Relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults

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The aim of this study was to assess the relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults. Methods The research material included the data of 11,901 individuals aged 40–64 years (7967 women). Depressive symptoms were used as outcome variables. The declared number of lost teeth was analysed according to the following categories: 0–4, 5–8, ≥ 9, and a complete lack of natural teeth. Multivariate logistic regression analysis for depressive symptoms was used in relation to the number of lost teeth. The following covariates were included in the adjusted model: age, sex, place of residence, education, marital status, BMI, diabetes status, stressful life events in the last year, use of antidepressants, smoking, and sugar and sweet consumption. Results The likelihood of both moderate ( p < .020) and severe ( p < .001) depressive symptoms increased the most with a total lack of natural teeth. A loss of more than 8 natural teeth was also significantly associated (p < .008) with the occurrence of severe depressive symptoms. Conclusions The results indicated that loss of natural teeth was positively related to the occurrence of depressive symptoms in middle-aged adults. Population aging will lead to growing problems related to oral health and its consequences, including mental disorders. As a result, appropriate prophylactic and educational actions need to be taken, dedicated to middle-aged individuals. depressive symptoms tooth loss middle-aged adults Introduction Depression is one of the most common mental health disorders worldwide and can originate from genetic, biological, and environmental factors [ 1 , 2 ]. Depressive symptoms, such as lowered mood (sadness, despondency, reliving of negative events, anhedonia, and indifference); decreased psychomotor drive (psychomotor retardation or inhibition, loss of energy, and persistent fatigue); abnormal circadian rhythm; and somatic symptoms (hyposomnia, hypersomnia, dry mucous membranes in the mouth, and weight changes), may also occur in people who do not meet the clinical diagnostic criteria for depression and who experience subthreshold depression. Many recent studies suggest the existence of a relationship between oral health and the occurrence of depressive symptoms [ 3 , 4 ]. One of the most severe oral conditions is tooth loss [ 5 , 6 ]. Its direct causes are usually untreated caries and periodontal diseases [ 7 – 9 ]. The prevalence of tooth loss and the factors that directly determine it depend largely on economic development, access to dental care, social factors, and lifestyle, which is why they may differ between countries and regions [ 8 – 15 ]. Loss of teeth not only reduces the effectiveness of mastication but also contributes to a limitation, or even complete elimination, of hard products from the diet (e.g., nuts and some raw fruits and vegetables), significantly reducing the nutritional value of food [ 16 ]. Consequently, such changes may impact the nutritional status and health of individuals. Loss of teeth results in a gradual decrease in bone tissue and may lead to malocclusion and disorders of the temporomandibular joints. It also causes speech impediments, especially lisping, since without proper support in the form of teeth, the tongue cannot be positioned to correctly articulate some sounds [ 17 ]. Furthermore, visibly missing teeth constitute an aesthetic blemish, while poorly fitted dentures and incorrect articulation reduce self-confidence, make it difficult for individuals to be active in the job market, and cause individuals to withdraw from social life, which in turn may reduce mental well-being [ 17 , 18 ]. These relationships have, to date, been analysed predominantly among elderly individuals, with very few publications addressing the topic among middle-aged adults. The aim of this study was to assess the relationship between the number of lost teeth and the occurrence of depressive symptoms among individuals aged 40–64 years. Materials and methods Study design and participants An analysis was performed on the data obtained as part of the PONS project (POlish-Norwegian Study), which was conducted in the Świętokrzyskie Province in Poland. The goal of the project was to observe the health and prevalence of chronic noncommunicable diseases among the residents of southeastern Poland. The Ethics Committee at the Cancer Center and Institute of Oncology in Warsaw (No. 69/2009/1/2011) approved the project and method of data collection. Further data analysis was also approved by the Committee on Bioethics at the Faculty of Health Sciences, Jan Kochanowski University in Kielce (No. 45/2016). Participants were recruited by sending invitations to participate in the project to all men and women aged 45–64 years living in the Kielce District (Świętokrzyskie Province, Poland). The response rate was 12%. A small number of participants also responded that they were younger (37–44 years) or older (65–66 years) than the intended age group. Consequently, the collected data encompassed the results of 13,172 individuals aged 37–66 years. For the purposes of the analyses conducted in this study, individuals aged ≥ 65 years and < 40 years, as well as individuals whose data were incomplete, were excluded. Ultimately, the research material for the study included the data of 11,901 individuals aged 40–64 years (3934 men). Measurements Sociodemographic data and data related to depressive symptoms, the declared number of lost teeth, and lifestyle factors were collected via face-to-face interviews with structured questionnaires. The sociodemographic variables included sex (male or female), age (years), place of residence (city or village), education level (higher, secondary, primary, or vocational), and marital status (married or in a stable relationship, single, or widowed/widowered). Measurements of depressive symptoms, used as outcome variables, were adapted from the Prospective Urban and Rural Epidemiological (PURE) study [ 20 ]. The participants were assessed based on the responses provided to eight questions concerning the occurrence of the following symptoms in the last 12 months: fatigue (loss of energy), weight gain or loss, problems falling asleep, loss of concentration, loss of interest and pleasure, feeling of helplessness (low self-esteem), sadness (worry), and thoughts about death. The respondents answered “yes” or “no” to each question. The answers were scored as 1 point or 0 points. The participants were then divided into three tercile groups based on their total scores (from 0 to 8 points): no or mild depressive symptoms (0–2 points), moderate depressive symptoms (3–5 points), and severe depressive symptoms (6–8 points) [ 21 ]. The respondents were also asked about the use of antidepressants and whether they had experienced any stressful life events in the last year, such as a serious disease or injury or death or serious disease of a close family member. The declared number of lost teeth was analysed according to the following categories: 0–4, 5–8, ≥ 9, and a complete lack of natural teeth. Body height and mass were measured and subsequently used to calculate BMI (kg/m 2 ). The assessment of diabetes status included a diagnosis of diabetes, diabetes treatment, or current abnormal fasting glucose in the blood serum (≥ 100 mg/dL/5.5 mmol/L) measured using the enzyme method with hexokinase. Participants who did not meet the above criteria were classified as nondiabetic. Total consumption of sugar, sweets, and sweetened beverages was assessed with a validated, semiquantitative food frequency questionnaire from the PURE study, which was used in the PONS project [ 22 ]. The declared frequencies of consumption and sizes of portions of the analysed food products were converted into daily doses. Smoking status was determined by dividing the respondents into current smokers (smoking every day), former smokers (those who had not smoked for more than six months at the time of the study), and never smokers (the remaining respondents). Statistical analysis Counts and percentages were calculated for each categorical (qualitative) variable. The arithmetic mean ( X ) and standard deviation ( SD ) were calculated for the continuous variables, i.e., age, BMI, and sugar and sweets consumption. The internal consistency and reliability of the eight-question test used to assess depressive symptoms were calculated based on Cronbach’s alpha, which equaled 0.81 in this sample. Individual logistic regression analyses were also conducted to calculate odds ratios (ORs ) and 95% confidence intervals (CIs ). Depressive symptoms were treated as a binary variable, with moderate (3–5 points) and severe (6–8 points) symptoms forming the model categories and no or mild (0–2 points) symptoms forming the reference group (ref.). The number of lost teeth was an independent variable (ref. 0–4). Multivariate models were also calculated adjusted for the following covariates: age and consumption of sugar and sweets (continuous variables) and categorical variables: sex (ref. women), place of residence (ref. city), education (ref. higher), marital status (ref. in a relationship), BMI (ref. 18.5–24.9 kg/m 2 ), diabetes status (ref. no), stressful life events in the last year (ref. no), use of antidepressants (ref. no), and smoking (ref. never smokers). The covariates were selected based on a review of the subject literature [ 7 – 18 ] and a previous study [ 21 ]. The data were analysed using STATISTICA 13.3 software (STATSOFT, PL). The results were considered significant at p ≤ .05. Results Table 1 presents the sociodemographic and clinical data of the participants. The majority of the participants were women (63.89%), lived in a city, had secondary education, and were in a stable relationship. The mean BMI was 28.14 ± 4.65 kg/m 2 , and diabetes or elevated glucose was observed in more than 1/3 of the participants. In terms of the number of lost teeth, the largest group included individuals who lost 9 or more teeth (28.56%). The mean intensity of depressive symptoms was 2.22 ± 2.29 points. Only 2.91% of the participants used antidepressants regularly. Over 22% declared experiencing stressful life events in the last year. The mean total consumption of sugar, sweets, and sweetened beverages was 4.32 ± 3.60 times/day. Almost 1/5 of the participants were current smokers. Table 1 Sociodemographic and clinical characteristics of the respondents ( N = 11,901). Variables N (%) Sociodemographic Sex Men 3934 (33.06) Women 7967 (63.89) Age (years) X ± SD 55.64 ± 5.34 Place of residence City 7414 (62.30) Village 4487 (37.70) Education Higher 3127 (26.28) Secondary 5310 (44.62) Primary or vocational 3464 (29.11) Marital status In a relationship 9441 (79.33) Single 2460 (20.67) Clinical and health BMI (kg/m 2 ) < 18.5 51 (0.47) 18.5–24.9 3068 (28.21) 25.0–29.9 5198 (43.15) ≥ 30.0 3584 (28.17) Diabetes status No 7941 (66.73) Yes 3960 (33.27) Number of lost teeth 0–4 2908 (24.45) 5–8 2932 (24.64) ≥ 9 3399 (28.56) No natural teeth 2662 (22.37) Depressive symptoms None or mild (0–2 points) 7469 (62.76) Moderate (3–5 points) 3038 (25.53) Severe (6–8 points) 1394 (11.71) Use of antidepressants No 11555 (97.09) Yes 346 (2.91) Stressful life events in the last year No 9255 (77.77) Yes 2646 (22.23) Lifestyle Sugar and sweets consumption (times/day) X ± SD 4.32 ± 3.60 Smoking Never 5588 (46.95) Former 3996 (33.58) Current 2317 (19.47) Table 1 . Sociodemographic and clinical characteristics of the respondents ( n = 11,901). According to the unadjusted model, a greater number of lost teeth was associated with a greater likelihood of both moderate and severe depressive symptoms (Table 2 ). After adjusting for the confounding variables, the relationships between the number of lost teeth and depressive symptoms were weaker, but a total lack of natural teeth was still the factor that most strongly increased the likelihood of both moderate ( p < .020) and severe ( p < .001) symptoms (Table 3 ). A loss of more than 8 natural teeth was also significantly associated (p < .008) with the occurrence of severe depressive symptoms. Table 2 Multivariate logistic regression analysis of moderate and severe depressive symptoms in relation to the number of lost teeth (unadjusted). Depressive symptoms Number of lost teeth OR (95% CI) p Moderate vs. none or mild 0–4 Ref. 5–8 1.129 (0.999–1.276) 0.051 ≥ 9 1.346 (1.197–1.513) < 0.001 No natural teeth 1.474 (1.301–1.669) < 0.001 Severe vs. none or mild 0–4 Ref. 5–8 1.342 (1.116–1.613) 0.002 ≥ 9 1.854 (1.562–2.202) < 0.001 No natural teeth 2.624 (2.207–3.120) < 0.001 Table 3 Multivariate logistic regression analysis of depressive symptoms in relation to the number of lost teeth (adjusted*). Depressive symptoms Number of lost teeth OR (95% CI) p Moderate vs. none or mild 0–4 Ref. 5–8 1.052 (0.926–1.196) 0.437 ≥ 9 1.132 (0.993–1.291) 0.064 No natural teeth 1.189 (1.028–1.376) 0.020 Severe vs. none or mild 0–4 Ref. 5–8 1.165 (0.951–1.426) 0.141 ≥ 9 1.315 (1.075–1.609) 0.008 No natural teeth 1.846 (1.488–2.290) < 0.001 * - adjusted for sex, age, place of residence, education, marital status, BMI, diabetes status, use of antidepressants, stressful life events in the last year, sugar and sweets consumption, and smoking Discussion The conducted analyses showed that the loss of natural teeth in middle-aged adults was significantly related to an increased risk of depressive symptoms. Most long-term studies have demonstrated that oral health problems and a lack of natural teeth may play a role in the development or worsening of depressive symptoms [ 23 , 24 ]. In a study conducted in Brazil, individuals who experienced tooth loss over a six-year follow-up were at a greater risk of exhibiting depressive symptoms (adjusted prevalence ratio = 1.86; 95% CI: 1.01–3.53) [ 25 ]. In the Chilean population, individuals aged 38–74 years with fewer than 20 natural teeth were shown to have higher odds of incident depression at two- and four-year follow-ups [ 26 ]. The existence of positive relationships between tooth loss and the occurrence of depressive symptoms was also substantiated by the results of meta-analyses [ 27 ] and cross-sectional studies [ 28 , 29 ]. Matsuyama et al. reported that the effect of tooth loss on depression seemed to be greater in young adults [ 29 ]. This phenomenon can be explained by the fact that individuals usually associate the loss of teeth with old age, and consequently, if the problem occurs at a young age, it may exacerbate depressive symptoms. Elderly individuals may treat tooth loss as a natural consequence of old age and adapt their daily life to it more easily than young individuals. The oral health of Poles has remained unsatisfactory for many years compared to that of other European countries, despite a recent trend toward improvement [ 12 , 30 , 31 ]. A total lack of natural teeth, reported by 22.37% of the participants in this study aged 40–64 years, was similar in prevalence to the global prevalence among individuals aged ≥ 45 years, which amounts to 22% [ 32 ]. As a result, all negative health outcomes of tooth loss can be expected to appear much earlier in the Polish population. The mechanism of the relationship between the loss of natural teeth and depressive symptoms has not been investigated or explained in depth thus far. In their long-term study, Yamamoto et al. observed that problems with smiling, laughing, and exposing teeth without embarrassment may cause individuals to isolate themselves and eat alone, which in turn exacerbates their depressive symptoms [ 23 ]. Kusama et al. also reported that the deterioration of oral function and orofacial appearance are the main factors contributing to the development of depression due to the loss of natural teeth [ 18 ]. Sun et al., based on research conducted among the Chinese population, concluded that dietary dissatisfaction was a contributing factor to the development of depressive symptoms following the loss of teeth [ 33 ]. This occurs because food plays an important role in meetings with family and friends and is a medium for maintaining social contact, expressing friendships, and caring for family members. In middle-aged individuals, embarrassment and dissatisfaction with one’s own appearance due to loss of teeth also led to frustration and problems with satisfying activity on the job market, even when dentures were used [ 17 ], because removable, unstable dentures did not eliminate certain problems related to aesthetics and oral health. Researchers suggest that depressive symptoms may also be further exacerbated by inflammation of the nervous system resulting from a history of periodontitis or autonomic nerve imbalance caused by oral pain and discomfort [ 27 ]. Moreover, Wingfield et al. noted that depression may be related to the state of the oral cavity microbiome [ 34 ]. The authors described explicit changes in the composition and amount of specific bacterial taxa in the salivary microbiome in young adults with depression compared to a reference group of individuals without depression. Limitations The limitations of this study include, first and foremost, its cross-sectional design. It should be noted that the relationship between tooth loss and the occurrence of depressive symptoms may be bidirectional [ 27 ]. Analysis of depressive symptoms suggested that self-neglect, lowered mood, and lack of energy may cause individuals to neglect oral hygiene and proper eating habits, leading to health problems in the form of oral diseases and tooth loss [ 28 ]. Aldosari et al. demonstrated that oral cavity disorders, including tooth loss, were more prevalent among individuals with severe internalization problems [ 24 ]. Another limitation concerns the research tool, which did not allow for a clinical diagnosis of depression. However, the questionnaire used in this paper has been successfully applied for the assessment of depressive symptoms in other international studies [ 20 ]. Conversely, the strengths of this study were the large sample size, uniformity in terms of age, and large number of confounders included in the analysis. Conclusions The results indicated that loss of natural teeth was positively related to the occurrence of depressive symptoms in middle-aged adults. Edentulism increased the likelihood of both moderate and severe depressive symptoms the most. Population aging is accompanied by deterioration of oral health and its consequences, including mental disorders. As a result, appropriate prophylactic and educational actions need to be taken, dedicated to middle-aged individuals. This will require the involvement of not only psychologists but also the entire medical community, including dentists, as well as the introduction of appropriate changes in the health care system in Poland aimed at increasing the real availability of dental services. Abbreviations PONS POlish-Norwegian Study PURE Prospective Urban and Rural Epidemiological Study X arithmetic mean SD standard deviation BMI Body mass index OR odds ratio CI Confidence interval Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee at the Cancer Center and Institute of Oncology in Warsaw (No. 69/2009/1/2011). Written informed consent was obtained from participants before the survey. The material analyses were approved by the Committee on Bioethics at the Faculty of Health Sciences, Jan Kochanowski University in Kielce (No. 45/2016). Consent for publication Not applicable. Availability of Data The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by Jan Kochanowski University in Kielce, Poland (No 2024). The founders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Acknowledgements The data collection was supported by the Maria Sklodowska-Curie Institute of Oncology in Warsaw (Poland) and the Polish-Norwegian Foundation Research Fund. References GBD 2019 Mental Disorders Collaborators Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022;9:137–50. Malhi GS, Mann JJ. Depression. Lancet. 2018;392:2299–312. Joury E, Kisely S, Watt RG, Ahmed N, Morris AJ, Fortune F, Bhui K. Mental Disorders and Oral Diseases: Future Research Directions. J Dent Res. 2023;102:5-12. Skallevold HE, Rokaya N, Wongsirichat N, Rokaya D. Importance of oral health in mental health disorders: An updated review. 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Variations in the oral microbiome are associated with depression in young adults. Sci Rep. 2021;11:15009. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Mar, 2024 Reviews received at journal 13 Feb, 2024 Reviewers agreed at journal 13 Feb, 2024 Reviews received at journal 10 Feb, 2024 Reviewers agreed at journal 01 Feb, 2024 Reviewers invited by journal 16 Jan, 2024 Editor assigned by journal 16 Jan, 2024 Editor invited by journal 21 Dec, 2023 Submission checks completed at journal 21 Dec, 2023 First submitted to journal 21 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3785812","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":262919935,"identity":"65ef0205-2e60-4a66-92bd-d7d47c0fa3bb","order_by":0,"name":"Martyna Głuszek-Osuch","email":"","orcid":"","institution":"Jan Kochanowski University","correspondingAuthor":false,"prefix":"","firstName":"Martyna","middleName":"","lastName":"Głuszek-Osuch","suffix":""},{"id":262919936,"identity":"aa7f770a-625b-49dd-8300-dc3b6ea0498c","order_by":1,"name":"Elżbieta Cieśla","email":"","orcid":"","institution":"Jan Kochanowski University","correspondingAuthor":false,"prefix":"","firstName":"Elżbieta","middleName":"","lastName":"Cieśla","suffix":""},{"id":262919937,"identity":"080b9d19-5755-40c3-a151-0990d5023e45","order_by":2,"name":"Edyta Suliga","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYFCCBAjFxwwkPjCwGQApELbAp4WxAUSxAbUwzkBokSBCCxAz80CU49fCz55j/uAHQ11iGzv7xc+2bXzGDOzN2yQYd+DWItnzxrCxh+FwYhszT7F0bhubGQPPsTIJxjO4tRjcyDFs4GE4ANKSANJiwyCRYybB2IZbiz1QS+MfkMOYeZJ/W4K0yL/Br8VAIsewmYeBGaiF/Zg0I8hhEjz4tUiceVY4W8bgsDHQFjbLnnNsxmw8acUWiXj8wt+evOHjm4o62X7+449v/Cg7ZtjPfnjjjY87bHBqYWDgMIBEBAMPiDwGjiCGxAY8OhjYHyAzaiBsRrxaRsEoGAWjYIQBAGMKSPfMD5EAAAAAAElFTkSuQmCC","orcid":"","institution":"Jan Kochanowski University","correspondingAuthor":true,"prefix":"","firstName":"Edyta","middleName":"","lastName":"Suliga","suffix":""}],"badges":[],"createdAt":"2023-12-21 08:44:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3785812/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3785812/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":48760739,"identity":"ee505e34-597f-4fb9-958e-ba7040378803","added_by":"auto","created_at":"2023-12-25 06:01:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":279021,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3785812/v1/f4817483-0120-4839-ab79-8d330a77cf74.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDepression is one of the most common mental health disorders worldwide and can originate from genetic, biological, and environmental factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Depressive symptoms, such as lowered mood (sadness, despondency, reliving of negative events, anhedonia, and indifference); decreased psychomotor drive (psychomotor retardation or inhibition, loss of energy, and persistent fatigue); abnormal circadian rhythm; and somatic symptoms (hyposomnia, hypersomnia, dry mucous membranes in the mouth, and weight changes), may also occur in people who do not meet the clinical diagnostic criteria for depression and who experience subthreshold depression. Many recent studies suggest the existence of a relationship between oral health and the occurrence of depressive symptoms [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. One of the most severe oral conditions is tooth loss [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Its direct causes are usually untreated caries and periodontal diseases [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The prevalence of tooth loss and the factors that directly determine it depend largely on economic development, access to dental care, social factors, and lifestyle, which is why they may differ between countries and regions [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Loss of teeth not only reduces the effectiveness of mastication but also contributes to a limitation, or even complete elimination, of hard products from the diet (e.g., nuts and some raw fruits and vegetables), significantly reducing the nutritional value of food [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Consequently, such changes may impact the nutritional status and health of individuals. Loss of teeth results in a gradual decrease in bone tissue and may lead to malocclusion and disorders of the temporomandibular joints. It also causes speech impediments, especially lisping, since without proper support in the form of teeth, the tongue cannot be positioned to correctly articulate some sounds [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, visibly missing teeth constitute an aesthetic blemish, while poorly fitted dentures and incorrect articulation reduce self-confidence, make it difficult for individuals to be active in the job market, and cause individuals to withdraw from social life, which in turn may reduce mental well-being [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These relationships have, to date, been analysed predominantly among elderly individuals, with very few publications addressing the topic among middle-aged adults. The aim of this study was to assess the relationship between the number of lost teeth and the occurrence of depressive symptoms among individuals aged 40\u0026ndash;64 years.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eStudy design and participants\u003c/p\u003e \u003cp\u003eAn analysis was performed on the data obtained as part of the PONS project (POlish-Norwegian Study), which was conducted in the Świętokrzyskie Province in Poland. The goal of the project was to observe the health and prevalence of chronic noncommunicable diseases among the residents of southeastern Poland. The Ethics Committee at the Cancer Center and Institute of Oncology in Warsaw (No. 69/2009/1/2011) approved the project and method of data collection. Further data analysis was also approved by the Committee on Bioethics at the Faculty of Health Sciences, Jan Kochanowski University in Kielce (No. 45/2016). Participants were recruited by sending invitations to participate in the project to all men and women aged 45\u0026ndash;64 years living in the Kielce District (Świętokrzyskie Province, Poland). The response rate was 12%. A small number of participants also responded that they were younger (37\u0026ndash;44 years) or older (65\u0026ndash;66 years) than the intended age group. Consequently, the collected data encompassed the results of 13,172 individuals aged 37\u0026ndash;66 years. For the purposes of the analyses conducted in this study, individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years and \u0026lt;\u0026thinsp;40 years, as well as individuals whose data were incomplete, were excluded. Ultimately, the research material for the study included the data of 11,901 individuals aged 40\u0026ndash;64 years (3934 men).\u003c/p\u003e \u003cp\u003eMeasurements\u003c/p\u003e \u003cp\u003eSociodemographic data and data related to depressive symptoms, the declared number of lost teeth, and lifestyle factors were collected via face-to-face interviews with structured questionnaires. The sociodemographic variables included sex (male or female), age (years), place of residence (city or village), education level (higher, secondary, primary, or vocational), and marital status (married or in a stable relationship, single, or widowed/widowered). Measurements of depressive symptoms, used as outcome variables, were adapted from the Prospective Urban and Rural Epidemiological (PURE) study [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The participants were assessed based on the responses provided to eight questions concerning the occurrence of the following symptoms in the last 12 months: fatigue (loss of energy), weight gain or loss, problems falling asleep, loss of concentration, loss of interest and pleasure, feeling of helplessness (low self-esteem), sadness (worry), and thoughts about death. The respondents answered \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; to each question. The answers were scored as 1 point or 0 points. The participants were then divided into three tercile groups based on their total scores (from 0 to 8 points): no or mild depressive symptoms (0\u0026ndash;2 points), moderate depressive symptoms (3\u0026ndash;5 points), and severe depressive symptoms (6\u0026ndash;8 points) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The respondents were also asked about the use of antidepressants and whether they had experienced any stressful life events in the last year, such as a serious disease or injury or death or serious disease of a close family member. The declared number of lost teeth was analysed according to the following categories: 0\u0026ndash;4, 5\u0026ndash;8, \u0026ge; 9, and a complete lack of natural teeth. Body height and mass were measured and subsequently used to calculate BMI (kg/m\u003csup\u003e2\u003c/sup\u003e). The assessment of diabetes status included a diagnosis of diabetes, diabetes treatment, or current abnormal fasting glucose in the blood serum (\u0026ge;\u0026thinsp;100 mg/dL/5.5 mmol/L) measured using the enzyme method with hexokinase. Participants who did not meet the above criteria were classified as nondiabetic. Total consumption of sugar, sweets, and sweetened beverages was assessed with a validated, semiquantitative food frequency questionnaire from the PURE study, which was used in the PONS project [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The declared frequencies of consumption and sizes of portions of the analysed food products were converted into daily doses. Smoking status was determined by dividing the respondents into current smokers (smoking every day), former smokers (those who had not smoked for more than six months at the time of the study), and never smokers (the remaining respondents).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCounts and percentages were calculated for each categorical (qualitative) variable. The arithmetic mean (\u003cem\u003eX\u003c/em\u003e) and standard deviation (\u003cem\u003eSD\u003c/em\u003e) were calculated for the continuous variables, i.e., age, BMI, and sugar and sweets consumption. The internal consistency and reliability of the eight-question test used to assess depressive symptoms were calculated based on Cronbach\u0026rsquo;s alpha, which equaled 0.81 in this sample. Individual logistic regression analyses were also conducted to calculate odds \u003cem\u003eratios (ORs\u003c/em\u003e) and 95% confidence \u003cem\u003eintervals (CIs\u003c/em\u003e). Depressive symptoms were treated as a binary variable, with moderate (3\u0026ndash;5 points) and severe (6\u0026ndash;8 points) symptoms forming the model categories and no or mild (0\u0026ndash;2 points) symptoms forming the reference group (ref.). The number of lost teeth was an independent variable (ref. 0\u0026ndash;4). Multivariate models were also calculated adjusted for the following covariates: age and consumption of sugar and sweets (continuous variables) and categorical variables: sex (ref. women), place of residence (ref. city), education (ref. higher), marital status (ref. in a relationship), BMI (ref. 18.5\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e), diabetes status (ref. no), stressful life events in the last year (ref. no), use of antidepressants (ref. no), and smoking (ref. never smokers). The covariates were selected based on a review of the subject literature [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and a previous study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The data were analysed using STATISTICA 13.3 software (STATSOFT, PL). The results were considered significant at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the sociodemographic and clinical data of the participants. The majority of the participants were women (63.89%), lived in a city, had secondary education, and were in a stable relationship. The mean BMI was 28.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.65 kg/m\u003csup\u003e2\u003c/sup\u003e, and diabetes or elevated glucose was observed in more than 1/3 of the participants. In terms of the number of lost teeth, the largest group included individuals who lost 9 or more teeth (28.56%). The mean intensity of depressive symptoms was 2.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29 points. Only 2.91% of the participants used antidepressants regularly. Over 22% declared experiencing stressful life events in the last year. The mean total consumption of sugar, sweets, and sweetened beverages was 4.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60 times/day. Almost 1/5 of the participants were current smokers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and clinical characteristics of the respondents (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11,901).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003eSociodemographic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3934 (33.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7967 (63.89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.64\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7414 (62.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4487 (37.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3127 (26.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5310 (44.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary or vocational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3464 (29.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn a relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9441 (79.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2460 (20.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"16\" rowspan=\"17\"\u003e \u003cp\u003eClinical and health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (0.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u0026ndash;24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3068 (28.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u0026ndash;29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5198 (43.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3584 (28.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiabetes status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7941 (66.73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3960 (33.27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eNumber of lost teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2908 (24.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2932 (24.64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3399 (28.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo natural teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2662 (22.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone or mild (0\u0026ndash;2 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7469 (62.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate (3\u0026ndash;5 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3038 (25.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSevere (6\u0026ndash;8 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1394 (11.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUse of antidepressants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11555 (97.09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e346 (2.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStressful life events in the last year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9255 (77.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2646 (22.23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSugar and sweets consumption (times/day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5588 (46.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFormer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3996 (33.58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2317 (19.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Sociodemographic and clinical characteristics of the respondents (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11,901).\u003c/p\u003e \u003cp\u003eAccording to the unadjusted model, a greater number of lost teeth was associated with a greater likelihood of both moderate and severe depressive symptoms (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After adjusting for the confounding variables, the relationships between the number of lost teeth and depressive symptoms were weaker, but a total lack of natural teeth was still the factor that most strongly increased the likelihood of both moderate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.020) and severe (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) symptoms (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A loss of more than 8 natural teeth was also significantly associated (p\u0026thinsp;\u0026lt;\u0026thinsp;.008) with the occurrence of severe depressive symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis of moderate and severe depressive symptoms in relation to the number of lost teeth (unadjusted).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of lost teeth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eModerate vs. none or mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.129 (0.999\u0026ndash;1.276)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.346 (1.197\u0026ndash;1.513)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo natural teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.474 (1.301\u0026ndash;1.669)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSevere vs. none or mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.342 (1.116\u0026ndash;1.613)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.854 (1.562\u0026ndash;2.202)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo natural teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.624 (2.207\u0026ndash;3.120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis of depressive symptoms in relation to the number of lost teeth (adjusted*).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of lost teeth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eModerate vs. none or mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.052 (0.926\u0026ndash;1.196)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.132 (0.993\u0026ndash;1.291)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo natural teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.189 (1.028\u0026ndash;1.376)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSevere vs. none or mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.165 (0.951\u0026ndash;1.426)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.315 (1.075\u0026ndash;1.609)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo natural teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.846 (1.488\u0026ndash;2.290)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* - adjusted for sex, age, place of residence, education, marital status, BMI, diabetes status, use of antidepressants, stressful life events in the last year, sugar and sweets consumption, and smoking\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe conducted analyses showed that the loss of natural teeth in middle-aged adults was significantly related to an increased risk of depressive symptoms. Most long-term studies have demonstrated that oral health problems and a lack of natural teeth may play a role in the development or worsening of depressive symptoms [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In a study conducted in Brazil, individuals who experienced tooth loss over a six-year follow-up were at a greater risk of exhibiting depressive symptoms (adjusted prevalence ratio\u0026thinsp;=\u0026thinsp;1.86; 95% CI: 1.01\u0026ndash;3.53) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In the Chilean population, individuals aged 38\u0026ndash;74 years with fewer than 20 natural teeth were shown to have higher odds of incident depression at two- and four-year follow-ups [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The existence of positive relationships between tooth loss and the occurrence of depressive symptoms was also substantiated by the results of meta-analyses [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and cross-sectional studies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Matsuyama et al. reported that the effect of tooth loss on depression seemed to be greater in young adults [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This phenomenon can be explained by the fact that individuals usually associate the loss of teeth with old age, and consequently, if the problem occurs at a young age, it may exacerbate depressive symptoms. Elderly individuals may treat tooth loss as a natural consequence of old age and adapt their daily life to it more easily than young individuals. The oral health of Poles has remained unsatisfactory for many years compared to that of other European countries, despite a recent trend toward improvement [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A total lack of natural teeth, reported by 22.37% of the participants in this study aged 40\u0026ndash;64 years, was similar in prevalence to the global prevalence among individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;45 years, which amounts to 22% [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. As a result, all negative health outcomes of tooth loss can be expected to appear much earlier in the Polish population.\u003c/p\u003e \u003cp\u003eThe mechanism of the relationship between the loss of natural teeth and depressive symptoms has not been investigated or explained in depth thus far. In their long-term study, Yamamoto et al. observed that problems with smiling, laughing, and exposing teeth without embarrassment may cause individuals to isolate themselves and eat alone, which in turn exacerbates their depressive symptoms [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Kusama et al. also reported that the deterioration of oral function and orofacial appearance are the main factors contributing to the development of depression due to the loss of natural teeth [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Sun et al., based on research conducted among the Chinese population, concluded that dietary dissatisfaction was a contributing factor to the development of depressive symptoms following the loss of teeth [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This occurs because food plays an important role in meetings with family and friends and is a medium for maintaining social contact, expressing friendships, and caring for family members. In middle-aged individuals, embarrassment and dissatisfaction with one\u0026rsquo;s own appearance due to loss of teeth also led to frustration and problems with satisfying activity on the job market, even when dentures were used [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], because removable, unstable dentures did not eliminate certain problems related to aesthetics and oral health. Researchers suggest that depressive symptoms may also be further exacerbated by inflammation of the nervous system resulting from a history of periodontitis or autonomic nerve imbalance caused by oral pain and discomfort [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Moreover, Wingfield et al. noted that depression may be related to the state of the oral cavity microbiome [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The authors described explicit changes in the composition and amount of specific bacterial taxa in the salivary microbiome in young adults with depression compared to a reference group of individuals without depression.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThe limitations of this study include, first and foremost, its cross-sectional design. It should be noted that the relationship between tooth loss and the occurrence of depressive symptoms may be bidirectional [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Analysis of depressive symptoms suggested that self-neglect, lowered mood, and lack of energy may cause individuals to neglect oral hygiene and proper eating habits, leading to health problems in the form of oral diseases and tooth loss [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Aldosari et al. demonstrated that oral cavity disorders, including tooth loss, were more prevalent among individuals with severe internalization problems [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Another limitation concerns the research tool, which did not allow for a clinical diagnosis of depression. However, the questionnaire used in this paper has been successfully applied for the assessment of depressive symptoms in other international studies [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Conversely, the strengths of this study were the large sample size, uniformity in terms of age, and large number of confounders included in the analysis.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results indicated that loss of natural teeth was positively related to the occurrence of depressive symptoms in middle-aged adults. Edentulism increased the likelihood of both moderate and severe depressive symptoms the most.\u003c/p\u003e \u003cp\u003ePopulation aging is accompanied by deterioration of oral health and its consequences, including mental disorders. As a result, appropriate prophylactic and educational actions need to be taken, dedicated to middle-aged individuals. This will require the involvement of not only psychologists but also the entire medical community, including dentists, as well as the introduction of appropriate changes in the health care system in Poland aimed at increasing the real availability of dental services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePONS\u0026nbsp;POlish-Norwegian Study\u003c/p\u003e\n\u003cp\u003ePURE Prospective Urban and Rural Epidemiological\u0026nbsp;Study\u003c/p\u003e\n\u003cp\u003eX arithmetic mean\u003c/p\u003e\n\u003cp\u003eSD standard deviation\u003c/p\u003e\n\u003cp\u003eBMI Body\u0026nbsp;mass index\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp;odds ratio\u003c/p\u003e\n\u003cp\u003eCI Confidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the\u0026nbsp;Ethics Committee at the Cancer Center and Institute of Oncology in Warsaw (No. 69/2009/1/2011). Written informed consent was obtained from participants before the survey. The material\u0026nbsp;analyses\u0026nbsp;were approved by the Committee on Bioethics at the Faculty of Health Sciences, Jan Kochanowski University in Kielce (No. 45/2016).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of Data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Jan Kochanowski University in Kielce, Poland (No 2024).\u0026nbsp;The founders had no role in\u0026nbsp;the\u0026nbsp;study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collection was supported by the Maria Sklodowska-Curie Institute of Oncology in Warsaw (Poland) and the Polish-Norwegian Foundation Research Fund.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGBD 2019 Mental Disorders Collaborators Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022;9:137\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eMalhi GS, Mann JJ. Depression. Lancet. 2018;392:2299\u0026ndash;312.\u003c/li\u003e\n\u003cli\u003eJoury E, Kisely S, Watt RG, Ahmed N, Morris AJ, Fortune F, Bhui K. Mental Disorders and Oral Diseases: Future Research Directions. J Dent Res. 2023;102:5-12.\u003c/li\u003e\n\u003cli\u003eSkallevold HE, Rokaya N, Wongsirichat N, Rokaya D. Importance of oral health in mental health disorders: An updated review. J Oral Biol Craniofac Res. 2023;13:544-52.\u003c/li\u003e\n\u003cli\u003eTu C, Wang G, Hu Z, Wang S, Yan Q, Liu X. Burden of oral disorders, 1990-2019: estimates from the Global Burden of Disease Study 2019. Arch Med Sci. 2023;19:930-40. \u003c/li\u003e\n\u003cli\u003ePeres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herre\u0026ntilde;o CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet. 2019;394:249-60.\u003c/li\u003e\n\u003cli\u003eCosta FO, Lages EJ, Cota LO, Lorentz TC, Soares RV, Cortelli JR. Tooth loss in individuals under periodontal maintenance therapy: 5-year prospective study. J Periodontal Res. 2014;49:121-8. \u003c/li\u003e\n\u003cli\u003eKassebaum NJ, Bernab\u0026eacute; E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global Burden of Severe Tooth Loss: A Systematic Review and Meta-analysis. J Dent Res. 2014;93(7 Suppl):20S-8S.\u003c/li\u003e\n\u003cli\u003eJiang L, Li J, Yang Z, Huang X, Zhong X, Huang Y, Liu B, Wu L, Huang S, Fan W. Analysis of epidemiological trends of and associated factors for tooth loss among 35- to 44-year-old adults in Guangdong, Southern China, 1995-2015: a population-based cross-sectional survey. BMC Oral Health. 2023;23:74. \u003c/li\u003e\n\u003cli\u003eRaskiliene A, Kriaucioniene V, Siudikiene J, Petkeviciene J. Self-Reported Oral Health, Oral Hygiene and Associated Factors in Lithuanian Adult Population, 1994-2014. Int J Environ Res Public Health. 2020;17:5331. \u003c/li\u003e\n\u003cli\u003eCooray U, Watt RG, Tsakos G, Heilmann A, Hariyama M, Yamamoto T, Kuruppuarachchige I, Kondo K, Osaka K, Aida J. Importance of socioeconomic factors in predicting tooth loss among older adults in Japan: Evidence from a machine learning analysis. Soc Sci Med. 2021;291:114486.\u003c/li\u003e\n\u003cli\u003eGabiec K, Bagińska J, Łaguna W, Rodakowska E, Kamińska I, Stachurska Z, Dubat\u0026oacute;wka M, Kondraciuk M, Kamiński KA. Factors Associated with Tooth Loss in General Population of Bialystok, Poland. Int J Environ Res Public Health. 2022;19:2369.\u003c/li\u003e\n\u003cli\u003eT\u0026ocirc;rres LHDN, Hilgert JB, Hugo FN, Sousa MDLR, De Marchi RJ. Predictors of tooth loss in Brazilian older adults: An 8-year follow-up. Gerodontology. 2023;40:207-12.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;sterberg T, Dey DK, Sundh V, Carlsson GE, Jansson JO, Mellstrom D. Edentulism associated with obesity: a study of four national surveys of 16416 Swedes aged 55\u0026ndash;84\u0026thinsp;years. Acta Odontol Scand. 2010;68:360\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eWiener RC, Shen C, Findley PA, Sambamoorthi U, Tan X. The association between diabetes mellitus, sugar-sweetened beverages, and tooth loss in adults: Evidence from 18 states. J Am Dent Assoc. 2017;148:500-9.e4.\u003c/li\u003e\n\u003cli\u003eHsu KJ, Lee HE, Wu YM, Lan SJ, Huang ST, Yen YY. Masticatory factors as predictors of oral health-related quality of life among elderly people in Kaohsiung City, Taiwan. Qual Life Res. 2014;23:1395-405.\u003c/li\u003e\n\u003cli\u003eCortez GFP, Barbosa GZ, T\u0026ocirc;rres LHDN, Unfer B. Reasons for and consequences of tooth loss in adults and elderly people in Brazil: a qualitative metasynthesis. Cien Saude Colet. 2023;28:1413-24.\u003c/li\u003e\n\u003cli\u003eKusama T, Kiuchi S, Umehara N, Kondo K, Osaka K, Aida J. The deterioration of oral function and orofacial appearance mediated the relationship between tooth loss and depression among community-dwelling older adults: A JAGES cohort study using causal mediation analysis. J Affect Disord. 2021;286:174-9.\u003c/li\u003e\n\u003cli\u003eZatonski WA, Manczuk M, Kielce PONS Team: POlish-Norwegian Study (PONS): Research on chronic noncommunicable diseases in European high risk countries \u0026ndash; study design. Ann Agric Environ Med. 2011;18:203\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eKoon T, Chow CK, Vaz M, Rangarajan S, Yusuf S. The Prospective Urban Rural Epidemiology (PURE) study: Examining the impact of societal infl uences on chronic noncommunicable diseases in low-, middle-, and high income countries. Am Heart J. 2009;158:1-7.\u003c/li\u003e\n\u003cli\u003eGłuszek-Osuch M, Cieśla E, Suliga E. Relationship between multimorbidity and sociodemographic factors, depressive symptoms, and lifestyle in middle-aged adults. Medical Studies/Studia Medyczne. 2023;39:182-91.\u003c/li\u003e\n\u003cli\u003eDehghan M, Ilow R, Zatonska K, Szuba A, Zhang X, Mente A, Regulska-Ilow B. Development, reproducibility and validity of the food frequency questionnaire in the Poland arm of the Prospective Urban and Rural Epidemiological (PURE) study. J Hum Nutr Diet. 2012;25:225-32.\u003c/li\u003e\n\u003cli\u003eYamamoto T, Aida J, Kondo K, Fuchida S, Tani Y, Saito M, Sasaki Y. Oral Health and Incident Depressive Symptoms: JAGES Project Longitudinal Study in Older Japanese. J Am Geriatr Soc. 2017;65:1079-84.\u003c/li\u003e\n\u003cli\u003eAldosari M, Helmi M, Kennedy EN, Badamia R, Odani S, Agaku I, Vardavas C. Depression, periodontitis, caries and missing teeth in the USA, NHANES 2009-2014. Fam Med Community Health. 2020;8:e000583.\u003c/li\u003e\n\u003cli\u003eKunrath I, Silva AER. Oral health and depressive symptoms among older adults: longitudinal study. Aging Ment Health. 2021;25:2265-71.\u003c/li\u003e\n\u003cli\u003eOrtu\u0026ntilde;o D, Mart\u0026iacute;nez C, Caneo C. Association between number of remaining teeth and incident depression in a rural Chilean cohort. BMC Oral Health. 2023;23:633.\u003c/li\u003e\n\u003cli\u003eCademartori MG, Gastal MT, Nascimento GG, Demarco FF, Corr\u0026ecirc;a MB. Is depression associated with oral health outcomes in adults and elders? A systematic review and meta-analysis. Clin Oral Investig. 2018;22:2685-702.\u003c/li\u003e\n\u003cli\u003eSkośkiewicz-Malinowska K, Malicka B, Ziętek M, Kaczmarek U. Oral health condition and occurrence of depression in elderly individuals. Medicine (Baltimore). 2018;97:e12490.\u003c/li\u003e\n\u003cli\u003eMatsuyama Y, J\u0026uuml;rges H, Dewey M, Listl S. Causal effect of tooth loss on depression: evidence from a population-wide natural experiment in the USA. Epidemiol Psychiatr Sci. 2021;30:e38.\u003c/li\u003e\n\u003cli\u003eMehr K, Olszanecka-Glinianowicz M, Chudek J, Szybalska A, Mossakowska M, Zejda J, Wieczorowska-Tobis K, Grodzicki T, Piotrowski P. Dental status in the Polish senior population and its correlates\u0026mdash;Results of the national survey PolSenior. Gerodontology. 2018:35: 398\u0026ndash;406.\u003c/li\u003e\n\u003cli\u003eRaport 2021; Olczak-Kowalczyk, D. Choroba Pr\u003cem\u003e\u0026oacute;\u003c/em\u003echnicowa i Stan Tkanek Przyzebia Populacji Polskiej. Podsumowanie Wynik\u003cem\u003e\u0026oacute;\u003c/em\u003ew Badan z Lat 2016\u0026ndash;2019; Ministerstwo Zdrowia: Warszawa, Polska, 2021 [Caries Disease and the condition of periodontal tissues in the Polish population. Summary of research results from 2016\u0026ndash;2019; Ministry of Health: Warsaw, Poland, 2021.]. Available online: https://www.gov.pl/attachment/e837445b-41ef-4b49-b261-d21d869e0018 (accessed on 4 September 2023) ISBN 978-83-7637-555-7. (In Polish)\u003c/li\u003e\n\u003cli\u003eBorg-Bartolo R, Roccuzzo A, Molinero-Mourelle P, Schimmel M, Gambetta-Tessini K, Chaurasia A, Koca-\u0026Uuml;nsal RB, Tennert C, Giacaman R, Campus G. Global prevalence of edentulism and dental caries in middle-aged and elderly persons: A systematic review and meta-analysis. J Dent. 2022;127:104335.\u003c/li\u003e\n\u003cli\u003eSun Q, Wang Y, Chang Q. Oral health and depressive symptoms among older adults in urban China: a moderated mediation model analysis. BMC Geriatr. 2022;22:829.\u003c/li\u003e\n\u003cli\u003eWingfield B, Lapsley C, McDowell A, Miliotis G, McLafferty M, O\u0026apos;Neill SM, Coleman S, McGinnity TM, Bjourson AJ, Murray EK. Variations in the oral microbiome are associated with depression in young adults. Sci Rep. 2021;11:15009.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"depressive symptoms, tooth loss, middle-aged adults","lastPublishedDoi":"10.21203/rs.3.rs-3785812/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3785812/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Many recent studies suggest the existence of a relationship between oral health and the occurrence of depressive symptoms. The aim of this study was to assess the relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe research material included the data of 11,901 individuals aged 40\u0026ndash;64 years (7967 women). Depressive symptoms were used as outcome variables. The declared number of lost teeth was analysed according to the following categories: 0\u0026ndash;4, 5\u0026ndash;8, \u0026ge;\u0026thinsp;9, and a complete lack of natural teeth. Multivariate logistic regression analysis for depressive symptoms was used in relation to the number of lost teeth. The following covariates were included in the adjusted model: age, sex, place of residence, education, marital status, BMI, diabetes status, stressful life events in the last year, use of antidepressants, smoking, and sugar and sweet consumption.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe likelihood of both moderate (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.020) and severe (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) depressive symptoms increased the most with a total lack of natural teeth. A loss of more than 8 natural teeth was also significantly associated (p\u0026thinsp;\u0026lt;\u0026thinsp;.008) with the occurrence of severe depressive symptoms.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe results indicated that loss of natural teeth was positively related to the occurrence of depressive symptoms in middle-aged adults. Population aging will lead to growing problems related to oral health and its consequences, including mental disorders. As a result, appropriate prophylactic and educational actions need to be taken, dedicated to middle-aged individuals.\u003c/p\u003e","manuscriptTitle":"Relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-25 05:53:36","doi":"10.21203/rs.3.rs-3785812/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-04T15:03:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-14T02:59:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126d31d8-64c6-490b-b56b-8cbd21d93f0c","date":"2024-02-13T23:01:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-10T23:57:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54703c95-b8c5-4a6c-b1db-c82d6945c5d9_SNPRID","date":"2024-02-01T19:28:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-16T09:00:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-16T08:55:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-12-21T11:35:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-12-21T11:33:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2023-12-21T08:34:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"970b3356-3068-44c0-98e7-c11c6f735d8e","owner":[],"postedDate":"December 25th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-06T08:27:33+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-25 05:53:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3785812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3785812","identity":"rs-3785812","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}