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Received: 3 September 2019    Revised: 15 November 2019    Accepted: 28 November 2019

DOI: 10.1111/ger.12457

ORIGINAL ARTICLE

A metatheory explaining how patients manage tooth loss

Maha M. Al-Sahan1,2  | Michael I. MacEntee1  | S. Ross Bryant1

1
Department of Oral Health Sciences,
Faculty of Dentistry, University of British
Columbia, Vancouver, BC, Canada
2
Department of Prosthetic Dental Sciences,
College of Dentistry, King Saud University,
Riyadh, Saudi Arabia
Correspondence
S. Ross Bryant, Department of Oral Health
Sciences, Faculty of Dentistry, University
of British Columbia, 2199 Wesbrook Mall,
Vancouver, BC V6T1Z3, Canada.
Email: r.bryant@ubc.ca
Funding information
Canadian Institutes of Health Research,
Grant/Award Number: 14R90998
Abstract
Objectives: To explore how a metatheory composed of five dominant psychosocial
theories of communication, developmental regulation, emotions, resources and so-
cial cognition, explains the beliefs, concerns and experiences, of people experiencing
tooth loss.
Background: Complete tooth loss is the leading cause of disability associated with
oral conditions in 19 of 21 global regions, and it is among the most difficult treatment
challenges in dentistry.
Methods: Interviews with 18 participants were analysed inductively using interpre-
tive description and qualitative synthesis to explain their beliefs and experiences re-
lating to tooth loss.
Results: Theoretical constructs from the five dominant theories constituting the
metatheory explained the beliefs, concerns and experiences of the participants. For
example, both before and after tooth loss they engaged in adaptive behaviours ac-
cording to developmental regulation theory; implemented management strategies
according to emotion theory, social cognitive theory, and resource theory; sought
help from friends and dental professionals according to communication theory; and
modified their physical and social activities according to social cognitive theory.
Conclusion: A metatheory synthesised from five dominant theories addressing com-
munication, personal background, emotions, resources and social awareness, offers
a comprehensive and plausible explanation of how people respond psychologically
and socially to the loss of their teeth, and expands the scope of information needed
to help manage their loss and subsequent treatment.

KEYWORDS

denture, metatheory, theory, tooth loss

1 |  I NTRO D U C TI O N
Complete tooth loss is the leading cause of disability associated with
oral conditions in 19 of 21 global regions,1 and it is among the most dif-
ficult treatment challenges in dentistry.2-4 Tooth loss can be emotion-
5 6
ally and socially disturbing. Fiske et al explained it, according to grief
7
theory interpreted by Kubler-Ross, as a multi-staged grieving process
of denial, anger, bargaining, depression and finally acceptance. A more
complicated, idiosyncratic and variable process of grieving a loss has
challenged the apparent rigidity and linearity of this explanation of
grief.8,9 Others interpreted the psychosocial disturbances of tooth loss
and dentures as a neurosis, but offered limited evidence to support
this diagnosis.10-14 There is also the view that beliefs and experiences
associated with tooth loss are more complicated and uncertain than

© 2020 Gerodontology Association and John Wiley & Sons Ltd

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2       AL-SAHAN et al.
manifestations of staged grief or personality theories.15 Others found
that some people, particularly those who had little experience with
chronic disability, respond poorly to tooth loss and dentures because
they feel disembodied subsequent to unexpected tooth loss.16-18 For
example, some denture-wearers accept tooth loss as little more than
a chronic indisposition, whereas others experience chronic embarrass-
ment and pain from their dentures.5,19-21 Likewise, negative feelings
of social stigma, loss of social status and diminished self-esteem from
missing teeth contrast with the positive benefits of successful den-
22,23
tures. However, there has been little attention given to the theo-
retical foundation that might explain how people respond to tooth loss.
Metatheorizing as a part of systems science is, according to
Edwards,24 “a process of theory building that integrates, synthesizes
or constructively analyses other theories and methods… [to] explore
new ways of understanding” complex phenomena. It is possible that
the complex psychological and social challenges of tooth loss and den-
ture use can be explained only by a metatheory combining multiple
primary theories that reflect the perspectives of several healthcare
disciplines. Eighty-nine primary theories potentially relevant to loss
of anatomical parts were found in our systematic literature review
(PROSPERO registration: CRD42019118764) of how people respond
to loss, and an interpretive analysis of the findings synthesised a meta-
theory of responses from five dominant theories addressing commu-
nications, developmental regulation, emotions, resources and social
cognition.25,26,27
Communication theory addresses the importance of patient-pro-
vider cooperation, patient preparation and involvement in treatment
decisions. 28 Developmental regulation theory explains the influence
of experiences and life-long adaptive capacities on personal goals. 29
Emotion theory attends to appraisal, emotions and coping with
stressful events.30 Resource theory explains how personal and en-
vironmental resources modulate the influence of loss,31 while social
cognitive theory focuses on the social and environmental influences
32
on beliefs and behaviours. However, there is considerable over-
lap of the constructs associated with the five theories. For example,
“problem-focused coping” and “emotion-focused coping” are con-
structs of management strategies from emotion theory that are sim-
ilar to “assimilative coping” and “accommodative coping” constructs
from developmental regulation theory.
The aim of this exploration is to report the relevance of this
metatheory composed of the five dominant psychosocial theories of
communication, developmental regulation, emotions, resources and
social cognition, to the beliefs, concerns and experiences of people
experiencing tooth loss.
2 | M E TH O DS
2.1 | Recruitment
Qualitative synthesis of these complex human phenom-
ena followed the general principles of Thorne's Interpretive
Description. 25,26 Patients attending a dental school for tooth
extractions and immediate replacement with dentures were re-
cruited for open-ended interviews immediately before, and within
one year after, tooth extractions. Approval was obtained from
the University's Behavioral Research Ethics Board (H03-80164).
Patients conversant in English who were living independently in
the community, and who required extraction of all, but at least
five, natural teeth in one or both jaws, were included. The clinical
status of each participant was documented from dental records.
They also responded to a self-administered questionnaire on gen-
eral and oral health and on a visual analogue scale measuring their
satisfaction with oral health before the interview. 33 All but one
of the participants were fluent in English, and the one participant
who was not completely fluent obtained help from a family mem-
ber to interpret some questions. The interviews continued to so-
licit responses until the information recorded was meaningfully
saturated with explanations of the participants’ beliefs and expe-
riences around tooth loss and dentures. 34
2.2 | Interviews
A total of 21 interviews were conducted among 18 participants
selected purposefully to freely solicit information on personal ex-
periences before and after extensive tooth loss. 34 A male social
worker familiar with interviewing techniques conducted 19 in-
terviews: four before the extraction of teeth; three both before
and after tooth loss for the same participants; and nine after the
extraction of teeth. 35 Using similar interviewing techniques, one
female prosthodontist conducted two other interviews with par-
ticipants before teeth were removed. The interviewers obtained
demographic information from each participant and when neces-
sary used an interview guide to explore what they knew about
the effects of tooth loss (Figure 1). 5,20,36 Each interview required
approximately 1 hour and was audio-recorded and transcribed
verbatim by a professional transcriptionist or the interviewer. The
interviewer and a prosthodontist read the transcript as soon as
possible after each interview, and through an iterative process of
constant comparison modified the interview guide to clarify and
expand emerging themes. 34,37
2.3 | Data analysis
We proposed that the metatheory of five dominant theories might
help to explain beliefs and experiences relating to the psychosocial
consequences of tooth loss. Details of the theoretical foundation and
analytical method underlying initial development of the metatheory
are published elsewhere. 27 The current analysis also followed the
concept of qualitative synthesis to appraise the themes arising from
the interviews and relate them to the theories. 26,38 One prosthodon-
tist (MA), in consultation with two other prosthodontists, analysed
the 21 interviews for contextual themes and constructs associated
with the five dominant theories. This entailed coding the transcripts
AL-SAHAN et al.
F I G U R E 1   The central questions and
themes in the interview guide
using QSR NVivo 11 software (Qualitative Solutions Research
International), supplemented with analytical maps, tables and figures
to identify, interpret, aggregate and record related words, phrases
and relationships that explain the beliefs, concerns and experiences
of the participants.39,40
3 | R E S U LT S
3.1 | Participants
The 18 participants, 10 women and eight men, aged 30-84 years
had relatively low incomes and at least one health-related disorder
(Table 1). Half (n = 9) assessed their general health as “good” or “fair”
and their oral health as “good”, and prior to the extractions all were
partially edentate in one or both jaws because of caries, periodontal
disease or other dental defects.
3.2 | Relevance of themes to theories
Thematic analysis of the interviews identified 57 themes repre-
senting experiences and beliefs relevant to managing tooth loss.
The themes focus on the influence of tooth loss and dentures
on eating, social activities, body image and future treatment
needs (Table 2). Themes relevant to seven construct categories
were interconnected within the scope of each theory (Figure 2).
The interaction between appraisal and resources reflect on how
participants appraise the loss of their teeth and the resources
available to help manage the physical, psychological and social
consequences of the loss. During this process, participants tended
|
      3
to modify their management strategies to either adapt or strive for
an improved outcome.
The participants’ quotes below provide the context in which
the themes were identified during the analysis, and the relevance
of the themes to the constructs and dominant theories of the
metatheory.
3.2.1 | Theme: Dentist-patient rapport;
Relevant construct: Provider-patient relationship;
Dominant theory: Communication
Participants established a good rapport with their dentists as a con-
sequence of mutual trust and the dentist's ability to explain the
stages of treatment. Keanu, for example, said he likes his dentist be-
cause “everything is explained, the communication is good” (2B),1
and likewise, Kent praised his dentist because she “explains what
she's doing and why.”(3B).
3.2.2 | Theme: Treatment decisions; Relevant
construct: Decision-making; Dominant theory:
Communication
Understanding treatment options and involvement in treatment deci-
sions was important for all the participants to reduce the risk of dis-
appointment with the treatment outcomes. Tami misunderstood her
 1The source of each quotation is identified by the pseudonym of the participant as
identified in Table 2, and the time of the source interview either before (B) or after (A)
tooth extractions.
TA B L E 1   Demographic and health status of the 18 participants and the prosthodontic treatment they were offered or received
|

Demographics General Health Self- Oral Health

4      

rated life Prosthodontic treatment offered

Participanta  Sex Age in years Disorders Self-rated satisfaction Status Self-rated (O) or received (R)

1. Thora F 31 Psoriasis Fair Fair Mx/Mn partial edentulism Poor (R) Mx/Mn Im CRDP
Hiatus hernia Mx interim PRDP
Smokes cigarettes Caries and fractured restorations
2. Keanu M 71 HD Good Excellent Mx/Mn partial edentulism Poor (R) Mx Im CRDP/ Mn T PRDP
Periodontal disease and apical infection
3. Kent M 84 HD Excellent Poor Mx/Mn partial edentulism Excellent (R) Mx/Mn Im CRDP
Impaired vision and mobility Caries and fractured restorations
4. Jason M 45 Hepatitis C NA NA Mx partial edentulism NA (O) Mx ISD/ Mn dentition
Caries and fractured restorations
5. Robert M 83 HD NA NA Mx/Mn partial edentulism NA (O) Mx/Mn CRDP
Mild cognitive impairment Caries and fractured restorations
Transient ischaemic attack
6. Tobias M 65 DM (Type 2) Good Good Mx/Mn partial edentulism Good (O) Mx CRDP/ Mn PRDP
GERD Caries and periodontal disease
7. Francesca F 65 HD Fair Fair Mx/Mn partial edentulism Fair (O) Mx CRDP/ Mn PRDP
GERD Caries and fractured restorations
8. Tami F 45 NA Fair Good NA Good (O) Mx/Mn CRDP
9. Efram F 61 GERD Good Good Mx/Mn partial edentulism Good (O) Mx CRDP/ Mn PRDP
Caries and retained roots
10. Bellen F 63 Depression Good Fair Mx/Mn partial edentulism Good (R) Mx/Mn Im CRDP
Fibromyalgia Mn PRDP 5 years
Smokes 5 cigarettes/day Caries and fractured restorations
11. Tamara F 57 NA Poor Fair NA Fair (R) Mx/Mn CRDP
12. Nina M 52 DM (type 2) Good Good Mx/Mn partial edentulism Good (R) Mx CRDP/ Mn SDA
Caries and fractured restorations
13. Grant M 58 Hypertension Excellent Good Mx CRDP/Mn partial edentulism Good (R) Mx CRDP Rm/ Mn Im CRDP
Smokes cigarettes 1.5 packs/ Caries and fractured restorations
day
14. Gaylene F 75 NA Good Good Mx/Mn partial edentulism Good (R) Mx CRDP/ Mn PRDP
Caries and fractured restorations
15. Karsten M 62 COPD Fair Fair Mx/Mn partial edentulism Fair (R) Mx/Mn Im CRDP
Osteoarthritis Caries and fractured restorations
Cluster migraine headache
Allergy to penicillin
AL-SAHAN et al.

(Continues)
 AL-SAHAN et al. |
      5

dentist because “I thought I was going to get caps… [and] keep my

Prosthodontic treatment offered

teeth but the [dentist] said [I] had to get dentures and I had my big cry…

Im, Immediate; ISD, Implant-supported Denture; Mn: Mandibular jaw; Mx, Maxillary jaw; NA, Not available; PRDP, Partial Removable Dental Prosthesis; Rm, Remake; SDA, Shortened Dental Arch; T,
Abbreviations: COPD, Chronic Obstructive Pulmonary Disease; CRDP, Complete Removable Dental Prosthesis; DM, Diabetes Mellitus; GERD, Gastroesophageal Reflux Disease; HD, Heart Disease;
I was devastated! (8B).” Some participants were able to make collabo-
rative decisions with their dentist. Efram explained that the dentist:

(R) Mx CRDP/ Mn ISD

(R) Mx/Mn Im CRDP
(O) or received (R)

(R) Mx/Mn CRDP

Gave me the option of extracting all or some of my teeth
[but] there’s part of me at times that just wants to say
‘pull them all out get plates’. At the same time, I recognize
that as soon as I do that, I remove those binding struc-
tures in there that stabilize the denture. I’m at a decision
point right now.
Self-rated

(9B)
Good

Good
Fair

3.2.3 | Theme: Effect of past experiences with

dental treatment; Relevant construct: Critical period;
Dominant theory: Developmental Regulation
Caries and fractured restorations

Mx/Mn complete edentulism

The participants’ capacity, either psychologically or socially, to learn

Mx/Mn partial edentulism

and develop from past experiences throughout life influenced their

current feelings about teeth and dentists. Keanu identified two criti-
Mx PRDP10 years

cal life events influencing his trust of dentists:

Oral Health

As a young child we were not encouraged to see a dentist,

Status

and in fact, we never saw a dentist… as a welfare case

NA

when you have a toothache you go to the hospital and

satisfaction

stand in line and then you sit in the dentist’s chair and
rated life

there’s a pair of scissors… that they put in your mouth…

Good

Good
Self-

Fair

a nurse on your leg and a nurse on top of you holding

your arms. You’re screaming… [the dentist with] the pliers
Self-rated

extracts- no freezing, no nothing. Now you can see where

[I got] my distrust of dentists. When I joined the armed
Good
Good
Fair

forces, my teeth were not nice. One day I had a tooth-

ache. I [went] to the dentist and I was shaking. The den-
tist said, ‘I won’t hurt you.’ He didn’t hurt me. And then
it was fine. This is how I got away from my scare of the
Surgery left eye cataract
Precancerous skin lesion

Carpal tunnel syndrome

dentist. And then, from that moment on, everything was

Allergy to penicillin

okay… [until my] teeth started to wobble and to move…

General Health

Osteoporosis

[and] it wasn’t comfortable anymore.

DM (type1)
Disorders

(2B)
HD

NA

Nerissa, in contrast, blamed her dental experiences on ill health

when growing up:
Age in years

As I got older, all these diseases… complicated my dental

[health]… I spent thousands of dollars getting my teeth
80

46
55
TA B L E 1   (Continued)

done every year… but a lot of it was because of diabetes

and osteoporosis. My teeth were falling out, they were
Sex

F
F

decaying, [and] they were just loose… Well there’s no use

Demographics

fighting it. I mean, if you’re going to lose your teeth, you’re

Pseudonyms.
Participanta 

17. Arbutus
18. Heloise
16. Nerissa

Transitional.

losing your teeth. I know that all my life I’ve looked after my
teeth. It’s not through neglect… it’s just through ill health.
(16A)
a
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6       AL-SAHAN et al.

TA B L E 2   The 57 themes associated with the five dominant theories and seven construct categories of the metatheory found in
interviews with 18 participants before or after tooth loss

Participants and time of interview before

Metatheory (B) or after (A) tooth loss

1. 2. 3. 4.
Thora Keanu Kent Jason
Construct Dominant
Themes Constructs Categories theories B A B A B A B

Anticipating progress Self-efficacy Environmental SC     × × ×   ×

and Personal
Resources
Self-control over health Self-regulation; Self-   R; SC     × × ×   ×
control; resilience
Positive attitude Optimism   R; E     ×   ×    
Determined to manage difficulties Self-determination   R; SC       × ×    
Expectations from treatment Outcome expectations   R; SC × × ×   ×   ×
outcomes
Values and beliefs; religious/Spiritual Values and beliefs;   R; E              
Religiosity
Support from family and friends Social support   R ×   × × × × ×
Financial support; financial Financial influences   R × × ×   × ×  
constraints
Appraising the significance of losing Appraisal Cognitive DR; E × × × × × × ×
teeth and challenges with wearing Appraisal
dentures
The impact of general health and its General health Physical C; DR; E; R; SC × × ×   × ×  
relationship with oral health Status
Oral function and comfort Oral function; Oral   C; E; SC × × × ×     ×
pain and comfort
History of tooth loss; investing in Oral health   C; DR; E; R; SC × × × ×     ×
oral health; life-style; diet; oral
habits; oral hygiene
Blame (blaming others, blamed Emotions (negative) Psychological E ×     ×     ×
by others); self-responsibility/ Status
regret, (blame themselves);
embarrassment; shame; fear;
anxiety; frustration; sadness; anger;
denial; depression; jealously; envy;
hopelessness
Hope; relief; humour Emotions (positive)   E       ×     ×
Self-consciousness; self-confidence; Appearance and   E; SC × ×   × × × ×
intimacy; privacy self-image
Disembodiment from the dentures Embodiment   D; E; SC              
Performance and social integration Activity and Social E; SC × ×   × × × ×
participation Influences
Effect of past experiences with Critical period   DR     ×        
dental treatment; access to dental
care
Dentist advice; dentist-patient Provider-patient   C ×   × × × × ×
rapport; negative communication relationship
Preparedness to losing teeth and Patient preparation   C ×   × × × × ×
wearing dentures
Uncertainty regarding treatment and Uncertainty   C; DR × × × ×      
adaptation
Treatment decisions Decision-making   C × × × ×      
AL-SAHAN et al. |
      7

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Robert Tobias Francesca Tami Efram Bellen Tamara Nina Grant Gaylene Karsten Nerissa Arbutus Heloise

B B B B B A A A A A A A A A

× ×   × × ×   × × × ×   ×  

× × × × × ×   × × × ×      

  ×   × × ×   ×   ×     ×  
    ×             × ×      
× × × × × ×   × × ×     × ×

      × × ×   ×   ×        

× ×   × × × × ×   × × × × ×
  × × × × × × ×     × × × ×

× × × × × × × × × × × × × ×

      × × × × × × × × × × ×

× × × × × × × × × × × × × ×

× ×   × × × × × × × × × × ×

×   × × × × × ×   × × × × ×

×         ×   ×   ×     × ×
×     × × ×   × × × × × × ×

                      ×    
× ×   × × × ×     × ×   ×  

×   × × × × × ×   ×     × ×

× ×   × × × × ×   × × × × ×

×                 ×     ×  

        ×   ×     × ×     ×

        ×   ×     × ×     ×

(Continues)
 |
8       AL-SAHAN et al.

TA B L E 2   (Continued)

Participants and time of interview before

Metatheory (B) or after (A) tooth loss

1. 2. 3. 4.
Thora Keanu Kent Jason
Construct Dominant
Themes Constructs Categories theories B A B A B A B

Experience of loss and social Social comparisons   C; DR; E; R; SC ×           ×

comparisons
Regaining normal appearance and Returning to normality   E; SC × × × × × × ×
function
Managing problems associated Problem-focused Management DR; E ×           ×
with tooth loss and dentures (eg coping Strategies
planning for treatment in stages)
Managing emotions associated Emotion-focused   DR; E × × × × × × ×
with tooth loss and dentures (eg coping
accepting limitations of dentures)
Well-being; satisfaction; quality of Well-being; Treatment C; DR; E × × × × × × ×
life (eg wealth and health) Satisfaction; Quality Outcomes
of life

Note: Participants have pseudonyms.

Abbreviations: C, Communications; DR, Developmental regulation; E, Emotion; R, Resource; SC, Social cognition.

3.2.4 | Theme: Planning for treatment in stages;
Relevant construct: Problem-focused coping;
Dominant theory: Emotion
Participants described their appraisal of emotional stressors and
management strategies before and after tooth loss. Jason tackled
the problem in stages:
If I deal with getting the denture first, and seeing how
it works initially, then maybe I’ll be more comfortable
with it. I don’t know how it’s going to take. That’s why
I want to do it in stages… [extract] the back teeth first
and then, if comfortable and okay, I will do the next
[stage].
(4B)
3.2.5 | Theme: Accepting limitations of dentures;
Relevant construct: Emotion-focused coping;
Dominant theory: Emotion
Participants faced many challenges in terms of function, such as
Nerissa, who accepted the limitations of dentures:
You have to accept certain limitations, and I accept the
fact that I had to have dentures… so I can’t eat a big
steak. I don’t eat meat much anyway so it doesn’t bother
me… we can’t have everything we want, can we?
(16A)
3.2.6 | Theme: Family support; Relevant construct:
Social support; Dominant theory: Resource
Participant's valued the support of family and friends whilst also
often acknowledging the limitations imposed by financial resources.
Francesca's son, as she stated, was “always grinding [food] for me
and gets me baby food and a straw” (7B), while Robert acknowl-
edged happily that “there [are] so many things, I can eat… And I have
a wonderful wife for that… She just accommodates all that.”(5B).
3.2.7 | Theme: Financial constraints;
Relevant construct: Financial Influences;
Dominant theory: Resource
The financial constraints and ineffective investment in oral health
were major concerns addressed by the participants. For instance,
Keanu was frustrated by the loss of his teeth because of “all the fill-
ings, all the work that I had done - thousands of dollars that I had
to pay - down the drain completely.”(2B) Thora was also distressed
about her failed investment and limited insurance:
Financially, that’s why I’m having a lot of problems, be-
cause I haven’t had dental [insurance] coverage for many
years. Being a single mom, the cleanings, the fillings,
re-fillings, because a lot of my fillings are falling out. Then
my teeth deteriorated. I [now] have dental [insurance]…
which covers just my dentures.
(1B)
AL-SAHAN et al. |
      9

5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Robert Tobias Francesca Tami Efram Bellen Tamara Nina Grant Gaylene Karsten Nerissa Arbutus Heloise

B B B B B A A A A A A A A A

×   × × × ×       ×   × × ×

× × × × × × × × × × × × × ×

×   × × × ×   ×   ×       ×

×     × × × × ×   ×   × × ×

× × × × × × × × × × × × × ×

3.2.8 | Theme: Anticipating progress; Relevant 3.3.2 | Theme: Determined to manage

construct: Self-efficacy; Dominant theory: difficulties; Relevant construct: Self-determination;
Social Cognition Dominant theories: Resource and social cognition

Participants believed that they could learn to manage with dentures.
Bellen cautiously said that she had anticipated learning to func-
tion with dentures because “once I get use to them, I’ll be able to
chew… [I’ve] only had them three weeks… It's a learning curve"(10A).
Similarly, Thora explained that: “It's going to be quite the experience
learning to speak again.” (1B).
Self-determination, from resource and social cognitive theories, was
evident in Keanu's comment that “if I set my mind to do something, I
have to do it” (2A), and in Kent's view that “if I would let my general
health affect me in a negative way I would probably feel it all over my
body. But I don't!” (3B).

3.3.3 | Theme: Regaining normal

3.3 | Relevance of themes to the
overlapping theories
There was also ample evidence of the harmonious confluence of
developmental regulation, emotion, resource and social cogni-
tive theories in the optimism, self-determination, emotions, social
comparisons and sense of embodiment that several participants
revealed.
appearance and function; Relevant construct:
Returning to normality; Dominant theories:
Emotion and social cognition
Emotion and social cognitive theories explained how participants
want to look, eat and socially integrate, normally. Robert expected
that dentures would enable him to chew and “go out for a steak
dinner”(5B), whereas Thora:

Could eat without them… friends they understood, but

3.3.1 | Theme: Positive attitude; Relevant construct:
Optimism; Dominant theories: Emotion and Resource
Some of the participants highlighted the importance of maintain-
ing a positive attitude to overcome difficulties associated with
tooth loss. Keanu felt that previous good experiences helped him
to prepare emotionally for losing his teeth because “you have to
be positive… not that I disregard difficulties, but they come and
they go.”(2A).
going out to a restaurant was a challenge… [dentures]
make me happy, I’m just more able to go out there and
actually smile and talk to people, not feeling embarrassed
about the way my teeth look.
(1A)
Nerissa reappraised and managed her situation according to social
cognitive theory by removing the lower denture because “people don't
notice, it's not very obvious” (16A), and according to emotion theory by
 |
10       AL-SAHAN et al.
the positive feeling when “you don't get toothache or you don't have
fillings falling out.”(16A).
3.3.4 | Theme: Experience of loss and social
comparisons; Relevant construct: Social comparisons;
Dominant theories: Emotion and social cognition
Participants engaged in downward and upward social comparisons.
They compared themselves downwardly to others who experienced
similar loss to see themselves as better than others. For example,
Tami explained that she:
Look[s] at other people with worse teeth… they have to
live like that all the time, so why am I feeling bad, and
I’m getting my teeth fixed which a lot of people can’t. I
should be so grateful for what I got. I’m doing very well
compared to others.
(8B)
Heloise, in contrast, perceived her oral condition as poor compared
with others who “have their own natural teeth, so I actually envy them
and it's horrid.”(18A).
3.3.5 | Theme: Disembodiment from the denture;
Relevant construct: Embodiment; Dominant theories:
Developmental regulation, emotion and
social cognition
Nerissa felt “disembodied” from her dentures, as explained by a com-
bination of developmental regulation, emotion, and social cognitive
theories, because she was:
Conscious that I have dentures, I think, even if they fit
perfectly… they’re not my own teeth. The thing that re-
ally bugs me about dentures is the… falseness of it all,
not being natural. When I hear of all these women having
plastic surgery, I think no, I don’t think I could do that,
that’s how I feel about dentures - that it’s unnatural.
(16A)
4 |  D I S CU S S I O N
This qualitative exploration reveals how a metatheory composed
of five conceptually broad dominant theories addressing commu-
nication, personal background, emotions, resources and social
awareness explains the complex psychosocial challenges of tooth
loss. Participant responses reflect the primary and secondary ap-
praisals and management strategies of emotion theory, which had
a dominant role in the beliefs and experiences of all the partici-
pants. 30 Clearly, these management strategies complement each
other in the adaptation process by adopting positive emotions as
a barrier against anxiety and fear. 41 Participants managed to seek
the dentist's help, while also modifying their social engagements,
denture use and emotions, to meet the challenges of tooth loss
and dentures. Developmental regulation theory addresses a life-
long adaptive capacity to adjust and learn from various stages
of dental deterioration, 29 whereas self-efficacy is at the core of
social cognitive theory, explaining how people anticipate learn-
ing to manage the loss and its consequences. 32 Social compari-
sons also help to maintain self-esteem and self-confidence in the
face of real or potential embarrassment, stress and uncertainty
of treatment. The management and consequences of uncertainty
from good and bad experiences with dentists throughout life can
be explained by both communication and developmental regu-
lation theories. 28,29 Resource theory has a social and financial
role in the beliefs and experiences of the participants. 31 Family
and friends were a significant resource that featured mostly
after teeth were extracted and participants were managing the
physical limitations and social embarrassments. However, there
were concerns about the financial consequences of unsuccessful
prostheses.
We are unsure about how the experiences and beliefs of our
participants represent those attending private dental clinics.
The medical profile of patients attending dental schools is typ-
ically similar to the profile of the general population, at least in
North America. However, we are not certain about socioeconomic
similarities.42 To recruit participants, we used a purposeful sam-
pling method based on the principle of information saturation34;
however, we were unable to recruit patients who were severely
distressed about losing teeth or wearing dentures. The three par-
ticipants interviewed both before and after tooth loss gave the
deepest insights to the relevance of the metatheory. Initially, the
intent was to interview participants before and after tooth loss,
but we lost contact with six of the nine participants interviewed
before tooth loss, or they declined a second interview after they
received dentures. Subsequently, we interviewed another nine
participants after they received dentures. This allowed us to clar-
ify and expand on the information that had emerged from the
preceeding interviews until the evidence seemed meaningfully
saturated. 34 Overall, our objective was not to test the predictive
potential or other psychometric properties of the metatheory but
to identify and explain the relevance of the metatheory to the par-
ticipants. 26,43 The relevance of our findings to other populations
and the psychometric properties of the metatheory will need fur-
ther exploration.
The participants explained that their beliefs and experiences
with tooth loss were more complicated than the limitations of
staged grief theory or personality disorders as previous opinions
have proposed. 6,10-13 For example, initially, they experienced
distress from oral discomfort and limited function, but then, in
keeping with a dynamic emotional response to loss, 8,9 they ad-
opted different management strategies, such as seeking emo-
tional support from their family and friends or professional help
AL-SAHAN et al.
F I G U R E 2   The constructs and seven construct categories associated with the five dominant theories in the metatheory
from a dentist. Furthermore, we found no evidence of neurosis
or other disordered responses, as others have suggested,10-11,13
even when participants were very unhappy with the prospect of
losing teeth or the limitations of dentures. The usual response
to pain was to avoid triggering the pain and seeking professional
help. Appraisal and management strategies, as in emotion theory,
pervaded most of the interviews, as others have reported from
people who lose other anatomical parts. For instance, the loss of
breasts or limbs precipitated responses that alternated between
assimilating or focusing on the loss to enhance rehabilitation, and
accepting or avoiding social activities as a self-protective strat-
egy against negative emotions. 41,44 In contrast to Bury's theory
17
of biographical disruption, our participants anticipated losing
all their teeth, and they did not feel that their biographical expec-
tations were disrupted. Expectations from dentures frequently
focused on a return to normal appearance and physical function,
|
      11
as others reported from older experienced denture wearers and
in support of the neurocognitive model of body-ownership, even
if this required some minor adjustments of chewing and social
behaviour. 5,16,18
4.1 | Clinical implications and future research
The research findings provide new empirical evidence to support
a patient-centered focus on how people are likely to seek treat-
ment for tooth loss and how they might respond to dentures. The
metatheory, combining five dominant theories, acknowledges the
importance of communication in improving rehabilitation out-
comes.44 It also suggests that treatment involving tooth loss should
consider a patients’ developmental or historical background, ex-
periences, and communications with dental personnel, emotional
 |
12       AL-SAHAN et al.
and physical expectations, and social and financial resources,
along with their social awareness and ability to manage disrupted
self-confidence, social interactions and limited food choices. 5,22,23
Counselling early in the treatment could help patients appraise,
anticipate realistically, and manage their predicament to facilitate
resilience and prevent negative psychological responses, 21 much
as others have proposed for managing amputations of other ana-
tomical parts.41,44,46 For example, the desire of people undergoing
a mastectomy to “return to normal life” was a motivation to man-
age and recover successfully.45
Further application and exploration of this metatheory should
expand our limited knowledge of patients’ responses to dental
prostheses, especially among patients who are severely anxious be-
fore tooth loss, and among those who have not responded well to
dentures.5-6,10-14,20-23
5 |  CO N C LU S I O N S
A metatheory synthesised from five dominant theories addressing
communication, personal background, emotions, resources and so-
cial awareness offers a comprehensive and plausible explanation of
how people respond psychologically and socially to the loss of their
teeth, and expands the scope of information needed to help manage
their loss and subsequent treatment.
AC K N OW L E D G E M E N T S
This study was funded by the Canadian Institutes of Health
Research Grant #14R90998. We are grateful for the contribution
of Dr Peter Crocker and Dr Anita DeLongis to the development
of the PhD thesis from which this article has evolved. We are
also grateful for the advice from Dr Sally Thorne on the research
methods.
AU T H O R C O N T R I B U T I O N S
MA developed the study design, conducted some and analyzed all of
the interviews. MM and SRB contributed to the design of the study
and the analysis of the interviews. MA wrote the first draft, and MM
and SRB contributed to subsequent drafts of the article. All authors
approved the final submission.
ORCID
Maha M. Al-Sahan  https://orcid.org/0000-0002-3680-7223
Michael I. MacEntee  https://orcid.org/0000-0001-7015-3131
S. Ross Bryant  https://orcid.org/0000-0002-1625-9370
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How to cite this article: Al-Sahan MM, MacEntee MI, Bryant
SR. A metatheory explaining how patients manage tooth loss.
Gerodontology. 2020;00:1–13. https://doi.org/10.1111/
ger.12457