{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T05:01:54Z","timestamp":1790226114086,"version":"4.1.0"},"reference-count":32,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T00:00:00Z","timestamp":1790208000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Dental care utilization may serve as a behavioral marker of healthy aging, but previous studies have largely relied on single-time-point measures. Whether long-term utilization patterns are associated with cognitive aging and through which functional pathways remains unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We analyzed eight biennial waves (2006\u20132020) of the Health and Retirement Study. Group-based trajectory modeling identified dental care utilization trajectories among 14,599 adults aged \u226550\u202fyears at baseline. Cognitive function was assessed using a 27-point summary score. Linear mixed-effects models estimated associations between trajectory and cognitive decline. Serial mediation analysis using empirical Bayes individual slope estimates examined mediation through longitudinal changes in self-rated health (SRH) and activities of daily living (ADL) limitations, with Persistent High as the reference.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Three trajectories were identified: Persistent High (53.3%), Decreasing (14.5%), and Persistent Low (32.2%). Compared with Persistent High, both suboptimal trajectories showed faster cognitive decline (Decreasing:\n                      <jats:italic>\u03b2<\/jats:italic>\n                      \u202f=\u202f\u22120.085 per 2-year wave, 95% CI\u202f\u2212\u202f0.118 to \u22120.053; Persistent Low:\n                      <jats:italic>\u03b2<\/jats:italic>\n                      \u202f=\u202f\u22120.107, 95% CI\u202f\u2212\u202f0.133 to \u22120.081; both\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.0001), corresponding to approximately 0.60 and 0.75 additional points of decline over 14\u202fyears, respectively, against a 2.29-point decline in the Persistent High group. The difference between the Persistent Low and Decreasing trajectories was not significant (\n                      <jats:italic>\u03b2<\/jats:italic>\n                      difference\u202f=\u202f\u22120.0217, 95% CI\u202f\u2212\u202f0.0580 to 0.0146;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.241). Worsening ADL limitations accounted for 9.3 and 11.6% of the associations for the Decreasing and Persistent Low trajectories, respectively. In a lagged analysis separating exposure and mediator assessment (2006\u20132016) from outcome assessment (2016\u20132020), the direct associations and ADL-mediated pathway remained significant, whereas the SRH-to-cognition pathway did not.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Persistently low and declining dental care utilization were associated with similarly faster cognitive decline, with functional deterioration representing the principal mediating pathway. Long-term dental care utilization may be an accessible behavioral marker of broader functional vulnerability. Although modest, these associations may have public health relevance because utilization can be captured through surveys and administrative or claims data. Causal inference cannot be established from this observational study.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1938854","type":"journal-article","created":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T04:37:48Z","timestamp":1790224668000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Long-term dental care utilization trajectories as behavioral markers of cognitive aging: a 14-year national cohort study"],"prefix":"10.3389","volume":"14","author":[{"given":"Young-Suk","family":"Jung","sequence":"first","affiliation":[{"name":"Department of Periodontology, School of Dentistry, Chonnam National University","place":["Gwangju, Republic of Korea"]},{"name":"Leader's Dental Clinic","place":["Jeju, Republic of Korea"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hyunjoo","family":"Joo","sequence":"additional","affiliation":[{"name":"Department of Preventive Medicine, College of Medicine, Dankook University","place":["Cheonan, Republic of Korea"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,24]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"2695","DOI":"10.1111\/jgs.17978","article-title":"Periodontal health, cognitive decline, and dementia: a systematic review and meta-analysis of longitudinal studies","volume":"70","author":"Asher","year":"2022","journal-title":"J Am Geriatr Soc"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"2039","DOI":"10.1016\/j.jamda.2021.05.009","article-title":"Dose-response meta-analysis on tooth loss with the risk of cognitive impairment and dementia","volume":"22","author":"Qi","year":"2021","journal-title":"J Am Med Dir Assoc"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"345","DOI":"10.1186\/s12888-018-1927-0","article-title":"Tooth loss as a risk factor for dementia: systematic review and meta-analysis of 21 observational studies","volume":"18","author":"Fang","year":"2018","journal-title":"BMC Psychiatry"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1111\/jgs.13190","article-title":"Tooth loss associated with physical and cognitive decline in older adults","volume":"63","author":"Tsakos","year":"2015","journal-title":"J Am Geriatr Soc"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"105970","DOI":"10.1016\/j.archger.2025.105970","article-title":"Association of oral health and chewing ability with cognitive impairment and dementia in older adults: longitudinal findings from a national panel study","volume":"138","author":"Choi","year":"2025","journal-title":"Arch Gerontol Geriatr"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"313","DOI":"10.1159\/000540086","article-title":"Association of gum treatment with cognitive decline and dementia risk among older adults with periodontal symptoms: a 12-year prospective cohort study","volume":"59","author":"Qi","year":"2025","journal-title":"Neuroepidemiology"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"63","DOI":"10.1016\/j.bbi.2019.07.002","article-title":"Systemic inflammation linking chronic periodontitis to cognitive decline","volume":"81","author":"Wang","year":"2019","journal-title":"Brain Behav Immun"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"eaau3333","DOI":"10.1126\/sciadv.aau3333","article-title":"Porphyromonas gingivalis in Alzheimer\u2019s disease brains: evidence for disease causation and treatment with small-molecule inhibitors","volume":"5","author":"Dominy","year":"2019","journal-title":"Sci Adv"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"375","DOI":"10.1016\/j.jdsr.2023.10.001","article-title":"The relationships between mastication and cognitive function: a systematic review and meta-analysis","volume":"59","author":"Sta Maria","year":"2023","journal-title":"Jpn Dent Sci Rev"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"1111","DOI":"10.1111\/ggi.14980","article-title":"Consensus statement on \"oral frailty\" 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":"ref11","doi-asserted-by":"publisher","first-page":"112075","DOI":"10.1016\/j.exger.2022.112075","article-title":"Oral frailty as a risk factor for mild cognitive impairment in community-dwelling older adults: Kashiwa study","volume":"172","author":"Nagatani","year":"2023","journal-title":"Exp Gerontol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"glag006","DOI":"10.1093\/gerona\/glag006","article-title":"Oral frailty and the trajectories of psychological well-being and cognitive function: findings from the 12-year community-based Kashiwa study","volume":"81","author":"Tanaka","year":"2026","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"ref13","doi-asserted-by":"publisher","DOI":"10.1007\/s11357-025-02015-8","article-title":"Oral functional limitation and risk of frailty onset in older adults: a sex-stratified 4-year cohort study with competing risk analysis","author":"Do","year":"2025","journal-title":"GeroScience"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1186\/s12903-018-0613-4","article-title":"Income and wealth as correlates of socioeconomic disparity in dentist visits among adults aged 20 years and over in the United States, 2011\u20132014","volume":"18","author":"Kailembo","year":"2018","journal-title":"BMC Oral Health"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"0046958016652523","DOI":"10.1177\/0046958016652523","article-title":"Differences among older adults in the types of dental services used in the United States","volume":"53","author":"Manski","year":"2016","journal-title":"Inquiry"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"2685","DOI":"10.1007\/s00784-018-2611-y","article-title":"Is depression associated with oral health outcomes in adults and elders? A systematic review and meta-analysis","volume":"22","author":"Cademartori","year":"2018","journal-title":"Clin Oral Investig"},{"key":"ref17","doi-asserted-by":"crossref","DOI":"10.4159\/9780674041318","volume-title":"Group-Based Modeling of Development","author":"Nagin","year":"2005"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1146\/annurev.clinpsy.121208.131413","article-title":"Group-based trajectory modeling in clinical research","volume":"6","author":"Nagin","year":"2010","journal-title":"Annu Rev Clin Psychol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"604","DOI":"10.1177\/00220345251315155","article-title":"Longitudinal trajectories of dental attendance in Australian adults","volume":"104","author":"Kaur","year":"2025","journal-title":"J Dent Res"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"e0320658","DOI":"10.1371\/journal.pone.0320658","article-title":"Dental care trajectories among formerly incarcerated older adults in the United States","volume":"20","author":"Testa","year":"2025","journal-title":"PLoS One"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"e296","DOI":"10.1002\/mco2.296","article-title":"Frailty trajectory predicts subsequent cognitive decline: a 26-year population-based longitudinal cohort study","volume":"4","author":"Li","year":"2023","journal-title":"MedComm"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"855553","DOI":"10.3389\/fnagi.2022.855553","article-title":"Multi-concept frailty predicts the late-life occurrence of cognitive decline or dementia: an updated systematic review and meta-analysis of longitudinal studies","volume":"14","author":"Guo","year":"2022","journal-title":"Front Aging Neurosci"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"21","DOI":"10.2307\/2955359","article-title":"Self-rated health and mortality: a review of twenty-seven community studies","volume":"38","author":"Idler","year":"1997","journal-title":"J Health Soc Behav"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"576","DOI":"10.1093\/ije\/dyu067","article-title":"Cohort profile: the health and retirement study (HRS)","volume":"43","author":"Sonnega","year":"2014","journal-title":"Int J Epidemiol"},{"key":"ref25","doi-asserted-by":"crossref","DOI":"10.7826\/ISR-UM.06.585031.001.05.0010.2005","volume-title":"Documentation of Cognitive Functioning Measures in the Health and Retirement Study","author":"Ofstedal","year":"2005"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1017\/S1041610299005694","article-title":"A revised CES-D measure of depressive symptoms and a DSM-based measure of major depressive episodes in the elderly","volume":"11","author":"Turvey","year":"1999","journal-title":"Int Psychogeriatr"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v078.i02","article-title":"Estimation of extended mixed models using latent classes and latent processes: the R package lcmm","volume":"78","author":"Proust-Lima","year":"2017","journal-title":"J Stat Softw"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v048.i02","article-title":"Lavaan: an R package for structural equation modeling","volume":"48","author":"Rosseel","year":"2012","journal-title":"J Stat Softw"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"879","DOI":"10.3758\/BRM.40.3.879","article-title":"Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models","volume":"40","author":"Preacher","year":"2008","journal-title":"Behav Res Methods"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"1507","DOI":"10.1016\/S0277-9536(99)00045-3","article-title":"Integrating response shift into health-related quality of life research: a theoretical model","volume":"48","author":"Sprangers","year":"1999","journal-title":"Soc Sci Med"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"250083","DOI":"10.5888\/pcd22.250083","article-title":"The impact of oral health and dental services on the prevalence of subjective cognitive decline among middle-aged and older US adults: behavioral risk factor surveillance system, 2022","volume":"22","author":"Alshanbari","year":"2025","journal-title":"Prev Chronic Dis"},{"key":"ref32","volume-title":"Global Oral Health Status Report: Towards Universal Health Coverage for Oral Health by 2030","year":"2022"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1938854\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T04:38:03Z","timestamp":1790224683000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1938854\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,24]]},"references-count":32,"alternative-id":["10.3389\/fpubh.2026.1938854"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1938854","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,24]]},"article-number":"1938854"}}