Regional Inequalities in Oral Frailty and Social Capital

INTRODUCTION

Oral frailty leads to poor nutritional status, which, in turn, leads to frailty. This cross-sectional study aimed to determine regional differences in the prevalence of oral frailty and to identify factors associated with oral frailty using 3-level multilevel models.

METHODS

This study comprised 165,164 participants aged ≥65 y without long-term care requirements in the Japan Gerontological Evaluation Study. The dependent variable was oral frailty, which was calculated based on age, number of teeth, difficulty in eating tough foods, and choking. The individual-level independent variables included sociodemographics, present illness, social participation, frequency of meeting friends, and social capital. The local district-level independent variable was social capital (n = 1,008) derived from exploratory factor analyses. The municipality-level independent variable was population density (n = 62). Three-level multilevel Poisson regression analysis was performed to calculate the prevalence ratios (PRs).

RESULTS

The prevalence of oral frailty in municipalities ranged from 39.9% to 77.6%. Regarding district-level factors, higher civic participation was significantly associated with a lower probability of oral frailty. At the municipality level, the PR of the rural-agricultural area was 1.17 (95% confidence interval, 1.11-1.23) (reference: metropolitan).

CONCLUSION

These results highlight the usefulness of oral frailty prevention measures in encouraging social participation in rural areas.

KNOWLEDGE TRANSFER STATEMENT

The results of the present study showed regional differences in oral frailty. In particular, rural-agricultural areas show higher prevalence rates of oral frailty than those in metropolitan cities. Promoting measures of social participation among older adults may help prevent oral frailty in rural areas.

Heterogeneous Association of Tooth Loss with Functional Limitations

Tooth loss is prevalent in older adults and associated with functional capacity decline. Studies on the susceptibility of some individuals to the effects of tooth loss are lacking. This study aimed to investigate the heterogeneity of the association between tooth loss and higher-level functional capacity in older Japanese individuals employing a machine learning approach. This is a prospective cohort study using the data of adults aged ≥65 y in Japan (N = 16,553). Higher-level functional capacity, comprising instrumental independence, intellectual activity, and social role, was evaluated using the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC). The scale ranged from 0 (lowest function) to 13 (highest function). Doubly robust targeted maximum likelihood estimation was used to estimate the population-average association between tooth loss (having <20 natural teeth) and TMIG-IC total score after 6 y. The heterogeneity of the association was evaluated by estimating conditional average treatment effects (CATEs) using the causal forest algorithm. The result showed that tooth loss was statistically significantly associated with lower TMIG-IC total scores (population-average effect: -0.14; 95% confidence interval, -0.18 to -0.09). The causal forest analysis revealed the heterogeneous associations between tooth loss and lower TMIG-IC total score after 6 y (median of estimated CATEs = -0.13; interquartile range = 0.12). The high-impact subgroup (i.e., individuals with estimated CATEs of the bottom 10%) were significantly more likely to be older and male, had a lower socioeconomic status, did not have a partner, and had poor health conditions compared with the low-impact subgroup (i.e., individuals with estimated CATEs of the top 10%). This study found that heterogeneity exists in the association between tooth loss and lower scores on functional capacity. Implementing tooth loss prevention policy and clinical measures, especially among vulnerable subpopulations significantly affected by tooth loss, may reduce its burden more effectively.

Effect of Tooth Loss on Cognitive Function among Older Adults in Singapore

Evidence suggests a longitudinal association between tooth loss and cognitive function. However, the temporality of this association is not well understood. We investigated the effect of several emulated tooth loss prevention scenarios on cognitive function. We used data from 3 waves (baseline: 2009, second wave: 2011-2012, and third wave: 2015) of the Panel on Health and Ageing of Singaporean Elderly (PHASE). PHASE targeted older adults, aged ≥60 y, in Singapore. Number of teeth was used as a time-varying exposure (baseline, second wave). Cognitive function (Short Portable Mental Status Questionnaire score) in the third wave was assessed as the outcome. Multiple time-invariant (baseline) and time-varying (baseline and second wave) covariates were included. The "longitudinal modified treatment policy approach" combined with targeted minimum loss-based estimation was used to define and estimate additive effects of emulated tooth loss prevention scenarios. Emulated scenarios were the following: what if edentate people retained 1 to 4 teeth (scenario 1), what if those with <5 teeth retained 5 to 9 teeth (scenario 2), what if those with <10 teeth retained 10 to 19 teeth (scenario 3), and what if everyone retained ≥20 teeth (scenario 4)? A total of 1,516 participants, excluding those with severe cognitive impairment, were included (male: 41.6%). The mean age at baseline was 70.6 y (SD = 7.1). The mean SPMSQ score at baseline was 2.06 (SD = 0.02) for edentulous, 1.55 (SD = 0.04) for 1 to 4 teeth, 1.61 (SD = 0.03) for 5 to 9 teeth, 1.73 (SD = 0.02) for 10 to 19 teeth, and 1.71 (SD = 0.02) for ≥20 teeth. Additive effect of hypothetical intervention gradually increased with intensity of prevention from scenario 1 to scenario 4 (scenario 1: -0.02 [95% CI, -0.08 to 0.04], scenario 2: -0.05 [95% CI, -0.11 to -0.00], scenario 3: -0.07 [95% CI, -0.14 to -0.00], scenario 4: -0.15 [95% CI, -0.23 to -0.06]). Emulated tooth loss prevention interventions were associated with better cognitive function score. Therefore, preventing tooth loss could potentially benefit maintenance of cognitive function among older adults.

Change in Geographic Accessibility to Dental Clinics Affects Access to Care

Access to dental clinics is a feature of the neighborhood service environment that may influence oral health care utilization. However, residential selection poses a challenge to causal inference. By studying the involuntary relocation of survivors of the 2011 Great East Japan Earthquake and Tsunami (GEJE), we examined the association between changes in geographic distance to dental clinics and dental visits. Longitudinal data from a cohort of older residents in Iwanuma City directly impacted by the GEJE were analyzed in this study. The baseline survey was conducted in 2010, 7 mo before the occurrence of GEJE, and a follow-up was conducted in 2016. Using Poisson regression models, we estimated the incidence rate ratios (IRR) and 95% confidence intervals (CIs) for the uptake of denture use (as a proxy for dental visits) according to changes in distance from the nearest dental clinic to their house. Age at baseline, housing damage by the disaster, deteriorating economic conditions, and worsened physical activity were used as confounders. Among the 1,098 participants who had not worn dentures before the GEJE, 495 were men (45.1%), with a mean ± SD age at baseline of 74.0 ± 6.9 y. During the 6-year follow-up, 372 (33.9%) participants initiated denture use. Compared to those who experienced a large increase in distance to dental clinics (>370.0-6,299.1 m), a large decrease in distance to dental clinics (>429.0-5,382.6 m) was associated with a marginally significantly higher initiation of denture use among disaster survivors (IRR = 1.28; 95% CI, 0.99-1.66). The experience of major housing damage was independently associated with higher initiation of denture use (IRR = 1.77; 95% CI, 1.47-2.14). Improved geographic access to dental clinics may increase dental visits of disaster survivors. Further studies in non-disaster-affected areas are needed to generalize these findings.

Impact of Teeth on Social Participation: Modified Treatment Policy Approach

Social participation prevents social isolation and loneliness among older adults while having numerous positive effects on their health and well-being in rapidly aging societies. We aimed to estimate the effect of retaining more natural teeth on social participation among older adults in Japan. The analysis used longitudinal data from 24,872 participants in the Japan Gerontological Evaluation Study (2010, 2013, and 2016). We employed a longitudinal modified treatment policy approach to determine the effect of several hypothetical scenarios (preventive scenarios and tooth loss scenarios) on frequent social participation (1 = at least once a week/0 = less than once a week) after a 6-y follow-up. The corresponding statistical parameters were estimated using targeted minimum loss-based estimation (TMLE) method. Number of teeth category (edentate/1-9/10-19/≥20) was treated as a time-varying exposure, and the outcome estimates were adjusted for time-varying (income, self-rated health, marital status, instrumental activities of daily living, vision loss, hearing loss, major comorbidities, and number of household members) and time-invariant covariates (age, sex, education, baseline social participation). Less frequent social participation was associated with older age, male sex, lower income, low educational attainment, and poor self-rated health at the baseline. Social participation improved when tooth loss prevention scenarios were emulated. The best preventive scenario (i.e., maintaining ≥20 teeth among each participant) improved social participation by 8% (risk ratio [RR] = 1.08; 95% confidence interval [CI], 1.05-1.11). Emulated tooth loss scenarios gradually decreased social participation. A hypothetical scenario in which all the participants were edentate throughout the follow-up period resulted in a 11% (RR = 0.89; 95% CI, 0.84-0.94) reduction in social participation. Subsequent tooth loss scenarios showed 8% (RR = 0.92; 95% CI, 0.88-0.95), 6% (RR = 0.94; 95% CI, 0.91-0.97), and 4% (RR = 0.96; 95% CI, 0.93-0.98) reductions, respectively. Thus, among Japanese older adults, retaining a higher number of teeth positively affects their social participation, whereas being edentate or having a relatively lower number of teeth negatively affects their social participation.

Weight Loss Mediated the Relationship between Tooth Loss and Mortality Risk

Tooth loss is a risk factor for increased mortality; however, the underlying mechanism remains unclear. This study aimed to evaluate the mediating effect of weight change on the relationship between tooth loss and mortality risk. This was a 10-y follow-up prospective cohort study using the data from the Japan Gerontological Evaluation Study (JAGES). The participants were independent older adults aged ≥65 y at baseline and were followed up from 2010 to 2020. The incidence of death in 2013 and 2020, incidence of >5% weight loss/gain in 2010 and 2013, and the number of remaining teeth in 2010 were used as the outcome, mediator, and explanatory variables, respectively. We conducted causal mediation analysis by fitting the Cox proportional hazard model, including possible confounders. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) of the total effect (TE), natural indirect effect (NIE), and proportion mediated (PM) were estimated. Among the 34,510 participants, the mean age was 72.6 (SD = 5.4) y, and 47.6% were men. From 2013 to 2020, 14.0% of the participants (n = 4,825) died, 60.5% (n = 20,871) had 0 to 19 remaining teeth, and 17.2% (n = 5,927) and 8.4% (n = 2,907) experienced >5% weight loss and gain, respectively. The mortality rate was 0.016 per person-year among those with ≥20 remaining teeth and 0.027 per person-year among those with 0 to 19 remaining teeth. Weight loss of >5% significantly mediated the association between tooth loss and higher mortality risk (TE: HR, 1.28 [95% CI, 1.16 to 1.40]; NIE: HR, 1.03 [95% CI, 1.02 to 1.04]; PM, 13.1%); however, we observed a slight mediating effect for >5% weight gain (NIE: HR, 1.003 [95%CI, 1.0001 to 1.01]; PM, 1.3%). The present study suggests that a clinically meaningful level of weight loss mediated the association between tooth loss and increased risk of mortality among independent older adults.

Post-Disaster Mental Health and Dietary Patterns among Older Survivors of an Earthquake and Tsunami

OBJECTIVES

Research suggests that cardiometabolic disease risks are elevated among survivors of natural disasters, possibly mediated by changes in diet. Using the Brief Dietary History Questionnaire, we examined (1) dietary patterns among older survivors of the 2011 Great East Japan Earthquake and Tsunami, and (2) the contribution of posttraumatic stress symptoms (PTSS)/depressive symptoms, as well as relocation to temporary housing on dietary patterns and (3) gender differences in the associations.

DESIGN, SETTING AND PARTICIPANTS

Data came from a prospective cohort study of 1,375 survivors aged 65-89 years (44.6% male).

MEASUREMENTS

PTSS/depression onset was evaluated in 2013, 2.5 years after the disaster. Dietary data was collected with a self-administered brief-type diet history questionnaire in 2020. A principal component analysis identified three posterior dietary patterns.

RESULTS

Diet 1 consisted of high intake of vegetables, soy products, and fruits; Diet 2 consisted of carbohydrate-rich foods and snacks/sweets; Diet 3 consisted of high intake of alcoholic beverages, meat, and seafood. Least-squares linear regression revealed that individuals with PTSS/depression were less likely to exhibit Diet 1, while individuals with PTSS were more likely to exhibit Diet 2 and 3. Especially, males who had depression showed an unhealthy dietary pattern. Those who have lived in a trailer-style temporary housing reported less consumption of Diet 3.

CONCLUSION

Survivors of disaster with symptoms of mental illness tended to exhibit less healthy dietary patterns after 9 years. Diet varied by type of post-disaster mental illness, gender, and current social circumstances. We lacked pre-disaster BDHQ data, which is a limitation.

COVID-19 Effects on Income and Dental Visits: A Cross-sectional Study

OBJECTIVES

In April 2020, the Japanese government declared a state of emergency owing to the outbreak of the novel coronavirus disease (COVID-19) pandemic, which resulted in reduced workforce and job losses. Furthermore, income is one of the most consistent predictors of dental visits. Therefore, this study examined the association between income changes and dental clinic visits during the COVID-19 state of emergency in Japan.

METHODS

An online, self-reported cross-sectional survey about health activities including dental visits during the first COVID-19 state of emergency was conducted in Osaka, Japan (June 23 to July 12, 2020). Among participants with toothaches, the assessment for the association between "refrained from visiting a dentist despite wanting treatment for toothache during the state of emergency (refrained treatment)" and income changes before and after the state of emergency using a multivariate Poisson regression model adjusted for sex, age, self-rated health, frequency of regular dental visits, and employment status.

RESULTS

Among 27,575 participants, 3,895 (14.1%) had toothaches, and 1,906 (6.9%) reported refrained treatment. Among people with decreased income (n = 8,152, 29.6% of overall participants), the proportions of the refrained treatment group were 8.0% (income decreased by 1%-49%), 9.9% (50%-99% decreased), and 9.1% (100% decreased). Among participants with toothache, after adjusting for all variables, compared with participants with no income change, we observed significantly higher prevalence ratios (PRs) for refrained treatment in those who experienced a decreased income owing to COVID-19 (1%-49% decrease: PR = 1.08; 95% confidence interval [CI], 1.005-1.17; 50%-99% decrease: PR = 1.18; 95% CI, 1.06-1.32; 100% decrease: PR = 1.18; 95% CI, 1.04-1.33).

CONCLUSION

Decreased income was associated with refrained dental treatment during the COVID-19 state of emergency in Osaka, Japan. The economic damage related to the COVID-19 pandemic could lead to oral health inequalities.

KNOWLEDGE TRANSFER STATEMENT

Our study found that individuals with decreased income owing to COVID-19 before and after the state of emergency showed significantly higher prevalence ratios for refraining from visiting a dentist despite wanting treatment for toothache. We believe that our study makes a significant contribution because it provides novel, basic data that economic damages related to the COVID-19 pandemic might expand to oral health inequalities.

Oral Status and Dementia Onset: Mediation of Nutritional and Social Factors

Some modifiable risk factors for dementia are closely related to oral health. Although eating and speaking abilities are fundamental oral functions, limited studies have focused on the effect of malnutrition and lack of social interaction between oral health and dementia. We investigated the mediating effects of nutritional and social factors on the association between the number of teeth and the incidence of dementia. This 6-y cohort study used data from the Japan Gerontological Evaluation Study targeting older adults aged 65 y and above. The number of teeth (exposure) and covariates in 2010 (baseline survey), mediators (weight loss, vegetable and fruit intake, homeboundness, social network) in 2013, and the onset of dementia (outcome) between 2013 and 2016 were obtained. The Karlson-Holm-Breen mediation method was applied. A total of 35,744 participants were included (54.0% women). The mean age at baseline was 73.1 ± 5.5 y for men and 73.2 ± 5.5 y for women. A total of 1,776 participants (5.0%) had dementia during the follow-up period. There was a significant total effect of the number of teeth on the onset of dementia (hazard ratio, 1.14; 95% CI, 1.01-1.28). Controlling for nutritional and social mediators, the effect of the number of teeth was reduced to 1.10 (95% CI, 0.98-1.25), leaving an indirect effect of 1.03 (95% CI, 1.02-1.04). In the sex-stratified analysis, the proportion mediated by weight loss was 6.35% for men and 4.07% for women. The proportions mediated by vegetable and fruit intake and homeboundness were 4.44% and 4.83% for men and 8.45% and 0.93% for women, respectively. Furthermore, the proportion mediated by social networks was 13.79% for men and 4.00% for women. Tooth loss was associated with the onset of dementia. Nutritional and social factors partially mediated this association.

Dental Pain and Worsened Socioeconomic Conditions Due to the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has led to economic contraction and significant restrictions on society. The shock to the economy could lead to a deterioration of physical health outcomes, including dental health. The present study investigated the association between worsened socioeconomic conditions due to the COVID-19 pandemic and dental pain in Japan. The mediating effects of psychological distress and oral health-related behaviors were also evaluated. Cross-sectional data from the Japan COVID-19 and Society Internet Survey conducted from August to September 2020 (n = 25,482; age range, 15-79 y) were analyzed. Multivariable logistic regression models were fitted to evaluate the independent associations of household income reduction, work reduction, and job loss due to the COVID-19 pandemic with dental pain within a month. Dental pain was reported by 9.8%. Household income reduction, work reduction, and job loss were independently associated with dental pain after adjusting for confounders (odds ratios: 1.42 [95% confidence interval (CI), 1.28-1.57], 1.58 [95% CI, 1.41-1.76], 2.17 [95% CI, 1.64-2.88], respectively). The association related to household income reduction was mediated by psychological distress, postponing dental visits, toothbrushing behavior, and between-meals eating behavior by 21.3% (95% CI, 14.0-31.6), 12.4% (95% CI, 7.2-19.6), 1.5% (95% CI, -0.01 to 4.5), and 9.3% (95% CI, 5.4-15.2), respectively. Our findings showed that worsened socioeconomic conditions due to the COVID-19 pandemic deteriorated dental health. Policies that protect income and job loss may reduce dental health problems after the pandemic.

Effect of Copayment on Dental Visits: A Regression Discontinuity Analysis

Despite their prevalence and burdens, oral diseases are neglected in universal health coverage. In Japan, a 30% copayment (out of pocket) by the user and a 70% contribution by Japan’s universal health insurance (JUHI) are required for dental and medical services. From the age of 70 y, an additional 10% is offered by JUHI (copayment, 20%; JUHI, 80%). This study aimed to investigate the effect of cost on dental service use among older adults under the current JUHI system. A regression discontinuity quasi-experimental method was used to investigate the causal effect of the JUHI discount policy on dental visits based on cross-sectional data. Data were derived from the 2016 Japan Gerontological Evaluation Study. This analysis contained 7,161 participants who used JUHI, were aged 68 to 73 y, and responded to questions regarding past dental visits. Analyses were controlled for age, sex, number of teeth, and equalized household income. Mean ± SD age was 72.1 ± 0.79 y for the discount-eligible group and 68.9 ± 0.78 y for the noneligible group. During the past 12 mo, significantly more discount-eligible participants had visited dental services than noneligible participants (66.0% vs. 62.1% for treatment visits, 57.7% vs. 53.1% for checkups). After controlling for covariates, the effect of discount eligibility was significant on dental treatment visits (odds ratio [OR], 1.36; 95% CI, 1.32 to 1.40) and dental checkups (OR, 1.49; 95% CI, 1.44 to 1.54) in the regression discontinuity analysis. Similar findings were observed in triangular kernel-weighted models (OR, 1.38 [95% CI, 1.34 to 1.44]; OR, 1.52 [95% CI, 1.47 to 1.56], respectively). JUHI copayment discount policy increases oral health service utilization among older Japanese. The price elasticity for dental checkup visits appears to be higher than for dental treatment visits. Hence, reforming the universal health coverage system to improve the affordability of relatively inexpensive preventive care could increase dental service utilization in Japan.

Impact of Dental Diseases on Quality-Adjusted Life Expectancy in US Adults

Comparing the burden of dental conditions to other health outcomes provides useful insight for public policy. We aimed to estimate quality-adjusted life expectancy (QALE) loss due to dental conditions in the US adult population. Social inequalities in QALE loss by dental conditions were also examined. Data from 3 cross-sectional waves of the National Health and Nutrition Examination Survey (NHANES waves 2001 to 2002, 2003 to 2004, and 2011 to 2012) were pooled and analyzed. The average age of study participants ( n = 9,445) was 48.4 y. Disutility scores were derived from self-rated health and the numbers of physically unhealthy days, mentally unhealthy days, and days with activity limitation, employing a previously published algorithm. The associations between the disutility scores and the numbers of decayed teeth, missing teeth, and periodontitis were examined by multiple linear regression stratified by age groups (20–39, 40–59, and ≥60 y), adjusted for other covariates (age, sex, wave fixed effect, educational attainment, smoking, and diabetes). The QALE loss due to dental conditions at the age of 20 was estimated using life tables. Decayed and missing teeth, but not periodontitis, were associated with a larger disutility score. The coefficient for decayed teeth was larger among the older population, whereas that of missing teeth was smaller among them. The estimated QALE loss was 0.43 y (95% confidence interval [CI], 0.28–0.59), which reached 5.3% of QALE loss (8.15 y; 95% CI, 8.03–8.27) due to overall morbidity. There were clear social gradients in QALE loss by dental conditions across the life course, and people with high school or less education had 0.32 y larger QALE loss in total compared with people with college or more education. This study suggests that improvements in people’s dental health may yield substantial gains in population health and well-being. The necessity of more comprehensive public health strategies is highlighted.

Residential relocation and obesity after a natural disaster: A natural experiment from the 2011 Japan Earthquake and Tsunami

Natural disasters are often associated with forced residential relocation, thereby affected people experience a change of food environment that results in the increased body mass index. However, there are a few studies that examined whether a change in food environment caused risk of obesity after a natural disaster. To address this question, we leveraged a natural experiment of residential relocation in the aftermath of the 2011 Japan Earthquake and Tsunami. Our baseline data came from a nationwide cohort study of older community-dwelling adults conducted 7 months prior to the disaster. By chance, one of the field sites (Iwanuma City, Miyagi Prefecture) was directly in the line of the tsunami. Approximately 2.5 years after the disaster, we ascertained the residential addresses and health status of 3,594 survivors aged 65 years or older (82.1% follow-up rate). Fixed effects multinomial logistic regression showed that shortened distances to food outlets/bars increased the risks of transitioning from BMI in the normal range (18.5–22.9) to obesity (≥25.0) (Odds ratios: 1.46 for supermarkets; 1.43 for bars; 1.44 times for fast food outlets). Radically changed food access after a natural disaster may raise the risk of obesity among older survivors.

Telomere length determined by the fluorescence in situ hybridisation distinguishes malignant and benign cells in cytological specimens

BACKGROUND

Telomeres are tandem repeats of TTAGGG at the end of eukaryotic chromosomes that play a key role in preventing chromosomal instability. The aim of the present study is to determine telomere length using fluorescence in situ hybridisation (FISH) on cytological specimens.

METHODS

Aspiration samples (n = 41) were smeared on glass slides and used for FISH.

RESULTS

Telomere signal intensity was significantly lower in positive cases (cases with malignancy, n = 25) as compared to negative cases (cases without malignancy, n = 16), and the same was observed for centromere intensity. The difference in DAPI intensity was not statistically significant. The ratio of telomere to centromere intensity did not show a significant difference between positive and negative cases. There was no statistical difference in the signal intensities of aspiration samples from ascites or pleural effusion (n = 23) and endoscopic ultrasound-guided FNA samples from the pancreas (n = 18).

CONCLUSIONS

The present study revealed that telomere length can be used as an indicator to distinguish malignant and benign cells in cytological specimens. This novel approach may help improve diagnosis for cancer patients.

Dental Status and Compression of Life Expectancy with Disability

This study examined whether the number of teeth contributes to the compression of morbidity, measured as a shortening of life expectancy with disability, an extension of healthy life expectancy, and overall life expectancy. A prospective cohort study was conducted. A self-reported baseline survey was given to 126,438 community-dwelling older people aged ≥65 y in Japan in 2010, and 85,161 (67.4%) responded. The onset of functional disability and all-cause mortality were followed up for 1,374 d (follow-up rate = 96.1%). A sex-stratified illness-death model was applied to estimate the adjusted hazard ratios (HRs) for 3 health transitions (healthy to dead, healthy to disabled, and disabled to dead). Absolute differences in life expectancy, healthy life expectancy, and life expectancy with disability according to the number of teeth were also estimated. Age, denture use, socioeconomic status, health status, and health behavior were adjusted. Compared with the edentulous participants, participants with ≥20 teeth had lower risks of transitioning from healthy to dead (adjusted HR, 0.58 [95% confidence interval (CI), 0.50-0.68] for men and 0.70 [95% CI, 0.57-0.85] for women) and from healthy to disabled (adjusted HR, 0.52 [95% CI, 0.44-0.61] for men and 0.58 [95% CI, 0.49-0.68] for women). They also transitioned from disabled to dead earlier (adjusted HR, 1.26 [95% CI, 0.99-1.60] for men and 2.42 [95% CI, 1.72-3.38] for women). Among the participants aged ≥85 y, those with ≥20 teeth had a longer life expectancy (men: +57 d; women: +15 d) and healthy life expectancy (men: +92 d; women: +70 d) and a shorter life expectancy with disability (men: -35 d; women: -55 d) compared with the edentulous participants. Similar associations were observed among the younger participants and those with 1 to 9 or 10 to 19 teeth. The presence of remaining teeth was associated with a significant compression of morbidity: older Japanese adults' life expectancy with disability was compressed by 35 to 55 d within the follow-up of 1,374 d.

Can sleep disturbance influence changes in mental health status? Longitudinal research evidence from ageing studies in England and Japan

BACKGROUND

Little is known about the role of sleep disturbance in relation to changes in depressive states. We used data obtained from the participants aged 65 and over in the English Longitudinal Study of Ageing (ELSA, waves four and five, N = 3108) and the Japan Gerontological Evaluation Study (JAGES, 2010 and 2013 sweeps, N = 7527) to examine whether sleep disturbance is longitudinally associated with older adults' patterns of depressive states.

METHODS

We created four patterns of depressive states (non-case, recovered, onset, repeatedly depressive) by combining responses to the measures (scoring four or more on seven items from the Center for Epidemiological Studies Depression Scale for the ELSA participants and scoring five or more for the Geriatric Depression Scale-15 for the JAGES participants) obtained at the baseline and follow-up. Sleep disturbance was assessed through responses to three questions on sleep problems. Age, sex, partnership status, household equivalised income, alcohol and cigarette use, and physical function were treated as confounders in this study. Additionally, information on sleep medication was available in JAGES and was included in the statistical models.

RESULTS

More ELSA participants were non-depressive cases and reported no sleep disturbances compared with the JAGES participants. Findings from multinomial logistic regression analysis showed that more sleep disturbance was associated with the onset group in ELSA (RRR = 2.37, 95% CI = 1.44-3.90) and JAGES (RRR = 2.41, 95% CI = 1.79-3.25) as well as the recovery (RRR = 3.42, 95% CI = 1.98-5.90, RRR = 2.71, 95% CI = 1.95-3.75) and repeatedly depressed group (RRR = 7.24, 95% CI = 3.91-13.40, RRR = 5.16, 95% CI = 3.82-6.98).

CONCLUSIONS

Findings suggest that the association between sleep disturbance and depression in older adults is complex.

Endocytoscopic observation of various esophageal lesions at ×600: can nuclear abnormality be recognized?

Endocytoscopy (ECS) is a novel endoscopic technique that allows detailed diagnostic examination of the gastrointestinal tract at the cellular level. We previously reported that use of ECS at ×380 magnification (GIF-Y0002) allowed a pathologist to diagnose esophageal squamous cell carcinoma (ESCC) with high sensitivity (94.9%) but considerably low specificity (46.7%) because this low magnification did not reveal information about nuclear abnormality. In the present study, we used the same magnifying endoscope to observe various esophageal lesions, but employed digital 1.6-fold magnification to achieve an effective magnification of ×600, and evaluated whether this improved the diagnostic accuracy in distinguishing neoplastic from non-neoplastic lesions.We examined the morphology of surface cells using vital staining with toluidine blue and compared the histological features of 40 cases, including 19 case of ESCC and 21 non-neoplastic esophageal lesions (18 cases of esophagitis, 1 case of glycogenic acanthosis, 1 case of leiomyoma, and 1 case of normal squamous epithelium). One endoscopist classified the lesions using the type classification, and we consulted one pathologist for judgment of the ECS images as 'neoplastic', 'borderline', or 'non-neoplastic'. At ×600 magnification, the pathologist confirmed that nuclear abnormality became evident, in addition to the information about nuclear density provided by observation at ×380. The overall sensitivity and specificity with which the endoscopist was able to predict neoplastic lesions using the type classification was 100% (19/19) and 90.5% (19/21), respectively, in comparison with values of 94.7% (18/19 cases) and 76.2% (16/21), respectively, for the pathologist using a magnification of ×600. The pathologist diagnosed two non-neoplastic lesions and one case of ESCC showing an apparent increase of nuclear density with weak nuclear abnormality as 'borderline'. Among the 21 non-cancerous lesions, two cases of esophagitis that were misdiagnosed by the endoscopist were also misinterpreted as 'neoplastic' by the pathologist. We have shown, by consultation with a pathologist, that an ECS magnification of ×600 (on a 19-inch monitor) is adequate for recognition of nuclear abnormality. We consider that it is feasible to diagnose esophageal neoplasms on the basis of ECS images, and that biopsy histology can be omitted if a combination of increased nuclear density and nuclear abnormality is observed.

Nutritional status and dysphagia risk among community-dwelling frail older adults

OBJECTIVES

Although the presence of dysphagia is a key determinant of nutritional status among older adults, few studies have focused on the association between malnutrition and dysphagia risk in community-dwelling frail older adults. This study estimated the prevalence of malnutrition and quantified the association between malnutrition and dysphagia risk among community-dwelling older Japanese adults requiring long-term care.

DESIGN

Cross-sectional study.

SETTING

This study was conducted with the cooperation of the Japan Dental Association and local dental associations in all 47 prefectures from January to February 2012.

PARTICIPANTS

Individuals aged ≥65 years capable of oral nutrient intake who were living at home and receiving home dental care and treatment.

MEASUREMENTS

Individual demographic characteristics and factors associated with health loss-related functional decline were obtained through interviews by home-visit dentists and self-administered questionnaires. Nutritional status and dysphagia risk were evaluated using the Mini Nutritional Assessment Short Form and the Dysphagia Risk Assessment for the Community-dwelling Elderly.

RESULTS

Among 874 respondents (345 men and 529 women), 24.6% were malnourished, 67.4% were at risk of malnutrition, and 8.0% were well nourished. Dysphagia risk was related to an increased likelihood of malnutrition at an old age, even after adjusting for covariates (PR = 1.30, 95% CI = 1.01-1.67).

CONCLUSION

Malnutrition is highly prevalent among community-dwelling frail older adults, and dysphagia risk is independently associated with malnutrition. Dysphagia may be an important predictor of malnutrition progression in aged populations.

[Lymph node metastasis in superficial squamous carcinoma of the esophagus]

The definition of early carcinoma of the esophagus has changed with time on the basis of new data. As from 2007 an early carcinoma is defined as an intramucosal carcinoma with or without metastasis. In the subclassification based on invasion depth, m1 and m2 squamous cell carcinomas have no metastasis and are considered curable by endoscopic resection alone, whereas less than 10% of m3 carcinomas and some 20% of sm1 squamous cell carcinomas have lymph node metastasis. In this article the relationship between various histopathological findings and the incidence of lymph node metastasis is reviewed. The m3 and sm1 superficial squamous cell carcinomas showing 0-I and 0-III types, large tumors over 50 mm in size or those showing vessel permeation have higher incidences of lymph node metastasis. In the field of gastrointestinal surgical pathology pathologists are now expected to not only diagnose the presence or absence of malignancy but also to investigate in detail many of the histological factors related to the prevalence of lymph node metastasis.

Detailed features of palisade vessels as a marker of the esophageal mucosa revealed by magnifying endoscopy with narrow band imaging

The palisade vessels present at the distal end of the esophagus are considered to be a landmark of the esophagogastric junction and indispensable for diagnosis of columnar-lined esophagus on the basis of the Japanese criteria. Here we clarified the features of normal palisade vessels at the esophagogastric junction using magnifying endoscopy. We prospectively studied palisade vessels in 15 patients undergoing upper gastrointestinal endoscopy using a GIF-H260Z instrument (Olympus Medical Systems Co., Tokyo, Japan). All views of the palisade vessels were obtained at the maximum magnification power in the narrow band imaging mode. We divided the area in which palisade vessels were present into three sections: the area from the squamocolumnar junction (SCJ) to about 1 cm orad within the esophagus (Section 1); the area between sections 1 and 3 (Section 2); and the area from the upper limit of the palisade vessels to about 1 cm distal within the esophagus (Section 3). In each section, we analyzed the vessel density, caliber of the palisade vessels, and their branching pattern. The vessel density in Sections 1, 2, and 3 was 9.1 ± 2.1, 8.0 ± 2.6, and 3.3 ± 1.3 per high-power field (mean ± standard deviation [SD]), respectively, and the differences were significant between Sections 1 and 2 (P= 0.0086) and between Sections 2 and 3 (P < 0.0001). The palisade vessel caliber in Sections 1, 2, and 3 was 127.6 ± 52.4 µm, 149.6 ± 58.6 µm, and 199.5 ± 75.1 µm (mean ± SD), respectively, and the differences between Sections 1 and 2, and between Sections 2 and 3, were significant (P < 0.0001). With regard to branching form, the frequency of branching was highest in Section 1, and the 'normal Y' shape was observed more frequently than in Sections 2 and 3. Toward the oral side, the frequency of branching diminished, and the frequency of the 'upside down Y' shape increased. The differences in branching form were significant among the three sections (P < 0.0001). These results indicate that the density of palisade vessels is highest near the SCJ, and that towards their upper limit they gradually become more confluent and show an increase of thickness. Within a limited area near the SCJ, observations of branching form suggest that palisade vessels merge abruptly on the distal side. We have demonstrated that palisade vessels are a useful marker for endoscopic recognition of the lower esophagus.

Oral health and cancer, cardiovascular, and respiratory mortality of Japanese

Cardiovascular diseases, cancer, and respiratory disease are major causes of death in developed countries. No study has simultaneously compared the contribution of oral health with these major causes of death. This study examined the association between oral health and cardiovascular diseases, cancer, and respiratory mortality among older Japanese. Self-administered questionnaires were mailed to participants in the Aichi Gerontological Evaluation Study (AGES) Project in 2003. Mortality data were analyzed for 4425 respondents. Three categories of oral health were used: 20 or more teeth, 19 or fewer teeth and eat everything, 19 or fewer teeth and eating difficulty. Sex, age, body mass index (BMI), self-rated health, present illness, exercise, smoking, alcohol, education, and income were used as covariates. During 4.28 years' follow-up, 410 people died, 159 from cancer, 108 of cardiovascular diseases, and 58 of respiratory disease. Multivariate adjusted Cox proportional hazard models showed that, compared with the respondents with 20 or more teeth, respondents with 19 or fewer teeth and with eating difficulty had a 1.83 and 1.85 times higher hazard ratio for cardiovascular disease mortality and respiratory disease mortality, respectively. There was no significant association with cancer mortality. Oral health predicted cardiovascular and respiratory disease mortality but not cancer mortality in older Japanese.

Geographical accessibility to dental care in the Japanese elderly

OBJECTIVE

The current research aims to clarify the factors relevant to elderly people's access to dental care in Japan, particularly focusing on geographical accessibility.

METHODS

The sample was taken from among the Japanese elderly, aged 65 and over, who responded to a postal survey conducted in 2003 (n = 2,192). Six types of geographical accessibility to the dental clinics were calculated using Geographic Information Systems. Logistic regression analysis was conducted using 'having a regular dentist' as a dependent variable and geographical accessibility as an explanatory variable.

RESULTS

The results showed an association between having a regular dentist and geographical accessibility only for females. In the univariate model, distance to the closest dental clinics (OR = 0.62 (95% CI: 0.43-0.90)), number of dental clinics at the school district level (OR = 1.14 (95% CI: 1.03-1.26)), number of dental clinics at the municipality level (OR = 1.02 (95% CI: 1.00-1.05)), and density distribution of dental clinics (OR = 1.56 (95% CI: 1.11-2.19)) showed significant relations with having a regular dentist. After controlling for demographic, socioeconomic, and health related variables, only the density distribution of dental clinics showed significant relations at the 5% level, although distance and number of dental clinics kept a marginal significance.

CONCLUSION

The current study verifies that geographical accessibility correlates with access to dental care among women, and that there were large gender differences concerning the issue of geographical access.

Association between caregiver behaviours to prevent vertical transmission and dental caries in their 3-year-old children

BACKGROUND

It has been suggested that oral organisms in children are mainly those transmitted from their mothers. That may account for the relationship between caries levels in children and their parents. However, few studies have investigated the effect of trying to prevent vertical transmission of oral organisms on dental caries levels in children, and the findings in the studies are controversial. The aim of this study was to investigate the association between measures to prevent vertical transmission of oral organisms and the caries experience in 3-year-old children.

METHODS

Data were collected from dental examinations for 3-year-old children and a self-administered questionnaire for their caregivers. Absence of maternal sharing of utensils and mouth-to-mouth feeding between caregivers and children was used as the variable about behaviour to prevent vertical transmission of oral organisms. Sex, age in months, dietary behaviour, oral health behaviour and sociodemographic factors were used as covariates.

RESULTS AND CONCLUSION

Data for 3,035 children (73.5% of the subjects) were analysed. Caregivers who practised vertical transmission prevention tended to have better oral health behaviours. Multivariate logistic regression analysis did not show any significant association between behaviour to prevent vertical transmission and caries experience (OR = 1.10, 95% CI = 0.86-1.41). This study suggests that caregiver behaviour to prevent vertical transmission was not effective in reducing levels of childhood caries.

Barriers to the utilization of primary care services for mental health prolems among adolescents in a secondary school in malaysia

OBJECTIVE

To study the barriers toward the utilization of primary care services for mental health problems among adolescents in a secondary school in Hulu Langat, Selangor, Malaysia.

METHODS

This was a cross-sectional study conducted in July 2008 at a secondary school in Hulu Langat, Selangor. The respondents were selected using randomised cluster sampling among Form Four and Form Five students. Students were given self-administered questionnaire, consisting socio-demographic data and questions on their help-seeking barrier and behaviour. Help-seeking behaviour questions assess the use of medical facility and help-seeking sources. The formal help-seeking sources include from teachers, counsellors and doctors. The informal help-seeking sources include from friends, parents and siblings.

RESULTS

A total of 175 students were included in the study. None of the students admitted of using the primary health care services for their mental health problems. Majority of the students were not aware of the services availability in the primary health care (97.1%). More than half of them thought the problems were due to their own mistakes (55.4%) and the problems were not that serious (49.1%). With regard to perception of the primary health care services, (43.2%) of the students were worried about confidentiality, half of them were concerned about other people's perception especially from their family members (44.6%) and friends (48.6%). Minority of them (10.8%) thought that nobody can help them. Few of them thought smoking (3.4%), alcohol (3.4%) and recreational drugs (1.1%) can solve their emotional problems.

CONCLUSION

One of the major barriers identified in the students' failure to use the health care facilities was their unawareness of the availability of the service for them in the community. Thus there is a need to promote and increase their awareness on this issue.

Relationships between patient characteristics and reasons for tooth extraction in Japan

OBJECTIVES

The purpose of this study was to examine the relationships between patient characteristics and reasons for extraction of permanent teeth.

METHODS

5131 dentists were selected from the list of the membership directory of the Japan Dental Association by systematic random selection. The dentists were asked to record the reason for each extraction of permanent teeth during a period from February 1 to 7, 2005. Reasons for tooth extraction were assigned to five groups: caries, fracture of teeth weakened by caries or endodontics, periodontal diseases, orthodontics and other reasons. We used cross tabulation and multiple logistic regression analysis to estimate the relationships between patient characteristics and reasons for tooth extraction.

RESULTS

2001 dentists (response rate of 39.0%) returned the forms, and complete information on 7333 patients was obtained. A total of 3,196 (43.6%) patients underwent tooth extraction due to caries and its sequela, and 2721 (37.1%) patients underwent tooth extraction due to periodontal disease. Multiple logistic regression analysis showed that denture wearers were more likely to undergo tooth extraction due to periodontal disease in all age groups (p < 0.05). Males tended to undergo tooth extraction due to periodontal disease than did females in all age groups (p < 0.05) except for age group 30-49. Subjects with 19 or less teeth were more likely to undergo tooth extraction due to periodontal disease in the age groups 30-49 (p < 0.001) and 50-69 (p < 0.001). In the age group of 50 years or older, female (p<0.01) and the possession of 20 or more natural teeth (p < 0.05) were related to caries extraction. However, there was no clear relationship between caries extraction and patient characteristics under 50 years old.

CONCLUSION

There was a significant relationship between denture wearing and periodontal extraction. In the middle aged population, patients with 19 or less teeth lost their teeth mainly due to periodontal disease.

Association between experience of stressful life events and muscle-related temporomandibular disorders in patients seeking free treatment in a dental hospital

OBJECTIVES

Psychological factors are known to play an important role in the etiology and maintenance of temporomandibular disorders. Since there have been very few studies on this issue in Asian countries, the study was aimed to investigate the relationship between various stressful life events and temporomandibular disorders in patients seeking free treatment in a Dental Hospital, Bangladesh.

MATERIALS AND METHODS

Five hundred and twenty Bangladeshi adults (370 males and 150 females; mean age, 30.9 +/- 8.2 years) participated in this study. The subjects were given a questionnaire to evaluate their stress status in the last 12 months. The Research Diagnostic Criteria for TMD (RDC/TMD) was used as TMD diagnostic system by three standardized examiners. Two hundred and thirty-six patients were RDC/TMD-defined TMD-positive and were subsequently classified into 7 groups: group I, myofacial pain only; group II, disk displacement only; group III, joint pain only; group IV, myofacial pain and disc displacement; group V, myofacial pain and joint pain; group VI, disc displacement and joint pain; and group VII, myofacial pain, disk displacement and joint pain. Two hundred and eighty-four subjects were RDC/TMD-defined TMD-negative subjects (controls). Adjusted odds ratios were calculated by multiple logistic regression analysis.

RESULTS

Logistic regression analysis revealed that patients diagnosed with myofacial pain (group I) and a combination of myofacial and joint pain (group V) had significantly higher levels of financial and job stress than did the controls. Self-health-related stress and stress related to a spouse or deaths of a relative were also identified as predisposing factors for myofacial pain (group I).

CONCLUSION

This study suggests that myofacial pain is more common in individuals with various types of psychological stress. When treating patients with facial pain, dentists should consider the possible presence of psychological factors.

Early squamous cell carcinoma of the oesophagus: the Japanese viewpoint

In Japan, more than 90% of oesophageal malignancies are squamous cell carcinomas, and superficial and early carcinomas now account for about 40% and 20%, respectively, of all oesophageal carcinomas. Definition of early carcinoma has changed on the basis of new data. As of 2007, early carcinoma is defined as intramucosal carcinoma with or without metastasis. In the subclassification based on depth of cancer invasion, m1 and m2 carcinomas have no metastasis and are considered curable by endoscopic mucosal resection alone, whereas < 10% of m3 carcinomas and about 20% of sm1 carcinomas have lymph node metastasis. The relationship between various pathological findings and the incidence of lymph node metastasis has been reviewed. High-grade squamous dysplasia (squamous cell carcinoma in situ in Japan) requires surgical or endoscopic removal. Very minute carcinomas have recently been detected by magnifying endoscopy and/or narrowband imaging. Endocytoscopy could replace biopsy histopathological examination for diagnosis of oesophageal squamous cell carcinoma, and endocytoscopic diagnosis and endoscopic therapy may be performed simultaneously. As a result of advances in the development of endoscopes, pathologists are now expected to diagnose very minute lesions, < 1 mm in size, in the oesophagus.

An Ecological Study on the Association of Public Dental Health Activities and Sociodemographic Characteristics with Caries Prevalence in Japanese 3-Year-Old Children

The aim of this ecological study was to determine the association of the frequency of dental health activities conducted as public health service and sociodemographic characteristics with caries prevalence in Japanese 3-year-old children using data for each municipality as one unit. Data on caries prevalence in 3-year-old children in 2000 were obtained from 3,251 municipalities (almost all municipalities in Japan). Caries prevalence for each municipality was recalculated using the empirical Bayes estimation model to make adjustments for variations in municipalities with small numbers of children. Explanatory factors included annual frequency of dental health activities such as dental health education and topical fluoride application programs and various sociodemographic characteristics. Multiple linear regression analysis was applied to examine the associations between caries prevalence and annual frequency of dental health activities with adjustment of other sociodemographic variables. Variations in caries prevalence in municipalities with small populations became smaller after being adjusted by the empirical Bayes estimation model. Multiple linear regression analysis showed significant associations of caries prevalence with sociodemographic characteristics such as the proportion of residents with university degrees, total fertility rate, and the proportion of workers in the manufacturing industry (p < 0.001). Annual frequency of topical fluoride application showed a significant but relatively weak association with caries prevalence (p < 0.001), explaining only 0.8% of the total variation in caries prevalence, whereas no correlation was found between caries prevalence and annual frequency of dental health education. It was concluded that the effect of the fluoride application service on caries prevalence in 3-year-old children, although statistically significant, was of far lower clinical significance than sociodemographic characteristics.

A case of pulmonary hemorrhage in Henoch-Schönlein purpura accompanied by polyarteritis nodosa in an elderly man

A 77-year-old male diagnosed as having Henoch-Schönlein purpura (HSP) died of acute respiratory and renal failure. Autopsy revealed necrotizing glomerulonephritis with IgA deposition in mesangium and capillary walls of glomeruli. The lungs showed leukocytoclastic vasculitis of the alveolar walls and immunohistochemically revealed IgA deposition and ultrastructurally electron-dense deposits in the capillary basement membrane and interstitium of the alveoli. Moreover, fibrinoid necrosis of small and medium-sized arteries were observed in the kidneys, bronchial arteries of the lungs, stomach and small intestine. We have concluded that this case may be diagnosed as polyangitis overlap syndrome in an elderly man consisting of HSP and polyarteritis nodosa (PN), and the pulmonary hemorrhage may be significantly relevant to the pulmonary lesions not in PN but in HSP.