DENTAL AND ORAL HEALTH

Chewing Ability and Tooth Loss: Association with Cognitive Impairment in an Elderly Population Study
Duangjai Lexomboon, DDS, PhD,* Mats Trulsson, DDS, PhD, Inger Wardh, DDS, PhD, and Marti G. Parker, PhD

OBJECTIVES: To determine whether there is an association between tooth loss, chewing ability, and cognitive function in a general elderly population. DESIGN: Data from the Panel Study of Living Conditions of the Oldest Old in 2002 were analyzed. Stepwise logistic regression analyses were used to examine the relationship between cognitive function and tooth loss and chewing ability. PARTICIPANTS: Five hundred fty-seven persons who were nationally representative of the Swedish population aged 77 and older. MEASUREMENTS: Cognitive function was measured using the abridged version of the Mini-Mental State Examination. Information on dental status and chewing difculty was obtained according to self-assessment. RESULTS: Persons with multiple tooth loss and persons with difculty chewing hard food had signicantly higher odds of cognitive impairment. When adjusted for sex, age, and education, the odds of cognitive impairment were not signicantly different between persons with natural teeth and with multiple tooth loss, but the odds of impairment remained signicantly higher for persons with chewing difculty even when adjusted for sex, age, education, depression, and mental illness. CONCLUSION: Sex, age, education, and certain illnesses do not explain the association between cognition and chewing ability. Whether elderly persons chew with natural teeth or prostheses may not contribute signicantly to cognitive impairment as long as they have no chewing difculty. The results add to the evidence of the association between chewing ability and cognitive impairment in elderly persons. J Am Geriatr Soc 60:19511956, 2012.

Key words: chewing ability; multiple cognitive impairment; elderly population

tooth

loss;

From the *Department of Health and Environmental Sciences, Oral Health, Karlstad University, Karlstad, Sweden; Department of Dental Medicine, Karolinska Institute, Hagalund, Sweden; and Aging Research Center, Karolinska Institute/Stockholm University, Karlstad, Sweden. Address correspondence to Duangjai Lexomboon, Department of Health and Environmental Sciences, Oral Health, Karlstad University, SE-651 88, Karlstad, Sweden. E-mail: duangjai.lexomboon@kau.se DOI: 10.1111/j.1532-5415.2012.04154.x

ognitive impairment in old age is an early sign of clinical dementia.1 Risk factors of dementia include genetic factors; vascular disease such as hypertension, diabetes mellitus, hypercholesterolemia, and cardiovascular disease; and lifestyle factors such as smoking, alcohol and drug abuse, diet, and stress.2 Protective factors include education, exercise, and active social engagement.2 These risk factors are interrelated, resulting in a complex etiology model that is not completely understood. Tooth loss has been shown to be associated with poorer cognitive function in some cross-sectional elderly population studies.35 Several pathways have been hypothesized. Periodontal diseases create inammation, which can increase the risk of cardiovascular disease,6 subsequently increasing the risk of metabolic disease and stroke, which are common risk factors for cognition decline and dementia. It has been hypothesized that periodontal disease causes systemic infection, which increases the risk of Alzheimers disease.7 Nevertheless, population studies and longitudinal studies have mixed results.811 Some studies relate cognitive performance to chewing function. In experimental studies in rats, chewing was shown to increase the survival of newly generated cells in the dentate gyrus of the hippocampus, the part of the brain that relates to cognition.12 Evidence in human studies is lacking. The relationship between mastication and cognitive impairment has been studied in various animal models.13 In an experimental study, male Wistar rats on a soft diet were shown to have lower neurogenesis in the dentate gyrus than those on a hard diet at all ages. In another experimental study, when all molar teeth were cut off in a group of mice, the learning ability of the mice in the water maze decreased. Fos protein, an indicator of neural plasticity, was also lower than in mice in the control group.

JAGS 60:19511956, 2012 2012, Copyright the Authors Journal compilation 2012, The American Geriatrics Society

0002-8614/12/$15.00

1952

LEXOMBOON ET AL.

OCTOBER 2012VOL. 60, NO. 10

JAGS

These effects were partially reversed when the teeth were restored with articial teeth. Three mechanisms explaining these animal studies were proposed to relate to a neurogenesis in part of the brain that is associated with cognition: an increase in corticosterone and a decrease of hippocampal glucocorticoid associated with stress, a disruption of cholinergic neurotransmitter system associated with learning ability, and spatial memory.13 Stress can increase hippocampus damage, and chewing is shown in rats to reduce stress-induced hippocampal long-term potentiation, the neuromechanism involving memory and learning in the hippocampus.12 Substantial evidence to demonstrate the pathway in humans is lacking. In humans, a few experimental studies have shown that chewing and clenching increase cerebral blood ow and may decrease the risk of cognitive impairment.14,15 Chewing a piece of spearmint gum was shown to be associated with immediate better cognitive performance,13 although there were many methodological limitations to this study. A reexamination study that controlled for potential bias reported no signicant difference in cognitive performance,16 and sucking gum was shown to have effects similar to chewing in another experimental study.17 In another experimental study, the association between chewing gum and cognitive performance depended on individual differences such as feeling thirsty and being an introvert.18 An association between chewing ability and cognition was found in a population study. Rural community residents aged 70 to 74 without dementia in Japan who reported having poor chewing ability were found to perform worse on some cognitive tests.19 Studies have been performed on community-based or other selected populations, but to the knowledge of the authors of the current study, no studies have included a representative sample of elderly people. The aim of this study was to determine whether there is an association between multiple tooth loss and cognitive impairment in a sample representative of the total elderly population and whether there is an association between chewing difculty and cognitive impairment.

recall, attention and concentration, visual-spatial ability, and comprehension. A cutoff point for cognitive impairment was determined through comparison with corresponding items in a sample of persons who had completed the entire MMSE and with clinical diagnoses of dementia.20 A score of 12 or less (out of a possible 18) corresponded to a score of 23 or less on the complete MMSE and was used to identify persons with cognitive impairment.

Independent Variables
The independent variables include self-reported dental status and chewing difculty. Participants were asked to choose from among ve phrases to describe the condition of their teeth. The answers were categorized into multiple tooth loss and having natural teeth. Multiple tooth loss included the phrases no teeth or only a few, complete dentures or partial dentures, and own teeth but in poor shape, i.e., many missing. Having natural teeth included own teeth, many crowns, llings, bridge, and own teeth in good shape, few llings. Being edentulous or having only a few teeth can be compromise chewing ability. Therefore, multiple tooth loss was used as an independent variable instead of edentulousness. Information on chewing difculty was obtained using a single question Can you chew hard food such as hard bread or apples? The answer Yes, without difculty was classied as not having chewing difculty. The answers Yes, but I must be careful and No, not at all were classied as having chewing difculty.

Confounding Variables
Analyses controlled for sex, age, and years of education. Older age and less education have been shown to be related to being edentulous and having poorer cognitive function.21 Other illnesses such as depression, mental illness, and cerebral thrombosis are also potential factors underlying chewing difculty and cognitive dysfunction.22 A history of these illnesses was also self-reported, with yes or no as the answer.

METHODS Data
The study analyzed data from the Swedish Panel Study of Living Conditions of the Oldest Old people (SWEOLD) in 2002. The Karolinska Institute regional ethics committee reviewed and approved the SWEOLD 2002 project (KI Dnr 03413), and permission to use the data was obtained from the Aging Research Center. The 736 potential participants were randomly selected, representing the national population aged 77 and older; 115 of these did not respond, and 621 (84.4%) were interviewed.

Samples Included in the Analysis

Of the 621 respondents, one lacked data on dental status and chewing difculty, 16 lacked data on MMSE score, and 82 were interviewed by proxy. The reasons for proxy interviews included frailty, dementia, hearing problems, and strokes that hindered a direct interview. The proxies were knowledgeable about chewing ability because they were care providers, spouses, or other close relatives who assisted with daily activities, including eating. Of persons who lacked data on MMSE score or were interviewed by proxy, 35 were diagnosed as having dementia. These persons were included in the analysis as having cognitive impairment. Five hundred fty-seven persons were therefore included in the nal analysis, with primarily complete data on independent and dependent variables. Respondents with missing data were slightly older than the respondents included in the analysis, but the sex difference and mean number of years of education were not statistically signicantly different.

Dependent Variable
Cognitive function was measured using an abridged version of the Mini-Mental State Examination (MMSE) that included the domains of registration, orientation, delayed

JAGS

OCTOBER 2012VOL. 60, NO. 10

ASSOCIATION BETWEEN CHEWING AND COGNITION

1953

Statistical Analysis
The MannWhitney test and Fisher exact test were used to determine the bivariate association between dependent and confounding variables and cognitive impairment. Two stepwise logistic regression analyses were used to determine the odds of having cognitive impairment with multiple tooth loss and with chewing difculty. Simple regression was used in Model 1. To adjust for sex, age, and years of education, stepwise multiple logistic regression analyses were performed in Model 2. In Model 3, the history of illness that was signicantly associated with cognitive impairment in bivariate analyses was added to the regression analysis of cognitive impairment with chewing difculty. The categorical variables used a simple contrast method with men, no history of illness, mainly natural teeth, and no chewing difculty as reference groups. All of the statistical analyses were performed using SPSS Statistics (Release 17.0.0, SPSS, Inc., Chicago, IL).

RESULTS
Of the 557 persons included in the analysis, 41.1% were men and 58.9% were women (Table 1) with a mean age of 83.0 4.7 (range 7798) and a mean of 8.0 3.0 years of education (range 227). The prevalence of multiple tooth loss was 59.2% and of chewing difculty was 20.8%. Persons with multiple tooth loss had signicantly higher rates of chewing difculty (P < .001, data not shown). In all, 22.1% of participants scored below the cutoff on the cognitive test. Except for a history of cerebral

thrombosis, all confounding variables and independent variables were signicantly associated with cognitive impairment (Table 1). Table 2 shows stepwise logistic regression with multiple tooth loss as the independent variable. Model 1 shows the simple regression, and Model 2 shows the results of regression analyses after sex, age, and education were entered into the analysis. The odds ratios (ORs) of cognitive impairment in persons with multiple tooth loss was 2.10 (P = .001) compared with persons with natural teeth, although the OR was not signicant after adjusting for sex, age, and years of education. Table 3 shows the results of stepwise regression analyses with chewing difculty as the independent variable. The regression was adjusted for sex, age, education, and history of illness, which were potential confounding factors. History of cerebral thrombosis was not included in the analysis because it was not signicantly associated with cognitive impairment. Three persons lacked data on depression or mental illness, so the number of persons included in the regression analyses is 554. The simple logistic regression in Model 1 shows the OR of cognitive impairment in persons with chewing difculty was 2.32 compared with persons without chewing difculty (P < .001). The odds remained signicantly higher when adjusted for sex, age, and education (OR = 1.82; P = .01) and when adjusted for history of depression and mental illness (OR = 1.72; P = .03). When the answers to the question about chewing difculty were dichotomized differently, that is, when persons who answered that they had to be careful when they chewed hard food were grouped with no chewing dif-

Table 1. Persons with and without Cognitive Impairment According to Sex and with and without Depression, Mental Illness, Cerebral Thrombosis, Dental Status, and Chewing Difculty (n = 557)
Without Cognitive Impairment Characteristic n n (%) With Cognitive Impairment P-Valuea

Sex Men Women Depression b No Yes Mental illnessb No Yes Cerebral thrombosisc No Yes Dental status Natural teeth Multiple tooth loss Chewing difculty No Yes Cognitive impairment No Yes
a b c

229 328 465 89 543 11 527 25 227 330 441 116 434 123

188 (82.1) 246 (75.0) 378 (81.3) 54 (60.7) 427 (78.6) 5 (45.5) 415 (78.7) 16 (64.0) 193 (85.0) 241 (73.0) 359 (81.4) 75 (64.7)

41 (17.9) 82 (25.0) 87 (18.7) 35 (39.3) 116 (21.4) 6 (54.5) 112 (21.3) 9 (36.0) 34 (15.0) 89 (27.0) 82 (18.6) 41 (35.3)

.049 <.001 .02

.07 <.001 <.001

Fisher exact test. n = 554 because of missing data. n = 552 because of missing data.

1954

LEXOMBOON ET AL.

OCTOBER 2012VOL. 60, NO. 10

JAGS

Table 2. Cognitive Impairment in Persons with and without Multiple Tooth Loss (n = 557)
Model 1 Odds Ratio (95% Condence Interval) Model 2 Odds Ratio (95% Condence Interval)

Factor

PValue

PValue

Women Age Years of education Multiple tooth loss

1.29 (0.822.01) 1.14 (1.091.19) 0.87 (0.790.96) 2.10 (1.353.25) .001 1.36 (0.842.19)

.26 <.001 .007 .20

culty, the prevalence of chewing difculty was lower, but all regressions gave similar results.

DISCUSSION
This cross-sectional study examined the association between self-reported chewing ability and tooth loss and cognitive function in the national Swedish population aged 77 and older. Multiple tooth loss and difculty chewing hard food were found to correlate with signicantly greater odds of cognitive impairment. The greater odds of cognitive impairment in persons with multiple tooth loss compared with persons with natural teeth became nonsignicant when sex, age, and education were entered into the regression analysis, but the difference in cognitive impairment between persons with and without chewing difculty remained signicant. The difference remained signicant even after history of depression and mental illness were added to the analysis. These ndings suggest that the association between tooth loss and cognition was mainly due to age and education in this population. The persisting signicantly greater odds of cognitive impairment in elderly persons with difculty chewing hard food after adjusting for confounding factors suggests that the association between cognition and chewing ability is stronger than the association with number of natural teeth. That is, an individuals perceived ability to chew hard food, with natural or prosthetic teeth, may be more important for cognition than tooth loss. The effect of poor chewing ability on cognition found in the

general Swedish elderly population was in agreement with the ndings of earlier studies with limited samples and community dwellers without dementia.19 Even though various causal associations between chewing and cognition have been proposed, the direction of association has still not been determined. It could be that cognitive impairment increases the likelihood of having difculty chewing. Persons with cognitive impairment may have poorer ability to maintain oral hygiene, which would increase the risk of dental caries and periodontal disease, the major causes of tooth loss and limited ability to chew hard food. The nonsignicant difference in cognitive impairment between having natural teeth and having multiple tooth loss does not support this direction of association. Although some studies show that elderly persons with cognitive impairment have a signicantly higher risk of having dental caries,23 the association between periodontal disease and cognitive impairment is not well established. Although a signicant association was found in the National Health and Nutrition Examination Survey (NHANES), a noninstitutionalized population survey in the United States, a 32-year prospective study of healthy men living in Boston,8,9 a longitudinal study of Catholic nuns in Milwaukee, and a 6-year prospective cohort study of institutionalized elderly people in a city of Japan all reported nonsignicant associations.10,11 In addition, a 7year longitudinal study found no signicant tooth loss pattern when comparing elderly adults with and without dementia.24 Therefore, it is less likely that having impaired cognition will lead to tooth loss and chewing difculty. The ndings of the current study leartoward the other direction of causal association. Although the results cannot determine whether the mechanism is the increase in cerebral blood ow, reduction of stress hormones, or both, they conrm the signicant association between ability to chew hard food and cognitive impairment. Experimental studies with small sample sizes show that chewing with maximum force with natural teeth or clenching with an implant prosthesis can increase cerebral blood but that chewing with lower force such as by tapping teeth did not.14,15 In another study, the ability to chew moderately hard and hard foods was shown to be associated with the ability to perform intellectual activities such as lling in pension forms and reading newspapers, but the ability to chew soft foods was not associated with intellectual activities.25 It is possible that persons with difculty chewing hard food avoid heavy chewing that can increase cerebral

Table 3. Cognitive Impairment in Persons with and without Chewing Difculty (n = 554)
Model 1 Odds Ratio (95% Condence Interval) Model 2 Odds Ratio (95% Condence Interval) Model 3 Odds Ratio (95% Condence Interval)

Factor

P-Value

P-Value

P-Value

Women Age Years of education Depression Mental illness Chewing difculty

1.38 (0.882.16) 1.14 (1.091.19) 0.87 (0.790.96) <.001

.16 <.001 .006

2.32 (1.483.65)

1.82 (1.132.94)

.01

1.28 1.14 0.87 2.29 3.38 1.72

(0.812.02) (1.091.19) (0.790.96) (1.353.90) (0.8812.90) (1.052.80)

.29 <.001 .007 .002 .07 .03

JAGS

OCTOBER 2012VOL. 60, NO. 10

ASSOCIATION BETWEEN CHEWING AND COGNITION

1955

blood ow, although the results of the current study cannot support the hypothesis that chewing with natural teeth is more effective for increasing cerebral blood ow than chewing with prostheses, because there was no signicant difference in the odds of cognitive impairment with and without natural teeth. The insignicant association with multiple tooth loss is not in agreement with cross-sectional population studies that report signicant associations between number of natural teeth and cognitive impairment. A population study of persons aged 35 to 85 in Umea, in northern Sweden, found lower MMSE scores in edentulous persons.3 Studies of persons aged 65 and older in Japan,4 national Finnish data on persons aged 55 and older,5 and a population study of persons aged 60 to 79 old in Germany 26 also reported a signicant association between low MMSE scores and number of remaining teeth, although persons with dementia were excluded from the analysis in the Umea study, and persons with a history of stroke, traumatic brain injury, Parkinsons disease, multiple sclerosis, or epilepsy were excluded from the study in Germany. The other two studies included only persons who could perform the MMSE. A national health survey in England also found a signicant association in elderly people living in the community but not in people in nursing homes.27 In the current study, frail individuals with dementia, hearing impairment, or stroke were not excluded, and data were obtained by interviewing a proxy. Thus, the different ndings could be a result of variations in the inclusion and exclusion criteria of the samples. There are some limitations to this study. One concerns the assessment methods of tooth loss. Multiple tooth loss rather than edentulousness was used as an indicator of tooth loss, and it was self-reported. Although previous studies have validated self-reported number of teeth in persons aged 70 and older,28 this assessment method may contribute to the insignicant association between dental status and cognition found in the current study. A crosssectional study of persons aged 65 and older in Korea that assessed number of teeth using an oral examination found that having fewer teeth was signicantly associated with incidence of dementia and Alzheimers disease,29 although existing longitudinal studies measuring tooth loss using oral examination had inconsistent ndings. A 32-year study of healthy men living in Boston reported greater risk of low MMSE scores for each additional tooth lost,9 whereas a 6-year study of institutionalized persons in Japan reported a nonsignicant difference in the incidence of mental impairment according to number of remaining teeth.11 Methodological variations between these two studies indicate that more population studies are needed before a denite conclusion can be drawn. Although the ndings of the current study are based on a nationally representative sample of persons aged 77 and older, including persons with dementia, they may not be generalizable to future cohorts of elderly people. A previous study using the same original database showed that birth cohort had a signicant effect on incidence of tooth loss and edentulousness.30 From a life-course perspective, the persons included in the current study had lived their young life and midlife when Sweden did not have dental services and preventive programs. Teeth were more often

extracted than restored in older cohorts. Socioeconomic factors such as education strongly inuenced access to services. Future cohorts may show other patterns. In conclusion, this study shows that age and education levels can largely explain the association between tooth loss and cognitive impairment in a general Swedish population aged 77 and older, although there remains a signicant association between chewing ability and cognitive function even after adjusting for age, sex and education. Persons with difculty chewing hard food have signicantly greater odds of cognitive impairment. The mechanism for this association is not known, and clinical dietary recommendations would be premature on the basis of the existing evidence, although numerous animal studies and epidemiological results support the association between chewing and cognition, and more attention should be given to chewing ability in elderly populations. More studies in different populations and longitudinal studies are needed to better understand the nature of these associations, as are clinical studies to understand the mechanisms involved and to develop preventive strategies.

ACKNOWLEDGMENTS
We are grateful for nancial support from the National Society for Research on Aging, the Swedish Council for Working Life and Social Research, and the Swedish Research Council. Conict of Interest: The editor in chief has reviewed the conict of interest checklist provided by the authors and has determined that the authors have no nancial or any other kind of personal conicts with this paper. Wardh and Parker are board members of the National Society for Research on Aging, which partially funded this study. Author Contributions: DL: literature review, study design, data analysis, interpretation, writing drafts, nalizing manuscript, revising manuscript, responses to editors and reviewers. MT and IW: literature review, data analysis, interpretation, comments and suggestions in all parts of the manuscript, comments and suggestions to the revised manuscript and responses to editors and reviewers. MGP: literature review, study design, data analysis, interpretation, comments and suggestions in all parts of the manuscript, comments and suggestions to the revised manuscript and responses to editors and reviewers. Sponsors Role: The funding organization had no role in any part of the study or preparation of this article.

REFERENCES
1. Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183194. 2. Qui C, De Ronchi D, Fratiglioni L. The epidemiology of dementias: An update. Curr Opin Psychiatry 2007;20:380385. 3. Bergdahl M, Habib R, Bergdagl J et al. Natural teeth and cognitive function in humans. Scand Psychol 2007;48:557565. 4. Okamoto N, Morikawa M, Okamoto K et al. Relationship of tooth loss to mild memory impairment and cognitive impairment: Findings from the Fujiwara-Kyo study. Behav Brain Funct 2010;6:77. 5. HanneleSyrjala A-M, Ylostalo P, Sulkava R et al. Relationship between cognitive impairment and oral health: Results of the Health 2000 Health Examination Survey in Finland. Acta Odontol Scand 2007;65:103 108.

1956

LEXOMBOON ET AL.

OCTOBER 2012VOL. 60, NO. 10

JAGS

6. Kinane D, Bouchard P. Periodontal diseases and health: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008;35(Suppl 8):333337. 7. Watts A, Crimmins EM, Gatz M. Inammation as a potential mediator for the association between periodontal disease and Alzheimers disease. Neuropsychiatr Dis Treat 2008;4:865876. 8. Yu Y-H, Kuo H-K. Association between cognitive function and periodontal disease in older adults. J Am Geriatr Soc 2008;56:16931697. 9. Kaye EK, Valencia A, Baba N et al. Tooth loss and periodontal disease predict poor cognitive function in older men. J Am Geriatr Soc 2010;58:713718. 10. Stein PS, Desroslers M, Donegan SJ et al. Tooth loss, dementia and neuropathology in the Nun Study. J Am Dent Assoc 2007;138:13141322. 11. Shimazaki Y, Soh I, Saito T et al. Inuence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res 2000;80:340345. 12. Ono Y, Yamamoto T, Kubo KY et al. Occlusion and brain function: Mastication as a prevention of cognitive dysfunction. J Oral Rehabil 2010;37:624640. 13. Weijenberg RAF, Scherder EJA, Lobbezoo F. Mastication for the mind: The relationship between mastication and cognition in ageing and dementia. Neurosci Biobehav Rev 2011;35:483497. 14. Miyamoto I, Yoshida K, Tsuboi Y et al. Rehabilitation with dental prostheses can increase cerebral regional blood volume. Clin Oral Implants Res 2005;16:723727. 15. Hasegawa Y, Ono T, Hori K et al. Inuence of human jaw movement on cerebral blood ow. J Dent Res 2007;86:6468. 16. Miles C, Johnson AJ. Chewing gum and context-dependent memory effects: A re-examination. Appetite 2007;48:154158. 17. Baker JR, Bezance JB, Zellaby E et al. Chewing gum can produce contextdependent effects upon memory. Appetite 2004;43:207210. 18. Stephens R, Edelstyn NMJ. Do individual differences moderate the cognitive benets of chewing gum? Psychology 2011;2:834840.

19. Moriya S, Tei K, Murata A et al. Association between self-assessed masticatory ability and higher brain function among the elderly. J Oral Rehabil 2011;37:553559. 20. Parker MG, Gatz M, Thorslund M. Use of a short cognitive test in a sociological interview survey of the old-old. Aging Clin Exp Res 1996;8:354359. 21. Crum RM, Anthony JC, Bassett SS et al. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:23862391. 22. Dotson VM, Beydoun MA, Zonderman AB. Recurrent depressive symptoms and the incidence of dementia and mild cognitive impairment. Neurology 2010;75:2734. 23. Syrjala A-MH, Ylostalo P, Ruoppi P et al. Dementia and Oral Health Among Subjects Aged 75 Years or Older [on-line]. Available at http://onlinelibrary.wiley.com.proxy.kib.ki.se/doi/10.1111/j.17412358.2010.00396.x/ pdf Accessed July 1, 2011. 24. Chen X, Shuman SK, Hodges JS et al. Patterns of tooth loss in older adults with and without dementia: A retrospective study based on a Minnesota cohort. J Am Geriatr Soc 2010;58:23002307. 25. Takata Y, Ansai T, Soh I et al. Relationship between chewing ability and high-level functional capacity in an 80-year-old population in Japan. Gerodontology 2008;25:147154. 26. Grabe HJ, Schwahn C, Volzke H et al. Tooth loss and cognitive impairment. J Clin Periodontol 2008;36:550557. 27. Stewart R, Hirani V. Dental health and cognitive impairment in an English national survey population. J Am Geriatr Soc 2007;55:14101414. 28. Douglass CW, Berlin J. The validity of self-reported oral health status in the elderly. J Public Health Dent 1991;51:220222. 29. Kim JM, Stewart R, Prince M et al. Dental health, nutritional status and recent-onset dementia in a Korean community population. Int J Geriatr Psychiatry 2007;22:850855. 30. Ahacic K, Parker MG, Thorslund M. Aging in disguise: Age, period and cohort effects in mobility and edentulousness over three decades. Eur J Ageing 2007;4:8391.