Received : 10‑01‑15

Review completed : 28‑02‑15

Review Article Accepted : 12‑03‑15

DIFFERENT CLASSIFICATION SYSTEMS OF COMPLETE DENTURE

PATIENTS BASED ON MENTAL ATTITUDE: A REVIEW

Ajay V Gaikwad, * Kapil Pal Singh J, ** Puja Hazari, ***

Sumit Deshpande, † Geetika Babar, †† Jayesh Kumar Jain †††

* Reader, Department of Prosthodontics, RKDF Dental College & Research Centre, Bhopal, Madhya Pradesh, India
** Senior Lecturer, Department of Prosthodontics, RKDF Dental College & Research Centre, Bhopal, Madhya Pradesh, India
*** Senior Lecturer, Department of Prosthodontics, People’s Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
† Reader, Department of Prosthodontics, PDU Dental College, Sholapur, Maharashtra, India
†† Post Graduate Student, Department of Prosthodontics, JSS Dental College & Hospital, Mysore, Karnataka, India
††† Senior Lecturer, Department of Prosthodontics, College of Dental Sciences, Davangere, Karnataka, India
_______________________________________________________________________
ABSTRACT "The patient's mental attitude may be classed
Diagnosis is the examination of the physical under one of four possible groups, viz.,
state, evaluation of the mental or psychological Hysterical; Exacting or Hypercritical; Indifferent;
makeup and understanding the needs of each and Philosophical".[4] A search of the literature
patient to ensure a predictable result. Patient suggests that Dr M. M. House was not the first to
evaluation is the first step to be carried out in describe the mental classification system of
treating a patient. The dentist should begin denture patients for which he is credited. His
evaluating the patient as soon as he/she enters contribution appears to be a detailed expansion of
the clinic. the classification and popularization of the
KEYWORDS: Classification; dentures; system.[5]
complete; mental attitude PERSONALITY
Jamieson stated that “fitting the personality of the
INTRODUCTION aged patient is often more difficult than fitting the
The House classification system has been cited on denture to the mouth”.[6]
numerous occasions in the literature, dental House Classification (1950) [3]
textbooks, and presentations before dental In 1950, Dr MM House, whose contributions
societies and Prosthodontics specialty groups. advanced the science and art of prosthodontics,
The classification system is based on how patients devised a classification system on the basis of
react to the thought of becoming edentulous and patients’ psychological responses to becoming
how they adapt to complete dentures. Although edentulous and adapting to dentures. Relying
attributed to Dr Milus M. House, the origin of this strictly on his clinical impressions, House
classification system can be questioned. The classified patients into 4 types: philosophical
House classification system is described in detail mind, exacting mind, hysterical mind, and
in a chapter by S. Howard Payne[1] in John J. indifferent mind.
Sharry's textbook Complete Denture 1) Philosophical patient: The best mental
Prosthodontics. Payne attributes the classification attitude for denture acceptance is the
to unpublished notes of "Study Club No. 1" on philosophical type. This patient is rationale,
"Full Denture Technique" in 1937. Rahn and sensible, calm and composed in different
Heartwel[2] list the classification in their textbook situations. His motivation is generalized, as he
and footnote the narrative with "Lecture by MM considers dentures for the maintenance of health
House. In an article published in 2003 in the and appearance and feels that having teeth
journal of Prosthetic Dentistry, Gamer et al., replaced is a normal acceptable procedure. These
credit Dr House with devising the classification patients are willing to rely on the dentist’s advice
system in 1950.[3] An extensive review of the for diagnosis and treatment. Philosophical
literature did not find any publication by House patients will follow the dentist’s advice when
that describes a classification system for complete advised to replace their dentures.
denture patients. In 1932 Dr Ewell Neil wrote 2) Exacting: The exacting patient may have all of
good attributes of the philosophical patients;

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Behavioral profile of patients[3]

Patient
Engagement Willingness to submit (trust)
type
+++ “I see you as a professional who is in a position
+++ “What you say makes sense, but there are
Ideal to help me, and willingly, I accept you in that
some questions I’d appreciate being answered.”
capacity.”
++++ “You are the best dentist I’ve ever had. No, ++++ “You know everything and will never
Submitter you are the best dentist around. I admire you, idealize make an error. Therefore I will submit to
you, and think of you in the most glowing terms.” whatever you suggest without question.”
++ “It isn’t you I distrust, but my destiny.
++ “Please don’t take this personally, but I just don’t
Nothing ever works out in my life. Therefore I
Reluctant think you, or any other dentist, is going to be able to
will reluctantly follow your instructions, but I
help me.
doubt this will work.”
+ ‘You are a dentist like any dentist, what does it
Indifferent + “I wouldn’t even give you a second thought.” matter whom I see. I will listen and follow
instructions, I guess, for now.
++++ “You authority-types are all the same. You
+ “You’ve got to be crazy if you think I’m going
expect us patients to just accept what you say. If you
Resistant to do just what you say. I need to grill you to
think I’m one of those types of patients, you are sadly
determine that you are not a charlatan!”
mistaken.”
however he may require extreme care, effort and the patient’s reactions and behaviors are
patience on the part of dentist. This patient is codetermined by the treatment and behavior of
methodical, precise, and accurate and at times the dentist. The proposed new classification
makes severe demands. They are above average includes both the patient and the dentist as co-
in intelligence often dissatisfied with past determiners of treatment outcomes, regardless of
treatment, doubt the dentist’s ability to make whether the patient is edentulous or dentate.
dentures that would satisfy their esthetic and WINKLERS CLASSIFICATION[7]
functional needs and often want written Winkler also mentioned the following categories
guarantees or remakes at no additional charge. of patients.
Once satisfied an exacting patient may become The Hardy elderly: These are individuals who
the practioner’s greatest supporter. are well-preserved physically and
3) Hysterical: The hysterical type is emotionally psychologically, are active in their professional
unstable, excitable and excessively apprehensive. and social lives and quickly adapt to their age
These patients submit to treatment alas a last changes.
resort, have negative attitude, are often in poor 2. The Senile aged syndrome: These are
health, are poorly adjusted, often appear exacting individuals who are disadvantaged emotionally
but with unfounded complaints, have failed at and physically and may be described as
past attempts to wear dentures, and have handicapped, chronically ill, disabled, infirm and
unrealistic expectations. They expect the truly aged. They cannot handle daily stresses and
prosthesis to look and function like natural teeth. are susceptible to disease.
Prognosis is poor for these patients. 3. The Satisfied old denture wearer: These
4) Indifferent: The indifferent type of patients patients are satisfied with their old dentures in
presents a questionable or unfavorable prognosis. spite of severe problems. They have learned to
This patient evidences little if any concern; he is live with them and are happy with them.
apathetic and uninterested and lacks motivation. 4. The Geriatric patient who does not want
He has managed to survive without wearing dentures: An elderly person who has been
dentures. He pays no attention to instructions, will without teeth for many years and has no desire for
not co-operate, and is prone to blame the dentist complete dentures and lacks motivation.
for poor dental health. The last two categories of patients lack
One important reason for reevaluation of House motivation and have a poor prognosis if forced
classification is that it pertains to the patient in into undergoing treatment.
isolation. House provided little attention to how

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IDEAL PATIENT which results in a high degree of engagement

The ‘ideal’ geriatric denture patient O’Shea[8] and utter surrender. This renders the submitter
characterised the ideal dental patient as incapable of providing genuine informed
compliant, sophisticated and responsive. consent because he/she has surrendered the
Winkler[7] described four traits that characterise use of critical faculties and therefore cannot
the ideal patient’s response: realises the need for be an active partner in the treatment.
the prosthetic treatment, wants the dentures, 3. The Reluctant patient rates + + on engagement
accepts the dentures and attempts to learn to use and ++ on willingness to submit. He is often
the dentures. It is evident from the various leery of the dentist and skeptical of the
classifications that a so-called ideal psychological treatment plan.
profile, though rare, is often desired by most 4. The Indifferent patient, who corresponds to
dentists as it provides the greatest chance of House’s indifferent mind, rates + on
success. Strictly speaking, the definition of the engagement and + on willingness to submit
term ‘ideal’ may be relative, but it does provide a (trust). Usually forced to see the dentist by a
standard to refer to. concerned family member or friend, the
Simon Gamer et al.,[3] in 2003 presented an indifferent patient is minimally engaged and
expansion of the House classification to include indifferent to the dentist to the extent that
the behavior of the dentist as a codeterminer of willingness to submit (trust) is not an issue.
the patient’s behavior. 5. The Resistant patient corresponds to House’s
The Gamer classification is based on 2 factors: exacting mind and Boucher’s critical patient.
1. The level of patient engagement with the Resistant patients are skeptical of the dentist
dentist and treatment process exists along a as a person and of being helped by anyone
continuum from completely over involved (+ under any circumstance. The resistant
+ + +) to disengaged (+). patient is, paradoxically, very engaged with
2. The level of the patient’s willingness to the dentist but in an adversarial way. Rather
submit (trust) also exists along a continuum than being dependent, they challenge the
from willingness to submit to the dentist’s dentist. And, like the indifferent patient, there
recommendations without a second thought (+ is no trust.
+ + +) to intense reluctance to do anything the Patient may also be classified as:
dentist recommends (+). 1. Cooperative
1. The Ideal patient, which corresponds to They may or may not recognize the need for
House’s philosophical mind, is reasonably dentures but they are open-minded and are
engaged (+ + +) and reasonably willing to amenable to suggestion. Procedures can be
submit (trust) (+ + +) to the dentist. This type explained with very little effort and they become
of patient is not ranked + + + + in either fully cooperative.
category, because these patients are 2. Apprehensive
considered mature with a healthy life balance. Even though these patients realize the need for
The ideal patient has a healthy level of dentures they have some irritational problem
distrust. Any reasonable patient should have which cannot be overcome by ordinary
some skepticism; they should permit explanation. They are of different types.
themselves to have questions and doubts. a. Anxious
Patients deserve explanations for professional The patients are anxious and upset about the
dental treatment to understand the situation uncertainties of wearing dentures. They often put
and arrive at a decision regarding treatment. themselves into a neurotic state.
Therefore the ideal patient tends to be neither b. Frightened
overly suspicious nor blindly accepting of the They will have unwanted fear about the dentures.
dentist’s recommendations. c. Obsessive or exacting
2. The Submitter patient rates + + + + on They are naturally of an exacting nature. They
engagement and ++++ on willingness to state their wants and are inclined to tell the dentist
submit (trust). Such patients lack how to proceed. They must be handled firmly and
discrimination and tend to idealize the dentist, tactfully.

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d. Chronic complainers
They are a group of people who are habitually
fault finding and dissatisfied. Appreciating the
corporation and incorporating as many of their
ideas as possible with good denture construction
is the best way to handle them.
e. Self-conscious
The apprehension here centers chiefly on
appearance. It is wise to give overt reassurance to
the self-conscious patient and permit participation
as far as feasible in order to establish some
responsibility in the result.
3. Uncooperative
They do not feel a need for dentures though the
need exists. Their general attitude is negative.
They constitute an extremely different group of
potential denture members.
CONFLICT OF INTEREST & SOURCE OF
FUNDING
The author declares that there is no source of
funding and there is no conflict of interest among
all authors.
BIBLIOGRAPHY
1. Payne SH. The person. In: Shorry JJ.
Complete Dciittur ProMhodontic:. 3rd ed.
New York, NY: McGraw-Hill;1974:10.
2. Rahn AO, Heartwell CM Jr. Textbook of
Complete Dentures. 5th ed. Philadelphia, Pa:
Lea & Febiger; 1993:131-2.
3. Gamer S, Tuch R, Garcia LT. MM House
mental classification revisited: intersection
of particular patients types and particular
dentist's needs. J Prosthet Dent
2003;89:297-302.
4. Neil E. Full Denture Practice. Nashville,
Tenn: Marshall & Bruce;1932:1-5.
5. Winkler S. House mental classification of
Denture patients: The contribution of Milus
M House. J Oral Implant 2005;31(6):301-3.
6. Jamieson CN. Geriatrics and the denture
patient. J Prosthet Dent 1958;8:8-13.
7. Winkler S. The geriatric complete denture
patient. Dent Clin N Am 1977;21:403-25.
8. O’Shea RM, Corah NL, Ayer WA. Dentists’
perceptions of the ‘good’ adult patient: an
exploratory study. J Am Dent Assoc
1983;106:813-6.

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