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Are you inadvertently zapping your patients’ spoons?

May 21, 2023
For optimal dental appointment outcomes, it’s important to go the extra mile for patients living with a chronic illness. Karen Davis, BSDH, RDH, explains the basics of the spoon theory and how it’s relevant to your practice.

Have you heard any of your patients or friends say, “I don’t have enough spoons for that”? If you live with a chronic illness, or if you are close to someone navigating life with a chronic illness, you may already know about “spoonies.” For the rest of us, it is helpful to understand just what this means. 

Christine Miserandino developed the spoon theory in her effort to describe to a friend what it is like to live with a chronic illness. She grabbed a handful of spoons to represent the energy required to complete various tasks. “Spoonies,” or people living with a chronic illness, have a limited number of spoons every day (let’s say 12), so spoon usage requires careful consideration, or even altering plans. The only way to replenish one’s spoon supply is to rest. 

For many people living with a chronic illness, hallmark symptoms such as chronic pain, debilitating fatigue, and depression zap spoons quickly, and at some point, depending upon how well or unwell one feels on any given day, they may be out of spoons before the day ends, and plans may have to be altered. Spoonies often describe the isolation that envelops their world, since many people living with a chronic illness look perfectly fine on the outside, even though there may be a spoon-sucking battle ensuing internally that no one sees. Outside observers don’t always appreciate their invisible struggles, and in fact frequently comment on how good they look. 

You might also be interested in: When your patient is not OK: 4 ways to create a safe space

How chronic illness may impact patients

Let’s consider how being a spoonie might impact our patients. Most patients living daily with a chronic illness have learned the art of resilience. A patient may arrive to her appointment with her typical smile and/or social graces, but if she is experiencing a day clouded with internal symptoms, fatigue, or elevated pain, she may be low on spoons for her visit. If so, it could impact her ability to fully listen to customized home-care instructions or explanations for much-needed dental treatment. Additionally, many patients living with autoimmune diseases and chronic illnesses have higher levels of chronic inflammation in their bodies, and often have increased susceptibility to periodontal diseases and/or dental caries. Their clinical presentations may reflect living with patterns of high symptoms that, when coupled with low spoons, can impact successful daily oral hygiene strategies. At first glance, it may appear as though these patients just need to step up their oral hygiene, when in reality, living with inadequate daily spoons and increased susceptibility to oral diseases become significant risk factors in and of themselves. 

This sampling of published data provides insight into the increased susceptibility for oral consequences of a patient living with a chronic illness:

  • Patients with type 1 diabetes had higher caries rates, lower salivary rates, and higher bacterial loads in saliva and biofilm compared to controls.1
  • Patients with lupus had lower oral bacterial diversity and significantly lower pH and buffering capacity compared to controls.2
  • Patients with Sjögren’s syndrome had significantly higher decay rates requiring more invasive treatment compared to controls even though the majority of the patients with Sjögren’s brushed twice daily compared to the majority in the control group, who brushed only once daily.3
  • 70% of patients with rheumatoid arthritis suffered from periodontal disease, with 30% of cases classified as severe, compared to only 30% of controls having periodontal disease, with only 5% of them being severe.4
  • Methotrexate, used in the treatment of rheumatoid arthritis and Crohn’s disease, can cause oral ulcerations, ulcerative stomatitis, and mucositis.5
  • Biologic drugs used for immunosuppression to treat various autoimmune diseases can contribute to opportunistic infections in the oral cavity, such as candidiasis.5

How you can help

How can dental professionals help spoonies achieve better dental outcomes? Here are a few suggestions:

  • Ensure that medical history forms include inquiries about living with chronic pain, chronic fatigue, depression, and restricted diets to help identify patients who may be living with limited spoons and/or increased risks.
  • Make the comfort of dental appointments a priority for patients living with chronic illness by using comfort items as needed, such as neck pillows, blankets, topical anesthetics, and desensitizers. 
  • Identify patients using immunosuppressant medications and become their advocate for disease prevention of oral inflammatory conditions and remineralization of tooth structure. 
  • Maintain a broad resource of products to alleviate xerostomia, a common side effect of chronic illness. 
  • Recommend strategies that require fewer spoons for daily disease control (for example: power toothbrushes, water/air flossers, and interdental brushes).
  • Email, text, or provide written instructions and product recommendations requiring follow-up.

Once the message of the spoon theory began to spread, it resonated immediately with individuals worldwide struggling with chronic pain, fatigue, and management of their health as a full-time job. Understanding the spoon theory will enable you to be a better friend, neighbor, coworker, or dental provider to the spoonies around you. If you really want a glimpse of what it is like to live with chronic illness, take 13 minutes to view “The spoon theory” written and spoken by Christine Miserandino on YouTube.6

Editor's note: Originally posted in 2020 and updated regularly


  1. Coelho A, Paula A, Mota M, et al. Dental caries and bacterial load in saliva and dental biofilm of type 1 diabetics on continuous subcutaneous insulin infusion. J Appl Oral Sci. 2018;26:e20170500. doi:10.1590/1678-7757-2017-0500
  2. Yang L, Wang J, Xiao Y, et al. Saliva dysfunction and oral microbial changes among systemic lupus erythematosus patients with dental caries. Biomed Res Int. 2018;2018:8364042. doi:10.1155/2018/8364042
  3. Christensen LB, Petersen PE, Thorn JJ, Schiødt M. Dental caries and dental health behavior of patients with primary Sjögren syndrome. Acta Odontol Scand. 2001;59(3):116-120. doi:10.1080/000163501750266684
  4. Dental health and rheumatoid arthritis: a research update. December 23, 2015. Accessed September 15, 2020. https://www.hopkinsarthritis.org/arthritis-news/ra-news/dental-health-and-rheumatoid-arthritis-a-research-update/ 
  5. Muhvic´-Urek M, Tomac-Stojmenovic´ M, Mijandrušic´-Sincˇic´ B. Oral pathology in inflammatory bowel disease. World J Gastroenterol. 2016;22(25):5655-5667. doi:10.3748/wjg.v22.i25.5655
  6. The spoon theory written and spoken by Christine Miserandino. December 15, 2010. https://www.youtube.com/watch?v=jn5IBsm49Rk
About the Author

Karen Davis, BSDH, RDH

Karen Davis, BSDH, RDH, is the founder of Cutting Edge Concepts, an international continuing education company. She practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corporation, Periosciences, Hu-Friedy Group, and EMS. She can be reached at [email protected].