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Psychodynamic study of abnormal reactions to dentures
CO LLET T . . . V O L U M E 51, N O V E M B E R 1955 • 541
vom iting with the use of other general anesthetic agents, however, show that ethyl vinyl ether can com pare favorably with them. SUM M ARY
AND
C O N C L U S IO N S
Ethyl vinyl ether was used as a supple mentary anesthetic agent for exodontic procedures on 498 unselected patients varying in age from 2 to 46 years and above.
T h e anesthetic was fou n d to be satis factory fo r this purpose. Its advantages were ( 1) rapid induction, ( 2 ) quick em ergence and (3 ) m ild toxicity. Its dis advantages were ( 1) its explosibility, ( 2 ) the salivation produced, (3 ) the nausea and vom iting resulting and (4 ) the possible objectionability o f its odor. Ethyl vinyl ether is an agent that may be useful fo r anesthetization o f am bula tory patients fo r brief surgical procedures such as are required in exodontics.
Psychodynamic study of abnormal reactions to dentures H en ry A . 'Collett, D .D .S ., Brooklyn
M any patients have difficulty adjusting to dentures, even when there is no appar ent physiological or m echanical inaccu racy. O n the other hand, some patients adjust surprisingly well to dentures that have gross inaccuracies. Such instances are abnormal in the sense that the reac tion o f the patient is not appropriate to the physical situation. T he reactions sometimes are extreme and at other times are less so. T h e difference between the abnormal and norm al reaction seems to be one o f degree. Previous studies1,2 demonstrated that it was possible to trace abnormal reac tions to dentures to attitudes developed early in life and m odified in the years that follow ed by frustration. T h e patients w h o had difficulty in adjusting to den tures also had difficulty in adjusting to other problems in their everyday life. A n
understanding o f the reactions to den tures as adjustive mechanisms m ight aid the dentist in helping m any patients to adjust m ore adequately. T h e dentist is directly concerned with the emotional state o f his patients.3 It w ould be easy fo r dentists to blame failures in construction on the patients and to classify the patients as psycho logical failures. D oing this w ould seldom
The opinions or assertions contained in this article are the private ones of the writer and are not to be construed as official or reflecting the views of the Navy Department or the naval service at large. Commander, Dental Corps, U. S. Navy, U. S. Naval Dental Clinic. 1. Collett, H. A., and Brigas, D. L. Some psycho logic aspects of denture-stimulated ga g g in g . J. Pros. Den. 3:665 Sept. 1953. 2. Collett, H. A., and Briggs, D. L. Personality factors relating to overadaptation to dentures. J. Pros. Den. 4:269 March 1954. 3. Block, L. S. Muscular tensions in denture con struction. J. Pros. Den. 2:198 March 1952.
542 • THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
solve the problem . Careful evaluation must be made first to eliminate the pos sibility that the replacem ent is inaccurate to the extent that a norm al patient would not tolerate it. N eurotic reactions can be stimulated by im properly constructed dentures in patients w h o m ight react normally to satisfactory replacem ents.4,5 Physical ex aminations and case histories should be used to rule out lack o f tolerance due to subnormal oral and general health before the psychological aspects o f m aladjust m ent are considered. E T IO L O G Y O F E M O T IO N A L M A L A D JU S T M E N T TO D E N TU RE S
M aladjustm ent to the wearing o f den tures, as well as to m any other situations that the patient m ight be confronted with, frequently has its basis in the pa tient’s attitudes tow ard his parents and others that attended to his basic needs as he matured. I f the parents o f the patient rejected him as a child, or if he felt rejected (fo r instance, when a new sibling arrived and received most o f the attention ), the patient is apt to be fearful and insecure. H e m ay then develop atten tion seeking devices that he m ight use throughout life. His emotional insecurity is conducive to self-devaluation and to the evaluation o f the world as an inse cure and hostile place. If, however, the patient’s parents over protected or pam pered him, m aladjust ments are also likely to occur. Strecker calls this condition “ m om ism .” 6 T he m other watches over the child constantly, overdressing and overm edicating him and making up his m ind fo r him at every opportunity. O verprotection may result in a lack o f confidence in later life. T h e individual m ight becom e selfish and demanding. H e is often rebellious against authority and has aggressive and dem anding attitudes. Feelings o f inferi ority m ight easily be aroused in these individuals.
A patient m ay have had a serious illness in ch ildh ood which enabled him to avoid an unpleasant situation and at the same time gained fo r him more affection and attention. This situation cou ld lead to the developm ent o f a co n ditioned reaction. In later life the indi vidual m ight avoid stressful situations by acquiring a psychosomatic illness. H e m ight then gain the secondary reward o f extra attention in a socially acceptable manner. E M O T IO N A L T R A N S F E R E N C E
A condition o f emotional transference seems to underlie many o f the irrational attitudes patients have toward their den tist. Because o f his education and stand ing in the com m unity, the dentist m ight be considered by a patient as an authority figure. T h e patient might act out his attitudes tow ard authority in a way that is annoying to the dentist. O n e patient w ho had difficulties with authority, manifested by disciplinary ac tion taken against him a num ber o f times in his naval career, did not seek neces sary adjustm ent o f his dentures because he wished to avoid difficulty with the dentist, w hom he considered an authority figure. A nother patient with authority difficulties defied the dentist by gagging. Patients that have difficulty with au thority figures in general are likely to have difficulty in their reaction to den tures. SYM BOLS
T h e efficiency o f hum an activity is due to the extensive use o f symbols.7 Symbols
4. Schuyler, C. H. Full denture construction from the obtaining of the centric maxitlo-mandibular record to compietiorj of the dentures. J.A.D.A. 41:66 July 1950. 5. Scott, J. E. Scott system of precision articulation in three-dimensional occlusion. J. Pros. Den. 2:362 M a y 1952. 6. Strecker, Edward A . Their mother's sons. Phila delphia, J. B. Lippincott Co., 1946. 7. Shaffer, Laurance F. Psychology of adjustment. Boston, Houghton Mifflin Co., J936, p. 73.
CO LLET T . . . V O L U M E 51, N O V E M B E R 1955 • 543
act as a convenient short cut in thinking. It is possible for dentures to b ecom e a symbol which represents the dentist, w h o in turn represents authority. Patients who have difficulties with authority, by using their dentures, m ight gain some control over the dentist and at the same time obtain secondary gains, such as attention. Dentures m ight also symbolize advancing age w hich a patient is at tempting to deny. These factors seem to result in atti tudes and behavior which appear m aladjustive.
tion that this adjustment is required. In this manner the patient m ight develop a very annoying overdependency on the dentist for the satisfaction o f his em o tional need. If these needs are unsatis fied by the person on w hom the claims are m ade, the patient m ight rebel with hatred. This is likely to bring about a reaction from the dentist that m ight mobilize in the patient further feelings o f rejection and, consequently, further psychologic maladjustment to his den tures. DEFENSE
M O T IV A T IO N
T h e motives concerned with adjustment to dentures are based on the patient’s evaluation o f himself. T h e m ore secure the patient is in his self-evaluation, the more likely he will be to adjust to satis factory dentures. Conversely, the m ore inadequate and inferior he feels, the more he will depend on defensive d e vices to justify or excuse his inability to adjust properly to dentures. Security, affection and social approval are basic and are fundam ental to per sonality developm ent. I f these were d e nied the individual in early life, he is not likely to feel them in the years that follow . T h e lack o f attention in ch ild h ood m ight result in an excessive need for attention from everyone with w hom the person comes in contact. This is likely to lead to difficulties with his inter personal relations in general as well as with his dentist. T he absence o f satisfaction o f an exag gerated need fo r approval can be an annoying drive to activity w hich will cease only when the satisfying stimulus is presented. This need fo r approval may have been partially satisfied by an under standing dentist during treatment. Later, if the patient feels rejected in one o f his interpersonal relations, he m ay com e to the dentist for an adjustment to his den ture when there is n o biological indica
M E C H A N IS M S
FOR
S E L F -E V A L U A T IO N
F or a person to be secure it is necessary that his self-evaluation be adequate to com ply with his aspirations, his ideals and his evaluation o f other people. Selfevaluation is the only security the in dividual has fo r dealing w ith the world. F or this purpose he develops special technics or defense mechanisms. These are essential fo r the softening o f failures and the alleviation o f feelings o f guilt m obilized by supposed or real failures. T h e defense mechanisms maintain the feelings o f personal worth and adequacy. T hey protect the individual from intol erable anxiety aroused by a threat to his self-evaluation.8 I f a patient cannot function well with dentures because he lacks the necessary neurom uscular skill, o r if the esthetic result he desires is unattainable, he may feel that his worth and ability are on trial. W hen this condition exists, the p a tient m ay use defense mechanisms that could result in distortion o f reality and self-deception. D enial o f R eality • Few people accept the inevitability o f death. M an y people ignore or deny criticism, and they often
8. Coleman, James C. Abnorm al psychology and modern life. Chicago, Scott, Foresman & Co., 1950. p. 81.
544 • T H E J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
ignore things that are not com patible with desires or wishes. By denial o f reality some individuals protect themselves from the traumatic stress that m ight be aroused by certain conditions. Patients w h o are prone to use the device o f d e nial in some instances overadapt to den tures and d o not seek adequate service. Dam age to the supporting tissues may result because o f this. O n e patient had an exaggerated d e sire fo r good health. T o him , any physi cal illness represented disgrace and loss o f prestige in the eyes o f his associates. M u ch o f his self-evaluation was based on his excellent state of health. O f neces sity he had had dentures constructed originally, but seeking further service from the dentist seemed to be a threat to his im agined standing in the eyes o f others. In another patient studied, anxiety was aroused by any threat o f change in his environment. Because o f his inflexibility and his inability to adapt to change, he denied that anything was w ron g with dentures that were not biologically satis factory. In this way he mom entarily avoided precipitating anxiety associated with having to adjust to new dentures. A third patient had considerable d if ficulty with authority relations. In an effort to avoid difficulties with the den tist, w ho, to him, represented authority, he denied that anything was w ron g with his unsatisfactory dentures. Identification ' Som e patients enhance their feeling o f im portance by identifying themselves with others in a form o f hero worship. T h e strength, im portance and m oney o f a patient’ s father might be a means o f enhancing his prestige. This device m ight have a negative in fluence if based on undesirable models. M ost dentists have heard patients w ho have never worn dentures say that they anticipated trouble with m andibular dentures because someone they knew had had trouble. O n e patient stud
ied gagged w hen he attempted to wear a m andibular denture. It was found that a similar condition existed when his m other attempted to wear a m andibular denture. This patient, because o f changes that later took place in his environment, was able to wear the denture without gagging. P rojection • T h e device o f transferring the blam e fo r one’ s shortcomings to someone else is called projection. Pa tients w h o are unable to masticate effi ciently because they lack sufficient neuro muscular control, m ight attempt to jus tify this lack o f skill by claim ing that the denture was not properly constructed. Blaming the failure on the dentist re duces the tension engendered by their feelings o f inferiority, m obilized by their inability to function satisfactorily with their dentures. Rationalization • W ith the device o f rationalization the individual gives so cially acceptable reasons fo r his behavior. It involves making excuses fo r behavior the individual does not consider socially acceptable. It is a defense against feel ings o f inferiority. A n alcoholic patient studied claim ed that he needed dentures to get a job . A lthough he was most co o p erative during the construction o f his dentures, he failed to keep his appoint m ent when the finished dentures were to be inserted. In this manner he tem porarily avoided the anxiety that might have been engendered and the self-devaluation that m ight have resulted if he failed to obtain em ploym ent while wear ing dentures. N ot having dentures, to him, was a socially acceptable reason for unemployment. A tten tion Getting M echanism s • Some individuals w ho have an exaggerated need fo r attention find punishment in the form o f scolding m ore satisfying than being ignored. It is possible that some patients will not carry out instructions in
C O L L E fT . . . V O L U M E 51, N O V E M B E R 1955 • 545
the care and m anipulation o f the d en tures in order to obtain this negative kind o f attention from the dentist. M a lfu n c tioning dentures m ight also be used to get additional attention from friends and family. O n e patient w h o failed to adjust to dentures, although outwardly coop era tive during treatment, said, “ I am going to fight you every turn in making the dentures.” This patient in private life manifested his strong need fo r attention in one o f his hobbies, w hich was enter taining sick children. H e did this by visiting children’ s hospitals dressed as a clow n. H e was unable to wear dentures without gagging unless he chew ed gum. O n e o f his statements was, “ I f it gives me pleasure to gag, I will gag.” T here is little doubt that gagging was an atten tion getting device for this patient. P S Y C H O N E U R O T IG
D ISO R D E R S
Anxiety and fearfulness are generated in some people by conflicts and feelings o f inferiority. These people fear contact with others in social or business life and often find it difficult to make up their minds. T hey overreact to painful and pleasurable experiences. Failure w ould undermine the already insecure status o f these p eop le.9 Schuyler10 associates psychoneurosis with im properly constructed dentures. It is likely that extreme feelings o f self devaluation are m obilized by neurotic patients’ inability to function with un satisfactory dentures. In borderline psy choneurotic patients it is possible that a poor prosthesis w ould bring about a crisis. T h e underlying inferiority feelings o f neurotic patients are likely to be m ani fested by overreaction to flattery and by inability to tolerate criticism. For this reason it is g ood practice to have friends and relatives approve o f the appearance o f the patient’s dentures at the try in stage o f treatment. Later disapproval by
these associates might result in m alad justment, whereas approval might help adjustment to the prosthesis. T h e neurotic person’ s interpersonal re lationships are based on an exaggerated fear o f what people think of him. H e is extremely aware o f himself and is almost com pletely concerned with his feelings and ambitions. His aspirations are often beyond his ability, and he is continually com paring his status with that o f others. This factor is often illustrated by a patient’s strong desire fo r unattainable esthetic qualities in his dentures. N eurotic people often have difficulties in their conception o f time. T hey are usually living in the past o r the future. Some feel that they can never grow old or die.11 This m ay result in m alad justment when dentures fail to turn back the clock and give them the desired youthful appearance. A feeling o f further self-devaluation is m obilized, possibly b e cause dentures are associated with a d vancing age and becom e symbolic of this condition. T h e neurotic person does not feel in dependent or self-reliant. Because of this he m ay rely on others fo r reassurance and show an exaggerated need for ap proval and affection. This m ay be m ani fested in maladjustment to dentures, for the purpose of giving the patient an opportunity to have these needs satisfied by his interpersonal relations with the dentist. Conversely, he m ay tend to deny his dependency needs and display an exag gerated independence. This kind o f m al adjustment is illustrated by the failure of a patient with an inaccurate denture to seek service necessary fo r the health o f the supporting tissues o f the denture.
9. Coleman, Jam es C. Abnorm al psychology and modern life. Chicago, Scolt, Foresman & Co., 1950. p. 160. 10. Schuyler, C . H. Full denture service as influenced by our understanding of tooth selection and articula tion. J. Pros. Den. 2:730 Nov. 1952. 11. Horney, Karen. Neuroses and human growth. New York, W . W . Norton & Co., 1950, p. 46.
546 • THE J O U R N A L O F THE A M E R IC A N D E N T A L A S S O C IA T IO N
T h e neurotic person constantly utilizes reactions w hich the norm al person finds necessary only at especially difficult times. T h ey are exaggerated defense measures inappropriate to the life situation and are called forth by faulty self-evaluations and faulty evaluation o f the environ ment. Som atic symptoms such as psychologic gagging and other maladjustments to satisfactory dentures m ight be used to protect the patient from having to face traumatic situations and bring him sec ondary gains in extra sympathy and attention as well as some control over the people around him. I f the dentist is fam iliar with the re actions described, he m ay better be able to deal with this kind o f patient. SUM M ARY
Before considering m aladjustm ent to dentures as psychologic, the possibility of
biological and mechanical causes fo r the m aladjustm ent should be eliminated. Dentures that are inaccurately construct ed can stimulate neurotic symptoms. Psychological maladjustment to den tures has its basis in attitudes developed in early childhood. Irrational attitudes toward the dentist seem to result in some instances from em otional transference o f attitudes developed earlier. Dentures may be symbols fo r various life situations. T he patient’ s motives for psychologic m alad justment seem to be based on self-evaluation. A patient m ight resort to one o f several defense mechanisms in order to maintain a satisfactory self-evaluation. M aladjustm ent to dentures m ay be manifested in the patient’s failure to function properly with his dentures, re sulting in overdependence on the den tist with many requests fo r unnecessary service; or it m ay be manifested in the patient’ s overadapting to dentures and failing to request necessary service.
T h e Epidem iologist and Chronic Disease • Frequently, the epidem iologist’ s role in working tow ard this goal [epidem iologic study o f chronic disease] is to provide an initial clue, or even a well supported hypothesis, pointing toward a specific, hitherto unrecognized etiologic factor. It is left to other investigators, w orking in other disciplines, to follow up these clues and further test their validity. A n example may make this a little clearer. T h rou gh a lon g series of epidem io logic studies it was shown that there was an inverse relationship between the amount o f fluoride in a com m unity’ s water supply and the prevalence o f dental caries. T h e hypothesis that fluoride ingestion in appropriate amounts provided protection against caries was then tested in the laboratory by means of animal experiments which provided considerable support for it. It was finally tested through controlled observations on populations deliberately exposed to the effects of the agent. P. E. Sartwell, “ Som e A pproaches to the E pidem iologic Study of Chronic Disease/’ Am . J. Pub. H ealth 4 5 :6 0 9 M a y 1955.
vom iting with the use of other general anesthetic agents, however, show that ethyl vinyl ether can com pare favorably with them. SUM M ARY
AND
C O N C L U S IO N S
Ethyl vinyl ether was used as a supple mentary anesthetic agent for exodontic procedures on 498 unselected patients varying in age from 2 to 46 years and above.
T h e anesthetic was fou n d to be satis factory fo r this purpose. Its advantages were ( 1) rapid induction, ( 2 ) quick em ergence and (3 ) m ild toxicity. Its dis advantages were ( 1) its explosibility, ( 2 ) the salivation produced, (3 ) the nausea and vom iting resulting and (4 ) the possible objectionability o f its odor. Ethyl vinyl ether is an agent that may be useful fo r anesthetization o f am bula tory patients fo r brief surgical procedures such as are required in exodontics.
Psychodynamic study of abnormal reactions to dentures H en ry A . 'Collett, D .D .S ., Brooklyn
M any patients have difficulty adjusting to dentures, even when there is no appar ent physiological or m echanical inaccu racy. O n the other hand, some patients adjust surprisingly well to dentures that have gross inaccuracies. Such instances are abnormal in the sense that the reac tion o f the patient is not appropriate to the physical situation. T he reactions sometimes are extreme and at other times are less so. T h e difference between the abnormal and norm al reaction seems to be one o f degree. Previous studies1,2 demonstrated that it was possible to trace abnormal reac tions to dentures to attitudes developed early in life and m odified in the years that follow ed by frustration. T h e patients w h o had difficulty in adjusting to den tures also had difficulty in adjusting to other problems in their everyday life. A n
understanding o f the reactions to den tures as adjustive mechanisms m ight aid the dentist in helping m any patients to adjust m ore adequately. T h e dentist is directly concerned with the emotional state o f his patients.3 It w ould be easy fo r dentists to blame failures in construction on the patients and to classify the patients as psycho logical failures. D oing this w ould seldom
The opinions or assertions contained in this article are the private ones of the writer and are not to be construed as official or reflecting the views of the Navy Department or the naval service at large. Commander, Dental Corps, U. S. Navy, U. S. Naval Dental Clinic. 1. Collett, H. A., and Brigas, D. L. Some psycho logic aspects of denture-stimulated ga g g in g . J. Pros. Den. 3:665 Sept. 1953. 2. Collett, H. A., and Briggs, D. L. Personality factors relating to overadaptation to dentures. J. Pros. Den. 4:269 March 1954. 3. Block, L. S. Muscular tensions in denture con struction. J. Pros. Den. 2:198 March 1952.
542 • THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
solve the problem . Careful evaluation must be made first to eliminate the pos sibility that the replacem ent is inaccurate to the extent that a norm al patient would not tolerate it. N eurotic reactions can be stimulated by im properly constructed dentures in patients w h o m ight react normally to satisfactory replacem ents.4,5 Physical ex aminations and case histories should be used to rule out lack o f tolerance due to subnormal oral and general health before the psychological aspects o f m aladjust m ent are considered. E T IO L O G Y O F E M O T IO N A L M A L A D JU S T M E N T TO D E N TU RE S
M aladjustm ent to the wearing o f den tures, as well as to m any other situations that the patient m ight be confronted with, frequently has its basis in the pa tient’s attitudes tow ard his parents and others that attended to his basic needs as he matured. I f the parents o f the patient rejected him as a child, or if he felt rejected (fo r instance, when a new sibling arrived and received most o f the attention ), the patient is apt to be fearful and insecure. H e m ay then develop atten tion seeking devices that he m ight use throughout life. His emotional insecurity is conducive to self-devaluation and to the evaluation o f the world as an inse cure and hostile place. If, however, the patient’s parents over protected or pam pered him, m aladjust ments are also likely to occur. Strecker calls this condition “ m om ism .” 6 T he m other watches over the child constantly, overdressing and overm edicating him and making up his m ind fo r him at every opportunity. O verprotection may result in a lack o f confidence in later life. T h e individual m ight becom e selfish and demanding. H e is often rebellious against authority and has aggressive and dem anding attitudes. Feelings o f inferi ority m ight easily be aroused in these individuals.
A patient m ay have had a serious illness in ch ildh ood which enabled him to avoid an unpleasant situation and at the same time gained fo r him more affection and attention. This situation cou ld lead to the developm ent o f a co n ditioned reaction. In later life the indi vidual m ight avoid stressful situations by acquiring a psychosomatic illness. H e m ight then gain the secondary reward o f extra attention in a socially acceptable manner. E M O T IO N A L T R A N S F E R E N C E
A condition o f emotional transference seems to underlie many o f the irrational attitudes patients have toward their den tist. Because o f his education and stand ing in the com m unity, the dentist m ight be considered by a patient as an authority figure. T h e patient might act out his attitudes tow ard authority in a way that is annoying to the dentist. O n e patient w ho had difficulties with authority, manifested by disciplinary ac tion taken against him a num ber o f times in his naval career, did not seek neces sary adjustm ent o f his dentures because he wished to avoid difficulty with the dentist, w hom he considered an authority figure. A nother patient with authority difficulties defied the dentist by gagging. Patients that have difficulty with au thority figures in general are likely to have difficulty in their reaction to den tures. SYM BOLS
T h e efficiency o f hum an activity is due to the extensive use o f symbols.7 Symbols
4. Schuyler, C. H. Full denture construction from the obtaining of the centric maxitlo-mandibular record to compietiorj of the dentures. J.A.D.A. 41:66 July 1950. 5. Scott, J. E. Scott system of precision articulation in three-dimensional occlusion. J. Pros. Den. 2:362 M a y 1952. 6. Strecker, Edward A . Their mother's sons. Phila delphia, J. B. Lippincott Co., 1946. 7. Shaffer, Laurance F. Psychology of adjustment. Boston, Houghton Mifflin Co., J936, p. 73.
CO LLET T . . . V O L U M E 51, N O V E M B E R 1955 • 543
act as a convenient short cut in thinking. It is possible for dentures to b ecom e a symbol which represents the dentist, w h o in turn represents authority. Patients who have difficulties with authority, by using their dentures, m ight gain some control over the dentist and at the same time obtain secondary gains, such as attention. Dentures m ight also symbolize advancing age w hich a patient is at tempting to deny. These factors seem to result in atti tudes and behavior which appear m aladjustive.
tion that this adjustment is required. In this manner the patient m ight develop a very annoying overdependency on the dentist for the satisfaction o f his em o tional need. If these needs are unsatis fied by the person on w hom the claims are m ade, the patient m ight rebel with hatred. This is likely to bring about a reaction from the dentist that m ight mobilize in the patient further feelings o f rejection and, consequently, further psychologic maladjustment to his den tures. DEFENSE
M O T IV A T IO N
T h e motives concerned with adjustment to dentures are based on the patient’s evaluation o f himself. T h e m ore secure the patient is in his self-evaluation, the more likely he will be to adjust to satis factory dentures. Conversely, the m ore inadequate and inferior he feels, the more he will depend on defensive d e vices to justify or excuse his inability to adjust properly to dentures. Security, affection and social approval are basic and are fundam ental to per sonality developm ent. I f these were d e nied the individual in early life, he is not likely to feel them in the years that follow . T h e lack o f attention in ch ild h ood m ight result in an excessive need for attention from everyone with w hom the person comes in contact. This is likely to lead to difficulties with his inter personal relations in general as well as with his dentist. T he absence o f satisfaction o f an exag gerated need fo r approval can be an annoying drive to activity w hich will cease only when the satisfying stimulus is presented. This need fo r approval may have been partially satisfied by an under standing dentist during treatment. Later, if the patient feels rejected in one o f his interpersonal relations, he m ay com e to the dentist for an adjustment to his den ture when there is n o biological indica
M E C H A N IS M S
FOR
S E L F -E V A L U A T IO N
F or a person to be secure it is necessary that his self-evaluation be adequate to com ply with his aspirations, his ideals and his evaluation o f other people. Selfevaluation is the only security the in dividual has fo r dealing w ith the world. F or this purpose he develops special technics or defense mechanisms. These are essential fo r the softening o f failures and the alleviation o f feelings o f guilt m obilized by supposed or real failures. T h e defense mechanisms maintain the feelings o f personal worth and adequacy. T hey protect the individual from intol erable anxiety aroused by a threat to his self-evaluation.8 I f a patient cannot function well with dentures because he lacks the necessary neurom uscular skill, o r if the esthetic result he desires is unattainable, he may feel that his worth and ability are on trial. W hen this condition exists, the p a tient m ay use defense mechanisms that could result in distortion o f reality and self-deception. D enial o f R eality • Few people accept the inevitability o f death. M an y people ignore or deny criticism, and they often
8. Coleman, James C. Abnorm al psychology and modern life. Chicago, Scott, Foresman & Co., 1950. p. 81.
544 • T H E J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
ignore things that are not com patible with desires or wishes. By denial o f reality some individuals protect themselves from the traumatic stress that m ight be aroused by certain conditions. Patients w h o are prone to use the device o f d e nial in some instances overadapt to den tures and d o not seek adequate service. Dam age to the supporting tissues may result because o f this. O n e patient had an exaggerated d e sire fo r good health. T o him , any physi cal illness represented disgrace and loss o f prestige in the eyes o f his associates. M u ch o f his self-evaluation was based on his excellent state of health. O f neces sity he had had dentures constructed originally, but seeking further service from the dentist seemed to be a threat to his im agined standing in the eyes o f others. In another patient studied, anxiety was aroused by any threat o f change in his environment. Because o f his inflexibility and his inability to adapt to change, he denied that anything was w ron g with dentures that were not biologically satis factory. In this way he mom entarily avoided precipitating anxiety associated with having to adjust to new dentures. A third patient had considerable d if ficulty with authority relations. In an effort to avoid difficulties with the den tist, w ho, to him, represented authority, he denied that anything was w ron g with his unsatisfactory dentures. Identification ' Som e patients enhance their feeling o f im portance by identifying themselves with others in a form o f hero worship. T h e strength, im portance and m oney o f a patient’ s father might be a means o f enhancing his prestige. This device m ight have a negative in fluence if based on undesirable models. M ost dentists have heard patients w ho have never worn dentures say that they anticipated trouble with m andibular dentures because someone they knew had had trouble. O n e patient stud
ied gagged w hen he attempted to wear a m andibular denture. It was found that a similar condition existed when his m other attempted to wear a m andibular denture. This patient, because o f changes that later took place in his environment, was able to wear the denture without gagging. P rojection • T h e device o f transferring the blam e fo r one’ s shortcomings to someone else is called projection. Pa tients w h o are unable to masticate effi ciently because they lack sufficient neuro muscular control, m ight attempt to jus tify this lack o f skill by claim ing that the denture was not properly constructed. Blaming the failure on the dentist re duces the tension engendered by their feelings o f inferiority, m obilized by their inability to function satisfactorily with their dentures. Rationalization • W ith the device o f rationalization the individual gives so cially acceptable reasons fo r his behavior. It involves making excuses fo r behavior the individual does not consider socially acceptable. It is a defense against feel ings o f inferiority. A n alcoholic patient studied claim ed that he needed dentures to get a job . A lthough he was most co o p erative during the construction o f his dentures, he failed to keep his appoint m ent when the finished dentures were to be inserted. In this manner he tem porarily avoided the anxiety that might have been engendered and the self-devaluation that m ight have resulted if he failed to obtain em ploym ent while wear ing dentures. N ot having dentures, to him, was a socially acceptable reason for unemployment. A tten tion Getting M echanism s • Some individuals w ho have an exaggerated need fo r attention find punishment in the form o f scolding m ore satisfying than being ignored. It is possible that some patients will not carry out instructions in
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the care and m anipulation o f the d en tures in order to obtain this negative kind o f attention from the dentist. M a lfu n c tioning dentures m ight also be used to get additional attention from friends and family. O n e patient w h o failed to adjust to dentures, although outwardly coop era tive during treatment, said, “ I am going to fight you every turn in making the dentures.” This patient in private life manifested his strong need fo r attention in one o f his hobbies, w hich was enter taining sick children. H e did this by visiting children’ s hospitals dressed as a clow n. H e was unable to wear dentures without gagging unless he chew ed gum. O n e o f his statements was, “ I f it gives me pleasure to gag, I will gag.” T here is little doubt that gagging was an atten tion getting device for this patient. P S Y C H O N E U R O T IG
D ISO R D E R S
Anxiety and fearfulness are generated in some people by conflicts and feelings o f inferiority. These people fear contact with others in social or business life and often find it difficult to make up their minds. T hey overreact to painful and pleasurable experiences. Failure w ould undermine the already insecure status o f these p eop le.9 Schuyler10 associates psychoneurosis with im properly constructed dentures. It is likely that extreme feelings o f self devaluation are m obilized by neurotic patients’ inability to function with un satisfactory dentures. In borderline psy choneurotic patients it is possible that a poor prosthesis w ould bring about a crisis. T h e underlying inferiority feelings o f neurotic patients are likely to be m ani fested by overreaction to flattery and by inability to tolerate criticism. For this reason it is g ood practice to have friends and relatives approve o f the appearance o f the patient’s dentures at the try in stage o f treatment. Later disapproval by
these associates might result in m alad justment, whereas approval might help adjustment to the prosthesis. T h e neurotic person’ s interpersonal re lationships are based on an exaggerated fear o f what people think of him. H e is extremely aware o f himself and is almost com pletely concerned with his feelings and ambitions. His aspirations are often beyond his ability, and he is continually com paring his status with that o f others. This factor is often illustrated by a patient’s strong desire fo r unattainable esthetic qualities in his dentures. N eurotic people often have difficulties in their conception o f time. T hey are usually living in the past o r the future. Some feel that they can never grow old or die.11 This m ay result in m alad justment when dentures fail to turn back the clock and give them the desired youthful appearance. A feeling o f further self-devaluation is m obilized, possibly b e cause dentures are associated with a d vancing age and becom e symbolic of this condition. T h e neurotic person does not feel in dependent or self-reliant. Because of this he m ay rely on others fo r reassurance and show an exaggerated need for ap proval and affection. This m ay be m ani fested in maladjustment to dentures, for the purpose of giving the patient an opportunity to have these needs satisfied by his interpersonal relations with the dentist. Conversely, he m ay tend to deny his dependency needs and display an exag gerated independence. This kind o f m al adjustment is illustrated by the failure of a patient with an inaccurate denture to seek service necessary fo r the health o f the supporting tissues o f the denture.
9. Coleman, Jam es C. Abnorm al psychology and modern life. Chicago, Scolt, Foresman & Co., 1950. p. 160. 10. Schuyler, C . H. Full denture service as influenced by our understanding of tooth selection and articula tion. J. Pros. Den. 2:730 Nov. 1952. 11. Horney, Karen. Neuroses and human growth. New York, W . W . Norton & Co., 1950, p. 46.
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T h e neurotic person constantly utilizes reactions w hich the norm al person finds necessary only at especially difficult times. T h ey are exaggerated defense measures inappropriate to the life situation and are called forth by faulty self-evaluations and faulty evaluation o f the environ ment. Som atic symptoms such as psychologic gagging and other maladjustments to satisfactory dentures m ight be used to protect the patient from having to face traumatic situations and bring him sec ondary gains in extra sympathy and attention as well as some control over the people around him. I f the dentist is fam iliar with the re actions described, he m ay better be able to deal with this kind o f patient. SUM M ARY
Before considering m aladjustm ent to dentures as psychologic, the possibility of
biological and mechanical causes fo r the m aladjustm ent should be eliminated. Dentures that are inaccurately construct ed can stimulate neurotic symptoms. Psychological maladjustment to den tures has its basis in attitudes developed in early childhood. Irrational attitudes toward the dentist seem to result in some instances from em otional transference o f attitudes developed earlier. Dentures may be symbols fo r various life situations. T he patient’ s motives for psychologic m alad justment seem to be based on self-evaluation. A patient m ight resort to one o f several defense mechanisms in order to maintain a satisfactory self-evaluation. M aladjustm ent to dentures m ay be manifested in the patient’s failure to function properly with his dentures, re sulting in overdependence on the den tist with many requests fo r unnecessary service; or it m ay be manifested in the patient’ s overadapting to dentures and failing to request necessary service.
T h e Epidem iologist and Chronic Disease • Frequently, the epidem iologist’ s role in working tow ard this goal [epidem iologic study o f chronic disease] is to provide an initial clue, or even a well supported hypothesis, pointing toward a specific, hitherto unrecognized etiologic factor. It is left to other investigators, w orking in other disciplines, to follow up these clues and further test their validity. A n example may make this a little clearer. T h rou gh a lon g series of epidem io logic studies it was shown that there was an inverse relationship between the amount o f fluoride in a com m unity’ s water supply and the prevalence o f dental caries. T h e hypothesis that fluoride ingestion in appropriate amounts provided protection against caries was then tested in the laboratory by means of animal experiments which provided considerable support for it. It was finally tested through controlled observations on populations deliberately exposed to the effects of the agent. P. E. Sartwell, “ Som e A pproaches to the E pidem iologic Study of Chronic Disease/’ Am . J. Pub. H ealth 4 5 :6 0 9 M a y 1955.