The experience of tooth loss and the need for oral public health work in a rural part of Zimbabwe

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The experience of tooth loss and the need for oral

public health work in a rural part of Zimbabwe

Ida Hedberg

Anna Kristoffersson

Supervisors:

Björn Axtelius, Veronica Johansson

Thesis in Odontology (30 ECTS)

Malmö University

Dentistry program

Faculty of Odontology

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Abstract

Tooth loss may have a big impact on a person’s life. The aims of this study were twofold: examine how people, when seeking dental care at a volunteer clinic in Zimbabwe,

experienced losing teeth and the subsequent effects of this on their lives. For this purpose, semi-structured interviews were conducted at a clinic in Zimbabwe with 19 patients participating. To examine how oral public health work can be pursued in a rural part of Zimbabwe observations at rural schools, city schools and from the volunteer clinic were performed.

According to this study, chewing ability, different social and psychological qualities of life was not correlated to the number of remaining teeth. There was a considerable variation between the individuals own experiences and attitudes.

It is of great importance to expand the public health programs in these areas to establish a long-term positive effect on the patient’s oral health. The main problem in the future is to get the information and instructions to lead to a permanent change of patients' health care habits.

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Sammanfattning

Att förlora tänder kan ha en stor inverkan på en människas liv. Syftet med denna studie var dels att undersöka hur människor, som söker tandvård på en volontärklinik i Zimbabwe, upplever att förlora sina tänder. Studien berör även vilken effekt detta har på deras liv. Semistrukturerade intervjuer utfördes på volontärkliniken med 19 deltagande patienter. Ett ytterligare syfte var att undersöka hur oralt folkhälsoarbete kan bedrivas i en del av Zimbabwe med lågt socio-ekonomiskt status. Studien omfattar observationer vid skolor på landsbygden, stadsskolor och från volontärklinik.

Enligt denna studie är inte antalet tänder korrelerat till tuggförmåga eller sociala och psykologiska livskvaliteter. Det fanns en betydelsefull spridning mellan individer gällande upplevelser och attityder.

Det är av stor vikt att utöka offentliga hälsoprogram inom dessa områden för att etablera en långsiktigt positiv effekt på patienters munhälsa. Det största problemet i framtiden är att få information och instruktioner att leda till en permanent förändring av hälsorelaterade vanor.

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List of content

Abstract ... 2

Sammanfattning ... 3

Introduction ... 5

Material and method ... 6

Results ... 9

Discussion ... 19

Conclusions ... 22

Importance of the project ... 22

Recommendations for future studies ... 22

References ... 23

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Introduction

Tooth loss affects life in several aspects. Studies have shown that quality of life is

significantly reduced when people have less than 10 teeth in each jaw arch. Different views on which teeth are necessary for a satisfactory oral functioning have been presented. The Swedish Council on Health Technology Assessment, SBU, has stated that incisors, canines and premolars are sufficient, while Nguyen et al have stated that bilateral occluding molars are needed for adequate chewing ability (1,2).

The psychological problems with tooth loss are similar for those who have lost all their teeth compared to those who have lost only a few. Common social and psychological problems correlated to tooth loss are feeling less confident, having physical problems when speaking, avoiding laughing in public and avoiding forming close relationships. These complications are not short-lived and can affect people in a long-term perspective (3). The psychological and social problems may even lead to and initiate a depression (4). It has been found that women and men respond differently to losing teeth. Men generally care less about having natural teeth than women. Niesten and Yiengprugsawan concluded that women had more problems with oral health affecting their quality of life (5,6). Difficulties with chewing involve

limitation of food choice, enjoying food less and problems with swallowing (7,8). Aesthetics is even rated over function by many patients (9). A study in 11 US states showed that patients with missing teeth were more likely to have an unhealthier diet (10). The patients with

perceived problems also did not feel prepared for the tooth loss and thought that an explanation from the dentist would have helped (8).

Dental caries and periodontitis represent the major causes of tooth loss. In Zimbabwe, the prevalence of both diseases was high but its severity was low when Frencken et al studied this in 1995. The most common treatment for dental caries was extraction because of the

prevalence of unmet treatment needs. The need for information about oral health was estimated as high (11,12).

There are limitations in the previous studies. These studies results cannot be generalized since oral health related quality of life (OHRQoL) has a cultural and socio-economic dimension (11,13,14). Further, the emotions of people who seek help from volunteer clinics have not been explored.

Public oral health was defined by Downer et al (1994) as “The science and art of preventing oral disease, promoting oral health and improving the quality of life through the organized efforts of society”. It is also stated that several different disciplines need to be involved for effective promotion of oral health, such as sociology, psychology, health related behavior, epidemiology, health economics, health promotion and health service organizational methods. The historical development of public health in western countries can be divided into four phases. The first one being 1750-1830 is defined by the construction of statistics of the population which lead to an interest to promote survival, fertility and personal hygiene in order to keep the population growing. This was the start of the society taking responsibility for the preventive health work. The second phase during 1800 included the health relation to external factors and the impact of society. The new bacterial findings gave start to a wave of public health work to prevent infectious diseases. The third period during 1900th_{, health} condition was considerably improved in the west. Access to food improved and health centers was built to ease medical care. Vaccines and programs to administrate them to the public was invented. WHO was established in 1948 as an international health official and the health of the global population was in the purpose of the organization. The fourth period from 1970,

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6 Lalonde suggested that the focus should be changed from diseases to health. Lifestyle became a more important discussion compared to other factors. The aim of public health now is to change the environments to a health promoting setting. This include schools and cities. The promotion embrace personal skills for health protection and strengthen community action (15,16). Dentist Without Boarders concentrate mostly on information and instruction in groups and with local teachers with the hope to improve the individuals skills and knowledge about oral health.

Objectives

The first aim of this study was to examine how people, seeking dental care at a volunteer clinic in Zimbabwe, experience losing teeth and the effects on their lives. The second aim was to examine how the local oral public health work is pursued in a rural part of Zimbabwe and if there is a further need to develop this.

Question at issue

How does people, seeking dental care at a volunteer clinic in Zimbabwe, experience losing teeth and what effects does it have on their lives?

How is the local oral public health work pursued in a rural part of Zimbabwe and is there a further need to develop this?

Hypothesis

The first hypothesis was that it probably is more common to have lost teeth in this population than in western populations and that this might cause the social norms to be more accepting. This would in turn make people more willing to adapt to their tooth loss and thereby decrease the effect on their lives.

The second hypothesis was that the focus of the local volunteer work has been acute dental care. The preventive work contains information to patients and is therefore limited to a small group of people and depending on the workload and the time available. The need for

preventive care is of primary importance for dentistry in rural parts of Zimbabwe, but need to be developed and designed within that specific cultural context.

Material and method

Literature review

A review of the existing literature was conducted. PubMed was used as the search engine for articles. The Mesh term “tooth loss/psychology” was used. The search filters used were “ages 19+” and articles written in English or Swedish. This search resulted in 177 articles. The abstracts were read and reviewed by relevance to this study. Of these, 16 articles were chosen and read in full text. A total of 12 articles were relevant and used for this study. The

references of the studies were checked for additional relevant studies and one of these was consequently included. An additional search was conducted for background data about Zimbabwe’s situation concerning caries and periodontitis, which resulted in two articles. Additionally, a report concerning tooth loss by SBU was used. See table 1 for a review of the literature search in PubMed.

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7 Table 1. Result of literature search in PubMed.

Search Searched terms Hits Chosen articles

#1 "Tooth Loss"[Mesh] 2880 -

#2 "Tooth Loss/psychology"[Mesh] 213 -

#3 "Tooth Loss/psychology"[Mesh] AND

"adult"[MeSH Terms] 177 12

#4 ("dental caries"[MeSH Terms] OR ("dental"[All Fields] AND "caries"[All Fields]) OR "dental caries"[All Fields]) AND ("zimbabwe"[MeSH Terms] OR "zimbabwe"[All Fields])

21 1

#5 ("periodontal diseases"[MeSH Terms] OR ("periodontal"[All Fields] AND "diseases"[All Fields]) OR "periodontal diseases"[All Fields] OR ("periodontal"[All Fields] AND "disease"[All Fields]) OR "periodontal disease"[All Fields]) AND ("zimbabwe"[MeSH Terms] OR "zimbabwe"[All Fields])

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An examination of the quality of the studies was performed on all the relevant articles. For this, a form was used, developed by SBU, consisting of 21 subqueries (17). As a background check a study covering qualitative methods in medical research was used in order to

understand some of the potentials and limitations (18).

Ethical considerations

Prior to any study, it is of significance to consider moral and ethical aspects. According to Swedish law, studies that aim to involve humans or biological material from humans must get an ethical approval from the Central Ethical Review Board (CEPN) in Sweden. This does not apply to studies performed by students at a university as long as the data is not published. However, to ensure the ethical considerations there is a local committee at the faculty of Odontology at Malmö University, who makes ethical approvals of research executed by students. Since the study was to be performed by Swedish dental students in Zimbabwe, a discussion if the ethical approval should be executed in Sweden or Zimbabwe arose. The local committee at the university advised that the ethical approval should be done in Zimbabwe, since the study would take place there and relate to Zimbabwean law and guidelines. To ease the process of ethical approval, a contact person who worked with the organization Dentists Without Borders in Zimbabwe was established. He advised to apply for an ethical approval in Zimbabwe since a study requiring human contact must be registered with the medical research control authority of Zimbabwe (MRCZ), according to the country’s

regulations. Any foreign researcher must also be registered at the research control authority of Zimbabwe (RCZ). He noted that any study conducted out of this framework technically would be contravening the country’s laws. The MRCZ application required a full research proposal, informed consent and a detailed registration form that included collaborating institutions. For this study, the collaborating institutions were Malmö University and The United Methodist Dental Clinic. The RCZ required a registration form, CV of the principal investigators, and a copy of their passport.

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8 The contact person in Zimbabwe presented the applications for MRCZ and RCZ to an official of the registration body. The official concluded that there are only two qualified collaborating institutions for a foreign study to be approved, consisting of two major universities in

Zimbabwe. The official stated that a process to create collaboration would be cumbersome. Because of this, the official suggested that given the small size of the proposed study it would be better to proceed with it more or less as an informal investigation. He also stated that he could not see any reason to get an ethical approval in Zimbabwe since the study was non-invasive, only required a small number of participants and would not constitute any existing risk for them. The contact person in Zimbabwe had earlier hosted a few studies of similar nature without ethical approval. An issue on the ethical side would only arise if such a study were to be published. Since the study had been discussed with both the local ethical

committee at the faculty of Odontology at Malmö University in Sweden and with a representative of MRCZ, it was decided to continue with the study with no further ethical formalities. Still, the interviews were performed with great consideration to the Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects and the ethical guidelines provided by the Swedish Dental Association (SDA). Thereby it was included in the study to give the participants information that their participation was optional, they were to be anonymous, that the interview could be discontinued at any time, and that participation, or declining to participate, would not affect their treatment.

Meeting Zimbabwean patients

To get a deeper understanding and better communication with the Zimbabwean people, the principal investigators worked at a volunteer clinic in Old Mutare. During the first days at the site, only general communication and assisting at the clinic was performed and no interviews took place. The work included taking anamnesis and clinical examination to understand the patient’s chief concern and the probable treatment. Assisting during treatment and

cooperating with the local personnel working at the clinic was also performed at this stage.

Public health

An important part of preventive dental care is public health work. This was composed of giving preventive information at schools in the areas around the dental clinic. The information was given either in smaller groups or classes, but sometimes to whole schools at assemblies at the school yards, with up to 1,600 students at one time. The information included a discussion about the connection between diet and caries and brushing instructions with models. At rural schools, an interpreter helped with the communication because of the limited English

knowledge in those areas. The preventive work is the most emphasized by Dentists Without Borders and the part that is in process of expanding even more.

Interviews

A semi-structured interview (table 2) was constructed, based on the information gathered in the literature review. This qualitative method was used because the field of research data is limited and the range of significant data could not be foreseen. With a semi-structured interview technique it was deemed possible to get a dialogue with the participants that allowed a free flow of information. The dialogue would enable the investigators to get a deeper understanding of the phenomenon of experiencing tooth loss in Zimbabwe, despite the cultural and language barriers. Further, it could not be assumed that the studied sample had the ability to read, which excluded any method that required such a procedure, such as questionnaires.

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9 Table 2. These are the questions asked during the interviews to the participants.

The patients at a volunteer clinic by Dentists Without Borders in Old Mutare, Zimbabwe, were invited to participate. All participants in the interviews had to be 19+ years old in order to be accounted as adults. This is also the limit set by Pubmed. Another limit was that participants needed to have lost at least one permanent tooth, with the exception of wisdom teeth. A total of 10-20 participants were expected to be needed to get a data material rich enough in information. The final number of participants in the study were 19, of these 13 were women and six were men. The median age was 42 years, (mean 43.5, range 23 - 67 years). The participants had lost between 1 and 12 teeth in prior to the interview and visit to the volunteer clinic. Non-English speaking patients were included with the help of an

interpreter. The person who helped with the translation was not a professional interpreter but a worker in the reception at the dental clinic. No other interpreter was available.

Verbal informed consent was provided by the participants prior to the interview. The participants received information including that participation was optional, anonymous and would not affect their treatment in any way. No information was gathered that could be used to identify the participants. The interview took approximately 15 minutes. Each interview was executed by one interviewer while the other author took notes during the conversation.

The study was not estimated to constitute any risk for the patients. The patient might get more aware of the effect of their tooth loss, but it was not expected to make any difference in their life. Of course this cannot be known for sure.

Results

Literature Reviewed

Age and gender?

Number and position of missing teeth? How do you feel about losing your teeth?

Have you felt less confident since you lost your teeth? Do you think about your tooth loss often?

Do you find it difficult to accept losing your teeth? How long was it before accepting losing your teeth? In what way have the tooth loss affected your life? Do you try to keep your tooth loss a secret?

Do you avoid any kind of situation because your tooth loss? Do you have any problems with chewing food?

Have you changed your diet because of your missing teeth? Do you have difficulties speaking because of your missing teeth?

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10 The aim for the literature review was to give the authors an overview of existing knowledge of the field of study. This was deemed important when formulating the semi-structured interview. The results of the literature search are shown in Table 3. The literature review purposed to serve as a foundation for the interview questions and to assess the current field of science. According to literature, losing teeth is correlated to loss of confidence, limitation of food choice, avoiding certain social situations, feeling old and experiencing lowered self-esteem. Several studies have measured patients’ quality of life and found that it is correlated to the number of their remaining teeth. The patients with few remaining teeth experienced poorer dental health, higher levels of dental anxiety and depression were more common in this group. Therefore, preservation of teeth may contribute to a positive body image and higher self-worth. The vast majority of Zimbabweans is not receiving or is not seeking oral care. Level of education, socio-economic status, urban or rural location had a significant correlation to the oral health.

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Table 3. Literature overview Head author,

journal, year (reference number)

Material/method Results, conclusions and relevance Relevance for the interview questions Quality*

Coles, J Psychosom

Res, 2011 (4) 853 homeless people in UK participated. Questionnaire. Depression in this group of people is related to dental health status and oral-health-related factors. They experienced poorer dental health, higher levels of dental anxiety, more oral health impacts and more depression compared with the UK general population norms. Chronic oral pain and poor oral function (e.g., chewing) may contribute to lower self-esteem and depression. Those suffering depressive illness are frequently found to have extensive dental caries.

Age, sex, occupation, ethnicity,

nationality, religion etc. 19 yes of 21. Unclear if applicable on a different context. No description of the relation between investigator and participant.

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12 Craddock, Dent

Update, 2009 (9) Dental update, news article overview. Studies demonstrate that posterior teeth are usually lost before anterior teeth. Patients rated aesthetics above function in their priority for tooth replacement. It has been found that partially dentate patients have difficulties in accepting tooth loss and have cited the following factors: loss of confidence, limitation of food choice, reduction in enjoyment of food, avoidance of laughing in public and reluctance to form close relationships. People with

shortened dental arch, which only have 3-4 occluding pairs of premolars or with asymmetric arches, reported chewing difficulties.

Chewing ability, diet change, enjoying

food less, which teeth are missing. This type of examination of quality is not applicable on this article

Frencken, Int Dent

J, 1999 (11) 3,709 participants. The WHO Oral Health Assessment form and booklet was used for assessing the caries situation in Zimbabwe.

The prevalence of dental caries was high in all age groups, but its severity was low. The prevalence of unmet treatment needs was very high with tooth extraction as the predominant treatment. The survey showed that the vast majority of Zimbabweans are not receiving and/or are not seeking oral care.

Whether there is a need for public health

work in Zimbabwe. 16 yes of 18. Question 5d, e and g is not directly applicable on this study. No ethical discussion. No description of the relationship between examiner and participant

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13 Merchant, J Evid

Based Dent Pract, 2006 (10)

83,104 nurses participate in the baseline analysis and 59,467 in the longitudinal analysis. Questionnaire.

Edentulous women ate unhealthier than those with more teeth. Woman who lost teeth were more likely to change their diets in ways that raise cardiovascular disease risk. They tended to eat less foods needing more chewing.

Chewing ability, diet change. 20 yes of 21. The sample of participants is irrelevant since only nurses is included.

Niesten, BMC Public Health 2012 Oct , 2012 (5)

38 open-ended interviews with Dutch frail older (+65 years old) dentulous people. The relationship between natural teeth and QoL**.

Having natural teeth generally had a positive effect on QoL**. Men generally cared less about having natural teeth than women,

regardless of their level of frailty. Preservation of teeth contributes to a positive body image and self-worth.

Effects on well-being. Effects on

self-esteem. 20 yes of 21. No ethical considerations is included in the article.

Okoje, J Clin Pract,

2012 (3) 90 Nigerians undergoing tooth extraction completed questionnaire.

Some of the patients felt relief immediately after extraction but only 40.9% of the patients were emotionally prepared for losing their teeth. The number of patients that failed to come to terms with their tooth loss indicates that the effect of tooth loss on self-esteem and self-image is not as short lived as has been assumed; therefore preparing patients for tooth loss is of great necessity to the dentist.

Difficulties in accepting losing teeth and how long time did it take to accept it. Confidence, eating in public, meeting people in public, laughing in public, forming close relationships.

18 yes of 21. Have not described how the sample been chosen. No description of the relation between examiner and

participant. No ethical considerations.

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14 Pallegedara,

Community Dent Health, 2008 (18)

630 elderly (<60 years old) of Negambo in Sri Lanka. Questionnaire.

OHRQoL*** of older individuals was significantly affected by tooth loss, position of missing teeth and denture status. Tooth loss can have a considerable impact on the QoL** of the elderly. Studies on denture status and oral health-related QoL** have been mainly limited to populations from western countries. As OHRQoL*** has a cultural dimension it is of interest to study populations who are different to those of the west.

Cultural aspects of losing teeth. 19 yes of 21. No ethical considerations is

included in the article. No description of the relation between examiner and participant. Steele, Community Dent Oral Epidemiol, 2004 (13) 6,764 adult participants.

Questionnaire. Tooth loss is associated with negative impacts. A complete natural denture is related to the best OHRQoL***.

Negative impacts because of losing teeth. 20 yes of 21. No ethical considerations.

SBU, Tandförluster: en systematisk litteraturöversikt, 2010 (1)

Review People who lose teeth get reduced

quality of life, lower self-esteem, lower social status and reduced chewing function. Different people handle this loss in different ways. The anterior (3-3) teeth are very important for most persons’ social life, speaking ability and aesthetic look, which can affect their quality of life. Their posterior teeth is important in chewing ability. It is found that it is enough to have 5-5 for chewing ability.

Chewing function, self-esteem, speaking

ability, aesthetics. This type of examination of quality is not applicable on this article

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15 Saintrain,

Gerodontology, 2010 (14)

Brazil. Qualitative semi-structured

questionnaire/interview. 72 edentulous participants.

Tooth loss leads to lowered quality of life. 82% experienced

difficulties eating and avoided certain social situations.

Chewing ability, self-esteem. 20 yes of 21. No description of the relation between examiner and participant. Andersson, Int J Dent Hyg , 2010 (19) 204 patients, routine examination, interview and questionnaire.

Patients over 60 had significantly more missing teeth. Oral health affected 40% in their daily life. Missing more than 10 teeth associated with one or more impacts on OIDP****. Impaired chewing ability may lead to an unhealthier diet and malnutrition.

Diet change, enjoying food less, speaking, going out, smiling, laughing, socialize.

20 yes of 21. No clear description of how the participants were chosen.

Davis, Br Dent J,

2000 (7) 94 edentulous patients, routine prosthetic care and successful denture wearers, questionnaire

Over 75% felt unprepared for their tooth loss thought that an

explanation by the dentist would have helped. 45% experienced difficulties in accepting their tooth loss. Common emotion; feeling of relief and lack of concern by those with no difficulties being

edentulous. Those with difficulties felt a more complex range of emotion, sadness, depression, feelings of lost part of themselves, feeling old, sense of resignation, less confident, Choice of food was restricted and many avoided eating in public, avoided laughing in public, avoided forming close relationships.

Lowered self-confidence, concerns about appearance, not being able to talk about their loss, keeping their loss secret, behavior change, feeling of ageing, lack of preparation.

20 yes of 21. No ethical considerations is

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16 Yiengprugsawan,

Health Qual Life Outcomes, 2011 (6)

87,134 distance learning

students, questionnaire. Having less than 20 teeth was strongly associated with difficulty chewing, speaking. Females and the poor had more problems with oral health affecting their quality of life. Edentulous patients

experienced more pain, problems with chewing and getting nutrition.

Chewing, speaking, gender. 21 yes of 21

Frencken, Int Dent

J, 1999 (12) 3,709 participants examined. The WHO Oral Health Assessment form was used.

The prevalence of periodontal conditions was high but the severity was low. 4% needed treatment. Between 1985-1995, the periodontal health of adolescents was deteriorated. The majority of Zimbabweans were not receiving /seeking periodontal care. Level of education, socio-economic status, urban or rural location had a significant correlation to periodontal health.

Differences between rural areas and

cities in knowledge and oral health. 16 yes of 18. Question 5d, e and g is not directly applicable on this study. No ethical discussion. No description of the relation between

examiner and participant

Davis, Eur J Prosthodont Restor Dent, 2001 (8)

100 partially dentate people under treatment by students. Questionnaire.

53% found it difficult to accept their tooth loss. They also felt less confident, restricted in food choice, enjoyed food less, avoided

laughing in public, avoided

forming close relationships and felt less prepared for losing their teeth. There were no differences between losing anterior or posterior teeth, although patients in both groups wanted to keep their loss a secret and therefore needed/wanted replacements foranterior teeth more.

Diet change, enjoying food less, smiling,

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17 Nguyen, Int J

Prosthodont, 2011 (2)

2805 dentate subjects.

Questionnaire. A minority reported serious problems with chewing. Chewing ability was correlated with

sufficient molar regions for soft and hard foods and sufficient premolars regions for hard foods only. Chewing ability and OHRQoL*** were positively correlated.

Chewing ability 20 yes of 21. No ethical

considerations was included in the article.

* Quality assessment was performed by using the method for quality assessment described by SBU (17). The scores range from 0 to 21 points, with higher points representing higher quality.

** Quality of Life

*** Oral Health Related Quality of Life **** Oral Impact on Daily Performance

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Meeting Zimbabwean patients

The treatments took place at a clinic with limited equipment and tools. The clinic was usually open two days a week with only a nurse on staff, treating patients in need of extractions. The treatment was for free during the two weeks of volunteer work. This affected the amount of patients greatly since the patients had to pay during the rest of the year.

The patients walked from villages nearby or carpooled from more afar. Before receiving care, the patients waited outside, often for hours. The local nurse working at the clinic took care of whose turn it was. The clinic closed before all patients were treated and the ones left came back the next day instead. Sometimes the patients stayed in the village with the local people if the travel home was too long.

Almost all patients at the clinic were in pain and were very aware of which tooth needed treatment. Most teeth that hurt had to be extracted, which the patients did not question as it was the treatment they asked for. The patients were very respectful and thankful. During the treatments, the patients were tolerable and sometimes surprised that it had not hurt more. Among the patient group, HIV was common (estimated to 30-50%). All patients came with an anamnestic questionnaire and some also had a note from the health clinic stating if they were HIV positive or negative. The people in the area had a possibility, and were encouraged, to get tested every three month.

Public health

The main part of the preventive work was not performed at the volunteer clinic. Instead information and instruction was given to children ages 4-18 in schools.

The schoolchildren were curious, eager to answer questions and cooperated well during the informative sessions. The children at the schools generally had knowledge about foods that are cariogenic. Despite this, it was noticed that several children ate candy during breaks. All schools had smaller shops where it was possible to buy sweets.

The children knew that they should brush their teeth twice a day. The screening showed that the children had a lot of plaque. In rural areas the access of tooth paste was limited.

The knowledge of English varied between the schools. In larger cities they spoke and understood English better than in rural schools. During the visits it was perceived as if the children in the city schools consumed more sweets and had more problems with decayed teeth.

Interviews

The complete data set from the interviews is compiled in appendix 2.

Feelings towards tooth loss

The patients showed varied feelings towards tooth loss. Most participants felt that extraction was a necessary treatment to get rid of pain and have a normal life. Because of this, some looked at the extractions as something positive, while a few saw it as something bad and something to be sad about. In general, the men had no social or psychological problems with tooth loss, while approximately half of the women experienced some kind of social or psychological difficulties caused by their tooth loss.

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19 When it came to the experienced loss of self-confidence on behalf of the participants, the feelings were divided. Several did not have any trouble at all with their confidence. A few pointed out that losing teeth is a natural part of ageing and that it is normal. The connection made to ageing was also the reason for feeling afraid to lose more teeth. Still, several felt it was well accepted where they lived and that everyone loses teeth at some point. One young woman differed from the rest of the participants in that she was being bullied for her teeth. She felt very bad about the gaps from her missing teeth and tried to hide it as much as possible.

The majority did not find any problems with accepting their tooth loss at all. They accepted the situation directly after the tooth had been extracted, mostly because they wanted to get rid of the pain. For the ones that did not accept it right away, it took from a few days up to a few years to accept it. One woman had still not accepted her tooth losses. She wished to have all her teeth left or get partial denture.

Most of the participants did not avoid any kind of situations because of their tooth loss. There were three persons who avoided different life situations. These situations included laughing, smiling, speaking in public, eating in public and eating sweets. Most situations they avoided were socially related. The ones who avoided sweets did so to prevent further caries lesions and because it caused pain in the remaining teeth.

Chewing ability

When it came to chewing ability, the participants had a wide range of experiences, views and thoughts. The results showed a tendency that the more teeth lost, the harder it was to chew properly. It was found that the diet contained several hard types of foods and a few of the participants liked to chew on bones. One participant in particular was worried over not being able to continue this habit and it seemed very important for his quality of life. Hard foods and pieces of meat were the most difficult to chew and the part of the diet most common to change. Many of those who had problems tried to eat it anyway and took smaller pieces at a time. In some cases, the loss of teeth had led to chewing on only one side, especially if the person had lost occluding molars on one of the sides. In other words, they experienced lowered chewing ability. Although this seemed consistently, one participant without bilateral occluding molars did not feel that her chewing ability was lowered in any way. One

participant mentioned that he experienced stomach aches because of his lowered ability to chew.

Speaking ability

The participants who had problems with speaking ability had either problems with

pronunciation or biting the tongue. The one who had problem with pronunciation lacked a front tooth and the ones that bit themselves in the tongue had lost several posterior teeth. Although, participants who had lost many posterior or frontal teeth, did not necessarily have any problems with speaking or biting themselves.

Discussion

Meeting the Zimbabwean patients

The treatments at the dental clinic gave an overview of the dental status in the area and among the sample included in this study.

The HIV did not affect the dental treatment situations because of the precautions already taken to avoid transmitting diseases.

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Public health

The interest from the school children might be connected to the curiosity to meeting people from a different part of the world with a different background of culture and ethnicity, especially in the rural areas. The rural areas were not often visited by non-African people. Dentists Without Borders have visited this area several times before and the information they have given might be the reason for the knowledge the children have. Hopefully the teachers attending during the information make sure to pass it on to new classes.

The lower dental status in the cities may depend on the easy access to sweets and a better economic situation. Sweets are a part of their every-day which makes it difficult to change. The money given to the children as pocket change seemed to be used mostly for candy. The habit will need a bigger effort to get under control, even if more information and instructions are needed. If the habits change, it would lead to fewer decayed teeth, less pain and better health. It would also change the amount of time the children spend in school because of fewer sick-days. If only treatment of the problems is available, the long-term prognosis for the dental health is positive. The prophylactic work should therefore be the priority during dental health efforts.

Interviews

The participants were in general very open and friendly. Many of them pointed out, when being asked about avoiding certain situations, that even if they might want to hide their tooth losses in public, they could not do so because of how important they thought smiling and laughing was. This seemed to be a cultural norm and important to the Zimbabwean population in general. These kinds of norms probably affected the handling of several life events

including tooth loss and helped them keep a positive attitude towards life, at least in the interaction with others. There are exceptions to this, of course, and a few did have problems with laughing and smiling in public.

Some of the participants also stated that they avoided sweet foods because of its negative effects on their remaining teeth. This shows that information about caries had reached some of the population and that they applied it to prevent further extractions. The question is if the patients who felt okay about their tooth loss would apply the information the same way or if they would just continue with the same behavior anyway?

The fact that the women in this study had more social and psychological problems is in line with the findings of Yiengprugsawan, who concluded that women have more problems with oral health affecting their quality of life (6). The study made by Niesten showed that men cared less about having natural teeth (5). However, these finding are hard to compare with the results from the sample in the present study, since they did not have any possibilities to replace lost teeth except with total removable prosthetics. Because of the lack of available suitable prosthodontics in the presently studied population, it could be important for both genders to keep their natural teeth as long as possible.

In this study, it was chosen not to ask specifically about depression. To investigate if the participants could be diagnosed with depression, a more extensive examination would have been needed. None of the participants mentioned depression during the interviews. Coles showed that there might be a connection between losing teeth and getting depressed (4).

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21 Further studies are needed to properly examine if this is true for the population seeking care at volunteer clinics in Zimbabwe. Since this group differed in cultural ways from other studied groups, it is possible that they also responded to losing teeth in a manner that did not heighten the risk for depression.

It seemed like the most participants rated function over aesthetics, which is not in line with Cradock’s results (17). This might be caused by different cultural aspects such as norms in the different studied populations. The opportunities to replace and/or keep teeth are very limited in the Zimbabwean population seeking care at a volunteer clinic. The knowledge about fixed prosthodontics is probably restricted and the possibility to receive that kind of treatment does not occur as a potential treatment option.

Since the majority of the participants answered that they accepted their tooth loss right away because they wanted to get rid of the pain, they did not seem to need more preparation in order to help them with the feelings right after the extraction. The effect of better information prior to the extraction might have helped the ones that felt less confident because of the tooth loss. These more long-term consequences were harder to predict and a controlled study that followed the whole process would be needed in order to address this question.

Since the chewing ability in this study’s sample was lowered, it might have led to the participants having a less varied diet. This study did not involve any discussion with the participants concerning what they ate instead of the problematic types of food, such as hard foods and especially whole pieces of meat. If they excluded these types of food in total they may have a less nutritious diet compared to before losing their teeth.

Sources of errors

Although the chosen method of qualitative interviewing provides with a deeper understanding of a studied phenomenon, it will not be possible to quantify the data or repeat the study in exactly the same way (20).

Because the interviews were done outside of the volunteer clinic, the privacy of each conversation was a bit different. Sometimes it was a lot of people in the surroundings that were waiting in line to the clinic. This might have made it harder for the participants to give open answers, especially on the more sensitive questions. If they felt it was easier to say that everything was fine, our results might appear to be more positive than they were in reality. In some cases, an interpreter was needed for the communication since the studied sample included non-English speaking persons. To get a representative selection of the population the non-English speaking people could not be excluded. There might be a difference between the English speaking and non-English speaking participants. They possibly have different

socioeconomic status where the English-speaking have higher education, live in larger villages/cities or have jobs requiring English knowledge. The socioeconomic situation may also affect the views on losing teeth.

The native language of the investigators and the interviewed persons was not English and can therefore have caused simplifications and misunderstandings. There is also a possibility of different interpretations of the questions not only because of the language but also because the cultural backgrounds matter. The questions were designed with this in mind and some words, such as quality of life and depression, were left out to avoid misunderstandings. This is not seen as something that has changed the study in any major way, but might have affected some details.

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22

Conclusions

According to this study, chewing ability and different social and psychological qualities of life were not correlated to the number of remaining teeth in a Zimbabwean rural population. There was a considerable variation between different individuals’ own experiences and attitudes. The effect on their lives differs and cannot be generalized from the results of this study alone.

The local oral public health work performed by this volunteer organization is expanding. The main preventive work is to inform and instruct schoolchildren in oral health. It is of great importance to expand the public health programs in these areas in order to establish a long-term positive effect on their oral health. The framework for how the preventive work can be executed is restricted by the circumstances locally. A problem in the future could be to get the information and instructions to lead to a permanent change of health care habits.

Importance of the project

This study emphasizes a problem that foremost has been studied in western cultures. In a long-term perspective, this kind of study can help dentists to prepare patients differently, taking the cultural context into consideration when discussing with patients the consequences of tooth loss prior to the tooth extraction. Thus, this kind of study can also enhance

intercultural competence and understanding in oral public health care.

Recommendations for future studies

A new qualitative study could be performed with a professional interpreter or by a person speaking Shona. This would eliminate a part of the possible sources of errors. Further, the surrounding should be calmer and more private to allow the conversations to go deeper. Depending on the background of each person, they probably feel different towards tooth loss and further studies could single out more factors that are crucial for how tooth loss affects people. Further studies are needed to examine if the volunteer work in the area can be more effective and support the patients better when it comes to their psychological well-being and preparing them for their tooth loss.

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23

References

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(2) Nguyen TC, Witter DJ, Bronkhorst EM, Gerritsen AE, Creugers NH. Chewing ability and dental functional status. Int J Prosthodont 2011 Sep-Oct;24(5):428-436.

(3) Okoje VN, Dosumu OO, Alonge TO, Onyeaso C. Tooth loss: are the patients prepared? Niger J Clin Pract 2012 Apr-Jun;15(2):172-175.

(4) Coles E, Chan K, Collins J, Humphris GM, Richards D, Williams B, et al. Decayed and missing teeth and oral-health-related factors: predicting depression in homeless people. J Psychosom Res 2011 Aug;71(2):108-112.

(5) Niesten D, van Mourik K, van der Sanden W. The impact of having natural teeth on the QoL of frail dentulous older people. A qualitative study. BMC Public Health 2012 Oct 2;12:839-2458-12-839.

(6) Yiengprugsawan V, Somkotra T, Seubsman SA, Sleigh AC, Thai Cohort Study Team. Oral Health-Related Quality of Life among a large national cohort of 87,134 Thai adults. Health Qual Life Outcomes 2011 Jun 13;9:42-7525-9-42.

(7) Davis DM, Fiske J, Scott B, Radford DR. The emotional effects of tooth loss: a preliminary quantitative study. Br Dent J 2000 May 13;188(9):503-506.

(8) Davis DM, Fiske J, Scott B, Radford DR. The emotional effects of tooth loss in a group of partially dentate people: a quantitative study. Eur J Prosthodont Restor Dent 2001

Jun;9(2):53-57.

(9) Craddock HL. Consequences of tooth loss: 1. The patient perspective--aesthetic and functional implications. Dent Update 2009 Dec;36(10):616-619.

(10) Merchant AT. Losing teeth leads to an unhealthy diet associated with cardiovascular disease risk. J Evid Based Dent Pract 2006 Jun;6(2):187-188.

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(14) Saintrain MV, de Souza EH. Impact of tooth loss on the quality of life. Gerodontology 2012 Jun;29(2):e632-6.

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24 (15) Vilhelmsson A. Folkhälsoarbetets historia i socialmedicinsk belysning. 2012

Socialmedicinsktidskrift;89(1):44.

(16) Pine CM. Community Oral Health. ; 2002.

(17) Mall för kvalitetsgranskning av studier med kvalitativ forskningsmetodik -

patientupplevelser. Utvärdering av metoder i hälso- och sjukvården: SBU - Statens beredning för medicinsk utvärdering; 2014.

(18) Pallegedara C, Ekanayake L. Effect of tooth loss and denture status on oral health-related quality of life of older individuals from Sri Lanka. Community Dent Health 2008

Dec;25(4):196-200.

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Appendix 1

Participant 1 2 3

Age and gender Male, 67 Female, 32 Male, 54

Number and position of missing

teeth 16, 26, 35, 45, 46 16, 24, 25, 35, 36, 37 46

How do you feel about losing

your teeth Feel like it is a part of ageing but do not like the loss of function while eating Feels bad. Tries to hide that she is missing teeth. Avoids to smile Nothing special Have you felt less confident

since you lost your teeth No, want to be himself and likes to smile and laugh. Wouldn’t stop smiling even if he lost his front teeth Yes No Do you think about your tooth

loss often No. He doesn’t feel comfortable with the tooth loss but considering his age it feels ok. In the beginning often, but now only sometimes (every month) No Do you find it difficult to

accept losing your teeth

Accepts it. Worried about losing all teeth because of function. Thinks it would be harder if he was younger. He don’t think he will lose all of them before he dies

Yes No

How long was it before

accepting losing your teeth He has always accepted the tooth losses right away 1 year Accepted it right away In what way have the tooth loss

affected your life Stomach pain Avoid smiling. Only eats on the right side No

Do you try to keep your tooth

loss a secret No, he is who he is and is happy about it Yes No

Do you avoid any kind of situation because your tooth loss

No No No

Do you have any problems with

chewing food Yes, especially hard foods such as bones. Sometimes swallows food without chewing properly. Because of this he experiences stomach ache. Worried that he will have to change his diet

Can chew properly on the right

side No

Have you changed your diet

because of your missing teeth No, not yet No No

Do you have difficulties speaking because of your missing teeth

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26

Participant 4 5 6

Age and gender Female, 37 Male, 35 Female, 42

teeth 14, 47 44 36, 44, 24

your teeth Better than pain, feels good about losing the teeth that causes pain Feels hard, don’t want to lose any more teeth, doesn’t like taking them out

It’s painful for the mind, afraid to feel old

Have you felt less confident since

you lost your teeth No No Yes, feels ashamed when she meets other people

Do you think about your tooth

loss often No Yes, worried about bacteria and getting an infection after the extraction

Not very often

Do you find it difficult to accept

losing your teeth No Yes Yes, don’t like it

How long was it before accepting

losing your teeth Accepted it before the extraction 4 days 2-3 years

In what way have the tooth loss

affected your life Got rid of the pain but in no other way Thinks it’s a waste to have lost the tooth Harder to meet new people. Avoid making new friends Do you try to keep your tooth loss

a secret No No Yes but not to the family and closest friends

Do you avoid any kind of

situation because your tooth loss No No Avoids smiling and laughing around other people

chewing food No Yes because of pain and swelling that makes it hard to

open the mouth

Yes, chewing gum and meat

because of your missing teeth No Avoids hard foods Avoids sweet food, chewing gum and meat

Do you have difficulties speaking

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27

Participant 7 8 9

Age and gender Male, 31 Female, 60 Female, 41

teeth 26, 46 11, 36, 44 14, 15, 24

your teeth Feel ok about losing teeth because of the pain. It’s a normal thing. Don’t want to lose all teeth.

Feels good to get rid of the pain, taking

out the tooth causing it is necessary It’s better losing them than having pain Have you felt less confident since

you lost your teeth No, no one can see it Yes but it’s part of ageing No

loss often No Thinks about it once in a while. More often on the winter but she doesn’t know why

Almost never

losing your teeth No not at all No, she wants to get rid of all her teeth and get prosthetics. She don’t want to get pain in any of the remaining teeth. Don’t have the possibility to go to the dentist because of the cost and distance.

No, not at all as long as it’s needed

losing your teeth Directly Straight away Have always accepted it

affected your life It hasn’t affected him Yes, problems with chewing and she’s been forced to change diet In no way she can think of Do you try to keep your tooth loss

a secret No No, it’s accepted in her village to have lost teeth No

situation because your tooth loss No No No

chewing food No, still enough teeth to chew without any problem Yes, only uses one side, got pain on the other and the gaps makes it more difficult as well

No, it’s the same as before

because of your missing teeth No Yes, no hard things, no whole pieces of meat No Do you have difficulties speaking

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28

Participant 10 11 12

Age and gender Female, 52 Female, 23 Male, 25

teeth 14, 15, 24, 25, 26, 27, 36, 46 17, 22, 36, 37, 46, 47 11, 36

your teeth Feels fine but problems with chewing Feels very bad about losing her teeth. Painful No problem, it’s normal to lose teeth Have you felt less confident since

you lost your teeth No Yes No

loss often No Yes, several times a week Never

losing your teeth No, felt easy because of the pain Yes it has been but now she has accepted it No How long was it before accepting

losing your teeth Accepted it directly Long time, a few years Straight away

In what way have the tooth loss affected your life

Some chewing problems but not otherwise She’s been bullied in school because of her missing teeth. Been called names

Not at all

Do you try to keep your tooth loss

a secret No Yes as much as possible No

situation because your tooth loss No Avoids sweet food. Avoids to speak to a lot of people No, it doesn’t matter. Still have to laugh and live your life Do you have any problems with

chewing food Yes Yes No

because of your missing teeth Eats the same things as before but not as easy as before to eat hard things such as sugar canes

Yes, avoids chewing hard foods. Avoids sweet food because it hurts and is bad for the teeth

No

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29

Age and gender Female, 40 Female, 47 Female, 43

teeth 16, 17, 26, 36, 37, 46, 47 16, 24, 25 15, 16, 24, 26, 27, 36, 46

How do you feel about losing your

teeth Good because she got rid of the pain Does not feel good, hard to eat Bad Have you felt less confident since

you lost your teeth No, still the same person, happy and confident No, still smile big and often Yes, when she smiles or chews Do you think about your tooth loss

often No Yes, thinking about that she wish the teeth still were there,

it would be easier that way

Yes, often. Wish they were there

losing your teeth No Yes a bit but has accepted it No, went fast because of the pain from them

losing your teeth - A few days -

affected your life In no way Problems with chewing Only chewing, harder to chew hard food

Do you try to keep your tooth loss

a secret No No No, it is accepted in her village

Do you avoid any kind of situation

because your tooth loss No No Avoids eating in public

chewing food No Yes, only uses one side and it’s still hard to chew properly Yes Have you changed your diet

because of your missing teeth No No, can still eat everything Yes, changed it, no sugar and avoids hard things Do you have difficulties speaking

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30

Age and gender Male, 53 Female, 62 Female, 31

teeth 12, 14, 15, 16, 22, 23, 25, 26, 27, 35, 37, 46 22, 27, 37, 47 36, 37, 46 How do you feel about losing your

teeth Feels good, no problems It has been necessary because of the pain but she would like to still have all of the teeth left

Happy to lose them to get rid of the pain but would otherwise like to have kept them Have you felt less confident since

you lost your teeth No Feels less confident, especially because of her front tooth No, it’s very common to lose teeth and it feels normal and as nothing to feel less confident about

Do you think about your tooth loss

often Almost never Feels the missing teeth with her tongue and thinks about it. Really wants to keep her teeth and would like prosthetics if it was possible

No

losing your teeth No, not at all Yes, thinks about it often and wonder why she has been the one to lose teeth No, just happy How long was it before accepting

losing your teeth Directly Hasn’t accepted it Directly

affected your life A bit harder to chew but it’s fine anyway In no special way As long as she get rid of the pain she can work better and feel good Do you try to keep your tooth loss

a secret No Would like to hide it but people can see it when she smiles and you can’t avoid to smile

No

because your tooth loss None No No

chewing food Yes No No

because of your missing teeth Avoids hard food, takes smaller bites and more soft food than before

No No

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Participant 19

Age and gender Female, 51

Number and position of missing teeth 14, 15, 24, 25, 26, 27, 36, 46 How do you feel about losing your

teeth It’s sad, thinks it gives her bad breath

Have you felt less confident since you

lost your teeth Maybe a little bit, people sometimes turns away when she speaks Do you think about your tooth loss

often No, it’s so common

losing your teeth No, it’s ok

losing your teeth -

affected your life Not very much, changed diet Do you try to keep your tooth loss a

secret No

because your tooth loss No

chewing food Yes

Have you changed your diet because

of your missing teeth Yes, doesn’t drink cold, eat hard food or sweets. Usually warm up water before drinking it Do you have difficulties speaking