Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2015 42; 693–700
Dental status and self-assessed chewing ability in 70- and
80-year-old subjects in Sweden
€ †§, S. ORDELL¶** & G. E. CARLSSON† †
L. UNELL*†, A. JOHANSSON‡, G. EKBACK
€
*Post Graduate Dental Education Centre, Orebro €
County Council, Orebro, †
Sweden, ‡Department of Clinical Dentistry – Prosthodontics, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway,
§ €
Department of Dentistry, Orebro €
County Council, Orebro, ¶
Dental Commissioning Unit, Link€oping University, Link€oping, **Department of
Oral Public Health, Malm€o University, Malm€o, and ††Department of Prosthetic Dentistry/Dental Materials Science, University of Gothenburg,
G€oteborg, Sweden
SUMMARY The objective was to compare two
cohorts of elderly people, 70 and 80 years old, with
respect to dental status and self-assessed chewing
ability. The hypotheses were as follows: (i) dental
status is associated with self-assessed chewing
ability; (ii) chewing ability is poorer among the 80-
than the 70-year-old subjects. Identical
questionnaires were in 2012 sent to all subjects born
in 1942 and 1932, living in two Swedish counties.
The response rate was 70
1% resulting in samples of
5697 70- and 2922 80-year-old subjects. Answers to
questions on self-assessed chewing ability, dental
status and some other factors have been analysed.
Dental status varied but was in general good; 72%
of the 70- and 60% of the 80-year-old subjects
reported that they had all or only few missing
teeth. Rate of edentulism was 3% and 7%,
respectively. Removable partial dentures were
Introduction
Masticatory performance was previously often mea-
sured by comminution tests, in general using some
type of sieve system (1). As it has been shown to be a
poor correlation between self-assessed and laboratory
measured masticatory efficiency, it was suggested that
patient-based assessments would be most appropriate
for evaluation of chewing ability (2). A number of
definitions of masticatory function are found in the
literature (2–6). In the following, chewing ability is
© 2015 John Wiley & Sons Ltd
€
School of Health and Medical Sciences, Orebro €
University, Orebro,
reported by 6% and 10%, respectively, implant
treatment by 13% in both cohorts. Self-assessed
chewing ability was mostly good and correlated
with the number of teeth (Spearman rho = 0
46). A
majority of the edentulous subjects assessed their
chewing ability as very or fairly good. Logistic
regression showed that self-assessed chewing
ability was significantly associated with a number
of dental variables but also with general health. In
conclusion, dental status was relatively good at
both ages but somewhat poorer in the older cohort.
Dental status, some other dental variables and
being healthy were in both age groups significantly
associated with self-assessed chewing ability.
KEYWORDS: dry mouth, edentulism, general health,
gerodontology, logistic regression, mastication
Accepted for publication 21 March 2015
used for an individual’s own subjective assessment of
masticatory function, whereas masticatory perfor-
mance or efficiency refers to laboratory tests measur-
ing the capacity to grind and reduce food. In using
self-assessed chewing ability, it should be remembered
that it may include an under-reporting of problems
and it is not equal to masticatory performance.
Several studies have concluded that both mastica-
tory efficiency and chewing ability are strongly
associated with number and distribution of remaining
teeth (3–6). Indicating the far-reaching importance of
doi: 10.1111/joor.12299
694 L . U N E L L et al.
dental status and chewing ability, significant associa-
tions have been demonstrated between chewing abil-
ity and oral-health-related quality of life (7–9) as well
as between chewing ability and cognitive impairment
and higher brain functions (10–13). Furthermore,
impaired dental status has been associated with
increased mortality (14–16).
A longitudinal study of 50-year-old subjects
reported that the chewing ability was assessed worse
at age 60 than at age 50 although there was only a
minor impairment in dental status (17). In a study of
five cohorts of 70-year-old subjects examined over a
30-year period, dental status improved markedly but
the self-assessed chewing ability exhibited only minor
variation over time; chewing ability showed only
weak associations with dental status (18). There is
thus still some uncertainty as regards the relationship
between chewing ability and dental status, and there
is a scarcity of studies in older adults.
It was therefore the aim of this study to compare
two cohorts of elderly people, 70 and 80 years old,
with respect to dental status and self-assessed chewing
ability. The hypotheses were that there is a strong
relationship between dental status and self-assessed
chewing ability, and consequently the expected more
impaired dental status in the older group would result
in poorer chewing ability among the 80- than in the
70-year-old subjects.
Materials and methods
Identical questionnaires were in 2012 sent to all sub-
jects born in 1942 (n = 7889) and in 1932 (n = 4407)
living in the Swedish counties Orebro € and
€
Osterg€otland. The response rate was 72
2% for the 70-
year-old subjects and 66
4% for the 80-year-old sub-
jects, with an average of 70
1% for all participants.
Questionnaire
The questionnaire comprised 53 questions, with alto-
gether 123 items, and it has been described and dis-
cussed previously (19). The questions were divided into
socio-economic conditions (e.g. age, gender, occupa-
tion), general health and oral conditions (e.g. satisfac-
tion with teeth, oral problems, chewing ability,
number of teeth, presence of prostheses). In this study,
the focus has been on self-assessed chewing ability in
relation to dental status and some other factors.
In an early study in this series of investigations
using the same methods and questionnaire, clinical
examination was performed in 941 randomly
selected subjects of the total sample to validate and
quantify the responses regarding reported number of
remaining teeth and jaw opening capacity. There
was good congruence between self-reports and
clinical registrations (20). The Ethics Committee in
Uppsala, Sweden, approved the 2012 study (Dnr
2011/336).
Statistical methods
All statistical analyses were performed using the Sta-
tistical Package for Social Sciences (SPSS, Release 17
and 21*) on a Dell Personal Computer. Pearson’s chi-
squared test was used to analyse differences between
groups. Logistic regression enter was performed to
investigate associations between self-assessed chewing
ability and different background variables. In the
regression model, the following criteria were used for
selection of independent variables: (i) probable rele-
vance based on associations suggested in the litera-
ture; (ii) variables showing significant associations
between self-assessed chewing ability and background
factors according to a Spearman correlation analysis
(19, 21). However, because of multicollinearity not all
such variables in Table 1 were used. The dichotomisa-
tions of the independent variables included in the
logistic regression model are presented in Table 1. The
dependent variable was (i) individuals assessing their
chewing ability as very good or rather good
(n70 = 5212; n80 = 2545) and (ii) individuals assessing
their chewing ability as not so good or poor
(n70 = 298; n80 = 215).
Results
The dental status was relatively good in both age
groups, but the prevalence/proportion of those with
all teeth and only few missing teeth decreased from
72% among the 70-year to 60% in the 80-year-old
group. The rate of edentulism increased from 3% in
the younger to 7% in the older group. The differ-
ence between women and men with respect to
number of teeth was small in both age groups; it
*SPSS Inc., Chicago, IL, USA.
© 2015 John Wiley & Sons Ltd
 DENTAL STATUS AND SELF-ASSESSED CHEWING ABILITY 695

Table 1. Bivariate associations between dichotomised variables and chewing ability in the 70- and 80-year-old sample (Spearman’s
rho)

70 year 80 year

Variable Dichotomisation rho P rho P

Demographic
Gender Male 0
07 >0
05 0
4 0
02
Female
Social contacts during 6 or more people 0
07 <0
001 0
09 <0
001
a normal week 5 or less
Place of birth Sweden 0
12 <0
001 0
13 <0
001
Scandinavian/Other countries
Education High school/college/university 0
08 <0
001 0
06 0
007
Elementary school
Marital status Married, cohabiting 0
07 <0
001 0
04 0
031
Unmarried, divorced, widow/
widower
General health
Feeling healthy Yes/yes on the whole 0
20 <0
001 0
22 <0
001
No/absolutely not
Use of medicine last No 0
03 0
013 0
049 0
011
two weeks Yes
Smoking Remaining 0
04 0
001 0
03 0
11
Daily smoking
Oral health
When did you last >1 year ago/never had toothache/ 0
14 <0
001 0
11 <0
001
experience toothache? cannot remember
During the last three months/
during last year
Number of teeth All teeth remaining/missing a few teeth 0
32 <0
001 0
30 <0
001
Rather many teeth missing/almost
none left/edentulous
Dentures No dentures 0
22 <0
001 0
21 <0
001
Removable partial or complete denture
Dry mouth daily Never/no seldom/yes, sometimes 0
16 <0
001 0
22 <0
001
Often
TMD pain No problem 0
14 <0
001 0
21 <0
001
Some/rather many/great problems
Difficulty wide opening No problem 0
13 <0
001 0
18 <0
001
Some/rather many/great problems
Bruxism No problem 0
09 <0
001 0
11 <0
001
Some/rather many/great problems
Implant treatment Yes 0
00 0
218 0
03 0
121
No
Dental care
Refrain from dental visit due No 0
28 <0
001 0
24 <0
001
to high cost during last year Yes, one or more times
Belief to keep teeth for Yes, absolutely and probably 0
17 <0
001 0
20 <0
001
the rest of life Probably not and absolutely not
Satisfaction with dental care On the whole and very satisfied 0
30 <0
001 0
27 <0
001
Rather and very dissatisfied

was non-significant in the 70-year-old group There were only small differences between the 70-
(P = 0
153), whereas the distribution differed some- and 80-year-old groups for some of the questions:
what in the older group (P = 0
028; Table 2). place of birth (Sweden for 95% and 94%,

© 2015 John Wiley & Sons Ltd

696 L . U N E L L et al.

Table 2. Percentage distribution of 70- and 80-year-old men and women with respect to number of teeth

70-year-olds 70-year-old 70-year-old 80-year-olds 80-year-old 80-year-old

(n = 5406) men (n = 2685) women (n = 2721) (n = 2659) men (n = 1222) women (n = 1437)

All teeth remaining 12
7 12
3 13
2 8
5 7
0 9
7

Missing a few teeth 59
3 59
8 58
8 51
8 52
2 51
4
Missing many teeth 22
6 22
2 23
0 29
5 30
4 28
7
Almost no teeth 2
4 2
9 1
9 3
6 4
3 3
0
Edentulous 2
9 2
9 3
0 6
6 6
0 7
2

respectively); satisfaction with dental care received Table 3. Distribution of self-assessed chewing ability in % of
(94% and 96%); refrained from dental visit during 5374 70-year-old subjects with respect to number of teeth
the last year due to high cost (9% and 8%); tooth
Very Fairly Fairly
ache during the last 3 months and last year (9% and
good good poor Poor
7%). On the other hand, there were substantial dif-
ferences between the age groups for education and All teeth remaining 90
1 9
6 0
3 0
0
some health issues: elementary school (38% and n = 686
Missing a few teeth 74
7 24
3 0
9 0
2
63%; university and other higher education: 36%
n = 3198
and 15%); are you healthy: yes and on the whole Missing many teeth 33
6 52
2 11
2 3
0
(81% and 64%); dry mouth during the day: yes often n = 1214
and yes sometimes (30% and 41%). Almost no teeth 21
7 38
8 25
6 14
0
The prevalence of individuals with removable par- n = 129
Edentulous 31
3 46
9 9
5 12
2
tial dentures was low but was higher among the 80-
n = 147
year olds (10%) than in the 70-year olds (6%), Total (n = 5374) 64
8 29
8 3
9 1
5
whereas the prevalence of subjects with implant treat-
ment was similar in both age groups (approximately
13%). There were only small and non-significant sex Table 4. Distribution of self-assessed chewing ability in % of
differences with respect to prevalence of removable 2620 80-year-old subjects with respect to number of teeth
dentures and implants.
Very Fairly Fairly
The distribution of implant treatments varied with
good good poor Poor
respect to dental status; 5
8% of all implant treat-
ments were reported by the edentulous patients. The All teeth remaining 87
9 11
6 0
0 0
4
highest proportions of treatment with implants were n = 224
Missing a few teeth 66
6 31
8 1
2 0
4
reported by those who were missing single teeth
n = 1370
(46
3%) or many teeth (39
5%), whereas only few of Missing many teeth 30
1 55
7 12
4 1
8
those with almost no remaining teeth had implants n = 777
(3
6%). Almost no teeth 18
8 54
2 14
6 12
5
The self-assessed chewing ability was extremely n = 96
Edentulous 22
2 48
4 20
3 9
2
good in both age groups among those who had all or
n = 153
only missed a few teeth (Tables 3 and 4). The correla- Total (n = 2620) 53
6 38
6 6
0 1
8
tion between number of teeth and chewing ability
was statistically significant and relatively high
(P < 0
001, Spearman correlation, rho = 0
46 for both for the 80-year old than the 70-year-old subjects
cohorts taken together). A large proportion of both (P < 0
001).
age groups of the edentulous subjects with complete Edentulous people who had received implant treat-
dentures assessed their chewing ability as very or ment considered their chewing ability much better
rather good, 81
4% (70 years) and 78
9% (80 years). than those with removable denture (Table 5;
The self-assessed chewing ability was generally worse P = 0
001).

© 2015 John Wiley & Sons Ltd

 DENTAL STATUS AND SELF-ASSESSED CHEWING ABILITY 697

Table 5. Distribution of self-assessed chewing ability in % of groups, respectively, indicating a reasonable fit of the
edentulous 70- and 80-year-old subjects with removable den- model.
tures or implants

Very Fairly Fairly Discussion

good good poor Poor
Dental health is improving in most countries, but rel-
Edentulous with 24
6 50
4 15
0 10
0 evant epidemiological data on dental status in differ-
removable denture
ent age groups are difficult to find and interpret in
n = 240
Edentulous with 41
1 50
0 7
1 1
8 the literature (22–25). The improvement of dental
implants health has been reported to happen rapidly and epi-
n = 56 demiological studies need to be continuously renewed
(26, 27). Repeated population studies over 22 years in
Sweden demonstrated dramatic improvement of den-
tal health from 1975 to 1997. The prevalence of
Logistic regression
edentulism among 70-year-old subjects decreased
The variables numbers of teeth (no or few teeth lost), from approximately 50% in 1975 to 20% in 1997;
satisfaction with previous dental care, not refraining the corresponding values for 80-year-old subjects
from dental care due to high cost, being healthy, not were 65% and 40%, respectively. It was prognostica-
remember having had toothache, born in Sweden, ted that the prevalence in 2015 would be 7% for the
and no dry mouth at daytime were in both age 70-year olds and 14% for the 80-year olds (26). The
groups significantly associated with good self-assessed results of the present study, performed in the middle of
chewing ability (Table 6). The number of teeth was Sweden in 2012, showed prevalence of edentulism of
the variable showing by far the strongest association. 3% for the 70-year-old and 7% for the 80-year-old
Only one more variable among those being signifi- subjects, thus much lower than the prognosis for 2015.
cantly associated with chewing ability in the bivariate These results are also much lower than available data
analysis (Table 1) stayed significant in the logistic from elsewhere, suggesting that the dental health in
regression, viz. difficulty wide opening the mouth Swedes is on the top among other countries (23, 28).
among the 80-year olds (OR 4
44, 95% CI 2
62–7
53; A problem with all population investigations is the
P < 0
001). non-respondence. In this study, the response rate
In the logistic regression model used, the Nage- was 72
2% for the 70-year-olds and 66
4% for the
lkerke R2 values were 0
41 and 0
43 in the two age 80-year-olds, making it 70
1% for both samples taken

Table 6. Logistic regression model enter, presenting independent variables (reference in parenthesis) significantly associated with
good chewing ability (very good, rather good) in 70- and 80-year-old subjects. (dichotomisation see Table 1)

70-year olds 80-year olds

Variable OR (95% CI) OR (95%CI)

Native country (Sweden) 2
1** 1
28–3
28 4
49*** 2
43–8
29

Healthy (yes/on the whole) 2
42*** 1
75–3
35 2
57*** 1
64–4
01
Number of teeth (all teeth left/single missing) 13
78*** 9
1–20
72 10
84*** 6
04–19
47
Satisfied with dental care (very satisfied/overall satisfied) 4
6*** 3
13–6
75 3
65*** 1
85–7
17
Refrained from dental care due to cost (no) 4
57*** 3
23–6
39 3
49*** 1
99–6
11
Last time tooth ache (>1 year ago/have never had 1
95** 1
28–2
97 2
49* 1
32–4
71
toothache/cannot remember)
Dry mouth at daytime (yes sometimes, no seldom, never) 2
29*** 1
49–3
52 4
55*** 2
75–7
51
Nagelkerke R2 = 0
41 Nagelkerke R2 = 0
43

*P < 0
05.
**P < 0
01.
***P < 0
001.

© 2015 John Wiley & Sons Ltd

698 L . U N E L L et al.
together. A value above 70% has conventionally been
considered satisfactory for this type of research. How-
ever, any loss of participants and especially the lower
rate for the older group is a weakness of the study.
The poorer general health including cognitive impair-
ment, which is known to be increasing problems
among the octogenarians, may partly explain their
lower response rate. How this has affected the results
is impossible to say but it may be so that the results
in the older group are better than they would have
been with a higher response rate.
There was in general a close relationship between
number of teeth and chewing ability. The results were
thus supporting the first hypothesis and in accordance
with a recent systematic review (6). In both age
groups, very few of those who had all or most teeth
remaining assessed their chewing ability as poor or
rather poor (Tables 3 and 4). It deserves to be noted
however that the great majority of the edentulous
people (although most of those had complete den-
tures) assessed their chewing ability as very good or
rather good (81% of the 70-year olds, 79% of the
older group), a finding that agrees with previous
results (17, 29, 30). There is therefore not a strict lin-
ear relationship between chewing ability and number
of teeth when prostheses are included. This may also
be partially due to an under-reporting of masticatory
problems among elderly people, mentioned before, as
well as the complex relationship between chewing
ability and dental functional status (9).
Also the other hypothesis – that the octogenarians
would report a poorer chewing ability than the 70-
year-olds – was verified, probably related to, among
other things, their worse dental status and poorer
general health. However, it deserves to be mentioned
that the difference between the two age groups
regarding self-assessed chewing ability is relatively
small. The prevalence of those who assessed their
chewing ability as rather poor or poor was 5
4% at
age 70 and 7
8% at age 80. Even if this is not a longi-
tudinal study, it indicates a low incidence of reported
chewing problems over a 10-year period, probably
related to the relatively stable dental health in Swed-
ish older people (28). A longitudinal study of older
Canadians found that the 7-year incidence of chewing
dysfunction was 19%. It was concluded that poorer
general health at baseline increased the probability of
the onset of a chewing problem and decreased the
probability of recovery (31). The importance of dental
status for masticatory performance is illustrated by a
Japanese study of 80-year-old individuals; only 7%
had ≥20 teeth, 45% were edentulous, and 91% had
prostheses. It was concluded that most of the exam-
ined subjects had to recover their masticatory ability
with the assistance of prostheses, which still was
poorer than that of the dentate subjects without pros-
theses (32). The contrast to the present Swedish
results is striking.
The edentulous subjects who had received implants
reported much better chewing ability than those
without implants (Table 4). This corresponds with
results of studies comparing masticatory function in
complete denture wearers and subjects with implant-
supported fixed prostheses and implant overdentures
(33–36). In the present study, the type of implant res-
toration was not recorded. It is known however that
the great majority of the implant restorations placed
in edentulous jaws in Sweden are fixed prostheses
(36, 37).
As expected, the logistic regression analysis
showed significant associations between chewing
ability and some dental variables, number of teeth
being the strongest. The strong association between
chewing ability and general health is in line with
results of several previous studies in elderly persons
(38–41). Still however, no causal relationship has
been proven. Nevertheless, proper dental care all
through life is important to maintain a functional
dentition up to old age, also supported by the signif-
icant association between satisfaction with previous
dental care and chewing ability. It is also under-
scored by the finding that chewing ability was worse
in subjects who had had to refrain from dental visits
due to high costs.
Dry mouth at daytime has previously been shown
to be associated with impaired general health in mid-
dle-aged and elderly persons (42, 43). These findings
and the association found here between impaired
chewing ability and mouth dryness may partly be
explained by the fact that drug use is the most com-
mon cause of hyposalivation, and subjects with many
diseases and poor general health have high drug con-
sumption.
Subjects with TMD problems also often report mas-
ticatory problems (44–46), findings supported by the
present results of the significant association between
difficult mouth opening and impaired chewing ability
in the 80-year-old group.
© 2015 John Wiley & Sons Ltd
 DENTAL STATUS AND SELF-ASSESSED CHEWING ABILITY
Conclusions
The dental status was relatively good in both the 70-
and 80-year-olds but slightly poorer in the older
cohort. The rate of edentulism was 3% and 7% in the
two age groups, respectively. The self-assessed chew-
ing ability was extremely good in both age groups
among those who had all or only missed a few teeth.
The majority of the edentulous subjects assessed their
chewing ability as very or rather good; those who had
received implant treatment considered their chewing
ability much better than those without implants. Four
variables related to the dental situation, born in Swe-
den, dry mouth at daytime and being healthy were in
both age groups significantly associated with self-
assessed chewing ability, number of teeth showing
the strongest association.
Acknowledgments
This study was supported by the Department of Den-
€ Community Dent Oral Epidemiol. 2008;36:258–268.
tistry, Orebro County, Sweden and by the Dental Com-
€
missioning Unit, Osterg€ otland County, Sweden. The
authors declare that they have no conflict of interest.
References
1. van der Bilt A. Assessment of mastication with implications
for oral rehabilitation: a review. J Oral Rehabil.
2011;38:754–780.
2. Feine JS, Lund JP. Measuring chewing ability in randomized
controlled trials with edentulous populations wearing
implant prostheses. J Oral Rehabil. 2006;33:301–308.
3. Helkimo E, Carlsson GE, Helkimo M. Chewing efficiency
and state of dentition. A methodologic study. Acta Odontol
Scand. 1978;36:33–41.
4. Singh KA, Brennan DS. Chewing disability in older adults
attributable to tooth loss and other oral conditions. Gerod-
ontology. 2012;29:106–110.
5. Zhang Q, Witter DJ, Bronkhorst EM, Creugers NH. Chewing
ability in an urban and rural population over 40 years in
Shandong Province, China. Clin Oral Investig.
2013;17:1425–1435.
6. Naka O, Anastassiadou V, Pissiotis A. Association between
functional tooth units and chewing ability in older adults: a
systematic review. Gerodontology. 2014;31:166–177.
7. Brennan DS, Spencer AJ, Roberts-Thomson KF. Tooth loss,
chewing ability and quality of life. Qual Life Res.
2008;17:227–235.
8. Inukai M, John MT, Igarashi Y, Baba K. Association
between perceived chewing ability and oral health-related
quality of life in partially dentate patients. Health Qual Life
Outcomes. 2010;8:118. doi:10.1186/1477-7525-8-118.
© 2015 John Wiley & Sons Ltd
699
9. Nguyen TC, Witter DJ, Bronkhorst EM, Gerritsen AE, Creu-
gers NH. Chewing ability and dental functional status. Int J
Prosthodont. 2011;24:428–436.
10. Moriya S, Tei K, Murata A, Yamazaki Y, Hata H, Muramatsu
M et al. Associations between self-assessed masticatory abil-
ity and higher brain function among the elderly. J Oral
Rehabil. 2011;38:746–753.
11. Lexomboon D, Trulsson M, W ardh I, Parker MG. Chewing
ability and tooth loss: association with cognitive impairment
in an elderly population study. J Am Geriatr Soc.
2012;60:1951–1956.
12. Yamamoto T, Kondo K, Misawa J, Hirai H, Nakade M, Aida
J et al. Dental status and incident falls among older Japa-
nese: a prospective cohort study. BMJ Open. 2012;2:pii:
e001262.
13. Klineberg I, Palla S, Trulsson M. Contemporary relevance of
occlusion and mastication. Int J Prosthodont. 2014;27:411–
412.
14. Osterberg T, Carlsson GE, Sundh V, Steen B. Number of
teeth–a predictor of mortality in the elderly? A population
study in three Nordic localities. Acta Odontol Scand.
2007;65:335–340.
15. Osterberg T, Carlsson GE, Sundh V, Mellstr€ om D. Number
of teeth–a predictor of mortality in 70-year-old subjects.
16. Schwahn C, Polzer I, Haring R, D€ orr M, Wallaschofski H,
Kocher T et al. Missing, unreplaced teeth and risk of all-
cause and cardiovascular mortality. Int J Cardiol.
2013;20:1430–1437.
17. Johansson A, Unell L, Johansson AK, Carlsson GE. A 10-
year longitudinal study of self-assessed chewing ability and
dental status in 50-year-old subjects. Int J Prosthodont.
2007;20:643–645.
€
18. Osterberg T, Carlsson GE. Dental state, prosthodontic treat-
ment and chewing ability – a study of five cohorts of 70-
year-old subjects. J Oral Rehabil. 2007;34:553–559.
19. Unell L. On oral disease, illness and impairment among 50-
year-olds in two Swedish counties. Swed Dent J Suppl.
1999;135:1–45.
20. Unell L, S€ oderfeldt B, Halling A, Paulander J, Birkhed D.
Oral disease, impairment, and illness: congruence between
clinical and questionnaire findings. Acta Odontol Scand.
1997;55:127–132.
21. Johansson A, Unell L, Carlsson GE, S€ oderfeldt B, Halling A.
Differences in four reported symptoms related to temporo-
mandibular disorders in a cohort of 50-year-old subjects fol-
lowed up after 10 years. Acta Odontol Scand. 2008;66:50–
57.
22. Mojon P, Thomason JM, Walls AW. The impact of falling
rates of edentulism. Int J Prosthodont. 2004;17:434–440.
23. M€ uller F, Naharro M, Carlsson GE. What are the prevalence
and incidence of tooth loss in the adult and elderly popula-
tion in Europe? Clin Oral Implants Res. 2007;18(Suppl
3):2–14.
24. Zitzmann NU, Hagmann E, Weiger R. What is the preva-
lence of various types of prosthetic dental restorations in
Europe? Clin Oral Implants Res. 2007;18(Suppl 3):20–33.
700 L . U N E L L et al.
25. Slade GD, Akinkugbe AA, Sanders AE. Projections of U.S. E-
dentulism prevalence following 5 decades of decline. J Dent
Res. 2014;93:959–965.
€
26. Osterberg T, Carlsson GE, Sundh V. Trends and prognoses
of dental status in the Swedish population: analysis based
on interviews in 1975 to 1997 by Statistics Sweden. Acta
Odontol Scand. 2000;58:177–182.
27. Hugoson A, Koch G, G€ othberg C, Helkimo AN, Lundin SA,
Norderyd O et al. Oral health of individuals aged 3–80 years
in J€onk€ oping, Sweden during 30 years (1973–2003). II.
Review of clinical and radiographic findings. Swed Dent J.
2005;29:139–155.
28. Ekb€ack G, Unell L, Johansson A, Ordell S, Carlsson GE.
Changes in dental status and prevalence of symptoms
related to temporomandibular disorders in 50- to 70-year-
old subjects. Longitudinal and cross-sectional results. J Cra-
niomandib Funct. 2013;5:317–331.
29. Berg E. Acceptance of full dentures. Int Dent J. 1993;43(3
Suppl 1):299–306.
30. Carlsson GE, Omar R. The future of complete dentures in
oral rehabilitation. A critical review. J Oral Rehabil.
2010;37:143–156.
31. Locker D, Matear D, Lawrence H. General health status and
changes in chewing ability in older Canadians over seven
years. J Public Health Dent. 2002;62:70–77.
32. Tatematsu M, Mori T, Kawaguchi T, Takeuchi K, Hattori M,
Morita I et al. Masticatory performance in 80-year-old indi-
viduals. Gerodontology. 2004;21:112–119.
33. Lindquist LW, Carlsson GE. Long-term effects on chewing
with mandibular fixed prostheses on osseointegrated
implants. Acta Odontol Scand. 1985;43:39–45.
34. Feine JS, Carlsson GE (eds). Implant overdentures. The
standard of care for edentulous patients. Chicago (IL): Quin-
tessence; 2003.
35. Thomason JM, Kelly SA, Bendkowski A, Ellis JS. Two
implant retained overdentures – a review of the literature
supporting the McGill and York consensus statements. J
Dent. 2012;40:22–34.
36. Kronstr€ om M, Carlsson GE. Use of mandibular implant
overdentures: treatment policy in prosthodontic specialist
clinics in Sweden. Swed Dent J. 2003;27:59–66.
37. Ascher A, Carlsson GE, Kronstr€ om M. Use of implant-sup-
ported prostheses in edentulous mandibles among
prosthodontists in Sweden. Swed Dent J. 2014;38:161–
167.
38. Agerberg G, Carlsson GE. Chewing ability in relation to
dental and general health. Acta Odontol Scand.
1981;39:147–153.
39. €
Osterberg T, Carlsson GE, Tsuga K, Sundh V, Steen B. Asso-
ciations between self-assessed masticatory ability and some
general health factors in a Swedish population. Gerodontol-
ogy. 1996;13:110–117.
40. Miura H, Kariyasu M, Yamasaki K, Arai Y, Sumi Y. Rela-
tionship between general health status and the change in
chewing ability: a longitudinal study of the frail elderly in
Japan over a 3-year period. Gerodontology. 2005;22:200–
205.
41. Moriya S, Tei K, Murata A, Muramatsu M, Inoue N, Miura
H. Perceived chewing ability and need for long-term care in
the elderly: a 5-year follow-up study. J Oral Rehabil.
2012;39:568–575.
42. Johansson A-K, Johansson A, Unell L, Carlsson GE. Preva-
lence of self-reported xerostomia in 50-and 60-year-old sub-
jects. Int J Clin Pediatr Dent. 2008;1:93–101.
43. Johansson A-K, Johansson A, Unell L, Ekb€ack G, Ordell S,
Carlsson GE. A 15-yr longitudinal study of xerostomia in a
Swedish population of 50-yr-old subjects. Eur J Oral Sci.
2009;117:13–19.
44. Helkimo E, Carlsson GE, Carmeli Y. Bite force in patients
with functional disturbances of the masticatory system. J
Oral Rehabil. 1975;2:397–406.
45. Ahn HJ, Lee YS, Jeong SH, Kang SM, Byun YS, Kim BI.
Objective and subjective assessment of masticatory function
for patients with temporomandibular disorder in Korea. J
Oral Rehabil. 2011;38:475–481.
46. Bakke M, Hansdottir R. Mandibular function in patients
with temporomandibular joint pain: a 3-year follow-up.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2008;106:227–234.
Correspondence: Gunnar E. Carlsson, Department of Prosthetic
Dentistry/Dental Materials Science, Institute of Odontology, The
Sahlgrenska Academy, University of Gothenburg, Box 450, SE 405
30 G€
oteborg, Sweden.
E-mail: g.carlsson@odontologi.gu.se
© 2015 John Wiley & Sons Ltd