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Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 211-215
Relationship between perceived chewing ability, oral health related quality of life and depressive symptoms among completely edentulous individuals

1 Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College and Hospital, Dr. M.G.R Educational and Research Institute Univeristy, Chennai, Tamil Nadu, India
2 Chief Consultant, Revive Smile Dental Care, Changanacherry, Kerala, India
3 Department of Prosthodontics Dental Sciences, College of Dentistry, Al Zulfi Majmaah University, Riyadh, Kingdom of Saudi Arabia
4 Department of Public Health Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
5 Department of Clinical Science, College of Dentistry, Ajman Universiy, Ajman, United Arab Emirates
6 Basic Medical Sciences, College of Dentistry, Ajman Universiy, Ajman, United Arab Emirates

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Date of Submission29-Dec-2020
Date of Decision16-Apr-2021
Date of Acceptance24-Jun-2021
Date of Web Publication22-Nov-2021


Background: Edentulism affects the chewing ability of a person and can engender nutritional deficiencies which can affect the overall quality of life and depression. Aim: Our aim was to evaluate the association between perceived chewing ability, oral health-related quality of life (OHRQoL) and depressive symptoms among completely edentulous patients with and without dentures. Settings and Design: Institutional study and cross-sectional design. Methods: A cross-sectional study among 207 completely edentulous persons was conducted in South India. The subjects completed a self-administered questionnaire on demographics, Beck's depression inventory, oral health impact profile-edentulous (OHIP-EDENT), age when edentate, chewing ability, and denture satisfaction. Further, denture status was clinically evaluated. Statistical Analysis: Data were summarised and analysed using the Chi-square test and multivariate logistic regression. P < 0.05 was considered significant. Results: Persons not using complete dentures (odds ratio [OR] =3.5, P < 0.05), who reported impaired chewing ability (OR = 4.6, P < 0.05), those who became edentate before 55 years (OR = 4.6, P < 0.05) and with poor denture status (OR = 6.2, P < 0.05) were more likely to report depressive symptoms. Lesser impact in relation to OHRQoL was found to be protective against depression among completely edentulous (OR = 0.24, P < 0.05). Conclusion: Depressive symptoms were associated with impaired chewing ability, higher impacts on OHIP-EDENT, and edentulous persons not using complete dentures. High priority must be given to enhance awareness towards oral rehabilitation among completely edentulous to reduce the chance of depression occurring due to impaired chewing ability and poor OHRQoL.

Keywords: Chewing ability, depression, denture, edentulous, oral health-related quality of life

How to cite this article:
C Satishkumar C S, Nair SJ, Joseph AM, Suresh S, Muthupandian I, Kumaresan S, Ashekhi A, Nadeem G. Relationship between perceived chewing ability, oral health related quality of life and depressive symptoms among completely edentulous individuals. Indian J Dent Res 2021;32:211-5

How to cite this URL:
C Satishkumar C S, Nair SJ, Joseph AM, Suresh S, Muthupandian I, Kumaresan S, Ashekhi A, Nadeem G. Relationship between perceived chewing ability, oral health related quality of life and depressive symptoms among completely edentulous individuals. Indian J Dent Res [serial online] 2021 [cited 2022 Aug 12];32:211-5. Available from:

   Introduction Top

One of the common oral problems associated with advancing age is tooth loss. Tooth loss can occur as a consequence of untreated caries, periodontal diseases, trauma and many others. Oral health is an integral part of general health and edentulism does affect the overall well-being of an individual. The prevalence of edentulism in South India is reported to be 58.8% among females and 41.2% among males.[1] Tooth loss impairs the chewing efficiency of an individual, thus, restricting their choice to soft and easy to chew foods. Reduced chewing ability is considered to be a risk factor for depression.[2] The performance of chewing efficiency of a person with a complete denture is reported to be less than one-sixth compared to a person with dentition; thus, the chewing efficiency of a person without a denture can be considered to be much worse.[3] Tooth loss affects the social and psychological framework of a person. They tend to avoid social activities and reduce interaction due to embarrassment or functional limitations. Moreover, tooth loss is considered a serious event in life which is difficult to adjust to than retirement from work.[4] Tooth loss can thus cause discomfort, pain and functional limitations which could lead to disability, and finally, handicap; and may predispose to a feeling of depression. Reduced chewing ability and edentulism are considered to be independent risk factors for depression but their combined effect and the impact of oral health-related quality of life (OHRQoL) on depressive symptoms among completely edentulous has not been reported before.[5],[6] Hence, the objective of this study was to evaluate the association between perceived chewing ability, OHRQoL and depressive symptoms among completely edentulous patients with and without dentures.

   Methods Top

A cross-sectional study was conducted among 207 edentulous persons with or without removable dentures above 50 years of age who visited the dental college between July 2014 and January 2015; if with dentures, dentures not older than 2 years, without any debilitating illness and without any oral lesions. All the completely edentulous patients reporting to the dental college were recruited for the study. Ethical approval was obtained from the institutional IRB (Dr MGR Educational and Research Institute University 023/2014).

The sample size was calculated based on the prevalence of edentulous persons visiting the dental college over a period of 3 weeks and using the following formula: Zα/22 P (1-P)/d2 (Zα/2- normal deviate, P: 16% prevalence, D: 5% margin of error) and estimated to be 205.

All the participants signed the informed consent and answered a self-administered questionnaire demographic characteristics (age, sex, marital status, spouse-alive or dead, education, income, source of income, residence, medical problems, smoking and drinking habits), self-reported denture satisfaction (satisfied/dissatisfied), perceived chewing ability,[7] Beck's Depression Inventory (BDI) and oral health impact profile-edentulous (OHIP-EDENT).[8] The denture status was evaluated by a trained clinician.[9] BDI is a 21-item questionnaire and each item has a response from 0 to 3. The total scores for the 21 items are summated and scores within 1–10 are considered normal and as the scores increase, the severity of depression increases. The OHIP is a sophisticated instrument for assessing OHRQoL. The response is a choice of five answers and the total score is calculated by adding the responses to all the questions (0 = never; 1 = seldom; 2 = fairly often; 3 = often; 4 = very often) and the minimum score was 0 and maximum was 76. Lower scores indicate higher satisfaction of individuals' oral health and better quality of life. OHIP-EDENT is a modification of OHIP for edentulous patients and it is a 19-item questionnaire with seven subscales: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. The questionnaires were translated and validated using blind back translation into English by two separate persons proficient in both the regional language (Tamil) and English. Reliability was assessed using test-retest and the intraclass correlation coefficient was found to be 0.74 for BDI; 0.65 for OHIP-EDENT. The internal consistency was 0.75 and 0.73, respectively. Data were collected using short interviews which guided the patients to fill the questionnaire and it was conducted by a single interviewer. The data were summarised and analysed using SPSS V 16. The mean scores of BDI and OHIP-EDENT scales were compared with demographic and edentulous variables using independent T test and one-way Analysis of Variance. Categorical analysis was performed using the Chi-square test to assess the relationship between the variables and depressive symptoms. The odds ratio (OR) was calculated using multiple logistic regression (entry method) after adjusting for potential confounders. The level of statistical significance was set at 5%.

   Results Top

All 207 patients completed the study, of which 112 (54.1%) were males and 95 (45.9%) were females. The mean scores of BDI and OHIP-EDENT among different demographic variables and edentulous status are presented in [Table 1]. Females, individuals who became edentate before 55 years, incompetent chewing ability and poor denture status had high levels of depressive symptoms and poor OHRQoL.
Table 1: Comparison of mean BDI and OHIP-EDENT scores with various demographic variables and edentulous status

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Of the total samples, 53 (25.6%) patients reported symptoms of depression and they were below 55 years of age, females, married, educated, presently employed, those who did not use complete dentures, with impaired chewing ability and dissatisfied with their dentures [Table 2]. [Table 3] presents the OR from logistic regression analysis of the association between the chewing ability, OHIP-EDENT and depressive symptoms. After adjusting for covariates (age, sex, marital status, education and source of income), those who reported impaired chewing ability (OR = 4.9, P < 0.05), persons not using complete dentures (OR = 3.5, P < 0.05) were more likely to be depressed. Persons who reported not one/more fairly often or often response were less likely to be depressed (OR = 0.24, P < 0.05), and lesser impact in OHIP-prevalence was found to be protective against depression.
Table 2: Bivariate analysis of factors affecting depression among completely edentulous individuals

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Table 3: Multiple logistic regression with depression as the criterion variable#

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   Discussion Top

The present findings of our cross-sectional study contribute to the association between edentulism, impaired chewing ability, poor OHRQoL and its impact on depression. Depression has been reported to predispose to oral diseases due to biological disturbances and a lack of motivation.[10] Likewise, oral diseases have also been found to impair self-esteem, OHRQoL, and thereby, affecting the psychological well-being of individuals.[11] Edentulous persons aged less than 55 and those who lost all their teeth before 55 years of age reported more depressive symptoms than those who were elder to them. It is quite contradictory to the previous reports in the literature—older people are more susceptible to depression. But this finding can be explained by the fact that people less than 55 years are more likely to be employed and research indicates that edentulous individuals avoided chewing in front of others and reported embarrassment.[12] Depression among less than 55-year-olds is further strengthened by the fact that working people reported more depressive symptoms than pensioners, and those living from familial support. Employed people are exposed to a lot of stressors; edentulousness further accentuates them and this may lead to depression.

The chewing ability is impaired in the edentulous, and it can be a risk factor for depression.[2] Good or satisfactory denture status significantly improved the chewing ability compared to poor denture status; persons with poor denture status more likely suffered from depression in our findings. The chewing ability is associated with food choices. Impaired chewing ability implies poor food choices and it affects an individual's overall nutrition. It can play a key role in the onset and duration of depression.[13] Persons with incompetent chewing ability and without complete dentures were more likely to suffer from depression and this relationship was found even after adjusting for covariates during the analysis. Koshino reported improvement in the degree of eating satisfaction after complete denture rehabilitation which enhanced the psychological well-being by improving the overall quality of life.[14] We do not emphasise that edentulism is a major risk factor for depression, but suggesting from our study findings that it can play a significant role in accentuating the development of depression among susceptible individuals.

OHIP-EDENT impacts were fewer in persons who were normal when compared with persons who reported depressive symptoms. Similar to our findings, Shimazaki et al.[15] reported less impact on daily functions among elderly wearing complete dentures. Persons wearing complete dentures reported fewer impacts pertaining to questions on 'difficulty in chewing food', 'uncomfortable to eat any food', avoid eating some food' and 'unable to enjoy other people's company' compared to non-denture wearers. Zainab et al. reported a similar finding.[16] Recently, rehabilitation with conventional complete dentures among Nepalese adults has been reported to improve their OHRQoL.[17] The most common prosthesis among completely edentulous is a removable denture, but the impact of removable complete denture on the quality of life depends upon the quality of the denture, mental and nutritional status of the person, operator skills, chronic diseases and many others. Our study participants did not suffer from any debilitating diseases and denture use beyond 2 years were not included to avoid a possible confounding, but the lack of information regarding the qualification of the operator who made the denture can be considered a limitation of the study. Another limitation includes the selection bias which may have played a role and the possibility of reverse causality cannot be ignored.

In conclusion, edentulous persons not using complete dentures, with incompetent chewing ability and impaired OHRQoL are more likely to be depressed. A higher proportion of study participants were not denture wearers (53.6%); hence, high priority should be given to enhance the awareness and attitude toward early oral rehabilitation among the edentulous and to reduce the chance of depression occurring in susceptible individuals due to impaired chewing ability and poor OHRQoL as a result of edentulism.

Recommendations: The exact mechanism behind this association requires further long-term studies.


We thank all the participants who participated in this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. C S C Satishkumar
Assistant Professor, Department of Oral and Maxillofacial Surgery, Thai Moogambigai Dental College and Hospital, Dr. M.G.R Educational and Research Institute University, Chennai - 600 095, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.ijdr_1141_20

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  [Table 1], [Table 2], [Table 3]


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