Media & news

Shame, guilt and toothlessness

by: Dr. Bjorn Klinge

On treating the edentulous patient with respect as well as good oral care

The mouth, teeth and toothlessness collectively comprise an emotionally charged subject to say the least. Poor oral health is generally associated with shame and guilt. While the individual tries to hide such a predicament as much as possible, the opinion of the rest of the world is usually unmistakable: “It is your own fault! Poor oral health is self-inflicted, so you have no one but yourself to blame!” It’s not that simple, of course.

The Swedish author Per Olov Enquist writes in the beginning of his book Ett annat liv (A Different Life) of a mother who is associated, because of her edentulism, with “a teacup holding a prosthesis; she lost her teeth already at the age of seventeen. She never talks about this, doesn’t want to acknowledge the shame of it all, but when she laughs, her laughter is oddly restrained and unnerving, as if she still felt the shame.”

In my daily work I often meet this shame and self-reproach among desperate people who are about to lose their teeth because of disease, and among patients with ill-fitting, loose dentures that display the disgrace they’re trying to hide. I want to share with you some of the experiences that are especially etched into my memory.

The first story is about a grandson and his grandmother. The grandson, Christer, has heard that missing teeth can be replaced with implants and talks to us about his beloved grandmother and her toothlessness. He wonders if we can help her with new, bone-anchored teeth.

Grandmother loves to treat her extended family to dinner, and prepares quite a feast on Sundays. Over the years, Christer has noticed that his grandmother rarely sits with her family to enjoy the good food and fellowship around the table. There always seems to be something that needs to be done in the kitchen, keeping her away from her plate. A bowl needs to be refilled with gravy, more potatoes need to be served, or there is simply too little meat left on the serving plate.

When she serves herself, she always dishes up a miniscule portion and never spends more than a few moments at her seat. She moves the food around a bit to make it look like she is eating, but in fact she never takes a single bite. When he gets a chance to be alone with his grandmother, Christer confronts her with his observations. At first she hesitates to reply, but then she admits to the desperation she feels about her edentulism and ill-fitting dentures, and how anxious she is about being exposed as toothless. She is not prepared to bear this disgrace, not even in front of her closeknit family.

For years, she has struggled to conceal her situation. She never eats a meal with other people, even though she loves the social interaction around a table and has actually learned to enjoy mashed and finely cut food.

Like being reborn

This story has a happy ending. We operate and prepare a prosthesis, providing the grandmother with titanium implants in place of her lost natural tooth roots, and on top of them, we screw on a dental bridge. Christer’s grandmother describes the experience as being reborn. At one annual visit after the other, she tells me of some new aspect of the life she can now enjoy because of her bone-anchored teeth. Another story is about homelessness and edentulism, personified by a man named Pontus.

Our research group at Karolinska Institutet in Stockholm was involved in a project concerning the health of the homeless. It soon became clear that one of the main problems of this group—in addition to homelessness—is oral disease.

Previously, Pontus led a fairly normal life including work, home and a family. As a result of substance abuse, he lost everything and ended up among the homeless. To put it mildly, he neglected his oral health as a result of his addiction. Eventually, all that Pontus had left of his teeth were a few rotten root fragments.

After countless meetings with social workers and health care professionals, Pontus described how disgusted they all were by his rotten mouth, and how they were even reluctant to look him in the face. Eventually, Pontus came under the care of Dr. Patricia de Palma, a dentist in our group. She cleaned up his mouth and provided Pontus with a new denture. As he makes his way back from the fringes of society, Pontus says that the people he now encounters at Social Services seem happy to see him.

He is no longer invisible. They see him, meet his gaze and smile at him; and Pontus smiles back. He now has a place to live, a job, new friends, and he is back in touch with his daughter. This is not all due to his new teeth, of course, but Pontus claims that, for him, new teeth have meant the difference between life and death.

Like in the movies

When I had listened to a number of stories in which patients described the significance of their teeth and mouth to their lives in general, I felt at times uncertain.

Could the mouth and its contents really mean so much? I needed some first-hand experience, and knew exactly what to do. I turned to one of our skilled dental technicians, Jan Ringvall, who often makes special effects teeth for the movies and the theater, and asked him to make something out of the ordinary for me.

The appliance he designed could be worn over my natural teeth and made it look as if I were missing some front teeth and was suffering from advanced periodontal disease, gingivitis, loose teeth, tartar and plaque. I wore this “prosthesis” in a variety of social contexts, always with the same result: As soon as I revealedthese teeth with even the hint of a smile, people recoiled with disgusted looks on their faces and turned away.

Their relief was palpable when I removed the teeth. I was met with smiles, nervous laughter and often a hug. I found the strong reactions that my practical joke evoked disturbing, yet the experience did help me to better understand how important good teeth and a healthy mouth are to one’s quality of life.

At one point, I was scheduled to participate in a debate in an early morning TV show. The Minister of Social Affairs at the time and I were going to discuss the importance of good teeth as a social class identifier. As I was waiting in the green room for our turn in the TV studio, I drank a cup of coffee, browsed through a magazine and slipped my theatrical appliance into my mouth to see what kind of reaction I’d get. The two hosts, a man and a woman, came in to welcome us.

The woman approached diagonally from the front, while her male colleague stood behind me. There were a few of us sitting around a coffee table when she asked for the professor in dentistry. I rose, stretching out my hand, and smiled. She backed off, apparently terrified, right into the wall, murmuring something about a misunderstanding.

I took out the false teeth and she looked at me with wide-eyed relief. Her co-host, commenting on the incident, said it was a shame that there were no TV cameras to capture her reaction of disgust, which he would have loved to show their viewers. Interestingly, the woman refused to acknowledge her response, claiming to have been totally unaffected, much less disgusted, by a guest on the show.

As she did her best trying to save face, I found myself also wishing that the scene had been captured in pictures—not to humiliate her, but to demonstrate that the mouth is indeed a very sensitive subject, and that we treat people very differently depending on how we assess their teeth and gums. Just how strong an impact oral status has on social interaction can be seen very clearly in how oral healthcare is managed in nursing homes and other, similar facilities. Several studies show that oral healthcare is strongly neglected there. Sometimes the staff as training in oral healthcare and understands how essential it is, yet neglect the patients’ oral hygiene nevertheless. It is not that they lack knowledge; it’s just that they perceive their patients’ mouths as repulsive.

Change is imperative

We must change this attitude. As the population grows older, after all, we will find ourselves increasingly dependent on professional care at the end of our lives. Many of us want to die with teeth in our mouths—but certainly not in mismanaged, filthy mouths—and preferably not with a set of dentures in a glass of water onour bedside table. Several studies have shown the importance of the mouth and teeth for the quality of life. Many people find the prospect of losing one or more teeth demoralizing. The importance of appearance, function and self-esteem Edentulism is often named when people are asked what they most hope to avoid in life.

“To lose all my teeth” is as frightening a prospect, at least for women, as the possibility of breast cancer or the complete loss of one’s hair. The loss of teeth may prove painful in a number of different ways, as one is deprived of appearance, function and self-esteem. Edentulism sometimes leads to poor self-confidence and an altered self-image. An individual who loses teeth is likely to become less satisfied with his or her appearance, and it’s not a subject that is easy to discuss with others.

Most people, in fact, are unwilling to fully disclose their dental problems to others—often not even to close relatives and friends. People who have lost teeth sometimes alter their patterns of social interaction, and the manner in which they approach intimacy. Missing teeth are kept secret. Not too long ago, someone stolemy trick dentures. It doesn’t matter much; I still have my real teeth, after all; and in the long run, I wouldn’t want anyone to think that I’m making fun of the disabled.

They served their purpose, giving me a better understanding of the indignities that many other people are forced to suffer. For people with poor oral health, it’s not a question of fun and games in a TV studio. They have to live every day with the humiliating consequences of their situation, the demoralizing reactions of people around them, and their own deep feelings of disgrace. We who practice implant dentistry have an opportunity to change their world for the better, but with that opportunity comes a responsibility to respect the inevitable vulnerability of each edentulous patient we meet.

More to explore:

Originally published in Swedish as a chapter in Munnen, Tänder, kropp och själ (The Mouth, Teeth body and soul), the abridged text above has been translated from the Swedish original by Frederic Love. For readers of Swedish, the book is available from Karolinska Institutet University Press, ISBN 978-91-85565-29-0 and can be ordered via: www.kiup.se

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