DOI: 10.1111/ggi.

13508

ORIGINAL ARTICLE

EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH

Influence of lack of posterior occlusal support on cognitive

decline among 80-year-old Japanese people in a 3-year
prospective study
Kodai Hatta,1 Kazunori Ikebe,1 Yasuyuki Gondo,2 Kei Kamide,3 Yukie Masui,4 Hiroki Inagaki,4
Takeshi Nakagawa,5 Ken-ichi Matsuda,1 Taiji Ogawa,1 Chisato Inomata,1 Hajime Takeshita,1
Yusuke Mihara,1 Motoyoshi Fukutake,1 Masahiro Kitamura,6 Shinya Murakami,6 Mai Kabayama,3
Tatsuro Ishizaki,4 Yasumichi Arai,7 Ken Sugimoto,8 Hiromi Rakugi8 and Yoshinobu Maeda1
1 Aim: Previous studies have reported significant associations between tooth loss or periodon-
Department of Prosthodontics,
Gerodontology and Oral tal status and cognitive function; however, animal experimental studies have shown that
occlusion might be a more important factor in cognitive decline. The purpose of the present
Rehabilitation, Osaka University
study was to investigate the influence of a lack of posterior occlusal support by residual teeth
Graduate School of Dentistry,
on the decline of cognitive function over a 3-year period among 80-year-old Japanese people.
Osaka, Japan
2
Department of Clinical Methods: Participants were community-dwelling older adults (n = 515, age 79–81 years).
Cognitive function was measured using the Japanese version of the Montreal Cognitive
Thanatology and Geriatric
Assessment. At baseline, participants were divided into two groups: those with and without
Behavioral Science, Osaka
posterior occlusal support. Participants whose Japanese version of the Montreal Cognitive
University Graduate School of Assessment score decreased by ≥3 points over the 3-year period were defined as the declined
Human Sciences, Osaka, Japan group. Logistic regression was carried out for the decline in Japanese version of the Montreal
3
Osaka University Graduate School Cognitive Assessment scores, including dental status and possible risk factors as independent
of Allied Health Sciences, Osaka, variables.
Japan Results: More participants without posterior occlusal support tended to be in the cognitive
4
Tokyo Metropolitan Institute of decline group (49.4%) than in the maintained group (38.5%; χ2-test, P = 0.02). Logistic
Gerontology, Tokyo, Japan regression analysis showed that a lack of posterior occlusal support was a significant variable
5 (odds ratio 1.55, P = 0.03) for cognitive decline, even after adjusting for other risk factors.
National Center for Geriatrics and
Gerontology, Aichi, Japan However, the number of teeth or mean periodontal pocket depth was not significantly corre-
6 lated with cognitive decline.
Department of Periodontics,
Osaka University Graduate School Conclusions: The present findings suggest that a lack of posterior occlusal support pre-
of Dentistry, Osaka, Japan dicted the incidence of cognitive decline, even after adjusting for possible risk factors in
7
Center for Supercentenarian community-dwelling old-old people. Geriatr Gerontol Int 2018; 18: 1439–1446.
Medical Research, Keio University
Keywords: cognitive function, cohort study, community-dwelling older adults, oral status,
School of Medicine, Tokyo, Japan
8 risk factor.
Department of Geriatric and
General Medicine, Osaka
University Graduate School of
Medicine, Osaka, Japan

Correspondence
Professor Kazunori Ikebe DDS
PhD, Department of
Prosthodontics, Gerodontology
and Oral Rehabilitation, Osaka
University Graduate School of
Dentistry, 1-8, Yamadaoka, Suita,
Osaka 565-0871, Japan.
Email: ikebe@dent.osaka-u.ac.jp

Received: 30 November 2017

Revised: 5 July 2018
Accepted: 14 July 2018

Introduction show evidence of preventing cognitive decline in older peo-

ple.2 Therefore, identifying the risk factors for cognitive
Cognitive decline is a major health problem among older peo- decline and taking preventive action from a younger age are
ple, as it threatens active life, independence and eventually important for older people to live a long, independent and
survival.1 However, there are few effective treatments that healthy life.

© 2018 Japan Geriatrics Society | 1439

 K Hatta et al.
Many risk factors for dementia and cognitive decline have been
proposed, including lower education level, lower socioeconomic
status and cardiovascular factors (e.g. smoking, alcohol consump-
tion, hypertension and diabetes).3,4 Previous studies have reported
that physical inactivity,5 depression6 and inflammatory conditions7
also affect cognitive decline.
Recently, several studies have reported an influence of oral health
on cognitive decline.8 Periodontal disease has previously been dis-
cussed in relation to cognitive decline.9 It has been hypothesized that
the mechanism of this association might involve inflammatory mole-
cules, bacteria and bacterial products that enhance neuroinflamma-
tion.10 A systematic review reported that tooth loss predicts
cognitive decline, because tooth loss might reduce mastication-
induced sensory stimulation and lead to poor nutritional intake.11
Another study reported that the occlusal condition affects the activa-
tion of the brain through blood flow.12 Animal experiments using
mice reported that extraction of molar teeth resulted in learning and
memory deficits.13 In humans, one cross-sectional study suggested
that the posterior occlusal support is associated with cognitive func-
tion, and that a lack of posterior occlusal support influences cogni-
tive decline to a greater extent than the number of teeth alone.14
However, there have been no longitudinal studies showing any rela-
tionship between posterior occlusal support and cognitive decline.
Additionally, it has been reported that cognitive function tends
to decline from the early 80s.15 Therefore, it is important to iden-
tify cognitive decline as a risk factor for people of the same age in
their early 80s.
The aim of the present longitudinal study was to show the
independent influence of a lack of posterior occlusal support on
cognitive decline using multivariate analysis over a 3-year period
among 80-year-old Japanese people, while taking into account
other risk factors involved in cognitive decline.
Methods
Participants
This research was a longitudinal analysis of data collected during
baseline and follow-up assessments in a prospective cohort study
of health and longevity called the “SONIC” (Septuagenarians,
Octogenarians, Nonagenarians Investigation with Centenarians)
Study.16 This study was carried out in two regions of eastern and
western Japan (Tokyo metropolitan area and Hyogo prefecture,
respectively). Both of these regions include an urban area and a
rural area: Itami City, Hyogo (western urban); Asago City, Hyogo
(western rural); Itabashi ward, Tokyo (eastern urban); and Nishi-
tama county, Tokyo (eastern rural).
The inclusion criteria of this study were as follows: (i) persons
aged 79–81 years during the period of baseline assessment (July
2011 to March 2012); and (ii) all residents living near the research
venue in the urban areas, and all inhabitants in the rural areas. Our
sample of study participants was drawn from the Basic Resident
Register of the district, and invitation letters were sent to eligible
persons. A total of 5378 residents selected from each local resident
registry were invited to participate in the present study. A total of
973 volunteers participated, and 782 of these completed the base-
line survey in 2011. Of these 782 participants, 463 completed the
follow-up survey in July 2014 to March 2015, which used the same
methods and procedures as those used in the baseline.
The study protocol was approved by the institutional review
board of the Osaka University Graduate School of Dentistry
(approval number H22-E9). Osaka University Graduate School
Dentistry Review Committee complies with the guidelines laid
down in the Helsinki Declaration. Informed consent was obtained
from all participants.
Dental examination
Dental examinations were carried out by registered dentists with a
dental mirror and an explorer, without X-rays. Participants were
1440 |
divided into two groups based on the number of remaining teeth
at baseline: 0–19 remaining teeth and 20–32 remaining teeth.17
The participants were further divided into two groups according
to the presence or absence of at least one occlusal support of
remaining natural teeth among the four premolar and molar
regions. The periodontal pocket depth (PPD) of each tooth was
measured with a color-coded probe (CP-12; Hu-Friedy, Chicago,
IL, USA). The PPD was assessed at six sites (mesiobuccal, mid-
buccal, distobuccal, mesiolingual, midlingual and distolingual) for
all teeth present. The mean of the deepest PPD for each tooth was
used as an indicator of periodontal status.
Cognitive function
Well-trained students majoring in psychology assessed each par-
ticipant’s cognitive function using the Japanese version of the
Montreal Cognitive Assessment (MoCA-J). The MoCA-J total
score (0–30 points) was used as a measure of cognitive function. A
higher score reflects higher cognitive function. MoCA-J shows
greater reliability and validity in the detection of mild cognitive
impairment in community-dwelling older adults than conven-
tional cognitive tests.18
The MoCA-J score at the 3-year follow up subtracted from the
score at baseline was defined as the change in MoCA-J score. Pre-
vious studies have not established an authorized standard measure
of meaningful decline in MoCA-J scores. Therefore, participants
whose MoCA-J score decreased by ≥3 points, which is in the
highest third, were defined as the declined group, and participants
whose scores decreased by ≤2 points were defined as the main-
tained group.19
Physical performance
Isometric grip strength was measured using a Smedley handgrip
dynamometer (Model YD-100; Yagami, Tokyo, Japan) as an indica-
tion of general muscle strength. The test was carried out twice on the
dominant hand with the participant in a sitting position with their
arm held against their body, and the average was calculated.
Skeletal muscle function, assessed by recording the time taken
to walk 8 feet at normal speed, was measured twice and averaged
to give the usual walking speed.
Depression evaluation
Depression was evaluated using a five-item version of the Geriatric
Depression Scale. The five-item version of the Geriatric Depres-
sion Scale total score (0–5 points) was used as a measure of
depression. A higher score reflects a higher depressive tendency.
Participants with a five-item version of the Geriatric Depression
Scale score of ≥2 points were defined as having a depressive
tendency.20
Medical conditions
Diabetes was diagnosed based on fasting blood glucose concentra-
tion and medication situation. Hypertension was diagnosed based
on actual measured blood pressure values and medication situa-
tion. Dyslipidemia was diagnosed based on levels of total choles-
terol, high-density lipoprotein cholesterol, triglycerides, serum
albumin in the blood and medication situation. The diagnostic
criteria for these diseases were set using the same method as
Ryuno et al.4
Participants were also asked if they had a history of a stroke or
a malignant tumor.
Other recorded variables
Assessments of other variables were based on answers in the ques-
tionnaire. Participants were divided into groups based on educa-
tion level (junior high school, high school, or college or higher),
self-assessed economic status (dissatisfied, moderately satisfied,
© 2018 Japan Geriatrics Society
 Influence of occlusion on cognition
satisfied), living alone (yes or no), frequency of outings per week
(0–2, 3–4, >5), frequency of interactions with friends, relatives or
neighbors per month (0–1, 2–3, >4), drinking habit (yes or no)
and smoking habit (yes or no).
Statistical analysis
The Mann–Whitney U-test for continuous variables and the χ2-
test for categorical variables were carried out to compare baseline
characteristics between the dropout group and the follow-up
group, between the group with posterior occlusal support and the
group without posterior occlusal support, and between the cogni-
tive maintained and declined group (change in MoCA-J score).
Finally, logistic regression analysis, with change in cognitive func-
tion as the outcome variable, was carried out. Explanatory vari-
ables included posterior occlusal support, number of teeth and
periodontal disease; and adjusting variables included risk factors
associated with cognitive decline in previous studies (sex, educa-
tion level, economic status, living alone, frequency of interacting,
smoking, drinking, hypertension, diabetes, dyslipidemia, stroke,
malignant tumor, depressive tendency, grip strength, walking
speed and MoCA-J score at baseline). Because the number of
teeth and posterior occlusal support had a relatively high correla-
tion (rs = 0.77), they were separately entered in the model to avoid
multicollinearity. Furthermore, in the model including mean PPD,
edentulous participants were excluded from the analysis.
All statistical analysis was carried out with SPSS Statistics
24 (IBM Japan, Tokyo, Japan). P < 0.05 was considered to denote
statistical significance.
Results
During the 3-year follow-up period, 319 participants were lost to
the study as a result of death, hospitalization, inability to attend a
follow-up visit or other reasons. A total of 463 participants
(231 men, 232 women) were included in the final analysis (Fig. 1).
Table 1 shows the baseline characteristics of the dropout and
follow-up groups. There were no significant differences between
the groups in terms of sex, economic status, living alone, fre-
quency of interacting, drinking, hypertension, dyslipidemia,
Figure 1 Overview of the study
design.
© 2018 Japan Geriatrics Society
stroke, malignant tumor, posterior occlusal support, number of
teeth and PPD. However, participants with a lower education
level, lower outing frequency, smoking habit, diabetes, depressive
tendency, lower grip strength, slower walking speed and lower
MoCA-J score at baseline were more likely to be lost at follow up.
Table 2 shows a comparison of the baseline characteristics
between the groups with and without posterior occlusal support.
Women and participants with a lower education level, smoking
habit, fewer teeth, deep periodontal pockets and lower grip
strength tended to have no posterior occlusal support at baseline.
Table 3 shows a comparison of the baseline characteristics
between the maintained (66.1%) and declined (33.9%) groups for
cognitive function. More participants without posterior occlusal
support tended to be in the cognitive decline group (49.4%) than
in the maintained group (38.5%; P = 0.015). Additionally, the
MoCA-J scores at baseline were higher among participants in the
declined group than in the maintained group (P < 0.001).
Multiple logistic regression analysis showed that lower educa-
tion level, lower grip strength and a higher MoCA-J score at base-
line were independently significantly correlated with cognitive
decline during the 3-year period in 80-year-old participants
(Table 4). After adjusting for these variables, posterior occlusal
support was independently correlated with cognitive decline over
the 3-year period (model 1, odds ratio 1.61, 95% CI 1.03–2.49).
However, number of teeth (model 2) and mean PPD (model 3)
were not significantly correlated with cognitive decline.
Discussion
To our knowledge, this is the first longitudinal study to compare
the influence of posterior occlusal support, the number of teeth
and periodontal disease on cognitive decline. The highlight of the
present study was that not the number of teeth or periodontal dis-
ease, but only posterior occlusal support was identified as a signifi-
cant oral index of risk factors for cognitive decline. This
significant association might be explained by the fact that posterior
occlusal support is one of the major factors playing a role of affer-
ent nerve stimulation on brain activities, similarly the number of
teeth and posterior occlusal support reflects the nutritional intake
| 1441
 K Hatta et al.

Table 1 Comparison of baseline characteristics between the follow-up and dropout groups

Follow-up group Dropout group

Characteristic n (%) n = 463 (59.2%) n = 319 (40.8%) P-value†
Sex
Male 368 (47.1) 231 (49.9) 137 (42.9) 0.056
Female 414 (52.9) 232 (50.1) 182 (57.1)
Education level
Junior high school 245 (31.3) 128 (27.6) 117 (36.7) 0.014
High school 320 (40.9) 193 (41.7) 127 (39.8)
College or higher 217 (27.7) 142 (30.7) 75 (23.5)
Economic status
Dissatisfied 141 (18.0) 77 (16.6) 64 (20.1) 0.166
Moderately satisfied 452 (57.8) 264 (57.0) 188 (58.9)
Satisfied 189 (24.2) 122 (26.3) 67 (21.0)
Living alone
Yes 166 (21.2) 95 (20.5) 71 (22.3) 0.559
No 616 (78.8) 368 (79.5) 248 (77.7)
Frequency of going out
0–2 times in a week 216 (27.6) 113 (24.4) 103 (32.3) 0.032
3–4 182 (23.3) 107 (23.1) 75 (23.5)
>5 384 (49.1) 243 (52.5) 141 (44.2)
Frequency of interacting
0–1 times in a month 187 (23.9) 112 (24.2) 75 (23.5) 0.861
2–3 256 (32.7) 154 (33.3) 102 (32.0)
>4 339 (43.4) 197 (42.5) 142 (44.5)
Smoking habit
Yes 39 (5.0) 14 (3.0) 25 (7.8) 0.002
No 743 (95.0) 449 (97.0) 294 (92.2)
Drinking habit
Yes 238 (30.4) 150 (32.4) 88 (27.6) 0.151
No 544 (69.6) 313 (67.6) 231 (72.4)
Hypertension
Yes 632 (80.8) 375 (81.0) 257 (80.6) 0.881
No 150 (19.2) 88 (19.0) 62 (19.4)
Diabetes
Yes 125 (16.0) 63 (13.6) 62 (19.4) 0.029
No 657 (84.0) 400 (86.4) 257 (80.6)
Dyslipidemia
Yes 472 (60.4) 282 (60.9) 190 (59.6) 0.705
No 310 (39.6) 181 (39.1) 129 (40.4)
Stroke
Yes 36 (55.6) 20 (4.3) 16 (5.0) 0.648
No 746 (95.4) 443 (95.7) 303 (95.0)
Malignant tumor
106 (13.6) 54 (11.7) 52 (16.3) 0.063
676 (86.4) 409 (88.3) 267 (83.7)
Depressive tendency
Yes 298 (38.1) 160 (34.6) 138 (43.3) 0.014
No 484 (61.9) 303 (65.4) 181 (56.7)
Posterior occlusal support
Presence 441 (56.4) 269 (58.1) 172 (53.9) 0.247
Absence 341 (43.6) 194 (41.9) 147 (46.1)
No. teeth
0–19 430 (55.0) 246 (53.1) 184 (57.7) 0.209
20–32 352 (45.0) 217 (46.9) 135 (42.3)

Median (IQR) Median (IQR)

‡
Mean periodontal pocket depth (mm) 3.25 (2.91–3.86) 3.30 (2.94–3.67) 0.962
Grip strength (kgf ) 21.5 (17.0–27.8) 19.3 (14.8–25.8) <0.001
Walking speed (m/s) 0.92 (0.79–1.05) 0.84 (0.73–0.97) <0.001
MoCA-J score at baseline 22.0 (19.0–24.0) 20.0 (17.0–23.0) <0.001
†
P-values from χ2-tests for categorical variables and Mann–Whitney U-test for continuous variables. ‡Edentulous participants were excluded from
the analysis. IQR, interquartile range; MoCA-J, Japanese version of the Montreal Cognitive Assessment.

and functional abilities compared with other oral indexes.21–23 present study, and periodontal disease might have less effect on
The reason why the periodontal condition did not become signifi- the inflammatory condition of the whole body. We also evaluated
cant is probably that people who had severe inflammatory condi- oral health-related items, such as the frequency of regular dental
tions as a result of periodontal disease did not participate in the checkups, toothbrushing and the presence of a primary care

1442 | © 2018 Japan Geriatrics Society

 Influence of occlusion on cognition

Table 2 Comparison of baseline characteristics between groups with and without posterior occlusal support

Group with posterior Group without posterior

occlusal support occlusal support
Characteristic n (%) n = 269 (58.1%) n = 194 (41.9%) P-value†
Sex
Male 231 (49.9) 148 (55.0) 83 (42.8) 0.009
Female 232 (50.1) 121 (45.0) 111 (57.2)
Education level
Junior high school 128 (27.6) 64 (23.8) 64 (33.0) 0.012
High school 193 (41.7) 109 (40.5) 84 (43.3)
College or higher 142 (30.7) 96 (35.7) 46 (23.7)
Economic status
Dissatisfied 77 (16.6) 38 (16.6) 39 (20.1) 0.097
Moderately satisfied 264 (57.0) 152 (56.5) 112 (57.7)
Satisfied 122 (26.3) 79 (29.4) 43 (22.2)
Living alone
Yes 95 (20.5) 61 (22.7) 34 (17.5) 0.176
No 368 (79.5) 208 (77.3) 160 (82.5)
Frequency of going out
0–2 times in a week 113 (24.4) 55 (20.4) 58 (29.9) 0.061
3–4 107 (23.1) 67 (24.9) 40 (20.6)
>5 243 (52.5) 147 (54.6) 96 (49.5)
Frequency of interacting
0–1 times in a month 112 (24.2) 69 (25.7) 43 (22.2) 0.610
2–3 154 (33.3) 90 (33.5) 64 (33.0)
>4 197 (42.5) 110 (40.9) 87 (44.8)
Smoking habit
Yes 14 (3.0) 4 (1.5) 10 (5.2) 0.023
No 449 (97.0) 265 (98.5) 284 (94.8)
Drinking habit
Yes 150 (32.4) 94 (34.9) 56 (28.9) 0.168
No 313 (67.6) 175 (65.1) 138 (71.1)
Hypertension
Yes 375 (81.0) 218 (81.0) 157 (80.9) 0.976
No 88 (19.0) 51 (19.0) 37 (19.1)
Diabetes
Yes 63 (13.6) 36 (13.4) 27 (13.9) 0.869
No 400 (86.4) 233 (86.6) 167 (86.1)
Dyslipidemia
Yes 282 (60.9) 164 (61.0) 76 (39.2) 0.975
No 181 (39.1) 105 (39.0) 118 (60.8)
Stroke
Yes 20 (4.3) 11 (4.1) 9 (4.6) 0.774
No 443 (95.7) 258 (95.9) 185 (95.4)
Malignant tumor
54 (11.7) 36 (13.4) 18 (9.3) 0.175
409 (88.3) 233 (86.6) 176 (90.7)
Depressive tendency
Yes 160 (34.6) 88 (32.7) 72 (37.1) 0.326
No 303 (65.4) 181 (67.3) 122 (62.9)
No. teeth
0–19 246 (53.1) 55 (20.4) 191 (98.5) <0.001
20–32 217 (46.9) 214 (79.6) 3 (1.5)

Median (IQR) Median (IQR) Median (IQR)

Mean periodontal pocket depth‡ (mm) 3.18 (2.89–3.63) 3.67 (3.00–4.33) <0.001
Grip strength (kgf ) 22.5 (17.9–28.5) 20.0 (16.2–26.0) 0.003
Walking speed (m/s) 0.92 (0.81–1.05) 0.90 (0.77–1.05) 0.215
MoCA-J score at baseline 22.0 (20.0–24.0) 22.0 (19.0–24.0) 0.457
†
P-values from χ2-tests for categorical variables and Mann–Whitney U-test for continuous variables. ‡Edentulous participants were excluded from
the analysis. IQR, interquartile range; MoCA-J, Japanese version of the Montreal Cognitive Assessment.

dentist among the same participants. However, there was no sig-
nificant association between these variables and cognitive decline.
The present study also showed that grip strength predicts cogni-
tive decline in the early 80s. This result is consistent with previous
studies that reported that reduced handgrip strength over time
might serve as a predictor of cognitive loss with advancing age.24
Previous research suggested two plausible mechanisms to
explain the association between occlusion and cognitive decline.
First, loss of posterior occlusal support encompasses a reduction
in masticatory stimulation and a consequent decrease in brain
function activation.11 Reduced masticatory stimulation might lead
to cognitive decline through decreases in cerebral blood flow,

© 2018 Japan Geriatrics Society | 1443

 K Hatta et al.

Table 3 Comparison of baseline characteristics between the maintained and declined groups for cognitive function

Declined
Maintained group† group‡
Characteristic n (%) n = 306 (66.1%) n = 157 (33.9%) P-value†
Sex
Male 231 (49.9) 158 (51.6) 73 (46.5) 0.295
Female 232 (50.1) 148 (48.4) 84 (53.5)
Education level
Junior high school 128 (27.6) 88 (28.8) 40 (25.5) 0.061
High school 193 (41.7) 116 (37.9) 77 (49.0)
College or higher 142 (30.7) 102 (33.3) 40 (25.5)
Economic status
Dissatisfied 77 (16.6) 54 (17.6) 23 (14.6) 0.592
Moderately satisfied 264 (57.0) 175 (57.2) 89 (56.7)
Satisfied 122 (26.3) 77 (25.2) 45 (28.7)
Living alone
Yes 95 (20.5) 64 (20.9) 31 (19.7) 0.768
No 368 (79.5) 242 (79.1) 126 (80.3)
Frequency of going out
0–2 times in a week 113 (24.4) 83 (27.1) 30 (19.1) 0.161
3–4 107 (23.1) 69 (22.5) 38 (24.2)
>5 243 (52.5) 154 (50.3) 89 (56.7)
Frequency of interacting
0–1 times in a month 112 (24.2) 77 (25.2) 35 (22.3) 0.778
2–3 154 (33.3) 100 (32.7) 54 (34.4)
>4 197 (42.5) 129 (42.2) 68 (43.3)
Smoking habit
Yes 14 (3.0) 7 (2.3) 7 (4.5) 0.197
No 449 (97.0) 299 (97.7) 150 (95.5)
Drinking habit
Yes 150 (32.4) 103 (33.7) 47 (29.9) 0.418
No 313 (67.6) 203 (66.3) 110 (70.1)
Hypertension
Yes 375 (81.0) 250 (81.7) 125 (79.6) 0.589
No 88 (19.0) 56 (18.3) 32 (20.4)
Diabetes
Yes 63 (13.6) 41 (13.4) 22 (14.0) 0.855
No 400 (86.4) 265 (86.6) 135 (86.0)
Dyslipidemia
Yes 282 (60.9) 182 (59.5) 100 (63.7) 0.379
No 181 (39.1) 124 (40.5) 57 (36.3)
Stroke
Yes 20 (4.3) 11 (3.6) 9 (5.7) 0.284
No 443 (95.7) 295 (96.4) 148 (94.3)
Malignant tumor
54 (11.7) 36 (11.8) 18 (11.5) 0.924
409 (88.3) 270 (88.2) 139 (88.5)
Depressive tendency
Yes 160 (34.6) 109 (35.6) 51 (32.5) 0.502
No 303 (65.4) 197 (64.4) 106 (67.5)
Posterior occlusal support
Presence 269 (58.1) 190 (62.1) 79 (50.3) 0.015
Absence 194 (41.9) 116 (37.9) 78 (49.7)
No. teeth
0–19 246 (53.1) 156 (51.0) 90 (57.3) 0.195
20–32 217 (46.9) 150 (49.0) 67 (42.7)

Median (IQR) Median (IQR) Median (IQR)

‡
Mean periodontal pocket depth (mm) 3.26 (2.92–3.85) 3.25 (2.86–3.87) 0.795
Grip strength (kgf ) 21.9 (17.3–28.0) 21.0 (16.3–27.6) 0.184
Walking speed (m/s) 0.92 (0.80–1.06) 0.92 (0.78–1.04) 0.527
MoCA-J score at baseline 21.0 (19.0–23.0) 23.0 (21.0–26.0) <0.001
†
P-values from χ2-tests for categorical variables and Mann–Whitney U-test for continuous variables. ‡Edentulous participants were excluded from
the analysis. IQR, interquartile range; MoCA-J, Japanese version of the Montreal Cognitive Assessment.

activation of the cortical area and blood oxygen levels.25,26 Sec- poor oral status is associated with inadequate diet.17 In particular,
ond, nutritional changes resulting from poor oral status might a lack of posterior occlusal support has been associated with
lead to cognitive decline.27 Previous studies have reported that nutritional deficit, regardless of sex and age.23

1444 | © 2018 Japan Geriatrics Society

 Influence of occlusion on cognition

Table 4 Logistic regression model for change in cognitive decline

Independent variable Odds ratio (95% CI) P-value

Model 1
MoCA-J score at baseline 1.28 (1.19–1.38) <0.001
Education level
College or higher (reference 1
category)
High school 1.78 (0.97–3.25) 0.062
Junior high school 1.73 (1.02–2.92) 0.042
Grip strength (kgf ) 0.95 (0.91–0.99) 0.025
Posterior occlusal support 0.035
Presence (reference category) 1
Absence 1.61 (1.03–2.49)
Model 2
MoCA-J score at baseline 1.28 (1.19–1.38) <0.001
Education level
College or higher (reference 1
category)
High school 1.84 (1.00–3.36) 0.049
Junior high school 1.91 (1.04–3.00) 0.032
Grip strength (kgf ) 0.95 (0.91–0.99) 0.023
No. teeth 0.311
20–32 (reference category) 1
0–19 1.26 (0.81–1.95)
Model 3
MoCA-J score at baseline 1.32 (1.22–1.44) <0.001
Education level
College or higher (reference 1
category)
High school 2.08 (1.05–4.12) 0.035
Junior high school 1.93 (1.08–3.46) 0.027
Grip strength (kgf ) 0.94 (0.89–0.98) 0.015
Mean periodontal pocket depth (mm) 1.08 (0.81–1.44) 0.620
Model 1, 2 and 3 were adjusted for sex (male or female), economic status (dissatisfied, moderately satisfied, satisfied), living alone (yes or no), fre-
quency of going out for a week (0–2, 3–4, >5), frequency of interacting with friends in a month, relatives, neighbors (0–1, 2–3, >4), drinking habit
(yes or no), hypertension (yes or no), diabetes (yes or no), dyslipidemia (yes or no), stroke (yes or no), malignant tumor (yes or no), depressive ten-
dency (yes or no) and walking speed (m/s). Model 3 excluded edentulous participants (n = 68). CI, confidence interval; MoCA-J, Japanese version of
the Montreal Cognitive Assessment.

Logistic regression analysis showed that posterior occlusal
support independently influenced cognitive decline, adjusting for
other risk factors that could be related to cognitive function. We
examined the relationship in the reverse direction, and found that
the MoCA-J score at baseline did not significantly influence the
number of teeth lost over the 3-year period (rs = 0.03, P = 0.469).
Therefore, the present findings suggest that cognitive decline
might not predict loss of teeth. In contrast, a lack of posterior
occlusal support is thought to be a predictive risk factor for cogni-
tive decline.
Several limitations of the present study should be mentioned.
First, the study participants were not a representative sample of
older Japanese people in the general population. Thus, there is a
possibility that selection bias might have occurred. The range of
the present study population was narrow, and included only non-
institutionalized, community-dwelling and 80-year-old Japanese
people in limited areas, most of whom were mentally healthy and
not suffering from dementia, despite the sample being drawn from
the Basic Resident Register. However, according to a research
report by the Health, Labor and Welfare Laboratory of Japan, the
number of people suffering from dementia rises sharply after the
age of 80 years. A previous study found that cognitive function
tends to decline in the 80s.15 Therefore, it is important to identify
the risk factors for cognitive decline in people aged in their early
80s. Older adults who participated in the follow-up survey (60%
of the total study population) tended to achieve better baseline
results for the survey items of education level, frequency of out-
ings, smoking, diabetes, depression, grip strength, walking speed
and MoCA-J score than those who were lost at follow
up. However, we were unable to provide a direct comparison
between participants and non-participants in the study end-
points, because longitudinal studies are subject to attrition (loss at
follow up) because of non-participation or mortality. The second
limitation of the present study was the criteria for assessing cogni-
tive decline. There is no authorized cut-off point for a meaningful
decline in MoCA-J score. Therefore, the present study defined
participants with cognitive decline as the third of all participants
with the greatest decline in MoCA-J score over the 3-year period,
and then determined that the cut-off value for cognitive decline
was a reduction of 3 points.19,28 The MoCA-J scores of partici-
pants in the present study were lower than those of previous stud-
ies. This might be because of the older age of the participants in
this study. In fact, the average MoCA-J score in the present study
did not differ from that of a study targeted at participants of the
same age.29 The third limitation is that we could not take into
account the duration of the loss of posterior occlusal support. If
the loss of posterior occlusal support is a burden on cognitive
function, it is also important to know how long participants have
been without posterior occlusal support. We did not have data
about when participants lost their posterior occlusal support,
except for those who lost posterior occlusal support during the
3 years of the study. Statistical analysis was not possible, because
just 3% of participants lost posterior occlusal support during the
study. Future studies should include long-term longitudinal inves-
tigations that consider the timing of the loss of posterior occlusal
support. The fourth limitation was that we did not evaluate the
effect of the dentures. A previous study reported that the restora-
tion of missing teeth with dentures prevented dementia.30 In this

© 2018 Japan Geriatrics Society | 1445

 K Hatta et al.
study, almost all participants who lost posterior occlusal support
used removable dentures. Cognitive function had declined despite
using dentures, and the present study has not been able to find
the effect of dentures. Future prospective interventional studies
would need to consider including the effect of dentures.
The strengths of the present study are the reliability of the data
collected by specialists in dentistry, medicine and psychology with
the aim of carrying out their own research in health and longevity.
This allowed the present study to cover the variables of interest to
us (dental status and cognitive function) together with a number
of important confounding factors (socioeconomic status, lifestyle,
medical history, depression tendency, physical function) at a high-
quality level.
The present findings suggest important links between posterior
occlusal support and the incidence of cognitive decline in old-old
adults, but the findings do not prove causality. It is important to
note that our findings are of clinical importance, as they highlight
whether maintaining occlusal support could influence the inci-
dence of dementia over time.
In conclusion, a lack of posterior occlusal support at baseline
predicted the incidence of cognitive decline during the subsequent
3 years in old-old Japanese people after adjusting for possible risk
factors. Although the present data did not prove any causal rela-
tionship, it is conceivable that maintaining occlusal support could
reduce the incidence of cognitive decline.
Acknowledgements
This work was supported by a Grant-in-Aid for Scientific
Research (JP15H05025 and JP16H05523) from the Japan Society
for the Promotion of Science.
Disclosure statement
The authors declare no conflict of interest.
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How to cite this article: Hatta K, Ikebe K, Gondo Y,
et al. Influence of lack of posterior occlusal support on
cognitive decline among 80-year-old Japanese people in a
3-year prospective study. Geriatr. Gerontol. Int.
2018;18:1439–1446. https://doi.org/10.1111/ggi.13508
© 2018 Japan Geriatrics Society