Clinical Psychology of Oral Health: The Link Between Teeth and Emotions

Abstract

The effects of oral health conditions on physical and psychosocial dimensions have been a matter of interest for several authors over the last decades. Nevertheless, literature lacks studies that address the relationship between the oral health–related quality of life (OHRQoL) and emotions. The present study aimed to investigate the psychological impact of oral disorders on people’s emotional well-being, with a particular attention to gender and age differences. Two hundred twenty-nine dental patients in care at private dental clinics were individually tested. One hundred thirty of them were females (56.8%) and 99 males (43.2%), aged between 18 and 83 years (M = 38.11; SD = 16.7). For the evaluation, the Profile of Mood States (POMS) and the Oral Health Impact Profile (OHIP-14) were used. Data were analyzed using Pearson’s correlations, the ANOVA, and the Kruskal–Wallis test. OHRQoL showed several correlations with all the emotions explored, overcoming the well-known relationship with anxiety and depression (p < .05). The degree of OHRQoL produced differences on mood states, which could appear normal, moderately altered, or psychopathological (p < .03). Furthermore, in different life stages, patients showed specific OHRQoL and emotions.

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Article
Introduction
According to the World Health Organization (WHO; 2012),
Oral health is essential to general health and quality of life. It is
a state of being free from mouth and facial pain, oral and throat
cancer, oral infection and sores, periodontal (gum) disease, tooth
decay, tooth loss, and other diseases and disorders that limit an
individual’s capacity in biting, chewing, smiling, speaking, and
psychosocial wellbeing.
As the above-mentioned definition suggests, a number of
psychological factors seem to be implicated. At first, it is
well known that the concept of quality of life (QoL) is “mul-
tidimensional and may be categorized within five dimen-
sions: physical wellbeing, material wellbeing, social
wellbeing, emotional wellbeing, and development and activ-
ity” (Felce & Perry, 1995, p. 51).
As oral health–related quality of life (OHRQoL) is “an
integral part of general health and well-being,” it can be
hypothesized that oral disorders may impair at least three of
the QoL dimensions: the physical, emotional, and social
well-being (Åstrøm, Haugejorden, Skaret, Trovik, & Klock,
2005; Sischo & Broder, 2011).
Studies have demonstrated the impact of oral health con-
ditions on physical and psychosocial dimensions (John et al.,
2004; Locker & Allen, 2007; Settineri, Rizzo, Liotta, &
Mento, 2014), while there is a lack of scientific evidence
about the link between OHRQoL and emotions. The majority
of existing studies have focused exclusively on the relation-
ship with dental anxiety (Kurer, Watts, Weinman, & Gower,
1995; McGrath & Bedi, 2004) and/or depression (Marques-
Vidal & Milagre, 2006).
From a psychological point of view, all emotions play a
fundamental regulatory role in human behavior (Gross,
1998), as they intervene in stressful situations, such as facing
illness. Positive or negative feelings toward health problems
may produce different outcomes (Bowman, 2001), suggest-
ing a strict link between health and emotions. According to
Kressin, Reisine, Spiro, and Jones (2001), the personality
trait of “negative affectivity,” compared with the “positive
affectivity” trait, is associated not only with a worse general
physical health and worse health-related quality of life
(HRQoL) but also with specific aspects of OHRQoL. On the
728319SGOXXX10.1177/2158244017728319SAGE OpenSettineri et al.
research-article20172017
1University of Messina, Italy
Corresponding Author:
Carmela Mento, Department of Cognitive Sciences, Psychology,
Educational and Cultural Studies COSPECS, via Concezione 6/8,
98100 Messina, Italy.
Email: cmento@unime.it
Clinical Psychology of Oral Health: The
Link Between Teeth and Emotions
Salvatore Settineri1, Amelia Rizzo1, Marco Liotta1,
and Carmela Mento1
Abstract
The effects of oral health conditions on physical and psychosocial dimensions have been a matter of interest for several authors
over the last decades. Nevertheless, literature lacks studies that address the relationship between the oral health–related
quality of life (OHRQoL) and emotions. The present study aimed to investigate the psychological impact of oral disorders
on people’s emotional well-being, with a particular attention to gender and age differences. Two hundred twenty-nine dental
patients in care at private dental clinics were individually tested. One hundred thirty of them were females (56.8%) and 99
males (43.2%), aged between 18 and 83 years (M = 38.11; SD = 16.7). For the evaluation, the Profile of Mood States (POMS)
and the Oral Health Impact Profile (OHIP-14) were used. Data were analyzed using Pearson’s correlations, the ANOVA,
and the Kruskal–Wallis test. OHRQoL showed several correlations with all the emotions explored, overcoming the well-
known relationship with anxiety and depression (p < .05). The degree of OHRQoL produced differences on mood states,
which could appear normal, moderately altered, or psychopathological (p < .03). Furthermore, in different life stages, patients
showed specific OHRQoL and emotions.
Keywords
OHRQoL, emotions, psychological well-being

2 SAGE Open
contrary, an active coping and the trait of optimism seem to
be related to dental health behavior, suggesting that the trait
of optimism could be a determinant for both oral and general
health (Ylöstalo, EK, & Knuuttila, 2003).
OHRQoL—as a part of a broad range of QoL domains—
could have relationships with a wider emotional spectrum,
from a functional affect expression to a psychopathological
condition. In fact, emotions in clinical situations may become
pathological, for example, when “there is a lack of balance
between real and perceived danger” (Settineri, Mallamace,
Muscatello, Zoccali, & Mento, 2013, p. 168).
Furthermore, as individuals during life span vary in their
ability to regulate emotions and cope with stress (Wang &
Saudino, 2011), it can be hypothesized that even the relation-
ship between OHRQoL and emotions may differ across age,
even if the existing literature seems to have neglected this
point.
On the basis of these premises, the main aim of this study
was to investigate the relationship between all emotions
(Tension, Depression, Anger, Fatigue, Vigor, and Confusion)
and the patient’s OHRQoL, with a particular attention for
different life stages.
The hypotheses are the following:
Hypothesis 1: Poor OHRQoL is linked not only to anxi-
ety and depression but also to other mood states.
Hypothesis 2: In different life stages, there are different
OHRQoL degrees and different emotions.
Hypothesis 3: Different OHRQoL degrees produce dif-
ferent expression of emotions, until psychopathology.
Method
Instruments
For the evaluation, two questionnaires were used.
The POMS is a self-assessment mood scale consisting
of 58 items (McNair, Lorr, & Droppleman, 1992). The
participant has to indicate on a Likert-type scale from 0
(not at all) to 4 (very much) as the last week has experi-
enced the moods listed. The instrument consists of six
subscales: (a) Tension–Anxiety, (b) Depression–Dejection,
(c) Aggression–Anger, (d) Vigor–Activity, (e) Fatigue–
Indolence, and (f) Confusion–Bewilderment. The partici-
pant obtains a score for each subscale, which can be
transformed into standard scores (T points). Being a stan-
dardized instrument, on both clinical and nonclinical sam-
ples, it allows to discriminate between normal range
(40-60 T points) and psychopathology (over 61 T points).
The Oral Health Impact Profile (OHIP-14)—Italian ver-
sion edited by Franchignoni et al. (2010)—consists of 14
items (Slade, 1997). As described by Meredith, Strong, Ford,
and Branjerdporn (2016), each pair of item captures a specific
dimension of the perception of the state of oral health: (a)
Functional Limitation (e.g., difficulty chewing), (b) Physical
Pain (e.g., sensitivity of teeth), (c) Psychological Discomfort
(e.g., self-consciousness), (d) Physical Disability (e.g.,
changes to diet), (e) Psychological Disability (e.g., reduced
ability to concentrate), (f) Social Disability (e.g., avoiding
social interaction), and (g) Handicap (e.g., being unable to
work productively). Respondents were asked to indicate how
frequently they experienced each problem within a reference
period of 12 months on a 5-point Likert-type scale—never
(score 0), hardly ever (score 1), occasionally (score 2), fairly
often (score 3), and very often (score 4). Highest valor corre-
sponds to greater discomfort related to oral health; a non-
pathological condition is instead closer to zero.
Procedure
The study was in conformity with ethical principles of
research as it was conducted according to the Declaration of
Helsinki. Each participant was informed in advance about
methods and study aims and answered to the issued question-
naires only after signing informed consent. Data were col-
lected in the period from January to May 2013. The
administration was conducted by operators who had a brief
training for the administration of psychological tests. The
completion of the questionnaires required from 15 to 30 min,
being two self-report measures. Data were analyzed using
the Statistical Package for the Social Sciences (SPSS 17.0).
To verify our hypothesis, we performed Pearson’s correla-
tions, the ANOVA, and the Kruskal–Wallis test. The reliabil-
ity of questionnaire used obtained a Cronbach’s alpha value
of .93 for the OHIP-14 and .80 for the POMS.
Results
Sample
The whole sample consisted of 263 dental patients, all
belonging to private dental surgeries of the center of Messina,
Sicily (240,000 habitants). We included all participants with
mild or moderate dental problems (gingivitis, cavities,
plaque, sensitive teeth, halitosis, denture discomfort, etc.)
according to the judgment of the dentist. For the analysis, we
considered only the valid cases: 130 of them were females
(56.8%) and 99 males (43.2%), for a total of 229 participants
(see Table 1).
To verify any difference between life stages, patients aged
between 18 and 83 years (M = 38.11 ± 16.7) were split into
three age groups, based on age classes: (a) young patients,
from 18 to 30 years; (b) adult patients, from 31 to 50 years;
and (c) old age patients, from 51 to 83 years. The chi-square
values according to age and gender were not significant,
indicating that groups were well balanced. The measure of
sampling adequacy met the criteria for statistical analysis
(Kaiser–Meyer–Olkin [KMO] = .92, p < .001). Table 2
shows descriptive statistics of the scores obtained by dental
patients on the OHIP-14 and POMS.

Settineri et al. 3
Each dimension of OHIP-14 was referred to a pair of
items (e.g., Functional Limitation, Items 1 and 2; Physical
Pain, Items 3 and 4, etc.); subsequently, scores range from a
minimum of 0 to a maximum of 8. As regards the POMS
from raw scores, we obtained T points: Scores ranging from
40 to 60 are conventionally considered normal. In our dental
patients sample, each subscale scores exceed the norm (mini-
mum 6, maximum 98), even if the mean is contained in the
conventional range.
Hypothesis 1: Poor OHRQoL is linked not only to anxiety and
depression but also to other mood states. To verify our first
hypothesis, we performed Pearson’s correlation (see Table 3).
All the POMS subscales were positively related to OHIP-14
items. Oral health dimensions were significantly related not
only to the well-known constructs of Anxiety and Depression
but also with Aggression, Fatigue, and Confusion, with the
exception for Vigor subscales. The higher the level of emo-
tional psychopathology, the worse the OHRQoL. Further-
more, both physical and psychological aspects of oral health
were significantly linked to mood states.
Hypothesis 2: In different life stages, there are different OHRQoL
degrees and different emotions. Second, we excluded any pos-
sible significant effect of gender by performing the Student t
test for independent samples. On the contrary, the ANOVA
revealed significant difference in the OHIP between age
classes, as shown in Table 4.
Adult patients aged from 31 to 50 years had the higher
scores and hence the worse oral health profile in almost all
subscales, with the exception of Functional Limitation in
which old age patients were more compromised.
As regards POMS, there were no differences between
males and females and between age classes. In the whole
sample, 66 patients showed a level of Tension upper normal,
58 for Depression, 75 for Aggression, 86 for Fatigue, and 44
for Confusion.
Hypothesis 3: Different OHRQoL degrees produce different
expression of emotions, until psychopathology. According to the
classification of the total score of OHIP-14, one hundred
forty-four patients obtained a score lower than 14, which
indicates the absence of oral health problems; 79 patients
obtained a total score between 15 and 41, on the average; and
only six patients obtained a score higher than 42, showing
oral health problems. To verify our third hypothesis, we per-
form the nonparametric Kruskal–Wallis test (Table 4).
Patients who obtained a total score on the average (from
15 to 41) reported increased feelings of Depression and
Confusion. Instead, patients who obtained OHIP-14 total
scores higher than 42 reported more Aggression and Fatigue.
Discussion and Conclusions
At first, as general result, all mood states subscales resulted
positively related to oral health dimensions, with the excep-
tion for the Vigor, the unique positive mood state. Oral health
dimensions were strictly linked not only to the well-known
constructs of Anxiety and Depression but also with
Aggression, Anger, and Confusion. This result clearly con-
firmed our hypothesis: The perception of the patient’s
OHRQoL was connected to an emotional spectrum, broader
than known, ranging from adequately modulated mood, until
emotional dysregulation. In fact, in 19% to 37% of cases, the
patients tested showed mood alterations in association with
OHRQoL problems. Specifically, we observed that patients
who obtained a total oral health score on the average reported
increased feelings of Depression and Confusion. Instead,
patients who scored lower in the oral health profile, suggest-
ing a poor OHRQoL, reported more Aggression and Fatigue.
Different degrees of perceived severity of the OHRQoL con-
ditions were connected to different emotional shades. A pos-
sible explanation is that mood states may also depend on
cognitive evaluation of oral health impairment (i.e., having
coping abilities, self-efficacy, danger perceived, etc.), but
this pathway has not yet been investigated in detail. One of
the few attempts to draw the association between oral health
and mood states is the Meridian Tooth Chart developed by
Wilson and Williams (2011) (see Figure 1). The authors have
compiled a list of the associations between teeth, organs, and
positive or negative mood states. Although fascinating, this
theory borrowed from oriental medicine had never been the
subject of empirical studies: The psychometric investigation
of the relationship between teeth and emotions may even
serve as a first scientific evidence to support this intuitive
association.
Regarding the issue of age differences, we observed that
the most significantly impaired oral health dimension for
elderly patients is Functional Limitation which was in
Table 1. Descriptive Statistics of OHIP-14 and POMS.
OHIP-14 M SD
Functional Limitation 1.29 1.84
Physical Pain 3.07 2.19
Psychological Discomfort 2.52 2.41
Physical Disability 1.75 1.97
Psychological Disability 2.07 2.15
Social Disability 1.73 2.11
Handicap 1.06 1.79
POMS M SD
Tension–Anxiety 54.85 11.39
Depression–Dejection 53.08 11.94
Aggression–Anger 56.45 13.07
Vigor–Activity 53.59 11.00
Fatigue–Indolence 57.01 12.55
Confusion–Bewilderment 51.15 9.93
Note. OHIP-14 = Oral Health Impact Profile; POMS = Profile of Mood
States.

4 SAGE Open
association with specific mood states: Depression, low Vigor
and Confusion. These results are consistent with the findings
of similar studies conducted by Friedlander, Friedlander,
Gallas, and Velasco (2003). The authors found an association
between oral health and late life depression (LLD): Old age
patients with LLD seem to develop behavioral patterns char-
acterized by “compromised social function and impaired
self-maintenance skills (e.g., bathing, dressing, hygiene).”
The depressed, who lose pleasure and interest for daily life
activities, lose even the interest in personal oral hygiene.
Similarly, Macentee, Hole, and Stolar (1997) found, through
a structured interview, that in older adults, mouth has a par-
ticular significance related to three interacting themes: com-
fort, hygiene, and health. An amount of studies, coherent
Table 3. Differences in Oral Health Impact Profile Between Age Classes (OHIP-14).
18-30 years 31-50 years 51-83 years ANOVA
M SD M SD M SD F Significance
Functional Limitation 0.97 1.64 1.43 1.71 1.69 2.25 2.99 .050
Physical Pain 2.57 2.03 3.58 2.29 3.24 2.17 4.97 .008
Psychological Discomfort 2.20 2.43 3.00 2.46 2.41 2.24 2.46 .087
Physical Disability 1.44 1.85 2.19 2.11 1.67 1.90 3.28 .039
Psychological Disability 1.71 2.15 2.48 2.04 2.13 2.23 2.79 .063
Social Disability 1.34 1.88 2.30 2.26 1.61 2.13 4.68 .010
Handicap 0.57 1.35 1.53 2.07 1.28 1.87 7.04 .001
Note. In bold are statistically significant values. OHIP-14 = Oral Health Impact Profile.
Table 4. Differences in Mood States Based on OH Classification.
OH classification Kruskal–Wallis test
Low 0-14 (n = 144) On the average 15141 (n = 79) High 42-56 (n = 6) Grouping variable: OH classification
Mean rank Mean rank Mean rank Chi-square Asymptotic significance
Level of Tension 109.83 121.99 147.08 4.516 .105
Level of Depression 104.11 134.12*** 124.50 18.430 .000
Level of Aggression 103.5 134.65 138.25*** 16.589 .000
Level of Vigor 114.6 116.82 99.17 0.517 .772
Level of Fatigue 107.8 125.35 149.67* 6.912 .032
Level of Confusion 107.5 129.94** 109.17 9.024 .011
Note. OH = oral health.
*In bold are statistically significant values (p < .05; p < .01).
Table 2. Correlations Between POMS and OHIP-14.
Tension–Anxiety Depression–Dejection Aggression–Anger Vigor–Activity Fatigue–Indolence Confusion–Bewilderment
1. Difficult pronounce words .115 .111 .127* −.043 .099 .145*
2. Worsened taste .097 .143* .133* −.176** .160** .154*
3. Pain .200** .138* .152* −.025 .187** .132*
4. Uncomfortable to eat .128* .077 .089 −.092 .155* .113
5. Self-conscious .202** .214** .209** −.091 .206** .258**
6. Feel tensed .244** .217** .257** −.113 .274** .237**
7. Diet unsatisfactory .175** .259** .186** −.087 .225** .174**
8. Interrupted meals .245** .238** .259** −.050 .257** .230**
9. Difficult to relax .238** .232** .226** −.072 .280** .295**
10. Embarrassed .209** .221** .187** −.036 .229** .255**
11. Irritable .262** .280** .293** −.101 .305** .319**
12. Difficult to do jobs .247** .342** .284** −.085 .273** .300**
13. Life less satisfying .270** .319** .226** −.150* .262** .303**
14. Totally unable to function .274** .322** .272** −.113 .221** .305**
OHIP-A .279** .296** .278** −.116 .302** .309**
Note. POMS = Profile of Mood States; OHIP-14 = Oral Health Impact Profile; OHIP-A = Total Oral Health Impact Profile.
*Correlation is significant at the .05 level (2-tailed). **Correlation is significant at the .01 level (2-tailed).

Settineri et al. 5
with our results, have demonstrated that “many older adults
have chewing problems, pain, difficulties in eating, and
problems in social relationships because of oral disorders”
(Zainab, Ismail, Norbanee, & Ismail, 2008, p. 19). Even
Locker, Clarke, and Payne (2000) found that poor self-per-
ceived oral health and relatively poor QoL in older adults
coexist. On the contrary, adult patients of our sample aged
from 31 to 50 years scored worse oral health profile, in
almost all subscales. These results can be explained by the
epidemiological distribution of oral health–related problems
and its impact on the specified age range. According to
Nuttall, Steele, Pine, White, and Pitts (2001), “over half
(51%) of dentate adults said they had been affected in some
way by their oral health, and in 8% of cases the impact was
sufficient to have reduced their quality of life” (p. 121).
Locker and Miller (1994) comparing different age groups of
dental patients on self-reported oral health status obtained
that the initial hypothesis that younger participants would
report lower problems on oral health indicators has been not
supported. On all measures except ability to chew, younger
participants were as likely to be compromised by oral condi-
tions as older participants. On the contrary, in the present
study, younger patients showed the lower levels of oral
health impairment and adequate emotional regulation.
Nevertheless, we have reason to think that the oral compro-
mission of adolescents and young adults could be tied not so
much for the physical aspects, such as pain or discomfort,
assessed in this study, but above to other oral health aspects
belonging to the general health QoL such as dental aesthetics
perceptions and dysmorphic levels, as suggested by literature
(Settineri, Mento, et al., 2013; Settineri et al., 2014; Settineri,
Rizzo, Ottanà, Liotta, & Mento, 2015).
It is also necessary to discuss issues surrounding the
gender. Both in OHIP-14 and in the POMS, gender differ-
ences were not found. On the contrary, several studies
have shown that males and females have a different per-
ception of oral health status and oral health behavior in
favor of females. Young woman “had better oral health
Figure 1. Meridian Tooth Chart.
Source. Wilson and Williams (2011).

6 SAGE Open
behaviour and more factors associated with their oral
health in comparison with young men” (Tada & Hanada,
2004, p. 104). At the same time, women perceived oral
health as having a greater impact than men on their QoL in
general, having both a greater negative or positive impact
(McGrath & Bedi, 1999). Nevertheless, good general
health habits correlate with higher oral health behaviors in
males as well. For this reason, Fukai, Takaesu, and Maki
(1998) hypothesized that “gender specificities in oral
health depend on individual attitudes to oral health and
dental utilization” (p. 187).
Although the findings have offered a first level of study of
the psychopathology of emotions in dental patients, we must
point out some limitations of the study. First, the sample
showed the limits of generalizability, having been sourced in
the same geographic region, because there are some evidence
that oral health is influenced also by cultural background.
For example, in Australia, those aged between 30 and 49
years showed the worst oral health profile scores; in the
United Kingdom, instead, patients below 30 years showed
the highest scores, reporting the worse oral health quality
(Steele et al., 2004).
It would also be interesting to verify, both from the psy-
chological and the dental point of view, whether the discom-
fort felt by the patient is congruent with the severity attributed
by the dentist or whether there are differences attributable to
the degree of invasiveness of the treatment.
In conclusion, the results of this study showed a signifi-
cant relationship between the perception of the patient’s oral
health and the mood states experienced. This knowledge
may help to better understand the psychological mechanisms
involved in the treatment compliance. The attention about
the role of emotions in oral health life involves both psy-
chologists and dentists, who have to safeguard the psychoso-
cial, physical, and emotional well-being of dental patients.
The teeth moreover have a symbolic value in the emotional
life. The mouth, the main organ of our ability to express, can
be read scientifically as an organ to cure, or symbolically as
part of the body capable of recording and expressing our psy-
choemotional experience.
Acknowledgments
The authors are grateful to the dental students of the University of
Messina for the data collection which was carried out as a clinical
psychology exercise to deeper understand the psychological aspects
that influence dental patients’ behavior.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Salvatore Settineri is an associate professor of clinical psychology
at the University of Messina, Italy. He teaches in university courses
in clinical psychological, health psychology, and psychodynamics.
Amelia Rizzo received her PhD in psychological sciences at the
University of Messina, Italy. She deals with clinical psychology
research, psychopathology of emotions, and psychological
well-being.
Marco Liotta received his PhD in psychological sciences at the
University of Messina, Italy. He is interested in research topics on
the psychopathology of emotions in the clinical field.
Carmela Mento is an assistant professor of clinical psychology at
the University of Messina, Italy. She teaches in psychology courses
at the university and deals with psychopathology and clinic.