Recognising the emotional effects of tooth loss

Recognising the emotional effects of tooth loss

MOST general dental practitioners extract teeth as a routine part of their work. Such action is usually undertaken reluctantly, but once accomplished the dental practitioner and patient are faced with the challenge of whether or not to replace the missing tooth, and, if so, how best to do it. Periodontal health, caries susceptibility, occlusion and a myriad of other factors will all be carefully assessed in coming to a decision. Yet a factor that is often overlooked, or only briefl y considered, is the possible psychological impact that the loss of teeth, or even a single tooth, can have on people.

The loss of one or more natural teeth has long been recognised as a serious life event that can result in signifi cant disability by impacting on daily living activities, including chewing food adequately, preferred food selection and speech.1-3 These factors, plus possible changes in facial appearance, can lead people to avoid social situations. But what about the adjustment and psychological reactions to tooth loss?

Stages of bereavement

A study has shown that reactions to tooth loss follow a similar pattern to that which follows the loss of other body parts or the death of a loved one. The fi ve stages in this bereavement process are denial, anger, depression, bargaining and fi nally acceptance of the situation.4 These feelings will be refl ected in the patients’ comments.4

The fi rst stage of loss is denial and is refl ected in statements such as “I was utterly dismayed of course and disbelieving. I couldn’t believe it”. This is closely followed by anger, “I was really angry with the dentist because I really thought he could have saved them [my teeth]”. The third stage of bereavement is depression. Patients may make comments such as, “It made me very gloomy”, or “The end of the world – totally the end of the world. I didn’t want to go on. I didn’t know what to do”.

Bargaining is the stage of grief where people tell themselves that things are not a bad as they might seem. One patient stated, “I suddenly thought this is silly. I’ve got to pull myself together. I realised there are other people much worse off than me – everything is relative”. Acceptance is the fi nal stage, “Once it’s done, it’s done. You can’t go back on it, can you? You know you’ve got to go forward”.

The length of time it takes to complete this progression varies from person-to-person. Some people accept their tooth loss without any diffi culties whilst others never come to terms with their loss. Such people are often angry and depressed at what has happened and their subsequent dental treatment can present a considerable challenge.4

Common themes

A study of the literature shows a number of common themes with tooth loss impacting on self-confi dence, appearance and self-image. For some people it is associated with the ageing process and marks the beginning of their mortality. Tooth loss is often seen as a taboo subject which cannot be discussed with family or friends. As a consequence, it is something that the individual feels the need to keep secret and is the very reason why a number of people will ignore advice about not wearing dentures during the night. People who wear dentures can also sometimes express feelings of fear and panic in situations, including the dental surgery, where dignity is lost because dentures have to be removed. The same feelings can occur if a bridge or implant retained prosthesis has to be removed. It can be seen in the patient who sits in the dental chair and covers their mouth with their hand when their dentures are removed.4

Behavioural changes

Tooth loss can affect the way people behave. Some behaviour changes such as those related to eating and smiling are well-documented. The less well-documented are possible behaviour changes related to kissing and forming close relationships with people feeling embarrassed to kiss and worried about how potential partners will feel about their tooth loss.4 Studies which have examined the emotional effects of tooth loss indicate that between 40 to 50 per cent of people taking part experienced some diffi culties in accepting their tooth loss, and, of these, between 20 to 50 per cent had still not accepted their loss after a period of at least one year.5,6

In response to a question about how they felt when they lost teeth, those individuals who experienced diffi culties in accepting their tooth loss expressed a wider and more complex range of emotions compared to those who had no diffi culties.

Sadness, depression and feeling old were three commonly identifi ed emotions. Relief that it was all over was the over-riding feeling amongst the group who had no diffi culties. It is perhaps not surprising that the other group experienced feelings such as lack of self-confi dence more strongly. This group was also more likely to feel disadvantaged when carrying out a range of activities. They were more likely to restrict their choice of food as well as enjoy it less. They were also more likely to avoid eating in public and avoid forming close relationships.

Reactions to tooth loss

Cultural pressures and the expectations of society are likely to infl uence the way people react to their tooth loss. The more common tooth loss is within a society, the less likely it is that it will be accompanied by emotional effects. This is to some extent borne out by a study looking at the emotional effects of tooth loss between a group of people in Dundee, Scotland and a similar group in South East London.7,8 It was found that the group in Scotland (where tooth loss was more common) was less likely to have diffi culties accepting their tooth loss, whilst the London group took longer to come to terms with their tooth loss and were more likely to feel less confi dent as a result of that loss.

A preliminary study of the emotional effects of tooth loss in Saudi Arabia found considerable acceptance, with tooth loss accepted as an inevitable part of ageing.9 It was suggested that this was partly due to an acceptance of what fate had in store due to the strong influence of religion in the society.9

It would be logical to suggest that the method used to replace the missing teeth is likely to infl uence the long term emotional effects of tooth loss. All the people in the studies referred to in this article suffered from extensive tooth loss and were wearing either complete or partial dentures. It is well recognised that removable prostheses can present the wearers with considerable challenges compared to either bridgework or implant retained prostheses. Removable prostheses can be diffi cult to wear successfully and the need to remove them for cleaning is as a constant reminder of the tooth loss and reinforces the individuals’ feelings about that loss.

However it should be noted that about half of the individuals who stated that they had diffi culties accepting their tooth loss also expressed the view that they felt their dentures to be part of themselves. It is therefore clear that whilst dissatisfaction with dentures will play a part in people’s reaction to tooth loss it cannot account for the whole picture.

There is clearly a need to extend these studies to include people who have had their missing teeth replaced with either bridgework or implant retained prostheses to determine if their use results in less lasting emotional distress. There is also a need to extend the studies into an environment away from dental hospitals. It is likely that such groups of patients will contain some challenging cases resulting in a higher number of people who have diffi culties accepting their tooth loss. In a study undertaken in Hong Kong, looking at the emotional effects of tooth loss in community dwelling elderly people, 22 per cent of the participants reported diffi culty accepting their tooth loss.10 This was half the number in a group of people attending Hong Kong Dental Hospital for the provision of dentures to replace their missing teeth.

However, even allowing for these points, it should be recognised that tooth loss can have a profound impact on the lives of some people and that it affects more people than is realised. It should make us question how we can prepare people for tooth loss and how we can help them accept it.