Review article

Understanding the psychology of geriatric edentulous patients

Ashwin R. Mysore and Meena A. Aras

Department of Prosthodontics, Goa dental college and hospital, Bambolim, Goa, India

doi: 10.1111/j.1741-2358.2011.00496.x
Understanding the psychology of geriatric edentulous patients
Objective: This article focuses on understanding our older patients who require complete prosthodontic
care. By breaking down the patient psychology to its component parts, it is easier to obtain a clear picture of
this special cohort of patients. Considering the increase in number of geriatric edentulous patients, this
knowledge will help the dentist serve the geriatric population better.
Background: The role of psychology and personality in complete denture treatment is well documented.
The geriatric patient who needs complete dentures has a psychological aspect that needs consideration.
Although significant, these aspects may sometimes be ignored or considered irrelevant.
Materials and methods: A review of relevant literature was carried out to obtain data on the psychology
and personality of geriatric, complete denture patients and their behavioural changes. The obtained data
was filtered and condensed to provide a short but comprehensive look at the geriatric edentulous patient’s
psychology.
Conclusion: When handling geriatric edentulous patients, the dentist must be confident of addressing
and managing the psychology of these patients. A thorough understanding of the geriatric mental state
thus becomes important and significant for the clinician.

Keywords: geriatric patients, geriatric psychology, complete denture patients.

Accepted 28 November 2010

expertise are constantly being misused, wasted or

Introduction
Today, the geriatric population is on the rise
because of an increase in the quality and avail-
ability of medical facilities, introduction of new
drugs and disease control combined with better
nutrition and improved hygiene. This implies that a
greater number of geriatric patients will seek dental
care including complete prosthodontic care. The
success of complete dentures is related to technical
procedures, functional factors, aesthetics, biological
determinants and psychological factors. The
psychological factors include preparedness of the
patient, attitude towards dentures, relation and
attitude towards dentist, ability and intelligence to
learn use of dentures and the patient’s personality.1
The relationship between psychology of the
patient, personality, the dentist patient interaction
and denture treatment is well recognised.1–7
We have tended to stereotype the aged as senile,
financially and emotionally dependent, useless
and ill. Their wisdom, experience and accrued
ignored.8
For the population over 65 years of age, Birren
identifies five sources of frustration that are age-
related: (i) an age status system that idealises
youth, (ii) pressures of time and money that leads
us to a restriction of former interests, (iii) physio-
logical changes that demand or usurp attention,
(iv) technological changes that increasingly outdate
the skills of ageing persons and (v) with age, indi-
viduals become more ‘locked in’, being less able to
move out of a frustrating situation.9
The earlier the signs of frustration are detected
and correlated to the source(s) the better are the
chances of understanding the patient’s psycholog-
ical make-up and delivering better care.
What to expect?
Jamieson10 wrote that ‘fitting the personality of the
aged patient is often more difficult than fitting the
denture to the mouth’. The geriatric patient seeking

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e24 A. R. Mysore, M. A. Aras
complete denture treatment is classified in many
ways by various researchers. The numerous classi-
fications available in literature highlight the depth
of study of the psychology of the geriatric denture
patient and an effort to understand it to in turn
provide better care for the geriatric denture patient.
It also reflects the variety and wide variation that is
observed in the mental make-up of the geriatric
patient.
Ettinger and Beck11 divided geriatric patients
functionally into (i) functionally independent el-
derly: live in the community unassisted (ii) frail
elderly: have lost some of their independence, but
still live in the community with the help of support
services and (iii) functionally dependent elderly:
unable to live independently in the community.
Years ago, House classified patients into four types:
philosophical mind, exacting mind, hysterical mind
and indifferent mind.12 Patients with an exacting
mind, hysterical mind or indifferent mind were
believed to exhibit less than ideal adaptability to
edentulism and denture use. More recently, Gamer
et al.13 suggested a re-evaluation of the House’s
classification because of the following reasons (i)
the classification uses antiquated terminology (ii) it
considers the patient in isolation. The new system
classifies the patients into ideal, submitter, reluc-
tant, indifferent or resistant. This system, in addi-
tion to the patient, takes into consideration the
dentist and the interaction between the dentist and
the patient.
Winkler8 also mentioned the following catego-
ries of patients.
1. The hardy elderly: these are individuals who are
well-preserved physically and psychologically,
are active in their professional and social lives
and quickly adapt to their age changes.
2. The senile aged syndrome: these are individuals
who are disadvantaged emotionally and physi-
cally and may be described as handicapped,
chronically ill, disabled, infirm and truly aged.
They cannot handle daily stresses and are sus-
ceptible to disease.
3. The satisfied old denture wearer: these patients
are satisfied with their old dentures in spite of
severe problems. They have learned to live with
them and are happy with them.
4. The geriatric patient who does not want den-
tures: an elderly person who has been without
teeth for many years and has no desire for
complete dentures and lacks motivation.
The last two categories of patients lack motiva-
tion and have a poor prognosis if forced into
undergoing treatment.
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The ‘ideal’ geriatric denture patient
O’Shea et al.14 characterised the ideal dental patient
as compliant, sophisticated and responsive. Win-
kler15 described four traits that characterise the
ideal patient’s response: realises the need for the
prosthetic treatment, wants the dentures, accepts
the dentures and attempts to learn to use the
dentures. It is evident from the various classifica-
tions13–15 that a so-called ideal psychological pro-
file, though rare, is often desired by most dentists as
it provides the greatest chance of success. Strictly
speaking, the definition of the term ‘ideal’ may be
relative, but it does provide a standard to refer to.
Understanding the aged
No matter how the patients are classified, the
characteristic they all have in common is tooth loss.
Tooth loss brings about considerable changes in the
psychology of patients. Psychological assessment of
the patient becomes essential because the success of
the treatment depends on the expectations and the
self-concept of the patient.16 According to a study
conducted by J. Fiske et al., 17 the emotional effects
related to tooth loss ran parallel with the five stages
of bereavement, i.e. denial, anger, depression,
bargaining and acceptance. In patients who had
failed to reach the final stage of bereavement, the
following emotional responses were noted:
• lack of acceptance;
• diminished self-confidence;
• difficulty in adjusting to a change in appearance
and self-image;
• treating the subject of tooth loss as a taboo topic;
• secrecy or an attempt to hide the edentulousness;
• prosthodontic privacy or a fear of removing the
dentures;
• behaviour change;
• feeling of having aged prematurely;
• lack of preparation to face the tooth loss.
Handy proposed that, like losing a body part,
tooth loss too can affect the personality or psyche
and that it may be a response to the extractions
and/or denture construction and not an inherent
flaw in the psychological make-up of the patient.17
Tooth loss and its acceptance are one of the major
factors determining the psychology of geriatric
complete denture patients. Another important
factor is the inherent differences between young
and old patients. Older patients are behaviourally
different when compared to younger patients. They
are more sceptical, demanding and at times quite a
challenge to handle.
 Understanding the psychology of geriatric edentulous patients
Heartwell18 states that aged patients rarely ex-
pect to see with an artificial eye or to have natural
use of an artificial hand or leg, yet they frequently
expect artificial teeth to duplicate natural teeth in
form and function. Many of them have a tendency
to exaggerate their problems, and such situations
require the dentist to have a lot of patience and
understanding. Winkler8 states that geriatric pa-
tients remember all the claims made by the dentist
and if the prosthesis is not exactly as it was
described, they will invariably complain. Elderly
people develop fixed habits and ideas and do not
adapt readily to change in their mode of life. They
tend to endure increasing physical discomfort rather
than to make an effort to see a doctor for the early
treatment of an ailment that may become serious.10
At the other end of the spectrum, Winkler8 and
Iacopino19 separately mention the routine of the
geriatric patient who visits a sympathetic or
comforting dentist for reassurance. They also believe
that working briskly and being overly efficient is
construed as indifference by the geriatric patient.
Most geriatric patients come from an age where
speaking up is considered ungrateful and critical,
and an expression of emotions is considered as a
sign of poor self-control. Most patients are not
familiar with the concept of preventive treatment,
being used to curative treatment only. Lower
educational achievement is also a factor that
inhibits effective communication. Patients’ atti-
tudes are influenced by prior dental experience, the
importance of dentistry (from the patient’s point of
view) and dental awareness.20
Researchers have shown that older people take
more time to process new information, and they
need a slower pace of instruction and more time to
process new information. Another deterrent to
successful communication with older patients is the
normal, age-related decline in sensory processes. As
patients get older, they cannot see, hear, touch,
taste or smell as well as they did when they were
young. Depressed patients and those suffering from
hypochondria focus on the body; thus, they will be
more likely to respond to, or report as, pain even
minor non-pain sensations such as vibration.16 In
explaining the psychology of the dentally phobic
geriatric patient, Epstein20 states that the oral cav-
ity is often experienced by the patient as the point
wherein the dentist ‘trespasses’ into the patient’s
body.
Influence of personality
A correlation between the personality of a patient
and the denture acceptance exists.1,7 Ozdemir
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e25
et al.6 compared the denture satisfaction in type A
and type B personalities. Type A personalities lead
high stress lives, whereas type B personalities are
relaxed and stress free. Type AB personalities are
located between these two extreme groups.
Patients with personality Type A exhibited the
lowest levels of satisfaction with their dentures
with regard to aesthetics, speaking ability and
masticatory function.
Patient behaviour towards the dentist
Lefer et al.,3 commenting on the dynamics of the
dentist patient interaction, predict one of two
patient behaviour patterns. The patient may have
the expectation that the dentist will take care of
him and be gentle if he defers all decisions to the
dentist. At the other end of the spectrum, a patient
may feel that submission to an authority figure is a
sign of weakness. As a result, he may resist anyone
who displays authority. In a study conducted on
the dentist patient interaction, Hirsch et al.21 found
that patients treated by high authoritarian dentists
were less satisfied than those treated by low
authoritarian dentists.
The geriatric patient’s response to form and function of
dentures
Pan et al.22 when evaluating sex-related differences
in patient behaviour to complete dentures found
that elderly females are less satisfied with con-
ventional dentures than elderly males with regard
to aesthetics and ability to chew. This result is
partly supported by a previous study by Langer
et al.2 who found that more women complained
about the appearance of their dentures, while
more men had objections regarding mastication.
Waliszewski et al.23 evaluated preference of tooth
arrangement (aesthetics) among edentulous
patients using three types of set-ups, i.e. natural,
supernormal and denture look. The natural look
was a standard tooth arrangement, while the
supernormal and denture look were with larger
and smaller moulds of teeth, respectively. The
results showed that a natural look was chosen by
55% of the patients, whereas the other 45% chose
set-ups that were marked deviations from the
anatomical averages (either supernormal or den-
ture look).
Adaptation to dentures
The acceptance of dentures is usually unrelated to
the technical quality of the prosthesis2,17,19,24,25 All
e26 A. R. Mysore, M. A. Aras
or most of the above factors contribute to the
patient’s acceptance of the dentures.
According to Anderson,26 the popular belief
that patients adapt better to duplicated dentures
than new ones is unfounded. In comparing the
better technique for denture construction, Ellis
et al. 27 made the following observations: (i) after
delivery, the edentulous patients who received
complete dentures using either conventional or
duplication techniques showed similar improve-
ments in terms of overall patient satisfaction and
oral health-related quality of life and (ii) Patients’
reported satisfaction with their dentures and the
impact dentures had on their quality of life might
not be useful measures for determining the most
appropriate technique for providing new den-
tures.
A study by Fiske et al.28 investigated the role of a
self-help group in helping denture wearers with
long-standing problems. During the course of the
investigation, the following observations were
made: sharing problems helped people to accept
and cope with them. Patients included foods they
previously did not attempt to eat, and they com-
municated their problems better than before. It was
also found that the responsibility for successful
denture wearing was placed totally with the den-
tist, and most patients thought that there was
nothing they could do to contribute to successful
denture wearing. The patients suggested that the
dentists listen more and explain everything
including potential denture problems.
Conclusion
Knowledge of patient psychology helps us in
understanding the mental status of a patient who
has suffered tooth loss and is in need of treat-
ment. Knowing what to expect when treating a
geriatric edentulous patient puts the dentist at a
distinct advantage as a treatment plan can be
formulated accordingly. This will facilitate an
improved approach towards the patient and will
help in more appropriate management of the
patient, both psychologically and prosthodontic-
ally.
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Correspondence to:
Dr Mysore Ashwin Raghunandan,
Goa Dental College and Hospital – Prosthodontics,
Rajiv Gandhi Medical Complex, Bambolim, Goa
403202, India.
Tel.: 9890749016
Fax: 0091-0832-2459816
E-mail: ash_win1@rediffmail.com