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Critically evaluate the prosthodontic/dental research and epidemiological literature in regard to the relationship between the loss of teeth and the loss of oral function and/or quality of life. 
If you select this option, you should present an overview of the issues but in the main part of your review, you may focus your discussion on two of the following three considerations:

(i) the causes and implications of tooth loss in contemporary societies,

(ii) the relationship between maintaining dentitions and the quality of life, or

(iii) the debate over the number of occluding tooth pairs commensurate with satisfactory oral function (including a discussion of the philosophy of the shortened dental arch). As a starting point, you may wish to consider the following statement: 


"Recently examined cohorts of elderly subjects tend to be less satisfied with their chewing ability than those in earlier cohorts irrespective of dental state, which may indicate increasing expectation for masticatory function and an associated demand for replacement of lost teeth with time.A great number of variables are associated with tooth loss, and there is no consensus whether dental-disease-related or socio-behavioural factors are the most important risk factors." 

Factors Contributing to Tooth Loss

Tooth loss in the elderly is directly found to be related to mortality according to various literature studies. One of the etiological variables contributing to tooth loss includes periodontitis. Pathological type of microbial flora present in the gingival crevices provokes an inflammatory reaction from the host, which leads to inflammation and loss of gingival attachment. Various factors are responsible for the loss of tooth such as bleeding gums, periodontitis, decrease in clinical attachment level, increased loss of attachment of gingiva to the tooth structure etc. (Kassebaum et al., 2014). Most widely recognized cause of a toothache and tooth loss is periodontal damage of the erupted tooth structure. Other factors include non-restorable tooth (grossly carious, third grade mobile or tooth fracture) or peri-apical abscess or infection. However, a literature report revealed that thirty per cent of the tooth removed had endodontic treatment. Literature studies reveal that caries are the major common etiological factor for extraction contributing to almost forty percent of extraction cases, loss of periodontal attachment contributes to thirty percent, while the orthodontic causes at ten percent, the stresses and designs of the prosthetics were only two percent (Hayasaka et al., 2013). Coronary heart disease and diabetes mellitus were reported to be linked to periodontitis as per various literature reviews.

A study found a link between various markers of periodontitis and cardiovascular disease (CVD) (Ando et al., 2013). Appropriate oral hygiene is expected to reduce the chances of mortality among the adult population. It has been reported that an individual who maintains great oral hygiene and visits the dentist once a year has had a lower chance of mortality when he is compared with individuals who have not maintained great oral hygiene (Tsakos et al., 2015). However, elderly patients with periodontal disease require more extensive treatment than edentulous patients. Literatures studies reveal that patients who had not attended dental check-up once a year were are a greater risk of periodontal diseases (Colak, Dulgergil, Dalli & Hamidi, 2013). Various studies have shown that the use of dentures has been linked to the reduction in mortality in more elderly patients. Increased mortality can be explained by the reduction of teeth, which can facilitate the growth of pathological microbial flora with can be associated with various systemic diseases (Tsakos et al., 2015).

Another relation of periodontal diseases and tooth loss was low socio-economic conditions. A literature study was conducted to establish the relation between low income groups and prevalence of dental caries (Buchwald et al., 2013). It was found that the prevalence of periodontal infection and tooth loss was directly linked to the socio-economic conditions of the patients. The study concluded that there is a direct association between the status of income of the patient and periodontics, with decrease in income the prevalence of periodontal diseases increases (Friedman, Kaufaman & Karpas, 2014). Age of the patient was found to be another factor linked with loss of tooth. Increase Probing depth of more than 5mm or equal to 5 mm with radiant bone damage greater than 5 mm, increases with age regardless of the number of dental visits (Darcey et al., 2013). Tooth loss in elderly population was also associated with root caries and use of removable partial dentures. These two factors synergistically affect tooth decay in the old population. Patients, who wore dental prostheses, had greater chances of caries in supporting tooth structures. The supporting tooth structure was found to be more vulnerable to permanent damage and ultimately extraction (Patel, Kumar & Moss, 2013).

Relation between Tooth Loss and Mortality

Dental problems were associated with lower personal satisfaction due to inability to perform basic functional abilities such as mastication due to inflammation resulting from bacterial accumulation around the structure of the teeth as well as dentures (Buchwald et al., 2013). Continuous infection of oral tissues contributes to the association of diseases such as rheumatoid heart diseases, coronary disease, diabetes mellitus, persistent obstructive pulmonary disease and stroke. The purpose of this review is to assess the causes and implications of tooth loss in contemporary societies and find the relation between the tooth loss and quality of life (Friedman, Kaufaman & Karpas, 2014).

Causes of Tooth Loss

Patient education has been statically related to tooth loss when the population is more taught that they have more oral hygiene than uneducated populations, who tend to have more tooth loss. The research findings in lesser education coincide with the discoveries of Rusell, Gordon, Lukacs & Kaste (2013) that announced levels of low education and low individual wages are associated with higher chances of tooth loss (Costa et al., 2014). Moreover, it has been found that smoking and age significantly affect tooth loss; therefore, if a person is a chronic smoker, he will have more vulnerability of tooth loss than non-smokers (Patel, Kumar & Moss, 2013). Smoking, low level of knowledge and poor health has been associated with poor oral hygiene among middle-aged and adult populations, which coincided with the above findings. Smoking is associated with poor oral hygiene, stains on the lingual surface of the lower and upper anterior teeth and periodontitis. It also leads to yellowish discolouration of teeth, halitosis and risk of throat cancers. Increased build-up of plaque on teeth leads to loss of attachment between the tooth surface and the gingival tissue (Colak, Dulgergil, Dalli & Hamidi, 2013). This causes increased prevalence of gum issues and increased tooth mobility due to loss of attachment. Cigar smokers experience tooth loss due to loss of alveolar bone surrounding the tooth structure.

A combination of variables that can affect tooth decay, for example, to be old, male, married, living in a remote location, less educated, and inability to access health care facilities (Darcey et al., 2013). Most of the past variables are related to poor oral hygiene and subsequent tooth loss. Another study concluded a different result. It was found that tooth loss was independently associated with smoking as a risk factor. Ageing was not identified with tooth loss (Lucas et al., 2013).

Importance of Oral Hygiene for Preventing Tooth Loss

Literature studies reveal high prevalence of caries risk in Caucasians, males and chronic smokers, resulting in subsequent tooth loss. Diabetes has been associated with periodontitis and tooth loss. Activation of inflammatory mediators was found to be associated with increased bone hemostasis which leads to bone resorption around areas that surround the tooth structure (Kassebaum et al., 2014). Also, certain drugs were also found to increase the prevalence of dental caries. Certain drugs have a negative impact on the salivary organs. These drugs reduce the salivary secretion capacity and thus increase greater bacterial colonization (Colak, Dulgergil, Dalli & Hamidi, 2013). Xerostomia has been found to be a critical risk factor for increased incidence of dental caries.

When the caries involves the root dentin, it creates a positive relationship with the dental problems, as the restoration of these teeth proves to be more testing than the repair of caries in the coronal surface of the tooth (Tan, Peres & Peres, 2016). The main reason behind the tooth loss is the loss of integrity of the periodontal ligament accompanied by smoking, along with root caries involvement, there was an additional reason for the loss of the teeth (Colak, Dulgergil, Dalli & Hamidi, 2013).

Although tooth extraction is mostly on pathological basis, however, certain other factors were found to be linked to tooth extraction such as low income group people, uneducated patients and mental acceptance of tooth loss (Hoeksema et al., 2018).

Role of teeth is both related to aesthetics and functional. Various essential functions such as speaking, chewing and facial appearance are affected due to the loss of one or more teeth. Dental problems can also negatively affect feelings and oral well-being associated with personal satisfaction. Losing teeth at a younger age may further lead to reduced quality of life (Tan, Peres & Peres, 2015). Meanwhile, the complete loss of teeth can be more distressing than partial tooth loss. Besides the negative feelings of typical ageing, the loss of teeth adds to the emotional distress of the elderly. Tooth decay can be associated with mild emotional distress to extreme psychological depression. In addition to the emotional impact, tooth loss intertwines the functional failures, causing even more humiliating and other systemic issues. A person with teeth loss is unable to perform masticatory function which can become responsible for inadequate fulfilment of nutritional requirements in the persons (Gates III, Cooper, Sanders, Reside & De Kok, 2014). Elements, such as behavior, mental health, dental involvement and the qualities of the framework of medical services and financial components, play a vital role in the likelihood of tooth loss. Various literature studies indicate that tooth loss is related to the functional, psychological and social effects for the people. It has been found that at least twenty teeth are necessary to fulfil the ability to chew and bite (Colak, Dulgergil, Dalli & Hamidi, 2013). An unfavourable tooth, to the extent that the teeth are not able to make sufficient occlusion while performing the masticatory function can lead to various functional issues for the individual. Thus, maintaining more than 20 regular teeth is associated with a reasonable level of oral health (Masood, Newton, Bakri, Khalid & Masood, 2017). It can be seen that older people associate tooth loss as a consequence of ageing and thus accept it as a part of normal ageing process.

Relation between Dental Check-up and Tooth Loss

There is a lot of rationale evidence that demonstrates the relation of health to the personal satisfaction of individuals. Accoding to Gomes et al. (2014) there are oral diseases in all population groups that identify unambiguously with age, and as individuals become older, they increase in insight and seriousness. World Health Organization (WHO) goals concerned with tooth decay have been used in different nations to find ways to limit the social outcomes of oral diseases (Colak, Dulgergil, Dalli & Hamidi, 2013). Extensive research in the field of dentistry has led to improvement and access to oral health care resulting in increased personal satisfaction: improving and assessing the perception of oral well-being, oral health quality, dental effects on patients' lives, assessing emotional signs of oral wellbeing, related to personal satisfaction. This research was confirmed by the geriatric study, the progression of the proportions of dental effects on everyday life, the advancement of the evaluation of oral well-being in elderly (Masood, Newton, Bakri, Khalid & Masood, 2017). Oral well-being and general well-being in racial and ethnic groups were also evaluated in the study. Nevertheless, these assessments were not directed at improving the oral hygiene in these population groups and assessment of the state of oral well-being and in addition to its effects on the lives of individuals (Olofsson, Ljungqvist, Stjernfeldt, Wardh & Olin, 2017).

Australia has achieved WHO goals for oral well-being consistently since year 2000, but only up to twelve years of age. At any other age, the conditions of the oral cavity are below these goals, essentially due to tooth loss, and they become worse when individuals become more older. It is normal to reduce children's caries to have constructive results in the medium and long term, as well as the well-being of adults, despite the fact that it is not possible to say that this will happen (Tan, Peres & Peres, 2015).

Apart from giving and choosing intercessions that are aimed to increase the quality of life of the elderly, the study of factors that contribute to great personal satisfaction to individuals is of incredibly social and logical importance (Naka, Anastassiadou & Pissiotis, 2014).

The population survey shows that oral diseases, mainly dental caries and periodontal diseases, are still important general medical problems. These two conditions cause significant problems that affect personal satisfaction because dental caries and periodontal problems can lead to tooth loss (Feldens, Day, Borges, Feldens & Kramer, 2016).

Relation between Socio-economic Conditions and Tooth Loss

Personal satisfaction is characterized by the WHO as a "people's" impression of their life situation in terms of lifestyle and the valuable frameworks in which they live and their aims, desires, patterns and concerns (Razak et al., 2014). In this sense, several variables may affect the person's personal satisfaction, including oral well-being, and oral health must include the lack of agony of the person, the ability to bite appropriately, the simplicity of ingestion, and the absorption of food, and this must also be added to correspondence especially when we talk and smile, which can increase people's self-confidence (Antunes, Tan, Peres & Peres, 2016). Personal satisfaction implies preserving the potential results that individuals are accused of in their life. Oral health problems are likely to have many more similarities identified with personal satisfaction of man and close to the prosperity of the home than the ability of the individual to perform daily exercises (Colak, Dulgergil, Dalli & Hamidi, 2013).

Loss of teeth is associated with difficulty in speech and masticatory functioning. Interviews were conducted in a study to investigate the problems associated with tooth loss.

The patients stated that they felt humiliated when they had to talk to someone. Also, in these reactions the patients realized about the importance of teeth after losing teeth. The patient stated that they were unable to obtain adequate nutrition due to inability to chew food such as nuts, apples, and raw carrots. Each day, the intake of starch-free polysaccharides, proteins, calcium, hema-free, niacin, vitamin C, congenital and sugars was much lower in this collection (Razak et al., 2014).. Plasma ascorbate and retinol are substantially lower in edentulous patients as compared to dentinal ptients who have an effect on the acceptance of a healthy status (Naka, Anastassiadou & Pissiotis, 2014).

Loss of functional capacity for mastication due to carious or missing teeth, biting capacity, tooth portability, periodontal loss of attachment, and missing anterior and posterior teeth have an impact on activities of daily living. In addition, the financial situation, the utilization of dental administrations and statistical qualities also has an impact on the overall quality of life assessment. A reduced number of teeth, for example a shortened tooth “curve of spee” and masticatory functional capacity is also associated with poor quality of life, which has not been extensively studied in the literature (Olofsson, Ljungqvist, Stjernfeldt, Wardh & Olin, 2017). The masticatory function, aesthetics and speech that need to be protected, and which are essential, are firmly associated with the quality of life and the effects caused by oral hygiene and have a possible connection with person’s quality of life. There is inadequate data in literature related to this topic due to lack of agreement on the importance of the functional dentition (Colak, Dulgergil, Dalli & Hamidi, 2013).

Implications of Tooth Loss on Personal Satisfaction and Functional Ability

Functional dentition can be defined as the ability to maintain a characteristic, aesthetic, functional capacity of teeth, not less than twenty teeth throughout the entire life without requiring replacing the teeth. Nevertheless, the number of teeth alone is too short-sighted, making it impossible to present the state of oral well-being in terms of utility. There is some evidence that teeth additionally have to be much appropriated (not less than 10 teeth in each arch) to ensure satisfactory oral capacity (Hoeksema et al., 2018). Still, the idea of ??all well distributed teeth remains essentially quantitative given that it does not consider that each tooth plays alternative oral capacity. Nguyen et al. build a useful framework for tooth characterization in the light of five successive progressive levels that include the underlying assumptions including- not less than one molar tooth in each curve; not less than ten teeth in each curve; each curve contains a posterior teeth; three or four of premolars; and not less than one molar per arch, respectively. This new dental structure to characterize the functional dentition is used to include the population through the world (Colak, Dulgergil, Dalli & Hamidi, 2013).

According to these classification criteria, positive relation was seen in masticatory functioning and thus overall quality of life. Nevertheless, this framework excludes periodontal status within the meaning of functional dentition. Joining this view is legitimated by the study that the loss of tissue from periodontal ligament has a negative impact on masticatory capacity, which is one of the most critical oral cavity functions. Furthermore, the signs and side effects of periodontal diseases, for example, periodontal pockets more than five mm, swelling, pain and halitosis, show a connection with worse quality of life in patients suffering from periodontal treatment (Kassebaum et al., 2014). Better oral health and normal follow-up of patients undergoing periodontal treatment are reflected through improvement in quality of life and improvement of functional capacity. An extended classification for functional capacity has been established by incorporating the periodontal criteria into the framework for aesthetic, masticatory, and speech functions, designated as FD Class6 by the creators (Colak, Dulgergil, Dalli & Hamidi, 2013).

Conclusion

Dental ailments cause problems in the individual's satisfaction, especially when it affects their systemic health, appearance and nurturing status. There are various causes of tooth loss, while the most common cause is dental caries. Loss of integrity of periodontal ligament to the tooth structure is the second most common cause of tooth loss. Loss of tooth is directly linked to the reduction in the quality of life. Microbial colonization of the oral tissues is associated with inflammatory reaction. This interferes with the ability to perform basic function of mastication. Tooth loss is associated with emotional distress and loss of masticatory functioning resulting in inadequate fulfilment of nutritional requirements. Lack of education, low social-economic state and old age are considered as risk factors for tooth loss. In order to maintain the functional capacity, it has been found that at least twenty teeth are required to perform the normal functioning of masticatory capacity in humans. Moreover, it is essential to improve the knowledge and awareness regarding various methods of improving oral hygiene in communities to prevent tooth loss at an early age and help in improving the quality of life.

Relation between Oral Diseases and Tooth Loss

References

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Antunes, J. L. F., Tan, H., Peres, K. G., & Peres, M. A. (2016). Impact of shortened dental arches on oral health?related quality of life. Journal of oral rehabilitation, 43(3), 190-197.

Buchwald, S., Kocher, T., Biffar, R., Harb, A., Holtfreter, B., & Meisel, P. (2013). Tooth loss and periodontitis by socio?economic status and inflammation in a longitudinal population?based study. Journal of clinical periodontology, 40(3), 203-211.

Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. (2013). Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of natural science, biology, and medicine, 4(1), 29.  

Costa, F. O., Lages, E. J. P., Cota, L. O. M., Lorentz, T. C. M., Soares, R. V., & Cortelli, J. R. (2014). Tooth loss in individuals under periodontal maintenance therapy: 5?year prospective study. Journal of Periodontal Research, 49(1), 121-128.

Darcey, J., Horner, K., Walsh, T., Southern, H., Marjanovic, E. J., & Devlin, H. (2013). Tooth loss and osteoporosis: to assess the association between osteoporosis status and tooth number. British dental journal, 214(4), E10.

Feldens, C. A., Day, P., Borges, T. S., Feldens, E. G., & Kramer, P. F. (2016). Enamel fracture in the primary dentition has no impact on children's quality of life: implications for clinicians and researchers. Dental Traumatology, 32(2), 103-109.

Friedman, P. K., Kaufman, L. B., & Karpas, S. L. (2014). Oral health disparity in older adults: dental decay and tooth loss. Dental Clinics, 58(4), 757-770.

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Patel, M. H., Kumar, J. V., & Moss, M. E. (2013). Diabetes and tooth loss: an analysis of data from the National Health and Nutrition Examination Survey, 2003–2004. The journal of the american dental association, 144(5), 478-485.

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