Tooth loss experiences in adult and elderly users of Primary Health Care

From the theoretical perspective of phenomenology, this article seeks to understand the experiences of tooth loss in adult and elderly users of Primary Health Care in Porto Alegre, Rio Grande do Sul. Tooth loss was identified by the analysis of dental records of users that attended the oral health service at the Health Unit under study. Following this identification, individual household interviews were carried out. The sample was intentional. Data were interpreted by content analysis using the software ATLAS.ti (Visual Qualitative Data Analysis). The study had ethical approval. Losing teeth was an experience that expresses subjectivities, showing plural narratives and highlighting the social function of the mouth. Besides the number of missing teeth, the understanding of how people perceived themselves without their teeth determined how much tooth loss affected their lives. Wearing prostheses adds significance to individuals’ perceptions of their body, restoring the balance between their body and the world. Qualitative approach studies in health services should be considered in order to plan interventions which prioritize people’s individual needs in their own territories, thus reducing stigmas and social inequalities.


Introduction
The acts of taking care and preserving natural teeth are of vital importance since having them seems to contribute to an individual's quality of life, through a direct connection with feelings of pride, control, achievement and better functionality of their mouth as well as their semblance 1 .Loosing teeth, on the other hand, leads to physical, biological, and, sometimes, emotional changes 2 .The impact that tooth loss may have on people and their lives must not be underestimated 3 .A single tooth loss may be relatively insignificant in someone's life, but it could also be a devastating and disrupting experience 4 , resulting in alterations of their social daily activities and bringing about other limitations such as attending social meetings or eating in public 5 .
Moreover, tooth loss increases the demand for prosthetic treatments, demanding a great challenge from public health administration that is offering health care services which are adequate to their population needs 6 .
Brazilian epidemiology data from 2002-2003 confirmed edentulism as a serious problem in the country, which is associated to a great necessity of prostheses in adult and elderly citizens 7 .In the most recent epidemiological survey, from 2010, the results show an improvement in adults tooth loss in comparison to 2003, with a decrease from 13,5 to 7,4 in the mean number of missing teeth.In 1,3% of cases there was a need for total prosthesis in at least one maxillary tooth.It is important to mention that in 2003 this percentage was of 4,4%.In elderly people, on the other hand, edentulism was close to 54% in both studies.Numbers found in 2003 and 2010 are very close and represent over three million elderly people who needed total prosthesis in at least one maxillary tooth and more than four million who needed partial prosthesis 8,9 .
As tooth loss can be seen as a public health issue which may affect people's quality of life 10 , this study aims to understand the meaning of tooth loss experiences in adult and elderly users of Primary Health Care, according to the position and number of missing teeth.The theoretical perspective suggested this phenomenology focus, centered in the feeling of experiencing tooth loss.

Methods
The study was performed through a qualitative approach, designed as a case report whose pop-ulation was the adult and elderly users of the oral health service in the Primary Health Care of Porto Alegre, Rio Grande do Sul, who presented tooth loss.
The identification of eligible subjects was performed through the analysis of dental reports from users of the Health Unit under study.Patients whose reports contained the absence of at least one tooth in any of the dental arches were considered eligible.
Participants' ages ranged between 35 to 44 years for adult and 65 to 74 years for elderly patients, and they were selected according to the two previous epidemiological surveys on Brazilian oral health conditions 7,8 .
Reports from users who did not meet these criteria, who did not reside in the Health Unit's territory, or who did not have a complete clinical exam -for having accessed the Unit for emergency consultations only -were excluded from the study.
The analysis of tooth loss considered the position and number of missing teeth.The position was classified as anterior, posterior, anterior and posterior, and total (edentulous) tooth loss.Regarding the number of missing teeth, the classification set according to the reports ranged from 1 to 4; 5 to 9; 10 to 14; and 15 to 28 missing teeth.
This research assessed 1063 reports from users of the oral health service in the studied Unit from which 131 met the inclusion criteria.
Individualized, semi-structured, household interviews were conducted following a previously tested script, were recorded in an audio recording device and were then transcribed, in order to understand the meaning of tooth loss experiences.
The interviews were performed along 8 months, based on a flexible structure of open questions which allowed the interviewees to speak freely on the experience of tooth loss and its meanings, and were conducted by two qualified researchers, both undergraduate students of Dentistry with previous experience in qualitative research.All interviews were attended by Community Health Workers together with the patients.
The sample was intentional.As the researchers observed repetitions in the ideas presented and, considering the density of the collected material, data collection was intentionally terminated (n = 66).
The interviews totalized nine hours of taping.It is important to highlight that this time referred to specific reports on the investigated theme from the taped conversations.
Textual material obtained from the household interviews was interpreted by content analysis 11 using the ATLAS.tisoftware (Visual Qualitative Data Analysis) and involved the following steps: pre-analysis; material exploration; results treatment; inference; and interpretation.The results were organized by the "position of tooth loss" criteria.
The study was approved by Research Ethics Committees of the Federal University of Rio Grande do Sul and of Porto Alegre City Hall.

Results
A total of 66 users of the oral health service in the studied Health Unit with tooth loss participated in the household interviews, from which 31 were adult (35 to 44 years) and 35 were elderly subjects (65 to 74 years).Among these users, the majority were women, with posterior or with posterior and anterior tooth loss, from 15 to 28 teeth.Regarding dental prosthesis, 12 of the 66 subjects wore and did not need it (Table 1).

Experiences of posterior tooth loss
Adults with tooth loss of 1 to 5 posterior teeth, without prosthetic rehabilitation, associated the tooth absence with limitations in chew-ing, physical appearance, speech, smiling, work, social interactions and even pain.Such problems did not happen individually, but rather associated with each other, thus strongly affecting people's lives.Feelings of embarrassment and shame were related due to teeth loss (Table 2).
In other experiences, adults with posterior tooth loss, also without prosthetic rehabilitation, reported that such loss does not affect their lives.This situation was observed when people realized that the absent posterior teeth did not affect their chewing, aesthetics (the lack of them did not show) and that there was no tooth pain or decay in their mouth.
It Elderly patients with 6 to 10 missing posterior teeth without prosthetic rehabilitation noticed teeth absence as a burden that brought about some limitations to their lives -feeding, interpersonal relations, smiling, appearance -but, currently, it does not bother anymore or, rather, there was the perception of the limitation caused by the tooth loss, but when they think about their age or about the time they have been with this condition or when they compare themselves with the worst condition of oral health from other people that they know, this absence does not qualify as a problem, independently of the number of missing teeth (Table 3).

Experiences of anterior and posterior tooth loss
Adult and elderly subjects with anterior and posterior tooth loss (from 7 to 26 teeth) noticed functional and social limitations associated to such loss when the absent teeth were not replaced by the use of prostheses or when there was a par-tial prosthetic rehabilitation, in a single dental arch (Table 4).
People with tooth loss without rehabilitation manifested the desire of wearing prostheses and associated them to an improvement in their quality of life.
On the other hand, when there was a prosthetic rehabilitation of the missing teeth and the prostheses were well-adapted, did not hurt and neither caused pain or disturbances, the elderly individuals did not report problems or limitations caused by tooth loss.
[...] the prosthesis is well-adapted, it never hurt.From the first time I put it on, I continued to feed normally, it never hurt, excoriated, nothing.It is highlighted that in the reports where people had partial tooth loss and there was the presence of natural teeth that had oral illnesses which caused pain and functional limitations, these teeth affect people's lives much more than the tooth loss itself.Such situation may be noticed in the following report, from an elderly woman who no longer had superior teeth, did not wear prostheses and presented two anterior inferior teeth with advanced periodontal disease: [...] It gets hard to speak, even when speaking the tongue touches there, it touches and it hurts.I'm always in pain, 'Mary of pain'.People already look at you differently.It affects a lot, teeth and hair, I'll tell you!There is no doubt, the person gets awful.(Woman, 67 years old, edentulous in the superior arch and with inferior tooth loss of 12 teeth)

Experiences of complete tooth loss (edentulism)
In elderly edentulous patients without prosthetic rehabilitation, the complete absence of teeth revealed itself an important and many times even disabling problem due to the difficulties to adequately feed (chewing disability), to the aesthetics, to the pain and to the social interactions.
I In the reported cases of inappropriate prostheses, although there was the perception of On the other hand, in the adult users of prostheses which caused functional limitations related to feeding, people chose not to wear the prostheses and there was a situation of 'getting used to eat without the teeth' , even if noticing that it is a bad oral health condition.Now I eat without teeth.Before I had some fragments and I removed them.I did not adapt to the prosthesis, I couldn't chew, nor eat anything.It isn't good, but I've got used to it.I can manage.[...] it is bad not having teeth, isn't it?(Woman, 42 years old, who has superior and inferior Total Prostheses, but does not wear them) Tooth loss was not reported as a problem in the lives of elderly users of well-adapted prostheses which allowed speech, chewing and rescue of social interactions that were lost by the previous condition of aching teeth. [

...] it's been five years that I put them [the prostheses], I've never needed to adjust them, they fit well. I can speak, chew. I can communicate. I wear them all day long, and I don't take them out not even to sleep [...] before I could never talk to anyone (Woman, 71 years old, edentulous, user of superior and inferior Total Prostheses)
In this category, the experiences of tooth loss in elderly subjects have been associated to reports which mentioned both the limitations caused by this loss as well as the value of prostheses use in reestablishing the function of their mouths, improving their quality of life.

Discussion
Advances in oral health care in Primary Care have been noticed in the last decades in Brazil 12 .The implementation, in 2004, of the National Politics on Oral Health -'Smiling Brasil' -characterized oral health as one of the four priorities of Brazilian Unified Health System (SUS), aiming at the integrality of assistance accorded in its creation 13 .Even so, adult and, mainly, elderly users presented an elevated percentage of tooth loss.Clinical conditions associated to tooth decay and periodontal disease are the main causes of tooth loss in both groups 14 .
Nevertheless, researchers have not been paying much attention to studies on the experience and meaning of tooth loss and its replacement 4 .Focusing on the need of an analysis that allows a deeper look at the experiences lived by people with relation to tooth loss, this study aimed to understand the meaning of these experiences in adult and elderly users of SUS.In this qualitative analysis perspective, understanding means the exercise of putting yourself in someone else's shoes through clear, contextualized and theorized narratives 15 , and the meaning of this empathizing exercise has a structural role, reflecting the way people will organize their lives, including their own health care 16 .
"Experience is what passes on to us, what happens to us, what touches us" 17 .In this study, understanding how people looked at themselves in their social world without these teeth determined how much the tooth loss experience affected their lives, more than necessarily the number of missing teeth.The experiences thus expressed the subjectivity of the interviewed subjects, which is plural and full of senses 18 .The subjective, in this dimension of concrete human experience in specific times and places, is not a world apart, but it is necessarily connected to the world of which we are conscious 19 .Dealing with tooth loss in a phenomenological perspective is looking for meanings through the shared experience of the self in the world, which involves description and interpretation.There is no separation from the world of perceived experience -we are part of it 20 .
Tooth loss was considered a problem in the lives of adults with partial tooth loss (posterior or anterior/posterior) and of edentulous elderly subjects without prosthetic rehabilitation or with rehabilitation in only one of the arches, when it brought limitations involving chewing, speech, smiling, physical appearance (aesthetics), jobs, social interactions and when there was pain, apart from the feelings of embarrassment and shame triggered by tooth loss.Which means, it affected the self and its relation to the world in which it lives, what was expressed by the limitations imposed to these people's lives.
These same limitations in functional, social and relational daily activities, associated to the feeling of shame, are reported in studies involving the theme of tooth loss in adult and elderly individuals, affecting their quality of life 10,[21][22][23] , highlighting the perception of shared meanings on the experience of tooth loss.
Despite the acknowledgement that natural tooth loss results in a chronic disability, compromising chewing 24 and having consequences on the diet 25 , in both of the studied groups and even without prostheses use, one can notice singular experiences related to the location of the missing teeth.The absence of posterior teeth which did not limit chewing, smile and appearance, for example, was not considered a condition that affected the lives of adults with posterior tooth loss.On the other hand, anterior teeth loss was understood as a much more damaging and incapacitating condition than the posterior loss, which can be explained by the representation of the body in someone's relationship with the world, in this time and place.While it is an object of representations, values and imaginaries, the body has cultural and social meanings mediated by beauty, youth and health standards which determine the social imaginary of an ideal appearance 26,27 .In this relation of aesthetics and beauty valuing there is no space for a body whose appearance was visibly affected by the mark of anterior teeth loss.
Beyond being a physiological device which allows body nutrition, it is important to consider the social work that the mouth performs in human body and that, when people can maintain their daily life activities, even in a situation of teeth loss, such as the posterior ones which do not affect the person in the world, the negative perception regarding the experience does not establish itself.
The same is not observed when there is a limitation or even a disability to perform such activities.In this situation, the recovery of this ability by the use of prostheses adds value to their own body 28 , which was confirmed in the narratives of the elderly subjects interviewed.When there was oral rehabilitation by the use of prostheses and they allowed the rescue of speech, chewing and social interactions that the edentulous or partially edentulous elderly subjects had lost by their previous condition of toothache, tooth loss was not identified as a problem.
In experiences in which there was oral rehabilitation of the elderly person by the use of total prostheses but they were associated to reports of difficulties in feeding, causing pain and discomfort, it is important to consider that, although they acknowledge their unfavorable oral health condition, they preferred to bare this situation than to be 'without teeth' -what was not observed among the group of edentulous adults interviewed.Among the elderly subjects, a feeling of conformity was also observed, a feeling of acceptance of tooth loss due to their age and to the time that they have been with this condition, independently of the number of missing teeth.
It is necessary to deeply reflect on the complexity of this phenomenon in order to understand this 'non-reaction' of elderly people's bodies, even when they realize the pain, limitations and discomforts due to tooth loss.A complex thinking is needed for analyzing the experience of tooth loss since its meaning cannot be explained by the simplification paradigm 29 , which reduces it to a simple physical absence of an isolated structure that is part of the mouth.It is about the human, the totality of the body and the integration of this body to an existence of the 'Self ' in the world 30 .
In a first moment, one may think about the psychological attribute of resilience in elderly people.During elderliness, psychological resources are essential in overcoming adversities and recovering normal levels of performance and development in stressful situations -elements which play a central role of protecting the person from the influence of losses.Resiliency may be defined as an adaptative functioning pattern against current and cumulative risks along a person's lifetime, which comprehends biological, socioeconomic and psychological risks 31,32 .In spite of socioeconomics origins, personal experiences and adverse health situations, the elderly person may alter their meanings by cognitively reducing the level of stressful events, reducing their own negative reactions and sustaining their self-esteem even in face of unfavorable experiences 32,33 , as observed among the elderly people in this study.Be 'without teeth' would cause a much greater damage than living with the discomfort caused by the inadequate prosthesis.
Furthermore, there is the stigma that is associated to an edentulous elderly person, as it is an expected characteristic of the ageing process.It is the so called 'culture of edentulism' , where the loss of all teeth is considered a normal aspect of daily life, because of the great number of people affected by such phenomenon in this age group 34 , which may support the understanding of tooth loss acceptance as a 'normal' condition as the age increases.Nevertheless, it is necessary to go beyond this analysis.The fact that is expected for old people to 'naturally' have less or no teeth expresses a body marked with a negative and undesirable value which makes the edentulous elderly person different and with a disadvantage in comparison to the rest of the people with natural teeth 35 , which is defined by a dynamic social process that is reproduced with certain autonomy regarding these individuals 36 .
The stigma arises and stigmatization is created in specific contexts of culture and power 37 .Since it affects different domains of people's lives, stigmatization has a strong influence in the distribution of life opportunities in areas such as income, habitation, criminal involvement, health and life 38 .The stigmatized individual becomes aware of the way other people see him or her and goes through a process of normalization in order to reduce his or her difference from the current cultural norms 39 .This way, the stigma relates to the production of social inequalities, once stigmatization by the lack of teeth may lead to the undervaluing of some groups that become socially excluded 40 or understood as negatively valued in the society 37 and become vulnerable to individual discriminatory experiences bases on this stigma 41 .Thus, the use of prostheses, even if inadequate, may not solve the edentulism problem, but it makes the lack of teeth socially accepted 34 .
Another aspect to be taken into consideration in the analysis of experiences of tooth loss by elderly people is the memories of an objectively constituted body with the presence of natural teeth that were sick, caused pain and affected life, and now, without these teeth but with the prosthesis.It is a 'physical body' that had to adapt to a loss that brought an important functional limitation, but that the 'lived body' , in the intersection between man and world, managed to overcome.In this perspective, the body is understood as a vehicle of all living experience, of the self in the world 20 and the prosthesis may allow the reestablishment of balance between this body and the world.
Although there have been many advances since Smiling Brazil, such as the qualification of Primary Health Care and the creation of Dentistry Specialties Centers (CEOs), prosthetic rehabilitation for people with tooth loss, even if pres-ent in the principles of Brazilian Public Health System (SUS) and routinely offered in the range of procedures of medium complexity in Primary Care, is still insufficient to attend the great demand of Brazilian population 24 .
Allied to this reflection, there are reports of pain (both in natural teeth as well as in the mouth) in the narratives of the interviewees.Pain on natural teeth by oral diseases brought more problems to people than the very condition caused by these teeth's extraction.Resolution of pain, whether it is of dental origin or caused by the absence of teeth or by the use of an inadequate prosthesis, such as seen in this study, cannot be unattached from health care.So, the presence of pain in users of Primary Care Services indicates the need by the health team of rethinking the way these adult and elderly users access the system, thus assuring that their needs will be received and solved.This way, qualitative research provides an approximation between the oral health/health team and the problems experienced by people in their daily lives, favoring the definition of non-normative approaches in health 42 which take into account subjectivities and their meanings.
It is important to highlight that the interviews in this study happened through household visits performed during the working hours of the studied Health Unit (8 a.m. to 5 p.m.) that is also people's working hours, which may have prevented other interviews of people with different perceptions regarding tooth loss.

Final considerations
Tooth loss experiences among adult and elderly users of Primary Health Care expressed subjectivities and the need of a complex thinking in order to understand its meaning, exhibiting plural narratives in which the mouth, besides being associated to an important physiological function of the physical body related to chewing food, is also characterized as a social device for the interaction of the self with the world.Losing teeth may be, in this context, an experience that results in discomforts and limitations on daily life, affecting people's lives.On the other hand, the replacement of the missing teeth by the use of prostheses has a potential to add value to people's bodies, reestablishing their balance with the world and making this body socially accepted.
Qualitative approach researches in health services must be considered both for the planning of actions which aim at the necessities perceived by people in their own territories as well as for the understanding of tooth loss experiences in different groups and contexts which may produce or even reinforce stigmas and social inequalities.On any circumstance, the presence of stigmas must be identified and discussed by health teams in Primary Care, because it promotes fragilities in the fundamental principles of SUS and can compromise universality, equity and integrality of care.Understanding the stories connected to the emergence of a stigma and its probable consequences for the people and communities it affects may aid the development of more resolutive measures to combat it and reduce its effects.

Collaborations
FV Bitencourt, HW Corrêa and RFC Toassi substantially contributed in the conception and planning, analysis and interpretation of the data; significantly contributed in the sketch elaboration and in the critical review of the content; and participated in the approval of the final version of this manuscript.

Table 2 .
Number of posterior missing teeth, limitation and reports in which tooth loss affects adults' lives.from one side to the other, only if it is a softer food.In reality, if I chew with this side it enters between my tooth here and it hurts.Even popcorn I cannot eat with this side here, I eat with the other because it gets stuck here, so I can't, I have to take it out and it hurts.[...] it seems like it does not come out as a complete letter, it seems like a different sound.It is different than how it was before.[...] you are afraid to speak, you don't open your mouth very much, because you must keep it more closed.
[..] even to look for a job currently it is very ugly, I can already see it is very ugly.(Woman, 37 years old, superior and inferior I stopped going out because of the lack of teeth (shame).You have to keep taking care when speaking, smiling, you can't laugh hard anymore.It bothers me because of the social interactions.(Woman, 40 years old, superior and inferior posterior missing teeth) I have four missing teeth, so this interferes a lot in chewing.I can eat, but it is hard to chew, you have to throw the food around not to hurt the gums, there are some things that you can't.[...] I feel a discomfort, pain.It is embarrassing not having a perfect smile, the smile is any person's business card, there is no denying that.This affects a lot.(Woman, 40 years old, inferior I feel shame even nowadays.I don't have any teeth in the back, and I chew there, and with too much chewing using the gum it creates a little ball, it goes away after you stop eating, but with teeth it would be much better.[...] Tough meat I cannot even think about eating.[...] It hurts to chew, so I need to chew only at one side.(Woman, 42 years old, superior and inferior posterior missing teeth) [...] beautiful.It is like natural teeth to me.(Woman, 67 years old, tooth loss of 21 teeth, user of superior Total prosthesis and inferior Partial Removable prosthesis)

Table 3 .
Number of posterior missing teeth, limitation and reports where tooth loss is perceived and does not affect elderly people's lives.It would be better if I had all my teeth, some are missing, so I am already used to it.It does bother me.[...] there is not a good chewing, I can't eat apples, it is harder, but it is not like I stop eating, I always eat. [...] I have seen people worse than me [...] there are people who speak between the teeth, with the tongue stuck, [...] it changes much, the smile, the chewing, the looks, everything.(Woman, 65 years old, superior and inferior posterior missing teeth)

Table 4 .
Number of posterior and anterior missing teeth, limitation and reports in which tooth loss affects adult and elderly people's lives.try to eat soft food, [...] such as coffee with a wet bread, beans, very wet rice, apples I need to blend to eat [...] I can't chew a fried chicken anymore [...] I chew more to this side because I still have teeth, on the other side I don't chew anymore, the upper teeth hits the gum and it hurts.[...] I have to slice it very well.[...] They (the doctors) are also thinking that because I cannot chew the food properly I am getting fat.I am embarrassed, I don't get too close to my relatives anymore, even brushing my teeth and doing the oral hygiene I know that there will be a smell and many times I stay quiet, because I want to talk and in a bit I realize that the words are not leaving correctly.[...] when I had teeth I spoke very well.Now I have to think very well, but still there is that whistle.So I get embarrassed.What I can improve at the moment would be to take it all out and put a prosthesis.That would be ideal to me.Then I would smile, play, chat, because I really like to chat with people.(Man, 44 years old, I can chew, but it is not very easy, [...] I don't have all the upper teeth, only two.Teeth don't keep me from talking.With the prosthesis it would improve, I think so, from starters we would find it weird, but then we would get used.I feel shame only to laugh, because here at the front I don't have any upper teeth.[...] People with spoiled teeth, you know how it is... (Man, 70 years old, anterior [...] I don't eat some things because I can't chew.[...] I avoid opening the mouth too much to speak [...] meetings, parties and birthdays I feel bad.[...]There is no way I arrive at the place and talk to people and work with teeth like these.I used to sing in a group, I stopped because of the teeth.(Man, 67 years old, edentulous in the serious.The upper prosthesis is well, it is new.But in the lower one I have this pain, and sometimes I bleed, but I have already seen the doctor.There are some days when my voice fails, I really want to speak but my voice doesn't come out.With the prosthesis it may get better, I have to do it.(Woman, 75 years old, edentulous in the superior arch, user of Total Prosthesis and with inferior anterior and posterior missing teeth)