The man had spent a lifetime terrified of dentists. By the time he was in his 70s, his teeth were in such bad shape that several had broken off at the gum line and become infected. Realizing he would finally have to take action, he turned not to a dentist but to psychologist Bruce Peltier, PhD, MBA.

Over the course of almost a dozen sessions, Peltier taught the man self-hypnosis to relax and then used systematic desensitization to help him overcome his dental phobia. At the first session, for instance, the man imagined himself making a dental appointment. At the next, he imagined himself driving to the dentist's office and sitting in the waiting room. This rehearsal continued with ever-increasing detail until the man could finally imagine himself undergoing tooth extraction. When the time came for the actual surgery, Peltier accompanied the man to the dentist's office, helped him maintain a trance state and held his hand throughout the procedure. The operation was a success.

"The patient was proud, and the dentist felt good about it," says Peltier, an associate professor of psychology at the University of the Pacific School of Dentistry in San Francisco. "There's a lot psychologists can do for dentists, their staff and their patients."

Peltier is one of a growing number of psychologists who are working with dentists to enhance patients' health. Collaborative activities range from addressing the psychological causes of ostensibly dental problems to helping patients adapt to tooth loss to helping patients like Peltier's get to the dentist in the first place. Psychologists can also help the dental team to communicate and interact more effectively with patients and each other. At the same time these psychologists are helping patients, they're also helping their practices by moving beyond the reach of managed care.

Grin and bear it

Helping patients overcome their fear of dentistry is the most obvious overlap between psychology and dentistry, says Peltier.

Dental procedures can be uncomfortable, he admits, and negative media images of dentists don't help. Nor do childhood memories of old-school dentists, who often did things like hold their hands over the noses and mouths of unruly children until they settled down. Some people just hate the loss of control that occurs during dental procedures.

"If you weren't a little nervous about going to the dentist, we'd probably call you counter-phobic," Peltier laughs. "Being afraid to go to the dentist is more typical than not."

For some, says Peltier, fear crosses the line into phobias that threaten not only patients' oral health but their breath, self-esteem and even eating habits. With recent reports linking gum and heart disease, ignoring oral health could even be life-threatening.

Teaching future dentists how to keep patients free from fear occupies the bulk of Peltier's time.

The boiled-down version of his message? Slow down and give patients as much control as possible. Charge by the hour instead of by the filling, if necessary. Let patients decide large and small things, such as when to take breaks, how much work to do at one sitting and what time of day to schedule appointments.

"Although many dentists aren't aware of this, psychologists can provide enormously helpful assistance with phobic, anxious or difficult patients," he says.

Psychologists can also help dentists with patients' self-esteem issues, says psychologist Judith E.N. Albino, PhD, a former dental school faculty member who is now president of the California School of Professional Psychology in San Francisco. Albino's work focused on the relationship between self-esteem and orthodontic treatment.

"The majority of orthodontic treatment provided is not absolutely necessary from a dental point of view," says Albino. "The question is whether it's necessary from a psychological point of view."

Say a teen-aged patient insists on braces even though her teeth aren't that crooked, says Albino. A psychologist can determine whether there's been a critical incident that has made the patient self-conscious about her teeth or whether there's a more deep-seated self-esteem problem. Based on the psychologist's assessment, the patient might choose psychological counseling or some minimal orthodontic intervention.

Even problems that seem to be purely dental in nature can benefit from psychological treatment, says Albino.

Take temporomandibular disorder (TMD), a joint problem that can result in symptoms ranging from limited jaw function to clicking noises in the jaw to pain in the jaw, head or even back. Dentists have traditionally treated TMD as a physiological problem, says Albino. But patients often give up using appliances worn at night to prevent grinding, and surgery to replace the joint has left some patients unable to chew or even talk. Psychologists can not only help patients learn to relax their jaws, says Albino, but can also help them address the stress that underlies the clenching and grinding.

Psychologists can help dental patients even after they've lost their teeth, says research psychologist Neal R. Garrett, PhD, associate professor of advanced prosthodontics and co-director of the Weintraub Center for Reconstructive Biotechnology at the University of California, Los Angeles, School of Dentistry.

About 20 percent to 35 percent of denture recipients remain dissatisfied despite receiving clinically acceptable dentures, says Garrett. He and hiscolleagues are trying to find out why--and find solutions to complaints about function, appearance, pain, looseness, pressure and gagging. These problems have psychological ramifications as well, says Garrett, noting that patients often develop inhibitions about eating or even speaking with others.

Finding solutions is urgent, adds Garrett, noting that the rapid growth of the over-65 population will mean that the number of people with dentures will increase even as the rate of tooth loss drops. And baby boomers will face special challenges, he predicts. Not only are they more self-conscious about their looks, he says, but they'll also be losing their teeth later in life. That means they'll be trying to adapt to dentures at the same time they're facing other health-related challenges.

Psychologists can help, says Garrett, noting that psychologists could do everything from helping people adjust to dentures to conducting research on prosthodontics. "The field is wide open," he says.

Mutual benefit

That's good news to Elaine Rodino, PhD, president of Div. 42 (Independent Practice) and a private practitioner in Santa Monica, Calif.

The division has been encouraging practitioners to collaborate with other professionals.

Dentists make especially good partners because dentists don't tendto rely heavily on managed care as their source of payment, says Rodino. If a dentist recommends a psychologist, patients are likely to see thatcare as part of their dental treatment without expecting managed care to cover it.

What's more, most psychologists already have a potential partner.

"We all have a dentist--or we should," says Rodino. "We're all in contact with someone who can be a referral source for us. It's a mutual benefit."

The trick is to teach dentists how to make referrals without alarming patients. Enamel loss caused by frequent vomiting often makes dentists the first to spot bulimia, Rodino notes, but they're typically afraid to say anything. Psychologists can encourage dentists to call them for advice about making referrals, says Rodino.

"When psychologists have relationships with dentists, it helps both their practices," she adds. "And obviously it helps their patients, too."

To order copies of a marketing brochure outlining the benefits of psychologist/dentist collaborations, call Div. 42 toll-free at (877) 603-4000. Brochures can be customized with your contact information for an additional charge.

Rebecca A. Clay is a writer in Washington, D.C.