Received: 01/09/2013 Revised: 17/09/2013 Accepted: 26/09/2013
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Meet the mind of the patient before meeting the mouth of the patient, hence we understand that the patient attitudes and opinions can influence the outcome of the treatment. Obviously, not the least important factor in the diagnosis of patients needing complete denture service is their mental attitude. This is not a mechanical problem or a biologic problem. It is one that requires an understanding of people and the ways in which they must react to the situations they face. Doctor, with their background education in psychology, can learn to detect patient attitudes and reactions that mutual confidence, which is essential, can be established. In this process doctors must establish within themselves empathy for the patient. If they are unable to do so, the results of any treatment they prescribe are most likely to be less than successful. Doctors must have a sense of real concern for the health, comfort, and welfare of their patients to establish the necessary mutual confidence. Clinical experience has proved the merits of a “tender loving care” approach to dental patients. This should be done before treatment is started and continued throughout the treatment planning and the treatment itself.
Adaptive Response, Edentulous Patient, Emotional status, Mental Attitude.
Diagnosis and treatment planning for the completely edentulous patient must include considerations of the biological, physiological, social and economical status of the patient in addition to the dental problem . Authorities in dental medicine have long recognized a relationship between psychology and dentistry and have attempted to describe the factors that require consideration in dental therapy . Psychoanalytic theories were the first formal concepts used to understand the behavior of dental patients . As behavioral scientist become more formally involved in dental education, the theoretical approaches were replaced by a practical problem oriented approach that concentrated on patient management and the dentist-patient relationship [4,5]. The doctor is concerned with the emotional and psychological state of the patient for it is an essential component of the treatment and the success or failure of the treatment often depends on the emotional state of the patient . Doctor may consider treatment successful when they meet technological standards. However, patient evaluates the treatment from the point of view of their own satisfaction . The aim of this article is to provide a review of mental attitude and adaptive response of complete edentulous patient towards treatment.
Studies have shown that patient’s mental attitude and level of expectation can influence the treatment outcome. Complete edentulous treatment failure can result from misunderstanding between the doctor and the patient. The most important characteristic of the physician is his willingness to discuss the patient’s edentulous problems . In many a case, psychoanalyze suspect patients should be referred to a clinical psychologist or psychiatrist for proper diagnosis. The dentist should be able to identify negative and positive responses which can influence treatment outcome. Patients having few negative factors will have an overwhelming amount of positive traits. Some patients however have an abundance of negative factors which, if not modified by effective dentist-patient communication can result in prosthetic failure irrespective of the technical excellence of the prostheses.
The international prosthodontic workshop identified the following factors which produce an adaptive or maladaptive response. Winkler described traits that characterize the ideal completely edentulous response . Factors which produce an adaptive response to edentulous treatment
• The acceptance of the doctor and confidence in the doctor, which could be described as trust.
• Previous favourable experiences with authority figures.
• The capacity to cope favourably with change. Positive attitude increases this capacity
• Favourable physical conditions: youth and general health were factors which produces an adaptive response to complete denture
• Realistic expectation of the patient.
• Good learning capacity.
• The desire of the patient to please the doctor. 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.
• Recognition by the patient of the limitation and facts of success of complete denture treatment
• Good physical coordination on the part of the patient.
• The patient should be aware of the active role he must play in the cooperative treatment effort
Factors which produce a maladaptive response to edentulous treatment
• Lack of trust in the dentist.
• Poor communication between the dentist and his patient
• Negative previous experience, such as unfavourable experience with other dentist.
• Unrealistic expectation of the denture patient.
• Resistance to change arising from severe anxiety or depression or hopelessness.
• Low tolerance for anxiety or pain.
• A high level of anxiety on the part of the patient
• Inadequate tissue tolerance.
• Muscle in coordination
• Chronic dissatisfaction
In 1950 Dr.Milus M House proposed a general classification of completely edentulous patient’s mental attitude on the basis of how they behave in response to the prospect of becoming edentulous. The classification is based on extensive clinical experience rather than on scientific yardsticks or psychological inventories. It has stood up well to the test of time and deserves discussion at some length.
Patients in the philosophic class are willing to accept the judgment of their doctor without many questions. They accept their oral situation and know that their doctor will do the best that can be done. They have an ideal attitude for successful treatment, provided the biomechanical factors are reasonably favourable.
These types of patients have little concern for their teeth or oral health. They have little appreciation for the efforts of their doctor and often seek treatment because of the insistence of their families. They will give up easily if problems are encountered with their new teeth. Indifferent patients require more time for their instruction on the value and use of dentures. Their attitude can be very discouraging to doctors who treat them.
Patients in the critical group are those who find fault with everything that is done for them. They were never happy with their previous doctors, and this is usually because the previous doctor did not follow their instructions. They may bring with them a collection of dentures made by a number of doctors and will say their new doctor exactly what is wrong with each one. Careful observation and listening will reveal that the big mistakes had been the result of doctor trying to follow the directions of the patient.
Critical patients may try the temper of any doctor attempting to treat them. A failure to recognize critical patients during diagnosis is certain to cause the inexperienced doctor many problems. 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, but their successful treatment can be most rewarding. The first and most important phase of treatment is accomplished at the first professional contact. These people can be helped, despite themselves, when one identifies them early and works for a revision of their attitude. Many of these patients are poor in health, which affects their personalities and makes them tend to look for trouble. Medical consultation is always advisable for critical patients before treatment is started.
Patients who may be classed as skeptical are those who have had bad results with previous treatment and are therefore doubtful that anyone can help them. They are often in poor health, with severely restored residual ridges and other unfavourable conditions. They have tried to be good patients, but their problems seemed insurmountable. Often they may have had a recent series of personal tragedies such as loss of a spouse, business problems, or other things not directly related to their denture problem. They think the world is against them and simply doubt the ability of anyone to help them with problems that are greater than anyone else has to bear. They need kind and sympathetic help as much as they need new dentures .
Blum suggests a scheme for classifying patients as reasonable or unreasonable, realistic or unrealistic. He tested medical patients with psychological quiz which showed that the unreasonable patient has:
• Unreasonable expectation towards the doctor and towards medical science with regard to the quickness and certainty of the treatment.
• Unreasonable beliefs about the general incompetence or unpleasant and untrustworthy nature of the physician in general .
O Shea etal characterized the ideal dental patient as complaint, sophisticated and responsive . Jamieson stated that fitting the personality of the aged patient is often more difficult than fitting the prostheses to the patient mouth . Krochack, recognizing the critical need to understand the behaviour of the edentulous patient stated that many patients with favourable anatomy cannot tolerate a well fabricated prosthesis and yet other patient with unfavourable anatomy willing endure prosthesis that may be ill fitting. He asserted that the inconsistencies of patient adaptation in this situation may be related to the patient psychological state . Kent stated that the ability of a doctor to determine when a patient has unrealistic expectation and the ability to manage that interaction effectively may avert a conflict . Winkler discussed the need to fit oneself to the personality of the patient . Koper characterized and typed patient who have difficulty in adapting to complete denture as problem patients, difficult denture patient . A specific classification system has been presented to identify response by individuals who are edentulous. Three types of maladaptive responses are considered as probable consequences of fear, anxiety and depression associated with complete edentulism. In class1, the patient adapts physically but is maladaptive psychologically. In maladaptive class 2, the so called difficult patients is maladaptive physically and psychologically and there by keeps the doctor involved technically and emotionally for a protracted period of time . The maladaptive class 3 patient collapses with complete edentulisim. Physical and emotion maladaptibility is accompanied by much suffering and social withdrawal .
A careful and thorough examination can be the start of successful treatment. The doctor should take more time than usual in making examinations of skeptical patients, since care and attention to the detail at this time will help the patient begin to develop confidence in the new doctor. A hurried or cursory examination will destroy the confidence and trust that is essential for satisfactory treatment. These patients can be made into excellent patients if doctor recognize them and handle them properly, but it will take extra time before, during and after treatment.