

16. Giddon DB, Hittelman E. Psychologic aspects of

prosthodontic treatment for geriatric patients. J Pros-

thet Dent 1980; 43: 374–379.

17. Fiske J, Davis DM, Frances C, Gelbier S. The

emotional effects of tooth loss in edentulous people.

Br Dent J 1998; 184: 90–93.

18. Heartwell CM. Educating patients to accept den-

tures. J Prosthet Dent 1969; 21: 574–579.

19. Iacopino AM, Wathen WF. Geriatric prosthodon-

tics: an overview. Part I. Pretreatment considerations.

Quintessence Int 1993; 24: 259–266.

20. Epstein S. Treatment of the geriatric dentally phobic

patient. Dent Clin N Am 1988; 32: 715–721.

21. Hirsch B, Levin B, Tiber N. Effects of dentist

authoritarianism on patient evaluation of dentures.

J Prosthet Dent 1973; 30: 745–748.


e26 A. R. Mysore, M. A. Aras

22. Pan S, Awad M, Thomason JM et al. Sex differ-

ences in denture satisfaction. J Dent 2008; 36: 301–

308.

23. Waliszewski M, Shor A, Brudvik J, Raigrodski

AJ. A Survey of Edentulous Patient Preference

among Different Denture Esthetic Concepts. J Esthet

Restor Dent 2006; 18: 352–369.

24. Heydecke G, Klemetti E, Awad MA, Lund JP,

Feine JS. Relationship between prosthodontic eval-

uation and patient ratings of mandibular conven-

tional and implant prostheses. Int J Prosthodont 2003;

16: 307–312.

25. Mersel A, Peretz B. A behavioural approach in the

treatment of elderly patients: a new philosophy. Int

Dent J 2003; 53: 51–56.

26. Anderson JD. The need for criteria on reporting

treatment outcomes. J Prosthet Dent 1998; 79: 49–55.

27. Ellis JS, Pelekis ND, Thomason JM. Conventional

rehabilitation of edentulous patients: the impact on

oral health-Related quality of life and patient satis-

faction. J Prosthodont 2007; 16: 37–42.

28. Fiske J, Davis DM, Horrocks P. A self help group

for complete denture wearers. Br Dent J 1995; 178:

18–22.

Correspondence to:

Dr Mysore Ashwin Raghunandan,

Goa Dental College and Hospital – Prosthodontics,

Rajiv Gandhi Medical Complex, Bambolim, Goa

403202, India.

Tel.: 9890749016

Fax: 0091-0832-2459816

E-mail: [email protected]


Understanding the psychology of geriatric edentulous patients e27

Documents

Understanding the Psychology of Geriatric Edentulous Patients