The psychodynamic approach to immediate denture prosthesis

THE PSYCHODYNAMIC DENTURE

APPROACH TO IMMEDIATE PROSTHESIS

MARTIN B. PKOTELL, B.S., D.D.S., AND SYLVIA MAKKHAM, NEW YORK, N. Y.

P

M.A.,

SYCI-IOLOGICAL insights which have opened up new horizons in the understanding of physical ailments can render invaluable service to the practice of dentistry. No field, be it medicine, art, education, industry, or government, has been left untouched by the significant impact of new psychological findings. The dentist, no less than the physician, must seek new orientation in the theory and practice of dentistry for the purpose of establishing a better doctor-patient relationship and removing or reducing the fear and anxiety inherent in the dental situation. The psychosomatic approach to medicine demands that the physician or dentist treat the patient as a total personality, with an understanding of the latter’s needs, drives, fears, and defenses. No longer can the dentist view himself as simply a skilled mechanic, highly specialized in one restricted area of the human body, neglecting the emotional components of the personality. This article will concern itself with the re-evaluation of the role of the dentist in relation to his patient with a better understanding of the psychodyna.mics of personality and of the specific fears of the dental situation SO that the dental procedure will be facilitated, particularly in the field of the immediate denture prosthesis. No situation in the entire field of dentistry holds more terror for the patient than the one in which complete or rnultiplc extractions are contemplated. Patients show reactions which range all the way from a resigned, fatalistic acceptance of an inevitability to definite phobic behavior. Fear will be present in every person who is facing a real situation which, of necessity, must be painful. The extent of the fear will depend upon the past trauma,tic experiences of the patient, the neurotic components of his personality, and the skill with which the dentist handles the situation. Roth real fear and neurotic anxiety interfere seriously with the dentist’s efficient functioning during the treatment and with the patient’s postoperative recuperative process. At the onset, it is important to distinguish between the objective fear and neurotic fear, usually called a state of anxiety. Objective fear is the reaction 3

0 f ahrm or aplnehension in an individual who is responding to a dangerous or painful situation in the environment. Anxiety, on -the other hand, is a si rite of alarrti aroused lty intertlal shimllli iltlti is Only indirectly related to an external situation. Objective fear is directiy proportionat,e to the real danger. while the intensity of the aalxiety bears’ no direct relation to the real danger. Anxiety appears excessive and inappropriate. T;‘or instance, a person may rrmnifest grea-t anxiety when crossing a bridge, even though the possibility of fa,lling or injuring himself is very small. The reaction of the patient t,o a major dental procedure may be compounded of both objective fea,r and a nxiety. The extent to which the affective state is directly correlated with the real pa,in and feelings of organic loss measures the adjustment potentia.1 of the individual patient. The well-adjusted personality is able to face up to the loss of teeth and the discomforts of the operation with the same stoicism 1,ha.t he demonstrates in accepting other physiologic changes attendant on advancing age. In addition, the normal person is capable of acting decisively -when convinced of the need for immediate denture prosthesis without the The latt,er a,mbivalence and vacillation found so often in neurotic patients. tend to exaggerate the terrors of the situation, delay taking action a,nd give widenee of severe anxiety whieh may become phobic. Phobias are defense mechanisms in which a. person projects his anxiety to some external object or situation. In this way, the true nature of the inner threat is concealed, and the person is distracted from the frightening internal stimuli. To understand the true _nature of the dangerous inner stimuli which are ca.pable of arousing phobic anxiety, one must consider the unconscious meaning of tooth extraction. In the framework of Freudian dynamics, teeth represent phallic symbols. Consequently, a person may equa,te loss of teeth with castration. In childhood, eastration may be perceived as punishment for forbidden a.&, such as masturbation, fanta>sy that accompanies autoerotic play, or overt expression of hostility. Castration anxiety in the ea,rly years tends to give meanin g to the loss of teeth in adulthood. An adult, both consciously and unconsciously, views his loss of teeth as the beginning of his decline, particularly of his sexua.1 powers. Men view it as the end of their virility, while women interpret it as an overwhelming blow to their feminine attractiveness. In menopause, “a woman often feels that a denture is the last stra,w in her already wounded vanity a,nd self esteem.“” With the possibility of loss of sexual powers may come anxiety that mental vigor, physical endurance, and other areas of functioning will likewise suffer. The anxiety produced by such unconscious perceptions may be devastating in its effects. One, however, must not underestimate the importance of conscious experiences and memories in determining the psychological set of the patient. il’e rnay recall the t,rauma.tic dental experiences of childhood which have proved damaging by virtue of the fa,ct that the ego was too weak to deal In adulthood, simi1a.r a.dequately with the painful and frightening situa.tion. cues ‘ma,y reactivate the alarming situation which ha,d occurred in the past,

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and will tend to arouse fear, even though the ego ha.s strengthened and Emotional maturity in should be able to cope with the new circumstances. connection with dental experiences may be frozen at the childhood level. A4 psychosomatic approach to dentistry must consider the n.ced to dilute the abnormal, residual fear of the emotionally immature patient as well as the normal fea.r of the well-adjusted person, and to divest dental procedure of its terrifying aspects. The dentist can do much to reduce the anticipatory fear of the patient and create a more relaxed attitude in him. The dentist should seek to establish a rapport with his patient, which is similar to the transference relationship in psychotherapy. The patient tends to see his physician or dentist as a father surrogate a,nd to form a passive dependent relationship with him as one does with any authority figure. It is interesting and significant to note that the patient sitting in the dental chair will take criticism, direction and guidance which he would not ta.ke in ordinary situations. Women patients, particularly, may establish a wa,rm, affectionate transference which is reminiscent ot’ their early attachment to their fathers. HOWever, the patient’s relationship to the dentist is an ambivalent one compounded of both dependence on a parent,al figure who can heal and hostility toward a person who must, by the very nature of the treatment, inflict pain. This basic conflict complicates the doctor-patient relationship and therefore demands tremendous patience, understanding, and acceptance on the part of the therapist. The patient should be allowed to express his negative feelings, which may appear immediately or which may not appear until some time after treatment has begun. The dentist must be on the alert to recognize hostile feelings and take time out to ta,lk things over and discuss the problems so that good rapport may be obtained. Fun&mental to good rapport is the ability of the dentist to empathize with his patient,. Treatment should encompass the total personality of the patient with the sympatheic understanding of the patient’s problems, even though seemingly unrelated to the immediate dental work. JJet us now consider the application of the psychodynamic approach to immediate denture prosthesis. The rnost effective way of dealing with the fear and anxiety of patients is through the face-to-fact interview. Active treatment begins with the first visit. From past experience, it ha.s been found expedient to hold the first consultation in a setting removed from the treatment room and without any suggestion of dental instrumentarium. The room should offer a subdued, relaxing, and dignified atmosphere. A detailed a.namnesis is taken. which covers the medical, psychological, and dental aspects of the patient’s life. The medical history should include the name of the family physicia.rr and data conperning previous illnesses or operations, present ailments and date of their onset, together with facts about nervous tendencies, the cardiovascular, gastrointestinal, and genitourinary tracts, and the respiratory system. It should also include any family history of cancer, tuberculosis, arthritis, or rheumatism. To complete the medical picture, some informa,tion concerning the patient’s dietary, drinking (alcoholic), and smoking habits should be obta,ined. In order to gain some insight into the psychological

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MARTIN

M. PKWPFLI,

background

of the patient,

iI ) whether

the patient

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C;W,VIA

MARKHAM

Lhe following information sl~ould be elicited : any real tra.umatic experience rel.ated to dentistry; (2) what the patient cxpeet,s in terms of end results; (8) 8 dental hi&r-y, if possible, 01 mother, Patlier, and siblings ; and (4) an eva;luatiou of the patient’s reactions to the 1~~sof teeth. The dental cha.rting and history takin g obviously must, take place in the treatment room. This should include examination of ,the mueosa and gin&a as to color aud texture and of the dentition as to earious conditions, either vital or nonvital, and mobility. One should note the patient’s mouth hygiene n.nd type or types of dentifrice, mouthwash, and toothbrush used. The types of restorative dentistry present also should be recorded in the chart, To conclude, intraoral radiographs should bc taken and study models ma.de. A preliminary tentative estimate of the patient’s personality structure should emerge from the session. The difFerence between a healthy and n::urotic a,djustment of any one patient may not always be easy to determine. On the whole, the well-adjusted person tends to be cooperative, trusting, objective, and ca,pablc of rclatin g to the dent,ist on a, friendly level. Eowever, it! is not unusual to find that, wha,t appears to be a so-tailed normal fa$ade is masking a, neurotic or even psychotic underpinning. For example, the patient who presents an exterior of bravado, robust health, and abounding cheerfulness may be denying a basic depression which will manifest itself in a situation of stress. The dentist may have to depend on other clues, often nonverbal, to Attitude exascertain the presence of abnormal or unhealthy personality. pressed. in the way in which a patient selects and uses a dentifrice or toothbrush may suggest both the conscious and unconscious meaning o-f the teeth in the total economy of the patient’s personality. An overmeticulous care in practice, may be indicative of the teeth, which may be almost ritualistic of an obsessive-compulsive personality structure, or of erotic gratification related to the mouth. Where a person mainta.ins cleanliness a,nd personal pride in al.1 ma.tters of grooming and yet neglects his teeth, we may suspect a wish to deny strong oral passive needs. Fixations at the oral level may be manifested in a wide variety of dental symptoms, ranging all the way from total neglect to excessive preoccupation with the teeth. Symptoms which appear most frequently in handling neurotic patients are phobia-like anxiety, resistiveness, guarded suspiciousness, and hypochondria,ca,l and egocentric, narcissistic behavior. These symptoms ma.y appear singly or in combination. It is likely that the neurotic personality will maniAnxiety may be verbalized in exfest more than one of these symptoms. pressions of apprehension and dread or it mazy be revealed in involuntary physiologic signs, such a.s the manner of speaking (verbosity or undue reticence), general restlessness and fidgeting, chain smoking, wetting of lips, throa.t clearing, sweating, or the clenching of hands. Resistiveness may be manifested by the patient who withholds information, hurries through the interview, assumes an a.ir of indifference, or seems to be testing the dentist. He may be attempting to manipulate the therapist and to mana,ge the situa,tion has suffered

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to suit his own neurotic needs, For example, the career woman, often a spinster, who rushes in with an air of haste and importance and expresses herself in such terms as ‘(let’s get down to business and finish this thing off in a hurry” is an illustration of the oppositional patient whose unconscious fears are being mobilized in a situation which she perceives as threatening. The suspicious patient who projects onto the external world his own selfhatred and hostility will tend to perceive the dentist as another figure who is determined to exploit, cheat, and victimize him. He will be watchful, doubting, and overalert. At the extreme, his perception of reality may bc so disquality. The hypochondriacal patient may torted as to take on a paranoid pose serious problems for the dentist. He must be differentiated from those suffering from real, organic illnesses. The medical history will often disclose the imaginary or real nature of his past illnesses and his present complaints. The patient suffering from hypochondriasis is often overcooperative and highly suggestible. When asked to localize the painful area, he may ascribe pain to a variety of unrelated parts. He is unable to give a direct answer and, consequently, his inconsistencies make diagnosis difficult. The narcissistic character, more frequently found in women, will be These are manifested in egocentric, exhibitionist, and seductive behavior. personalities whose erotic attachment to themselves precludes any genuine object relationship. Their sole concern is to recapture or enhance their youth, beauty, and charm, with no real interest in the health or functional benefits to be derived from the prosthesis. Sometimes male narcissists may insist on ha,ving the gold and silver restorations in their own teeth duplicated in the denture in order to avoid any impression that the teeth a.re false. So long a,s the dentist can feed their narcissistic vanity a,nd achieve the results they were promised, a working relationship between patient and therapist can be established. Case History woman, narcissistic

of a Narcissistic and suspicious.

Character.-The She was married

patient was a 24-year-old and had no children.

white

Diaynosis : ~lmmediate Pull upper denture. Upon presentation of the diagnosis, the patient was not greatly concerned about the loss of her maxillary teeth, but was primarily concerned with the degree of esthetic improvement. The patient was reassured that a marked cosmetic effect could be achieved. It was deemed advisable, bofore proceeding with the treatment planning, that a review of the presentation be given to the husband in the presence of the wife. At the conclusion of the interview, it was further suggested that the diagnosis bc fully discussed at home. During all consultations emphasis was placed on the loss of teeth, the conscious or unconscious effect it might have upon the sexual relationship, and the possible embarrassments that might occur. Both husband and wife, after procedure would in no way interfere ment was instigated.

discussing with their

the matter relationship.

for

a week, Upon this

agreed that the assurance, treat-

The patient was hospitalized, her teeth were surgically removed, and an immediate upper denture was inserted. ‘When the patient fully reacted after surgery her only concern was “Wow do 1 10olr?‘~ She was more than gratified with the cosmetic result. Twenty-four hours postopera.tively the patient developed a crying spell, was terribly clistraught, questioning whether or not she was as sexually attractive to her husband as

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heforo Ircetment. Ln fact, she exhibited a great ideal of regret that she had consented to tho operation. Much time was spent at her bedside reassuring her. The husband ‘LI’BS Advice was given as contacted and his wife’s psichological problems were exlllsineci. to how he might act and l-&k in order to reassure his wife. Within ten days after the 11k.d ie-established her usual patterns of behaVior. [Jr”““du 1’0 was ~~orrrpletecl, the patient This could not have been accomplished without the complete understanding and full cooperation of the husband.

One should not overlook the fact that the dentist is also being observed ant? ,judged by his pat&t, in their first interview. The meeting is a form of social interaction, the positive results of which will depend on the skill of the dentist in putting his pa,tient, at ease a.rtd in winning his confidence and t~l”1E.t. The dentist’s own inner security, which is based on his self-knowledge The 01 eonrpetence and experience, will communicate itself to the patient. patient’s behavior in the dental chair may confirm a.nd amplify the preliminary findings which emerge during the face-to-fact interview. Evidences of anxiety, even though verba.lly denied, may be exhibited in such physiologic lowering of the symptoms as increased body tensiou, excessive perspiration, or excessive pain t,hrcshold, a r&less tongue, gagging, and insufficient saliva,tiori. On the other hand, the patient who has eroticized his oral region will manifost pleasure in having the dentist manipulate his mouth. The dentist is able to utilize the deeper psychological knowledge of his patient's personality, gained through the first interview and clinical examination, to guide him in the next phase of treatment, namely, the approach in presenting the diagnosis. This is accomplished at, the second visit. For the purpose of this article, the presentation of only one diagnosis, immediate denture prosthesis, is being considered. In nearly all cases such a diagnosis will be traumatizing a.nd will a.rouse tremendous apprehension in both welladjusted and neurotic persons. At this point one should stress the advantages of the hospital a.pproe.ch as corrrpared to of&e treatment, such a.s the benefits of complete a.nesthesia with reduction of trauma. and tbe superior care and It is likely that the presentation of the a,ttention ava,il a ble in the hospita,l. diagnosis will be more fearful and shocking to the neurotic patient. In such cases, further reassurances are often necessary. One should go into a deta.iled explanation of procedure, before, during, a.nd after the operation, evaluating them in terms of the patient’s needs. This reassurance in combination with a warm, empathic relatedness is of great value in warding off anxiety of even the most well-adjusted person. The latter, however, will be concerned with the end results in terms of ‘improved health and, therefore, the dentist can be more objective in his approa,ch to him. Tn summary, zor: n,rcz To quote not suggesting thmt th,e dentist play the de of the psychintrist. Kellnk zF We do not propose that the doctor wonder what terrible psychopathology js We do not expect that the doctor be as alert brewing in every new patient. to manifestations of psychiatric problems as he is to any manifestation of other illnesses. With the relatively well adjusted patient there need be only a minimum of psychological consideration-~--such as is dictated by tact, humaneness,

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the percepts of medicine in gcneral, and the principles of communicating with With the extremely disturbetl people in emotionally charged situations. patient, psychiatric consultation and treatment should be arranged. However, our discussion centers about that majority of people between these two OXtremes; the person who, when affected by an illness, will distort the specific features of the illness by all kinds of rather common misconceptions and a few personal irrationalities. He will then add a groat additional emotional burden to the realities and inconveniences of the illness. It is this person who can be greatly helped.

presenting the diagnosis to the resistive patient, one is obliged to a direct, impersonal, permissive attitude, observing very carefully the “no trespassing sign” which the patient has put up. The diagnosis should be positive, lea.ving no doubt as to the course of treatment. The decision must be left entirely to the patient, without attempting to influence him. One adopts In addition, cona similar attitude in dealing with the suspicious patient. sultation with another dentist is often deemed advisable to allay the unrealistic fears of this kind of patient. In dealing with the hypochondriacal patient, the dentist should avoid falling in with his distorted perceptions of body functioning. It' is important that the patient be brought in closer with the real situation in order to lessen his phobia-like anxiety. The diagnosis should b e presented in a detached, calm manner, and the dentist should be careful not to arouse unnecessary apprehension. If narcissism is a major component of the patient’s personality, the dentist would be wise to stress the cosmetic advantages of the dentures. By permitting him to participate in the decisions as to color, size, and arrangement of the teeth, his interest and cooperation will be secured. An illustration of good psychological preoperative prepnration in an anxiety-ridden patient is the case of Mr. K. E’rom his own words we get a better picture of the way in which apprehension can be reduced and the patient made psychologica.lly ready for the surgical procedure. In

assume

ease History of Mr. B.--The patient was a white man, aged 47 years. He was divorced. The patient had been wearing upper dentures for seven years and a lower partial (stool) with acrylic saddles replacing molar teeth. All remaining mandibular teeth present (from lower right second premolar to lower left first premolar) showed marked periodontoclasia and were mobile. The patient described his reactions in this way:

The entire modus operandi are outstsndingly extraordinary, which is one of the main reasons I’m taking the trouble to Put this in writing. Arriving at your office, I was nervous, suspicious, and-all right-1 was scared! My first surprise was to not find myself sitting in a chair with a towel chained around my neck, staring at a drill, nervously awaiting the appearance of the dentist. Instead, .I found myself sitting in an ofYice, smoking a cigarette, chatting away as though the dentist and I had gone through college together. I’m sure you do, but .r can’t help but wonder if you really appreciate to its full extent the wonderful psychological effect this first impression has on a prospective patient? nervousness, and everything .A11 my fear-you might even say “dread’‘-worry, else went right out the window and I was thoroughly and completely at ease, and actually glad I had come! I have devoted quite a lot of space to this phase because of the importance and I think you will agree it is .possibly the most oi the initial impression,

important part of the entire operation. Another, and extremely impo?tant fnetori was your method of working on me mentally throughout all of my visits. I.t, was so casual and snbtle that I wasn’t even aware of what was going on, until it suddenly dawned on me lhl, I was :~ctuall,v anxious to yet to the hospital.

1 do not want to leave this phase of the operation without commenting, in passing, on the way you patiently and honestly answered all of my ridiculous questions and even went further and volunteered information and explanation as we went along. This complete honesty and removal of everything even bordering on secrecy connected with what is being done, or going to be done, moutEl is an extremely intelligent phase of dentist-patient reto the patient’s lationship and one which, in my humble opinion, should have been adopted by all dentists a long t,ime ago! 1 have no idea how long I was actually in Surgery. I have only the recthat the entire thing was completed and over and I had a little rliflioulty, on waking up, in reconciling myself to the fact that it wccs all over.

ollection

The whole routine 1 use as a comparative with my “uppers.”

is tremendously impressing--doubly so, I imagine, when yardstick the situation I went through a few years ago

Where the entire method adds up to relaxed confidence; lack of fear; reduction of pain and suffering; a knowledge and understanding of what was going on-and why-at all times, and a minimum of discomfort, my earlier experience was in violent contrast: shock, fear, pain, inability to eat, and extreme discomfort, and “being out of circulation” for a while-in other words, “partial disability.” There was no “build-up” or preparation whatever.

The patient facing immediate denture prosthesis is confronted with a situation which is a major threat in a very real sense. Among the realistic dangers are the loss of an important part of the body, pain, uncertainty concerning the dentist’s skill and competence, expense of the opera.tion and hospitalization, and a significant change in his body image. Psychologically, the hospital setting for immediate denture prosthesis offers many advantages The helplessness of persons who are to both the patient a.nd the dentist. seriously ill, or who have undergone a major surgical operation often produces a, regression to immature patterns of behavior in which body preoccupation There is an intense withand narcissistic needs supplant all other interests. drawal of interest from the external world onto the self. The pa.tient demands sympa,thy and a.ttention in the same way that a child ca,lls on his mother for immediate gratification of his needs. Bellak6 states : All severe, temporarily incapacitating illnesses increase the need to be loved and be cared for. Enforced inactivity, in turn, adds to the wish to return to a Such an unconscious desire may exdependent, more or less childlike status. press itself in rationalizations, in appropriate symptoms and “demandingness.” Fears of possible harm by lack of care, stand in the center of rationalizations.

The hospital, as opposed to the dental office, is more adequately equipped to furnish the kind of service and nursing care that caters to the patient’s needs while he is in a state of helplessness and trauma incident to prosthetic surgery. The hospital nurse plays an important part in the patient’s recuperative process. She becomes psychologically equated with the beneficent mot;hcr who gratifies

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the child’s wants and gives him sheltering and comfort. “IIer mere presence during the first few postoperative days may mean the difference between his being able to carry out elementary functions, ox the taking of fluids spataneously, or the need for mechanical procedures in this regard. It is also probable that the return of interest from self onto the objects and people of the outside world is enhanced by the nurse’s presence, and forms a very significant part of the psychological readiness to get well.” The patient is being placed in a setting where hc holds the center of attention and where his importance is being enhanced. ‘There can be no question that an operative procedure under a general anesthetic, with a trained anesthetist in constant attendance, is much safer and more efficient in the hospital than in the dental office. The advantages of the general anesthetic in surgery such as this far outweigh the disadvantages. As compared to a local anesthetic, there is less traumatization to the gingival tissues, less edema around the mouth, fewer hematomas, and better healing. A better operative fie1.d is present because of the absence of extraneous fluids (no injections of local anesthetic). In addition, it is not always necessary to remove posterior teeth prior to actual surgery, and the possibility of postoperative infection is reduced. The complete amnesia of the patient blocks out the shock of the surgical procedure and hastens the recuperative process. The hospital likewise offers many practical benefits to the dentist who is performing surgical prosthesis. He is secure in the knowledge that all facilities are available in case of emergencies or unexpected difficulties. The number of postoperative visits is reduced, since recuperation is hastened. The use of a hospital instead of a dental office for surgical prosthetics is of inestimable importance in raising the self-esteem and professional status of the dental surgeon to the same category as general surgery. As hospital procedure for surgical prosthesis becomes more widespread, general hospitals will dou’btlcss improve their equipment to provide all the facilities required for this kind of surgery. The psychodynamic approach to immediate denture prosthesis is predicated on the need to treat the dental patient as a total personality with an understanding of his emotional requirements and with respect for his The dental situation produces apprehension and dread in all uniqueness. persons, normal as well as neurotic. The kind of fear experienced by the neurotic patient can be understood only in the light of the psyehogenicity of anxiety. r\Teurotic anxiety is not directiy related to the real threat in -the environment (that is, the pain of the operation and the loss of teeth), but originates in unconscious ideation in which extraction of teeth takes on sym.bolic meaning. Such anxiety also may be the product of traumatic experiences of the patient or of parents or siblings which are related to dental It is recommended that the dentist obtain a fu1.l anamnesis coversituations. ing medical, psychological, and dental background of his patient. Basic to psychological understanding and good. management is the establishment of a

The use of the hospital for surgical prosthesis is a most important aid in allaying anxiety in the patient, reducing both his physical and psychological, trauma., aid hastening the recupera,tiIre process. In addition, the hospital lends status to a surgical. procedure which too often is regarded as routine him o%ce praclice, and gives professional dignity to the dentist by removing from the %veqda;Y concept” of the title, denfi~t. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. il. 12.

Freud, 8.:

to Psychoanalysis, New York, 1952, Garden City Books. Freud, 5.: The Problem of Anxiety, New York, 1936, The Psychoanalytic Quarterly Press and W. W. Norton & Company, Inc. Thompson, C., and Mullahy, P.: Psychoanalysis, Evolution and Development, New York, 7 950, Hermitage House. Ryan, E. J.: Psychobiologic Foundations in Dentistry, Springfield, Ill., 1946, Charles C Thomas. Weiss, E., and English, 0. 8.: Psychosomatic Medicine, Philadelphia, 1949, W. B. Saunders Company. Bellak, L.: Psychology of Physical Illness, New York, 1952, Grune & Stratton, Inc. McCartney, J. I>.: Psyehosomaties in Dentistry, New York J. Dent. 21: 344, 1951. Stolzenberg, .I. : Psychosomatics and Suggestion Therapy in Dentistry, New York, 1950, Philosophical Libruy, Inc. Moulton, R. : Psychologic Problems Associated With Complete Denture Service, J. Am. Dent. A. 33: 476. 1946. Tarmhow, 8. : Relationshi of the Dontist to Neurotic Psychological Types, New York J. Dent. 16: 189. 1946. Weiss, E.: Psychosomatib Aspects of Dentistry, D. J. Australia 17: 105, 1945. Goldhlatt, A. : Procedure in collahoratinm with Aaron Qoldblatt, 11.1). for Anesthesia Personal Cornmnnication. A

General

Introduction