{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T02:19:02Z","timestamp":1793153942010,"version":"4.5.0"},"reference-count":43,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2026,8,22]],"date-time":"2026-08-22T00:00:00Z","timestamp":1787356800000},"content-version":"vor","delay-in-days":233,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Singapore Ministry of Health\u2019s National Medical Research Council","id":[{"id":"https:\/\/ror.org\/04x3cxs03","id-type":"ROR","asserted-by":"crossref"}]},{"name":"Research Training Fellowship","award":["RTF24jan-0007"],"award-info":[{"award-number":["RTF24jan-0007"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,9,8]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background and Objectives<\/jats:title>\n                    <jats:p>Poor oral health is associated with functional decline and mortality in older adults, yet causal evidence linking oral health improvement with functional independence remains limited. We simulated the effects of hypothetical reductions in oral frailty on the cumulative probability of being alive and independent in basic activities of daily living (ADLs) among older adults in Brazil.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Research Design and Methods<\/jats:title>\n                    <jats:p>Data from the EpiFloripa Aging Cohort Study of community-dwelling adults aged 60 years or older in Florian\u00f3polis, Brazil, followed from 2009 to 2023, were analyzed (1702 participants). Oral frailty was measured at waves 1-3 using a seven-item composite score (range 0-7). The primary outcome was the cumulative probability of being alive and ADL-independent through wave 5, estimated using a discrete-time survival model. Longitudinal modified treatment policies with targeted maximum-likelihood estimation simulated nine oral health improvement scenarios, accounting for time-varying confounding and censoring.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>336 deaths occurred during follow-up. A stepwise reduction in oral frailty increased the probability of being alive and ADL independent by 73% (probability ratio 1.73, 95% CI 1.48-2.02), corresponding to 15\u2009829 additional functionally independent older adults per 100\u2009000 individuals. Preventing edentulism with preserved masticatory function also improved the probability of being alive and ADL independent (probability ratio 1.21, 95% CI 1.08-1.36). Effects on survival alone were smaller and less certain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion and Implications<\/jats:title>\n                    <jats:p>Reducing oral frailty and preserving masticatory function increases functional independence among older adults, with smaller and uncertain effects on survival. Oral health is a modifiable determinant of healthy ageing.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/geroni\/igag091","type":"journal-article","created":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T11:50:59Z","timestamp":1787226659000},"source":"Crossref","is-referenced-by-count":1,"title":["Reducing oral frailty improves functional independence in older Brazilians: a causal inference study of disability-free survival using longitudinal modified treatment policies"],"prefix":"10.1093","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3042-3103","authenticated-orcid":false,"given":"John Rong Hao","family":"Tay","sequence":"first","affiliation":[{"name":"Health Services Research & Population Health Programme, Duke-NUS Medical School , Singapore,","place":["Singapore"]},{"name":"National Dental Research Institute Singapore, National Dental Centre Singapore , Singapore,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huihua","family":"Li","sequence":"additional","affiliation":[{"name":"National Dental Research Institute Singapore, National Dental Centre Singapore , Singapore,","place":["Singapore"]},{"name":"Oral Health Academic Clinical Programme, Duke-NUS Medical School , Singapore,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen G","family":"Peres","sequence":"additional","affiliation":[{"name":"National Dental Research Institute Singapore, National Dental Centre Singapore , Singapore,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9978-4276","authenticated-orcid":false,"given":"Rahul","family":"Malhotra","sequence":"additional","affiliation":[{"name":"Health Services Research & Population Health Programme, Duke-NUS Medical School , Singapore,","place":["Singapore"]},{"name":"Centre for Ageing Research & Education, Duke-NUS Medical School , Singapore,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Quialheiro","sequence":"additional","affiliation":[{"name":"IA&Sa\u00fade - The Artificial Intelligence and Health Research Unit, Polytechnic University of Health, CESPU, Vila Nova de Famalic\u00e3o, Portugal , Lisbon,","place":["Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eleonora","family":"D\u2019Orsi","sequence":"additional","affiliation":[{"name":"Department of Public Health, Federal University of Santa Catarina , Florian\u00f3polis,","place":["Brazil"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8329-2808","authenticated-orcid":false,"given":"Marco A","family":"Peres","sequence":"additional","affiliation":[{"name":"Health Services Research & Population Health Programme, Duke-NUS Medical School , Singapore,","place":["Singapore"]},{"name":"National Dental Research Institute Singapore, National Dental Centre Singapore , Singapore,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,21]]},"reference":[{"key":"2026092703014554400_igag091-B1","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1007\/s40520-025-03021-8","article-title":"Aging, longevity, and healthy aging: the public health approach","volume":"37","author":"Gianfredi","year":"2025","journal-title":"Aging Clin Exp Res"},{"key":"2026092703014554400_igag091-B2","doi-asserted-by":"publisher","first-page":"563","DOI":"10.1016\/s0140-6736(14)61462-8","article-title":"Health, functioning, and disability in older adults\u2014present status and future implications","volume":"385","author":"Chatterji","year":"2015","journal-title":"Lancet."},{"key":"2026092703014554400_igag091-B3","doi-asserted-by":"publisher","first-page":"2145","DOI":"10.1016\/s0140-6736(15)00516-4","article-title":"The World report on ageing and health: a policy framework for healthy ageing","volume":"387","author":"Beard","year":"2016","journal-title":"Lancet"},{"key":"2026092703014554400_igag091-B4","doi-asserted-by":"publisher","first-page":"igaf100","DOI":"10.1093\/geroni\/igaf100","article-title":"Estimating the causal impact of chewing disability on depressive symptoms mediated by loneliness: a longitudinal marginal structural model study of older adults in Singapore","volume":"9","author":"Tay","year":"2025","journal-title":"Innov Aging"},{"key":"2026092703014554400_igag091-B5","doi-asserted-by":"publisher","first-page":"283","DOI":"10.1111\/jre.70053","article-title":"Impact of tooth preservation or replacement on diet quality: modified treatment policies approach","volume":"61","author":"Tay","year":"2025","journal-title":"J Periodontal Res."},{"key":"2026092703014554400_igag091-B6","doi-asserted-by":"publisher","DOI":"10.3390\/dj11090222","article-title":"Diet, nutrition, and oral health in older adults: a review of the literature","volume":"11","author":"Chan","year":"2023","journal-title":"Dent J"},{"key":"2026092703014554400_igag091-B7","doi-asserted-by":"publisher","first-page":"1661","DOI":"10.1093\/gerona\/glx225","article-title":"Oral frailty as a risk factor for physical frailty and mortality in community-dwelling elderly","volume":"73","author":"Tanaka","year":"2018","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"2026092703014554400_igag091-B8","doi-asserted-by":"publisher","DOI":"10.1111\/jre.70096","article-title":"Dental implant rehabilitation mitigates the increased mortality risk associated with tooth loss: a population-based study","author":"Tay","year":"2026","journal-title":"J Periodontal Res."},{"key":"2026092703014554400_igag091-B9","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1016\/S0140-6736(19)31133-X","article-title":"Ending the neglect of global oral health: time for radical action","volume":"394","author":"Watt","year":"2019","journal-title":"The Lancet."},{"key":"2026092703014554400_igag091-B10","doi-asserted-by":"publisher","DOI":"10.1111\/jre.70133","article-title":"Periodontal diseases as a public health challenge: rationale, prevention, equity, and sustainable care \u2013 a global call for action","author":"Peres","year":"2026","journal-title":"J Periodontal Res."},{"key":"2026092703014554400_igag091-B11","doi-asserted-by":"publisher","first-page":"106655","DOI":"10.1016\/j.jdent.2026.106655","article-title":"Subjective masticatory function and healthy life expectancy among older adults in Singapore: a multistate life table analysis","volume":"169","author":"Li","year":"2026","journal-title":"J Dent"},{"key":"2026092703014554400_igag091-B12","doi-asserted-by":"publisher","first-page":"663","DOI":"10.1007\/s11357-022-00663-8","article-title":"Oral frailty indicators to target major adverse health-related outcomes in older age: a systematic review","volume":"45","author":"Dibello","year":"2023","journal-title":"Geroscience"},{"key":"2026092703014554400_igag091-B13","doi-asserted-by":"publisher","first-page":"e064","DOI":"10.1590\/1807-3107bor-2025.vol39.064","article-title":"Predictive models of weakness among older adults: the contribution of oral health indicators","volume":"39","author":"Mello","year":"2025","journal-title":"Braz Oral Res"},{"key":"2026092703014554400_igag091-B14","doi-asserted-by":"publisher","first-page":"104","DOI":"10.11606\/s1518-8787.2017051006776","article-title":"EpiFloripa Aging cohort study: methods, operational aspects, and follow-up strategies","volume":"51","author":"Schneider","year":"2017","journal-title":"Rev Saude Publica"},{"key":"2026092703014554400_igag091-B15","doi-asserted-by":"publisher","first-page":"740","DOI":"10.1590\/s0034-8910.2013047004364","article-title":"Inequalities in self-rated oral health in adults","volume":"47","author":"Luchi","year":"2013","journal-title":"Rev Saude Publica"},{"key":"2026092703014554400_igag091-B16","doi-asserted-by":"publisher","first-page":"651","DOI":"10.1111\/ggi.14634","article-title":"Oral frailty five-item checklist to predict adverse health outcomes in community-dwelling older adults: a Kashiwa cohort study","volume":"23","author":"Tanaka","year":"2023","journal-title":"Geriatr Gerontol Int"},{"key":"2026092703014554400_igag091-B17","doi-asserted-by":"publisher","first-page":"687","DOI":"10.1111\/j.1532-5415.1988.tb07169.x","article-title":"Validity of a Brazilian version of the Older Americans Resources and Services (OARS) mental health screening questionnaire","volume":"36","author":"Blay","year":"1988","journal-title":"J Am Geriatr Soc"},{"key":"2026092703014554400_igag091-B18","doi-asserted-by":"publisher","first-page":"305","DOI":"10.5123\/s1679-49742017000200008","article-title":"Life and health conditions among elderly: results of the EpiFloripa Idoso cohort study","volume":"26","author":"Confortin","year":"2017","journal-title":"Epidemiol Serv Saude"},{"key":"2026092703014554400_igag091-B19","doi-asserted-by":"publisher","first-page":"220","DOI":"10.1097\/00005650-199603000-00003","article-title":"A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity","volume":"34","author":"Ware","year":"1996","journal-title":"Med Care"},{"key":"2026092703014554400_igag091-B20","doi-asserted-by":"publisher","first-page":"213","DOI":"10.1007\/s10985-023-09606-7","article-title":"Causal survival analysis under competing risks using longitudinal modified treatment policies","volume":"30","author":"D\u00edaz","year":"2024","journal-title":"Lifetime Data Anal"},{"key":"2026092703014554400_igag091-B21","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1097\/ede.0000000000001764","article-title":"Studying continuous, time-varying, and\/or complex exposures using longitudinal modified treatment policies","volume":"35","author":"Hoffman","year":"2024","journal-title":"Epidemiology"},{"key":"2026092703014554400_igag091-B22","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1007\/bf01318961","article-title":"A method for using epidemiologic data to estimate the potential impact of an intervention on the health status of a target population","volume":"7","author":"Morgenstern","year":"1982","journal-title":"J Community Health."},{"key":"2026092703014554400_igag091-B23","doi-asserted-by":"publisher","first-page":"268","DOI":"10.7326\/m16-2607","article-title":"Sensitivity analysis in observational research: introducing the e-value","volume":"167","author":"VanderWeele","year":"2017","journal-title":"Ann Intern Med"},{"key":"2026092703014554400_igag091-B24","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v045.i03","article-title":"Mice: multivariate imputation by chained equations in R","volume":"45","author":"Van Buuren","year":"2011","journal-title":"J Statis Softw"},{"key":"2026092703014554400_igag091-B25","doi-asserted-by":"publisher","first-page":"489","DOI":"10.1007\/s41999-025-01319-4","article-title":"Deteriorated oral health and function as risk factors for physical disability and mortality in community-dwelling older adults: a systematic review and meta-analysis","volume":"17","author":"Ko","year":"2026","journal-title":"Eur Geriatr Med."},{"key":"2026092703014554400_igag091-B26","doi-asserted-by":"publisher","first-page":"100636","DOI":"10.1016\/j.lanhl.2024.08.005","article-title":"Effect of oral health on functional disability and mortality in older adults in Japan: a cohort study","volume":"5","author":"Abe","year":"2024","journal-title":"Lancet Healthy Longevity"},{"key":"2026092703014554400_igag091-B27","doi-asserted-by":"publisher","first-page":"112446","DOI":"10.1016\/j.exger.2024.112446","article-title":"Oral frailty is associated with mortality independently of physical and psychological frailty among older adults","volume":"191","author":"Watanabe","year":"2024","journal-title":"Exp Gerontol"},{"key":"2026092703014554400_igag091-B28","doi-asserted-by":"publisher","first-page":"338","DOI":"10.1111\/j.1532-5415.2011.03791.x","article-title":"Association between dental status and incident disability in an older Japanese population","volume":"60","author":"Aida","year":"2012","journal-title":"J Am Geriatr Soc"},{"key":"2026092703014554400_igag091-B29","doi-asserted-by":"publisher","first-page":"106297","DOI":"10.1016\/j.jdent.2025.106297","article-title":"Tooth loss and masticatory function in older adults: a 15-year population-based time trend study in Singapore","volume":"165","author":"Tay","year":"2026","journal-title":"J Dentistry."},{"key":"2026092703014554400_igag091-B30","doi-asserted-by":"publisher","DOI":"10.1111\/jre.70122","article-title":"Periodontitis and quality of life: a systematic review and meta-analyses.","author":"Nascimento","year":"2026","journal-title":"J Periodontal Res"},{"key":"2026092703014554400_igag091-B31","doi-asserted-by":"publisher","first-page":"887","DOI":"10.1177\/00220345231164106","article-title":"Impact of teeth on social participation: modified treatment policy approach","volume":"102","author":"Cooray","year":"2023","journal-title":"J Dent Res"},{"key":"2026092703014554400_igag091-B32","doi-asserted-by":"publisher","first-page":"100968","DOI":"10.1016\/j.jnha.2026.100968","article-title":"The effect of increases in physical activity on oral health and function in older adults in Singapore: A longitudinal causal inference study.","volume":"30","author":"Tay","journal-title":"J Nutr Health Aging"},{"key":"2026092703014554400_igag091-B33","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1177\/00220345251363851","article-title":"Perceived masticatory function and mortality: a causal study","volume":"105","author":"Tay","year":"2026","journal-title":"J Dent Res"},{"key":"2026092703014554400_igag091-B34","doi-asserted-by":"publisher","first-page":"1111","DOI":"10.1111\/ggi.14980","article-title":"Consensus statement on \u201cOral frailty\u201d from the Japan Geriatrics Society, the Japanese Society of Gerodontology, and the Japanese Association on Sarcopenia and Frailty","volume":"24","author":"Tanaka","year":"2024","journal-title":"Geriatr Gerontol Int"},{"key":"2026092703014554400_igag091-B35","doi-asserted-by":"publisher","first-page":"468.e3","DOI":"10.1016\/j.jamda.2022.11.022","article-title":"The relationship of oral health with progression of physical frailty among older adults: a longitudinal study composed of two cohorts of older adults from the United Kingdom and United States","volume":"24","author":"Kimble","year":"2023","journal-title":"J Am Med Dir Assoc"},{"key":"2026092703014554400_igag091-B36","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1111\/jgs.15175","article-title":"Influence of poor oral health on physical frailty: a population-based cohort study of Older British Men","volume":"66","author":"Ramsay","year":"2018","journal-title":"J Am Geriatr Soc"},{"key":"2026092703014554400_igag091-B37","doi-asserted-by":"publisher","first-page":"104653","DOI":"10.1016\/j.archger.2022.104653","article-title":"Oral frailty dissected and conceptualized: a scoping review","volume":"100","author":"Parisius","year":"2022","journal-title":"Arch Gerontol Geriatr"},{"key":"2026092703014554400_igag091-B38","doi-asserted-by":"publisher","first-page":"1755","DOI":"10.1111\/j.1532-5415.2012.04104.x","article-title":"Relationship between oral health-related quality of life, oral health, socioeconomic, and general health factors in elderly Brazilians","volume":"60","author":"de Andrade","year":"2012","journal-title":"J Am Geriatr Soc"},{"key":"2026092703014554400_igag091-B39","doi-asserted-by":"publisher","first-page":"e00162324","DOI":"10.1590\/0102-311xen162324","article-title":"Evolution of socioeconomic inequalities in oral health and use of dental services in adult population of Brazil between 2013 and 2019","volume":"41","author":"Teixeira","year":"2025","journal-title":"Cad Saude Publica"},{"key":"2026092703014554400_igag091-B40","doi-asserted-by":"publisher","first-page":"677","DOI":"10.1111\/clr.70116","article-title":"Prosthetic Outcomes of Implant-Assisted Maxillary Restorations in the Edentulous Maxilla: A Systematic Review and Meta-Analysis","volume":"37","author":"Ng","year":"2026","journal-title":"Clin Oral Implants Res"},{"key":"2026092703014554400_igag091-B41","doi-asserted-by":"publisher","DOI":"10.1111\/jre.70121","article-title":"Tooth loss and edentulism are associated with poorer quality of life: a systematic review and meta-analyses.","author":"Leite","year":"2026","journal-title":"J Periodontal Res"},{"key":"2026092703014554400_igag091-B42","doi-asserted-by":"publisher","first-page":"220345251410462","DOI":"10.1177\/00220345251410462","article-title":"implementation research is underdeveloped in oral health: bridging the gap","author":"Tay","year":"2026","journal-title":"J Dent Res."},{"key":"2026092703014554400_igag091-B43","doi-asserted-by":"publisher","first-page":"518","DOI":"10.1111\/jre.70104","article-title":"Economic impact of periodontitis: global, regional and national estimates of periodontal expenditure, with forecasts to 2050","volume":"61","author":"Chow","year":"2026","journal-title":"J Periodontal Res"}],"container-title":["Innovation in Aging"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/innovateage\/advance-article-pdf\/doi\/10.1093\/geroni\/igag091\/70760088\/igag091.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/innovateage\/article-pdf\/10\/10\/igag091\/70760088\/igag091.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/innovateage\/article-pdf\/10\/10\/igag091\/70760088\/igag091.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T07:01:52Z","timestamp":1790492512000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/innovateage\/article\/doi\/10.1093\/geroni\/igag091\/8767978"}},"subtitle":[],"editor":[{"given":"Michelle","family":"Putnam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026]]},"references-count":43,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2026,9,8]]}},"URL":"https:\/\/doi.org\/10.1093\/geroni\/igag091","relation":{},"ISSN":["2399-5300"],"issn-type":[{"value":"2399-5300","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026]]},"published":{"date-parts":[[2026]]},"article-number":"igag091"}}