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Body image in dentistry
Body image
in dethtry
Philip Ament, D.D.S.,* and Aaron Ament, Buffalo, N. Y., and Silver Spring, Md.
M.D.**
B
ody image is a broad concept, one often used vaguely and generally. In its simplest form, the concept has to do with how a person visualizes himself; but surely it is more than that. A person may visualize himself as he was, is now, or will be. His self-esteem may rest on how that visualization compares with the qualities others admire. In some ways, that internal picture reflects what one would be, as well as what one is. The statesman, the athlete, or the lover may march across the screen of the truck driver’s daydreams. The child, when less inhibited than usual, plays at being Batman; he strikes poses and looks embarassingly heroic. In the daydreams of the truck driver and in the play of the child, the body image expresses a portion of the identity of each. ROLE OF THE MOUTH IN BODY IMAGE A most significant part of the body image has to do with the mouth. The degree of its significance becomes apparent when we review the history of a person’s mouth. The mouth is not only used and felt by its owner, it is seen as well. “Ego” psychologists and learning theorists lead us to understand that the newborn child does not have an integrated, combined control of the parts of his body and senses. However, the mouth is surely tremendously important in the baby’s life in these respects: functionally, as an organ through which to receive nourishment; emotionally, as an organ of pleasure (children who suck their thumb in preference to the nipple) ; and adaptively, as an organ of testing, learning, and understanding. The mouth is remarkable as a social signal. The smile of a baby in response to the smile of an adult is beautiful. The mouth is also a source of contention. As the child explores his environment, he may put rattles, shoes, thumbs, and the dog’s bone into his mouth with equal interest but hardly with equal parental approval. Some foods are wonderful, but hot liquids and pepper cause dismay. New teeth are misery personified, and biting makes things feel better. Sometimes biting is fun in and of itself, but when the nursing infant bites his mother, the fun is over. When Presented
at the American
Society
of Psychosomatic
Dentistry
Pa.
362
*Consultant
in Hypnoanesthesia,
**Meninger
Clinic.
Rowe11 Park Memorial
Institute.
and Medicine,
Tamiment,
Body
image
in dentistry
363
the child can crawl and “toddle,” the mouth examines anything left lying around, and soon everyone wants his mouth to be confined to eating. When speech comes, the mouth becomes a seat of power in a new sense, and later, when the child experiments with words which young children are not permitted to use, the mouth gets the child in trouble. Adults recognize the mouth is at fault, and some treat the difficulty by washing the offending mouth with soap. And the same mouth must be used to kiss “Mommie” and “Daddy” good night. The 3-year-old child who plays “tiger” growls ferociously and bares his teeth. His cousin is told that such things are all right for boys but that she must learn to act like a lady and smile prettily. Obviously the mouth of a tough guy is quite different from the mouth of a beautiful lady. Then the “baby” teeth fall out, usually before the solution to the Oedipal problem has crystalized. Most children are frightened about the loss of any part of their bodies. The loss of the teeth is a milestone in growing up though, and most children hang onto that solace. In some families the loss is made good quickly. The “tooth fairy” leaves a coin under the pillow at night. Adolescence brings one plight after another relating to how the child believes he is regarded by the rest of the world. Next to pimples, orthodontic appliances are the ultimate in shame and degradation. Yet these are reasonable reactions when we remember how constantly adolescents are bombarded with exhortations to keep their breath “kissing sweet,” to “wonder where the yellow went,” and to give their mouths “sex appeal.” One must pay attention to what one’s date thinks, and from this time on, the mouth becomes more and more the focus of romantic interest. It continues to be a measure of an adult. What professional person would address a seminar heedless of discolored teeth and fetid breath? Up to this point, we have not considered the experience of forced feeding by parents, forced manipulation of the tongue blade by the physician, or a forced approach by the dentist. Most of us forget the impression of an angry attack, the totally helpless, passive, and defenselessness type of anger, terror and frustration. Some children give the impression that they will never cooperate, and in the urgency and heat of the situation, some adults feel that a fast job will get the nasty business over sooner. The adult sitting in the dental chair was an adolescent who was a child who was an infant. This person has been on pathways of development which have been altered by his many gratifications, discoveries, relationships, identifications, and insults at each developmental level. As he sits in the dental chair, he is still developing. It is a tribute to man’s adaptiveness that he can be rational and helpful in times of stress. For some patients, the dental experience can be one of being cared for and supported almost as with a mother’s love. For others who do not do well, the dental experience may be one perceived as an assault which recapitulates the old feelings of helplessness and terror. Also, they may gag, vomit, jerk away, never be pleased, or never come to the office. HYPNOSIS IN RESTORATIVE PROCEDURES Most patients under hypnosis are occupied in their fantasies, and usually they picture themselves in scenes far removed from the dental chair. When hypnosis
364
Ament
.i. Pros. Dent. October. 1970
and Ament
is used to induce anesthesia, the hypnotic interlude can be a profoundly enjoyable experience. With time distortion techniques, a long operative procedure can he subjectively perceived as a 10 minute interlude based on the patient’s ability to place himself in a temporary passive position. At least it seems like a passive position to we who watch, and this is a point of great misunderstanding. The patient cannot enter into and maintain a hypnotic state except by active psychologic work. If we understand this and help our patients to understand it, even those who SPC themselves as helpless in the dental chair will be better able to enter into a collaboration with us to produce the psychologic flexibility we need. The standard techniques of inducing oral anesthesia are sufficient for most patients, but we are expecially concerned with the patient whose mouth is a focus of concern, distress, bad memories, and unhappiness. A detailed patient history is essential. However, the history must extend far beyond previous dental treatment, illnesses, medications, and drug sensitivities and beyond the usual somatically oriented material. Often it is best to assist the patient to tell you about himself, including his childhood, his parents, and difficulties of any sort even when he was young. If you can let the patient talk freely and follow his lead for a while, many of the difficulties which led to his becoming a difficult dental patient will become clear. However, these matters should not be pointed out to the patient directly. To do so abruptly, often proves shocking and painful to him. When this preparation has helped the patient move into the hypnotic state, an evaluation of him may indicate a need to give him an even greater psychologic distance from the work going on in his mouth. Under hypnosis, we may ask the patient to project his teeth out of his mouth and away from him into the room, providing the opportunity to do his dental work for him without disturbing him as he thinks of a scene elsewhere. He may be told that he is turning the mouth over to you and that it will be returned to its rightful place when the work of the day is accomplished. We have found that this maneuver can sometimes give relief even to the occasional patient who can enter the hypnotic state but who cannot allow himself to produce anesthesia. It may also be effective in the patient who finds himself unable to give up his hypersensitive gag reflex. HYPNOSIS
IN SELECTION
OF TEETH
The selection of artificial teeth for dentures was discussed by Rosenthal and ass0ciates.l They indicated that the personality of the dentist may well be the determining factor in the choice of teeth rather than the patient’s physical, psychologic, or cosmetic needs and that, statistically, fewer adjustments and dissatisfactions follow when the patients were allowed to choose their own size, shape, color, and arrangement of teeth. While this series included some psychiatric patients, most of the patients were quite adaptable and able to tolerate teeth of their own choice. Some of their comments were most instructive. Several patients first chose an aggressive-looking arrangement and then changed their minds in favor of a nonindividualistic arrangement. Other choices seemed to coincide with, and probably were predicated by, basic personality patterns (eg., patients, who strove to maintain a passive position relative to others, tended to pick the “passive” type of arrangement). This is rough experimental proof of our clinical understanding of psychodynamics. The patient’s unconscious wishes are not available to him for his
Body image
in dentistry
365
logical examination. The person whose internal needs force him to chose the identity of a weakling may be burning with repressed anger. He may choose teeth that would fit a tiger. The lady who unhappily saw youth fade years ago may be driven to wish for the brilliant, white, flashing teeth of the beauty-contest winner. The huge, husky laborer with unresolved homosexual strivings may desire dainty, feminine teeth. Given their choices, each of these people would probably look odd and be quite uncomfortable because forbidden, psychologically unacceptable wishes were symbolically gratified. Some of them would be “denture patients who are never satisfied.” Our technique circumvents forcing a patient to wear cosmetically or psychologically unacceptable teeth and also protects the patient from putting himself in such a position. We assume that with hypnosis the patient can accomplish remarkable, perhaps total recall. The hypnotized patient is usually capable of picking both the teeth and arrangement which are “just like his own teeth.” This selection is something we direct, but once done, it must be interpreted as an active stop on the patient’s part which strengthens his bond with reality and diminishes the strength of his unconscious wishes. Our clinical experience suggest that the patient almost always finds that he had identified the teeth which he can integrate most easily into his body image. The technique of having the patient choose teeth “like his own teeth” under hypnosis has an additional major advantage. We can use suggestions so that the patient, still knowing that the prosthesis is really something made for him, can feel as if his new dentures are really his own teeth and that he has always had them. The patient has a deep desire to feel whole again, as if nothing had really been taken from him. If he can follow our suggestion, we will have helped him avoid seeing himself as a cripple with a very fine prosthesis. How much better it is to feel whole and unhurt! HYPNOSIS
IN GAGGING
AND
ADJUSTMENTS
The patient afllicted with pernicious gagging most frequently is responding to . . a psychologrc stunulus rather than a neurologic hypersensitivity. The extensive “case” history will make some of the predisposing events clear. By allowing the patient to feel as if the dentures are his own teeth, we circumvent any unconscious feelings that something foreign has been intruded into his mouth, and we avoid recapitulating some of the events to which gagging is a defense. These techniques all but eliminate adjustments which stem from misinterpretation of the sensations caused by new dentures in the mouth. This sort of misinterpretation is similar to the excessive awareness that causes us to listen for the smallest squeak or rattle in our new car. The patient is anxious that there may be something wrong with this very-important new part of him. However, when it is not perceived as new and when the patient perceives it as a natural-feeling part of himself, the prosthesis is no longer the focus of this sort of anxiety. ACTIVE
PARTICIPATION
BY THE PATIENT
IN HYPNOSIS
It might seem that each technique is a specific solution to some single problem that troubles a patient. However, people are much too complicated for this to be true. The patient has come to us reluctantly, afraid to have dental work done, and
366
Ament
.1. Pros. Dent. October. 1970
and Ament
is made terribly anxious by oral manipulation. Such a person may have complicated and compounded original fears and unfortunate experiences hundreds of times over. It may be necessary to recognize his distress empathically, but to remind him that although earlier experiences have made him anxious, things are different now. He is older and better able to understand and deal with problems, and this situation may remind him of a situation that bothered him; but it is different. When thr patient understands that he produces the hypnotic state, hypnosis allows him to take an active part in his treatment, moving him away from a position of passive, helpless submission toward one of collaboration with his dentist. When the dentist’s position is empathic and kindly, conditions may be sufficiently changed to make the dental experience pleasant and rewarding. Not every patient has the necessary psychologic resources to use all of the techniques described. In fact, some might find them utterly intolerable; for example, a person with a tenuous grasp on reality might interpret a displacement of his teeth outside his body as a terrifying experience threatening to fragment his personality. Therefore, it is es.re’ntial that suggestions be made permissively at all times (eg., ‘iyou may want too, . . , and when you have, please let me know by means of a signal”). The patient will not put himself in a psychologically destructive position, and if we do not force him into such a position with an overbearing authoritative approach, he will not exceed his limits of psychologic safety. In the same sense, it is essential when the patient returns to the normal waking state in which his perceptions must not make the world seem frighteningly unreal. For instance, if we neglected to suggest the return of the patient’s teeth to their rightful place after hc had displaced them outside himself, the experience could be very frightening. So we must undo all our suggestions except those that we desire to remain active, such as, the feeling that the dentures are the patient’s own teeth. As in all other areas of dentistry, meticulous technique makes for the best result. SUMMARY The development of oral components of body image and the problems which beset their development was discussed. Several hypnotic techniques relating directly and indirectly to body image in dentistry were presented so that they might be used particularly with patients whose fears make them extremely difficult to work with. Techniques which assist in problems of denture composition and pernicious gagging were stressed. Results are congruent with the excellence of the basic hypnotic technique. Reference 1. Rosenthal, L. E., Pleasure, M. A., and Lefer, J. D. Med. 19: 103-110, 1964. DR. PHILIP AYENT: 964 DELAWARE AVE. BUFFALO, N. Y. 14209 DR. AARON AMENT: 12911 FALMONTH DR. SILVER SPRING, MD. 20904
L.: Patient
Reaction
to Denture
Esthetics,
in dethtry
Philip Ament, D.D.S.,* and Aaron Ament, Buffalo, N. Y., and Silver Spring, Md.
M.D.**
B
ody image is a broad concept, one often used vaguely and generally. In its simplest form, the concept has to do with how a person visualizes himself; but surely it is more than that. A person may visualize himself as he was, is now, or will be. His self-esteem may rest on how that visualization compares with the qualities others admire. In some ways, that internal picture reflects what one would be, as well as what one is. The statesman, the athlete, or the lover may march across the screen of the truck driver’s daydreams. The child, when less inhibited than usual, plays at being Batman; he strikes poses and looks embarassingly heroic. In the daydreams of the truck driver and in the play of the child, the body image expresses a portion of the identity of each. ROLE OF THE MOUTH IN BODY IMAGE A most significant part of the body image has to do with the mouth. The degree of its significance becomes apparent when we review the history of a person’s mouth. The mouth is not only used and felt by its owner, it is seen as well. “Ego” psychologists and learning theorists lead us to understand that the newborn child does not have an integrated, combined control of the parts of his body and senses. However, the mouth is surely tremendously important in the baby’s life in these respects: functionally, as an organ through which to receive nourishment; emotionally, as an organ of pleasure (children who suck their thumb in preference to the nipple) ; and adaptively, as an organ of testing, learning, and understanding. The mouth is remarkable as a social signal. The smile of a baby in response to the smile of an adult is beautiful. The mouth is also a source of contention. As the child explores his environment, he may put rattles, shoes, thumbs, and the dog’s bone into his mouth with equal interest but hardly with equal parental approval. Some foods are wonderful, but hot liquids and pepper cause dismay. New teeth are misery personified, and biting makes things feel better. Sometimes biting is fun in and of itself, but when the nursing infant bites his mother, the fun is over. When Presented
at the American
Society
of Psychosomatic
Dentistry
Pa.
362
*Consultant
in Hypnoanesthesia,
**Meninger
Clinic.
Rowe11 Park Memorial
Institute.
and Medicine,
Tamiment,
Body
image
in dentistry
363
the child can crawl and “toddle,” the mouth examines anything left lying around, and soon everyone wants his mouth to be confined to eating. When speech comes, the mouth becomes a seat of power in a new sense, and later, when the child experiments with words which young children are not permitted to use, the mouth gets the child in trouble. Adults recognize the mouth is at fault, and some treat the difficulty by washing the offending mouth with soap. And the same mouth must be used to kiss “Mommie” and “Daddy” good night. The 3-year-old child who plays “tiger” growls ferociously and bares his teeth. His cousin is told that such things are all right for boys but that she must learn to act like a lady and smile prettily. Obviously the mouth of a tough guy is quite different from the mouth of a beautiful lady. Then the “baby” teeth fall out, usually before the solution to the Oedipal problem has crystalized. Most children are frightened about the loss of any part of their bodies. The loss of the teeth is a milestone in growing up though, and most children hang onto that solace. In some families the loss is made good quickly. The “tooth fairy” leaves a coin under the pillow at night. Adolescence brings one plight after another relating to how the child believes he is regarded by the rest of the world. Next to pimples, orthodontic appliances are the ultimate in shame and degradation. Yet these are reasonable reactions when we remember how constantly adolescents are bombarded with exhortations to keep their breath “kissing sweet,” to “wonder where the yellow went,” and to give their mouths “sex appeal.” One must pay attention to what one’s date thinks, and from this time on, the mouth becomes more and more the focus of romantic interest. It continues to be a measure of an adult. What professional person would address a seminar heedless of discolored teeth and fetid breath? Up to this point, we have not considered the experience of forced feeding by parents, forced manipulation of the tongue blade by the physician, or a forced approach by the dentist. Most of us forget the impression of an angry attack, the totally helpless, passive, and defenselessness type of anger, terror and frustration. Some children give the impression that they will never cooperate, and in the urgency and heat of the situation, some adults feel that a fast job will get the nasty business over sooner. The adult sitting in the dental chair was an adolescent who was a child who was an infant. This person has been on pathways of development which have been altered by his many gratifications, discoveries, relationships, identifications, and insults at each developmental level. As he sits in the dental chair, he is still developing. It is a tribute to man’s adaptiveness that he can be rational and helpful in times of stress. For some patients, the dental experience can be one of being cared for and supported almost as with a mother’s love. For others who do not do well, the dental experience may be one perceived as an assault which recapitulates the old feelings of helplessness and terror. Also, they may gag, vomit, jerk away, never be pleased, or never come to the office. HYPNOSIS IN RESTORATIVE PROCEDURES Most patients under hypnosis are occupied in their fantasies, and usually they picture themselves in scenes far removed from the dental chair. When hypnosis
364
Ament
.i. Pros. Dent. October. 1970
and Ament
is used to induce anesthesia, the hypnotic interlude can be a profoundly enjoyable experience. With time distortion techniques, a long operative procedure can he subjectively perceived as a 10 minute interlude based on the patient’s ability to place himself in a temporary passive position. At least it seems like a passive position to we who watch, and this is a point of great misunderstanding. The patient cannot enter into and maintain a hypnotic state except by active psychologic work. If we understand this and help our patients to understand it, even those who SPC themselves as helpless in the dental chair will be better able to enter into a collaboration with us to produce the psychologic flexibility we need. The standard techniques of inducing oral anesthesia are sufficient for most patients, but we are expecially concerned with the patient whose mouth is a focus of concern, distress, bad memories, and unhappiness. A detailed patient history is essential. However, the history must extend far beyond previous dental treatment, illnesses, medications, and drug sensitivities and beyond the usual somatically oriented material. Often it is best to assist the patient to tell you about himself, including his childhood, his parents, and difficulties of any sort even when he was young. If you can let the patient talk freely and follow his lead for a while, many of the difficulties which led to his becoming a difficult dental patient will become clear. However, these matters should not be pointed out to the patient directly. To do so abruptly, often proves shocking and painful to him. When this preparation has helped the patient move into the hypnotic state, an evaluation of him may indicate a need to give him an even greater psychologic distance from the work going on in his mouth. Under hypnosis, we may ask the patient to project his teeth out of his mouth and away from him into the room, providing the opportunity to do his dental work for him without disturbing him as he thinks of a scene elsewhere. He may be told that he is turning the mouth over to you and that it will be returned to its rightful place when the work of the day is accomplished. We have found that this maneuver can sometimes give relief even to the occasional patient who can enter the hypnotic state but who cannot allow himself to produce anesthesia. It may also be effective in the patient who finds himself unable to give up his hypersensitive gag reflex. HYPNOSIS
IN SELECTION
OF TEETH
The selection of artificial teeth for dentures was discussed by Rosenthal and ass0ciates.l They indicated that the personality of the dentist may well be the determining factor in the choice of teeth rather than the patient’s physical, psychologic, or cosmetic needs and that, statistically, fewer adjustments and dissatisfactions follow when the patients were allowed to choose their own size, shape, color, and arrangement of teeth. While this series included some psychiatric patients, most of the patients were quite adaptable and able to tolerate teeth of their own choice. Some of their comments were most instructive. Several patients first chose an aggressive-looking arrangement and then changed their minds in favor of a nonindividualistic arrangement. Other choices seemed to coincide with, and probably were predicated by, basic personality patterns (eg., patients, who strove to maintain a passive position relative to others, tended to pick the “passive” type of arrangement). This is rough experimental proof of our clinical understanding of psychodynamics. The patient’s unconscious wishes are not available to him for his
Body image
in dentistry
365
logical examination. The person whose internal needs force him to chose the identity of a weakling may be burning with repressed anger. He may choose teeth that would fit a tiger. The lady who unhappily saw youth fade years ago may be driven to wish for the brilliant, white, flashing teeth of the beauty-contest winner. The huge, husky laborer with unresolved homosexual strivings may desire dainty, feminine teeth. Given their choices, each of these people would probably look odd and be quite uncomfortable because forbidden, psychologically unacceptable wishes were symbolically gratified. Some of them would be “denture patients who are never satisfied.” Our technique circumvents forcing a patient to wear cosmetically or psychologically unacceptable teeth and also protects the patient from putting himself in such a position. We assume that with hypnosis the patient can accomplish remarkable, perhaps total recall. The hypnotized patient is usually capable of picking both the teeth and arrangement which are “just like his own teeth.” This selection is something we direct, but once done, it must be interpreted as an active stop on the patient’s part which strengthens his bond with reality and diminishes the strength of his unconscious wishes. Our clinical experience suggest that the patient almost always finds that he had identified the teeth which he can integrate most easily into his body image. The technique of having the patient choose teeth “like his own teeth” under hypnosis has an additional major advantage. We can use suggestions so that the patient, still knowing that the prosthesis is really something made for him, can feel as if his new dentures are really his own teeth and that he has always had them. The patient has a deep desire to feel whole again, as if nothing had really been taken from him. If he can follow our suggestion, we will have helped him avoid seeing himself as a cripple with a very fine prosthesis. How much better it is to feel whole and unhurt! HYPNOSIS
IN GAGGING
AND
ADJUSTMENTS
The patient afllicted with pernicious gagging most frequently is responding to . . a psychologrc stunulus rather than a neurologic hypersensitivity. The extensive “case” history will make some of the predisposing events clear. By allowing the patient to feel as if the dentures are his own teeth, we circumvent any unconscious feelings that something foreign has been intruded into his mouth, and we avoid recapitulating some of the events to which gagging is a defense. These techniques all but eliminate adjustments which stem from misinterpretation of the sensations caused by new dentures in the mouth. This sort of misinterpretation is similar to the excessive awareness that causes us to listen for the smallest squeak or rattle in our new car. The patient is anxious that there may be something wrong with this very-important new part of him. However, when it is not perceived as new and when the patient perceives it as a natural-feeling part of himself, the prosthesis is no longer the focus of this sort of anxiety. ACTIVE
PARTICIPATION
BY THE PATIENT
IN HYPNOSIS
It might seem that each technique is a specific solution to some single problem that troubles a patient. However, people are much too complicated for this to be true. The patient has come to us reluctantly, afraid to have dental work done, and
366
Ament
.1. Pros. Dent. October. 1970
and Ament
is made terribly anxious by oral manipulation. Such a person may have complicated and compounded original fears and unfortunate experiences hundreds of times over. It may be necessary to recognize his distress empathically, but to remind him that although earlier experiences have made him anxious, things are different now. He is older and better able to understand and deal with problems, and this situation may remind him of a situation that bothered him; but it is different. When thr patient understands that he produces the hypnotic state, hypnosis allows him to take an active part in his treatment, moving him away from a position of passive, helpless submission toward one of collaboration with his dentist. When the dentist’s position is empathic and kindly, conditions may be sufficiently changed to make the dental experience pleasant and rewarding. Not every patient has the necessary psychologic resources to use all of the techniques described. In fact, some might find them utterly intolerable; for example, a person with a tenuous grasp on reality might interpret a displacement of his teeth outside his body as a terrifying experience threatening to fragment his personality. Therefore, it is es.re’ntial that suggestions be made permissively at all times (eg., ‘iyou may want too, . . , and when you have, please let me know by means of a signal”). The patient will not put himself in a psychologically destructive position, and if we do not force him into such a position with an overbearing authoritative approach, he will not exceed his limits of psychologic safety. In the same sense, it is essential when the patient returns to the normal waking state in which his perceptions must not make the world seem frighteningly unreal. For instance, if we neglected to suggest the return of the patient’s teeth to their rightful place after hc had displaced them outside himself, the experience could be very frightening. So we must undo all our suggestions except those that we desire to remain active, such as, the feeling that the dentures are the patient’s own teeth. As in all other areas of dentistry, meticulous technique makes for the best result. SUMMARY The development of oral components of body image and the problems which beset their development was discussed. Several hypnotic techniques relating directly and indirectly to body image in dentistry were presented so that they might be used particularly with patients whose fears make them extremely difficult to work with. Techniques which assist in problems of denture composition and pernicious gagging were stressed. Results are congruent with the excellence of the basic hypnotic technique. Reference 1. Rosenthal, L. E., Pleasure, M. A., and Lefer, J. D. Med. 19: 103-110, 1964. DR. PHILIP AYENT: 964 DELAWARE AVE. BUFFALO, N. Y. 14209 DR. AARON AMENT: 12911 FALMONTH DR. SILVER SPRING, MD. 20904
L.: Patient
Reaction
to Denture
Esthetics,