Oral frailty among dentate and edentate older adults in long-term care.

BACKGROUND: The objectives of this study were to compare oral frailty (OFr) among edentate and dentate older adults living in long-term care facilities (LTCF) and to clarify how edentulism and oral disease burden (ODB) of dentate older adults are associated with OFr. METHODS: The population of this study comprised 94 edentate and 209 dentate residents in LTCF in Helsinki, Finland, who had previously participated in a nutritional study. The participants underwent a clinical oral examination. The dentate residents were further divided into three ODB groups based on asymptotic dental score. The edentate and different ODB groups were compared with each other regarding demographics and oral and medical findings. OFr was defined as ≥ 2 of following: having a diet of soft/pureed food, residue of food in the oral cavity, inability to keep the mouth open during examination, unclearness of speech, dry mouth. The association between OFr and edentulousness and various levels of ODB was analyzed by a multivariate logistic model. RESULTS: Participants with low ODB had significantly less OFr than their edentate peers (p = 0.009). Furthermore, the edentate and dentate with high ODB had similar odds for OFr. CONCLUSIONS: Edentulousness and high ODB are equally harmful conditions and may predispose to OFr. This study suggests that maintaining healthy natural teeth and good oral health (low ODB) may protect against OFr. TRIAL REGISTRATION: The Ethics Committee of the Hospital District of Helsinki and Uusimaa approved the protocols for the nutritional status and oral healthcare studies and the merging of the data, including patient medical records (Register number HUS/968/2017).

Relationship between oral frailty, health-related quality of life, and survival among long-term care residents.

PURPOSE: We evaluated oral frailty (OFr) and its association with health-related quality of life (HRQoL), energy and protein intake, and survival among older long-term care residents. METHODS: This cross-sectional study with a 3-year follow-up for survival assessed 349 residents in long-term care facilities (73% female, mean age 82 years). We defined OFr with six signs (dry mouth, food residue on oral surfaces, unclear speech, inability to keep mouth open or pain expression during the clinical oral examination, diet pureed/soft) and OFr severity was categorized as Group 1, (mild) = 0-1 signs, Group 2 (moderate) = 2-4 signs, and Group 3 (severe) = 5-6 signs. We measured HRQoL with 15D instrument, and energy and protein intake by a 1- to 2-day food record. Mortality was retrieved from central registers on March 2021. RESULTS: Of the residents, 15% had 0-1, 67% 2-4 and 18% 5-6 OFr signs. HRQoL decreased linearly from Group 1 to Group 3. OFr correlated with such dimensions of HRQoL as mobility, eating, speech, excretion, usual activities, mental function, and vitality. We found no association between OFr categories and energy and protein intake. Survival decreased linearly from Group 1 to Group 3. CONCLUSIONS: OFr was common among older long-term care residents and OFr severity predicts poorer outcomes. The six oral signs denoting OFr may be used at the bedside to screen residents at risk for OFr.

Subgingival microbiome at different levels of cognition.

Oral health and declining cognition may have a bi-directional association. We characterized the subgingival microbiota composition of subjects from normal cognition to severe cognitive decline in two cohorts. Memory and Periodontitis (MINOPAR) include 202 home-living participants (50-80 years) in Sweden. Finnish Oral Health Studies in Older Adults (FINORAL) include 174 participants (≥65 years) living in long-term care in Finland. We performed oral examination and assessed the cognitive level with Mini Mental State Examination (MMSE). We sequenced the 16S-rRNA gene (V3-V4 regions) to analyse the subgingival bacterial compositions. The microbial diversities only tended to differ between the MMSE categories, and the strongest determinants were increased probing pocket depth (PPD) and presence of caries. However, abundances of 101 taxa were associated with the MMSE score. After adjusting for age, sex, medications, PPD, and caries, only eight taxa retained the significance in the meta-analyses of the two cohorts. Especially Lachnospiraceae [XIV] at the family, genus, and species level increased with decreasing MMSE. Cognitive decline is associated with obvious changes in the composition of the oral microbiota. Impaired cognition is accompanied with poor oral health status and the appearance of major taxa of the gut microbiota in the oral cavity. Good oral health-care practices require special deliberations among older adults.

Relationship of occlusal status with health-related quality of life among older adults in long-term care facilities.

BACKGROUND: Loss of teeth is common among residents in long-term care facilities (LTCF). To maintain occlusal support, lost teeth may be replaced with removable dentures. OBJECTIVES: The relationship of occlusal status with health-related quality of life (HRQoL) was evaluated. METHODS: A cross-sectional FINORAL study (FINnish ORAL Health Studies in older adults), including comprehensive geriatric assessment, was performed in LTCF. Demographic and medical information was retrieved from medical records. HRQoL was assessed with the 15D instrument and nutritional status with Mini-Nutritional Assessment (MNA). A standardised questionnaire filled in by trained nurses collected information on need for assistance in personal care or mobility, eating, and food consistency and swallowing difficulties. Clinical oral examination focusing on occlusal status was conducted for 338 residents. Four study groups (Gr) were established: Gr1 ≥ 10 natural teeth occlusal contact units (CU) (N = 51), Gr2 < 10 natural teeth CU (N = 87), Gr3 having CU of removable denture/s with or without natural teeth (N = 89), and Gr4 no CU (N = 111). RESULTS: 15D index score (adjusted for age, sex, MNA, and Charlson comorbidity index) showed higher HRQoL in Gr1 and Gr3; Gr1 participants had significantly higher crude values in mobility and Gr3 participants in eating, speech, and mental function than the other groups. Differences were present between the study groups in nutritional status, swallowing difficulties, and need for assistance in eating and mobility. CONCLUSION: Occlusal status of partial or complete denture/s with or without natural teeth or natural teeth having 10 or more occlusal CU was associated with higher HRQoL than other statuses.

Why and when older people lose their teeth: A study of public healthcare patients aged 60 years and over in 2007-2015.

OBJECTIVES: This register-based study on public sector patients aged 60 years and over assessed annual age-specific volume of and reasons for tooth extractions as well as changes in these across the period 2007-2015. BACKGROUND: Alongside the rapidly ageing population, the demand for public oral healthcare services is growing. Damaged teeth may induce a long-lasting inflammation burden in old age. MATERIALS AND METHODS: Data used the electronic documentation of oral healthcare procedures recorded according to healthcare regulation. The study population consisted of all patients over 60 years of age (n = 216 059) who were treated 2007-2015 in public oral health care available to all citizens of Helsinki, Finland. Data for the 9-year time series included reasons for tooth extractions and were aggregated by patient age into 5-year groups. Statistical analyses included rates and proportions, mean values, correlation coefficients and linear regression modelling. RESULTS: Extraction patients (n = 48 623) were more likely in the older age groups: 21.8% in the age group 60-64 and 27.5% in the age group 90+. Mean number of tooth extractions among all patients was 0.4 per patient and 1.7 per extraction patient. Among all tooth extractions (n = 82 677), main reasons were caries 29.5%, apical periodontitis 19.4%, tooth remnant 19.4% and periodontitis 18.0%. Tooth remnant predominated as extraction reason in the oldest age groups, while apical periodontitis displayed an upward trend by calendar year. CONCLUSION: Tooth extractions attributable to caries were common in all old-age groups, tooth remnant extractions were most common in older age groups, and apical periodontitis abounded as extraction reason during 2007-2015.

Oral hypofunction and association with need for daily assistance among older adults in long-term care.

BACKGROUND: Oral hypofunction (OHF) is related to occlusal status and bite force. It has specific symptoms and varying degrees of severity. OBJECTIVES: OHF was determined with five signs. The relationships between OHF and need for assistance in oral hygiene, moving, eating and occlusal status in older adults living in long-term care (LTC) were examined. METHODS: A comprehensive clinical oral examination was conducted on 393 residents who lived in LTC in Helsinki, Finland. The five signs to determine OHF were mouth dryness, visible food residue on oral or denture surfaces, ability to keep the mouth open during examination, clearness of speech, and diet of pureed or soft food. Score points of 0-2 were given for each sign, and the sum was categorised as mild, moderate or severe OHF. Participants were divided into three groups accordingly, and occlusal status was determined based on contact units. In addition, nurses collected background information on number of medications and level of cognition. Need for assistance was based on oral hygiene, moving and eating. RESULTS: Of participants (n = 319), 21% showed severe and 41% moderate OHF. Occlusal status differences between the OHF groups were significant. OHF severity associated linearly with increased severity of cognitive impairment and increased need for assistance in oral hygiene, eating and moving. CONCLUSIONS: OHF score based on the five signs can be used to determine OHF severity. OHF was common and associated with occlusal status, cognitive impairment and need for assistance in oral hygiene, moving and eating in older adults living in LTC.

Oral hygiene and health-related quality of life in institutionalized older people.

PURPOSE: We evaluated the level of oral hygiene and its association with oral health status and need for oral treatment among older residents in long-term care facilities. In addition, the association between oral hygiene level and health-related quality of life (HRQoL) was explored. METHODS: This cross-sectional study assessed 231 dentate residents in long-term care facilities (71% female, mean age 81 years, 70% had dementia). Nurses assessed residents and completed questionnaires on participants' background information, diagnoses, oral healthcare habits, and HRQoL with the 15D instrument. Two qualified dentists performed clinical oral examinations (number of teeth, plaque index, periodontal condition, open caries lesions, and dry mouth). We used a modified plaque index (PI) to measure the level of oral hygiene (good, moderate, and poor) and calculated the clinical Asymptotic Dental Score (ADS) to determine the oral inflammation burden. RESULTS: Of the residents, 21% had good, 35% moderate, and 44% poor oral hygiene according to PI. Poor oral hygiene was associated with poorer cognitive status (P = 0.010) and higher oral inflammation burden (P < 0.001). Moreover, poor oral hygiene was associated with poorer HRQoL in a correlation analysis adjusted for age and gender. CONCLUSIONS: Oral hygiene of older individuals in long-term care is insufficient. Poor oral hygiene is a marker for poor HRQoL. Residents also have a high burden of oral inflammatory diseases and a need for dental care. Older residents' oral hygiene and HRQoL may be improved with oral care education of caregivers and regular dental check-ups.

Oral disease burden of dentate older adults living in long-term care facilities: FINORAL study.

BACKGROUND: A growing number of older adults have natural teeth and are at high risk of oral diseases, which are induced by oral bacterial accumulation and proceed unnoticed and quietly. Our aim was (1) to examine the association of oral disease burden (ODB) with health and functioning among dentate long-term care residents, and (2) to find easily detectable signs for nurses to identify residents' poor oral health. METHODS: In this cross-sectional observational study dentists examined 209 residents' oral status, and nurses assessed residents for their functioning and nutrition in long-term care facilities in Helsinki, Finland. ODB was defined by asymptotic dental score (ADS). Six clinical signs of residents' poor oral health were considered as potentially easy for nurses to detect: lesions on lips, teeth with increased mobility, lesions on oral mucosa, eating soft or pureed food, unclear speech, and needing assistance in eating. The association of these was tested with high ODB as outcome. RESULTS: Participants were grouped according to their ADS scores: low (n = 39), moderate (n = 96) and high ODB (n = 74). ODB was linearly associated with coronary artery disease and poor cognitive and physical functioning: needing assistance in eating, poor ability to make contact, and unclear speech but not with other diseases including dementia or demographic characteristics. Furthermore, ODB was linearly associated with eating soft or pureed food. Of the six selected, easily detectable signs, having at least two positive signs gave 89% sensitivity to detecting high ODB. CONCLUSION: Poor oral health was common and ODB accumulated among residents with poor functioning. Nurses may use a few easily detectable signs to screen residents' oral health when considering a resident's need for consultation with an oral health professional.

Relationship between Fried's frailty phenotype and oral frailty in long-term care residents.

BACKGROUND: oral frailty (OFr) may be called a syndrome lacking a consensus on its definition. OBJECTIVE: the aim was to prove the relationship between OFr to the phenotype of frailty, general health and nutrition in long-term care. DESIGN: the FINnish ORAL Health Study in Long-Term Care study is a cross-sectional clinical research comprising findings on oral and general health and nutrition. SETTING: participants were divided into groups according to the number of OFr signs: Group 1 (0-1 sign), Group 2 (2-4 signs) and Group 3 (5-6 signs). SUBJECTS: the study includes data on 349 older residents of long-term care facilities in Helsinki, Finland. METHODS: frailty status was defined according to Fried's frailty phenotype. OFr was evaluated with six signs: dry mouth, diet of pureed or soft food, residue of food on oral surfaces, unclear speech, inability to keep mouth open during the clinical oral examination and pain expression during the examination. RESULTS: a significant linear relationship across the OFr groups with Fried's frailty phenotype was found (P for linearity = 0.008, adjusted by gender and age). A linear trend existed between OFr groups and general health; prevalence of dementia and malnutrition increased from Group 1 to Group 3. The need for help with eating and oral hygiene procedures increased from Group 1 to Group 3. Moreover, OFr had a linear relationship with chewing and swallowing difficulties. CONCLUSIONS: OFr is related to Fried's frailty phenotype, general health, nutrition and need for help with daily activities.

Age- and Time-Related Trends in Oral Health Care for Patients Aged 60 Years and Older in 2007-2017 in Public Oral Health Services in Helsinki, Finland.

BACKGROUND: Population aging will likely have an impact on oral health care trends. The aim of this study was to describe age- and time-related trends in oral health care in people ages 60 and older in Public Oral Health Services (POHS) in Helsinki, Finland. MATERIALS AND METHODS: Material for the study comprised the electronic documentation of oral health care procedures performed on patients 60 years and older (N = 282,143) in POHS during 2007-2017. Patients were aggregated into 5-year age groups. The 5 most common treatment categories, restorations, periodontal treatment, extractions, endodontics, and prosthetics, were selected for analysis. Changes by time (calendar year) and differences by age group were shown as percentages and percentage points; corresponding trends were assessed by applying linear regression models to the data. RESULTS: The attendance rate for these patients increased from 14.5% in 2007 to 23.1% in 2017, with the total number of visits increasing by 76.4% in the 11-year period. The average number of visits per patient decreased from 3.5 visits in 2007 to 3.0 visits in 2017. In 2007, 60.5% of patients received restorative treatment and 41.3% received periodontal care. In 2017, the corresponding figures were 55.5% and 49.8%, respectively. The older the patient, the fewer the visits and restorative, periodontal, and endodontic treatments and the greater the rate of tooth extractions and prosthetics. CONCLUSION: A declining age group-related trend was recognized for restorative, periodontal, and endodontic treatments. Owing to ongoing population growth, POHS will be facing huge challenges in providing treatment for all individuals seeking services.

Survey of health care personnel's attitudes toward oral hygiene in long-term care facilities in Finland.

AIM: To survey long-term residences' health care personnel's opinions and attitudes toward maintenance of older adults' daily oral hygiene. METHODS AND RESULTS: The survey was directed to the health care personnel of three long-term care facilities in Helsinki, Finland. We analyzed the survey responses focusing on opinions and attitudes toward older adults' daily oral hygiene. To measure this aspect, a scoring system was developed. When the analysis was based on two specific statements, 60% of responding members of health care personnel had a negative attitude toward older adults' oral hygiene. They tended to experience more refusals when assisting oral hygiene measures, more often experienced a lack of time, and were willing to get more training related to the task. CONCLUSION: The health care personnel of long-term care facilities considered older adults' oral health important. Members of the health care personnel who showed a negative attitude with our scoring system toward older adults' daily oral hygiene indicated in their questionnaire responses the need for additional training and additional time for the task.

Dentition, nutritional status and adequacy of dietary intake among older residents in assisted living facilities.

OBJECTIVE: We examined the relationships between dentition, nutritional status and dietary intakes of energy, protein and micronutrients among older people in assisted living facilities in Helsinki. BACKGROUND: Poor dentition is associated with malnutrition. Less is known about how dentition is associated with detailed nutrient intakes in institutionalised older people. MATERIALS AND METHODS: This cross-sectional study assessed 343 participants (mean age 83 years). Dentition was assessed by trained ward nurses and divided into edentulous participants without dentures (group 1), edentulous participants with removable dentures (group 2) and those with any natural teeth (group 3). Nutritional status was assessed by Mini Nutritional Assessment (MNA). The energy, protein and nutrient intakes were calculated from detailed 1-day food diaries and compared with the recommendations of the Finnish National Nutrition Council as a measure of dietary adequacy. Assessment included also participants' cognitive and functional status. RESULTS: Of the participants, 8.2, 39.1 and 52.8% were in groups 1, 2 and 3, respectively. Altogether 22% were malnourished according to MNA. Group 1 had the poorest nutritional status. A large proportion of participants consumed less than the recommended amounts of energy, protein or micronutrients. Half of the participants consumed <60 g/day of protein. The intake of protein was significantly lower in group 1 than in other two groups. CONCLUSION: Malnutrition and inadequate protein intake were very common and associated with dentition among older people with multiple disabilities in assisted living facilities. Assessment of dental status should be part of good nutritional care in long-term care.

Pathology related to third molars in the elderly persons.

OBJECTIVES: The objective of this study was to clarify the discrepancy of pathology between earlier and recent studies related to third molars in the elderly persons. Evidence of third molars in the elders is limited. Earlier radiographic studies show rather few pathologic findings related to third molars. Recently, clinical studies have shown totally different numbers for pathology. MATERIALS AND METHODS: Participants were drawn from the population-based Helsinki Aging Study. The study included panoramic radiographs of 293 persons (mean age 79 years, SD ± 3.9 years). We examined the prevalence of third molars and associated pathology and used the chi-squared test to perform the statistical analysis. RESULTS: Of the whole group of elderly persons, 19% had at least one third molar. The usual dental diseases, caries and periodontal pathology (80 and 33%, respectively), were common in the third molars. The surviving third molar most often appeared in the mandible (P < 0.01), in men (P < 0.05), in the mesioangular position (P < 0.05), and far from the mandibular canal (P < 0.001). Pathology was present in every third molar, although the proportion of serious pathology (i.e., cyst and tumor), accounted for only 2% of third molars. CONCLUSIONS: Although serious pathology related to third molars in the elders is uncommon, universal biofilm diseases (caries and periodontal pathology) widely affect third molars as well as all other teeth. CLINICAL RELEVANCE: Because all of the surviving third molars of the elders were diseased, it would be justifiable to extract these teeth at a younger age.

A 5-year follow-up of signs and symptoms of TMD and radiographic findings in the elderly.

PURPOSE: The aim was to clarify the associations among subjective symptoms, clinical signs of temporomandibular disorders (TMD), and radiographic findings in the mandibular condyles of elderly people during a 5-year follow-up. MATERIALS AND METHODS: As part of a comprehensive medical survey of a random sample born in 1904, 1909, and 1914 (Helsinki Aging Study), 364 subjects living in Helsinki participated in the dental part of the examination during 1990 and 1991; after 5 years, 103 of these were reexamined. Comprehensive data on TMD were available for 94 subjects, and radiographic data were available for 88. TMD were assessed by Helkimo's anamnestic and clinical indices, and radiographic status was assessed by panoramic radiographs. RESULTS: During the 5-year follow-up, reported anamnestic symptoms of TMD for men changed little (9%); among women, the change from baseline was 42%. When the unchanged indices were compared, the gender difference was obvious. At baseline, 5% of the women, but no men, had severe signs (clinical index III) of TMD. At the end of follow-up, none showed severe signs. Comparison of radiographic findings between baseline and follow-up showed no differences, nor did differences appear in associations between radiographic findings and anamnestic or clinical indices. CONCLUSION: During the 5-year follow-up, signs and symptoms of TMD in these elderly individuals became milder or vanished. The radiographic status of the condyles remained stable, and no association appeared between radiographic findings and signs and symptoms of TMD.

A 5-year follow-up of occlusal status and radiographic findings in mandibular condyles of the elderly.

PURPOSE: The aim of the present 5-year follow-up was to clarify the nature of occlusal support status and radiographic changes in condyles of the elderly, and the association between these two variables. MATERIALS AND METHODS: The present study is part of a comprehensive medical survey of a random sample born in 1904, 1909, and 1914. A total of 364 subjects living in Helsinki participated in the dental part of the examination during 1990 to 1991, and after 5 years a total of 103 were reexamined. Comprehensive data on occlusal support status were available for 94 subjects, and radiographic data were available for 88 subjects. Occlusal support status was assessed on the basis of the Eichner index, radiographic changes were assessed from panoramic radiographs, and symptoms of temporomandibular disorders were assessed using Helkimo's anamnestic index. RESULTS: The most frequent radiographic finding in the mandibular joint was flattening of the articular surface of the condyle associated with osteoarthrosis, found at baseline in 17% and during follow-up in 13% of the subjects. During the 5-year follow-up, Eichner index for natural dentition remained unaltered in 94% of the subjects and in 85% of the subjects when removable dentures were included. There were no radiographic changes in 92% of the cases. No differences based on age or gender were found. A logistic regression model revealed associations between the selected baseline factors. The odds ratio for baseline Helkimo's anamnestic index was 4.1, 5.7 for Eichner index with the support of removable dentures, and 356 for radiographic findings. CONCLUSION: Radiographic changes in condyles of elderly people were small during the 5-year follow-up, but baseline radiographic findings, Helkimo's anamnestic index, and Eichner index with removable dentures were risk factors for radiographic findings at the end of the follow-up.