This study examined the association between oral health factors and mortality in older Japanese adults. Over 17,000 participants aged 75 and over underwent oral health examinations assessing dental status, swallowing ability, dry mouth, plaque, and oral hygiene. Participants were followed for mortality, with a median follow up of 9.4 years. Poor oral health factors like fewer teeth, poor oral hygiene, and dry mouth were significantly associated with higher all-cause mortality based on Cox proportional hazards models, with a cumulative effect of multiple poor oral health factors further increasing mortality risk.

1. Association of oral health factors
related to oral function with mortality
in older Japanese
Mizuki Saito; Yoshihiro Shimazaki; Toshiya Nonoyama;
Yasushi Tadokoro
Gerodontology. 2021 Jun;38(2):166-173. By
Dr. Souma Mukherjee

2. CONTENTS OF THIS TEMPLATE
1) Prologue
2) Abstract
3) Methodology
4) Conclusion
5) Critical Evaluation

3. DISEASES IN THE OLDER AGE
GROUP
DEPARTMENT OF ETHNOGERIATRICS; STANFORD
MEDICINE
CANCER CVD PNEUMONIA
MALNUTRITION

4. CANCER

5. CVD

6. CVD

7. PNEUMONIA

8. PNEUMONIA

9. MALNUTRITION

10. PLAQUE AND
MICROBIAL LOAD
DENTITION
STATUS
SWALLOING
CAPABILITIES
XEROSTOMIA
GINGIVAL AND
PERIODONTAL
STATUS
HABITS

11. SURVIVAL ANALYSIS

12. SURVIVAL ANALYSIS
TIME SINCE DIAGNOSIS

13. SURVIVAL ANALYSIS
TIME SINCE DIAGNOSIS
HAZARD PARAMETER

14. SURVIVAL ANALYSIS
TIME SINCE DIAGNOSIS
HAZARD PARAMETER

15. KAPLAN-MEIER ESTIMATOR

16. KAPLAN-MEIER ESTIMATOR

17. HAZARD RATIO
OUTCOME MEASURE
TIME TO EVENT
ANALYSIS
RATIO OF HAZARDS

18. HAZARD RATIO
HAZARD?
Instantaneous event rate
Probability that an individual at time t has an
event at that time (assuming event free survival
to time t)

19. HAZARD RATIO
• HR=1 (even rates are the same in both arms)
• HR=2 (at any time, twice as many patients in the
treatment group are having an event proportionally to the
comparator group)
• HR=0.5 (at any time, half as many patients in the
treatment group are having an event proportionally to the
comparator group)

20. HAZARD RATIO
• Often interpreted as relative risk
-Technically they are no the same.

21. LINEAR REGRESSION
LOGISTIC
REGRESSION
COX PROPORTIONAL
HAZARD
REGRESSION

22. COX-REGRESSION
Cox proportional hazards model.

23. COX-REGRESSION
Cox proportional hazards model.
This regression is then designed to assess
the effects of each predictor on the shape of
the survival curve.

24. COX-REGRESSION

25. COX-REGRESSION

26. COX-REGRESSION

27. ABSTRACT

28. METHODOLOGY
PARTICIPANTS
MIE PERFECTURE INSURER
17,338 (75 YEARS) 16,040(80 YEARS)

29. METHODOLOGY
ORAL HEALTH EXAMINATION
• Dentists used detailed manuals to standardize the assessment of oral health.
• Sound, decayed, filled or missing.
• Number of sound, decayed and filled teeth, excluding third molars

30. METHODOLOGY
ORAL HEALTH EXAMINATION
• The Repetitive Saliva Swallowing Test (RSST)
• Swallow saliva three times or more in 30 seconds.
• Swallowed less than 3 times

31. METHODOLOGY
ORAL HEALTH EXAMINATION
• Participants included edentulous individuals, and oral hygiene status was classified
based on visual assessment of the residual food debris in the oral cavity.
• Classification included “good” (cannot see food debris on visual inspection),
“moderate” (food debris are observed in the inter-dental spaces) and “bad” (food
debris are found in the oral vestibule).
• Dry mouth was evaluated using a scale that included the objective condition of the
oral mucosa and was classified into four categories as normal, mild, moderate or
severe

32. METHODOLOGY
ORAL HEALTH EXAMINATION
• Number of teeth into two categories (≥20 teeth vs ≤19 teeth)
• The oral hygiene status into two categories (good vs moderate or bad)
• Oral dryness into two categories (normal or mild vs. moderate or severe)

33. METHODOLOGY
Questionnaire
• Information on lifestyle and health - selfadministered questionnaire.
• Body mass index (<18.5 kg/m2,18.5-<25 kg/m2 or >=25kg/m2)
• Smoking habit (non-smoker vs smoker)
• Current medical history (stroke, cardiovascular disease, cancer and pulmonary
disease) were used as factors associated with mortality.

34. METHODOLOGY
MORTALITY
• Date on which a patient's data were deleted from the data managed by the insurer
for the latestage medical care system in Mie Prefecture due to death.
• The follow-up period for confirming survival or death was from the month in which
each participant underwent an oral health examination to March 2018.
• Thirty people who were excluded from the database by the medical insurer for
reasons other than death by the end of March 2018 were regarded as CENSORED
data for survival until the time of exclusion.

35. RESULTS

36. RESULTS

37. RESULTS

38. RESULTS

39. RESULTS

40. DISCUSSION
Aims and Objectives Results Inference
• A lomgitudinal study was
conducted by Ayumi et al in the
year 2014
• Associations of number of teeth
with all-cause mortality and
cause-specific mortality among
middle-aged and elderly
Japanese men.
In total participants, an inverse
relationship between number of
teeth and all-cause mortality was
found (P for trend = 0.049). Among
men aged 40-64 years, inverse
relationships were also found in
risks for mortality from all
causes, CVD, and cancer:
multivariate-adjusted HRs (95%
CI) for all-cause mortality in men
with no teeth, 1-9 teeth, and 10-
19 teeth relative to men with ≥20
teeth were 2.75 (1.37-5.49), 1.89
(0.99-3.63), and 1.94 (1.09-3.43),
respectively.
SIMILAR

41. DISCUSSION
Aims and Objectives Results Inference
• A longitudinal study was
conducted by Naruishi et al in
the year 2018
• Examine the significant factors
for predicting life prognosis of
elderly in end-of-life care.
There were no significant
differences in number of days when
divided with or without past illness
of aspiration pneumonia,
cerebrovascular disorder and
impaired cognitive function. The
survival probabilities of elderly
with impaired swallowing
function were significant lower
than in elderly with the normal
function.
SIMILAR

42. CROSS REFERENCE

43. LIMITATIONS
• As the oral health examinations were voluntary, the participants were probably relatively
healthy and interested in their oral health.
• Since the participants were community-dwelling independent older people, the risk factors for
mortality are thought to differ if the targeted people are frail or need long-term care.
• Multiple statistical tests were performed using all possible combinations of oral health factors.
And associations between factor may have introduced multiplicity errors into the analysis.
• Did not consider the use or condition of dentures, which affect occlusion or swallowing, as an
oral condition item.
• Specific medications are associated with dry mouth and may lead to a risk of mortality, but no
information was there about the participants’ medications.
• The causes of death of the participants were unknown, it is unclear what diseases contributed
to mortality.

44. CONCLUSION
Oral dryness, oral hygiene and number of teeth are significantly related to the risk of
mortality, and a cumulative poor oral status significantly increased the risk of mortality.

45. CRITICAL EVALUATION
08
SOURCE OF THE ARTICLE: Gerodontology

46. ABOUT THE JOURNAL

47. ABOUT THE JOURNAL

48. ABOUT THE JOURNAL
Peer Reviewed
Publisher: Wiley & sons
Editor: Prof. Dr Murray Thomas
Section Under Which Article Was Published: Original Article
Publication Frequency: Semimonthly

49. DOI:DOI: 10.1111/ger.12508
Submitted: 30 April 2020
Accepted: Accepted: 24 October 2020
Year of publication: 2020
Volume : 38, Issue 2
Impact factor: 2.750

50. About the Authors
Author name and institutional attachment mentioned
Designation not mentioned for the authors
Department mentioned
Correspondence address and mail access mentioned

51. Mizuki Saito
• Department of Preventive Dentistry and Dental Public Health, School of
Dentistry, Aichi Gakuin University, Nagoya, Japan
• 15 Publications
AREA OF INTEREST
• Dementia and oral health
• Factors associated with tooth loss in geriatric patients

52. Yoshihiro Shimazaki
• Aichi Gakuin University · Department of Preventive Dentistry and
Dental Public Health
DDS, PhD
• 123
AREA OF INTEREST
• Geriatrics and oral health
• Periodontal inflammation and rheumatoid arthiritis

53. Toshiya Nonoyama
• Department of Preventive Dentistry and Dental Public Health, School of
Dentistry, Aichi Gakuin University, Nagoya, Japan
• 10
AREA OF INTEREST
• Denture and Oral Health
• Number of teeth and hospitalization duration

54. Yasushi Tadokoro
• Mie Dental Association, Tsu, Japan
• 11
AREA OF INTEREST
• Geriatrics and oral health

55. TITLE
Meaningful
Reflects the aim of the study.
Study design is not mentioned.
Study population is mentioned.
Study location is not mentioned.

56. Title and Abstract
1. (a) Indicate the study’s design with a commonly used term in the
title or the abstract- Not mentioned
2. (b) Provide in the abstract an informative and balanced summary of
what was done and what was found - yes

57. Introduction
Seminar approach
It conveys the need and rationale for study
Meaningful and comprehensive
Aim is mentioned
Presents literature relevant to the research
Citations are relevant

58. Introduction
2. Background/rationale
Explain the scientific background and rationale for the investigation being
reported- Yes
3. Objectives
State specific objectives, including any prespecified hypotheses- Yes

59. METHODOLOGY
Methods
4. Study design Present key elements of study design early in the
paper
Mentioned
5. Setting Describe the locations, setting, and relevant dates Not Mentioned
6. Participants Give the eligibility criteria, sources and methods of
selection of participants
Mentioned
7. Variables Clearly define all outcomes, predictors, exposures,
potential confounders, effect modifiers. Give diagnostic
criteria, if applicable.
Yes including the
confounders.

60. METHODOLOGY
8. Data sources/
Measurement
For each variable of interest, give
sources of data and details of methods of assessment
(measurement).
Mentioned
assessment &
calibration
9. Bias Describe any efforts to address potential sources of
bias
Not Mentioned
10. Study size Explain how the study size was arrived at Mentioned
11. Quantitative
variables
Explain how quantitative variables were handled in
the analyses. If applicable, describe which groupings
were chosen and why
Mentioned

61. METHODOLOGY
12. Statistical methods
(a)Describe all statistical methods, including those used to control
for confounding
(a)Describe any methods used to examine subgroups and
interactions
(b)Explain how missing data were addressed
(c)If applicable, describe analytical methods taking account of
sampling strategy
(d)Describe any sensitive analyses
Mentioned
Mentioned
Mentioned

62. RESULTS
Results
13. Participants (a)Report numbers of individuals at each stage of study
(b)Give reasons for non- participation at each stage of the
study
(c)Consider use of a flow diagram
a) Mentioned
b) Mentioned
c) Not
mentioned
14. Descriptive data (a)Give characteristics of study participants and information
on exposures and potential confounders
(b)Indicate number of participants with missing data for each
variable of interest
Mentioned
Mentioned

63. RESULTS
15. Outcome data Report numbers of outcome events or summary
measures over time
Mentioned
16. Main Results (a)Give unadjusted estimates or confounder-
adjusted and their precision
(b)Report category boundaries when continuous
variables were categorized
Mentioned
17. Other analyses Report other analyses done Mentioned

64. RESULTS
• Results are presented in a logical and comprehensive manner.
• Presented in table and text form, and both the data match.
• Tables are numbered and titled properly.
• Accompanied by footnotes.
• Results are based on the objectives of the study.

65. DISCUSSION
Discussion
18. Key results Summarise key results with reference to study
objectives
Mentioned
19. Limitations Discuss limitations of the study Mentioned
20. Interpretation Give a cautious overall interpretation of results
considering objectives, limitations,
results from similar studies, and other relevant
evidence
Mentioned
21. Generalisability Discuss the generalisability (external validity) of the
study results
Not mentioned

66. CONCLUSION
Conclusion is mentioned
It is in line with the aim of the study

67. Other Information
Acknowledgement- mentioned
Conflict of interest- mentioned
Other Information
22. Funding Give the source of funding and
the role of funders for the
present study
Mentioned

68. REFERENCES
36
Vancouver style of referencing

69. CRITICAL REFLECTION
PRESENT
STUDY
GENERALIZABILITY
PUBLIC
HEALTH
SIGNIFICANCE
REPRODUCIBILITY

70. CRITICAL REFLECTION
THANK YOU