International Dental Journal (2009) 59, 127-132
Background: Aesthetics and function of the orofacial region are very important aspects of
human life which may be affected by tooth loss and impact on the quality of life. The aim
of this study was to identify the effects of anterior tooth loss on patients’ quality of life and
satisfaction with their dentition. Methods: Fifty partially edentulous patients with missing
anterior teeth and 50 control subjects who had no missing teeth were recruited into the
study. The control subjects matched the patients by age, gender, and level of education.
A Dental Impact on Daily Living questionnaire was used to assess dental impacts on daily
living and satisfaction with the dentition. Results: Tooth loss has a definite measurable
impact on patients’ daily living and satisfaction with their appearance, pain levels, oral
comfort, general performance, and eating capacities (p=0.000). Age and level of education
had no effect on patients’ total satisfaction with their dentition and daily living. However,
females were less satisfied with appearance, general performance and eating (p=0.003,
0.005 and 0.007 respectively) than males. There were significant correlations between
the number of missing anterior teeth and patients’ total satisfaction (p=0.028) and patients
satisfaction with appearance, oral comfort, general performance, and eating dimensions
(p= 0.001, 0.048, 0.011 and 0.009 respectively). Conclusion: Tooth loss has definitive
impact on patients’ satisfaction with their dentition regardless of personal factors such as
age, gender and level of education. The higher the number of missing teeth the lower the
levels of satisfaction with the dentition and daily living.
© 2009 FDI/World Dental Press
Impacts of missing upper anterior
teeth on daily living
Key words: Missing anterior teeth, dental impact, daily living
Mahmoud K. AL-Omiri and Jumana A. Karasneh
Irbid 22110, Jordan
Edward Lynch, Philip-John Lamey and Thomas J. Clifford
Among the most important goals of dental care is help-
ing patients in their attempts to reach an acceptable level
of satisfaction with their oral cavity and dentition1.
Dentofacial problems have known definitive effects
on patients’ satisfaction with their dentition as it affects
aesthetics, performance, and function2,3.
Dental professionals need an accurate perception of
how patients feel about their teeth and the impact this
has on their daily living. Strauss and Hunt concluded
that dental disease may influence an individual’s capacity
to live comfortably, enjoy life, experience relationships,
be successful in employment, and possess a positive
self-image4. Various factors, such as chewing ability,
taste, pain, speech, and aesthetics could affect different
aspects of life quality as well as satisfaction with the
Despite the fact that dental disease is rarely life
threatening, it can affect quality of life. Pain, speech,
aesthetics, fear, chewing and eating have definitive im-
pacts on quality of life2,5. Different levels of oral status
have various impacts on people’s daily living; therefore,
the clinical status and psychological dimensions should
be assessed whenever we assess dental needs2,6.
Tooth loss and oral function are considered as indica-
tors of oral health7. Tooth loss is particularly important
due to its psychological, social, functional, and financial
impacts on humans8. Tooth loss impacts general health
in terms of eating problems, weight loss and social
handicaps related to appearance and communication9.
It has significant effects on patients’ emotions and
confidence and patients face difficulties in accepting
Tooth loss might result from dental caries, periodon-
tal disease or other reasons such as dental trauma9,11-19
and is the product of complex interactions between
socio-behavioural, clinical, and patho-physiological
International Dental Journal (2009) Vol. 59/No.3
factors20,21. Physical and social activities are enhanced
by preventing tooth loss and preserving masticatory
capabilities22-24. The absence of teeth is closely related
to one’s daily activities24.
Most previous studies on the impact of missing
teeth were related to chewing ability, nutritional intake
and mastication related to ageing which in turn affects
physical activity and mental health22-28.
The position of missing teeth is more influential on
a person’s subjective need for tooth replacement and
most previous studies demonstrated higher needs to
replace anterior teeth than posterior ones29-37. Schuurs
et al. concluded that losing an anterior tooth was more
worrying to patients, due to aesthetics, than a poste-
rior tooth35. However, cultural and socio-demographic
factors might determine the subjective need for tooth
replacement regardless of the position of the missing
The relationship between anterior tooth loss and
psychosocial factors including satisfaction with the
dentition and quality of life has not been thoroughly
investigated in the literature. This study was conducted
to investigate the impacts of upper anterior tooth loss
on daily living and satisfaction with the dentition. The
possible effects of patient’s gender, age, education and
number of missing anterior teeth on quality of life and
satisfaction with the dentition were also studied.
Fifty consecutive patients who were partially edentulous
and were seeking dental treatment for missing teeth were
recruited into this study. The patients were referred by
general practitioners and/or specialists to the Depart-
ment of Restorative Dentistry, Jordan University of
Science and Technology, Irbid, Jordan and approval
for this study was sought and granted by Deanship of
Research at the institution.
To be included in the study, recruited patients had
to be 18 years of age or older in order to understand
and score the questionnaire, had not received any pre-
vious treatment for their edentulous spaces and had
no medical disease (including mental problems and
psychological disorders) that might affect their ability
to understand and/or to score the questionnaire. Each
patient was assessed to record the position and number
of missing teeth and were included if they had one or
more missing upper anterior tooth and no missing upper
posterior or lower teeth. The assessment also included
patients’ dental and medical histories, complaints, and
personal information regarding name, age, sex, educa-
tion, occupation, address and marital status.
The null hypothesis was that in patients with miss-
ing anterior teeth, no relationship could be established
between tooth loss and patients’ quality of life and
satisfaction with their dentition.
One investigator (MK) conducted all clinical exami-
nations in the prosthodontic clinic. Intra examiner reli-
ability was performed on five duplicate clinical examina-
tions using Kappa statistics. Kappa was 1.00 indicating
Assessment of patient satisfaction and quality of life
was carried out using the Dental Impact on Daily Living
Questionnaire (DIDL) and its scale (Figure 1)2,38,39. This
questionnaire was validated for the Jordanian population
in previous studies and was found valid and reliable40-
42. The DIDL measures the impact and proportional
importance of each dimension (weight of the dimen-
sion) to the patient. The DIDL consists of 36 items
grouped into five dimensions: comfort, appearance,
1. I am satisfied with my teeth in general.
2. I am satisfied with the appearance of my teeth.
3. I am satisfied with the colour of my teeth.
4. I am satisfied with the position of my teeth.
5. I feel spontaneous pain in my teeth.
6. I feel dental pain when eating or drinking hot or cold.
7. I changed my food because of pain.
8. I feel pain in my jaw joint.
Oral Comfort dimension:
9. I have worries with my teeth.
10. I suffer from food packing between my teeth.
11. I have halitosis and bad smelling breath.
12. I have loose teeth.
13. I am not satisfied with my gums.
14. I have bleeding gums.
15. I have sensitivity to hot or cold due to gum recession.
General performance dimension:
16. My work capacities affected by the appearance of my teeth.
17. My work capacities affected by ability to eat and talk.
18. My contact with people is affected by the appearance of my teeth.
19. My contact with people is affected by my ability to eat and talk.
20. My contact with people is affected by dental pain.
21. My romance is affected by dental pain.
22. My romance is affected by my ability to eat and talk.
23. My self-confidence is affected by appearance of my teeth.
24. I feel embarrassment because of my teeth.
25. My romance is affected by the appearance of my teeth.
26. I try to avoid showing my teeth when I smile.
27. I am not satisfied with my smile.
28. My work capacity is affected by pain.
29. I feel stress because of pain.
30. I sleep badly because of pain.
Eating and chewing dimension:
31. I am satisfied with the capacity to chew.
32. I am satisfied with chewing in general.
33. I am satisfied with the capacity to bite.
34. I am satisfied with biting in general.
35. I did not change the way of food preparation because of teeth.
36. I did not change the type of food because of teeth.
Figure 1. Dental Impact on Daily Living Questionnaire items and
their respective dimensions
AL-Omiri et al.: Impacts of missing upper anterior teeth
pain, performance, and eating restriction, and impacts
for each item are scored. A weight for each dimension is
calculated on an individual basis by dividing the summed
responses of that dimension by the total possible scale
score. To construct an overall score, scores within
each dimension are first calculated by multiplying the
summed dimension responses by the dimension weight.
Weighted dimension scores are then summed to give a
DIDL score. Total score of the DIDL ranged from -1
to +1 in all sample individuals.
The questionnaire was administered to the patients,
and the process of completing the questionnaire was
supervised by the investigator. Each patient was pro-
vided with a full explanation of the dimensions as well
as the methods of scoring the questionnaire. Ten sub-
jects answered the questionnaire twice with one week
interval. Reliability was carried out on all questions using
correlation coefficient. The correlation coefficients were
high and ranged from 0.81-0.89.
The DIDL was chosen in this study because it is a
smooth and easy tool for use by the patients and clini-
cians, being completed in a relatively short time period.
The literature reveals that this test is considered reliable,
accurate and reproducible2,38-42.
Fifty control subjects who had no missing teeth were
recruited into this study. They matched the study sample
by age, sex, and level of education. They were recruited
from a Jordanian population, including university stu-
dents and employees, following proper announcement.
They were all clinically assessed to rule out the presence
of tooth loss. Only those who had no current active
dental disease nor had missing teeth (except third mo-
lars) were recruited into the control group. The DIDL
questionnaire and its scale were used to assess dental
satisfaction in the control group.
An invitation to participate in the study was extended
to the patients and controls. Each participant was given a
brief explanation of the study and an informed consent
was obtained from each subject before being recruited
into the study.
The data were analysed using the SPSS (Statistical
Package for the Social Sciences, version 11.0, SPSS
Inc., Chicago, IL, USA). The association between the
variables was analysed using the Pearson correlation
test, while the ANOVA test was used to compare the
control and patients groups. For all statistical analyses,
the significance level was set at P≤0.05.
Fifty patients (28 men and 22 women) and fifty controls,
who matched the patients group by age, gender and
education, were recruited into this study, aged 20-45
years (mean: 31.3 years, SD: 9.5); controls 19-43 years
(mean: 30.5 years, SD: 8).
Levels of patients’ education ranged from primary
to tertiary education, two patients received primary
education (up to age 16 years), 31 patients received
secondary education (up to level A), and 17 received
tertiary education (university or college). Levels of
control subjects’ education matched those of the patients’
group. Table 1 presents the distribution of missing teeth
among the patients’ group. Total satisfaction scores of the
DIDL questionnaire showed that 64% of patients were
dissatisfied with their teeth and scored below 0, 36% were
relatively satisfied and scored between 0 and 0.69, and
none were totally satisfied with their teeth. The highest
total satisfaction score was +0.6 while the lowest total
satisfaction score was -0.77 (mean: -0.2; SD: 0.14).
Regarding the control group; it was found that none
of the control subjects scored below 0, 24% were rela-
tively satisfied and scored between 0 and 0.69, and 76%
were totally satisfied with their teeth. The highest total
satisfaction score was +1 while the lowest total satisfac-
tion score was +0.25 (mean: 0.71; SD: 0.18). Satisfaction
with each dimension of the DIDL questionnaire among
Table 1 Distribution of missing teeth among the
Number of missing teeth Number of patients
Table 2 Scores of individual satisfaction dimensions in the study sample
Dissatisfied (%)In between (%)Satisfied (%)
Dimension PatientsControlPatients ControlPatientsControl
Eating and chewing
International Dental Journal (2009) Vol. 59/No.3
patients and controls is shown in Table 2. It is obvious
that levels of satisfaction with each dimension were
higher in the control group.
Age, gender, and education levels of subjects were
correlated to the total satisfaction scores as well as to
individual scores of each dimension of the questionnaire.
Within the control group, none of these factors had any
significant relationship with subjects’ total satisfaction
or satisfaction with each dimension of the questionnaire
(p>0.05). However, within the patients’ group no statisti-
cally significant differences were detected in satisfaction
scores between younger and older patients (p>0.05).
Female patients were less satisfied in respect to appear-
ance, general performance and eating (p= 0.003, 0.005,
and 0.007 respectively, r = -0.341, -0.316, and -0.309
respectively) than males. Both genders were comparable
in their total satisfaction scores and their satisfaction with
pain and comfort dimensions (p>0.05). The higher the
level of education the lower the patients’ satisfaction with
their oral comfort (p=0.013 and r = -0.283).
There were significant correlations between the
number of missing anterior teeth and patients’ total
satisfaction (p=0.028, r= -0.252) and patients’ satisfac-
tion with appearance, oral comfort, general perform-
ance, and eating dimensions (p= 0.001, 0.048, 0.011 and
0.009 respectively, r= -0.46, -0.228, -0.356 and -0.367
respectively). The higher the number of missing teeth
the lower the levels of satisfaction.
Using ANOVA test, the total satisfaction score as
well as all individual dimension satisfaction scores were
significantly different between the groups. The control
group demonstrated more satisfaction with their denti-
tion than the patients’ group. Total satisfaction, appear-
ance, pain, oral comfort, general performance and eating
satisfaction scores were significantly different between
groups (p=0.000, F= 182.7, 192.97, 194.97, 373.7, 275.8
and 184.7 respectively).
A socio-dental instrument, the Dental Impact of Daily
Living, was used in this study, because unlike other
socio-dental indicators, it assesses the dental impact on
daily living, the relative importance that respondents
attribute to each dimension, and oral status. Addition-
ally, as impacts seldom occur separately, a single impact
score is given to assess total oral impact. Since there are
important links between quality of life and clinical oral
status, the significant impacts should be used to assess
needs. Instruments such as the Oral Health Impact
Profile (OHIP) do not weight dimension scores and
then combine the weighted scores into a single score,
as does the DIDL. Both the DIDL and OHIP allow a
respondent to indicate whether a problem is entirely
internal or if it has interpersonal or social impacts. The
instrument has been tested for validity and reliability
and thus was chosen for this study2,38-42.
Although participants from both genders were not
different in their total satisfaction and satisfaction with
pain and oral comfort dimensions, females were less
satisfied with their appearance, general performance
and eating than males. This might be explained by the
fact that females are more concerned in respect to their
appearance and function than males. Previous studies
demonstrated that females were more affected by tooth
loss in terms of eating and body activity24,43.
It was found that the higher the level of educa-
tion the lower the patients’ satisfaction with their oral
comfort. This might be explained on the basis that
patients’ needs increase as their levels of education are
The number of missing anterior teeth was signifi-
cantly related to patients’ total satisfaction and satisfac-
tion with appearance, oral comfort, general perform-
ance, and eating; the higher the number of missing
anterior teeth the lower the levels of satisfaction. This
concurs with the findings of previous studies that
reported significant effects of the number of missing
teeth on function and wellbeing44-50. However, Rosenoer
and Sheiham51 reported a very poor association between
satisfaction with the dentition and the number of miss-
ing posterior teeth.
In this study, tooth loss had certain impacts on pa-
tients’ satisfaction with their dentition. In comparison to
controls, partially edentulous patients had significantly
higher levels of dissatisfaction with their dentition in
general and with their appearance, pain, oral comfort,
general performance, and eating. This might be ex-
plained by the fact that the tooth loss could affect oral
functions and aesthetics and negatively changed some
of these aspects leading to patients’ dissatisfaction with
their dentition and daily living.
Previous studies reported a negative association
between tooth loss and quality of life when all func-
tional, psychosocial, and economic implications are
considered8. Omar et al.52 suggested that aesthetics could
affect mastication and therefore there is a need to have
an index that separates the aesthetic element from chew-
ing and occlusion. So, masticatory ability is influenced
by factors other than just function. Consequently, many
subjects with impaired masticatory function can still
masticate, and if they have a satisfactory dental appear-
ance do not need to have their dentition changed27,52.
Kayser53 concluded that social functions such as com-
munication and aesthetics were more important than
chewing. Aesthetics influence psychological values of
Results from this study are the first into the effects
of tooth loss on oral health and quality of life in the
Jordanian environment. No reliable tooth loss incidence
studies are available for the Jordanian setting and inves-
tigations in this regard are required.
Personality traits might have a certain role in deter-
mining satisfaction with the dentition and this might
AL-Omiri et al.: Impacts of missing upper anterior teeth
affect the results obtained via this study. Investigation of
the relationship between satisfaction with the dentition
and personality profiles in patients with missing teeth
should be considered in future studies.
Tooth loss has negative impacts on the satisfaction
with different aspects of the dentition and oral func-
tions including chewing, speaking, oral comfort, general
performance, communication, smiling and appearance.
This in turn will affect the quality of life and dental
perceptions of patients. The number of missing anterior
teeth influences patients’ perception of, and satisfaction
with, their dentition. Professionals should consider this,
so they are able to produce suitable treatment for their
patients in order to avoid the negative effects of tooth
loss on their quality of life. They must also prepare their
patients socio-psychologically to accept the management
for missing teeth that is offered.
Thanks to Mrs M. AbdelAziz for all her help during
the preparation of this paper. Thanks also to Jordan
University of Science and Technology for making this
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Correspondence to: Dr Mahmoud K. AL-Omiri, Jordanian Board,
Faculty of Dentistry, Jordan University of Science and Technology,
P.O. Box 3030, Irbid 22110, Jordan. Email: email@example.com