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Inoue Y, Cooray U, Ishimaru M, Saito K, Takeuchi K, Kondo K, Aida J. Oral Self-Care, Pneumococcal Vaccination, and Pneumonia Among Japanese Older People, Assessed With Machine Learning. J Gerontol A Biol Sci Med Sci 2023; 78:2170-2175. [PMID: 37429575 DOI: 10.1093/gerona/glad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Pneumonia is a leading cause of death worldwide. It is a particularly serious burden in older people, as they tend to have a weakened immune response. Identifying the role of oral self-care and pneumococcal vaccination in healthy, independent older people can aid pneumonia prevention among them. This study investigated the associations between oral self-care, pneumococcal vaccination, and pneumonia experience among independent older people. METHODS This cross-sectional study used data from the 2016 Japan Gerontological Evaluation Study. We used machine learning to examine the association between oral self-care and the experience of pneumonia over the previous year, stratified by pneumococcal vaccination. The covariates were sex, age, years of education, equivalent annual income, medical history of stroke, oral health status (choking, dryness, number of teeth), and smoking status. The analysis included 17 217 independent older people aged 65 and over. RESULTS The prevalence of pneumonia experienced among those who brushed their teeth once or less per day was 4.5% and 5.3% for those with and those without pneumococcal vaccinations, respectively. In the unvaccinated group, the odds ratio of pneumonia experience for those who brushed their teeth once or less a day was 1.57 (95% confidence interval: 1.15-2.14) compared to those who brushed their teeth 3 or more times a day. By contrast, there was no significant association between the frequency of toothbrushing and the experience of pneumonia among people who received pneumococcal vaccination. CONCLUSIONS Oral care influenced the experience of pneumonia among independent older people who did not receive pneumococcal vaccination.
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Affiliation(s)
- Yuko Inoue
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Upul Cooray
- Department of International and Community Oral Health, Graduate School of Dentistry, Tohoku University, Miyagi, Japan
| | - Miho Ishimaru
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kousuke Saito
- Division of International Health, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Kenji Takeuchi
- Department of International and Community Oral Health, Graduate School of Dentistry, Tohoku University, Miyagi, Japan
| | - Katsunori Kondo
- Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Jun Aida
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Kurinami N, Ashida K, Sugiyama S, Morito Y, Hasuzawa N, Yoshida A, Morita A, Hieshima K, Miyamoto F, Kajiwara K, Jinnouchi K, Jinnouchi T, Jinnouchi H, Nomura M. Reduced Number of Remaining or Healthy Teeth in Patients with Type 2 Diabetes Mellitus: A Cross-sectional Study Assessed by Dentists or Dental Hygienists in Japan. Intern Med 2023; 62:987-993. [PMID: 37005297 PMCID: PMC10125810 DOI: 10.2169/internalmedicine.9773-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Objective This study assessed the relationships between oral health (number of remaining and healthy teeth and periodontal disease) and type 2 diabetes mellitus (T2DM) to contribute to improved patient care. Patients We conducted a cross-sectional cohort study of consecutive patients being regularly treated for chronic diseases (T2DM, hypertension, and dyslipidemia). A dentist or dental hygienist accurately evaluated the oral environment. Patients with fewer than 20 teeth were classified as having reduced remaining teeth (RRT). Results A total of 267 patients were enrolled, including 153 patients (57%) with T2DM and 114 without (43%). Patients with T2DM had 3 fewer remaining teeth on average than those without DM [median: 22 (interquartile range (IQR): 11-27) vs. median: 25 (IQR: 17.3-28), p=0.02]. In addition, patients with T2DM had 4 fewer healthy teeth on average than those without DM [median: 8 (IQR: 2.8-15) vs. median: 12 (IQR: 6-16), p=0.02]. The frequency of RRT was higher in the T2DM group (n=63; 41%) than in the non-DM group (n=31; 27%, p=0.02). Multivariable logistic regression for the presence of RRT in the T2DM group found that age [odds ratio (OR), 1.08; 95% confidence interval (CI), 1.03-1.13; p<0.01] and regular dental consultations (OR, 0.28; 95% CI, 0.10-0.76; p=0.01) were independently and significantly associated. Conclusion The number of remaining or healthy teeth was significantly lower in patients with T2DM than in those without T2DM in current Japanese clinical practice. Regular dental consultation is recommended to preserve remaining teeth in patients with T2DM.
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Affiliation(s)
- Noboru Kurinami
- Kurinami Clinic, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Japan
- Diabetes Care Center, Jinnouchi Hospital, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Japan
| | - Seigo Sugiyama
- Diabetes Care Center, Jinnouchi Hospital, Japan
- Division of Cardiovascular Medicine, Diabetes Care Center, Jinnouchi Hospital, Japan
| | | | - Nao Hasuzawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Japan
| | | | | | | | | | | | | | | | - Hideaki Jinnouchi
- Diabetes Care Center, Jinnouchi Hospital, Japan
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Kumamoto University Hospital, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Japan
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Are Public Oral Care Services Evenly Distributed?-Nation-Wide Assessment of the Provision of Oral Care in Japan Using the National Database of Health Insurance Claims. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010850. [PMID: 34682591 PMCID: PMC8536066 DOI: 10.3390/ijerph182010850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 01/05/2023]
Abstract
The provision of oral health care services is one of the global challenges under the realization of universal health coverage in many countries. Despite the increasing importance of oral health care in an aging society, the disparities in the provision of oral care in Japan have not been clarified. Therefore, this study investigated the status of oral and dental care provision using the National Database of Health Insurance Claims and Specific Health Checkups (NDB) at the level of prefectures and secondary medical care areas. Additionally, a multiple regression model was applied to identify the influence of human resources in oral care services and economic factors on the standardized claims data ratio (SCR) of total dental receipts. The results showed that the total amount of oral care provided tended to be higher in metropolitan areas, with bimodal peaks in children aged 5-9 and adults in their 70s. The SCR for dental caries showed little difference nationally, but SCR for periodontal disease tended to be higher in prefectures including metropolitan areas. In a multiple regression model, the number of dentists and prefectural income per capita influenced the SCR of total dental receipts. In secondary medical care areas, some depopulated areas are supplemented by adjacent areas. These results suggest that oral health care services in the national health insurance system are generally well provided; however, they are likely to be influenced by human resources and economic disparities, and regional differences may occur in the care of periodontal diseases.
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Kotronia E, Brown H, Papacosta AO, Lennon LT, Weyant RJ, Whincup PH, Wannamethee SG, Ramsay SE. Oral health and all-cause, cardiovascular disease, and respiratory mortality in older people in the UK and USA. Sci Rep 2021; 11:16452. [PMID: 34385519 PMCID: PMC8361186 DOI: 10.1038/s41598-021-95865-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/02/2021] [Indexed: 11/09/2022] Open
Abstract
Preventing deterioration of oral health in older age can be crucial for survival. We aimed to examine associations of oral health problems with all-cause, cardiovascular disease (CVD), and respiratory mortality in older people. We used cohort data from the British Regional Health Study (BRHS) (N = 2147, 71-92 years), and the Health, Aging and Body Composition (HABC) Study (USA) (N = 3075, 71-80 years). Follow-up was 9 years (BRHS) and 15 years (HABC Study). Oral health comprised tooth loss, periodontal disease, dry mouth, and self-rated oral health. Cox regression was performed for all-cause mortality, competing risks for CVD mortality, and accelerated failure time models for respiratory mortality. In the BRHS, tooth loss was associated with all-cause mortality (hazard ratio (HR) = 1.59, 95% CI 1.09, 2.31). In the HABC Study, tooth loss, dry mouth, and having ≥ 3 oral problems were associated with all-cause mortality; periodontal disease was associated with increased CVD mortality (subdistribution hazard ratio (SHR) = 1.49, 95% CI 1.01, 2.20); tooth loss, and accumulation of oral problems were associated with high respiratory mortality (tooth loss, time ratio (TR) = 0.73, 95% CI 0.54, 0.98). Findings suggest that poor oral health is associated with mortality. Results highlight the importance of improving oral health to lengthen survival in older age.
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Affiliation(s)
- Eftychia Kotronia
- Population Health Sciences Institute, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Heather Brown
- Population Health Sciences Institute, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - A Olia Papacosta
- Department of Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Lucy T Lennon
- Department of Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Robert J Weyant
- Department of Dental Public Health, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter H Whincup
- Population Health Research Institute, St George's University of London, London, UK
| | - S Goya Wannamethee
- Department of Primary Care and Population Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Sheena E Ramsay
- Population Health Sciences Institute, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
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Badewy R, Singh H, Quiñonez C, Singhal S. Impact of Poor Oral Health on Community-Dwelling Seniors: A Scoping Review. Health Serv Insights 2021; 14:1178632921989734. [PMID: 33597810 PMCID: PMC7841244 DOI: 10.1177/1178632921989734] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022] Open
Abstract
The aim of this scoping review was to determine health-related impacts of poor oral health among community-dwelling seniors. Using MeSH terms and keywords such as elderly, general health, geriatrics, 3 electronic databases-Medline, CINAHL, and Age Line were searched. Title and abstracts were independently screened by 3 reviewers, followed by full-texts review. A total of 131 articles met our inclusion criteria, the majority of these studies were prospective cohort (77%, n = 103), and conducted in Japan (42 %, n = 55). These studies were categorized into 16 general health outcomes, with mortality (24%, n = 34), and mental health disorders (21%, n = 30) being the most common outcomes linked with poor oral health. 90% (n = 120) of the included studies reported that poor oral health in seniors can subsequently lead to a higher risk of poor general health outcomes among this population. Improving access to oral healthcare services for elderly can help not only reduce the burden of oral diseases in this population group but also address the morbidity and mortality associated with other general health diseases and conditions caused due to poor oral health. Findings from this study can help identify shortcomings in existing oral healthcare programs for elderly and develop future programs and services to improve access and utilization of oral care services by elderly.
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Affiliation(s)
- Rana Badewy
- Faculty of Dentistry, University of
Toronto, Toronto, ON, Canada
| | | | - Carlos Quiñonez
- Faculty of Dentistry, Director of
Graduate Program in Dental Public Health, University of Toronto, Toronto, ON,
Canada
| | - Sonica Singhal
- Faculty of Dentistry, University of
Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON,
Canada
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Costa RTF, Pellizzer EP, Vasconcelos BCDE, Gomes JML, Lemos CAA, de Moraes SLD. Surface roughness of acrylic resins used for denture base after chemical disinfection: A systematic review and meta-analysis. Gerodontology 2021; 38:242-251. [PMID: 33410217 DOI: 10.1111/ger.12529] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study aimed to systematically review the literature regarding the surface roughness of polymethylmethacrylate (PMMA) for denture bases, disinfected with different chemical agents and analyse the outcomes of the included studies. BACKGROUND Various chemical disinfection protocols to clean the removable dental prosthesis are reported in the literature, however systematic reviews analysing the outcomes in the surface roughness of the PMMA are lacking. METHODS The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) checklist was used to structure this systematic review. The inclusion criteria were as follows: clinical trials, in vitro studies, studies in English and studies comparing the effects of chemical disinfection products on the surface roughness of PMMA. An electronic search was performed in the following databases: PubMed/MEDLINE, Scopus and Web of Science.; we also conducted a manual search for articles published in specific journals of dental prostheses and dental materials. RESULTS Thirteen in vitro studies in this systematic review and meta-analysis. According to the meta-analysis, the effects of 0.5% (P = .32; MD: 0.06; CI: -0.05 to 0.17; heterogeneity: P < .00001; I2 = 92%) and 1% NaOCl solutions (P = .27; MD: 0.01; CI: -0.01. to 0.03; heterogeneity: P = .03; I2 = 55%) did not statistically differ between the groups studied. Effects of alkaline peroxide were statistically significant (P = .0009; MD: 0.01; CI: 0.01-0.02; heterogeneity: P = .004; I2 = 65%), suggesting that it promotes deterioration of the PMMA surface. CONCLUSION The alkaline peroxide, when used as a disinfectant, generated changes on the surface roughness of PMMA and should be used with caution; however, NaOCl, even at different concentrations, caused fewer changes on the surface of the denture base.
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Affiliation(s)
| | - Eduardo Piza Pellizzer
- Department of Dental Materials and Prosthodontics, Araçatuba Dental School, São Paulo State University, São Paulo, Brazil
| | | | - Jéssica Marcela Luna Gomes
- Department of Dental Materials and Prosthodontics, Araçatuba Dental School, São Paulo State University, São Paulo, Brazil
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Lu TY, Chen JH, Du JK, Lin YC, Ho PS, Lee CH, Hu CY, Huang HL. Dysphagia and masticatory performance as a mediator of the xerostomia to quality of life relation in the older population. BMC Geriatr 2020; 20:521. [PMID: 33267812 PMCID: PMC7709251 DOI: 10.1186/s12877-020-01901-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background The impact of poor oral health on older adults’ quality of life is a public health problem. In this study, the mediating effects of dental status, occlusal condition, dysphagia, and masticatory performance on the association between xerostomia and oral health-related quality of life (OHRQoL) were assessed in the older adult population. Methods Stratified cluster sampling was used to recruit 1076 community-dwelling adults aged 65 years and older from Kaohsiung, Taiwan. Community care centers were randomly selected according to their geographic classifications (urban, rural, or mountainous areas). Assessments of dental status and occlusal condition were performed by dentists. Information on demographics, physical function, xerostomia, dysphagia and depression was collected through face-to-face interviews. Masticatory performance was evaluated using color-changeable chewing gum. OHRQoL was measured using the Geriatric Oral Health Assessment Index. Hierarchical regression models were used to assess the relationships between OHRQoL and physical function, dental status and oral function in older adults. Path analysis was used to estimate direct and indirect pathways between xerostomia and OHRQoL. Results Participants with xerostomia exhibited a 0.20 OHRQoL reduction (p < .001) compared with patients with no xerostomia, and the direct effect accounted for 83.3% of the total effect. Dysphagia and masticatory performance were found to exert significant mediating effects on the association between xerostomia and OHRQoL (βs = 0.20 and − 0.12, respectively; both p < .001; βs = 0.06 and − 0.09, respectively; both p < .05). Moreover, potential mediating effects of the number of functional teeth (βs = − 0.11 and − 0.43, respectively; both p < .001) and occlusal condition (βs = 0.09 and 0.13, respectively; both p < .05) on the relationship between xerostomia and masticatory performance were noted. Conclusions Dysphagia and masticatory performance may serve as pathways through which xerostomia affects quality of life. Early oral function intervention may be a valuable and actionable target for older adults to maintain quality of life. Our results further suggest that checkup and screening for oral dysfunction are essential to prevent or delay the onset of complications.
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Affiliation(s)
- Ting-Yu Lu
- Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, No. 100 Shih-Chuan 1st Road, Kaohsiung City, 807, Taiwan.,Department of Oral Hygiene, Hsin Sheng Junior College of Medical Care and Management, Taoyuan City, Taiwan
| | - Jen-Hao Chen
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Department of Dentistry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Je-Kang Du
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Department of Dentistry, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Ying-Chun Lin
- Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, No. 100 Shih-Chuan 1st Road, Kaohsiung City, 807, Taiwan
| | - Pei-Shan Ho
- Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, No. 100 Shih-Chuan 1st Road, Kaohsiung City, 807, Taiwan.,Division of Medical Statistics and Bioinformatics, Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chien-Hung Lee
- Department of Public Health, College of Health Sciences and Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chih-Yang Hu
- School of Public Health, Health Sciences Center, Louisiana State University, New Orleans, LA, USA
| | - Hsiao-Ling Huang
- Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, No. 100 Shih-Chuan 1st Road, Kaohsiung City, 807, Taiwan.
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Association between periodontal disease and tooth loss and mortality in an elderly Chinese population. Aging Clin Exp Res 2020; 32:2375-2382. [PMID: 32020486 DOI: 10.1007/s40520-019-01446-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/11/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Poor oral health is a risk indicator of poor quality of life and mortality. However, whether these associations remain potent in elderly subjects after adequately considering the confounding factors is not yet clearly elucidated. The present study aimed to investigate the associations between periodontal disease and tooth loss and total mortality and cardiovascular disease (CVD) outcomes in the elderly > 75 years old. METHODS A total of 1385 individuals, receiving periodontal treatment in Shanghai, participated in this retrospective study. Data on oral status were obtained from radiographs to calculate the proportion of residual bone. The information about mortality was collected from the Shanghai Municipal Center for Disease Control and Prevention (SCDC). Univariate Cox proportional hazards model, multivariable-adjusted model, and competing risk hazard model were used to analyze the association between periodontal disease or tooth loss and mortality. RESULTS Those with severe periodontitis were associated with higher risk of total mortality than healthy individuals [hazard ratio (HR) = 1.48, 95% confidence interval (95% CI) 1.11-1.98]. Further, missing teeth increased the risk of total mortality (HR = 1.02, 95% CI 1.01-1.03). However, no significant difference was detected in the association between periodontitis or tooth loss and CVD mortality. In competing risk hazard model, an increased risk was observed for other-cause mortality, not CVD mortality, in those with severe periodontitis and missing teeth. CONCLUSION Periodontal diseases and tooth loss were the potential predictors of total mortality even after adjustment for confounding factors. However, these were not independent indicators for CVD mortality.
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Oliveira EJP, Alves LC, Santos JLF, Duarte YADO, Bof DE Andrade F. Edentulism and all-cause mortality among Brazilian older adults: 11-years follow-up. Braz Oral Res 2020; 34:e046. [PMID: 32578797 DOI: 10.1590/1807-3107bor-2020.vol34.0046] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/23/2020] [Indexed: 11/22/2022] Open
Abstract
We assessed the association between edentulism and all-cause mortality among community-dwelling older adults from São Paulo, Brazil, from 2006 to 2017. This prospective cohort study used data from the Health, Well-being and Aging Study (SABE, Portuguese acronym). Edentulism was evaluated by means of clinical oral examination and all-cause mortality data were obtained from state official records. Covariates included socioeconomic factors (age, sex, and schooling); health behavior (smoking, alcohol intake, and physical activity); dental care (prostheses use); general health (multimorbidity); and nutritional status (underweight). Kaplan-Meier survival curves were stratified by edentulism and compared using the log-rank test. Cox proportional hazards model was applied to calculate hazard ratios (HRs) for the association between edentulism and mortality after adjusting for covariates. The study sample included 1,687 participants (age, 60-102 years; edentulous: 47.2%). In the 11 years of follow-up, we analyzed 10,494 person-years and 566 deaths. In bivariate analysis, edentulous older adults were found to be at a higher risk of dying from all causes than the dentate participants (HR: 1.81; 95%CI: 1.53-2.15). After sequential adjustment for socioeconomic factors, health behavior, dental care, general health, and nutritional status, this association was attenuated, but remained significant (HR: 1.34; 95%CI: 1.10-1.63). In conclusion, edentulism is a significant predictor of all-cause mortality among older adults.
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Affiliation(s)
- Eduardo José Pereira Oliveira
- Fundação Oswaldo Cruz - Fiocruz, Instituto René Rachou, Programa de Pós Graduação em Saúde Coletiva, Belo Horizonte, MG, Brasil
| | - Luciana Correia Alves
- Universidade Estadual de Campinas - Unicamp, Instituto de Filosofia e Ciências Humanas, Departamento de Demografia, Campinas, SP, Brasil
| | - Jair Licio Ferreira Santos
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto, Departamento de Medicina Social, Ribeirão Preto, SP, Brasil
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