Original article

Impact of tooth loss on the quality of life

Maria Vieira de Lima Saintrain1 and Eliane Helena Alvim de Souza2

1
Collective Health, University of Fortaleza, Fortaleza, Ceará, Brazil; 2Department of Dental Public Health, University of Pernambuco, Recife,
Pernambuco, Brazil

doi: 10.1111/j.1741-2358.2011.00535.x
Impact of tooth loss on the quality of life of elderly people
Introduction: There is scientific evidence that shows health contributes to the quality of life. These
measurements have not been well guided towards the free response of oral health in people’s lives.
Objective: This study aimed to investigate the impact of tooth loss on the quality of life of elderly people.
Material and methods: Qualitative investigation with descriptive features – which used a random
sample out of the total edentulous elderly people, who lived in an institution in Fortaleza, Brazil – was
carried out. From 250 residents screened, 72 completely edentulous elderly, with ages from 60 to 79 years
were selected. A semi-structured questionnaire was used with closed and opened questions in which the
last one was used for the free flow of the interviewee’s responses. The content was analysed and codified
according to Bardin.
Results: In total, 84.7% had attended the dentist to have exodontia. Of them, 81.9% reported difficulties
after losing their teeth. Physical dimensions, characterised by the difficulties in eating and social dimen-
sions, because of interference in communication with other people were obtained.
Conclusion: Tooth loss causes disorder in the individual’s quality of life, mainly when it affects their well-
being and appearance.

Keywords: oral health, tooth loss, elderly, quality of life.

Accepted 29 November 2010

index9, components of self-reported oral health and

Introduction
According to Buss1, there is a great deal of scientific
evidence that shows the contribution of health to
the quality of life of people.
There are oral diseases in all population groups,
which are strongly related to age, and as people get
older they increase in prevalence and severity. The
goals established by the World Health Organisation
(WHO) concerned with dental caries have been
used in different countries to find ways to minimise
the social consequence of oral diseases2.
In dentistry, there is also extensive research and
measurements to evaluate the quality of life:
development and evaluation of oral health impact
profile3, oral health quality4, impact of dental
conditions on patients’ quality of life5, evaluation
of subjective oral health status indicators6, assess-
ing oral health-related quality of life: findings from
the normative ageing study7, the development of
measures of dental impacts on daily living8,
development of the geriatric oral health assessment
general health in racial and ethnic groups10 among
others. However, those measurements have not
been well guided towards free responses and eval-
uation of the oral health condition as well as its
repercussions on people’s lives.
The population survey11 shows that the oral
diseases, mainly dental caries and periodontal dis-
eases, are still major public health problems. These
two conditions cause major problems that affect the
quality of life, as dental caries and periodontal
disease may lead the individuals to tooth loss.
Brazil reached the desired goals from the WHO in
oral health by the year of 2000, but only up to the
age of 12 years11. In all other ages, oral health
conditions are below these goals, mainly because of
edentulism, and they are getting worse as people
get older. It is expected that decreasing caries in
children will have positive effects in the medium
and long term as well as the conditions of the
health of adult, even though it is not possible to
state that it is going to happen12.

e632  2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e632–e636

Investigation into the conditions that provide
good quality of life for people as well as the varia-
tions of the age is of great social and scientific
importance, besides providing and generating
alternatives towards interventions which are aimed
at the well-being of the elderly13.
Quality of life is defined by the WHO as ‘indi-
viduals’ perceptions of their position in life in the
context of the culture and value systems in which
they live and in relation to their goals, expecta-
tions, standards and concerns’14. Thus, several
factors have the potential to influence the quality
of life of a person, including oral health.
Good oral health should include the absence of
facial pain, ability to chew properly, ease of
ingestion and digestion of food. This should also
contribute to communication, especially when
speaking and smiling, which have the potential to
increase the self-esteem of people15.
Quality of life means maintaining the possibilities
that people have been enjoying through their
life16. To Sheiham17, oral health problems probably
have many more similarities related to an individ-
ual’s quality of life and in personal well-being than
the ability of the person to perform daily activities.
Starfield18 states that the health of an individual
or population is determined by their genetic com-
bination and it is largely modified by the physical
and social environment and their behaviour which
is culturally and socially determined by the atten-
tion that was given to health.
Nowadays, in Brazil, only 10% of people from 65
to 74 years of age have 20 or more teeth11. How-
ever, the Ministry of Health has launched a pro-
gramme ‘Brasil Sorridente’, and expectations have
been raised to achieve an improvement in the
Brazilian population’s oral health conditions that
might be effective in minimising the damage
caused by poor dental conservation among most of
the Brazilian elderly people.
Epidemiological studies about health from the last
20 years show that the improvement related to oral
health has been considered slow for most Brazilian
adults and elderly people. The purpose of this study
was to investigate the impact of tooth loss on peo-
ple’s quality of life within this context on a group of
elderly people, taking into account some individual
perspectives, as well as evaluating the importance
that was given to the dental elements.
Methodology
The study was based on a qualitative investigation
with descriptive and exploratory aspects, which
involved a sample of edentulous people through
 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e632–e636
Impact of tooth loss on the quality of life e633
the study of convenience. The residents who par-
ticipated were from an institution that takes care of
elderly people located in the county of Fortaleza,
Ceará, Brazil. Two hundred and fifty residents were
screened; 72 completely edentulous elderly people
were selected by age, which varied between 60 and
79 years old and they belonged to the socio-eco-
nomic class with low income. Most of them were
retired and received the minimal wage and others
depended on philanthropic support. The variants of
the study were obtained from the primary data
through the interviews, when they were used as a
research tool. A semi-structured questionnaire
without nominal identification of closed and
opened questions was used, with the last one being
to allow for the free flow of the interviewee’s
responses. The criteria of inclusion were individuals
aged 60 years old or more, edentulous and who
were able to answer the questions. Two conductive
questions were asked: 1) what is the major problem
caused by the loss of the teeth, based on your own
experience? 2) how do you feel without your
teeth? Interviews lasting 1–2 h each were con-
ducted during routine clinical activities and were
enriched with participant observation.
In this study, the qualitative analysis of the con-
tent is to highlight the important data of the inter-
viewee’s responses and to co-operate with the
understanding of the attitudes, competence and
social relations within dentistry. According to
Minayo19 (p.17) ‘nothing could be intellectually
considered a problem whether this would not be
firstly a problem from the daily life’. The author
considered that the phenomenon or social process
had to be understood within their determinations
and transformations, which were given by the
individuals.
The data interpretation was carried out by
the interviews towards a descriptive analysis of the
interviewees’ responses that was interpreted by
the content. A researcher recorded the patient’s
responses as brief handwritten notes on a prepared
form, expanded into descriptive text immediately
afterwards. After repeated readings, its content was
analysed and codified according to Bardin20. The
responses were interpreted against a theoretical
backdrop on ageing, medical and community den-
tistry.
The interviews were made under free agreement
and explanation. All the interviewees were initially
informed about the research objective and the
importance of their reports to have a deeper
knowledge about people’s feelings, their difficulties
and anxieties relating to the loss of their teeth and
the repercussion on their quality of life. The
e634 M. V. L. Saintrain, E. H. A. Souza
research protocol was approved by the Committee
of Ethics in Research from the University of Fort-
aleza in May of 2003.
Results and discussion
Within the 72 participants, 50 (69.4%) were wo-
men and 22 (30.6%) were men. More than half
(54.2%t) had not graduated from elementary
school and only seven (9.7%) of them had gradu-
ated from elementary school. With regard to mar-
ital status, 24 (33.3%) were widowed, 17 (23.6%
were married, 17 (23.6%) were single and 14
(19.5%) were separated or divorced. With regard to
their origin, 41(56.9% elder people came from the
cities and 31(49.1%) migrated from rural commu-
nities. All the participants were edentulous; only 38
(52.8%) used a dental prosthesis and the remain-
der had no prostheses.
From the 72 elderly people who were inter-
viewed, only 11 (15.3%) stated that they had
gone regularly to the dentist. Most of them
(84.7%) had gone to the dentist to have extrac-
tions. Throughout the reports relating to the
answers which were given to the question ‘what
is the major problem caused by the lack of teeth,
based on your own experience?’ it was possible to
group the participants into two dimensions: one
with a negative impact and another with a posi-
tive one.
In the first situation, more than two-thirds of the
interviewees 59 (81.9%) reported difficulties after
losing their teeth. Most of them reported that they
were more concerned with the physical level than
the social level.
… Lord takes out the teeth, but he widens the
throat… We ourselves eat like animals…
The ultimate dehumanisation of human beings
is atrocities of war which animalises the body of
the enemy21. In oral health, edentulism may lead
to dehumanisation of the patient who is deprived
of food for their needs, as the interviewees
reported:
… Everything seems to be as a whole… To eat care-
fully… We have to tear the meat with the hands,
otherwise we have to eat everything well-cooked…
For these researchers22–27, tooth loss is the result
of a complex interaction of dental diseases, lack of
preventive measures, poverty, faulty nutrition and
hunger, access barriers, inadequate treatment and
much more. Within this context, the interviewees’
response was:
.… Unfortunately we can¢t eat all sort of food… It is
very sad, when a person can¢t eat... I can¢t eat hard
brown sugar made of sugar cane… I can¢t suck sugar
 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e632–e636
cane either… nor chewing naturally… We wish we
could bite, but we can¢t…
Researchers showed that depression associated
with both lower quality of diet and lower self-
assessment scores included decreased appetite28, as
reported in an individual’s response:
… The digestion of food… The food is not chewed
enough… everything becomes heavy… and disturbs
our sleepiness...
Researchers showed in the distribution of
responses to the OHIP-14 items that 37.3% of the
patients have painful mouths and 32.3% feel
uncomfortable eating any kind of food29.
Tooth loss and communication
limitation
The social representation was marked by the most
remarkable comments from the interviewees.
…The speech gets blurred; the pronunciation of the
words is different… I get embarrassed when I have to
talk to someone… That is, when a person is toothless;
he puts the hand over the mouth in order to cover it…
… After taking out my teeth, I couldn¢t meet my
boyfriend anymore… I was ashamed of him… I star-
ted crying… There are so many gap-toothed people…
The fact is that I am one of them…
…There are so many… The toothless people don¢t
worth anything… The face gets ugly… It gets older…
The mouth gets thinner… Toothless means to be ugly,
horrible…
…It is very good to have your own teeth… I miss them
a lot… I feel well with my denture… With my denture
I feel complete…
In these responses, the denture represents the
importance of the teeth which were lost.
Foods such as nuts, apples and raw carrots
cannot be eaten easily by over half the edentu-
lous. Daily intake of non-starch polysaccharides,
protein, calcium, non-haem iron, niacin, vitamin
C, intrinsic and the milk sugar was significantly
lower in this group. Plasma ascorbate and retinol
were significantly lower in the edentulous than
dentate patients, affecting intakes of nutritional
status30.
With regard to the dimension of the positive
impact, 13 elderly people (18%) answered that
they felt relieved after tooth extraction. From this
dimension, emerged the category below.
Pain relief because of tooth loss
… It was a relief… It was the best thing, have no
toothache anymore… When I used to have my teeth, I
had so much headache… I couldn¢t sleep well… I

have swollen face… I used to have all kind of herbs to
relieve the pain…To take out the teeth was the best
thing I did, because I don¢t suffer with toothache
anymore… The toothache is strong …
In the research of Fleck et al.13, the importance of
eating well and having an appetite were considered
relevant to the evaluation of elderly people’s
quality of life. In this context, the need for dentures
also remains associated with the influence of oral
health in establishing relationships31.
Nowadays, it is understood that collective
health represents the direction to improve the
quality of life and the population’s health as a
priority of the Agenda 2132. It is urgent and
necessary to discuss the problem related to health
in the social, collective and public field to
incorporate effectively the complex ‘promotion-
health-disease-care’ under a new pragmatic per-
spective through public health policies with
effective society participation33. According to Esan
et al.34, edentulism is attributed to low educational
level as well as the patient’s social and economical
status.
Research about the perception of the conditions
of elderly people’s oral health concluded that
agreements between the needs that are defined
clinically and subjectively are not so huge. The
objectivity offered by elderly patients is useful as
complementary evaluation for clinical information
to identify those who need educational, preventive
and curative actions35,36.
The information offered by the second conduc-
tive question ‘how do you feel without your teeth?’
is somewhat similar to the first one ‘what is the
major problem caused by the teeth loss, based on
your own experience?’.
Personal experience regarding tooth
loss
I¢m getting used to it… God will help me… I¢m
adapting myself… It is difficult to chew... I can¢t eat
well…The denture has to be used… Gosh, it is very
bad…To swallow like an animal… There is a lack… It
is like a punishment… I never get used to… It is
somewhat strange… I miss them… tasteless… Well,
because of the pain relief… I don¢t suffer anymore… I
don¢t have bad breath anymore...
The analysis of the situations presented by el-
derly people in relation to ‘how do you feel
without your teeth?’ is agreed by Dolan37 when
the author defines oral health as the absence of
pain and infection as a result of a functional and
comfortable dentition which could be natural or
prosthetic that let the individual play his social
 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e632–e636
Impact of tooth loss on the quality of life e635
role. Pinto38 says that the fundamental problems
such as edentulism have strong social and eco-
nomical roots and could only be well understood
and explained when the edentulous are heard and
when self-diagnosis and opinions from these
people are respected. In this context, Saintrain
and Lopes39 point out the importance of identi-
fying the fragmentations of the current oral health
system as well as finding operational ways to
contribute to the improvement of the population’s
oral health.
Conclusion
Tooth loss causes disorder in the quality of life of
the individual, especially when it affects their well-
being, appearance and nutritional status. The
elderly people in this research contributed signifi-
cantly through their reports for the strengthening
of new ways of observing dentistry, which is
essential to the improvement of the health profes-
sional considering people’s belief and knowledge,
as well as their perception of values.
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Correspondence to:
Maria Vieira de Lima Saintrain, Rua Irmã Simas,
100 apto 201 Bloco A. Varjota, CEP: 60165-220,
Fortaleza, Ceará, Brazil.
Tel.: +55(85)32673220
E-mail: mariavieira@bol.com.br