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Supplementary file 1_Long-term dental care utilization trajectories as behavioral markers of cognitive aging: a 14-year national cohort study.docx Young-Suk Jung (3424724) Hyunjoo Joo (25102045) Public Health and Health Services not elsewhere classified activities of daily living cognitive aging cognitive decline dental care utilization group-based trajectory modeling Health and Retirement Study mediation analysis older adults Introduction<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.</p>Methods<p>We analyzed eight biennial waves (2006–2020) of the Health and Retirement Study. Group-based trajectory modeling identified dental care utilization trajectories among 14,599 adults aged ≥50 years 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.</p>Results<p>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: β = −0.085 per 2-year wave, 95% CI − 0.118 to −0.053; Persistent Low: β = −0.107, 95% CI − 0.133 to −0.081; both p < 0.0001), corresponding to approximately 0.60 and 0.75 additional points of decline over 14 years, respectively, against a 2.29-point decline in the Persistent High group. The difference between the Persistent Low and Decreasing trajectories was not significant (β difference = −0.0217, 95% CI − 0.0580 to 0.0146; p = 0.241). 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 (2006–2016) from outcome assessment (2016–2020), the direct associations and ADL-mediated pathway remained significant, whereas the SRH-to-cognition pathway did not.</p>Conclusion<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.</p> 2026-09-24T04:35:02Z Dataset Dataset 10.3389/fpubh.2026.1938854.s001 https://figshare.com/articles/dataset/Supplementary_file_1_Long-term_dental_care_utilization_trajectories_as_behavioral_markers_of_cognitive_aging_a_14-year_national_cohort_study_docx/33979570 CC BY 4.0