Psychologic aspects of prosthodontic treatment for geriatric patients

Psychologic aspects of prosthodontic for geriatric patients Donald B. Giddon, D.M.D., New York University,

Ph.D.,*

and Eugene Hittelman,

Presented at the Second International Prosthodontic Congress, Las Vegas, Nev. *Professor of Behavioral Science and Community Health, College of Dentistry; Professor of Psychology, Faculty of Arts and Science; Professor of Anesthesiology, School of Medicine. **Assistant Professor and Acting Chairman, Department of Behavioral Science and Community Health, College of De&try.

APRIL 1960

Ed. D. * *

New York, N. Y.

or the older adult, physical and mental health are the primary determinants of the quality of life. Physiologic aging (the progressive loss of function), unlike chronologic aging (the passing of years), is directly dependent upon the absence of chronic and acute illness.’ As the population attains an increasing life span, chronic disease, rather than acute illness, is of primary importance. Dental disease is the most prevalent chronic condition. Further, as the aging patient begins to suffer chronic illness, other aspects of functioning essential to the maintenance of life’s quality begin to diminish: enjoyment of social interaction, recreation, and, of course, the enjoyment of food. The dentist thus has an essential role in maintaining or improving dental health as part of the total health care services available to the elderly. Even though the data indicate a decline in the need for complete dentures, the need for highquality and easily accessible prosthodontic care for the elderly is increasing. Unfortunately, some health planners, educators, and government officials may be misusing the data, thus creating serious problems for the dental profession and the public. Health planners sometimes fail to recognize that the dentist plays a crucial role in the maintenance of the quality of life for the elderly patient. The overall effect of these misinterpretations has resulted in a loss of care to patients in general, particularly to geriatric patients who can least tolerate this fractionation of

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dental care. Consequently, while denturists have been encouraged to increase their activities and numbers, dental educators have been encouraged to reduce the basic technology in prosthodontic care. The dental profession, particularly prosthodontists, should not accept these developments as a threat or a criticism. Rather, the reduced need for prostheses should be viewed as a tribute, challenge, and opportunity. Through prevention and patient education, the dental profession has reduced the number of edentulous patients and provided better service to those who need prosthodontic care. Only the dentist has the knowledge and experience necessary to meet the total oral health needs of the general public and the complex, oral health needs of the elderly patient. Only the dentist is aware that more than technically excellent prosthetic restorations is required in the treatment of the geriatric patient. Only the dentist is able to design an appropriate program of oral rehabilitation and maintenance which will contribute to the quality of the patient’s life and health. The dentist is best able to appreciate the importance of improved function and esthetics to the physical and mental health of the patient. Extensive training and experience is necessary to integrate the physical, social, and psychologic changes that accompany the aging process with the technical requirements for good patient care.

QUALITY

OF LIFE

Aging is generally thought to be a gradual process of deterioration associated with chronologic age; recent research suggests that physiologic aging is only apparent after a sudden, precipitous insult such as the loss of a body part.’ A prime example of such accelerated aging is the marked change in diet which becomes necessary following the loss of masticator-y function. Through recognition and proper evalua-

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tion of the patient’s problem, the dentist can provide the proper care and can be helpful in the transition to older adulthood..’ The dentist’s knowledge of the biomedical, clinical, and social aspects of total patient care qualifies him alone to provide accurate dental treatment as part of the comprehensive health care that profoundly affects all aspects of the patient’s life. The dentist should remember that the psychologic, ecologic, and biomechanical systems of the mouth must be kept in balance and that altering one of these variables may exert a profound influence on the other two. The orofacial area is crucial to the patient’s functioning. It is critical to survival in (1) the need to eat and drink, (2) the detection of precancerous and eroding lesions which often accompany prosthetic application and change in oral environment, (3) social well-being for communication and self-esteem, and (4) the quality of life resulting from enjoyment of food, talking, music, and expressions of love. Pain seems to be less tolerated in the mouth than would be expected from the actual lesion caused by oral infection or the effects of treatment. In addition to being a site of both suffering and pleasure, the mouth is the target of other psychosomatic disorders such as acute necrotizing ulcerative gingivitis (in younger patients), lichen planus, candidiasis, and a myriad of other mysterious and painful oral disorders of the tongue and mucous membranes (in older patients).’ There is in fact some evidence for possible behaviorally or physiologically mediated psychogenic component of cancer.’ The dentist has the technical knowledge to treat these disorders and attend to the mechanical difficulties of the aging patient. Of course, many of these disorders may be secondary to behavioral changes in eating habits (nutritional disorders). The great importance of the face and mouth is understandable in view of the disproportionate representation of the orofacial areas in the cerebral cortex.;’ It is generally assumed that there is a decline with age in certain sensory and motor functions. The sensory functions of pain and taste are of primary clinical significance to the prosthodontist. Recent evidence suggests that age-related differences in the perception of pain appear to be due to changes in the tissues where pain fiber endings are embedded.” While the size of the pulp chamber does decrease with age and the dentin becomes sclerotic, painsensitive fibers in the pulp do not appear to change their threshold for external irritation.” On the other

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hand, older individuals are more likely to interpret sensations of dental origin as pain; that is, their tolerance for the same sensory input: is less than that for younger individuals.’ However, pain related to dental procedures is more than pulpal, particularly in prosthodontic treatment. In addition to pulpal and periosteal pain, there is pain emanating from the periodontal ligament and soft tissues of the lips which are innervated by the more rapidly conducting, larger myelinated fibers. The pain experience is not a simple sensation in the brain, but a complex interaction of the sensory inputs from pulp, periodontium, and surrounding soft tissues. These inputs may be attenuated by most centrally mediated nerve fibers which act as “gates” on the pain sensation being transmitted to the brain. In addition, recent evidence indicates that “morphine-like” substances are released within the brain and are activated by physical or psychologic factors-the most obvious example of this is the placebo effect.” PRIMARY Pain

FACTORS

FOR THE

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Understanding pain and making an effort to control it for geriatric patients must include consideration of the following: 1. Total pain sensations from the pulp are probably reduced, but the aging patient is more likely to report other sensations, such as pressure, as painful. 2. Pain sensations from the periodontal and labial tissues depend in part on the flexibility of tissues which decreases with age. 3. Even with reduced pain input from oral areas, the patient may experience more suffering because of supervening psychologic factors. For example, depressed and hypochondriacal patients focus on the body; thus they will be more likely to respond to, or report as, pain even minor nonpain sensations such as vibration.” 4. Great caution must be exercised in the management of pain in the elderly patient. Particularly when other diseases are present, there is great danger of unsuspected drug interactions. Of equal concern is the fact that pharmacologic effects of drugs on the elderly patient may differ from the effects on younger patients. This is due mainly to differences in absorption and excretion and the action of medications on already compromised organ systems.” 5. Pharmacologic intervention should be re-

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which has been shown to improve taste perception in the elderly.13 The perception or appreciation of flavors in food is more important than the identification of the taste quality. For example, the identification of taste in liquids applied to the tongue is only slightly affected by age, even in a patient with complete dentures. The appreciation of flavor differences in solid foods, however, is adversely affected by complete dentures. As shown by the slopes in Fig. 1, the denture wearer was unable to distinguish among different concentrations of sucrose in specially baked cookies. The denture wearers took more than twice as long as a person with natural dentition to render a less accurate judgment, 15 versus 6 seconds.” When restricted to 10 seconds, (the maximum time that natural dentition patients took to render a more accurate judgment), the denture patient was unable to distinguish increasing levels of sucrose in cookies. Fig. 1. Ability of denture wearers and natural dentition patients to discriminate sweetness. (From Giddon, D. B., Dreisbach, M. E., Pfaffman, C., and Manly, R. ‘3.: Relative abilities of natural and artificial dentition patients for judging the sweetness of solid foods, J PROSTHET DENT 4263, 1954.) stricted to only those patients who require it after adequate physical evaluation and laboratory studies. 6. Dentists should use their interpersonal skills. A warm, supportive personality entering into the doctor-patient relationship can be the greatest therapeutic alliance for any age group, but this is particularly true for the elderly patient. Such psychologic treatment for pain is effective and may in fact operate through control of central nervous system mediators such as the endorphins. Perhaps the most dramatic example of these effects are the now classical studies of Egbert and Simply stated, they found that the associates’l postoperative requirements of hospitalized patients undergoing surgery were reduced by one-half if the anesthetist or surgeon visited the patients the night before surgery. The mechanism is the communication of concern by the doctor for the patient.

Taste Taste perception is complex. While there are selective losses in sensitivity to sweet and sour tastes, there is an increase in the sensitivity to bitter tastes. This is thought to be related to the relative increase in the size of the circumvallate papillae.” Often, the problem is simply a matter of cleansing the tongue,

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Often behavior during eating places the denture wearer in a socially stressful situation. Denture wearers do not wish to appear different. In the presence of persons with natural dentitions, they will attempt to chew the food faster than their usual rate or will avoid certain foods. In doing so, they reduce their ability and opportunity to perceive and enjoy the subtle differences in the flavor of solid foods. Part of the denture wearer’s handicap is the loss of adaptability and compensatory ability. Natural dentition patients compensate for less time or fewer masticatory strokes by increasing the force of each chewing stroke.” The denture wearer cannot do so because of reduced chewing efficiency.” The food industry recognizes that oral stimulation is enhanced by the textures and sounds of food. Slick, slimy, mushy, and sticky textures, for example, pose problems of lack of control of the food, which provokes survival anxiety and gagging or choking. Crunchy foods, on the other hand, provide the patient reassurance of control over discrete mouthfuls.17 These observations and concerns provide additional reasons for consideration of the status of other sensory modalities, such as appropriate consultation on audition and related bone conduction, in the prosthodontic treatment plan for elderly patients.” The appreciation of food as related to taste is a complicated sequence of sensory and motor events including mastication, manipulation of the bolus, and deglutition. These processes in turn depend on the chewing efficiency of the artificial or natural

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dentition, temporomandibular joint function, muscle tone, sensory cues relating to the location and texture of the bolus, and social cues relating to the eating situation.

CHALLENGE

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PROFESSION

Thorough consideration of age-related changes in pain, taste and masticatory ability thus pose a challenge to the dentist. More than technical expertise is required to provide a successful prosthodontic treatment. While some patients may be best served by technically perfect dentures, others may require deferral of prosthetic treatment until their biologic and psychologic status is appropriate. A primary source of most dentists’ difficulty in attending to the psychosocial requirements of appropriate prosthodontic therapy is the common misconception of the elderly in our society. Many individuals, including many elderly patients themselves, believe that when one gets old, he cannot expect much from life and should resign himself to die. Another common misconception is that up to 50% of elderly patients live in caretaking institutions. Actually, only 5% (approximately 1.5 million) of those over the age of 65 live in such institutions.‘” Most of these individuals cannot function without help, but the majority of the elderly can live alone or with others well into their senior years. With some help, most elderly individuals can continue their independence until death occurs. Some senior citizens live in specialized residential communities which cater to their needs and provide support for semi-independent functioning. As responsible health professionals, dentists must strive to ensure that their patients have maximal opportunity to enjoy their late years. Moreover, the dentists must accept modern perceptions of what it means to be elderly. Citizens who enjoy good health can be active, vital individuals who still retain a thirst for growth and life. There is a general impression that the ability to learn declines with age. Actually, intellectual functioning is exceedingly complex, consisting of several components which may improve with age rather than deteriorate. Of course, some patients may have difficulties in communication as a function of neurophysiologic changes in the sensory motor system.’ There is evidence that apparent differences in intelligence may be related to a difference between “crystallized” and “fluid” intelligence. “Fluid” or flexible intelligence may decrease with age, while crystallized intelligence usually remains constant or

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may even increase.” Thus, patient’s compliance with a dental procedure which requires flexibility can be made easier if the dentist recognizes the need to work with the patient’s available resourc.es. The dentist should build upon existing patient skills and habits, working with the patient to achieve a mutually desired goal. For the patient to change his behavior, he must first be aware of what the dentist wants him to do; he must then see the probability that the behavior change will provide a desired result. It is important that the patient understands the way the task is to be performed and, finally, that he is able to execute the desired behavior. If the dentist builds upon already existing knowledge and skills rather than trying to develop new or different methods, the patient will perform better in all of these areas. Thus, the dentist wishing to teach a patient how to adjust to and care for a new restoration should begin by determining whether the patient has had any previous experience with similar prostheses such as discussions with! or observations of, friends caring for their restorations. Even though the previous methods learned may be less than optimum, it is more likely that the patient will follow them rather than some new, less familiar course. Social behavior is also related to self-concept. The appearance of the face, often the key to feelings about self, is frequently dependent on prosthodontic care. This can be extremely important in maintaining or improving the appearance and self-confidence of the geriatric patient. Diagnosis and treatment planning for the elderly patient must include consideration of the biologic, psychologic, social, and economic status of the patient in addition to the obvious technical prosthodontic problems, Only a dentist can provide appropriate and complete oral health care to the patient. To accomplish this, the dentist must take into account the patient’s past experience and determine his medical, dental, and social history. He must then ascertain the patient’s present goals and expectations and be prepared to work with the patient to achieve these objectives.”

HISTORY While thorough knowledge of every patient’s history is always important, it is even more vital with an elderly patient. Awareness of the patients history gives the dentist a better understanding of the medical, dental, and psychosocial factors which caused the patient to seek denture treatment. The clinician can be alerted to the presence of concomi-

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tant medical or psychosomatic problems, such as depression or hypochondriasis and the possibility of drug interactions. He will also be aware of the patient’s cognitive processes; for example, the relative degree of rigidity or flexibility, irritableness or agreeableness, and of course, the patient’s ability to comprehend what is said during an interview. By careful and attentive listening, the dentist can establish a therapeutic alliance with the patient. Listening communicates that the dentist does care and will work with the patient in accepting and adapting to the physical, sensory, and social changes presented by prosthodontic care. Such attention by the dentist is much appreciated by elderly patients, who are often rejected by relatives tired of hearing repetitive complaints and stories. Many dentists have worked diligently with a seemingly cooperative patient to provide satisfactory treatment with complete dentures, only to find that the patient will not or cannot wear the dentures. The patient liked the attention from the dentist during the treatment, but once the treatment is finished, the patient became depressed and saw no value in the dentures. This behavior is consistent with adjustment to general health problems.“’ The dentist can help alleviate the patient’s distress through gentle prodding, explanation of the value of the prostheses, and teaching the patient to learn to tolerate the “foreign object.” Obviously, the dental treatment as well as the behavior of the dentist must be suited to the biologic and psychologic needs of the patient. Psychologic assessment of the patient becomes essential because the success of the treatment depends on the expectations and the self-concept of the patient. Patients interpret their experience in terms of their perceptions and expectations, not in terms of objective reality. Even though many dentists provide a perfectly reasonable treatment plan (as judged by fellow professionals) and successfully provide optimum dental care as measured by the standards of dentistry, they fail to meet the patient’s needs. Expectations with regard to esthetics, function, comfort, or cost are often different for patient and dentist, resulting from both a lack of patient comprehension about the treatment or its implications and from uncorrected misconceptions. As indicated earlier, a careful history which elicits the patient’s expectations and comprehension prior to administration of prosthetic treatment can avoid many of these conflicts. Thus, it is essential that the dentist identify and clarify the patient’s current level of functioning and expectation of treatment. 378

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Once the patient’s needs and expectations are recognized, the dentist may attempt to modify them in accordance with a better treatment procedure and a more satisfying life-style for the patient. It is folly to proceed without successfully involving the patient in the treatment and outcome goals. The dentist must work with the patient to achieve a change in attitudes, expectations, and behavior. Such modification requires in-depth interviewing, evaluation, supportive interaction, and a great deal of explanation and education. It is important, however, that the dentist not become overzealous. Extreme care must be taken throughout the interviewing process not to intrude on the patient’s privacy, or to challenge the patient’s sense of autonomy or self-esteem. The dentist, although an authority figure, is usually younger. Mutual respect is therefore essential. Thus, the dentist must be invited by the patient to examine the often delicate psychic areas containing conflicts and anxieties which the patient may not be prepared to deal with when exposed by the dentist.“’ Finally, the importance of the orofacial areas to self-fulfillment must be recognized. Not only is the sensory aspect of taste important, but so is the appreciation of taste tind food. A diet history helps to determine what kinds of foods are enjoyed. Many patients become less able to tolerate seasoning because of other health problems. Heavily seasoned or hot, spicy foods may not require a precisely functioning masticatory apparatus as would the appreciation of more subtle flavors. SUMMARY In summary, the orofacial region is essential to the quality of life and must be reemphasized for the geriatric patient. The extent to which the face and mouth have provided satisfaction of basic biologic and social needs in the past will determine their significance to the quality of life. Such oral contributions to self-fulfillment include the continuation of musical abilities such as singing or playing an instrument, and, of course, the expression of love. The extent to which the face and mouth have provided satisfaction of basic biologic and social needs in the past will also determine the significance of the changes in the orofacial areas to the aging person. Although it is not absolutely necessary for digestion of food, a properly functioning dentition will provide greater opportunity for variation in diet and appreciation of food. Equally important is the influence of appearance and function of the orofacial areas on socialization. APRIL 1980

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communication skills, and interpersonal relations.” Sometimes, for example, the dentist may decide that the preservation of esthetics and improvement of self-image are more important than preserving the natural dentition. Finally, dentists must apply their humanity, training, experience, and clinical judgment in evaluating the biosocial history of each individual patient; this treatment must include consideration of the patient’s needs and expectations of treatment outcome. Dentists, with their extensive training and experience in the biosocial and technical aspects of clinical practice, can provide this essential service to the geriatric patient requiring prosthodontic care. We wish to thank Ms. Marcia E. Scheuer the bibliographic research of this article.

for her assistance

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5. 6. 7.

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Timirias, P. S.: Developmental Physiology and Aging. New York, 1972, Macmillan Publishing Co. Birren, J.: Toward an experimental psychology of aging. Am Psycho1 23:125, 1970. Bagnall, W. E., Datta, S. R., and Knox, J.: Geriatric medicine in Hull: A comprehensive service. Br Med J 2:102, 1977. Giddon, D. B.: The objective need for dental care: A description of observable dental disease in relation to socioeconomic and environmental factors, In Dworkin, S. F.: Ference, T. P., and Giddon, D. B., editors: Behavioral Science and Dental Practice. St. Louis, 1978, The C. V. Mosby Co.. chap 3. Giddon, D. B.: The mouth and the quality of life. N Y J Dent 48:3, 1978. Mumford, J. M.: Toothache and Orofacial Pain. Edinburgh, 1976, Churchill Livingstone. Woodrow, K. M., Friedman, G. D., Siegelaub, A. B., and Collen, M. F.: Pain tolerance: Differences according to age, sex, and race. Psychosom Med 34:548, 1972. Levine, J. D., Gordon, N. C., and Fields, N. C.: The mechanism of placebo analgesia. Lancet 2:654, 1978. Giddon, D. B.: Psychophysiological factors in sensation, perception, and tolerance of pain in the teeth and periodontal tissues. Presented at the Workshop on Mechanisms of Sensitivity and Pain in the Teeth and Periodontal Tissues, Fairleigh Dickinson University, 1973.

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REFERENCES 1.

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