Tooth Loss and Mental Health

Tooth loss is associated with poorer psychological wellbeing, including higher depressive symptom scores and reduced oral health-related quality of life (Gerritsen et al., 2010; Matsuyama et al., 2021). Matsuyama et al. (2021) reported causal evidence from a population-wide natural experiment suggesting that tooth loss increases depressive symptoms in US adults, independent of measured confounding factors such as age and socioeconomic status.

Systematic review evidence further supports an association between oral health and depression. Tooth loss, oral pain, and impaired oral function have been consistently associated with increased depressive symptoms, and greater tooth loss has been linked to higher odds of both the onset and progression of depression (Karimi et al., 2024). The relationship is likely complex and may be bidirectional: depression can affect oral hygiene, dental attendance, diet, and salivary factors, while tooth loss, oral pain, and impaired oral function may contribute to psychological distress (Karimi et al., 2024).

Systematic reviews have also shown that tooth loss is associated with impaired oral health-related quality of life, with the severity of impact influenced by the number, location, and distribution of missing teeth (Gerritsen et al., 2010). In addition, people with severe mental illness experience a higher burden of advanced dental disease and tooth loss compared with the general population (Kisely et al., 2011).

Among edentulous patients, tooth loss has both functional and psychosocial consequences. Complete denture therapy may improve function and quality of life for many patients, but outcomes vary and are influenced by clinical, anatomical, psychological, and social factors (Allen & McMillan, 2003; Oweis et al., 2022).

Several biological and psychosocial pathways have been proposed to explain the relationship between tooth loss and mental health outcomes.

Psychosocial mechanisms may include altered facial aesthetics and self-perception, impaired speech, dietary restriction, embarrassment, and reduced participation in social eating. These factors may contribute to social withdrawal and reduced quality of life (Allen & McMillan, 2003; Gerritsen et al., 2010; Karimi et al., 2024).

Physiological mechanisms may include nutritional compromise due to masticatory impairment, chronic oral discomfort, oral pain, and inflammatory processes that have been implicated in both oral disease and depression (Allen & McMillan, 2003; Karimi et al., 2024).

Tooth loss and poorly functioning dentures can affect nutrition, communication, social participation, and emotional wellbeing (Allen & McMillan, 2003; Gerritsen et al., 2010). Healthcare professionals outside dentistry may be the first to recognise these impacts, particularly in older adults, people with chronic illness, and those living in residential aged care.

Difficulties with chewing, speech, or denture comfort may contribute to reduced dietary intake, frustration, social withdrawal, and low mood (Allen & McMillan, 2003; Karimi et al., 2024). Awareness of these relationships can help clinicians identify when oral health issues may be contributing to broader wellbeing concerns.

Healthcare professionals may observe signs suggesting oral health is affecting a patient's emotional or social wellbeing. These may include: avoiding meals or eating slowly; reluctance to speak, smile, or engage in conversation; complaints about dentures or difficulty chewing; restricted diet or reduced appetite; frustration related to eating or speaking; and withdrawal from shared meals, particularly in residential care settings.

These signs are consistent with reported functional, social, and psychological impacts of tooth loss and denture difficulties (Allen & McMillan, 2003; Gerritsen et al., 2010; Karimi et al., 2024).

Where these signs are present, dental review may be considered. If low mood, social withdrawal, or emotional distress appear significant, referral for further assessment, including mental health support where appropriate, may also be considered.

Psychological distress can influence how patients perceive and report treatment outcomes. Patients who are anxious, experiencing low mood, or socially isolated may find it more difficult to adapt to new dentures and may report dissatisfaction even when treatment has been technically well delivered (Allen & McMillan, 2003; Oweis et al., 2022).

Dissatisfaction with dentures does not necessarily indicate a problem with the dental appliance itself. Broader psychosocial factors, including patient expectations, emotional state, previous denture experience, adaptability, and social context, can influence how oral health is experienced and reported (Allen & McMillan, 2003; Oweis et al., 2022).

Clear expectation-setting and supportive follow-up are important components of care, particularly for patients experiencing emotional difficulties. Where multiple health concerns are present, interdisciplinary collaboration may improve overall outcomes (Karimi et al., 2024; Oweis et al., 2022).

Oral health-related quality of life is a multidimensional construct encompassing functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. It is commonly assessed using validated instruments such as the Oral Health Impact Profile (Gerritsen et al., 2010; Oweis et al., 2022).

Edentulous patients treated with conventional complete dentures often report improvements in oral health-related quality of life following treatment; however, some continue to experience psychological and social limitations despite technically satisfactory prostheses (Allen & McMillan, 2003; Oweis et al., 2022).

Clinicians may recognise that patient-reported dissatisfaction with dentures, particularly where clinical quality appears adequate, can be associated with a range of factors, including psychological and social influences, rather than prosthetic factors alone (Allen & McMillan, 2003; Oweis et al., 2022).

Psychological and psychosocial factors can influence denture satisfaction and adaptation. Patient expectations, emotional state, previous denture experience, adaptability, and social circumstances have been identified as relevant factors alongside clinical considerations such as denture quality, anatomical support, retention, stability, comfort, and chewing ability (Allen & McMillan, 2003; Oweis et al., 2022).

Patient satisfaction with removable prostheses can also be influenced by aesthetics, comfort, chewing ability, speech, previous denture experience, number and location of missing teeth, and denture type (Awawdeh et al., 2024; Oweis et al., 2022).

Patients presenting with elevated anxiety or depressive symptoms may require a longer adaptation period, more frequent review appointments, and clear expectation-setting at the outset of treatment. Where psychological distress is suspected, use of a validated screening approach already in routine practice, or liaison with the patient's GP, may help identify those who would benefit from concurrent mental health support (Karimi et al., 2024).

Motivational interviewing techniques and collaborative goal-setting may also support patient engagement and self-efficacy during denture rehabilitation.

Routine prosthetic consultations can provide an opportunity to recognise factors that may affect a patient's wellbeing, particularly in older or socially isolated individuals. When discussing treatment options, clinicians may consider observable changes such as social withdrawal, reduced participation in meals, embarrassment, or signs of emotional distress (Allen & McMillan, 2003; Karimi et al., 2024).

Open-ended questions such as "How has this been affecting your day-to-day life?" or "Are you finding this is getting you down?" can facilitate discussion without adding formal screening burden.

Where significant distress is identified, referral to the patient's GP or a mental health professional is appropriate.

Dissatisfaction with prosthetic outcomes, particularly where technical quality appears adequate, can be associated with a range of factors, including psychological and social influences. Repeating or remaking prostheses without considering these factors may not address the patient's concerns (Allen & McMillan, 2003; Oweis et al., 2022).

Where psychological distress may be present, patients can be encouraged to consult their GP, who can assess their needs and, where appropriate, initiate a Mental Health Treatment Plan under Medicare. Eligible patients may be able to access subsidised sessions with a psychologist or other eligible mental health professional.

For patients requiring immediate or low-barrier access, Medicare Mental Health can be contacted on 1800 595 212. Additional supports include Beyond Blue on 1300 22 4636 and MindSpot, which offer accessible mental health information, assessment, and support options.

Clinicians are not expected to provide mental health treatment; however, early identification and appropriate referral represent an important component of holistic patient care.