Journal of Oral Rehabilitation 2006 33; 330–334

Chewing ability and quality of life in an 80-year-old population
Y . T A K A T A * , T . A N S A I †, S . A W A N O †, M . F U K U H A R A * , K . S O N O K I * , M . W A K I S A K A * , K . F U J I S A W A * , S . A K I F U S A † & T . T A K E H A R A † *Divisions of General Internal Medicine and †Community
Oral Health Science, Department of Health Promotion, Kyushu Dental College, Kitakyushu, Japan

SUMMARY As quality of life (QOL) could be influenced by oral status in the elderly, we examined whether chewing ability or number of teeth affected QOL in 80-year olds. A cross-sectional survey included dental examination, chewing self-assessment, and a QOL questionnaire. A total of 823 people who were 80 years old participated in this study. QOL was assessed in terms of satisfaction with physical condition, meals, daily living and social interactions, and with face-scale scores. After adjustment for gender, spouse and activities of daily living, dissatisfaction with social interactions was 3Æ9 times more prevalent in individuals

able to chew four foods or fewer than in those chewing 15. Dissatisfaction with physical condition, meals and daily living, and poor face-scale scores, were 2Æ7, 2Æ4, 3Æ4, and 2Æ4 times more prevalent, respectively, in subjects chewing four foods or fewer. The number of teeth showed little effect. In conclusion, self-assessed chewing ability but not number of teeth was associated with QOL in 80-year-old subjects. KEYWORDS: elderly populations, quality of life, chewing ability, number of teeth Accepted for publication 29 July 2005

Introduction
Tooth loss commonly occurs in association with ageing, compromising mastication of food (1–4). Impaired chewing ability may adversely affect nutritional status (5–10) and undermine general well-being (4, 8, 10–12). In a longitudinal study where subjects were followed up between age 75 and 80 years, a relationship between chewing problems and general functional limitations was evident (9). Quality of life (QOL), defined as a person’s sense of well-being derived from satisfaction with daily living, was reported to be closely related to chewing ability in elderly persons residing in a rural community in Japan (13). Better QOL was seen more often in dentulous than edentulous individuals aged ‡70 years (11). Similarly, in an Italian population aged 70–75 years, functional dental status was shown to be associated with several QOL domains and the authors encouraged
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extensive use of dentures (14). In subjects with a mean age of 83 years, Canadian investigators (15) found a significant effect of oral disorders on well-being and life satisfaction. Although several studies suggest a relationship between chewing ability and QOL in the elderly as mentioned above, such an association has not yet been broadly established. We concluded from observations in an 80-year-old Japanese population that decreased physical capacity associated with tooth loss could be improved by the use of dentures (16), and that a positive relationship existed between chewing ability and physical activity (17). More recently, we found an association between activities of daily living (ADL) scores and chewing ability in an 80-year-old population (18). In the present study, we therefore examined relationships of QOL status in 80-year olds to chewing ability as well as to number of teeth. The number of foods that the subjects could chew was used as an indicator of chewing ability.
doi: 10.1111/j.1365-2842.2005.01567.x

QOL AND CHEWING IN THE ELDERLY
foods that are very hard to chew, six foods moderately hard to chew, three foods slightly hard to chew, and three foods easy to chew (28). The number of these foods that a subject could chew was used as an index of chewing ability, which was assessed as a possible independent influence on QOL status by logistic regression analyses. The factors gender, spouse and ADL were considered as possible influences upon number of teeth, number of foods reported to be chewable and QOL. Adjustments were made for these categorical factors in order to identify independent risk factors for QOL compromise. All data are reported as the mean Æ s.d. Logistic regression analysis was carried out to evaluate which factors were related to QOL after adjustment for confounding variables. All statistical analyses were performed using StatView 5Æ0*. Results were considered statistically significant when P-value was below 0Æ05.

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Materials and methods
In 1998, we enrolled 1282 80-year-old individuals residing in one of three cities (Buzen, Yukuhashi or Munakata), four towns (Katsuyama, Tikujo, Toyotsu or Kanda), one village (Shinyoshitomi), or one ward (Tobata of Kikakyushu City) in the Fukuoka Prefecture of Japan to participate in the present study. Of the 1282 individuals, 823 participated (309 male and 514 female). As the other 36% of potential subjects declined to participate, self-selection factors could have introduced some bias in the present findings. The study was approved by the Human Investigations Committee of Kyushu Dental College, and informed consent was obtained from all participants. The authors performed dental examination of each subject in the manner recommended by the World Health Organization (19). Quality of life status was determined using a prepared questionnaire with multiple choices for responses. Queried items included the following: ‘have a spouse’ (1, yes; 2, no); ‘satisfied with physical condition’ (1, yes; 2, no); ‘good mood after a meal’ (1, yes; 2, no); ‘satisfied with daily life’ (1, yes; 2, no); and ‘satisfied with social interactions’ (1, yes; 2, no). Face-scale scores (20) (1, score of 1 or 6; 2, score of 10–20) and ADL status (1, independent; 2, dependent) were determined by public health nurses who classified subjects as either independent or dependent (i.e. requiring day-to-day assistance) using the guidelines of the Health, Labor, and Welfare Ministry of Japan. Oral health-related QOL instruments, such as Geriatric Oral Health Assessment Index (GOHAI) (21) and Oral Health Impact Profile (OHIP) (22), were developed in 1990 and 1994 respectively. However, the Japanese versions of these instruments were not established until 2004 for GOHAI (23) and 2002 for OHIP (24). As the present study was performed in 1998, these instruments for evaluating QOL related to oral health were not yet established in Japan. Questionnaires concerning food intake have proven valuable in epidemiological surveys of masticatory function in the elderly (3, 25–27). Accordingly, each subject was asked about his/her ability to chew the following 15 foods: peanuts, yellow pickled radish, hard rice cracker, French bread, beefsteak, octopus in vinegar, pickled shallots, dried scallops, dried cuttlefish, squid sashimi, konnyaku, a tubular roll of boiled fish paste, boiled rice, tuna sashimi, and grilled eel. These 15 foods were selected to represent four groups: three

Results
The mean number of teeth was 7Æ5 Æ 8Æ7, and the mean number of foods that subjects could chew was 11Æ2 Æ 3Æ8. QOL was evaluated in 813 individuals. The number of subjects satisfied with their health status was 331 (40Æ7%), while 482 (59Æ3%) were dissatisfied. While 454 subjects (56Æ2%) felt satisfied after a meal, 354 (43Æ8%) did not. Most subjects (677; 83Æ8%) were satisfied with their daily life, while 131 (16Æ2%) were not satisfied. The number of individuals satisfied with interactions with family or friends was 698 (86Æ7%), while 107 subjects (13Æ3%) were dissatisfied. Face-scale groups of 1 and 6 were classified as good QOL (n ¼ 436; 56Æ4%), with those of 10, 15 and 20 representing poor QOL (n ¼ 337; 43Æ6%). Subjects were divided into four groups according to number of foods chewed (0–4, 5–9, 10–14 or 15), which was used as an index of chewing ability, and also were classified into four groups by number of teeth (0, 1–9, 10–19 or ‡20). Compared by logistic regression analysis to findings in subjects who were able to chew 15 foods, dissatisfaction with physical condition was 2Æ1 times prevalent in individuals with 5–9 chewable foods and 2Æ9 times prevalent in those chewing 0–4 foods. Unhappy moods after meals were significantly more prevalent in subjects who could chew only 10–14, 5–9 or 0–4 foods than in those chewing 15 foods.
*SAS Institute, Cary, NC, USA

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Prevalence of dissatisfaction with daily life was 3Æ7 times greater in individuals able to chew £4 foods than in those who could chew 15 foods; such dissatisfaction was 2Æ1 times as prevalent in those who had 10–19 teeth than in those with ‡20 teeth. Dissatisfaction with interactions with family or friends also was more prevalent in individuals with £9 chewable foods. A face-scale of 10–20, indicating negative mood, was more prevalent in individuals with £4 chewable foods and in those with 10–19 teeth. Similarly, subjects were divided into four groups according to chewing ability using the number of chewable foods. Logistic regression analysis after adjustment for gender difference, spouse status, and ADL status revealed odds ratios (OR) and 95% confidence intervals (CI) for a poor QOL (Table 1). These three potential confounders were included in aggregate in the logistic regression analysis. Compared with individuals able to chew 15 foods, dissatisfaction with physical condition was significantly more prevalent among individuals able to chew only 5–9 foods, or £4 foods (Table 1). Prevalence of unhappiness after a meal in individuals able to chew 10–14, 5–9 and £4 foods was 1Æ7, 2Æ2 and 2Æ4 times higher, respectively, than those chewing 15 foods. Dissatisfaction with daily life in subjects able to chew £4 foods was 3Æ4 times more likely than in those chewing 15 foods. Dissatisfaction with interactions involving family or friends also was prevalent in individuals with 5–9 chewable foods or those with £4 foods. Similarly, a face-scale score indicating a negative mood, was more prevalent in individuals with £4 chewable foods. Compared with individuals able to chew 15 foods, those with a reduced number of chewable foods showed more dissatisfaction according to all scales used (Table 1). In contrast, no consistent difference in prevalence of poor QOL status was found between four groups defined by remaining numbers of teeth, using logistic regression analysis with adjustment. However, dissatisfaction with daily life was more prevalent in groups with 10–19 teeth, and an unfavourable face-scale score was more prevalent in individuals with 10–19 teeth or no teeth than in subjects with ‡20 teeth. Dissatisfaction with daily life or with social interactions was significantly more prevalent in dependent subjects than in independent subjects. Gender difference was also slightly observed in satisfaction with daily life or social interactions (Table 1).

Discussion
In the present study, we found a relationship between poor chewing ability and poor QOL status in 80-yearold subjects. The relationship was confirmed by logistic regression analysis with adjustment for confounding factors. No consistent significant relationship was found between number of teeth and QOL status. Thus,

Table 1. Logistic regression analysis of prevalence of poor QOL, adjusted for various confounding factors, in relation to number of chewable foods or number of teeth Satisfaction with physical condition Number of chewable foods 15 1 10 to 14 1Æ2 (0Æ9–1Æ8) 5 to 9 2Æ1 (1Æ3–3Æ2)** 0 to 4 2Æ7 (1Æ4–5Æ4)** Gender difference 1Æ0 (0Æ7–1Æ5) Spouse status 1Æ1 (0Æ7–1Æ5) ADL status 1Æ0 (0Æ6–1Æ7) Number of teeth ‡20 1 10 to 19 1Æ0 (0Æ6–1Æ6) 1 to 9 0Æ9 (0Æ5–1Æ4) 0 0Æ9 (0Æ6–1Æ4) Gender difference 1Æ1 (0Æ8–1Æ6) Spouse status 1Æ0 (0Æ7–1Æ5) ADL status 1Æ2 (0Æ8–2Æ0) Mood after a meal Satisfaction with daily life Satisfaction with social interactions Face-scale score

1 1Æ7 2Æ2 2Æ4 0Æ9 1Æ0 1Æ2 1 1Æ4 1Æ5 1Æ6 0Æ9 1Æ0 1Æ4

(1Æ2–2Æ4)** (1Æ4–3Æ3)*** (1Æ3–4Æ5)** (0Æ6–1Æ2) (0Æ7–1Æ4) (0Æ7–2Æ0)

1 1Æ1 1Æ6 3Æ4 0Æ6 1Æ5 2Æ0 1 2Æ3 1Æ5 1Æ4 0Æ7 1Æ4 2Æ7

(0Æ7–1Æ9) (0Æ9–2Æ9) (1Æ6–7Æ0)*** (0Æ4–1Æ0)* (0Æ9–2Æ4) (1Æ1–3Æ5)*

1 1Æ4 3Æ8 3Æ9 0Æ5 0Æ9 2Æ4 1 1Æ4 1Æ2 1Æ4 0Æ6 1Æ0 2Æ9

(0Æ8–2Æ6) (2Æ0–7Æ2)*** (1Æ7–8Æ9)** (0Æ3–0Æ9)* (0Æ5–1Æ6) (1Æ3–4Æ3)**

1 1Æ3 1Æ2 2Æ4 0Æ9 0Æ8 1Æ2 1 1Æ9 1Æ5 1Æ6 0Æ9 0Æ8 1Æ3

(0Æ9–1Æ9) (0Æ8–1Æ9) (0Æ3–4Æ6)** (0Æ6–1Æ3) (0Æ5–1Æ1) (0Æ7–2Æ1)

(0Æ8–2Æ3) (1Æ0–2Æ5) (1Æ0–2Æ5) (0Æ6–1Æ3) (0Æ7–1Æ4) (0Æ9–2Æ3)

(1Æ1–4Æ7)* (0Æ8–3Æ1) (0Æ7–2Æ7) (0Æ4–1Æ1) (0Æ9–2Æ3) (1Æ6–4Æ5)***

(0Æ7–3Æ0) (0Æ6–2Æ6) (0Æ7–2Æ8) (0Æ4–1Æ0) (0Æ6–1Æ6) (1Æ7–5Æ1)***

(1Æ2–3Æ2)* (0Æ9–2Æ4) (1Æ0–2Æ6)* (0Æ6–1Æ2) (0Æ5–1Æ1) (0Æ8–2Æ2)

Values are given as OR (95% CI). * P < 0.05, ** P < 0.01, *** P < 0.001.
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 330–334

QOL AND CHEWING IN THE ELDERLY
chewing ability, but not number of teeth, may contribute to QOL status in very elderly individuals. Similarly, QOL in centenarians was associated with preservation of masticating ability (29). Locker et al. (15) also found a negative impact of oral disorders upon well-being and life satisfaction in elderly people with a mean age of 83 years. Although the association of chewing ability but not number of teeth with QOL measures in the present study might appear paradoxical, it could be explained by drawing the distinction that functional teeth related to chewing ability may improve QOL in octogenarians. It might also be possible that simply counting teeth is not enough to evaluate an oral status. Some attempt to estimate the function of teeth is probably necessary. The simplest way would be to count the occluding pairs of teeth or using a functional index such as the Eichner index, often used in European studies. In our previous studies, impaired physical activity associated with tooth loss was found to be improved by use of dentures (16). Furthermore, electrocardiographic ST segment (the segment between the end of the QRS complex and the beginning of the T wave) depression indicative of myocardial ischaemia was linked with poor dentition status in elderly subjects (30). We also found an association between chewing ability and physical ability (17) or ADL (18) in an 80-year-old population. Heydecke et al. (31) found that mandibular overdentures retained by two implants provided elderly patients with improved oral healthrelated QOL, and also detected that general healthrelated QOL may be improved in the implant group. Although the reason why chewing ability and number of teeth differed in importance was not established in the present study, our present and previous findings together with Heydecke’s observations suggest that QOL status might be improved in elderly patients by enhancing chewing ability using appropriate dentures. However, as no Japanese oral health-related QOL measures existed at the time of this study, some concerns remained about the instrument for evaluating QOL. It also is possible that a cross cultural validity of the chewing ability scale might be questionable. These could be a limitation for the present study. An ‘80/20 movement’ recently was set as a goal in Japan, referring to retention of ‡20 teeth at age 80 years (32). This 80/20 movement includes nationwide surveys concerning relationships between general and oral conditions in 80-year-old subjects; the present study was performed as part of this initiative. Precision of analysis presumably was enhanced in our survey by limiting subject age to 80 years, as an influence of age could be completely excluded in statistical analysis. As chewing ability reflects the subjects self-perceived ability to chew different foods, it may be closer related to the subject’s overall satisfaction with his/her daily life, social interactions, and other quality of life measures than a more hard measure as number of teeth. Furthermore, as functional status is a key domain of QOL, and chewing ability is intrinsically linked to functional status, the finding that chewing ability is closely related to QOL may appear tautological in a sense. Yet, it has the important implication that QOL status may be promoted by oral care. In conclusion, self-assessed chewing ability but not number of teeth was associated with QOL in 80-yearold subjects.

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Acknowledgments
This work was supported in part by Grants-in-Aid for Scientific Research (B) 15390655, (C) 15592194, and (C) 16592092 from Japan Society for the Promotion of Science.

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Correspondence: Dr. Yutaka Takata, Division of General Internal Medicine, Department of Health Promotion, Kyushu Dental College, Manazuru 2-6-1, Kokurakita-ku, Kitakyushu City, 803-8580, Japan. E-mail: yutaka@kyu-dent.ac.jp

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 330–334

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