Oral Health and Mortality Among Older Adults: A Doubly Robust Survival Analysis

Published:September 21, 2022DOI:


      Evidence on the association between oral health and mortality is inconclusive, and few studies have accounted for the nonrandom selection bias in estimating their relationship. This study aims to investigate the link between oral health and mortality in community-dwelling older adults by adjusting for confounding factors with a doubly robust survival estimation.


      Data came from the third National Health and Nutrition Examination Survey (1988–1994) and were linked to the National Death Index mortality data through December 2015. The analytic sample consisted of 4,880 adults aged ≥60 years. Oral health measures included objective clinical indicators (edentulism, periodontitis, and untreated dental caries) and self–rated oral health. Cox proportional hazards regression models and inverse probability weighting with regression adjustment for observational survival-time estimation were utilized to assess the relationship between oral health and mortality. Analyses were conducted in 2021.


      Edentulism (average treatment effect= −26.13, 95% CI= −48.69, −3.57) was associated with a reduction in survival time. Periodontal conditions and dental caries were related to all-cause mortality in Cox models but became nonsignificant when inverse probability weighting with regression adjustment survival estimation was applied. Good self–rated oral health was significantly related to an increase in survival time (average treatment effect=21.50; 95% CI= 4.92, 38.07).


      Both objective and subjective oral health are risk factors for mortality among older adults. Improving access to dental screening and treatment among community-dwelling older adults has the potential to reduce oral health‒related risks of mortality.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Heilmann A
        • Tsakos G
        • Watt RG.
        Oral health over the life course.
        in: Burton-Jeangros C Cullati S Sacker A Blane D Life Course Research and Social Policies. Springer, Cham, Switzerland2015: 39-59
      1. Dental caries (tooth decay) in seniors (age 65 and over). National Institute of Dental and Craniofacial Research. Updated July 2018. Accessed September 1, 2022.

      2. Edentulism and tooth retention. Centers for Disease Control and Prevention. Updated December 9, 2021. Accessed September 1, 2022.

        • National Institute of Dental and Craniofacial Research
        Oral health in America: advances and challenges: executive summary.
        National Institute of Dental and Craniofacial Research, Bethesda, MD2021 (Published December. Accessed September 1, 2022)
        • Dietrich T
        • Webb I
        • Stenhouse L
        • et al.
        Evidence summary: the relationship between oral and cardiovascular disease.
        Br Dent J. 2017; 222: 381-385
        • Nwizu N
        • Wactawski-Wende J
        • Genco RJ.
        Periodontal disease and cancer: epidemiologic studies and possible mechanisms.
        Periodontol 2000. 2020; 83: 213-233
        • Gomes-Filho IS
        • da Cruz SSD
        • Trindade SC
        • et al.
        Periodontitis and respiratory diseases: a systematic review with meta-analysis.
        Oral Dis. 2020; 26: 439-446
        • Schenkein HA
        • Loos BG.
        Inflammatory mechanisms linking periodontal diseases to cardiovascular diseases.
        J Clin Periodontol. 2013; 40: S51-S69
        • Schenkein HA
        • Papapanou PN
        • Genco R
        • Sanz M.
        Mechanisms underlying the association between periodontitis and atherosclerotic disease.
        Periodontol 2000. 2020; 83: 90-106
        • Genkinger JM
        • Platz EA
        • Hoffman SC
        • Comstock GW
        • Helzlsouer KJ.
        Fruit, vegetable, and antioxidant intake and all-cause, cancer, and cardiovascular disease mortality in a community-dwelling population in Washington County, Maryland.
        Am J Epidemiol. 2004; 160: 1223-1233
        • Söderström L
        • Rosenblad A
        • Thors Adolfsson E
        • Bergkvist L.
        Malnutrition is associated with increased mortality in older adults regardless of the cause of death.
        Br J Nutr. 2017; 117: 532-540
        • Sheiham A
        • Steele J.
        Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrient and dietary intake and nutritional status amongst older people?.
        Public Health Nutr. 2001; 4: 797-803
        • Oakes JM
        • Johnson PJ.
        Propensity score matching for social epidemiology.
        in: Oakes JM Kaufman JS Methods in Social Epidemiology. 2nd ed. Jossey-Bass, San Francisco, CA2017: 283-304
        • Adolph M
        • Darnaud C
        • Thomas F
        • et al.
        Oral health in relation to all-cause mortality: the IPC cohort study.
        Sci Rep. 2017; 7: 44604
        • Sabbah W
        • Slade GD
        • Sanders AE
        • Bernabé E.
        Denture wearing and mortality risk in edentulous American adults: a propensity score analysis.
        J Dent. 2020; 100103360
        • Li A
        • Chen Y
        • Visser A
        • Marks LAM
        • Tjakkes G-HE
        Combined association of cognitive impairment and poor oral health on mortality risk in older adults: results from the NHANES with 15 years of follow-up.
        J Periodontol. 2022; 93: 888-900
        • Xu F
        • Lu B.
        Prospective association of periodontal disease with cardiovascular and all-cause mortality: NHANES III follow-up study.
        Atherosclerosis. 2011; 218: 536-542
        • Kim JK
        • Baker LA
        • Davarian S
        • Crimmins E.
        Oral health problems and mortality.
        J Dent Sci. 2013; 8: 115-120
        • Komiyama T
        • Ohi T
        • Tomata Y
        • et al.
        Dental status is associated with incident functional disability in community-dwelling older Japanese: a prospective cohort study using propensity score matching.
        J Epidemiol. 2020; 30: 84-90
        • Como DH
        • Stein Duker LI
        • Polido JC
        • Cermak SA.
        The persistence of oral health disparities for African American children: a scoping review.
        Int J Environ Res Public Health. 2019; 16: 710
        • Patrick DL
        • Lee RSY
        • Nucci M
        • Grembowski D
        • Jolles CZ
        • Milgrom P.
        Reducing oral health disparities: a focus on social and cultural determinants.
        BMC Oral Health. 2006; 6 (suppl 1): S4
        • Funk MJ
        • Westreich D
        • Wiesen C
        • Stürmer T
        • Brookhart MA
        • Davidian M.
        Doubly robust estimation of causal effects.
        Am J Epidemiol. 2011; 173: 761-767
        • StataCorp
        Stata Statistical Software.
        StataCorp LP, 2017
        • Joshy G
        • Arora M
        • Korda RJ
        • Chalmers J
        • Banks E.
        Is poor oral health a risk marker for incident cardiovascular disease hospitalisation and all-cause mortality? Findings from 172 630 participants from the prospective 45 and up Study.
        BMJ Open. 2016; 6e012386
        • Romandini M
        • Baima G
        • Antonoglou G
        • Bueno J
        • Figuero E
        • Sanz M.
        Periodontitis, edentulism, and risk of mortality: a systematic review with meta-analyses.
        J Dent Res. 2021; 100: 37-49
        • Henshaw MM
        • Calabrese JM.
        Oral health and nutrition in the elderly.
        Nutr Clin Care. 2001; 4: 34-42
        • Nowjack-Raymer RE
        • Sheiham A.
        Association of edentulism and diet and nutrition in U.S. adults.
        J Dent Res. 2003; 82: 123-126
        • Winning L
        • Patterson CC
        • Linden K
        • Cullen KM
        • Kee F
        • Linden GJ.
        Systemic inflammation and the relationship between periodontitis, edentulism, and all-cause mortality: a 17-year prospective cohort study.
        J Clin Periodontol. 2021; 48: 1260-1269
        • Holt-Lunstad J
        • Smith TB
        • Baker M
        • Harris T
        • Stephenson D.
        Loneliness and social isolation as risk factors for mortality: a meta-analytic review.
        Perspect Psychol Sci. 2015; 10: 227-237
        • MA Al-Rafee
        The epidemiology of edentulism and the associated factors: a literature review.
        J Family Med Prim Care. 2020; 9: 1841-1843
        • Northridge ME
        • Chakraborty B
        • Kunzel C
        • Metcalf S
        • Marshall S
        • Lamster IB.
        What contributes to self-rated oral health among community-dwelling older adults? Findings from the ElderSmile program.
        J Public Health Dent. 2012; 72: 235-245
        • Gupta A
        • Felton DA
        • Jemt T
        • Koka S.
        Rehabilitation of edentulism and mortality: a systematic review.
        J Prosthodont. 2019; 28: 526-535
        • Chae S
        • Lee Y
        • Kim J
        • Chun KH
        • Lee JK.
        Factors associated with perceived unmet dental care needs of older adults.
        Geriatr Gerontol Int. 2017; 17: 1936-1942