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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Dental status and incident falls among older Japanese: a prospective
cohort study</title><author><name sortKey="Yamamoto, Tatsuo" sort="Yamamoto, Tatsuo" uniqKey="Yamamoto T" first="Tatsuo" last="Yamamoto">Tatsuo Yamamoto</name><affiliation><nlm:aff id="aff1">Division of Sociological Approach in Dentistry, Department of Dental Sociology, Kanagawa Dental College, Yokosuka-shi, Kanagawa, Japan</nlm:aff></affiliation></author><author><name sortKey="Kondo, Katsunori" sort="Kondo, Katsunori" uniqKey="Kondo K" first="Katsunori" last="Kondo">Katsunori Kondo</name><affiliation><nlm:aff id="aff2">Center for Well-being and Society, Nihon Fukushi University, Nagoya-shi, Aichi, Japan</nlm:aff></affiliation></author><author><name sortKey="Misawa, Jimpei" sort="Misawa, Jimpei" uniqKey="Misawa J" first="Jimpei" last="Misawa">Jimpei Misawa</name><affiliation><nlm:aff id="aff2">Center for Well-being and Society, Nihon Fukushi University, Nagoya-shi, Aichi, Japan</nlm:aff></affiliation></author><author><name sortKey="Hirai, Hiroshi" sort="Hirai, Hiroshi" uniqKey="Hirai H" first="Hiroshi" last="Hirai">Hiroshi Hirai</name><affiliation><nlm:aff id="aff3">Department of Civil and Environmental Engineering, Faculty of Engineering, Iwate University, Morioka-shi, Iwate, Japan</nlm:aff></affiliation></author><author><name sortKey="Nakade, Miyo" sort="Nakade, Miyo" uniqKey="Nakade M" first="Miyo" last="Nakade">Miyo Nakade</name><affiliation><nlm:aff id="aff4">Department of Nutrition, Faculty of Health and Nutrition, Tokaigakuen University, Nagoya-shi, Aichi, Japan</nlm:aff></affiliation></author><author><name sortKey="Aida, Jun" sort="Aida, Jun" uniqKey="Aida J" first="Jun" last="Aida">Jun Aida</name><affiliation><nlm:aff id="aff5">Department of International and Community Oral Health, Tohoku University Graduate School of Dentistry, Sendai-shi, Miyagi, Japan</nlm:aff></affiliation></author><author><name sortKey="Kondo, Naoki" sort="Kondo, Naoki" uniqKey="Kondo N" first="Naoki" last="Kondo">Naoki Kondo</name><affiliation><nlm:aff id="aff6">Department of Health Sciences, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo-shi, Yamanashi, Japan</nlm:aff></affiliation></author><author><name sortKey="Kawachi, Ichiro" sort="Kawachi, Ichiro" uniqKey="Kawachi I" first="Ichiro" last="Kawachi">Ichiro Kawachi</name><affiliation><nlm:aff id="aff7">Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA</nlm:aff></affiliation></author><author><name sortKey="Hirata, Yukio" sort="Hirata, Yukio" uniqKey="Hirata Y" first="Yukio" last="Hirata">Yukio Hirata</name><affiliation><nlm:aff id="aff1">Division of Sociological Approach in Dentistry, Department of Dental Sociology, Kanagawa Dental College, Yokosuka-shi, Kanagawa, Japan</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">22855628</idno><idno type="pmc">4400665</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400665</idno><idno type="RBID">PMC:4400665</idno><idno type="doi">10.1136/bmjopen-2012-001262</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">002870</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002870</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Dental status and incident falls among older Japanese: a prospective
cohort study</title><author><name sortKey="Yamamoto, Tatsuo" sort="Yamamoto, Tatsuo" uniqKey="Yamamoto T" first="Tatsuo" last="Yamamoto">Tatsuo Yamamoto</name><affiliation><nlm:aff id="aff1">Division of Sociological Approach in Dentistry, Department of Dental Sociology, Kanagawa Dental College, Yokosuka-shi, Kanagawa, Japan</nlm:aff></affiliation></author><author><name sortKey="Kondo, Katsunori" sort="Kondo, Katsunori" uniqKey="Kondo K" first="Katsunori" last="Kondo">Katsunori Kondo</name><affiliation><nlm:aff id="aff2">Center for Well-being and Society, Nihon Fukushi University, Nagoya-shi, Aichi, Japan</nlm:aff></affiliation></author><author><name sortKey="Misawa, Jimpei" sort="Misawa, Jimpei" uniqKey="Misawa J" first="Jimpei" last="Misawa">Jimpei Misawa</name><affiliation><nlm:aff id="aff2">Center for Well-being and Society, Nihon Fukushi University, Nagoya-shi, Aichi, Japan</nlm:aff></affiliation></author><author><name sortKey="Hirai, Hiroshi" sort="Hirai, Hiroshi" uniqKey="Hirai H" first="Hiroshi" last="Hirai">Hiroshi Hirai</name><affiliation><nlm:aff id="aff3">Department of Civil and Environmental Engineering, Faculty of Engineering, Iwate University, Morioka-shi, Iwate, Japan</nlm:aff></affiliation></author><author><name sortKey="Nakade, Miyo" sort="Nakade, Miyo" uniqKey="Nakade M" first="Miyo" last="Nakade">Miyo Nakade</name><affiliation><nlm:aff id="aff4">Department of Nutrition, Faculty of Health and Nutrition, Tokaigakuen University, Nagoya-shi, Aichi, Japan</nlm:aff></affiliation></author><author><name sortKey="Aida, Jun" sort="Aida, Jun" uniqKey="Aida J" first="Jun" last="Aida">Jun Aida</name><affiliation><nlm:aff id="aff5">Department of International and Community Oral Health, Tohoku University Graduate School of Dentistry, Sendai-shi, Miyagi, Japan</nlm:aff></affiliation></author><author><name sortKey="Kondo, Naoki" sort="Kondo, Naoki" uniqKey="Kondo N" first="Naoki" last="Kondo">Naoki Kondo</name><affiliation><nlm:aff id="aff6">Department of Health Sciences, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo-shi, Yamanashi, Japan</nlm:aff></affiliation></author><author><name sortKey="Kawachi, Ichiro" sort="Kawachi, Ichiro" uniqKey="Kawachi I" first="Ichiro" last="Kawachi">Ichiro Kawachi</name><affiliation><nlm:aff id="aff7">Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA</nlm:aff></affiliation></author><author><name sortKey="Hirata, Yukio" sort="Hirata, Yukio" uniqKey="Hirata Y" first="Yukio" last="Hirata">Yukio Hirata</name><affiliation><nlm:aff id="aff1">Division of Sociological Approach in Dentistry, Department of Dental Sociology, Kanagawa Dental College, Yokosuka-shi, Kanagawa, Japan</nlm:aff></affiliation></author></analytic><series><title level="j">BMJ Open</title><idno type="eISSN">2044-6055</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>To examine if self-reported number of teeth, denture use and chewing ability are
associated with incident falls.</p></sec><sec><title>Design</title><p>Longitudinal cohort study (the Aichi Gerontological Evaluation Study).</p></sec><sec><title>Setting</title><p>5 Japanese municipalities.</p></sec><sec><title>Participants</title><p>1763 community-dwelling individuals aged 65 years and older without
experience of falls within the previous year at baseline.</p></sec><sec><title>Main outcome measures</title><p>Self-reported history of multiple falls during the past year at the follow-up
survey about 3 years later. Baseline data on the number of teeth present
and/or denture use and chewing ability were collected using self-administered
questionnaires. Logistic regression analyses controlled for sex, age, functional
disability during follow-up period, depression, self-rated health and educational
attainment.</p></sec><sec><title>Results</title><p>86 (4.9%) subjects reported falls at the follow-up survey. Logistic regression
models fully adjusted for all covariates showed that subjects having 19 or fewer
teeth but not using dentures had a significantly increased risk for incident falls
(OR 2.50, 95% CI 1.21 to 5.17, p=0.013) compared with those having 20 or
more teeth. Among subjects with 19 or fewer teeth, their risk of falls was not
significantly elevated so long as they wore dentures (OR 1.36, 95% CI 0.76 to
2.45, p=0.299). No significant association was observed between chewing
ability and incident falls in the fully adjusted model.</p></sec><sec><title>Conclusions</title><p>Having 19 or fewer teeth but not using dentures was associated with higher risk
for the incident falls in older Japanese even after adjustment for multiple
covariates. Dental care to prevent tooth loss and denture treatment for older
people might prevent falls, although the authors cannot exclude the possibility
that the association is due to residual confounding.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Matsuda, R" uniqKey="Matsuda R">R Matsuda</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tinetti, Me" uniqKey="Tinetti M">ME Tinetti</name></author><author><name sortKey="Speechley, M" uniqKey="Speechley M">M Speechley</name></author><author><name sortKey="Ginter, Sf" uniqKey="Ginter S">SF Ginter</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nevitt, Mc" uniqKey="Nevitt M">MC Nevitt</name></author><author><name sortKey="Cummings, Sr" uniqKey="Cummings S">SR Cummings</name></author><author><name sortKey="Kidd, S" uniqKey="Kidd S">S Kidd</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Hayashi, Y" uniqKey="Hayashi Y">Y 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Hirai</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Aida, J" uniqKey="Aida J">J Aida</name></author><author><name sortKey="Hanibuchi, T" uniqKey="Hanibuchi T">T Hanibuchi</name></author><author><name sortKey="Nakade, M" uniqKey="Nakade M">M Nakade</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lord, Sr" uniqKey="Lord S">SR Lord</name></author><author><name sortKey="Clark, Rd" uniqKey="Clark R">RD Clark</name></author><author><name sortKey="Webster, Iw" uniqKey="Webster I">IW Webster</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ivers, Rq" uniqKey="Ivers R">RQ Ivers</name></author><author><name sortKey="Cumming, Rg" uniqKey="Cumming R">RG Cumming</name></author><author><name sortKey="Mitchell, P" uniqKey="Mitchell P">P Mitchell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Grundstrom, Ac" uniqKey="Grundstrom A">AC 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<front><journal-meta><journal-id journal-id-type="nlm-ta">BMJ Open</journal-id><journal-id journal-id-type="iso-abbrev">BMJ Open</journal-id><journal-id journal-id-type="publisher-id">bmjopen</journal-id><journal-id journal-id-type="hwp">bmjopen</journal-id><journal-title-group><journal-title>BMJ Open</journal-title></journal-title-group><issn pub-type="epub">2044-6055</issn><publisher><publisher-name>BMJ Group</publisher-name><publisher-loc>BMA House, Tavistock Square, London, WC1H 9JR</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22855628</article-id><article-id pub-id-type="pmc">4400665</article-id><article-id pub-id-type="publisher-id">bmjopen-2012-001262</article-id><article-id pub-id-type="doi">10.1136/bmjopen-2012-001262</article-id><article-categories><subj-group subj-group-type="heading"><subject>Dentistry and Oral Medicine</subject><subj-group><subject>Research</subject></subj-group></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>1506</subject><subject>1686</subject><subject>1692</subject><subject>1698</subject></subj-group></article-categories><title-group><article-title>Dental status and incident falls among older Japanese: a prospective
cohort study</article-title><alt-title alt-title-type="short">Dental status and incident falls among older
Japanese</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Yamamoto</surname><given-names>Tatsuo</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Kondo</surname><given-names>Katsunori</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Misawa</surname><given-names>Jimpei</given-names></name><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Hirai</surname><given-names>Hiroshi</given-names></name><xref ref-type="aff" rid="aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Nakade</surname><given-names>Miyo</given-names></name><xref ref-type="aff" rid="aff4">4</xref></contrib><contrib contrib-type="author"><name><surname>Aida</surname><given-names>Jun</given-names></name><xref ref-type="aff" rid="aff5">5</xref></contrib><contrib contrib-type="author"><name><surname>Kondo</surname><given-names>Naoki</given-names></name><xref ref-type="aff" rid="aff6">6</xref></contrib><contrib contrib-type="author"><name><surname>Kawachi</surname><given-names>Ichiro</given-names></name><xref ref-type="aff" rid="aff7">7</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Hirata</surname><given-names>Yukio</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Division of Sociological Approach in Dentistry, Department of Dental Sociology, Kanagawa Dental College, Yokosuka-shi, Kanagawa, Japan</aff><aff id="aff2"><label>2</label>Center for Well-being and Society, Nihon Fukushi University, Nagoya-shi, Aichi, Japan</aff><aff id="aff3"><label>3</label>Department of Civil and Environmental Engineering, Faculty of Engineering, Iwate University, Morioka-shi, Iwate, Japan</aff><aff id="aff4"><label>4</label>Department of Nutrition, Faculty of Health and Nutrition, Tokaigakuen University, Nagoya-shi, Aichi, Japan</aff><aff id="aff5"><label>5</label>Department of International and Community Oral Health, Tohoku University Graduate School of Dentistry, Sendai-shi, Miyagi, Japan</aff><aff id="aff6"><label>6</label>Department of Health Sciences, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo-shi, Yamanashi, Japan</aff><aff id="aff7"><label>7</label>Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA</aff><author-notes><corresp><label>Correspondence to</label> Dr Yukio Hirata; <email>hiratay@kdcnet.ac.jp</email></corresp></author-notes><pub-date pub-type="collection"><year>2012</year></pub-date><pub-date pub-type="epub"><day>31</day><month>7</month><year>2012</year></pub-date><volume>2</volume><issue>4</issue><elocation-id>e001262</elocation-id><history><date date-type="received"><day>4</day><month>4</month><year>2012</year></date><date date-type="accepted"><day>5</day><month>7</month><year>2012</year></date></history><permissions><copyright-statement>Published by the BMJ Publishing Group Limited. For permission to
use (where not already granted under a licence) please go to
http://group.bmj.com/group/rights-licensing/permissions</copyright-statement><copyright-year>2012</copyright-year><license license-type="open-access"><license-p>This is an open-access article distributed under the terms of the Creative Commons
Attribution Non-commercial License, which permits use, distribution, and
reproduction in any medium, provided the original work is properly cited, the use
is non commercial and is otherwise in compliance with the license. See: <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/2.0/">http://creativecommons.org/licenses/by-nc/2.0/</ext-link> and <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/2.0/legalcode">http://creativecommons.org/licenses/by-nc/2.0/legalcode</ext-link>.</license-p></license></permissions><self-uri xlink:title="pdf" xlink:type="simple" xlink:href="bmjopen-2012-001262.pdf"></self-uri><abstract><sec><title>Objective</title><p>To examine if self-reported number of teeth, denture use and chewing ability are
associated with incident falls.</p></sec><sec><title>Design</title><p>Longitudinal cohort study (the Aichi Gerontological Evaluation Study).</p></sec><sec><title>Setting</title><p>5 Japanese municipalities.</p></sec><sec><title>Participants</title><p>1763 community-dwelling individuals aged 65 years and older without
experience of falls within the previous year at baseline.</p></sec><sec><title>Main outcome measures</title><p>Self-reported history of multiple falls during the past year at the follow-up
survey about 3 years later. Baseline data on the number of teeth present
and/or denture use and chewing ability were collected using self-administered
questionnaires. Logistic regression analyses controlled for sex, age, functional
disability during follow-up period, depression, self-rated health and educational
attainment.</p></sec><sec><title>Results</title><p>86 (4.9%) subjects reported falls at the follow-up survey. Logistic regression
models fully adjusted for all covariates showed that subjects having 19 or fewer
teeth but not using dentures had a significantly increased risk for incident falls
(OR 2.50, 95% CI 1.21 to 5.17, p=0.013) compared with those having 20 or
more teeth. Among subjects with 19 or fewer teeth, their risk of falls was not
significantly elevated so long as they wore dentures (OR 1.36, 95% CI 0.76 to
2.45, p=0.299). No significant association was observed between chewing
ability and incident falls in the fully adjusted model.</p></sec><sec><title>Conclusions</title><p>Having 19 or fewer teeth but not using dentures was associated with higher risk
for the incident falls in older Japanese even after adjustment for multiple
covariates. Dental care to prevent tooth loss and denture treatment for older
people might prevent falls, although the authors cannot exclude the possibility
that the association is due to residual confounding.</p></sec></abstract><abstract abstract-type="summary"><title>Article summary</title><sec><title>Article focus</title><list list-type="bullet"><list-item><p>An association has been reported between dental occlusion and physical function
including lower extremity dynamic strength and balance.</p></list-item><list-item><p>Whether number of teeth, denture use and chewing ability predict subsequent
incidence of falls is unknown.</p></list-item><list-item><p>The aim of this study was to examine if self-reported number of teeth, denture
use and chewing ability are associated with incident falls.</p></list-item></list></sec><sec><title>Key messages</title><list list-type="bullet"><list-item><p>Having 19 or fewer teeth but not using dentures was a strong independent
predictor of incident falls in a community-dwelling older population.</p></list-item><list-item><p>In addition to preventing tooth loss, denture treatment for older people might
prevent falls.</p></list-item></list></sec><sec><title>Strengths and limitations of this study</title><list list-type="bullet"><list-item><p>Strengths of this study include large sample size, population-based sampling
and control for many potential confounding factors.</p></list-item><list-item><p>The following limitations should be considered: the information on dental
status and falls was self-reported and misclassification of cases is possible.
Moreover, we cannot exclude the possibility that the association is due to
residual confounding.</p></list-item></list></sec></abstract></article-meta></front><body><sec sec-type="intro"><title>Introduction</title><p>Falls occur frequently in older people and adversely affect their quality of life. More
than one-third of persons aged 60 years and older fall each year in Japan,<xref rid="b1" ref-type="bibr">1</xref> England<xref rid="b2" ref-type="bibr">2</xref> and
the USA,<xref rid="b3" ref-type="bibr">3</xref> and in half of cases, falls are
recurrent.<xref rid="b3" ref-type="bibr">3</xref> The consequences of falls are
severe: 6% of falls lead to a fracture and 24% lead to other serious injuries.<xref rid="b2" ref-type="bibr">2</xref> Thus, falls impose a burden on the sustainability
of health and long-term care in Japan and many other countries, where population is
rapidly ageing.<xref rid="b4" ref-type="bibr">4</xref> In Japan, the annual health and
long-term care costs attributable to falls are about 730 thousand million Japanese yen
in 2002, which amounts to roughly 5% of the entire health and long-term care costs.<xref rid="b5" ref-type="bibr">5</xref></p><p>A number of studies<xref rid="b6" ref-type="bibr">6</xref> including those using
Japanese data<xref rid="b7" ref-type="bibr">7</xref> have identified risk factors for
falls, including female sex, older age, having a history of falls, arthritis,
cerebrovascular disease, depression and the impairment of muscle strength and/or
balance. Although exercise programmes including balance training are effective,<xref rid="b8" ref-type="bibr">8</xref> multifactorial fall prevention programmes to
address these risk factors have not been successful in reducing falls.<xref rid="b9" ref-type="bibr">9</xref> A recent systematic review concluded that there is
limited evidence to suggest that multifactorial fall prevention programmes in primary
care, community or emergency care settings are effective in reducing the number of
falls.<xref rid="b10" ref-type="bibr">10</xref> Therefore, identification of
additional modifiable risk factors may be helpful to establish more effective programmes
for fall prevention.</p><p>Unhealthy dental status is a candidate risk factor for falls.<xref rid="b11" ref-type="bibr">11</xref><xref rid="b12" ref-type="bibr">12</xref> A longitudinal study showed that partial or
complete loss of dental occlusion was associated with a decline in lower extremity
dynamic strength and balance function.<xref rid="b13" ref-type="bibr">13</xref> One
1-year prospective longitudinal study using 146 demented older people reported the
association between dental occlusion and subsequent physical health.<xref rid="b14" ref-type="bibr">14</xref> Researchers have argued that these potential
links between dental health and physical health may be because jaw position affects body
posture.<xref rid="b11" ref-type="bibr">11</xref> Proprioceptive receptors of the
masticatory muscular system and dentoalveolar ligaments provide sensory afferent
input,<xref rid="b15" ref-type="bibr">15</xref> and hence poor dental occlusion may
decrease that proprioception, thereby interfering with the stability of head posture
(and increasing the risk of falling). However, whether or not dental occlusion and
chewing ability actually predict the subsequent incidence of falls is largely
unknown.</p><p>Therefore, this prospective study aimed to determine the association between dental
health in terms of the number of teeth present, denture use and chewing ability and the
incidence of falls in a large cohort of older Japanese people.</p></sec><sec sec-type="methods"><title>Methods</title><sec><title>Study population</title><p>Our analyses were based on data from the Aichi Gerontological Evaluation Study (AGES)
Project, an on-going Japanese prospective cohort study.<xref rid="b16" ref-type="bibr">16</xref><xref rid="b17" ref-type="bibr">17</xref> The detailed protocol of the AGES and
baseline characteristics of the study participants have been published
elsewhere.<xref rid="b16" ref-type="bibr">16</xref><xref rid="b18" ref-type="bibr">18</xref> In brief, the AGES aims to investigate the
factors related to the loss of healthy years, such as functional decline, cognitive
impairment or death among non-institutionalised older people. The sample was
restricted to those who did not already have a physical or cognitive disability at
baseline, defined by not receiving public long-term care insurance benefits and
self-reported dependence in walking, toileting and bathing.</p><p>The sampling frame for the AGES cohort was selected as follows. In 2003, the
residential registers of five municipalities in Aichi prefecture were obtained with
the cooperation of city officials. From these comprehensive registers, we selected a
random sample of one in three citizens aged 65 years or older in four towns
(1281, 1537, 1766 and 1873) and a random sample of 1666 in a city. They
(N=8123) were then mailed the baseline questionnaire, inviting them to
participate in the AGES cohort study. Responses were obtained from 3998 subjects
(49.2%), and 3981 subjects were identified using ID. We mailed a follow-up survey
between March 2006 and March 2007 to the 3471 subjects after excluding 510 subjects
who died or started receiving insurance benefits due to certified disability
(N=472) or could not be traced (N=38). Two thousand six hundred and
forty subjects responded to the follow-up survey (76.1%) and formed the analytic
sample for our study. After excluding 166 and 545 subjects who experienced multiple
and single falls, respectively, as well as 106 subjects without information of falls
at baseline, we were left with 1823 subjects who did not report experiencing falls at
baseline. After excluding 56 subjects without information on falls at follow-up and
four subjects without information on age, a total of 1763 subjects formed the final
analytic population of this study. The AGES protocol was reviewed and approved by the
Ethics Committee on Research of Human Subjects at Nihon Fukushi University.</p></sec><sec><title>Outcome variables</title><p>History of falls was ascertained by asking, “Have you had any falls over the
past year?” with possible answers of “multiple times,”
“once” or “none.” Multiple falls was used as an outcome
and the last two categories were combined because previous studies have found that
single fallers are more similar to non-fallers than to recurrent fallers on a range
of medical, physical and psychological risk factors.<xref rid="b3" ref-type="bibr">3</xref><xref rid="b19" ref-type="bibr">19</xref><xref rid="b20" ref-type="bibr">20</xref></p></sec><sec><title>Dental health variables</title><p>Dental status and chewing ability were assessed using a self-administered
questionnaire. Respondents were asked to classify their dental status as having 20 or
more teeth, having 19 or fewer teeth with dentures, having 19 or fewer teeth without
dentures, having few teeth with dentures or having few teeth without dentures. Data
from having 19 or fewer teeth with dentures and those from having few teeth with
dentures were combined. Data from having 19 or fewer teeth without dentures and those
from having few teeth without dentures were also combined.</p><p>Chewing ability was ascertained by asking, “How is your ability to
chew?” with possible answers being “I can chew anything I
want,” “I can chew most foods with some exceptions,” “I
can eat limited foods as I cannot chew very well,” “I can hardly chew
anything” and “I have liquid foods as I cannot chew at all.”
Data from the last three categories were combined due to the small number of
respondents.</p></sec><sec><title>Covariates</title><p>Studies suggest that falls are associated with sex,<xref rid="b7" ref-type="bibr">7</xref><xref rid="b21" ref-type="bibr">21</xref> age,<xref rid="b2" ref-type="bibr">2</xref><xref rid="b7" ref-type="bibr">7</xref> stroke,<xref rid="b7" ref-type="bibr">7</xref> severe foot problems,<xref rid="b2" ref-type="bibr">2</xref> impaired
vision and impaired hearing,<xref rid="b2" ref-type="bibr">2</xref> activities of
daily living (ADL),<xref rid="b3" ref-type="bibr">3</xref><xref rid="b6" ref-type="bibr">6</xref><xref rid="b21" ref-type="bibr">21</xref> body mass index (BMI),<xref rid="b21" ref-type="bibr">21</xref> use of sedatives,<xref rid="b2" ref-type="bibr">2</xref>depression,<xref rid="b2" ref-type="bibr">2</xref> self-rated health,<xref rid="b21" ref-type="bibr">21</xref> exercise,<xref rid="b2" ref-type="bibr">2</xref> mobility<xref rid="b2" ref-type="bibr">2</xref> and socioeconomic
status.<xref rid="b22" ref-type="bibr">22</xref> Therefore, associations of
incident fall with sex, age, present illness related to falls, ADL, BMI, use of
sedatives, depression, self-rated health, exercise (how much they walked in minutes
per day), frequency of outings, educational attainment and equivalised household
income were analysed. Self-reported current medical treatment of stroke,
osteoporosis, joint disease/neuralgia, injury/fracture, impaired vision and/or
impaired hearing was used as a variable for present illness related to falls. To
evaluate functional status, the survey asked whether the respondents had difficulty
or needed someone's assistance in performing any of the following ADL: basing,
walking and using the toilet.<xref rid="b23" ref-type="bibr">23</xref> Subjects
without difficulty for all three ADL items were categorised into ADL without
limitation and those with at least one ADL item with difficulty into ADL with
limitation. BMI was categorised into three groups (<18.5, 18.5–24.9 and
25.0 or more).<xref rid="b24" ref-type="bibr">24</xref> Depression was assessed with
the short version of the Geriatric Depression Scale-15 developed for
self-administration in the community using a simple yes/no format<xref rid="b25" ref-type="bibr">25</xref> and was categorised into three groups:
0–4 (no), 5–9 (mild) and 10–15 (moderate to severe). To adjust
household income for household size, equivalised income was calculated by dividing
the household income by the square root of the number of household members and
grouped into one of the seven categories. In addition to these covariates, data on
functional disability during follow-up period were collected from the public
long-term care insurance database maintained by each participating municipality and
used as a covariate. Incidence of functional disability was determined based on when
a person newly qualified for the insurance benefit, new registrations to the public
long-term care insurance database.<xref rid="b26" ref-type="bibr">26</xref> The
distribution of each covariate at baseline for the overall AGES 2003 cohort
(n=32 891) has been reported elsewhere.<xref rid="b16" ref-type="bibr">16</xref></p></sec><sec><title>Statistical analysis</title><p>Categorical variables that included missing data were recorded by reassigning missing
values to separate “missing” categories in order to maximise the number
of subjects included in the statistical analysis and thereby maximise statistical
power. Logistic regression models were used to calculate the ORs and 95% CIs for the
incident falls at the follow-up. First, univariate ORs were calculated for each
dental health variable and each covariate. Variables that were marginally significant
(p<0.10) in the univariate analyses were selected as covariates for subsequent
multivariate analysis. Then, logistic regression analysis was performed for each
dental variable after including sex, age, functional disability during follow-up
period, depression, self-rated health and educational attainment as covariates. All
statistical analyses were conducted using IBM SPSS Statistics V.19 (IBM Co.).</p></sec></sec><sec sec-type="results"><title>Results</title><p>A total of 86 (4.9%) of the 1763 respondents reported the incidence of multiple falls at
the follow-up survey. <xref ref-type="table" rid="tbl1">Table 1</xref> shows the rates
of fallers and non-adjusted ORs for reporting multiple falls at the follow-up survey
according to dental health variables and covariates. Univariate models showed that poor
dental status, chewing ability, male sex, older age, lower functional disability during
follow-up period, depression, poor self-rated health and low educational attainment were
each associated with incident falls.</p><table-wrap id="tbl1" position="float"><label>Table 1</label><caption><p>Univariate associations of dental health variables and covariates with incident
falls</p></caption><table frame="hsides" rules="groups"><thead><tr><td rowspan="2" colspan="1"></td><td rowspan="1" colspan="1">Total</td><td rowspan="1" colspan="1">Fallers</td><td rowspan="2" colspan="1">OR (95% CI)</td><td rowspan="2" colspan="1">p Value</td></tr><tr><td rowspan="1" colspan="1">n</td><td rowspan="1" colspan="1">n (%)</td></tr></thead><tbody><tr><td colspan="5" rowspan="1">Dental status</td></tr><tr><td rowspan="1" colspan="1"> ≥20 teeth</td><td align="char" char="." rowspan="1" colspan="1">586</td><td align="char" char="(" rowspan="1" colspan="1">17 (2.9)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> ≤19 teeth with dentures</td><td align="char" char="." rowspan="1" colspan="1">958</td><td align="char" char="(" rowspan="1" colspan="1">49 (5.1)</td><td rowspan="1" colspan="1">1.80 (1.03 to 3.16)</td><td align="char" char="." rowspan="1" colspan="1">0.039</td></tr><tr><td rowspan="1" colspan="1"> ≤19 teeth without dentures</td><td align="char" char="." rowspan="1" colspan="1">198</td><td align="char" char="(" rowspan="1" colspan="1">17 (8.6)</td><td rowspan="1" colspan="1">3.14 (1.57 to 6.28)</td><td align="char" char="." rowspan="1" colspan="1">0.001</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">21</td><td align="char" char="(" rowspan="1" colspan="1">3 (14.3)</td><td rowspan="1" colspan="1">5.58 (1.50 to 20.76)</td><td align="char" char="." rowspan="1" colspan="1">0.010</td></tr><tr><td colspan="5" rowspan="1">Chewing ability</td></tr><tr><td rowspan="1" colspan="1"> Can chew anything</td><td align="char" char="." rowspan="1" colspan="1">719</td><td align="char" char="(" rowspan="1" colspan="1">30 (4.2)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Can chew most foods</td><td align="char" char="." rowspan="1" colspan="1">935</td><td align="char" char="(" rowspan="1" colspan="1">47 (5.0)</td><td rowspan="1" colspan="1">1.22 (0.76 to 1.94)</td><td align="char" char="." rowspan="1" colspan="1">0.414</td></tr><tr><td rowspan="1" colspan="1"> Cannot chew very well</td><td align="char" char="." rowspan="1" colspan="1">97</td><td align="char" char="(" rowspan="1" colspan="1">9 (9.3)</td><td rowspan="1" colspan="1">2.35 (1.08 to 5.11)</td><td align="char" char="." rowspan="1" colspan="1">0.031</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">12</td><td align="char" char="(" rowspan="1" colspan="1">0 (0.0)</td><td rowspan="1" colspan="1">0.00 (0.00)</td><td align="char" char="." rowspan="1" colspan="1">0.999</td></tr><tr><td colspan="5" rowspan="1">Sex</td></tr><tr><td rowspan="1" colspan="1"> Female</td><td align="char" char="." rowspan="1" colspan="1">853</td><td align="char" char="(" rowspan="1" colspan="1">32 (3.8)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Male</td><td align="char" char="." rowspan="1" colspan="1">910</td><td align="char" char="(" rowspan="1" colspan="1">54 (5.9)</td><td rowspan="1" colspan="1">1.62 (1.03 to 2.53)</td><td align="char" char="." rowspan="1" colspan="1">0.035</td></tr><tr><td colspan="5" rowspan="1">Age (years)</td></tr><tr><td rowspan="1" colspan="1"> 65–69</td><td align="char" char="." rowspan="1" colspan="1">707</td><td align="char" char="(" rowspan="1" colspan="1">23 (3.3)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 70–74</td><td align="char" char="." rowspan="1" colspan="1">569</td><td align="char" char="(" rowspan="1" colspan="1">27 (4.7)</td><td rowspan="1" colspan="1">1.48 (0.84 to 2.61)</td><td align="char" char="." rowspan="1" colspan="1">0.175</td></tr><tr><td rowspan="1" colspan="1"> 75–79</td><td align="char" char="." rowspan="1" colspan="1">325</td><td align="char" char="(" rowspan="1" colspan="1">18 (5.5)</td><td rowspan="1" colspan="1">1.74 (0.93 to 3.28)</td><td align="char" char="." rowspan="1" colspan="1">0.084</td></tr><tr><td rowspan="1" colspan="1"> 80–84</td><td align="char" char="." rowspan="1" colspan="1">120</td><td align="char" char="(" rowspan="1" colspan="1">12 (10.0)</td><td rowspan="1" colspan="1">3.30 (1.60 to 6.84)</td><td align="char" char="." rowspan="1" colspan="1">0.001</td></tr><tr><td rowspan="1" colspan="1"> ≥85</td><td align="char" char="." rowspan="1" colspan="1">42</td><td align="char" char="(" rowspan="1" colspan="1">6 (14.3)</td><td rowspan="1" colspan="1">4.96 (1.90 to 12.93)</td><td align="char" char="." rowspan="1" colspan="1">0.001</td></tr><tr><td colspan="5" rowspan="1">Present illness related to falls<xref ref-type="table-fn" rid="table-fn1">*</xref></td></tr><tr><td rowspan="1" colspan="1"> No</td><td align="char" char="." rowspan="1" colspan="1">1224</td><td align="char" char="(" rowspan="1" colspan="1">58 (4.7)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Yes</td><td align="char" char="." rowspan="1" colspan="1">539</td><td align="char" char="(" rowspan="1" colspan="1">28 (5.2)</td><td rowspan="1" colspan="1">1.10 (0.69 to 1.75)</td><td align="char" char="." rowspan="1" colspan="1">0.682</td></tr><tr><td colspan="5" rowspan="1">Activities of daily living</td></tr><tr><td rowspan="1" colspan="1"> Without limitation</td><td align="char" char="." rowspan="1" colspan="1">1669</td><td align="char" char="(" rowspan="1" colspan="1">81 (4.9)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> With limitation or missing</td><td align="char" char="." rowspan="1" colspan="1">94</td><td align="char" char="(" rowspan="1" colspan="1">5 (5.3)</td><td rowspan="1" colspan="1">1.10 (0.44 to 2.79)</td><td align="char" char="." rowspan="1" colspan="1">0.838</td></tr><tr><td colspan="5" rowspan="1">Functional disability during follow-up period</td></tr><tr><td rowspan="1" colspan="1"> No</td><td align="char" char="." rowspan="1" colspan="1">1734</td><td align="char" char="(" rowspan="1" colspan="1">81 (4.7)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Yes</td><td align="char" char="." rowspan="1" colspan="1">29</td><td align="char" char="(" rowspan="1" colspan="1">5 (17.2)</td><td rowspan="1" colspan="1">4.25 (1.58 to 11.43)</td><td align="char" char="." rowspan="1" colspan="1">0.004</td></tr><tr><td colspan="5" rowspan="1">Body mass index</td></tr><tr><td rowspan="1" colspan="1"> <18.5</td><td align="char" char="." rowspan="1" colspan="1">113</td><td align="char" char="(" rowspan="1" colspan="1">8 (7.1)</td><td rowspan="1" colspan="1">1.68 (0.78 to 3.62)</td><td align="char" char="." rowspan="1" colspan="1">0.189</td></tr><tr><td rowspan="1" colspan="1"> 18.5–24.9</td><td align="char" char="." rowspan="1" colspan="1">1196</td><td align="char" char="(" rowspan="1" colspan="1">52 (4.3)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> ≥25.0</td><td align="char" char="." rowspan="1" colspan="1">380</td><td align="char" char="(" rowspan="1" colspan="1">21 (5.5)</td><td rowspan="1" colspan="1">1.29 (0.77 to 2.17)</td><td align="char" char="." rowspan="1" colspan="1">0.342</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">74</td><td align="char" char="(" rowspan="1" colspan="1">5 (6.8)</td><td rowspan="1" colspan="1">1.59 (0.62 to 4.12)</td><td align="char" char="." rowspan="1" colspan="1">0.336</td></tr><tr><td colspan="5" rowspan="1">Use of sedatives</td></tr><tr><td rowspan="1" colspan="1"> No</td><td align="char" char="." rowspan="1" colspan="1">1602</td><td align="char" char="(" rowspan="1" colspan="1">80 (5.0)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Yes</td><td align="char" char="." rowspan="1" colspan="1">161</td><td align="char" char="(" rowspan="1" colspan="1">6 (3.7)</td><td rowspan="1" colspan="1">0.74 (0.32 to 1.72)</td><td align="char" char="." rowspan="1" colspan="1">0.478</td></tr><tr><td colspan="5" rowspan="1">Depression</td></tr><tr><td rowspan="1" colspan="1"> No</td><td align="char" char="." rowspan="1" colspan="1">1143</td><td align="char" char="(" rowspan="1" colspan="1">39 (3.4)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Mild</td><td align="char" char="." rowspan="1" colspan="1">311</td><td align="char" char="(" rowspan="1" colspan="1">21 (6.8)</td><td rowspan="1" colspan="1">2.05 (1.19 to 3.54)</td><td align="char" char="." rowspan="1" colspan="1">0.010</td></tr><tr><td rowspan="1" colspan="1"> Moderate to severe</td><td align="char" char="." rowspan="1" colspan="1">77</td><td align="char" char="(" rowspan="1" colspan="1">8 (10.4)</td><td rowspan="1" colspan="1">3.28 (1.48 to 7.29)</td><td align="char" char="." rowspan="1" colspan="1">0.004</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">232</td><td align="char" char="(" rowspan="1" colspan="1">18 (7.8)</td><td rowspan="1" colspan="1">2.38 (1.34 to 4.24)</td><td align="char" char="." rowspan="1" colspan="1">0.003</td></tr><tr><td colspan="5" rowspan="1">Self-rated health</td></tr><tr><td rowspan="1" colspan="1"> Excellent</td><td align="char" char="." rowspan="1" colspan="1">162</td><td align="char" char="(" rowspan="1" colspan="1">6 (3.7)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Good</td><td align="char" char="." rowspan="1" colspan="1">1192</td><td align="char" char="(" rowspan="1" colspan="1">50 (4.2)</td><td rowspan="1" colspan="1">1.14 (0.48 to 2.70)</td><td align="char" char="." rowspan="1" colspan="1">0.769</td></tr><tr><td rowspan="1" colspan="1"> Fair</td><td align="char" char="." rowspan="1" colspan="1">321</td><td align="char" char="(" rowspan="1" colspan="1">21 (6.5)</td><td rowspan="1" colspan="1">1.82 (0.72 to 4.60)</td><td align="char" char="." rowspan="1" colspan="1">0.206</td></tr><tr><td rowspan="1" colspan="1"> Poor</td><td align="char" char="." rowspan="1" colspan="1">59</td><td align="char" char="(" rowspan="1" colspan="1">9 (15.3)</td><td rowspan="1" colspan="1">4.68 (1.59 to 13.80)</td><td align="char" char="." rowspan="1" colspan="1">0.005</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">29</td><td align="char" char="(" rowspan="1" colspan="1">0 (0.0)</td><td rowspan="1" colspan="1">0.00 (0.00)</td><td align="char" char="." rowspan="1" colspan="1">0.998</td></tr><tr><td colspan="5" rowspan="1">Exercise (walk in minute/day)</td></tr><tr><td rowspan="1" colspan="1"> ≥60</td><td align="char" char="." rowspan="1" colspan="1">430</td><td align="char" char="(" rowspan="1" colspan="1">20 (4.7)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 30–59</td><td align="char" char="." rowspan="1" colspan="1">569</td><td align="char" char="(" rowspan="1" colspan="1">16 (2.8)</td><td rowspan="1" colspan="1">0.59 (0.30 to 1.16)</td><td align="char" char="." rowspan="1" colspan="1">0.126</td></tr><tr><td rowspan="1" colspan="1"> <30</td><td align="char" char="." rowspan="1" colspan="1">564</td><td align="char" char="(" rowspan="1" colspan="1">38 (6.7)</td><td rowspan="1" colspan="1">1.48 (0.85 to 2.58)</td><td align="char" char="." rowspan="1" colspan="1">0.167</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">200</td><td align="char" char="(" rowspan="1" colspan="1">12 (6.0)</td><td rowspan="1" colspan="1">1.31 (0.63 to 2.73)</td><td align="char" char="." rowspan="1" colspan="1">0.474</td></tr><tr><td colspan="5" rowspan="1">Frequency of outings</td></tr><tr><td rowspan="1" colspan="1"> Almost everyday</td><td align="char" char="." rowspan="1" colspan="1">843</td><td align="char" char="(" rowspan="1" colspan="1">37 (4.4)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 2–3 times a week</td><td align="char" char="." rowspan="1" colspan="1">532</td><td align="char" char="(" rowspan="1" colspan="1">27 (5.1)</td><td rowspan="1" colspan="1">1.17 (0.70 to 1.94)</td><td align="char" char="." rowspan="1" colspan="1">0.557</td></tr><tr><td rowspan="1" colspan="1"> Once a week or less</td><td align="char" char="." rowspan="1" colspan="1">335</td><td align="char" char="(" rowspan="1" colspan="1">20 (6.0)</td><td rowspan="1" colspan="1">1.38 (0.79 to 2.42)</td><td align="char" char="." rowspan="1" colspan="1">0.256</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">53</td><td align="char" char="(" rowspan="1" colspan="1">2 (3.8)</td><td rowspan="1" colspan="1">0.85 (0.20 to 3.65)</td><td align="char" char="." rowspan="1" colspan="1">0.831</td></tr><tr><td colspan="5" rowspan="1">Educational attainment (years)</td></tr><tr><td rowspan="1" colspan="1"> ≥13</td><td align="char" char="." rowspan="1" colspan="1">184</td><td align="char" char="(" rowspan="1" colspan="1">4 (2.2)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 10–12</td><td align="char" char="." rowspan="1" colspan="1">506</td><td align="char" char="(" rowspan="1" colspan="1">23 (4.5)</td><td rowspan="1" colspan="1">2.14 (0.73 to 6.28)</td><td align="char" char="." rowspan="1" colspan="1">0.165</td></tr><tr><td rowspan="1" colspan="1"> 6–9</td><td align="char" char="." rowspan="1" colspan="1">953</td><td align="char" char="(" rowspan="1" colspan="1">49 (5.1)</td><td rowspan="1" colspan="1">2.44 (0.87 to 6.84)</td><td align="char" char="." rowspan="1" colspan="1">0.090</td></tr><tr><td rowspan="1" colspan="1"> <6</td><td align="char" char="." rowspan="1" colspan="1">53</td><td align="char" char="(" rowspan="1" colspan="1">4 (7.5)</td><td rowspan="1" colspan="1">3.67 (0.89 to 15.22)</td><td align="char" char="." rowspan="1" colspan="1">0.073</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">67</td><td align="char" char="(" rowspan="1" colspan="1">6 (9.0)</td><td rowspan="1" colspan="1">4.43 (1.21 to 16.21)</td><td align="char" char="." rowspan="1" colspan="1">0.025</td></tr><tr><td colspan="5" rowspan="1">Equivalised household income (yen)</td></tr><tr><td rowspan="1" colspan="1"> <500 000</td><td align="char" char="." rowspan="1" colspan="1">53</td><td align="char" char="(" rowspan="1" colspan="1">0 (0.0)</td><td rowspan="1" colspan="1">0.00 (0.00)</td><td align="char" char="." rowspan="1" colspan="1">0.997</td></tr><tr><td rowspan="1" colspan="1"> 500 000–999 999</td><td align="char" char="." rowspan="1" colspan="1">108</td><td align="char" char="(" rowspan="1" colspan="1">7 (6.5)</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 1 000 000–1 499 999</td><td align="char" char="." rowspan="1" colspan="1">139</td><td align="char" char="(" rowspan="1" colspan="1">7 (5.0)</td><td rowspan="1" colspan="1">0.77 (0.26 to 2.25)</td><td align="char" char="." rowspan="1" colspan="1">0.627</td></tr><tr><td rowspan="1" colspan="1"> 1500 000–1 999 999</td><td align="char" char="." rowspan="1" colspan="1">262</td><td align="char" char="(" rowspan="1" colspan="1">15 (5.7)</td><td rowspan="1" colspan="1">0.88 (0.35 to 2.21)</td><td align="char" char="." rowspan="1" colspan="1">0.780</td></tr><tr><td rowspan="1" colspan="1"> 2000 000–2 999 999</td><td align="char" char="." rowspan="1" colspan="1">429</td><td align="char" char="(" rowspan="1" colspan="1">16 (3.7)</td><td rowspan="1" colspan="1">0.56 (0.22 to 1.39)</td><td align="char" char="." rowspan="1" colspan="1">0.213</td></tr><tr><td rowspan="1" colspan="1"> 3000 000–3 999 999</td><td align="char" char="." rowspan="1" colspan="1">263</td><td align="char" char="(" rowspan="1" colspan="1">15 (5.7)</td><td rowspan="1" colspan="1">0.87 (0.35 to 2.20)</td><td align="char" char="." rowspan="1" colspan="1">0.773</td></tr><tr><td rowspan="1" colspan="1"> ≥4000 000</td><td align="char" char="." rowspan="1" colspan="1">164</td><td align="char" char="(" rowspan="1" colspan="1">5 (3.0)</td><td rowspan="1" colspan="1">0.45 (0.14 to 1.47)</td><td align="char" char="." rowspan="1" colspan="1">0.187</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td align="char" char="." rowspan="1" colspan="1">345</td><td align="char" char="(" rowspan="1" colspan="1">21 (6.1)</td><td rowspan="1" colspan="1">0.94 (0.39 to 2.26)</td><td align="char" char="." rowspan="1" colspan="1">0.882</td></tr></tbody></table><table-wrap-foot><fn id="table-fn1"><label>*</label><p>Stroke, osteoporosis, joint disease/neuralgia, injury/fracture, impaired vision
and/or impaired hearing.</p></fn></table-wrap-foot></table-wrap><p>In the fully adjusted model, subjects with 19 or fewer teeth without dentures had a 2.50
(95% CI 1.21 to 5.17)-fold increased risk for incident falls compared with those having
20 or more teeth(<xref ref-type="table" rid="tbl2">Table 2</xref>). No significant
association was observed between incident falls and chewing ability after adding all
covariates in the logistic regression model. When the two dental health variables were
entered simultaneously into the same model with full adjustment for all covariates,
there was no change in the ORs for any of the dental status variables.</p></sec><sec sec-type="discussion"><title>Discussion</title><p>Results of the present study showed that subjects with 19 or fewer teeth without
dentures had a significantly higher risk for incident falls than those with 20 or more
teeth, even after adjusting for multiple potential confounding factors including
demographics, physical and mental health status, and socioeconomic status. These
findings are consistent with those of a 1-year longitudinal study using 146 older
patients with severe dementia, showing that patients with functionally inadequate dental
status had significantly more frequent falls than those with functionally adequate
occlusion composed of natural teeth, dentures or both.<xref rid="b14" ref-type="bibr">14</xref> Interestingly, among subjects with 19 or fewer teeth, their risk of falls
was not significantly elevated so long as they wore dentures. These results suggest that
the poor dental occlusion due to not using dentures after losing teeth is a strong risk
factor for falls among subjects with 19 or fewer teeth.</p><p>There are several possible pathways between not using dentures after losing teeth and
incident falls. One possibility is that the loss of occlusion due to not using dentures
may result in a decrease in functional balance and these functional declines lead to
falls. A cross-sectional study suggests that dental occlusal condition is associated
with balance function.<xref rid="b12" ref-type="bibr">12</xref> An 8-year longitudinal
study showed that partial or complete loss of occlusion was associated with a decrease
in balance function.<xref rid="b13" ref-type="bibr">13</xref> Because balance deficit is
a well-known risk factor for falls,<xref rid="b6" ref-type="bibr">6</xref> it is
plausible that poor balance may explain the increased risk of falls among subjects with
poor dental occlusion.</p><p>A clinical study showed that dental occlusion affects postural and gaze stabilisation
because proprioceptive receptors of the masticatory muscular system and dentoalveolar
ligaments provide sensory afferent input, and hence poor dental occlusion may decrease
that proprioception and interfere with the stability of head posture.<xref rid="b15" ref-type="bibr">15</xref> Another clinical study showed that denture use
improves postural swaying.<xref rid="b27" ref-type="bibr">27</xref> Because using
dentures reduced the OR for incident falls in the present study, proprioceptive
receptors of the masticatory muscular system might be more strongly associated with
balance function and falls than those of dentoalveolar ligaments.</p><p>Some subjects with 20 or more teeth may have had dentures in the present study; however,
the information was not obtained. Subjects with 20 or more teeth without dentures may be
more appropriate than those with 20 or more teeth with/without dentures as a reference,
and lack of the information might underestimate the association between dental status
and incident falls. However, studies show that people having at least 20 teeth usually
can eat anything even they do not ware dentures.<xref rid="b28" ref-type="bibr">28</xref><xref rid="b29" ref-type="bibr">29</xref> Therefore, the lack of the information of
with/without dentures in subjects having 20 or more teeth may be negligible.</p><p>We excluded individuals with history of falls because we wanted to examine prospectively
the risk of incident falls. In addition, there is a theoretical possibility that history
of falls might confound the association between number of teeth and risk of future
falls, that is, history of falls in the past can be a prior common cause of (1) number
of teeth (because some people may break teeth when they fall) and (2) past falls predict
future falls. For these reasons, we felt that it was justified to exclude those with
fall history at baseline.</p><p>In the present study, self-reported chewing ability was not associated with the incident
falls. This result disagreed with those from a cross-sectional study showing a
significant association between chewing ability judged from number of foods chewable and
one-leg standing time.<xref rid="b30" ref-type="bibr">30</xref> Because self-reported
mastication can be modified by cooking (eg, cooking soft meal helps chewing ability) and
is more subjective than self-reported number of teeth present and denture use, this
might dilute the association between self-reported chewing ability and the incident
falls. A study using 5643 subjects aged 40–89 years showed that number of
functional teeth which differentiate subjects with and without subjective dysphagia,
defined as suffering any kind of subjective impairment to eating function, including
biting difficulty, declined with age.<xref rid="b31" ref-type="bibr">31</xref>Additional studies using objective measures for chewing ability are required to clarify
the relationship between chewing ability and the incident falls.</p><p>Using dentures does not always recover chewing ability. For example, a cross-sectional
study showed that biting forces among removable partial and complete denture wearers
were 35% and 11%, respectively, when expressed as a percentage of the subjects with
natural dentition.<xref rid="b32" ref-type="bibr">32</xref> These results may explain
the different associations of dental status and chewing ability with incident falls in
the present study. When both dental status and chewing ability were simultaneously
entered in the fully adjusted logistic regression model in the present study, only
dental status was still significantly associated with incident falls.</p><p>Men were at increased risk of falls in the present study, which disagrees with a
meta-analysis<xref rid="b7" ref-type="bibr">7</xref> based on people aged
60 years or older showing that female sex was a risk factor. On the other hand,
our study result is also similar to another large study of 12 684 individuals
aged 85 years or older.<xref rid="b21" ref-type="bibr">21</xref> We feel that the
association between sex and risk of falls might vary according to the study population.
Indeed, current clinical guidelines for the prevention of falls do not include sex as a
risk factor,<xref rid="b6" ref-type="bibr">6</xref><xref rid="b33" ref-type="bibr">33</xref> and thus it may not be a settled question.</p><sec><title>Strengths and limitations</title><p>We note some strength of the present study including large sample size,
population-based sampling and control for many potential confounding factors.
However, the present study has a number of limitations. First, measurement of dental
status was based on self-report, not based on clinical examination. However, the
validity and reliability of self-reported number of teeth has been established by
multiple studies and widely used in epidemiological surveys.<xref rid="b34" ref-type="bibr">34</xref> For example, validation studies in the USA and Japan have
reported a high agreement between self-reported and examined number of teeth
(Pearson's correlation coefficient: r=0.97 and 0.93, respectively) in
50 community-dwelling individuals aged 70 years or older and 2496 subjects
with a mean age of 59.<xref rid="b35" ref-type="bibr">35</xref><xref rid="b36" ref-type="bibr">36</xref> Second, self-report of falls may not be
perfectly accurate.<xref rid="b37" ref-type="bibr">37</xref> However, the
associations with demographic factors and other covariates are in the generally
expected direction, suggesting that there may be sufficient value in this
outcome.</p></sec></sec><sec sec-type="conclusions"><title>Conclusions</title><p>The primary implication of this study is the importance of maintaining the dental
occlusion, especially with natural teeth, in order to prevent falls among older adults.
The loss of teeth might be an independent risk factor for incident falls, but it could
be prevented by using dentures. Promoting dental care including proper use of denture
might be an additional option for the prevention of falls in addition to current
interventions targeting conventional risk factors, which warrants further interventional
studies testing the effects of dental care and denture use on the prevention of
falls.</p><table-wrap id="tbl2" position="float"><label>Table 2</label><caption><p>Multivariate adjusted OR and 95% CI for the association of dental status and
chewing ability with incident falls</p></caption><table frame="hsides" rules="groups"><thead><tr><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">OR (95% CI)</td><td rowspan="1" colspan="1">p Value</td><td rowspan="1" colspan="1">OR (95% CI)</td><td rowspan="1" colspan="1">p Value</td></tr></thead><tbody><tr><td colspan="5" rowspan="1">Dental status</td></tr><tr><td rowspan="1" colspan="1"> ≥20 teeth</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> ≤19 teeth with dentures</td><td rowspan="1" colspan="1">1.36 (0.76 to 2.45)</td><td align="char" char="." rowspan="1" colspan="1">0.299</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> ≤19 teeth without dentures</td><td rowspan="1" colspan="1">2.50 (1.21 to 5.17)</td><td align="char" char="." rowspan="1" colspan="1">0.013</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td rowspan="1" colspan="1">5.75 (1.23 to 26.78)</td><td align="char" char="." rowspan="1" colspan="1">0.026</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td></tr><tr><td colspan="5" rowspan="1">Chewing ability</td></tr><tr><td rowspan="1" colspan="1"> Can chew anything</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Can chew most foods</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">0.97 (0.59 to 1.59)</td><td align="char" char="." rowspan="1" colspan="1">0.910</td></tr><tr><td rowspan="1" colspan="1"> Cannot chew very well</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.47 (0.64 to 3.37)</td><td align="char" char="." rowspan="1" colspan="1">0.361</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">0.00 (0.00)</td><td align="char" char="." rowspan="1" colspan="1">0.999</td></tr><tr><td colspan="5" rowspan="1">Sex</td></tr><tr><td rowspan="1" colspan="1"> Female</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Male</td><td rowspan="1" colspan="1">1.86 (1.16 to 2.96)</td><td align="char" char="." rowspan="1" colspan="1">0.010</td><td rowspan="1" colspan="1">1.86 (1.16 to 2.96)</td><td align="char" char="." rowspan="1" colspan="1">0.009</td></tr><tr><td colspan="5" rowspan="1">Age (years)</td></tr><tr><td rowspan="1" colspan="1"> 65–69</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 70–74</td><td rowspan="1" colspan="1">1.31 (0.73 to 2.34)</td><td align="char" char="." rowspan="1" colspan="1">0.366</td><td rowspan="1" colspan="1">1.36 (0.76 to 2.42)</td><td align="char" char="." rowspan="1" colspan="1">0.302</td></tr><tr><td rowspan="1" colspan="1"> 75–79</td><td rowspan="1" colspan="1">1.42 (0.74 to 2.74)</td><td align="char" char="." rowspan="1" colspan="1">0.290</td><td rowspan="1" colspan="1">1.57 (0.82 to 3.02)</td><td align="char" char="." rowspan="1" colspan="1">0.178</td></tr><tr><td rowspan="1" colspan="1"> 80–84</td><td rowspan="1" colspan="1">2.51 (1.17 to 5.39)</td><td align="char" char="." rowspan="1" colspan="1">0.018</td><td rowspan="1" colspan="1">2.84 (1.34 to 6.04)</td><td align="char" char="." rowspan="1" colspan="1">0.007</td></tr><tr><td rowspan="1" colspan="1"> ≥85</td><td rowspan="1" colspan="1">3.78 (1.27 to 11.19)</td><td align="char" char="." rowspan="1" colspan="1">0.017</td><td rowspan="1" colspan="1">4.63 (1.59 to 13.49)</td><td align="char" char="." rowspan="1" colspan="1">0.005</td></tr><tr><td colspan="5" rowspan="1">Functional disability during follow-up period</td></tr><tr><td rowspan="1" colspan="1"> No</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Yes</td><td rowspan="1" colspan="1">2.30 (0.75 to 7.06)</td><td align="char" char="." rowspan="1" colspan="1">0.144</td><td rowspan="1" colspan="1">2.11 (0.70 to 6.37)</td><td align="char" char="." rowspan="1" colspan="1">0.184</td></tr><tr><td colspan="5" rowspan="1">Depression</td></tr><tr><td rowspan="1" colspan="1"> No</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Mild</td><td rowspan="1" colspan="1">1.82 (1.01 to 3.26)</td><td align="char" char="." rowspan="1" colspan="1">0.046</td><td rowspan="1" colspan="1">1.82 (1.01 to 3.26)</td><td align="char" char="." rowspan="1" colspan="1">0.045</td></tr><tr><td rowspan="1" colspan="1"> Moderate to severe</td><td rowspan="1" colspan="1">2.47 (1.02 to 5.97)</td><td align="char" char="." rowspan="1" colspan="1">0.045</td><td rowspan="1" colspan="1">2.49 (1.03 to 6.02)</td><td align="char" char="." rowspan="1" colspan="1">0.042</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td rowspan="1" colspan="1">2.14 (1.09 to 4.17)</td><td align="char" char="." rowspan="1" colspan="1">0.026</td><td rowspan="1" colspan="1">2.07 (1.06 to 4.04)</td><td align="char" char="." rowspan="1" colspan="1">0.032</td></tr><tr><td colspan="5" rowspan="1">Self-rated health</td></tr><tr><td rowspan="1" colspan="1"> Excellent</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> Good</td><td rowspan="1" colspan="1">1.14 (0.47 to 2.77)</td><td align="char" char="." rowspan="1" colspan="1">0.767</td><td rowspan="1" colspan="1">1.07 (0.44 to 2.59)</td><td align="char" char="." rowspan="1" colspan="1">0.877</td></tr><tr><td rowspan="1" colspan="1"> Fair</td><td rowspan="1" colspan="1">1.43 (0.54 to 3.78)</td><td align="char" char="." rowspan="1" colspan="1">0.474</td><td rowspan="1" colspan="1">1.33 (0.50 to 3.54)</td><td align="char" char="." rowspan="1" colspan="1">0.568</td></tr><tr><td rowspan="1" colspan="1"> Poor</td><td rowspan="1" colspan="1">2.71 (0.83 to 8.77)</td><td align="char" char="." rowspan="1" colspan="1">0.097</td><td rowspan="1" colspan="1">2.60 (0.81 to 8.34)</td><td align="char" char="." rowspan="1" colspan="1">0.109</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td rowspan="1" colspan="1">0.00 (0.00)</td><td align="char" char="." rowspan="1" colspan="1">0.998</td><td rowspan="1" colspan="1">0.00 (0.00)</td><td align="char" char="." rowspan="1" colspan="1">0.998</td></tr><tr><td colspan="5" rowspan="1">Educational attainment (years)</td></tr><tr><td rowspan="1" colspan="1"> ≥13</td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td><td rowspan="1" colspan="1">1.00</td><td rowspan="1" colspan="1"></td></tr><tr><td rowspan="1" colspan="1"> 10–12</td><td rowspan="1" colspan="1">2.49 (0.83 to 7.45)</td><td align="char" char="." rowspan="1" colspan="1">0.102</td><td rowspan="1" colspan="1">2.59 (0.87 to 7.72)</td><td align="char" char="." rowspan="1" colspan="1">0.089</td></tr><tr><td rowspan="1" colspan="1"> 6–9</td><td rowspan="1" colspan="1">2.21 (0.77 to 6.33)</td><td align="char" char="." rowspan="1" colspan="1">0.140</td><td rowspan="1" colspan="1">2.50 (0.87 to 7.12)</td><td align="char" char="." rowspan="1" colspan="1">0.087</td></tr><tr><td rowspan="1" colspan="1"> <6</td><td rowspan="1" colspan="1">1.77 (0.37 to 8.56)</td><td align="char" char="." rowspan="1" colspan="1">0.476</td><td rowspan="1" colspan="1">2.24 (0.49 to 10.27)</td><td align="char" char="." rowspan="1" colspan="1">0.299</td></tr><tr><td rowspan="1" colspan="1"> Missing</td><td rowspan="1" colspan="1">2.78 (0.68 to 11.38)</td><td align="char" char="." rowspan="1" colspan="1">0.156</td><td rowspan="1" colspan="1">3.17 (0.77 to 13.01)</td><td align="char" char="." rowspan="1" colspan="1">0.110</td></tr></tbody></table></table-wrap></sec></body><back><fn-group><fn fn-type="other"><p><bold>To cite:</bold> Yamamoto T, Kondo K, Misawa J, <italic>et al</italic>. Dental
status and incident falls among older Japanese: a prospective cohort study.
<italic>BMJ Open</italic> 2012;<bold>2</bold>:e001262. doi:<ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1136/bmjopen-2012-001262">10.1136/bmjopen-2012-001262</ext-link></p></fn><fn fn-type="participating-researchers"><p><bold>Contributors:</bold> TY and YH had the idea for the study, participated in its design, performed the
statistical analysis and drafted the manuscript, and YH is the guarantor. KK is
coordinator of Aichi Gerontological Evaluation Study Project, helped develop the idea
of the study, participated in acquiring the data and with design and edited the
manuscript. JM participated in design of study and edited the manuscript. HH and MN
participated in acquiring the data and with design and critically revised the
manuscript. JA, NK and IK participated in the design of the study, deciding on
statistical methods used, helped in interpreting the results and revising the
manuscript.</p></fn><fn fn-type="financial-disclosure"><p><bold>Funding:</bold> This study was supported in part by a grant of the Strategic Research Foundation
Grant-aided Project for Private Universities from Ministry of Education, Culture,
Sport, Science and Technology, Japan (MEXT), 2009–2013, and Health Labour
Sciences Research Grant, Comprehensive Research on Aging and Health
(H22-Choju-Shitei-008) from the Japanese Ministry of Health, Labour and Welfare.</p></fn><fn fn-type="conflict"><p><bold>Competing interests:</bold> None.</p></fn><fn fn-type="other"><p><bold>Ethical approval:</bold> The Aichi Gerontological Evaluation Study protocol including the present study was
reviewed and approved by the Ethics Committee on Research of Human Subjects at Nihon
Fukushi University.</p></fn><fn fn-type="other"><p><bold>Provenance and peer review:</bold> Not commissioned; externally peer reviewed.</p></fn><fn fn-type="other"><p><bold>Data sharing statement:</bold> No additional data available.</p></fn></fn-group><ref-list><title>References</title><ref id="b1"><label>1</label><mixed-citation publication-type="book"><person-group person-group-type="author"><name><surname>Matsuda</surname><given-names>R</given-names></name></person-group><article-title>Life-style choices and falls</article-title>. In:
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