Complete dentures

Nonverbal communication in the dentist-patient

relationship

John R. Baseheart, Ph.D.*

University of Kentucky, School of Communications, Lexington, Ky.

lhe dentist-patient relationship abounds with instances of both verbal and non-
verbal communication behavior. Since implications of verbal communication for the
dentist-patient relationship have been dealt with adequately in the literature,‘-” this
article will focus only on various aspects of the nonverbal communication process
which appear to have implications for dentist-patient interaction.
Harrison4 indicated the importance of nonverbal communication when he
pointed out that, in the face-to-face communication situation (the situation most
analogous to the dentist-patient relationship), an estimated 65 per cent of the social
meaning in the situation is carried by the nonverbal communication band, leaving
only about 35 per cent of the meaning to be carried by the verbal component.
Although some disagreement exists among communications scholars concerning
what is commonly meant by “nonverbal communication,“5 it is generally accepted
that those human communication events or situations which go beyond the use of
spoken or written words are considered instances of nonverbal communication. These
events may take any number of forms, such as body motion, gestures, eye movements,
vocal qualities, speech hesitations, use and perception of personal space, and touch,
to name only a few. This discussion will focus on four nonverbal areas, suggesting
their significance to the dentist-patient interaction. These are ( 1) environmental
factors, (2) perception and use of personal space, (3) touching behavior, and (4)
various physical behaviors which have nonverbal communication potential.

ENVIRONMENTAL FACTORS
The environmental surroundings in which dental patients find themselves may
have significant influence on their reactions to the total dental situation. For
example, factors such as decor, color, furnishings, room temperature, and arrange-
ment of furniture may influence the patient’s psychologic as well as physiologic set
toward the situation. Maslow and MintzO compared the effects of an ugly room
(designed to give the impression of a disheveled janitor’s room), a beautiful room

*Associate Professor of Communication and Speech.

4
Volumr 31
Kumber I Nonverbal communication 5

(replete with drapes, carpeting, and the like), and an average room (described as a
professor’s office) on individuals. They found that the ugly room produced feelings
of monotony, fatigue, headache, discontent, drowsiness, irritability, and hostility in
both experimenters and subjects; whereas, the beautiful room produced feelings of
pleasure, comfort, enjoyment, importance, energy, and desire to continue the activity.
Colors may also influence one’s feelings. Wexne? has shown that certain colors
are often associated with various human “moods.” For example, blue typically con-
notes security and comfort; red, excitement and stimulation; black and brown,
despondence, dejection, unhappiness, melancholia, defiance, and hostility; and yel-
low, cheerfulness, jovialness, and joyfulness, to report only a few of the relationships
found.
Environmental temperature can also affect one’s psychologic disposition and
subsequent relationships with others. Griffitt and Veitchss !’ report that higher levels
of ambient room temperature produced greater negative affective feelings in indi-
viduals and greater feelings of dislike between individuals than did lower, more mod-
erate room temperatures.
The type of furniture present in a room can also act as a nonverbal cue bearing
on the dentist-patient relationship. Some furniture seems to invite the user to sit
down and be comfortable, whereas other furniture seems to produce feelings of dis-
comfort the moment one sits down. In fact, one furniture designer has deliberately
designed a chair which places disagreeable pressure on the individual’s spine so that
he will not become too comfortable and, hence, be more likely to move along.”
Placement of furniture, particularly the dentist’s desk, can further act as a
significant nonverbal cue. White’l has reported that, when a desk separated the
physician from his patients, only 10 per cent of the patients were judged to be at
ease. However, when the desk was absent from the office and no barrier stood be-
tween physician and patient, 55 per cent of the patients were perceived to be at ease.
Thus, the dentist can help the patient feel more comfortable by removing obstacles
such as desks and tables from between them.
The dentist, through an awareness of the possible messages being sent to the pa-
tient by the nonverbal cues associated with decor, color, temperature, and furnish-
ings in the office environment, can attempt to maximize the pleasantness of the pa-
tient’s visit by taking these factors into account.

PROXEMICS
Proxemics is the study of man’s use and perception of social and personal space
and appears particularly relevant to the dentist-patient situation. Hall’” has catego-
rized this informal space into the four subcategories of intimate space (ranging from
actual physical contact to about 18 inches), casual-personal space (from about 1 s
to 4 feet), social-consultative space (about 4 to 12 feet), and public distance (from
about 12 feet to the limits of visibility or hearing). This classification scheme is based
on the assumption that man has learned a behavior called “territorality”-that is,
“behavior characterized by identification with an a.rea in such a way as to indicate
ownership and defense of this territory against those who may ‘invade’ it.“‘”
Typically, the invasion of one’s territory results in defensive and/or evasive reac-
tions and, occasionally, aggressive behavior on the part of the invaded party in de-
6 Baseheart

fense of his personal space. Sommer”’ reports a study by Russo bearing on this point.
An investigation conducted over a two-year period was concerned with invading the
territory of women students seated in a college library. “Invasion” took various forms
such as sitting next to the subject, sitting across from her, and so on. Russo found
that, when the experimenter sat next to and moved her chair to within a foot of the
subject, 70 per cent of the subjects approached in this manner moved to another
part of the room within 30 minutes. Similar findings have been reported by other
investigators.‘“) ”
Fast”’ reports a study by Kinzel which compared the personal space demands of
aggressive prison inmates with those of nonaggressive inmates, which further illustrates
territorahty. He conducted an investigation using 15 volunteer prisoners, eight of
whom had a history of violent and aggressive behavior and seven of whom did not. Each
man stood in the center of an empty room while the experimenter slowly approached
him. The prisoner said “stop” when the experimenter reached that point in space
wherein the inmate began to feel uncomfortable by the closeness of the other person.
The violent prisoners demanded twice as much personal distance between them-
selves and the experimenter as that demanded by the seven nonaggressive inmates.
Thus, invasion of one’s territory may precipitate not only evasive behavior but also
aggressive and violent behavior.
By the very nature of the work, the dentist must invade the patient’s personal
space, and although social-consultative distance (4 to 12 feet) would seem to be the
most appropriate interaction distance between dentist and patient (at least in terms
of social relationships), the dentist and patient suddenly find themselves interacting
at an intimate distance. It is not surprising that a patient in this situation may be-
come uncomfortable and perhaps try (consciously or unconsciously) to take evasive
action in order to escape this unacceptable social distance. The patient may employ
evasive behavior other than flight (which is generally not a functional means of
escape for patients in the operative situation), such as becoming physically ill or
uncooperative in order to regain a social distance that is more acceptable for strang-
ers or nonintimate acquaintances.
Obviously, the dentist must violate the patient’s ‘“intimate” space in the course
of performing dental procedures. Both the patient and the dentist are well aware of
this. However, being aware that the patient may have difficulty coping with this
emotional situation, the dentist can endeavor to take precautions to minimize the
magnitude of this stressful situation.

TOUCH
Knapp”’ has suggesed that touching, or communication through tactile stimula-
tion, in our culture is generally considered a rather intimate, sensual, personal aspect
of human interaction. Physical contact is generally reserved for interactions of indi-
viduals between whom there is a more intimate relationship. Many children seem to
learn no-touch behavior as they grow older, perhaps with the idea that touching
others is something bad or undesirable,
During various dental procedures, it is obviously necessary for the dentist to come
into physical contact with the patient. This contact is generally with the head and
face only, but on occasion, the dentist must come in contact with other parts of the
Volumr 34 Nonverbal communication 7
Number 1

patient’s body. What can the dentist expect of the patient in the way of being at
ease and comfortable in this type of situation?
Unfortunately, little evidence is available to help answer this question. However,
WalkerI’ reports that, when individuals in same-sex and different-sex dyads partici-
pated in touching activities, the touching interactions were found to be very threat-
ening to the individuals, producing feelings of anxiety and general discomfort. These
feelings were more pronounced for male-male dyads but were also experienced by
interactants in male-female and female-female dyads.
In terms of the frequency of physical contacts between individuals, Jourard’”
reports that the frequency of physical contacts between couples observed in cafes in
Puerto Rico, Paris, Gainesville (Fla.), and London were 180, 110, 2, and 0, respec-
tively. Thus, Americans do not find touching (at least in public.) particularly
acceptable.
Jourard18 also reports on the parts of the body most often touched in various
encounters. The smallest amount of physical contact between men occurred in the
head region, with only slightly greater incidence of contact occurring between
women. Thus, men touching men in the head region (and to some extent women
touching other women in this region) appears to be rather uncommon and perhaps
socially unacceptable behavior in our society.
Thus, touching another person seems to communicate intimacy or personal ex-
pression of positive feeling and, hence, is engaged in only sparingly and on very
specific occasions by individuals. The dentist is in a difficult situation since, when he
comes into actual physical contact with a patient, particularly if the patient and
dentist are of the same sex, the patient may become extremely anxious and un-
comfortable and endeavor to reduce this anxious feeling by taking some type of
evasive action.

PHYSICAL BEHAVIOR
Often nonverbal physical behavior serves to reinforce what is being said verbally.
However, at other times, the meanings associated with various forms of nonverbal
behavior conflict with what is being said verbally: for instance, verbally saying “yes”
while simultaneously shaking one’s head; or verbally assuring a patient that there is
adequate time to discuss his problem while, at the same time, stuffing a briefcase
with papers, putting on one’s coat, and performing other acts which obviously say,
nonverbally, “I don’t have time right now to discuss your problem.” In these situa-
tions, it has been found that individuals are more likely to believe the nonverbal
message than what is being said verbal1y.l” Mehrabian2” reinforces this when he
states, “When any nonverbal behavior contradicts speech, it is more likely to deter-
mine the total impact of the message.” Thus, if he is sensitive to the various non-
verbal physical behavioral cues being emitted by his patient, the dentist can assess
the patient’s psychologic or emotional predispositions, which may influence the out-
come of the dentist-patient interaction.
Body movement. Body movement has been shown to convey information concern-
ing the attitudes of individuals in interaction situations. Mehrabia+ found that,
when men were seated with others whom they liked very much, their body orienta-
tion (i.e., the degree to which their shoulders and legs were turned in the direction
8 Basekeart J. Prosthet. Dent.
July, 1975

of the addressee) was rather indirect. Seated women employed very indirect body
orientations with intensely disliked receivers, relatively direct orientations with liked
receivers, and most direct with neutral receivers. Mehrabian2’ also reports that both
men and women who were seated perceived persons who leaned backward and away
from them in a chair as having a more negative attitude than individuals leaning
forward.
Dittmanr? reports that various movements may indicate particular moods. Leg
movements with a few accompanying movements of the head and hands tend to
indicate a depressed mood.
Ekman and Friesenz4 have investigated the nonverbal cues emitted by patients
when they are trying to deceive others. They focused on the face, hands, and legs/
feet as the primary areas of nonverbal leakage (i.e., revealing specific hidden infor-
mation) and deception (i.e., revealing that a deception is taking place). They re-
port that the legs/feet region is the best source of nonverbal leakage and deception,
with the hands next, followed by the facial region. Leg and feet cues generally take
the form of aggressive foot kicks, flirtatious display of the legs, or abortive, restless
flight movements. Deception cues may take the form of tense leg positions, frequent
shifts of leg posture, or restless and repetitive foot and leg activity. Further, indi-
viduals exhibit infrequent movements and assume indirect positions relative to their
addressee when being deceitful.‘J
Finally, Reece and Whitman”’ report that “warm” persons will make shifts in
posture toward the other interactant, whereas the “cold” person will exhibit a slump-
ing, less direct posture toward the other participant.
Gestures. Various hand gestures can serve to communicate information to the
dentist concerning the patient’s existing emotional predisposition. Krout’r, 28 reports
that hand-to-nose gestures represent a state of fear, fist gestures represent aggression,
fingers at the lips represent shame, and open hands dangling between the legs signify
feelings of frustration. Ekman and FrieserP report that nonverbal leakage and
deception cues associated with hand gestures generally take the form of the hands
digging into the cheeks and picking at the fingernails.
Eye contact. Willingness to establish and maintain eye contact or avoiding it with
others often can be a significant cue to the individual’s feelings. Mehrabian” re-
ports that, the greater the positive feeling of liking for another individual, the greater
will be the eye contact with that individual. Further, “warm” people tend to employ
more direct eye contact with others, whereas “cold” individuals tend to avoid direct
eye contact with others whenever possible.2F Holstein, Goldstein, and Bemzg report
that, in a dyadic interview situation, more instances of eye contact by a person with
the interviewer produced higher ratings of liking by the interviewer than did in-
frequent instances of eye contact.
Exline and Messicks” suggested that dependent individuals use more eye contact
with others than do less dependent individuals for two reasons. These are ( 1) to
communicate their positive feelings and attitudes toward the recipient and (2) to
elicit such attitudes and feelings from the recipient when they are not spontaneously
forthcoming.
Thus, increases in eye contact between individuals can communicate not only
Volume 34 Nonverbal communication 9
Number 1

positive feelings but can also aid in eliciting positive feelings from others toward the
instigator of the eye contact.
Speech. A final part of physical behavior that appears to have implications for
the dentist-patient relationship is that of speech. That is, how something is said may
communicate nonverbally to the dentist something about the patient’s emotional
state or feelings. For example, hesitant and halting speech, which includes errors,
incomplete sentences, and the repetition of words, has been found to indicate anx-
iety and negative feelings?, :j2 Communicators trying to deceive others have been
found to talk less, talk slower, and make more speaking errors than when not trying
to deceive othersZ” Thus, a patient’s speech behavior can be a significant nonverbal
cue to the dentist in making judgments concerning the patient’s feelings as well as
the truthfulness of his communication.

SUMMARY

This article presented a discussion of four aspects of the nonverbal communica-

tion process, suggesting implications for the dentist-patient relationship. The sub-
jects reviewed and discussed included (1) environmental factors, (2) the percep-
tion and use of personal space, (3) touching, and (4) various types of physical be-
havior. The outcome of any dentist-patient interaction can be significantly altered
depending upon the dentist’s awareness of, and responses to, the various nonverbal
cues present in the dentist-patient interaction.

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UNIVERSITY OF KENTUCKY
COLLEGE OF ARTS AND SCIENCES
LEXINGTON, KY. 40506