J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING©
DENTITION STATUS, MALNUTRITION AND MORTALITY AMONG OLDER SERVICE HOUSING RESIDENTS R.K.T. SAARELA1, H. SOINI2, K. HILTUNEN3, S. MUURINEN4, M. SUOMINEN5, K. PITKALA6 1. City of Helsinki, Department of social services and health care, Oral Health Care, Finland;2. City of Helsinki, Department of social services and health care, Developmental and operational support, Finland; 3. University of Helsinki, Institute of Dentistry; 4. National Institute for Health and Welfare, Finland; 5. Society of Memory Disorders Expertise in Finland, Helsinki, Finland; 6. Helsinki University Central Hospital, Unit of Primary Health Care and University of Helsinki, Department of General Practice, Finland. Corresponding author: Riitta Saarela, MSc, Department of social services and health care, Oral Health Care, Kaikukatu 3A, P.O. Box 6452, FI-00099 City of Helsinki, Phone: +358 40 336 0880, Fax: +358 9 310 42602, Email: riitta.saarela(at)hel.fi
Abstract: Background: Oral health status and oral health problems can affect eating habits and thus consequently the nutritional status of frail older people. Objectives: To assess older service house residents' dentition and its associations with nutritional status and eating habits, and as well as to explore the prognostic value of dentition status for mortality. Design: A cross-sectional study with a three-year follow-up. Methods: In 2007, we assessed the nutritional status of all residents in service houses in the two cities of Helsinki and Espoo in Finland (N=2188). Altogether 1475 subjects (67%) participated in the study; dentition status data were available for 1369 of them. Using a personal interview and assessment, trained nurses familiar to the resident collected the subjects´ demographic data, medical history, functional and cognitive status, information on dentition status, oral symptoms, eating habits and diets. We assessed nutritional status with the Mini Nutritional Assessment (MNA), and retrieved information on mortality from central registers on 6 July 2010. Results: Edentulousness was common; more than half of the residents (52%) had lost all their teeth: 7% (n=94) were totally edentulous without prosthesis (Group 1), 45% (n=614) had removable dentures (Group 2), and 48% (n = 661) of the residents, had some natural teeth left (Group 3). Dentition status was associated with age, gender, education and disability. According to the MNA, 13% were malnourished, 65% were at risk for malnutrition, and 22% were well nourished. Edentulousness without prosthesis was associated with malnutrition, oral symptoms and infrequent use of oral care services. In Group 1, 52% were deceased during follow-up period. The respective figures for Groups 2 and 3 were 48% and 40% (p=0.004). However, in Cox regression analysis adjusted for age, gender, comorbidity and MNA score, dentition status no longer predicted mortality. Conclusion: Edentulousness is still common among older service housing residents. Edentulousness without prosthesis was associated with poor nutritional status, oral symptoms and infrequent use of dental services. These findings suggest the need for co-operation between nursing staff and oral care services. Key words: Dentition status, nutrition, mortality, older adults, service housing residents.
frail persons, have shown that about one third of aged nursing home residents and about half of aged long-term care hospital patients were malnourished (18, 19). Also, nutritional problems are often poorly recognised and left untreated (19, 20). Lamy et al. (21) reported that edentulous subjects without dentures or with only one complete denture had significantly lower MNA scores, and consumed mashed food more frequently than did edentulous subjects with two complete dentures in both jaws. Soini et al. (22) showed that the number of eating problems was significantly associated with the MNA score, and that those with chewing and swallowing problems had lower MNA scores. Furthermore, several studies have shown an association between malnutrition and mortality (23-25), and between dentition status and mortality (26-31). In Finland service housing is provided for persons who cannot cope with everyday life in their own homes on home care. The residents mainly live in their own flats or in their own room in a group homes. The nursing care is provided round a clock and medical services are provided by primary care physicians. Little is known about dentition status and its association with the nutritional status and mortality of residents living in service houses. In our current study, we aimed to
Introduction In Finland, edentulousness is still common even though oral health has improved in past decades. A decade ago, a large and representative national survey in Finland showed that half of the population over 75 years of age was edentulous (1). The relationship between oral health and nutrition is multidirectional (2). Nutritional factors play a role in the development and prevention of oral diseases and tooth loss (2). The state of oral health affects an older persons´ ability and desire to eat and to maintain adequate nutritional status (3, 4). When chewing ability declines, people choose to eat foods that require less mastication or they process their food to make it easier to chew (5). These changes can lead to adverse changes in nutrient intake (6-8), diet quality (9-11), and quality of life (12-14). Joshipura et al. (15), for example, showed that edentulous participants consumed fewer vegetables, less fiber and carotene, and more cholesterol, saturated fat and calories than did participants with 25 or more teeth. Older people, especially those living in institutions, are at special risk for malnutrition (16-17). Finnish studies based on the Mini Nutritional Assessment MNA –test, which is wellvalidated and widely used nutritional screening tool in older, Received January 3, 2012 Accepted for publication March 13, 2013
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J Nutr Health Aging
DENTITION STATUS, MALNUTRITION AND MORTALITY AMONG OLDER SERVICE HOUSING RESIDENTS assess the dentition status of the older service housing residents (≥65 years) and its associations with nutritional status and eating habits. We also explored the prognostic value of dentition status for mortality. Materials and methods This research was originally a developmental project funded by two municipalities to improve the nutritional care of older residents in institutional care. This study comprised all service housing residents aged 65+ years in the cities of Helsinki and Espoo in Finland (N=2188). Altogether, 1475 (67%) residents participated in the study, 1369 of them, had available dentition status data. The rest either refused (28%) or were residents in temporary respite care (5%). The local ethics committee of the Helsinki University Hospital approved the study, and all participants provided their informed consent. Ward nurses familiar to residents interviewed and assessed each resident. The nurses received detailed training prior performing assessment. The structured questionnaire included information on demographics, dentition status, oral symptoms, medical diagnoses, functional and cognitive status, and eating habits. Ward nurses evaluated dentition status interviewing, observing and assessing the residents. All the residents´ active medical diagnoses were retrieved from their medical records. Comorbidity was computed for each resident using Charlson’s comorbidity index (32). This index is a validated and widely used weighted index, which take into account the seriousness and number of resident´s comorbid diseases. Cognitive and physical functioning were evaluated with questions retrieved from the Clinical Dementia Rating Scale (CDR) (33). The subject’s stage of cognition was evaluated according to the “Memory” score in the CDR (0 = no memory problems, 0.5 = possible memory problems, 1 = mild problems, 2 = moderate problems, or 3 = severe problems) and divided into two groups: those with CDR < 1 and those with CDR > 1 (cognitive impairment). Their dependence in activities of daily living (ADLs) was assessed according to the CDR “personal care” item. A CDR > 2 was defined as dependence in ADLs (requiring assistance in dressing, hygiene, managing personal effects, or requiring significant help with personal care, often involving incontinence). Mobility was assessed with the question “Can the resident walk indoors?”, (yes/no). Information on 3 –year mortality was retrieved from central registers on 6 July 2010. The nutritional status of each resident was assessed using the Mini Nutritional Assessment (MNA) (34). The MNA consist of measurements and questions of four categories: anthoropometric measurements, general status, dietary information and subjective assessment. Fewer than 17 points indicates malnutrition, 17-23.5 indicates a risk for malnutrition, and more than 23.5 points indicates good nutritional status. Residents’ weight and height were measured and their body mass index (BMI) was calculated by dividing a resident´s weight by the square of his/her height in metres. The nurses provided information about residents´ eating habits and diets. 2
The consistency of food was defined by three categories: normal food, soft food, pureed or liquid food. Nurses familiar to the residents observed and evaluated the average amount of food eaten in a normal meal compared with a model meal, which was provided as an image for the nurses. The amount of meal eaten by a resident was then categorised as eating adequately (usually eating amount of a model meal) or little (usually eating less than a model meal). The use of snacks in the service house between meals was enquired with yes/no questions. Oral symptoms (yes/no) were categorised as follows: chewing problems, swallowing difficulties, pain in the mouth, and dry mouth. The use of oral care services was assessed with the question and the responses provided by nurses: “When was the most recent oral examination performed by a dentist or dental hygienist? Responses were categorised as follows: 1 = less than one year ago, 2 = one to three years ago and 3 = more than three years ago. Statistical analysis We analysed the data using SPSS and NCSS statistical programs. The residents´ dentition status was classified according to the type of dentition: Group 1: edentulous without dentures; Group 2: edentulous with some removable dentures in one or both jaws (complete or partial); Group 3: all or some natural teeth left with or without removable denture in one or both jaws. The number of teeth was not counted. We compared these three dentition status groups using the X2 test or Fischer´s exact test for categorical variables and the Kruskal-Wallis -test for continuous variables. P –values < 0.05 were considered statistically significant. Cox regression analysis was used to explore the prognostic value of dentition status on mortality. Results Table 1 shows the characteristics of participants living in service housing according to their dentition status. Of the residents, 79% were women. The residents´ mean age was 83 years, 56% had a low level of education (i.e. primary school or less). The residents had lived in the present service house for a mean of 2.9 years. Of the subjects, 7% (N=94) were totally edentulous with no dentures (Group 1) and 45% (N = 614) were edentulous, but had some kind of dentures (Group 2) (complete dentures being the most common in this group (N=520)), and 48% (N = 661) had some natural teeth left (Group 3). Diabetes and prior hip fracture diagnoses were significantly associated with dentition status categories being least common among those with natural teeth left. According to the CDR class “Memory”, 55% of the residents had cognitive impairment. Subjects in Group 1 more often required assistance in personal care than those the other two groups. The mobility of the subjects also differed according to dentition status groups. In Group 1 17% were unable to walk at all. The respective figure in Groups 2 and 3 was 10%.
J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING© Table 1 Characteristics of Participants Living in Service Houses According to Dentition Status (Group 1: Edentulous without dentures; Group 2: Edentulous with some removable dentures in one or both jaws (complete or partial); Group 3: All or some natural teeth left with or without removable denture in one or both jaws) Group 1 (N = 94)
Group 2 (N = 614)
Group 3 (N = 661)
P-value
82.0 (7.8) 59.8 63.1
84.0 (7.8) 81.7 68.1
81.6 (7.8) 79.1 44.8
< 0.001 < 0.001 < 0.001
21.3 23.4 29.8 54.3 16.0 18.1 17.4 2.8 (1.0)
20.4 30.2 26.1 56.8 21.2 10.0 15.9 2.9 (1.0)
14.8 28.1 24.5 62.3 22.1 10.4 10.9 2.9 (1.1)
0.022 0.36 0.51 0.080 0.40 0.056 0.019 0.71
57.3 84.1 16.7
53.9 66.7 10.3
56.4 67.8 9.6
0.63 0.004 0.007
Demographics Mean age, years mean (SD) Females, % Education,< 8 years % Medical diagnoses Diabetes, % Coronary heart disease, % Prior stroke,% Dementia,% Depression,% Other psychiatric disease,% Prior hip fracture, % Charlson´s comorbidity index, mean (SD) Functional and cognitive status CDR Memory score >1,% CDR personal care score > 2, % Unable to walk inside, %
We used the chi-square test for categorical variables and the Kruskal-Wallis -test for non-normally distributed continuous variables to test for differences between the groups. SD = standard deviation. Charlson comorbidity index (32)
Table 2 Nutritional Status, Eating habits, and Oral Health of Participants Living in Service Houses According to Dentition Status: Group 1: edentulous without dentures; Group 2: edentulous with some removable dentures in one or both jaws (complete or partial); Group 3: All or some natural teeth left with or without removable denture in one or both jaws
Nutritional status MNA < 17 (malnutrition), % MNA 17-23.5(at risk of malnutrition),% MNA >23,5 (well nourished), % Mean BMI, Consistency of food, pureed or soft, % Eats little during meals, % Eats snacks, % Oral symptoms Chewing problems, % Dry mouth % Pain in the mouth, % Swallowing difficulties, % Oral examination < 3 years ago
Group 1 (N = 94)
Group 2 (N = 614)
Group 3 (N = 661)
P-value
23.4 62.8 13.8 24.7 47.3 16.5 54.9
12.2 63.8 23.9 25.7 7.4 27.4 60.1
12.1 65.5 22.4 25.4 11.2 22.6 58.4
0.063 < 0.001 0.003 0.600
55.3 16.0 6.4 21.3 50.0
19.7 23.1 7.3 11.1 62.9
17.2 20.9 6.5 11.5 81.5
< 0.001 0.24 0.83 0.015 < 0.001
0.014
We used the chi-square test for categorical variables and the Kruskal-Wallis -test for non-normally distributed continuous variables to test for differences between the groups. SD = standard deviation.
The association between dentition status and nutritional status and eating habits as well as between oral symptoms and the use of oral care services appears in Table 2. According the MNA, 22% of the service housing residents were well nourished and 13% malnourished. Nutritional status was significantly associated with dentition status (p = 0.014). Of the participants in Group 1, 23% were malnourished, 63% were at risk of malnutrition and 14% were well nourished. The respective figures for the Group 2 were 12%, 64% and 24%. In the Group 3 12% of the participants were malnourished, 65% at
risk of malnutrition and 22% were well nourished. Most of the residents were able to eat normal food. Dentition status categories were significantly associated with the consistency of food offered. Puréed or soft food was most common in Group 1. Of the subjects, 76% ate a normal amount of their food at meals. According to nurses´ evaluation totally edentulous residents (Group 1) on average ate adequately from the main meals more often than did other groups. Group 1 suffered from chewing problems and swallowing difficulties more often than Groups 2 and 3. Subjects in group 1 had more 3
J Nutr Health Aging
DENTITION STATUS, MALNUTRITION AND MORTALITY AMONG OLDER SERVICE HOUSING RESIDENTS often oral symptoms, but used oral care services less frequently than did those in Groups 2 and 3. Of the residents, 44% were deceased during the three-year follow-up. Of the subjects in Group 1, more than half (52%) were deceased; the respective figure in Group 2 was 48% and in Group 3 40% (P = 0.004). In the Cox regression analysis adjusted for age, gender, comorbidity and MNA score, dentition status no longer predicted mortality (Group 1: HR 1.19 (95%CI 0.87 to 1.63) and Group 2: HR 1.15 (95%CI 0.97 to 1.37) when Group 3 is used as the references group (HR 1.0). The findings were essentially the same when the analysis was repeated without MNA score (Group 1: HR 1.29 (95%CI 0.95 to 1.77) and Group 2: HR 1.13 (95%CI 0.96 to 1.34).
Understandably, pureed or soft food consumption was also reported most frequently in edentulous subjects without dentures. Surprisingly, the nurses´ evaluation indicated that edentulous residents in Group 1 ate normal amounts of food at meals more often than did those in other groups. This may be due to the fact that residents in Group 1 more often consumed pureed or soft food, the amount of which is difficult to evaluate and to compare with portions of normal food. It is alarming that Group 1 having the highest number of oral symptoms had the least possibilities to oral examinations. Bivariate analysis revealed that dentition status was significantly associated with mortality, although this association diminished after adjustment for age, gender, MNA score and comorbidity. This finding is inconsistent with earlier findings, however. Shimazaki et al. (26) reported that the sixyear mortality rate controlling for age, sex, physical-mental health status, type of institution, cerebrovascular disorder, cardiovascular disease and musculo-skeletal disease among edentulous subjects without dentures was significantly higher than that among subjects with 20 or more teeth. In Finnish study by Hämäläinen et al. (27) found that the smaller the number of teeth the subject had, the higher their risk of death. Dental variables proved to be significant predictors of mortality even after controlling for gender, number of chronic diseases and self-rated health. Österberg et al. (30) showed that the number of teeth was still an important predictor of mortality after adjusting for the most important covariates as health factors, sosio-economic factors and life-style factors. However, in all these three studies the population differs from ours having significantly less disabilities and comorbidities. Thus, in our frail population living their last years of life there are several other competing factors contributing to mortality. For example, based on previous studies (23-25) we considered nutritional status as a potential confounder in the analysis of the relationship between dentition status and mortality. The relationship between oral health and nutrition is multidirectional and complex (2, 37). Our results suggest a need for co-operation between nursing staff and oral health care professionals to maintain good nutritional status of older service housing residents. Dentition status and oral health should be considered a part of the nutritional assessment of older adults. There seems to be a need for training nurses to consider these issues. Older adults should also have regular oral examinations and treatment.
Discussion According to our findings edentulousness is still common among Finnish elderly residents living in service housing: more than half of the residents had lost all their teeth and 7% were edentulous without dentures. Edentulousness was associated with higher age, lower education, diabetes, disability, poor nutritional status, reported oral symptoms and poorer use of dental services. Mortality was higher among edentulous residents without dentures, but when adjusting for age, gender, comorbidity and MNA, dentition status lost its predictive value for mortality. The strength of our study is its large and representative sample of residents living in service housing in metropolitan area of Finland. The study population consisted of all residents residing in service housing in the cities of Espoo and Helsinki, 67% of whom participated in the study. Well-trained nurses collected the data on demographic factors; functional, nutritional and dentition status; as well as other study information. Information on medical diagnoses was obtained from medical records, which support the validity of data. In addition, nutritional status was measured with the MNA test (34), which is a simple, well-validated instrument developed especially for assessing the nutritional status of aged individuals. One limitation of our study is its cross-sectional design, which makes it impossible to draw causal relationships between dentition status and nutrition. An additional limitation of this study is that the number of teeth was not counted. Therefore, the group 3, with some natural teeth remaining, and with or without dentures to support their occlusal status, can be a heterogeneous group. Our results are consistent with those of earlier reports (21, 35) that dentition status among institutionalised older people is poor. Over 50% of the residents in our study were edentulous and 7% of the sample had no dentures. Those residents who were edentulous and had no dentures were at particular risk for malnutrition. This finding is in line with those of previous studies by Lamy et al. (21), Andersson et al. (36) and Soini e al. (35).
Acknowledgments: Conflict of Interest: The authors declare that there is no conflict of interest related to this study. The study was supported by the Cities of Helsinki and Espoo.
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DENTITION STATUS, MALNUTRITION AND MORTALITY AMONG OLDER SERVICE HOUSING RESIDENTS R.K.T. SAARELA1, H. SOINI2, K. HILTUNEN3, S. MUURINEN4, M. SUOMINEN5, K. PITKALA6 1. City of Helsinki, Department of social services and health care, Oral Health Care, Finland;2. City of Helsinki, Department of social services and health care, Developmental and operational support, Finland; 3. University of Helsinki, Institute of Dentistry; 4. National Institute for Health and Welfare, Finland; 5. Society of Memory Disorders Expertise in Finland, Helsinki, Finland; 6. Helsinki University Central Hospital, Unit of Primary Health Care and University of Helsinki, Department of General Practice, Finland. Corresponding author: Riitta Saarela, MSc, Department of social services and health care, Oral Health Care, Kaikukatu 3A, P.O. Box 6452, FI-00099 City of Helsinki, Phone: +358 40 336 0880, Fax: +358 9 310 42602, Email: riitta.saarela(at)hel.fi
Abstract: Background: Oral health status and oral health problems can affect eating habits and thus consequently the nutritional status of frail older people. Objectives: To assess older service house residents' dentition and its associations with nutritional status and eating habits, and as well as to explore the prognostic value of dentition status for mortality. Design: A cross-sectional study with a three-year follow-up. Methods: In 2007, we assessed the nutritional status of all residents in service houses in the two cities of Helsinki and Espoo in Finland (N=2188). Altogether 1475 subjects (67%) participated in the study; dentition status data were available for 1369 of them. Using a personal interview and assessment, trained nurses familiar to the resident collected the subjects´ demographic data, medical history, functional and cognitive status, information on dentition status, oral symptoms, eating habits and diets. We assessed nutritional status with the Mini Nutritional Assessment (MNA), and retrieved information on mortality from central registers on 6 July 2010. Results: Edentulousness was common; more than half of the residents (52%) had lost all their teeth: 7% (n=94) were totally edentulous without prosthesis (Group 1), 45% (n=614) had removable dentures (Group 2), and 48% (n = 661) of the residents, had some natural teeth left (Group 3). Dentition status was associated with age, gender, education and disability. According to the MNA, 13% were malnourished, 65% were at risk for malnutrition, and 22% were well nourished. Edentulousness without prosthesis was associated with malnutrition, oral symptoms and infrequent use of oral care services. In Group 1, 52% were deceased during follow-up period. The respective figures for Groups 2 and 3 were 48% and 40% (p=0.004). However, in Cox regression analysis adjusted for age, gender, comorbidity and MNA score, dentition status no longer predicted mortality. Conclusion: Edentulousness is still common among older service housing residents. Edentulousness without prosthesis was associated with poor nutritional status, oral symptoms and infrequent use of dental services. These findings suggest the need for co-operation between nursing staff and oral care services. Key words: Dentition status, nutrition, mortality, older adults, service housing residents.
frail persons, have shown that about one third of aged nursing home residents and about half of aged long-term care hospital patients were malnourished (18, 19). Also, nutritional problems are often poorly recognised and left untreated (19, 20). Lamy et al. (21) reported that edentulous subjects without dentures or with only one complete denture had significantly lower MNA scores, and consumed mashed food more frequently than did edentulous subjects with two complete dentures in both jaws. Soini et al. (22) showed that the number of eating problems was significantly associated with the MNA score, and that those with chewing and swallowing problems had lower MNA scores. Furthermore, several studies have shown an association between malnutrition and mortality (23-25), and between dentition status and mortality (26-31). In Finland service housing is provided for persons who cannot cope with everyday life in their own homes on home care. The residents mainly live in their own flats or in their own room in a group homes. The nursing care is provided round a clock and medical services are provided by primary care physicians. Little is known about dentition status and its association with the nutritional status and mortality of residents living in service houses. In our current study, we aimed to
Introduction In Finland, edentulousness is still common even though oral health has improved in past decades. A decade ago, a large and representative national survey in Finland showed that half of the population over 75 years of age was edentulous (1). The relationship between oral health and nutrition is multidirectional (2). Nutritional factors play a role in the development and prevention of oral diseases and tooth loss (2). The state of oral health affects an older persons´ ability and desire to eat and to maintain adequate nutritional status (3, 4). When chewing ability declines, people choose to eat foods that require less mastication or they process their food to make it easier to chew (5). These changes can lead to adverse changes in nutrient intake (6-8), diet quality (9-11), and quality of life (12-14). Joshipura et al. (15), for example, showed that edentulous participants consumed fewer vegetables, less fiber and carotene, and more cholesterol, saturated fat and calories than did participants with 25 or more teeth. Older people, especially those living in institutions, are at special risk for malnutrition (16-17). Finnish studies based on the Mini Nutritional Assessment MNA –test, which is wellvalidated and widely used nutritional screening tool in older, Received January 3, 2012 Accepted for publication March 13, 2013
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DENTITION STATUS, MALNUTRITION AND MORTALITY AMONG OLDER SERVICE HOUSING RESIDENTS assess the dentition status of the older service housing residents (≥65 years) and its associations with nutritional status and eating habits. We also explored the prognostic value of dentition status for mortality. Materials and methods This research was originally a developmental project funded by two municipalities to improve the nutritional care of older residents in institutional care. This study comprised all service housing residents aged 65+ years in the cities of Helsinki and Espoo in Finland (N=2188). Altogether, 1475 (67%) residents participated in the study, 1369 of them, had available dentition status data. The rest either refused (28%) or were residents in temporary respite care (5%). The local ethics committee of the Helsinki University Hospital approved the study, and all participants provided their informed consent. Ward nurses familiar to residents interviewed and assessed each resident. The nurses received detailed training prior performing assessment. The structured questionnaire included information on demographics, dentition status, oral symptoms, medical diagnoses, functional and cognitive status, and eating habits. Ward nurses evaluated dentition status interviewing, observing and assessing the residents. All the residents´ active medical diagnoses were retrieved from their medical records. Comorbidity was computed for each resident using Charlson’s comorbidity index (32). This index is a validated and widely used weighted index, which take into account the seriousness and number of resident´s comorbid diseases. Cognitive and physical functioning were evaluated with questions retrieved from the Clinical Dementia Rating Scale (CDR) (33). The subject’s stage of cognition was evaluated according to the “Memory” score in the CDR (0 = no memory problems, 0.5 = possible memory problems, 1 = mild problems, 2 = moderate problems, or 3 = severe problems) and divided into two groups: those with CDR < 1 and those with CDR > 1 (cognitive impairment). Their dependence in activities of daily living (ADLs) was assessed according to the CDR “personal care” item. A CDR > 2 was defined as dependence in ADLs (requiring assistance in dressing, hygiene, managing personal effects, or requiring significant help with personal care, often involving incontinence). Mobility was assessed with the question “Can the resident walk indoors?”, (yes/no). Information on 3 –year mortality was retrieved from central registers on 6 July 2010. The nutritional status of each resident was assessed using the Mini Nutritional Assessment (MNA) (34). The MNA consist of measurements and questions of four categories: anthoropometric measurements, general status, dietary information and subjective assessment. Fewer than 17 points indicates malnutrition, 17-23.5 indicates a risk for malnutrition, and more than 23.5 points indicates good nutritional status. Residents’ weight and height were measured and their body mass index (BMI) was calculated by dividing a resident´s weight by the square of his/her height in metres. The nurses provided information about residents´ eating habits and diets. 2
The consistency of food was defined by three categories: normal food, soft food, pureed or liquid food. Nurses familiar to the residents observed and evaluated the average amount of food eaten in a normal meal compared with a model meal, which was provided as an image for the nurses. The amount of meal eaten by a resident was then categorised as eating adequately (usually eating amount of a model meal) or little (usually eating less than a model meal). The use of snacks in the service house between meals was enquired with yes/no questions. Oral symptoms (yes/no) were categorised as follows: chewing problems, swallowing difficulties, pain in the mouth, and dry mouth. The use of oral care services was assessed with the question and the responses provided by nurses: “When was the most recent oral examination performed by a dentist or dental hygienist? Responses were categorised as follows: 1 = less than one year ago, 2 = one to three years ago and 3 = more than three years ago. Statistical analysis We analysed the data using SPSS and NCSS statistical programs. The residents´ dentition status was classified according to the type of dentition: Group 1: edentulous without dentures; Group 2: edentulous with some removable dentures in one or both jaws (complete or partial); Group 3: all or some natural teeth left with or without removable denture in one or both jaws. The number of teeth was not counted. We compared these three dentition status groups using the X2 test or Fischer´s exact test for categorical variables and the Kruskal-Wallis -test for continuous variables. P –values < 0.05 were considered statistically significant. Cox regression analysis was used to explore the prognostic value of dentition status on mortality. Results Table 1 shows the characteristics of participants living in service housing according to their dentition status. Of the residents, 79% were women. The residents´ mean age was 83 years, 56% had a low level of education (i.e. primary school or less). The residents had lived in the present service house for a mean of 2.9 years. Of the subjects, 7% (N=94) were totally edentulous with no dentures (Group 1) and 45% (N = 614) were edentulous, but had some kind of dentures (Group 2) (complete dentures being the most common in this group (N=520)), and 48% (N = 661) had some natural teeth left (Group 3). Diabetes and prior hip fracture diagnoses were significantly associated with dentition status categories being least common among those with natural teeth left. According to the CDR class “Memory”, 55% of the residents had cognitive impairment. Subjects in Group 1 more often required assistance in personal care than those the other two groups. The mobility of the subjects also differed according to dentition status groups. In Group 1 17% were unable to walk at all. The respective figure in Groups 2 and 3 was 10%.
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THE JOURNAL OF NUTRITION, HEALTH & AGING© Table 1 Characteristics of Participants Living in Service Houses According to Dentition Status (Group 1: Edentulous without dentures; Group 2: Edentulous with some removable dentures in one or both jaws (complete or partial); Group 3: All or some natural teeth left with or without removable denture in one or both jaws) Group 1 (N = 94)
Group 2 (N = 614)
Group 3 (N = 661)
P-value
82.0 (7.8) 59.8 63.1
84.0 (7.8) 81.7 68.1
81.6 (7.8) 79.1 44.8
< 0.001 < 0.001 < 0.001
21.3 23.4 29.8 54.3 16.0 18.1 17.4 2.8 (1.0)
20.4 30.2 26.1 56.8 21.2 10.0 15.9 2.9 (1.0)
14.8 28.1 24.5 62.3 22.1 10.4 10.9 2.9 (1.1)
0.022 0.36 0.51 0.080 0.40 0.056 0.019 0.71
57.3 84.1 16.7
53.9 66.7 10.3
56.4 67.8 9.6
0.63 0.004 0.007
Demographics Mean age, years mean (SD) Females, % Education,< 8 years % Medical diagnoses Diabetes, % Coronary heart disease, % Prior stroke,% Dementia,% Depression,% Other psychiatric disease,% Prior hip fracture, % Charlson´s comorbidity index, mean (SD) Functional and cognitive status CDR Memory score >1,% CDR personal care score > 2, % Unable to walk inside, %
We used the chi-square test for categorical variables and the Kruskal-Wallis -test for non-normally distributed continuous variables to test for differences between the groups. SD = standard deviation. Charlson comorbidity index (32)
Table 2 Nutritional Status, Eating habits, and Oral Health of Participants Living in Service Houses According to Dentition Status: Group 1: edentulous without dentures; Group 2: edentulous with some removable dentures in one or both jaws (complete or partial); Group 3: All or some natural teeth left with or without removable denture in one or both jaws
Nutritional status MNA < 17 (malnutrition), % MNA 17-23.5(at risk of malnutrition),% MNA >23,5 (well nourished), % Mean BMI, Consistency of food, pureed or soft, % Eats little during meals, % Eats snacks, % Oral symptoms Chewing problems, % Dry mouth % Pain in the mouth, % Swallowing difficulties, % Oral examination < 3 years ago
Group 1 (N = 94)
Group 2 (N = 614)
Group 3 (N = 661)
P-value
23.4 62.8 13.8 24.7 47.3 16.5 54.9
12.2 63.8 23.9 25.7 7.4 27.4 60.1
12.1 65.5 22.4 25.4 11.2 22.6 58.4
0.063 < 0.001 0.003 0.600
55.3 16.0 6.4 21.3 50.0
19.7 23.1 7.3 11.1 62.9
17.2 20.9 6.5 11.5 81.5
< 0.001 0.24 0.83 0.015 < 0.001
0.014
We used the chi-square test for categorical variables and the Kruskal-Wallis -test for non-normally distributed continuous variables to test for differences between the groups. SD = standard deviation.
The association between dentition status and nutritional status and eating habits as well as between oral symptoms and the use of oral care services appears in Table 2. According the MNA, 22% of the service housing residents were well nourished and 13% malnourished. Nutritional status was significantly associated with dentition status (p = 0.014). Of the participants in Group 1, 23% were malnourished, 63% were at risk of malnutrition and 14% were well nourished. The respective figures for the Group 2 were 12%, 64% and 24%. In the Group 3 12% of the participants were malnourished, 65% at
risk of malnutrition and 22% were well nourished. Most of the residents were able to eat normal food. Dentition status categories were significantly associated with the consistency of food offered. Puréed or soft food was most common in Group 1. Of the subjects, 76% ate a normal amount of their food at meals. According to nurses´ evaluation totally edentulous residents (Group 1) on average ate adequately from the main meals more often than did other groups. Group 1 suffered from chewing problems and swallowing difficulties more often than Groups 2 and 3. Subjects in group 1 had more 3
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DENTITION STATUS, MALNUTRITION AND MORTALITY AMONG OLDER SERVICE HOUSING RESIDENTS often oral symptoms, but used oral care services less frequently than did those in Groups 2 and 3. Of the residents, 44% were deceased during the three-year follow-up. Of the subjects in Group 1, more than half (52%) were deceased; the respective figure in Group 2 was 48% and in Group 3 40% (P = 0.004). In the Cox regression analysis adjusted for age, gender, comorbidity and MNA score, dentition status no longer predicted mortality (Group 1: HR 1.19 (95%CI 0.87 to 1.63) and Group 2: HR 1.15 (95%CI 0.97 to 1.37) when Group 3 is used as the references group (HR 1.0). The findings were essentially the same when the analysis was repeated without MNA score (Group 1: HR 1.29 (95%CI 0.95 to 1.77) and Group 2: HR 1.13 (95%CI 0.96 to 1.34).
Understandably, pureed or soft food consumption was also reported most frequently in edentulous subjects without dentures. Surprisingly, the nurses´ evaluation indicated that edentulous residents in Group 1 ate normal amounts of food at meals more often than did those in other groups. This may be due to the fact that residents in Group 1 more often consumed pureed or soft food, the amount of which is difficult to evaluate and to compare with portions of normal food. It is alarming that Group 1 having the highest number of oral symptoms had the least possibilities to oral examinations. Bivariate analysis revealed that dentition status was significantly associated with mortality, although this association diminished after adjustment for age, gender, MNA score and comorbidity. This finding is inconsistent with earlier findings, however. Shimazaki et al. (26) reported that the sixyear mortality rate controlling for age, sex, physical-mental health status, type of institution, cerebrovascular disorder, cardiovascular disease and musculo-skeletal disease among edentulous subjects without dentures was significantly higher than that among subjects with 20 or more teeth. In Finnish study by Hämäläinen et al. (27) found that the smaller the number of teeth the subject had, the higher their risk of death. Dental variables proved to be significant predictors of mortality even after controlling for gender, number of chronic diseases and self-rated health. Österberg et al. (30) showed that the number of teeth was still an important predictor of mortality after adjusting for the most important covariates as health factors, sosio-economic factors and life-style factors. However, in all these three studies the population differs from ours having significantly less disabilities and comorbidities. Thus, in our frail population living their last years of life there are several other competing factors contributing to mortality. For example, based on previous studies (23-25) we considered nutritional status as a potential confounder in the analysis of the relationship between dentition status and mortality. The relationship between oral health and nutrition is multidirectional and complex (2, 37). Our results suggest a need for co-operation between nursing staff and oral health care professionals to maintain good nutritional status of older service housing residents. Dentition status and oral health should be considered a part of the nutritional assessment of older adults. There seems to be a need for training nurses to consider these issues. Older adults should also have regular oral examinations and treatment.
Discussion According to our findings edentulousness is still common among Finnish elderly residents living in service housing: more than half of the residents had lost all their teeth and 7% were edentulous without dentures. Edentulousness was associated with higher age, lower education, diabetes, disability, poor nutritional status, reported oral symptoms and poorer use of dental services. Mortality was higher among edentulous residents without dentures, but when adjusting for age, gender, comorbidity and MNA, dentition status lost its predictive value for mortality. The strength of our study is its large and representative sample of residents living in service housing in metropolitan area of Finland. The study population consisted of all residents residing in service housing in the cities of Espoo and Helsinki, 67% of whom participated in the study. Well-trained nurses collected the data on demographic factors; functional, nutritional and dentition status; as well as other study information. Information on medical diagnoses was obtained from medical records, which support the validity of data. In addition, nutritional status was measured with the MNA test (34), which is a simple, well-validated instrument developed especially for assessing the nutritional status of aged individuals. One limitation of our study is its cross-sectional design, which makes it impossible to draw causal relationships between dentition status and nutrition. An additional limitation of this study is that the number of teeth was not counted. Therefore, the group 3, with some natural teeth remaining, and with or without dentures to support their occlusal status, can be a heterogeneous group. Our results are consistent with those of earlier reports (21, 35) that dentition status among institutionalised older people is poor. Over 50% of the residents in our study were edentulous and 7% of the sample had no dentures. Those residents who were edentulous and had no dentures were at particular risk for malnutrition. This finding is in line with those of previous studies by Lamy et al. (21), Andersson et al. (36) and Soini e al. (35).
Acknowledgments: Conflict of Interest: The authors declare that there is no conflict of interest related to this study. The study was supported by the Cities of Helsinki and Espoo.
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