Psychologic facets of esthetic developmental perspective
dental
health
care: A
Nadine A. Levinson, D.D.S.* University of California, Irvine, School of Medicine, Irvine, Calif. A developmental perspective is presented to explore dental health and esthetics in dentistry and to describe the speci5c ways human behavior and various aspects of esthetic health care interrelate. An investigation of the fascinating links between mind and mouth over the life cyclehh are elucidated to explain how and why the oral cavity is so psychologically important. Clinical examples of how personality factors can influence dental treatment and its outcome are illustrated. (J PROSTHETDENT
1990$34:486-91.)
H*
&&ally, dentistry as a profession has been associated with the biomechanical complexities of dental health care emphasizing preventative and restorative treatment of hard and soft structures. With new advances in research, diagnosis, treatment, and dental materials, a more sophisticated perspective of dental health care has evolved. Today, a modem view of dentistry is one that recognizes another crucial ingredient, the emotions or psychological essence of the patient in relationship to the dental situation, dental health care, and especially, esthetics. The role of emotional and personality factors in esthetics of the face and mouth is a complex and complicated one. Several articles have comprehensively reviewed the relationship of esthetics to oral health from historic,‘” psychosocial,4-g and economicgp lo perspectives. Other articles have attempted to describe end quantify more abstract concepts including body image, self-image, and self-concept, and their enhancement from improved dental and facial appearance. 11-16However, paradoxical findings have emerged in some studies reflecting the average clinical situation, which indicate that other, more elusive psychological factors influencing perception, self-concept, and personal motivation must also be considered. For example, although many teenagers rate attractiveness as important, many are found to have appalling dental behaviors and compliance problems in and out of the dental office. How can one explain the paradoxical response of patients with a “successful” orthognathic surgery who afterward become dissatisfied, depressed, and may even compulsively seek other consultations, more surgical procedures, or legal remedy? What about denture patients who
Presented at the American Academy of Esthetic Dentistry meeting, Lsguna Niguel, Cslif. *Associate Clinical Professor, Department of Psychiatry and Human Behavior; Clinical Associate, San Diego Psychoanalytic stitute, San Diego, Calif. 10/1/21776
486
In-
fail to accept their dentures, although the result is technically, esthetically, and functionally excellent? As all clinicians know, psychological changes can occur with the most minor esthetic revision on an anterior tooth or from a radical surgical repair of a severe maxillomandibular disfigurement. Dentists treat individuals with their personal, idiosyncratic reactions. These responses are determined by the structure of the patient’s personality and his or her developmental needs, expectations, concerns, and conflicts. This article elucidates the interrelationship between development, personality, and its manifestations in the dental situation. A few basic definitions from Moore and Fine’s’? Glossary of Psychoanalytic Terms and Concepts would be helpful in understanding more about the psychology of personality. The term “personality” refers to the characteristic or predictable ways the individual responds to life situations-his or her attitudes and habits. These characteristics evolve consciously and unconsciously and are based on a compromise between one’s wishes and a need to limit their expression. A primary function of the personality is to maintain a stable relationship between the person and his or her environment. Whereas “personality” refers to what is observed behaviorally, the “self” is a conceptual term that refers to an internal or mental representation of what a person thinks of him or herself as a total person-a psychophysiologic total. These images are constructed from the direct experience of sensations, emotions, thoughts, and from the indirect perceptions of the bodily and mental self.18 Patients having a realistic image of the self will correctly mirror their capabilities and their limitation. But sometimes these images can be unrealistic and distorted according to an individual’s wishes or defensive needs. For example, a 45year-old man feeling the impact of his midlife crises, sought orthodontics and bonding to try and capture his waning youth and virility. The dental treatment was more than adequately rendered with positive es-
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thetic results. However, the man kept returning and complaining that “the eye teeth are not bulky enough. . . I want more protuberance.” The external dental situation could not repair or make up for the inner sense of inadequacy and the wish to stand out in a crowd, which had plagued this man for a lifetime. Self-esteem or healthy narcissism is a positive psychological interest in the self but not to the exclusion of others. Pride and pleasure of one’s own body and mind are signs of healthy self-esteem. Injury to one’s self-esteem, or a part of the body, narcissistically invested, can cause anger and rage, thus accounting for some of the extreme, negative responses despite providing “good-enough” dentistry.
A PSYCHOANALYTIC DEVELOPMENTAL PERSPECTIVE: A BIOPSYCHOSOCIAL MODEL A psychoanalytic developmental perspective is helpful in understanding how and why a healthy smile is so essential to the overall emotional well-being of our patients. A psychoanalytic developmental perspective is one that emphasizes the importance of the mouth at all stages of development in the life cycle, from infancy through old age. With this approach, personality development, character, defenses, wishes, habits, and behaviors are viewed as emerging from an interaction and interdependence of biological and constitutional growth with environmental experience.lg>2oThe psyche emerges from a biological matrix, the mouth and its functions being a vital somatic constituent, and is characterized by transformations, progressions, and regressions, where there are many silent steps that are influenced by critical growth periods, timing, intensity of interactions, and most importantly, in the context of human relationships21 The final integration of bodily, mental, and social experiences over the life cycle make up the functioning personality. A more complicated psychoanalytic developmental theory has always existed, as opposed to the reductionistic caricatures portrayed by nonanalysts who inaccurately describe pathologic behaviors as being derived from sexual fixations at the oral, anal, or phallic level of development. An example of such a caricature took place at a major dental meeting where a prominent scholarly prosthodontist proposed his version of a so-called psychoanalytic model. He stated that the temporomandibular joint (TMJ) myofascial dysfunction of his patient was caused by a fixation at the oral phase because the patient didn’t get enough time to suck at the breast. Then later he never went on to develop more appropriate sexual behaviors. At 20, as an alternative to “being blind,” the patient started bruxing. This erroneous review of psychoanalytic theory mistakenly assumes that the only function of the mouth is a sexual or incorporative one, as emphasized by Freud22 in his seminal, but early essay, “Three Essays on the Theory of Sexuality.“22 In this essay, Freud discussed the sexual na-
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ture of the mouth in sucking and thumb-sucking. Particularly upsetting to many dentists was his assertion that thumb-sucking was an autoerotic, masturbatory equivalent. However, this was the first essay that systematically discussed infantile sexuality. Later articleslg* 23124 amended his previous psychosexual theories by examining the importance of the environment and important relationships. These inaccurate contentions are the result of several common problems and resistances to the incorporation of new information into any scientific discipline. All scientific fields progress through a developmental infancy where ideas and theories are first proposed. With time, these ideas are scrutinized, clarified, and subsequently revised by new ideas or by a change of emphasis of old ideas. Current developmental theory is still in a state of conceptual developmental flux with the continuing integration of new and old observational, psychobiological, and laboratory resea.rch.25 A contemporary psychoanalytic view of infantile sexuality and orality and its psychological manifestations is far richer and more complex and encompasses more than psychosexuality. The mouth and smile play a crucial role in the creation and maintenance of positive attitudes about the self and have tremendous emotional significance. In our society, the mouth has become a symbol for the total self. A smile is a window into the personality. Consider how a young child learns about emotions and feelings by assuming that the few essential lines of a mouth represent the person, for example, a happy face or a sad face. Expressions such as “a smile is worth a thousand words” or “she set her jaw in determination,” convey the use of the mouth as a metaphor for the total person. Dental advertisements emphasizing the need for whiter, brighter teeth also send a clear message. “If our mouths are beautiful, then so is the rest of us, and then, like the model with the beautiful smile, we will be happy, attractive, and successful.” The underlying meaning is that the mouth and a beautiful smile are the representation of an ideal of psychological, physical, and social adequacy. Dentists play an essential role in facilitating this ideal by magically transforming the unattractive, dowdy, and grotesque into an attractive, desirable individual. In most cases, the patient’s psychological welfare, selfesteem, and self-image are affected by these esthetic changes. The patient also lives in a social world and how he or she looks plays a role in influencing his or her interactions with others. Mary Shelley’s26 story of Frankenstein is a literary case in point. Although Frankenstein was born looking monstrous, he was not originally evil, but was gentle and kind. Like most people, he yearned for human love and affection. Only in time, after being rejected for looking repulsive and grotesque, did the monster begin to act congruent with his outward monstrous appearance. As Frankenstein poignantly self-observed, “I can not believe that I am the same creature whose thoughts were once filled 487
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Table I. Functions
of the mouth over the life cycle Toddler
Infancy 1. Nutritive interests 2. Pleasure interests
Sucking/ breast-feeding Thumb-sucking/ oral games
3. Crying 4. Language
x x Babbling One word Communication
5. Cognition
Oral games
6. Attachment
X (basic trust) Loving (sucking) vs hating (biting)
7. Oral anxiety Separation anxiety
Drinking (weaning) Mouthing
Latency
Adolescence
X (eating) X (eating/ drinking) Eating (X) Foreplay/ kissing
X Two words X (language proper) x x Introduction X (dental health care) X X
Loss of baby teeth X (body vulnerability)
X
X X [swearing]
Young adult
Midlife
Elderly
X
X
X
X
X
X
Wine tasting, gourmet indulging, smoking X X X X X X X
X X
X X
X
X Sexuality
Resolution-tolerance of ambivalence in human relationships X X Intimacy Loss of youth Loss of attractiveness
8. Oral Loving (sucking) vs conflicts hating (biting) Eating control struggles Dental self-care vs dental noncompliance
9. Self-esteem
X (social smile)
Dental Loss of control Oral perversions compliance /noncompliance Body image concerns X Eating disorders X X X X X X (love of body/self) X X (vs peer) X (vs lack of care) X X (love of body/care)
with sublime and transcendent visions of the beauty and majesty of g00clness.“26 By enabling the dental patient to acquire an appealing physical appearance and a pleasing smile, the dentist will also be promoting a positive socialization experience that supports and affirms a healthy self-concept. There is an ongoing and reciprocal feedback mechanism in which one’s feelings about oneself are influenced and reflected by how one reacts ta others and how others react back. The prototype of this meaningful affective feedback loop begins in the first few weeks of life. After being nursed, most babies will show a smile of satisfaction. That smile becomes linked to the mother who feeds and cares for the baby. The mother, knowing she has satisfied her infant, smiles back. This important psychological landmark, the reciprocal social smile, represents a mutual radiance and inner source of pleasure that is the basis for self-esteem for infant and parent. The same affective experience, derived from the first smile, occurs in the dental situation when the dentist and patient smile at one another after the dentist completes and the patient accepts a successful procedure. The current psychoanalytic meaning of sexuality (and
488
X X
X Tooth periodontal loss
Denial of aging
X
X X X X
X X X
incidentally, not very different from Freud’s usage) includes all aspects of sensuality, pleasure, and self-fullillment. The term “orality” refers to all feelings, thoughts, sensations, and a myriad of experiences and behaviors involving the mouth. 27 During each stage of development from infancy through adulthood, the mouth takes on new and different meanings and functions (Table I). It is these changing aspects of orality that inspire the development of the personality. A developmental framework tells us about children and adults from a functional point of view, a perspective that considers constitutional, biological, genetic, and interacting experiential factors, rather than chronological or statistical factors. The remainder of this article will examine some of these significant functions and meanings of the mouth and will endeavor to see why and how they are clinically important to dentists and their patients.
IMPORTANT FUNCTIONS OF THE MOUTH DURING INFANCY The mouth at birth is a well-developed sensory and perceptual organ with vital physiologic and homeostatic func-
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II. Functions of the mouth in infancy: Infancy (birth to 2% years) during the oral phase
tions such as breathing, crying, sucking, and swallowing28 (Table II). Crying, which requires respiration, signals need states such as hunger or discomfort. Sucking is used for the intake of nutritive sustenance. However, sucking and later thumb-sucking are self-regulative functions for quieting and soothing oneself.2g Swallowing incorporates the nutriments of the world, and this is the prototype of stimulus nutriment acquisition and the basis for future intelligence.30 There is an elaborate cortical and hypothalamic representation of these functions and the emotional and affective experiences connected with them. These earliest oral experiences, which are at first self-preservative, form the basis for a positive sense of self and for future attitudes about the mother, the father, the world, and the ability to trust and love.31 Attachment is the bonding established during the nursing experience in which the mouth is the site of emotional and empathic linkage with others.32 Major problems with attachment are illustrated by infants with cleft palate and lip where the physical appearance of the baby affects reciprocal bonding between parent and infant. Breastfeeding and weaning, two important oral experiences, play a major role in attachment and separation with the attainment of a stable sense of self and trust of others. Although there is a physiologic birth of the human infant, it takes several years before the psychological development of separation and individuation can occur.33 The mouth makes verbal and nonverbal communication possible. Infants cry as a signal to express hunger or discomfort; they make “mm” sounds at the breast as one of the earliest sounds of pleasure.34 Learning to speak occurs via the oral mode, by important oral games such as “the raspberry game.“35 Eventually, the mouth is used to express complex ideas and emotions that include both loving and hating feelings.36 The baby experiences, embraces, and explores the world with its mouth, which is also a prehensile mouth.37 Renee Spitz37 poetically referred to the mouth as the “cradle of perception.” Through touching, feeling, and being felt (the tongue in the mouth does it all simultaneously), the infant defines his own body image and identity and differentiates himself from the world around him. These early oral sensorimotor experiences form the basis for thought and mental representation.38 Analytic research has clearly demonstrated the importance of the mouth for this early differentiation of self from the external world and from
Table
others
A 23-year-old predental student wanted to have all his anterior teeth restored with ceramicsto closea small gap between his anterior teeth. He also wanted surgery to change his chin protuberance, although the oral surgeon felt his facial appearancewasmore than satisfactory. The patient was demanding and urgently wanted the procedures.What washisfantasy? He believed that he would not get into dental school unlesshe had an attractive smile. Additionally, he felt that if he were a dentist, and wassuc-
162%
37,39
The consolidation of body image and self-representation, resulting from different developmental tasks involving the mouth, takes place throughout the life cycle (Table I.).4o After infancy, during latency, loss of baby teeth and the acquisition of permanent teeth signals the shedding of babyhood and many orally-based anxieties. In adolescence, there is a recapitulation of early body image concerns heralded by preoccupation with the face, mouth, and espe-
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Self-preservation Breast-feeding andweaningby mother,with 1. Sucking eventualability to feedself Thumb-sucking,self-stimulation,andselfregulation 2. Breathing Respirationto language 3. Swallowing Eating, sensation,and perception,leading to self-objectdifferentiation Eventually takeson signallingfunction 4. Crying Attachment Basictrust (suckingand biting) resolved ambivalence Communication BabblingBeginninglanguageacquisition Crying Oral games Smiling Sensorimotor actionsasprecursorsto Cognition thoughts30 a. Oral reflex movements b. Perception,sensation;feed nutrimentto stimulusnutriment c. Greaterself/objectdifferentiation d. Self and objectpermanence Beginningself/objectdifferentiation Self-concept Differentiation through oral feedings, games, andotheraspects of maternalcare Self constancy33/object constancy33 Self-esteem Reciprocalsocialsmile(takesplaceduring feedingand games) Oral anxiety Lossof caretaking(soothing,feedingobject) (separation) Lossof love of object anxiety) Increasingbody(oral)vulnerabilityto damage
cially the smile.Love of self/body is augmentedby respect of body and body care.
THE
YOUNG
ADULT
With the young adult, intimacy, finding a mate, and finding a career are the main developmental tasks. Issues of appearancefor the young adult are crucial. However, a neurotic preoccupation with facial and dental appearance may be usedto avoid other narcissistic concerns.
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cessful, he Clearly, his appearance compensate he felt.
would do better with women and friends. preoccupation with his anterior gap and facial and the need to make it perfect, was to for and change the internal or emotional gap
ADULTHOOD In the mid-40s the effecta of an aging body and an aging mouth can be a source of narcissistic injury or can lead to a more realistic appraisal of the body?and the wish to take care of it. The normative conflict is between denying the aging process and acceptance of the loss of the young body.4O Many adults seeking dental treatment want to maximize function and esthetics. For others, it can mean magical repair of their body and denial of the aging process. There can be several conceivable symbolic meanings for the hypothetical case of a 40-year-old woman who seeks orthodontic treatment. Is it to help replace her husband after she has just undergone a second divorce? Is it to replace him with her dentist to whom she keeps returning for one adjustment after another and then for one more surgery? Is it to compete with her young, attractive, and luscious 17-year-old daughter? Is it to obtain better function and esthetics? Or is it to obtain what she never could obtain when she was younger? Any and all of these meanings are possible, and even multiple meanings can exist for this same woman.
THE
ELDERLY
In the elderly, there is generally a loss of function and esthetics, with sagging lips, irregular teeth, and broken or chipped teeth. The loss of teeth no longer symbolizes the loss of babyhood as with the latency age child, but symbolizes the loss of power to defend against the awareness of death and the passage of time.41* 42Esthetic and functional procedures at this age can be meaningful and can restore an inner glow caused by the patient’s having a more pleasing smile. Another meaning that dentists convey by simply being involved in treatment for the aged is the metacommunicative message that we have not given up on the elderly and that there is hope and that they are not worthless and inconsequential.
DISCUSSION The maintenance of healthy and esthetic oral structures over a lifetime is important for psychological as well as for physical reasons. These vignettes of dental patients throughout the life cycle elucidate the influence of past and present development, internal self-perceptions, self-concept, body image, feelings, motivation, and relationships with others as governing the specific ways human behavior and dental health interrelate. There is an oscillating, reciprocal relationship between how patients look, function, and feel, since mind and body are complexly and inextricably interrelated. A developmental framework and
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the specification of normative developmental tasks and conflicts is a useful explanatory model illuminating these complex relationships. Meaning is given to clinical dental problems, and particularly in those areas where changes in body image, facial appearance, facial pain, and anxiety occur. These meanings are interwoven in a developmental context, the knowledge of which will enhance our diagnostic and treatment skills. In addition to the routine history and physical examination including chief complaint, present illness, past medical, and past dental history, family, personal and social history, a psychologically-oriented dental history of the personal significance and importance of the mouth should be described and detailed. It is in a knowledge of the multiple and complex meanings of the patient’s early and later development that a better awareness of what the patient wants can be discerned and this knowledge will facilitate optimal provision of what can be realistically expected. Certainly some of the negative, paradoxical responses in spite of “good-enough” technical results can be avoided. Although these responses are rare, they can be intense and malignant for both the patient and the dentist. However, another even more interesting question to be raised might be why are there so many successes in individuals who seem somewhat emotionally vulnerable? A developmental perspective provides understanding of potential psychopathology as well as mental health. One of the predominant normal developmental tasks at all phases of the life cycle is to work through these narcissistic, changing body image issues. Adaptation to the changes in the body, including the mouth and the smile, may be one of the most important tasks for mental and dental health. The education and practice of modern dentistry can no longer ignore the importance of human behavior and the role of developmental experience in mental and dental health. Even the most routine procedures can be emotionally significant for patient and dentist. In order that dentists feel more comfortable with the feelings of their patients, they must have a firm grounding in the study of human behavior, psychological mechanisms, and the subtle range between health and disease and mental health and psychopathology. Human behavior to the unknowing, because of unconscious motivations, appears inexplicable and even threatening. The psychological differences are usually in degree, not kind,43 frustrating those dentists who prefer clear-cut and quantifiable answers. Many dentists simply defend against these painful, frightening, or upsetting emotions of their patients and turn their attention to “the procedure.” Optimal care for difficult patients, for the phobic patient, the patient with orthognathic surgery, the patient with a TMJ disorder, the patient with facial pain and trauma, or the patient seeking esthetic improvement is virtually impossible without paying strict attention to psychosocial dynamics.
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SUMMARY A psychoanalytic developmental perspective is a most useful theoretical construct to understand the emotional significance of the mouth and its interdependent relationship with mental health and dental health care. This article highlighted the role and influence of all aspects of the oral cavity and its clinical essence-a pleasing smile. The continuing ability of dentists to assist their patients with an appealing and physically attractive appearance contributes significantly to body image, positive self-concept, and enhances social interactions, which further augment healthy child and adult personality development. These ideas are well expressed by a woman dental patient who at 53 years of age completed orthodontic treatment for an extreme malocclusion and periodontal problem. “A beautiful smile-a marvelous self-confident broad smile exposes a healthy mouth. In my estimation, nothing tells more about a person than his mouth as he smiles or talks. It tells the world how he feels about himself, whether he likes others, how healthy he is, physically and mentally, and of course, whether his dentist is worth a plug nickel. My healthy smile is my instant passport to acceptance from my fellow man.” REFERENCES 1. Goldstein
2. 3. 4. 5. 6. 7. 8.
9.
10. 11. 12. 13.
RE. Esthetics in dentistry. Philadelphia: JB Lippincott Co, 1987. Guerini V. A history of dentistry from the most ancient times until the end of the eighteenth century. New York: Milford House, 1969. Fastlicht S. Dental inlays and fillings among the ancient Mayas. J Hist Med Allied Sci 1962;17:393. Baldwin DC. Appearance and aesthetics in oral health. Community Dent Oral Epidemiol 1980,5:244-56. Terry RI, Davis JS. Components of facial attractiveness. Percept Mot Skills 1976;42:918. Linn EL. Social meanings of dental appearance. J Health Human Behav 1966;7:289-95. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 19’70;40:284317. Shaw WC, Addy M, Ray C. Dental and social effects of malocclusion and effectiveness of orthodontic treatment: a review. Community Dent Oral Epidemiol 1980;8:35-45. Reisine ST. Social, psychological, and economic impacts of dental conditions and treatments. In: Cohen L, Bryant P, eds. Social science and dentistry. The Hague: Quintessence, 1984;387-425. Sheets C. Modern dentistry and the esthetically aware consumer. J Am Dent Assoc (Special issue on esthetics) December, 1987. Gochman DS. Traumatic encounters, self-concept, and perceived vulnerability to dental problems. J Public Health Dent 1977;37:95-9. Stricker G. Psychological issues pertaining to malocclusion. Am J Orthod 1970;58:276-83. Ament P, Ament A. Body image in dentistry. J ~ROSTHET DENT 1970;24:362-6.
14. Albino JE, Cunat JJ, Fox RN, Lewis EA, Slakter MJ, Tedesco LA. Variables discriminating individuals who seek orthodontic treatment. J Dent Res 1981;60:1661-7. 15. Klima RI, Witteman JK, McIver JE. Body image, self-concept, and the orthodontic patient, Am J Orthod 1979;75:507-16.
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16. Alvi HA, Agrawal NK, Chandra S, Rastogi M. A psychologic study of self-concept of patients in relation to artificial and natural teeth. J PROSTHET DENT 1984;51:470-5. 17. Moore BE, Fine BD. A glossary of psychoanalytic terms and concepts 2nd ed. New York: The American Psychoanalytic Association, 1968. 18. Jacobson E. The self and the object world. New York: International Universities Press, 1965. 19. Freud S. The ego and the id. The complete psychological works of Sigmund Freud. Standard edition 19, London: Hogarth Press, 1923. 20. Hartman H. Ego psychology and the problem of adaptation. London: Image, 1939. 21. Tyson RL. The roots of psychopathology and our theories of development. J Am Acad Child Psychiatry 1986;25:1-12. 22. Freud S. Three essays on the theory of sexuality. The complete psychological works of Sigmund Freud. Standard edition 7. London: Hogarth Press, 1905. 23. Freud S. Inhibitions, symptoms and anxiety. The complete psychological works of Sigmund Freud. Standard edition 20. London: Hogarth Press, 1926. 24. Freud S. An outline of psychoanalysis. The complete psychological works of Sigmund Freud. Standard edition. London: Hogarth Press, 1940. 25. Emde RN. From adolescence to midlife: remodeling the structure of adult development. J Am Psychoanal Assoc 1985;33 (suppl):59-112. 1917. 26. Shelley M. Frankenstein, 27. Sandler J, Dare C. The psychoanalytic concept of orality. J Psychosom Res 1970;14:211-22. 28. Bosma JF. Oral sensation and perception: the mouth of the infant. Springfield, 111: Charles C Thomas, 1972. 29. Hoffer W. Mouth, hand and ego-integration. Psychoanal Study Child 1949;3/4:49-56. 30. Piaget J (1936). The origins of intelligence in children. 2nd ed. New York: International Universities Press, 1952. 31. Erikson EH. Eight ages of man. In: Childhood and society. New York: WW Norton, 1963. 32. Bowlby J. Attachment. New York: Basic Books, 1969. 33. Mahler MS, Pine F, Bergman A. The psychological birth of the human infant. New York: Basic Books, 1975. 34. Greenson R (1954). About the sound “MM”. In: Explorations in psychoanalysis. New York: International Universities Press, 1978. 35. Call JD. Some prelinguistic aspects of language development. J Am Psychoanal Assoc 1980,28:259-89. 36. Abraham K. The influence of oral eroticism on character formation. In: Selected papers on psychoanalysis. London: Hogarth, 1927. 37. Spitz R. The first year of life. New York: International Universities Press, 1965. 38. Piaget J. Play, dreams, and imitation in childhood. New York: WW Norton, 1962. 39. Hoffer W. Development of the body ego. Psychoanal Study Child 1950;5:18-23. 40. Levinson N. Our smiles, ourselves: the psychology of dental health. Chicago: American Dental Association, 1986. 41. Colarusso C, Nemiroff R. Adult development: a new dimension in psychodynamic theory and practice. New York: Plenum Press, 1981. 42. Colarusso C, Nemiroff R. The race against time: psychotherapy and psychoanalysis in the second half of life. New York: Plenum Press, 1982. 43. Brenner C. An elementary textbook of psychoanalysis. New York: International Universities Press, 1955. Reprint
requests
to:
DR. NADINE A. LEVINSON 30131 TOWN CENTER, STE. 216 LAGUNA NIGUEL, CA 92677
491
dental
health
care: A
Nadine A. Levinson, D.D.S.* University of California, Irvine, School of Medicine, Irvine, Calif. A developmental perspective is presented to explore dental health and esthetics in dentistry and to describe the speci5c ways human behavior and various aspects of esthetic health care interrelate. An investigation of the fascinating links between mind and mouth over the life cyclehh are elucidated to explain how and why the oral cavity is so psychologically important. Clinical examples of how personality factors can influence dental treatment and its outcome are illustrated. (J PROSTHETDENT
1990$34:486-91.)
H*
&&ally, dentistry as a profession has been associated with the biomechanical complexities of dental health care emphasizing preventative and restorative treatment of hard and soft structures. With new advances in research, diagnosis, treatment, and dental materials, a more sophisticated perspective of dental health care has evolved. Today, a modem view of dentistry is one that recognizes another crucial ingredient, the emotions or psychological essence of the patient in relationship to the dental situation, dental health care, and especially, esthetics. The role of emotional and personality factors in esthetics of the face and mouth is a complex and complicated one. Several articles have comprehensively reviewed the relationship of esthetics to oral health from historic,‘” psychosocial,4-g and economicgp lo perspectives. Other articles have attempted to describe end quantify more abstract concepts including body image, self-image, and self-concept, and their enhancement from improved dental and facial appearance. 11-16However, paradoxical findings have emerged in some studies reflecting the average clinical situation, which indicate that other, more elusive psychological factors influencing perception, self-concept, and personal motivation must also be considered. For example, although many teenagers rate attractiveness as important, many are found to have appalling dental behaviors and compliance problems in and out of the dental office. How can one explain the paradoxical response of patients with a “successful” orthognathic surgery who afterward become dissatisfied, depressed, and may even compulsively seek other consultations, more surgical procedures, or legal remedy? What about denture patients who
Presented at the American Academy of Esthetic Dentistry meeting, Lsguna Niguel, Cslif. *Associate Clinical Professor, Department of Psychiatry and Human Behavior; Clinical Associate, San Diego Psychoanalytic stitute, San Diego, Calif. 10/1/21776
486
In-
fail to accept their dentures, although the result is technically, esthetically, and functionally excellent? As all clinicians know, psychological changes can occur with the most minor esthetic revision on an anterior tooth or from a radical surgical repair of a severe maxillomandibular disfigurement. Dentists treat individuals with their personal, idiosyncratic reactions. These responses are determined by the structure of the patient’s personality and his or her developmental needs, expectations, concerns, and conflicts. This article elucidates the interrelationship between development, personality, and its manifestations in the dental situation. A few basic definitions from Moore and Fine’s’? Glossary of Psychoanalytic Terms and Concepts would be helpful in understanding more about the psychology of personality. The term “personality” refers to the characteristic or predictable ways the individual responds to life situations-his or her attitudes and habits. These characteristics evolve consciously and unconsciously and are based on a compromise between one’s wishes and a need to limit their expression. A primary function of the personality is to maintain a stable relationship between the person and his or her environment. Whereas “personality” refers to what is observed behaviorally, the “self” is a conceptual term that refers to an internal or mental representation of what a person thinks of him or herself as a total person-a psychophysiologic total. These images are constructed from the direct experience of sensations, emotions, thoughts, and from the indirect perceptions of the bodily and mental self.18 Patients having a realistic image of the self will correctly mirror their capabilities and their limitation. But sometimes these images can be unrealistic and distorted according to an individual’s wishes or defensive needs. For example, a 45year-old man feeling the impact of his midlife crises, sought orthodontics and bonding to try and capture his waning youth and virility. The dental treatment was more than adequately rendered with positive es-
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thetic results. However, the man kept returning and complaining that “the eye teeth are not bulky enough. . . I want more protuberance.” The external dental situation could not repair or make up for the inner sense of inadequacy and the wish to stand out in a crowd, which had plagued this man for a lifetime. Self-esteem or healthy narcissism is a positive psychological interest in the self but not to the exclusion of others. Pride and pleasure of one’s own body and mind are signs of healthy self-esteem. Injury to one’s self-esteem, or a part of the body, narcissistically invested, can cause anger and rage, thus accounting for some of the extreme, negative responses despite providing “good-enough” dentistry.
A PSYCHOANALYTIC DEVELOPMENTAL PERSPECTIVE: A BIOPSYCHOSOCIAL MODEL A psychoanalytic developmental perspective is helpful in understanding how and why a healthy smile is so essential to the overall emotional well-being of our patients. A psychoanalytic developmental perspective is one that emphasizes the importance of the mouth at all stages of development in the life cycle, from infancy through old age. With this approach, personality development, character, defenses, wishes, habits, and behaviors are viewed as emerging from an interaction and interdependence of biological and constitutional growth with environmental experience.lg>2oThe psyche emerges from a biological matrix, the mouth and its functions being a vital somatic constituent, and is characterized by transformations, progressions, and regressions, where there are many silent steps that are influenced by critical growth periods, timing, intensity of interactions, and most importantly, in the context of human relationships21 The final integration of bodily, mental, and social experiences over the life cycle make up the functioning personality. A more complicated psychoanalytic developmental theory has always existed, as opposed to the reductionistic caricatures portrayed by nonanalysts who inaccurately describe pathologic behaviors as being derived from sexual fixations at the oral, anal, or phallic level of development. An example of such a caricature took place at a major dental meeting where a prominent scholarly prosthodontist proposed his version of a so-called psychoanalytic model. He stated that the temporomandibular joint (TMJ) myofascial dysfunction of his patient was caused by a fixation at the oral phase because the patient didn’t get enough time to suck at the breast. Then later he never went on to develop more appropriate sexual behaviors. At 20, as an alternative to “being blind,” the patient started bruxing. This erroneous review of psychoanalytic theory mistakenly assumes that the only function of the mouth is a sexual or incorporative one, as emphasized by Freud22 in his seminal, but early essay, “Three Essays on the Theory of Sexuality.“22 In this essay, Freud discussed the sexual na-
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ture of the mouth in sucking and thumb-sucking. Particularly upsetting to many dentists was his assertion that thumb-sucking was an autoerotic, masturbatory equivalent. However, this was the first essay that systematically discussed infantile sexuality. Later articleslg* 23124 amended his previous psychosexual theories by examining the importance of the environment and important relationships. These inaccurate contentions are the result of several common problems and resistances to the incorporation of new information into any scientific discipline. All scientific fields progress through a developmental infancy where ideas and theories are first proposed. With time, these ideas are scrutinized, clarified, and subsequently revised by new ideas or by a change of emphasis of old ideas. Current developmental theory is still in a state of conceptual developmental flux with the continuing integration of new and old observational, psychobiological, and laboratory resea.rch.25 A contemporary psychoanalytic view of infantile sexuality and orality and its psychological manifestations is far richer and more complex and encompasses more than psychosexuality. The mouth and smile play a crucial role in the creation and maintenance of positive attitudes about the self and have tremendous emotional significance. In our society, the mouth has become a symbol for the total self. A smile is a window into the personality. Consider how a young child learns about emotions and feelings by assuming that the few essential lines of a mouth represent the person, for example, a happy face or a sad face. Expressions such as “a smile is worth a thousand words” or “she set her jaw in determination,” convey the use of the mouth as a metaphor for the total person. Dental advertisements emphasizing the need for whiter, brighter teeth also send a clear message. “If our mouths are beautiful, then so is the rest of us, and then, like the model with the beautiful smile, we will be happy, attractive, and successful.” The underlying meaning is that the mouth and a beautiful smile are the representation of an ideal of psychological, physical, and social adequacy. Dentists play an essential role in facilitating this ideal by magically transforming the unattractive, dowdy, and grotesque into an attractive, desirable individual. In most cases, the patient’s psychological welfare, selfesteem, and self-image are affected by these esthetic changes. The patient also lives in a social world and how he or she looks plays a role in influencing his or her interactions with others. Mary Shelley’s26 story of Frankenstein is a literary case in point. Although Frankenstein was born looking monstrous, he was not originally evil, but was gentle and kind. Like most people, he yearned for human love and affection. Only in time, after being rejected for looking repulsive and grotesque, did the monster begin to act congruent with his outward monstrous appearance. As Frankenstein poignantly self-observed, “I can not believe that I am the same creature whose thoughts were once filled 487
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Table I. Functions
of the mouth over the life cycle Toddler
Infancy 1. Nutritive interests 2. Pleasure interests
Sucking/ breast-feeding Thumb-sucking/ oral games
3. Crying 4. Language
x x Babbling One word Communication
5. Cognition
Oral games
6. Attachment
X (basic trust) Loving (sucking) vs hating (biting)
7. Oral anxiety Separation anxiety
Drinking (weaning) Mouthing
Latency
Adolescence
X (eating) X (eating/ drinking) Eating (X) Foreplay/ kissing
X Two words X (language proper) x x Introduction X (dental health care) X X
Loss of baby teeth X (body vulnerability)
X
X X [swearing]
Young adult
Midlife
Elderly
X
X
X
X
X
X
Wine tasting, gourmet indulging, smoking X X X X X X X
X X
X X
X
X Sexuality
Resolution-tolerance of ambivalence in human relationships X X Intimacy Loss of youth Loss of attractiveness
8. Oral Loving (sucking) vs conflicts hating (biting) Eating control struggles Dental self-care vs dental noncompliance
9. Self-esteem
X (social smile)
Dental Loss of control Oral perversions compliance /noncompliance Body image concerns X Eating disorders X X X X X X (love of body/self) X X (vs peer) X (vs lack of care) X X (love of body/care)
with sublime and transcendent visions of the beauty and majesty of g00clness.“26 By enabling the dental patient to acquire an appealing physical appearance and a pleasing smile, the dentist will also be promoting a positive socialization experience that supports and affirms a healthy self-concept. There is an ongoing and reciprocal feedback mechanism in which one’s feelings about oneself are influenced and reflected by how one reacts ta others and how others react back. The prototype of this meaningful affective feedback loop begins in the first few weeks of life. After being nursed, most babies will show a smile of satisfaction. That smile becomes linked to the mother who feeds and cares for the baby. The mother, knowing she has satisfied her infant, smiles back. This important psychological landmark, the reciprocal social smile, represents a mutual radiance and inner source of pleasure that is the basis for self-esteem for infant and parent. The same affective experience, derived from the first smile, occurs in the dental situation when the dentist and patient smile at one another after the dentist completes and the patient accepts a successful procedure. The current psychoanalytic meaning of sexuality (and
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X X
X Tooth periodontal loss
Denial of aging
X
X X X X
X X X
incidentally, not very different from Freud’s usage) includes all aspects of sensuality, pleasure, and self-fullillment. The term “orality” refers to all feelings, thoughts, sensations, and a myriad of experiences and behaviors involving the mouth. 27 During each stage of development from infancy through adulthood, the mouth takes on new and different meanings and functions (Table I). It is these changing aspects of orality that inspire the development of the personality. A developmental framework tells us about children and adults from a functional point of view, a perspective that considers constitutional, biological, genetic, and interacting experiential factors, rather than chronological or statistical factors. The remainder of this article will examine some of these significant functions and meanings of the mouth and will endeavor to see why and how they are clinically important to dentists and their patients.
IMPORTANT FUNCTIONS OF THE MOUTH DURING INFANCY The mouth at birth is a well-developed sensory and perceptual organ with vital physiologic and homeostatic func-
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II. Functions of the mouth in infancy: Infancy (birth to 2% years) during the oral phase
tions such as breathing, crying, sucking, and swallowing28 (Table II). Crying, which requires respiration, signals need states such as hunger or discomfort. Sucking is used for the intake of nutritive sustenance. However, sucking and later thumb-sucking are self-regulative functions for quieting and soothing oneself.2g Swallowing incorporates the nutriments of the world, and this is the prototype of stimulus nutriment acquisition and the basis for future intelligence.30 There is an elaborate cortical and hypothalamic representation of these functions and the emotional and affective experiences connected with them. These earliest oral experiences, which are at first self-preservative, form the basis for a positive sense of self and for future attitudes about the mother, the father, the world, and the ability to trust and love.31 Attachment is the bonding established during the nursing experience in which the mouth is the site of emotional and empathic linkage with others.32 Major problems with attachment are illustrated by infants with cleft palate and lip where the physical appearance of the baby affects reciprocal bonding between parent and infant. Breastfeeding and weaning, two important oral experiences, play a major role in attachment and separation with the attainment of a stable sense of self and trust of others. Although there is a physiologic birth of the human infant, it takes several years before the psychological development of separation and individuation can occur.33 The mouth makes verbal and nonverbal communication possible. Infants cry as a signal to express hunger or discomfort; they make “mm” sounds at the breast as one of the earliest sounds of pleasure.34 Learning to speak occurs via the oral mode, by important oral games such as “the raspberry game.“35 Eventually, the mouth is used to express complex ideas and emotions that include both loving and hating feelings.36 The baby experiences, embraces, and explores the world with its mouth, which is also a prehensile mouth.37 Renee Spitz37 poetically referred to the mouth as the “cradle of perception.” Through touching, feeling, and being felt (the tongue in the mouth does it all simultaneously), the infant defines his own body image and identity and differentiates himself from the world around him. These early oral sensorimotor experiences form the basis for thought and mental representation.38 Analytic research has clearly demonstrated the importance of the mouth for this early differentiation of self from the external world and from
Table
others
A 23-year-old predental student wanted to have all his anterior teeth restored with ceramicsto closea small gap between his anterior teeth. He also wanted surgery to change his chin protuberance, although the oral surgeon felt his facial appearancewasmore than satisfactory. The patient was demanding and urgently wanted the procedures.What washisfantasy? He believed that he would not get into dental school unlesshe had an attractive smile. Additionally, he felt that if he were a dentist, and wassuc-
162%
37,39
The consolidation of body image and self-representation, resulting from different developmental tasks involving the mouth, takes place throughout the life cycle (Table I.).4o After infancy, during latency, loss of baby teeth and the acquisition of permanent teeth signals the shedding of babyhood and many orally-based anxieties. In adolescence, there is a recapitulation of early body image concerns heralded by preoccupation with the face, mouth, and espe-
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Self-preservation Breast-feeding andweaningby mother,with 1. Sucking eventualability to feedself Thumb-sucking,self-stimulation,andselfregulation 2. Breathing Respirationto language 3. Swallowing Eating, sensation,and perception,leading to self-objectdifferentiation Eventually takeson signallingfunction 4. Crying Attachment Basictrust (suckingand biting) resolved ambivalence Communication BabblingBeginninglanguageacquisition Crying Oral games Smiling Sensorimotor actionsasprecursorsto Cognition thoughts30 a. Oral reflex movements b. Perception,sensation;feed nutrimentto stimulusnutriment c. Greaterself/objectdifferentiation d. Self and objectpermanence Beginningself/objectdifferentiation Self-concept Differentiation through oral feedings, games, andotheraspects of maternalcare Self constancy33/object constancy33 Self-esteem Reciprocalsocialsmile(takesplaceduring feedingand games) Oral anxiety Lossof caretaking(soothing,feedingobject) (separation) Lossof love of object anxiety) Increasingbody(oral)vulnerabilityto damage
cially the smile.Love of self/body is augmentedby respect of body and body care.
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With the young adult, intimacy, finding a mate, and finding a career are the main developmental tasks. Issues of appearancefor the young adult are crucial. However, a neurotic preoccupation with facial and dental appearance may be usedto avoid other narcissistic concerns.
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cessful, he Clearly, his appearance compensate he felt.
would do better with women and friends. preoccupation with his anterior gap and facial and the need to make it perfect, was to for and change the internal or emotional gap
ADULTHOOD In the mid-40s the effecta of an aging body and an aging mouth can be a source of narcissistic injury or can lead to a more realistic appraisal of the body?and the wish to take care of it. The normative conflict is between denying the aging process and acceptance of the loss of the young body.4O Many adults seeking dental treatment want to maximize function and esthetics. For others, it can mean magical repair of their body and denial of the aging process. There can be several conceivable symbolic meanings for the hypothetical case of a 40-year-old woman who seeks orthodontic treatment. Is it to help replace her husband after she has just undergone a second divorce? Is it to replace him with her dentist to whom she keeps returning for one adjustment after another and then for one more surgery? Is it to compete with her young, attractive, and luscious 17-year-old daughter? Is it to obtain better function and esthetics? Or is it to obtain what she never could obtain when she was younger? Any and all of these meanings are possible, and even multiple meanings can exist for this same woman.
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In the elderly, there is generally a loss of function and esthetics, with sagging lips, irregular teeth, and broken or chipped teeth. The loss of teeth no longer symbolizes the loss of babyhood as with the latency age child, but symbolizes the loss of power to defend against the awareness of death and the passage of time.41* 42Esthetic and functional procedures at this age can be meaningful and can restore an inner glow caused by the patient’s having a more pleasing smile. Another meaning that dentists convey by simply being involved in treatment for the aged is the metacommunicative message that we have not given up on the elderly and that there is hope and that they are not worthless and inconsequential.
DISCUSSION The maintenance of healthy and esthetic oral structures over a lifetime is important for psychological as well as for physical reasons. These vignettes of dental patients throughout the life cycle elucidate the influence of past and present development, internal self-perceptions, self-concept, body image, feelings, motivation, and relationships with others as governing the specific ways human behavior and dental health interrelate. There is an oscillating, reciprocal relationship between how patients look, function, and feel, since mind and body are complexly and inextricably interrelated. A developmental framework and
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the specification of normative developmental tasks and conflicts is a useful explanatory model illuminating these complex relationships. Meaning is given to clinical dental problems, and particularly in those areas where changes in body image, facial appearance, facial pain, and anxiety occur. These meanings are interwoven in a developmental context, the knowledge of which will enhance our diagnostic and treatment skills. In addition to the routine history and physical examination including chief complaint, present illness, past medical, and past dental history, family, personal and social history, a psychologically-oriented dental history of the personal significance and importance of the mouth should be described and detailed. It is in a knowledge of the multiple and complex meanings of the patient’s early and later development that a better awareness of what the patient wants can be discerned and this knowledge will facilitate optimal provision of what can be realistically expected. Certainly some of the negative, paradoxical responses in spite of “good-enough” technical results can be avoided. Although these responses are rare, they can be intense and malignant for both the patient and the dentist. However, another even more interesting question to be raised might be why are there so many successes in individuals who seem somewhat emotionally vulnerable? A developmental perspective provides understanding of potential psychopathology as well as mental health. One of the predominant normal developmental tasks at all phases of the life cycle is to work through these narcissistic, changing body image issues. Adaptation to the changes in the body, including the mouth and the smile, may be one of the most important tasks for mental and dental health. The education and practice of modern dentistry can no longer ignore the importance of human behavior and the role of developmental experience in mental and dental health. Even the most routine procedures can be emotionally significant for patient and dentist. In order that dentists feel more comfortable with the feelings of their patients, they must have a firm grounding in the study of human behavior, psychological mechanisms, and the subtle range between health and disease and mental health and psychopathology. Human behavior to the unknowing, because of unconscious motivations, appears inexplicable and even threatening. The psychological differences are usually in degree, not kind,43 frustrating those dentists who prefer clear-cut and quantifiable answers. Many dentists simply defend against these painful, frightening, or upsetting emotions of their patients and turn their attention to “the procedure.” Optimal care for difficult patients, for the phobic patient, the patient with orthognathic surgery, the patient with a TMJ disorder, the patient with facial pain and trauma, or the patient seeking esthetic improvement is virtually impossible without paying strict attention to psychosocial dynamics.
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SUMMARY A psychoanalytic developmental perspective is a most useful theoretical construct to understand the emotional significance of the mouth and its interdependent relationship with mental health and dental health care. This article highlighted the role and influence of all aspects of the oral cavity and its clinical essence-a pleasing smile. The continuing ability of dentists to assist their patients with an appealing and physically attractive appearance contributes significantly to body image, positive self-concept, and enhances social interactions, which further augment healthy child and adult personality development. These ideas are well expressed by a woman dental patient who at 53 years of age completed orthodontic treatment for an extreme malocclusion and periodontal problem. “A beautiful smile-a marvelous self-confident broad smile exposes a healthy mouth. In my estimation, nothing tells more about a person than his mouth as he smiles or talks. It tells the world how he feels about himself, whether he likes others, how healthy he is, physically and mentally, and of course, whether his dentist is worth a plug nickel. My healthy smile is my instant passport to acceptance from my fellow man.” REFERENCES 1. Goldstein
2. 3. 4. 5. 6. 7. 8.
9.
10. 11. 12. 13.
RE. Esthetics in dentistry. Philadelphia: JB Lippincott Co, 1987. Guerini V. A history of dentistry from the most ancient times until the end of the eighteenth century. New York: Milford House, 1969. Fastlicht S. Dental inlays and fillings among the ancient Mayas. J Hist Med Allied Sci 1962;17:393. Baldwin DC. Appearance and aesthetics in oral health. Community Dent Oral Epidemiol 1980,5:244-56. Terry RI, Davis JS. Components of facial attractiveness. Percept Mot Skills 1976;42:918. Linn EL. Social meanings of dental appearance. J Health Human Behav 1966;7:289-95. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 19’70;40:284317. Shaw WC, Addy M, Ray C. Dental and social effects of malocclusion and effectiveness of orthodontic treatment: a review. Community Dent Oral Epidemiol 1980;8:35-45. Reisine ST. Social, psychological, and economic impacts of dental conditions and treatments. In: Cohen L, Bryant P, eds. Social science and dentistry. The Hague: Quintessence, 1984;387-425. Sheets C. Modern dentistry and the esthetically aware consumer. J Am Dent Assoc (Special issue on esthetics) December, 1987. Gochman DS. Traumatic encounters, self-concept, and perceived vulnerability to dental problems. J Public Health Dent 1977;37:95-9. Stricker G. Psychological issues pertaining to malocclusion. Am J Orthod 1970;58:276-83. Ament P, Ament A. Body image in dentistry. J ~ROSTHET DENT 1970;24:362-6.
14. Albino JE, Cunat JJ, Fox RN, Lewis EA, Slakter MJ, Tedesco LA. Variables discriminating individuals who seek orthodontic treatment. J Dent Res 1981;60:1661-7. 15. Klima RI, Witteman JK, McIver JE. Body image, self-concept, and the orthodontic patient, Am J Orthod 1979;75:507-16.
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16. Alvi HA, Agrawal NK, Chandra S, Rastogi M. A psychologic study of self-concept of patients in relation to artificial and natural teeth. J PROSTHET DENT 1984;51:470-5. 17. Moore BE, Fine BD. A glossary of psychoanalytic terms and concepts 2nd ed. New York: The American Psychoanalytic Association, 1968. 18. Jacobson E. The self and the object world. New York: International Universities Press, 1965. 19. Freud S. The ego and the id. The complete psychological works of Sigmund Freud. Standard edition 19, London: Hogarth Press, 1923. 20. Hartman H. Ego psychology and the problem of adaptation. London: Image, 1939. 21. Tyson RL. The roots of psychopathology and our theories of development. J Am Acad Child Psychiatry 1986;25:1-12. 22. Freud S. Three essays on the theory of sexuality. The complete psychological works of Sigmund Freud. Standard edition 7. London: Hogarth Press, 1905. 23. Freud S. Inhibitions, symptoms and anxiety. The complete psychological works of Sigmund Freud. Standard edition 20. London: Hogarth Press, 1926. 24. Freud S. An outline of psychoanalysis. The complete psychological works of Sigmund Freud. Standard edition. London: Hogarth Press, 1940. 25. Emde RN. From adolescence to midlife: remodeling the structure of adult development. J Am Psychoanal Assoc 1985;33 (suppl):59-112. 1917. 26. Shelley M. Frankenstein, 27. Sandler J, Dare C. The psychoanalytic concept of orality. J Psychosom Res 1970;14:211-22. 28. Bosma JF. Oral sensation and perception: the mouth of the infant. Springfield, 111: Charles C Thomas, 1972. 29. Hoffer W. Mouth, hand and ego-integration. Psychoanal Study Child 1949;3/4:49-56. 30. Piaget J (1936). The origins of intelligence in children. 2nd ed. New York: International Universities Press, 1952. 31. Erikson EH. Eight ages of man. In: Childhood and society. New York: WW Norton, 1963. 32. Bowlby J. Attachment. New York: Basic Books, 1969. 33. Mahler MS, Pine F, Bergman A. The psychological birth of the human infant. New York: Basic Books, 1975. 34. Greenson R (1954). About the sound “MM”. In: Explorations in psychoanalysis. New York: International Universities Press, 1978. 35. Call JD. Some prelinguistic aspects of language development. J Am Psychoanal Assoc 1980,28:259-89. 36. Abraham K. The influence of oral eroticism on character formation. In: Selected papers on psychoanalysis. London: Hogarth, 1927. 37. Spitz R. The first year of life. New York: International Universities Press, 1965. 38. Piaget J. Play, dreams, and imitation in childhood. New York: WW Norton, 1962. 39. Hoffer W. Development of the body ego. Psychoanal Study Child 1950;5:18-23. 40. Levinson N. Our smiles, ourselves: the psychology of dental health. Chicago: American Dental Association, 1986. 41. Colarusso C, Nemiroff R. Adult development: a new dimension in psychodynamic theory and practice. New York: Plenum Press, 1981. 42. Colarusso C, Nemiroff R. The race against time: psychotherapy and psychoanalysis in the second half of life. New York: Plenum Press, 1982. 43. Brenner C. An elementary textbook of psychoanalysis. New York: International Universities Press, 1955. Reprint
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