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The relationship between oral health status and biological and psychosocial function in the bedridden elderly
Archives of Gerontology and Geriatrics 33 (2001) 133– 140 www.elsevier.com/locate/archger
The relationship between oral health status and biological and psychosocial function in the bedridden elderly Nobuhiro Hanada a,*, Akio Tada b a
Department of Oral Science, National Institute of Infectious Diseases, 1 -23 -1, Toyama, Shinjuku-ku, Tokyo 162 -8640, Japan b Chiba City Health Center, 1 -3 -9, Saiwai, Mihama-ku, Chiba 261 -8755, Japan Received 27 December 2000; received in revised form 3 May 2001; accepted 16 May 2001
Abstract The present study was conducted in order to determine what item of biological and psychosocial function is related to oral health status in the bedridden elderly. The subjects were 94 elderly individuals (30 males, 64 females) who had been admitted to a nursing home in Chiba city, Japan. We assessed the number of remaining teeth and the number of functional teeth as oral health status variables. Biological and psychosocial function levels were determined using the functional independence measure method developed by the State University of New York at Buffalo. More than 70% of subjects had less than ten remaining teeth. Almost all subjects needed prosthesis treatment. More than 50% of subjects had 27 or less functional teeth. Mann–Whitney U-test and logistic regression models showed that ‘expression’ was concerned with the number of remaining teeth and ‘bladder management’, ‘locomotion’, ‘transfers’ were related to the number of functional teeth. These data suggest close relation between oral health status and biological and psychosocial function levels in the bedridden elderly. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Biological and psychosocial function; Oral health status; Elderly
* Corresponding author. 0167-4943/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 7 - 4 9 4 3 ( 0 1 ) 0 0 1 7 7 - 7
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N. Hanada, A. Tada / Arch. Gerontol. Geriatr. 33 (2001) 133–140
1. Introduction It is estimated that a quarter of the Japanese citizens will be aged 65 or more in the early 21st century (National Institute of Population and Social Security Research, 1992). Thus, maintaining and improving quality of life (QOL) is necessary to achieve a comfortable level of life for our aged society. In the human body, the physical functions of different organ systems decrease with age. In the oral cavity, chewing function is impaired with age because of tooth loss by dental caries and periodontal disease. It is thought that the habit of chewing sufficiently is an important factor contributing to longevity. It is reported that the average number of missing teeth increases rapidly in persons over 40 years of age (Dental Health Division of Health Policy Bureau, Ministry of Health and Welfare Japan, 1999). Tooth loss causes difficulty in food intake and adversely influences eating habits (Chauncey et al., 1984; O8 sterberg and Steen, 1984; Drummond et al., 1988; Petersen and Nortov, 1989; Hand et al., 1991; Masamura et al., 1996). Improvement of oral health status is thus important for the comfort of an aged society and maintaining the QOL. There have been many studies on the relationship between oral health and general health (Wegner, 1975; Agerberg and Carlsson, 1981; Palmquist et al., 1986; O8 sterberg et al., 1990; Bridges et al., 1996; Linden et al., 1996; Karjalainen et al., 1997), and the Ministry of Health and Welfare in Japan has also promoted such studies. Moreover, there have been a few reports statistically analyzing the relationship between oral health status and biological and psychosocial function in the elderly (Miura et al., 1997). Little is known about the effect of oral health on general health in the elderly. In the present study, we report the statistical analysis for the relationship between oral health status and biological and psychosocial function level assessed according to the functional independence measure (FIM) method.
2. Subjects and methods
2.1. Subjects The subjects were elderly people who had been admitted to a nursing home. Elderly individuals (30 males, 64 females) were examined during November 1997 in Chiba, Japan. The distribution of subjects by age and sex is shown in Table 1.
2.2. Methods 2.2.1. Oral examination Oral examinations were performed according to WHO oral examination procedures (1997). Examiners were three dentists, who were able to examine with reasonable consistency, using a common standard. The variables of oral health status were the number of remaining teeth, and the number of functional teeth. On
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135
Table 1 Population by age and sex (mean age) Age group
Male
Female
60–69 70–79 Above 80 Total
8 (66.0) 11 (73.8) 11 (85.0) 30
5 (65.2) 19 (75.3) 40 (87.6) 64
counting the number of teeth, the third molars were excluded. The number of remaining teeth and the number of functional teeth were calculated as follows: The number of remaining teeth = the number of sound teeth+ the number of treated teeth +the number of decayed teeth, the number of functional teeth= the number of remaining teeth+ the number of prosthesis teeth.
2.2.2. E6aluation of biological and psychosocial function Biological and psychosocial function was evaluated using the FIM method (Data Management Service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research, 1990). This method evaluates the burden of care in 18 items. We used seven items such as eating, bladder management, locomotion, transfers, expression, social interaction and sitting up. The FIM score varied between 1– 7 for each item. The distribution of FIM score of the subjects is shown in Table 2. 2.2.3. Statistical analysis Mann – Whitney U-test was used to analyze differences in the number of remaining teeth and the number of functional teeth between both sex, two age groups (60– 79, above 80) and between two groups, which were classified according to FIM score (higher: 5– 7 and lower: 1–4) in regard to each item. Stepwise logistic regression models were used to clarify the contributing factors for biological and psychosocial function. The dependent variables were FIM scores. Sex, age (60–79, Table 2 Distribution of subjects by score of each item in FIM method (number of subjects) Score Item
7
6
5
4
3
2
1
Eating Bladder management Locomotion Transfers Expression Social interaction Sitting up
12 16 11 7 23 51 23
37 21 31 25 4 3 28
12 6 5 6 30 3 3
10 2 4 5 13 20 1
4 7 4 2 9 5 3
6 5 7 6 10 4 7
12 37 32 42 3 5 28
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Table 3 Distribution of subjects according to the number of remaining teeth and of functional teeth (number of subjects (%)) Number of teeth
Remaining teeth
Functional teeth
0
1–9
10–19
20–28
40 (42.6)
29 (30.9)
16 (17.0)
9 (9.6)
0–9
10–19
20–27
28
26 (27.7)
16 (17.0)
11 (11.7)
41 (43.6)
above 80), the number of remaining teeth (0– 9, 10 and more) and the number of functional teeth (27 and less, 28) were used as independent variables. Differences at the 0.05 level were considered statistically significant. SPSS for Windows (version 9.0) was used in performing all statistical analyses.
3. Results
3.1. Oral health status The distribution of the subjects into subgroups according to the number of remaining teeth and of functional teeth is shown in Table 3. Edentulousness occurred in 42.6% of the subjects. Approximately 27% of subjects had ten or more teeth. Only 9.6% had 20 or more teeth. Almost all subjects (97.8%) clinically needed prosthesis. Approximately 55% of the subjects had 27 or less functional teeth. The rate of subjects that had less than 20 functional teeth was 44.7%. Table 4 shows the mean number of remaining teeth and of functional teeth of subjects by age and sex. The mean number of remaining teeth in subjects aged 60– 69 was the highest of all the age groups in both sexes. The mean number of functional teeth in the above 80 group was lowest of all the age groups in both sexes. Women had a lower mean number of functional teeth than men in all age groups. Table 4 Mean number of remaining teeth and functional teeth by age and sex Remaining teeth
60–69 70–79 Above 80
Functional teeth
Male
Female
Average
Male
Female
Average
14.0 3.1 5.6
10.8 10.0 2.9
12.8 7.6 3.4
15.5 18.9 14.2
26.6 21.4 16.5
19.8 20.5 15.9
Remaining teeth
Functional teeth 0
Sex Age group Eating Bladder management Locomotion Transfers Expression Social interaction Sitting up
Male Female 60–79 80– 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4
11 29 11 29 30 10 21 19 20 20 18 22 20 19 21 18 27 13
(36.7) (45.3) (25.6) (56.9) (49.2) (31.3) (47.7) (38.0) (42.6) (42.6) (47.4) (40.0) (35.1) (54.3) (36.8) (52.9) (50.0) (33.3)
1–9
10–19
20–28
P value
0–9
10–19
20–27
28
9 20 15 14 16 13 11 18 13 16 10 18 17 12 21 7 13 15
7 9 9 7 11 4 8 8 10 6 7 9 12 3 9 6 10 6
3 6 8 1 4 5 4 5 4 5 3 6 8 1 6 3 4 5
0.391
9 17 8 18 16 10 8 18 8 18 6 20 14 11 17 9 12 14
7 9 6 10 11 4 6 10 9 7 6 9 12 3 9 6 10 6
4 (13.3) 7 (10.9) 10 (23.3) 1 ( 2.0) 4( 6.6) 7 (21.9) 4 ( 9.1) 7 (14.0) 4 ( 8.5) 7 (14.9) 3 ( 7.9) 8 (14.5) 7 (12.3) 4 (11.4) 6 (10.5) 5 (14.7) 4 ( 7.4) 7 (17.9)
10 31 19 22 30 11 26 15 26 15 23 18 24 17 25 14 28 12
(30.0) (31.3) (34.9) (27.5) (26.2) (40.6) (25.0) (36.0) (27.7) (34.0) (26.3) (32.7) (29.8) (34.3) (36.8) (20.6) (24.1) (38.5)
(23.3) (14.1) (20.9) (13.7) (18.0) (12.5) (18.2) (16.0) (21.3) (12.8) (18.4) (16.4) (21.1) ( 8.6) (15.8) (17.6) (18.5) (15.4)
(10.0) (9.4) (18.6) (2.0) (8.6) (15.6) (9.1) (10.0) (8.5) (10.6) (7.9) (10.9) (14.0) (2.9) (10.5) (8.8) (7.4) (12.8)
0.000 0.116 0.622 0.456 0.928 0.030 0.281 0.161
(30.0) (26.6) (18.6) (35.3) (26.2) (31.3) (18.2) (36.0) (17.0) (38.3) (15.8) (36.4) (24.6) (31.4) (29.8) (26.5) (22.2) (35.9)
(23.3) (14.1) (14.0) (19.6) (18.0) (12.5) (13.6) (20.0) (19.1) (14.9) (15.8) (16.4) (21.1) ( 8.6) (15.8) (17.6) (18.5) (15.4)
P value (33.3) (48.4) (44.2) (43.1) (49.2) (34.4) (59.1) (30.0) (55.3) (31.9) (60.5) (32.7) (42.1) (48.6) (43.9) (41.2) (51.9) (30.8)
0.292 0.157 0.394 0.005 0.006 0.008 0.893 0.888 0.059
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Table 5 The distribution of each category of subjects according to the number of remaining teeth and functional teeth (number of subjects (%))
Missing data were excluded.
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Table 6 Odds ratios and 95% confident intervals from logistic regression analyses of FIM variables OR
95%CI
Bladder management Sex Age group Remaining teeth Functional teeth
0.867 1.783 1.026 3.671a
0.362–2.075 0.878–2.120 0.804–1.308 1.556–8.659
Locomotion Sex Age group Remaining teeth Functional teeth
0.486 1.029 0.920 2.955b
0.193–1.222 0.451–2.343 0.362–2.335 1.262–6.921
Transfers Sex Age group Remaining teeth Functional teeth
0.675 1.538 1.388 2.641b
0.282–1.616 0.680–3.479 0.533–3.485 1.139–6.123
Expression Sex Age group Remaining teeth Functional teeth
0.536 1.069 4.189b 0.770
0.218–1.313 0.459–2.486 1.294–13.563 0.330–1.791
OR, odds ratio; CI, confident interval. a PB0.01. b PB0.05.
3.2. Oral health status and biological and psychosocial function The distribution of subjects by remaining teeth and by functional teeth in both sexes, all age groups and the subgroups of FIM index are presented in Table 5. The younger group had more remaining teeth than the older group (PB 0.001). In ‘expression’, the higher group had a significantly greater number of remaining teeth than the lower group (P B 0.05). In regard to the number of functional teeth, the higher group had a significantly more number than the lower in ‘bladder management’, ‘locomotion’, ‘transfers’ (PB 0.01). Logistic regression analyses were performed to test whether oral health status variables are predictive factors for each biological and psychosocial function item. FIM scores of ‘expression’, of ‘bladder management’, of ‘transfer’ and of ‘locomotion’ were used as dependent variables in logistic regression models with age, sex, the number of remaining teeth and the number of functional teeth. The most predictive factor for ‘bladder management’, ‘locomotion’ and ‘transfers’ was having less than 28 functional teeth (bladder management: PB 0.01, locomotion, transfers: PB 0.05) (Table 6). A logistic stepwise regression model with ‘expression ’as the dependent variable showed the number of remaining teeth was the most predictive factor (P B 0.05).
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4. Discussion The mean number of remaining teeth in each age group of the subjects was lower than that shown in the national survey of dental disease in Japan (60–64: 20.4, 65– 69: 16.8, 70– 74: 12.9, 75– 79: 9.0, above 80: 6.2; Dental Health Division of Health Policy Bureau, Ministry of Health and Welfare Japan, 1999). Miura et al. (1997) reported that bedridden elderly had a lower mean number of remaining teeth than independent elderly. The findings of our study agree with that report. It is thought that tooth loss caused poor eating habits, resulting in the deterioration of general health. Less than 60% of subjects had 20 or more functional teeth, which may have led to poor eating habits due to poor oral health conditions. The score of ‘expression’ correlated significantly with the number of remaining teeth in the subjects (P B 0.05). It has been reported that tooth loss affects the activity of brain. Several epidemiological studies have suggested that tooth loss is a risk factor for the occurrence of Alzheimer disease (Kondoh et al., 1995; Nordenram et al., 1996). Rats that lost their molar teeth had lower learning ability, which implies that tooth loss is related to the malfunction of the cholinergic nervous system (Kato et al., 1997; Onozuka et al., 1999). Moreover, several reports have indicated a close relationship between the number of missing teeth and masticatory function (Agerberg and Carlsson, 1981; Slade et al., 1996; Miura et al., 1998). It is hypothesized that tooth loss affects the brain activity by decreasing stimulus to brain on mastication. In the subjects, who lose many teeth, tooth loss might reduce the subject’s ability to express their intention. It is suggested that the retention of teeth may lead to brain activation, resulting in the higher independent ability of ‘expression’. Mann – Whitney U-test and logistic regression analysis showed that subjects with higher independence in ‘bladder management’, ‘locomotion’ and ‘transfers’ correlated significantly with the number of functional teeth. These items are concerned with physical disabilities. There have been many reports on the relationship between physical function and mastication (Curtis et al., 1975; Moran et al., 1979; Bando et al., 1998). These reports support our data. Improvement of masticatory function by prosthesis treatment might prevent the decline of physical functions. There is little information on which biological and psychosocial function items are related to oral health status. Further accumulation of epidemiological studies on this point will promote the improvement of oral health to prevent the deterioration of biological and psychosocial function in old age. References Agerberg, G., Carlsson, G.E., 1981. Chewing ability in relation to dental and general health. Acta. Odontol. Scand. 39, 147 –153. Bando, K., Nitta, H., Matsubara, M., Ishikawa, I., 1998. Bone mineral dentistry in periodontally healthy and edentulous postmenopausal women. Ann. Periodontol. 3, 322 – 326. Bridges, R.B., Anderson, J.W., Saxe, S.R., Gregory, K., Bridges, S.R., 1996. Periodontal status of diabetic and non-diabetic men: effects of smoking, glycemic control and socioeconomic factors. J. Periodontol. 67, 1185 –1192.
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Chauncey, H.H., Muench, M., Kapur, K.K., Wayles, A.H., 1984. The effect of the loss of teeth on diet and nutrition. Int. Dent. J. 34, 98 –104. Curtis, T.A., Taylor, R.C., Rositano, S.A., 1975. Physical problems in obtaining records of the maxillofacial patient. J. Prosthetic Dent. 34, 539 – 554. Data Management Service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research, 1990. Guide Use of the Uniform Data Set. Ver 3.0. Dental Health Division of Health Policy Bureau, Ministry of Health and Welfare Japan, 1999. Report on the survey of dental disease in Japan. Oral Health Association Japan (in Japanese). Drummond, J.R., Newton, J.P., Yemm, R., 1988. Dentistry for the elderly: a review and an assessment of the future. J. Dent. 16, 47 –54. Hand, J.S., Hunt, R.J., Kohout, F.J., 1991. Five-year incidence of tooth loss in Iowans aged 65 and older. Community Dent. Oral Epidemiol. 19, 48 – 51. Karjalainen, K.M., Knuuttila, M.L., Kaar, M.L., 1997. Relationship between caries and level of metabolic balance in children and adolescents with insulin-dependent diabetes mellitus. Caries Res. 31, 13 –18. Kato, T., Usami, T., Noda, Y., Hasegawa, M., Ueda, M., Nabeshima, T., 1997. The effect of the loss of molar teeth on spatial memory and acetylcholine release from the partial cortex in aged rats. Behav. Brain Res. 83, 239 –242. Kondoh, K., Niino, M., Shido, K., 1995. A case control study of Alzheimer’s disease in Japan: significance of life style. Dementia 5, 314 – 326. Linden, J.G., Mullaly, H.B., Freeman, R., 1996. Stress and progression of periodontal disease. J. Clin. Periodontol. 23, 675 –680. Masamura, K., Ono, K., Inaba, R., Iwata, H., Yoshida, H., 1996. Self-assessed quality of mastication in relation to remaining teeth and self-assessed health status in elderly persons. Jpn. J. Publ. health 43, 835 –843 in Japanese. Miura, H., Araki, Y., Umenai, T., 1997. Chewing activity and activities of daily living in the elderly. J. Oral Rehabil. 24, 457 –460. Miura, H., Araki, Y., Hirai, T., Isogai, E., Hirose, K., Umenai, T., 1998. Evaluation of chewing activity in the elderly person. J. Oral Rehabil. 25, 190 – 193. Moran, J.H., Kaye, L.B., Fritz, M.E., 1979. Statistical analysis of an urban population of 236 patients with head and neck pain. Part III. Treatment modalities. J. Periodontol. 50, 66 – 74. National Institute of Population and Social Security Research, 1992. The estimation of population of Japan in the future – 1991–2025. Health and Welfare Statistic Association Japan (Tokyo) 46 – 47 (in Japanese). Nordenram, G., Ryd-Kjellen, E., Johansson, G., Nordstrom, G., Winblad, B., 1996. Alzheimer’s disease, oral function and nutritional status. Gerodontology 13, 9 – 16. Onozuka, M., Watanabe, K., Mirbod, S.M., Ozono, S., Nishiyama, K., Karasawa, N., Nagatsu, I., 1999. Reduced mastication stimulates impairment of spatial memory and degeneration of hippocampal neurons in aged SAMP8 mice. Brain Res. 826, 148 – 153. O8 sterberg, T., Steen, B., 1984. Relation between dental state and dietary intake in 70-year old men and women in Go¨ teborg, Sweden. J. Oral Rehabil. 11, 157 – 170. O8 sterberg, T., Mekkstrom, D., Sundh, V., 1990. Dental health and functional aging. Community Dent. Oral Epidemiol. 18, 313 –318. Palmquist, S., O8 sterberg, T., Carlsson, G.E., Mellstrom, D., 1986. Self-assessed general health and dental status among the elderly in a Swedish county. Gerondotology 5, 191 – 196. Petersen, P.E., Nortov, B., 1989. General and dental health in relation to life- style and social network activity among 67-year-old Danes. Scand. J. Prim. Health Care 7, 225 – 230. Slade, G.D., Spencer, A.J., Roberts-Thomson, K., 1996. Tooth loss and chewing capacity among older adults in Adelaide. Aust. N. Z. J. Public Health 20, 76 – 82. Wegner, H., 1975. Increment of caries in young diabetes. Caries Res. 9, 91 – 96. WHO, 1997. Oral Health Surveys Basic Methods fourth ed., World Health Organization, Geneva.
The relationship between oral health status and biological and psychosocial function in the bedridden elderly Nobuhiro Hanada a,*, Akio Tada b a
Department of Oral Science, National Institute of Infectious Diseases, 1 -23 -1, Toyama, Shinjuku-ku, Tokyo 162 -8640, Japan b Chiba City Health Center, 1 -3 -9, Saiwai, Mihama-ku, Chiba 261 -8755, Japan Received 27 December 2000; received in revised form 3 May 2001; accepted 16 May 2001
Abstract The present study was conducted in order to determine what item of biological and psychosocial function is related to oral health status in the bedridden elderly. The subjects were 94 elderly individuals (30 males, 64 females) who had been admitted to a nursing home in Chiba city, Japan. We assessed the number of remaining teeth and the number of functional teeth as oral health status variables. Biological and psychosocial function levels were determined using the functional independence measure method developed by the State University of New York at Buffalo. More than 70% of subjects had less than ten remaining teeth. Almost all subjects needed prosthesis treatment. More than 50% of subjects had 27 or less functional teeth. Mann–Whitney U-test and logistic regression models showed that ‘expression’ was concerned with the number of remaining teeth and ‘bladder management’, ‘locomotion’, ‘transfers’ were related to the number of functional teeth. These data suggest close relation between oral health status and biological and psychosocial function levels in the bedridden elderly. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Biological and psychosocial function; Oral health status; Elderly
* Corresponding author. 0167-4943/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 7 - 4 9 4 3 ( 0 1 ) 0 0 1 7 7 - 7
134
N. Hanada, A. Tada / Arch. Gerontol. Geriatr. 33 (2001) 133–140
1. Introduction It is estimated that a quarter of the Japanese citizens will be aged 65 or more in the early 21st century (National Institute of Population and Social Security Research, 1992). Thus, maintaining and improving quality of life (QOL) is necessary to achieve a comfortable level of life for our aged society. In the human body, the physical functions of different organ systems decrease with age. In the oral cavity, chewing function is impaired with age because of tooth loss by dental caries and periodontal disease. It is thought that the habit of chewing sufficiently is an important factor contributing to longevity. It is reported that the average number of missing teeth increases rapidly in persons over 40 years of age (Dental Health Division of Health Policy Bureau, Ministry of Health and Welfare Japan, 1999). Tooth loss causes difficulty in food intake and adversely influences eating habits (Chauncey et al., 1984; O8 sterberg and Steen, 1984; Drummond et al., 1988; Petersen and Nortov, 1989; Hand et al., 1991; Masamura et al., 1996). Improvement of oral health status is thus important for the comfort of an aged society and maintaining the QOL. There have been many studies on the relationship between oral health and general health (Wegner, 1975; Agerberg and Carlsson, 1981; Palmquist et al., 1986; O8 sterberg et al., 1990; Bridges et al., 1996; Linden et al., 1996; Karjalainen et al., 1997), and the Ministry of Health and Welfare in Japan has also promoted such studies. Moreover, there have been a few reports statistically analyzing the relationship between oral health status and biological and psychosocial function in the elderly (Miura et al., 1997). Little is known about the effect of oral health on general health in the elderly. In the present study, we report the statistical analysis for the relationship between oral health status and biological and psychosocial function level assessed according to the functional independence measure (FIM) method.
2. Subjects and methods
2.1. Subjects The subjects were elderly people who had been admitted to a nursing home. Elderly individuals (30 males, 64 females) were examined during November 1997 in Chiba, Japan. The distribution of subjects by age and sex is shown in Table 1.
2.2. Methods 2.2.1. Oral examination Oral examinations were performed according to WHO oral examination procedures (1997). Examiners were three dentists, who were able to examine with reasonable consistency, using a common standard. The variables of oral health status were the number of remaining teeth, and the number of functional teeth. On
N. Hanada, A. Tada / Arch. Gerontol. Geriatr. 33 (2001) 133–140
135
Table 1 Population by age and sex (mean age) Age group
Male
Female
60–69 70–79 Above 80 Total
8 (66.0) 11 (73.8) 11 (85.0) 30
5 (65.2) 19 (75.3) 40 (87.6) 64
counting the number of teeth, the third molars were excluded. The number of remaining teeth and the number of functional teeth were calculated as follows: The number of remaining teeth = the number of sound teeth+ the number of treated teeth +the number of decayed teeth, the number of functional teeth= the number of remaining teeth+ the number of prosthesis teeth.
2.2.2. E6aluation of biological and psychosocial function Biological and psychosocial function was evaluated using the FIM method (Data Management Service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research, 1990). This method evaluates the burden of care in 18 items. We used seven items such as eating, bladder management, locomotion, transfers, expression, social interaction and sitting up. The FIM score varied between 1– 7 for each item. The distribution of FIM score of the subjects is shown in Table 2. 2.2.3. Statistical analysis Mann – Whitney U-test was used to analyze differences in the number of remaining teeth and the number of functional teeth between both sex, two age groups (60– 79, above 80) and between two groups, which were classified according to FIM score (higher: 5– 7 and lower: 1–4) in regard to each item. Stepwise logistic regression models were used to clarify the contributing factors for biological and psychosocial function. The dependent variables were FIM scores. Sex, age (60–79, Table 2 Distribution of subjects by score of each item in FIM method (number of subjects) Score Item
7
6
5
4
3
2
1
Eating Bladder management Locomotion Transfers Expression Social interaction Sitting up
12 16 11 7 23 51 23
37 21 31 25 4 3 28
12 6 5 6 30 3 3
10 2 4 5 13 20 1
4 7 4 2 9 5 3
6 5 7 6 10 4 7
12 37 32 42 3 5 28
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Table 3 Distribution of subjects according to the number of remaining teeth and of functional teeth (number of subjects (%)) Number of teeth
Remaining teeth
Functional teeth
0
1–9
10–19
20–28
40 (42.6)
29 (30.9)
16 (17.0)
9 (9.6)
0–9
10–19
20–27
28
26 (27.7)
16 (17.0)
11 (11.7)
41 (43.6)
above 80), the number of remaining teeth (0– 9, 10 and more) and the number of functional teeth (27 and less, 28) were used as independent variables. Differences at the 0.05 level were considered statistically significant. SPSS for Windows (version 9.0) was used in performing all statistical analyses.
3. Results
3.1. Oral health status The distribution of the subjects into subgroups according to the number of remaining teeth and of functional teeth is shown in Table 3. Edentulousness occurred in 42.6% of the subjects. Approximately 27% of subjects had ten or more teeth. Only 9.6% had 20 or more teeth. Almost all subjects (97.8%) clinically needed prosthesis. Approximately 55% of the subjects had 27 or less functional teeth. The rate of subjects that had less than 20 functional teeth was 44.7%. Table 4 shows the mean number of remaining teeth and of functional teeth of subjects by age and sex. The mean number of remaining teeth in subjects aged 60– 69 was the highest of all the age groups in both sexes. The mean number of functional teeth in the above 80 group was lowest of all the age groups in both sexes. Women had a lower mean number of functional teeth than men in all age groups. Table 4 Mean number of remaining teeth and functional teeth by age and sex Remaining teeth
60–69 70–79 Above 80
Functional teeth
Male
Female
Average
Male
Female
Average
14.0 3.1 5.6
10.8 10.0 2.9
12.8 7.6 3.4
15.5 18.9 14.2
26.6 21.4 16.5
19.8 20.5 15.9
Remaining teeth
Functional teeth 0
Sex Age group Eating Bladder management Locomotion Transfers Expression Social interaction Sitting up
Male Female 60–79 80– 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4 5–7 1–4
11 29 11 29 30 10 21 19 20 20 18 22 20 19 21 18 27 13
(36.7) (45.3) (25.6) (56.9) (49.2) (31.3) (47.7) (38.0) (42.6) (42.6) (47.4) (40.0) (35.1) (54.3) (36.8) (52.9) (50.0) (33.3)
1–9
10–19
20–28
P value
0–9
10–19
20–27
28
9 20 15 14 16 13 11 18 13 16 10 18 17 12 21 7 13 15
7 9 9 7 11 4 8 8 10 6 7 9 12 3 9 6 10 6
3 6 8 1 4 5 4 5 4 5 3 6 8 1 6 3 4 5
0.391
9 17 8 18 16 10 8 18 8 18 6 20 14 11 17 9 12 14
7 9 6 10 11 4 6 10 9 7 6 9 12 3 9 6 10 6
4 (13.3) 7 (10.9) 10 (23.3) 1 ( 2.0) 4( 6.6) 7 (21.9) 4 ( 9.1) 7 (14.0) 4 ( 8.5) 7 (14.9) 3 ( 7.9) 8 (14.5) 7 (12.3) 4 (11.4) 6 (10.5) 5 (14.7) 4 ( 7.4) 7 (17.9)
10 31 19 22 30 11 26 15 26 15 23 18 24 17 25 14 28 12
(30.0) (31.3) (34.9) (27.5) (26.2) (40.6) (25.0) (36.0) (27.7) (34.0) (26.3) (32.7) (29.8) (34.3) (36.8) (20.6) (24.1) (38.5)
(23.3) (14.1) (20.9) (13.7) (18.0) (12.5) (18.2) (16.0) (21.3) (12.8) (18.4) (16.4) (21.1) ( 8.6) (15.8) (17.6) (18.5) (15.4)
(10.0) (9.4) (18.6) (2.0) (8.6) (15.6) (9.1) (10.0) (8.5) (10.6) (7.9) (10.9) (14.0) (2.9) (10.5) (8.8) (7.4) (12.8)
0.000 0.116 0.622 0.456 0.928 0.030 0.281 0.161
(30.0) (26.6) (18.6) (35.3) (26.2) (31.3) (18.2) (36.0) (17.0) (38.3) (15.8) (36.4) (24.6) (31.4) (29.8) (26.5) (22.2) (35.9)
(23.3) (14.1) (14.0) (19.6) (18.0) (12.5) (13.6) (20.0) (19.1) (14.9) (15.8) (16.4) (21.1) ( 8.6) (15.8) (17.6) (18.5) (15.4)
P value (33.3) (48.4) (44.2) (43.1) (49.2) (34.4) (59.1) (30.0) (55.3) (31.9) (60.5) (32.7) (42.1) (48.6) (43.9) (41.2) (51.9) (30.8)
0.292 0.157 0.394 0.005 0.006 0.008 0.893 0.888 0.059
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Table 5 The distribution of each category of subjects according to the number of remaining teeth and functional teeth (number of subjects (%))
Missing data were excluded.
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Table 6 Odds ratios and 95% confident intervals from logistic regression analyses of FIM variables OR
95%CI
Bladder management Sex Age group Remaining teeth Functional teeth
0.867 1.783 1.026 3.671a
0.362–2.075 0.878–2.120 0.804–1.308 1.556–8.659
Locomotion Sex Age group Remaining teeth Functional teeth
0.486 1.029 0.920 2.955b
0.193–1.222 0.451–2.343 0.362–2.335 1.262–6.921
Transfers Sex Age group Remaining teeth Functional teeth
0.675 1.538 1.388 2.641b
0.282–1.616 0.680–3.479 0.533–3.485 1.139–6.123
Expression Sex Age group Remaining teeth Functional teeth
0.536 1.069 4.189b 0.770
0.218–1.313 0.459–2.486 1.294–13.563 0.330–1.791
OR, odds ratio; CI, confident interval. a PB0.01. b PB0.05.
3.2. Oral health status and biological and psychosocial function The distribution of subjects by remaining teeth and by functional teeth in both sexes, all age groups and the subgroups of FIM index are presented in Table 5. The younger group had more remaining teeth than the older group (PB 0.001). In ‘expression’, the higher group had a significantly greater number of remaining teeth than the lower group (P B 0.05). In regard to the number of functional teeth, the higher group had a significantly more number than the lower in ‘bladder management’, ‘locomotion’, ‘transfers’ (PB 0.01). Logistic regression analyses were performed to test whether oral health status variables are predictive factors for each biological and psychosocial function item. FIM scores of ‘expression’, of ‘bladder management’, of ‘transfer’ and of ‘locomotion’ were used as dependent variables in logistic regression models with age, sex, the number of remaining teeth and the number of functional teeth. The most predictive factor for ‘bladder management’, ‘locomotion’ and ‘transfers’ was having less than 28 functional teeth (bladder management: PB 0.01, locomotion, transfers: PB 0.05) (Table 6). A logistic stepwise regression model with ‘expression ’as the dependent variable showed the number of remaining teeth was the most predictive factor (P B 0.05).
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4. Discussion The mean number of remaining teeth in each age group of the subjects was lower than that shown in the national survey of dental disease in Japan (60–64: 20.4, 65– 69: 16.8, 70– 74: 12.9, 75– 79: 9.0, above 80: 6.2; Dental Health Division of Health Policy Bureau, Ministry of Health and Welfare Japan, 1999). Miura et al. (1997) reported that bedridden elderly had a lower mean number of remaining teeth than independent elderly. The findings of our study agree with that report. It is thought that tooth loss caused poor eating habits, resulting in the deterioration of general health. Less than 60% of subjects had 20 or more functional teeth, which may have led to poor eating habits due to poor oral health conditions. The score of ‘expression’ correlated significantly with the number of remaining teeth in the subjects (P B 0.05). It has been reported that tooth loss affects the activity of brain. Several epidemiological studies have suggested that tooth loss is a risk factor for the occurrence of Alzheimer disease (Kondoh et al., 1995; Nordenram et al., 1996). Rats that lost their molar teeth had lower learning ability, which implies that tooth loss is related to the malfunction of the cholinergic nervous system (Kato et al., 1997; Onozuka et al., 1999). Moreover, several reports have indicated a close relationship between the number of missing teeth and masticatory function (Agerberg and Carlsson, 1981; Slade et al., 1996; Miura et al., 1998). It is hypothesized that tooth loss affects the brain activity by decreasing stimulus to brain on mastication. In the subjects, who lose many teeth, tooth loss might reduce the subject’s ability to express their intention. It is suggested that the retention of teeth may lead to brain activation, resulting in the higher independent ability of ‘expression’. Mann – Whitney U-test and logistic regression analysis showed that subjects with higher independence in ‘bladder management’, ‘locomotion’ and ‘transfers’ correlated significantly with the number of functional teeth. These items are concerned with physical disabilities. There have been many reports on the relationship between physical function and mastication (Curtis et al., 1975; Moran et al., 1979; Bando et al., 1998). These reports support our data. Improvement of masticatory function by prosthesis treatment might prevent the decline of physical functions. There is little information on which biological and psychosocial function items are related to oral health status. Further accumulation of epidemiological studies on this point will promote the improvement of oral health to prevent the deterioration of biological and psychosocial function in old age. References Agerberg, G., Carlsson, G.E., 1981. Chewing ability in relation to dental and general health. Acta. Odontol. Scand. 39, 147 –153. Bando, K., Nitta, H., Matsubara, M., Ishikawa, I., 1998. Bone mineral dentistry in periodontally healthy and edentulous postmenopausal women. Ann. Periodontol. 3, 322 – 326. Bridges, R.B., Anderson, J.W., Saxe, S.R., Gregory, K., Bridges, S.R., 1996. Periodontal status of diabetic and non-diabetic men: effects of smoking, glycemic control and socioeconomic factors. J. Periodontol. 67, 1185 –1192.
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