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 Table of Contents  
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 9-15

Impact of oral frailty on general frailty in geriatric population: A scoping review

1 Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Oral Medicine and Radiology, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission28-May-2021
Date of Decision28-Aug-2021
Date of Acceptance27-Dec-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
Chandrashekar Janakiram
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi - 682 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_91_21

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Background: Oral health is believed to be an important component of aging and frailty. Poor oral health is highly prevalent among older adults and has been linked to general health and chronic diseases including different components of frailty. Literature previous evidence has demonstrated a strong link between self-reported oral health and nutrition. Objectives: The objective of the study was to find the current impacts of oral frailty on general frailty in geriatric population. Sources of Evidence: A systematic search was conducted in one electronic bibliographic database (PubMed) to identify relevant peer-reviewed studies. Sources included different types of information such as practice guidelines, reviews, and quantitative and qualitative research. Charting Methods: Pie charts, sunburst, and tree map were used. Results: The searches from the databases hit a total of 8697 records (PubMed: 180) that led to a total of 180 titles and abstracts that were screened after the removal of duplicates. We retrieved a total of 55 full-text articles from our different libraries. Six records were excluded with full text. The full-text screening stage led to 49 potential articles relevant to our scoping review. A total of 49 articles (39 quantitative and 3 qualitative studies, 6 reviews, and 1 Practice guidelines) were included in our final analysis. Maximum studies were found in Asia (44.8%), Europe (22.4%), and North America (14.2%) of the articles related to Oral frailty on General frailty. The included articles used a variety of terminology to describe physical and oral Frailty. The prevalence of physical frailty ranged from 1.5% to 66.6% and oral frailty ranged from 4.1% to 63.7%. Conclusions: Oral frailty is a crucial aspect of general frailty. More cohort studies need to establish a causal relationship between oral and physical frailty. Medical–dental collaboration is inadequate and should be improved in geriatric medicine.

Keywords: Frailty, geriatric, oral health, physical health

How to cite this article:
Ayoob AK, Neelamana SK, Janakiram C. Impact of oral frailty on general frailty in geriatric population: A scoping review. J Indian Assoc Public Health Dent 2022;20:9-15

How to cite this URL:
Ayoob AK, Neelamana SK, Janakiram C. Impact of oral frailty on general frailty in geriatric population: A scoping review. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2023 Nov 29];20:9-15. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2022/20/1/9/338527

  Introduction Top

Frailty may be a clinical condition during which a person's vulnerability to acquiring dependency and/or mortality increases after they are subjected to a stressor.[1] Frailty is most regularly characterized as an aging-related disorder of physiological decline, characterized by marked vulnerability to unfavorable health outcomes such as comorbidities, polypharmacy, the loss of independence, increasing hospitalizations, and mortality.

In frail patient's occlusal force, masseter muscle thickness, oral diadochokinetic rate, and articulatory oral motor abilities diminish with age in a quicker rate.[2] Tooth loss is related to communication difficulties, loss of mobility and physical quality, poor mental health, malnutrition, and loss of weight. The number of remaining functional teeth may be a risk factor for malnutrition. The four hypothesized instruments by which poor oral health may lead to frailty: functional, physiological, psychosocial, and therapeutic.[3] Poor oral health, general health, and chronic infections have a connection and are predominant among elderly adults in various aspects of components of frailty.[4],[5] Rapp et al. illustrated a critical relationship between oral health and nutrition. It remains uncertain as to whether poor oral health is an independent risk estimated for frailty.[6] Previous studies have examined the predominance of frailty within the community-dwelling older populations in Japan, Mexico, Brazil, and the UK.[3],[4],[7],[8] As the elderly population grows around the world, there is a significant gain in the prolongation of healthy life expectancy. A previous report showed that the costs of care would diminish if early interventions were introduced for the frail elderly.[9] In geriatric studies and in the anticipation of long-term care, frailty and sarcopenia are considered as vital components. Therefore, it is important to create a viable early prevention strategy to delay onsets of physical frailty, diminishing the consequent requirement for long-term care and mortality. Poor oral health is an imperative issue in common health, as it is related to the pathogenesis of frailty, which suggests a multidimensional geriatric syndrome[10],[11] and only a few longitudinal associations.[12],[13] Frail older patients frequently display an increased burden of side effects including weakness and fatigue, therapeutic complexity, and decreased resilience to therapeutic and surgical interventions. Awareness of frailty and related risks for adverse health outcomes can progress the care for most vulnerable subset of patients. Hence, assessment of accumulated oral frailty is a potential factor for predicting physical frailty. We conducted this scoping review to assess the extent of the available evidence, to organize it into groups, and to highlight gaps so that it can be used to decide whether it would be useful to conduct a systematic review. What is impact of oral frailty on the physical frailty among adults?

  Methodology Top

From the systematic searches from electronic bibliographic databases such as PubMed and Google Scholar, we obtained original peer-reviewed articles published from January 1980 to December 2020 in English language journals. A reference manager software (Zotero) was used to transfer all identified articles from the searches and to remove the duplicates and titles in other languages. An online systematic review software (Covidence) was used for screenings from the transferred Zotero file. The eligibility criteria were established using the PICOS (participants, intervention, context, outcomes, and study design) framework. Original peer-reviewed articles which were included had to meet five criteria description, prevalence, and assessment tools of the oral or physical frailty. Quantitative, qualitative, or mixed methods research was only considered from the peer-reviewed articles written in English. Systematic reviews were also included and they were carefully revised for all eligible and additional relevant studies from the reference lists. Excluded articles included gray literature, narratives, commentaries, or other document types such as reports and essays.

Selection of relevant and reliable studies

The eligibility criteria were applied, and the articles for selection were screened by two reviewers (AKA and CJ). The title and abstract screening followed by full-text screening was carried out. The consensus was reached by the two reviewers if there were any conflicts generated in the screening stages.

Data extraction from included studies

The selected articles and the following data were recorded in a spreadsheet: author (s), year, region, description of the oral and physical frailty, characteristic of participants, prevalence of oral and physical frailty, assessment tools or scales for these frailties, study purpose, study design (e.g., quantitative, qualitative, or mixed methods), measurement methods, outcomes measured, and key findings. The data were extracted by one author, and another author validated them to ensure accuracy before the quality appraisal phase.

Collating, summarizing, and reporting the findings

A narrative account of the included studies was prepared to present the description and relationship between physical and oral frailty. Since the outcomes were comprehensive, they were combined thematically to record the relationship between as positive, adverse, neutral, or mixed for the quantitative or mixed methods studies in some cases. Studies that presented quantitative measurement tools were assigned neutral impact but did not present significant results as a positive or adverse effect of the measured outcomes in their findings. The mixed impact was used to classify studies that presented both positive and adverse effects of the measured outcomes.

  Results Top

Identification of potential studies

A total of 8697 records from the database searches (PubMed: 180) led to a total of 180 titles and abstracts that were screened after the removal of duplicates. A total of 55 full-text articles were retrieved from our different libraries. Six full-text articles were excluded. Additional articles were excluded after full-text assessment for the reasons mentioned in the flowchart [Figure 1]. A total of 49 articles (39 quantitative and 3 qualitative studies, 6 reviews, and one practice guidelines) were therefore included in our final data extraction, quality appraisal, and narrative account stages.
Figure 1: Prisma flow chart

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Maximum studies were found in Asia (44.8%), Europe (22.4%), and North America (14.2%) [Figure 2] of the articles related to Oral frailty on General frailty. Quantitative studies revealed a significant relationship between the occurrences of oral frailty in general frailty. Nutrition showed a significant relation with poor oral health. Furthermore, the number of teeth was one of the markers that consistently appeared a significant association with frailty. Qualitative studies have shown poor oral health may contribute to frailty through numerous pathways, which incorporate functional pathways as poor oral health and inadequate dentition are conversely related to dietary intake.
Figure 2: Region of study

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In terms of the geographic scope of the included studies, they are primarily from two world regions where 44.8% and 22.4% were conducted and detailed findings from Asia and Europe, respectively. Research in North America was predominantly from the US with 15% included studies. The included studies in our research have used three sorts of study design (number of studies = 39) used quantitative methods, (no of studies = 3) used subjective methods, and (no of studies = 7) have explored reviews. Among the quantitative studies, (no of studies = 39) used cross-sectional studies, (no of studies = 4) cohort, (no of studies = 1) randomized controlled trial, (no of studies = 1) secondary data analysis, and (no of studies = 1) cluster analysis [Figure 3]. In-depth and semi-structured interviews, focus groups, surveys, and observation questionnaires were used to gather information for the qualitative approach. Qualitative approaches incorporated ethnography, grounded theory, and case studies. However, in most of the cases, it was difficult to identify the qualitative approaches because the authors did not provide enough details on their methodology.
Figure 3: Research designs

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Description of physical and oral frailty

The included articles used a variety of terminology to describe physical and oral Frailty. Among the most common type of terminology for physical frailty was used: (number of studies = 21) fried frailty phenotype mode, (number of studies = 3) presence of sarcopenia, (no of studies = 3) frailty index, (number of studies = 2) clinical frailty scale, (number of studies = 2) Kihon checklist, (number of studies = 1) obesity, (number of studies = 1) Short Performance Physical Battery (SPPB), (number of studies = 1) Groningen Frailty Index (GFI), (number of studies = 1) quality of life, and (number of studies = 1) Redmonton Frailty Scale [Figure 4].
Figure 4: Characteristics of outcomes assessed of included studies

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Oral frailty was described by the battery of measures such as (no of studies = 15 number of remaining teeth/numbers of functional dentition/number of natural teeth, (number of studies = 2) dysphagia, n = 10 denture use, n = 4 periodontal status, (number of studies = 6) dry mouth, (number of studies = 4) tongue pressure, number of studies = 4 oral diadochokinesis (ODK) rate, (number of studies = 2) occlusal force, (number of studies = 2) masseter muscle thickness, (number of studies = 1) salivary bacterial count, and n = 1 oral hypofunction [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d, [Figure 5]e.
Figure 5: (a-e) Relationship between physical and oral frailty

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Prevalence of physical and oral frailty

The prevalence of physical frailty ranged from 1.5% to 66.6%, and oral frailty ranged from 4.1% to 63.7%.

  Discussion Top

To the best of our knowledge, this is the first scoping review carried out to understand the pattern of evidence and gap in knowledge regarding the impact of oral frailty on general frailty in the geriatric population. Scoping reviews are exploratory, and they typically address a broad question. We conducted this scoping review to assess the extent of the available evidence, to organize it into groups and to highlight gaps so that it can be used to decide whether or not it would be useful to conduct a systematic review.

In 2013, in Japan oral frailty was introduced as a new concept which was about oral function.[2] In recent times, oral frailty has become one of the most important issues regarding dental and oral health and has been suggested that “oral frailty” should be considered as a geriatric syndrome.[14] Frailty is a disorder of multiple interrelated physiological systems. Nutrition and inflammation have been considered among the mechanisms that influence the pathophysiological process of frailty. The extent of association between oral and physical frailty is less reported. Hence, this scoping review was done to assess types of evidence reporting the relationship between oral and physical frailty among older adults.

The Japanese Society of Gerontology defined “oral hypofunction as a presentation of seven oral signs and symptoms including oral uncleanness, oral dryness, and declines in five types of oral functions such as occlusal force, motor function of tongue and lips, tongue pressure, chewing, and swallowing.” They also presented oral frailty as a prestage of oral hypofunction.[15] As of 2019, oral frailty is considered a separate concept rather than an early stage of oral hypofunction.[16] The concept of an oral and maxillofacial geriatric syndrome includes five types of geriatric oral and maxillofacial dysfunctions: salivary gland hypofunction, chronic oral mucosal pain disorders, taste disorders, swallowing disorders, and oral and maxillofacial movement disorders.[14]

In this review, most of the studies were quantitative, most of the studies were observational studies as the review was based on the association of oral and physical frailty. However, our analysis was not extensive as we did not include multiple databases. Most of the studies were community studies rather than hospital-based studies. One secondary data analysis in the Netherlands included 43,704 elderly.[17] Frailty is an age-related state of high vulnerability to adverse health outcomes after a stressor event. Physical frailty is well established in Geriatric Health Assessment.

Most of the studies described physical frailty in terms of Fried Frailty phenotype[3],[8],[12],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] followed by sarcopenia.[7],[30] The other frailty assessment tools used in this study were Frailty index,[26],[31],[32] Clinical frailty scale,[33] Kihon checklist,[13],[34],[35] Obesity, SPPB,[30] GFI,[36] and Redmonton Frailty Scale.[37]

Oral Frailty was described by the number of remaining teeth/numbers of functional dentition/number of natural teeth followed by dysphagia, denture use, periodontal status, dry mouth, tongue pressure, ODK rate, occlusal force, masseter muscle thickness, salivary bacterial count, and oral hypofunction in most of the studies.

Functional evidence indicates that malnutrition is a significant risk factor for the development of frailty. The number of teeth was significantly associated with frailty according to many studies.[5],[11],[21],[23],[26],[28],[30],[35],[38],[39],[40],[41] Participants with 20 or more teeth had a 63.1% lower chance of being frail than edentulous individuals.[39] This could be attributed to the association of the number of teeth and nutritional status resulting from chewing problems, changes in quality and quantity of food, and ultimately malnutrition. Impaired masticatory ability was associated with frailty in two studies which could be attributed to the impact of oral function on nutrition which in turn can affect oral nutrition and frailty.[28] The number of teeth was associated with the salivary bacterial count in one study.[35] They also recognized that frail people were having poor hygiene than the robust group. Physical frailty and oral hygiene status are bidirectional. In elderly patients, physical frailty in turn can affect oral hygiene status and the condition of remaining teeth. Furthermore, the quality of frail older people is positively influenced by natural teeth. Preservation of teeth contributes to a positive body image and self-worth.[42] There was a gender effect in that men generally cared less about having natural teeth than women regardless of their level of frailty.[43] Dry mouth[12],[41] and oral pain[44] also be found to be associated with the functional hypothesis. The second hypothesized link between oral health and frailty is the physiologic/inflammatory pathway. Studies have indicated that periodontitis was associated with frailty incidence.[23],[41],[45] One prospective study did not identify the link between both.[8] Further studies are needed in this aspect.

A recent Japanese study showed that a decline in social function may directly influence a decline in oral and physical function.[28] Social frailty was directly related to oral frailty, and oral frailty in turn was directly related to physical frailty. Hence, optimal management of oral frailty will require evaluation and management of Social Frailty also. Another proposed link between oral health and frailty is the utilization of dental services. Oral health, nonuse of dental service, teeth, and health were found associated with frailty in many studies.[17],[23],[35],[39],[46] Edentate individuals not wearing dentures were 82.2% likely to be underweight and 60% overweight/obese.[17] Wearing dentures alone could not completely make up the defect of tooth loss. Effective interventional studies should be carried out regarding restoration of the remaining teeth for the prevention of frailty.

The latest concept linking oral health and frailty could be sarcopenia which can be evaluated through tongue pressure.[18] Older persons with sarcopenia have been commonly shown to have swallowing disorders and dysphagia.[47],[48] Decreased tongue pressure is common in older persons and is associated with dysphagia. Persons with poor oral health are more likely to have aspiration malnutrition, sarcopenia, and physical frailty. They recognized that tongue pressure was independently associated with frailty, and it can be used as a simple screening tool for frailty.[18],[28],[30] ODK and persistent pain in older adults are quite common and have multiple determinants. This symptom represents a determinant of accelerated aging.[11],[16],[24],[30],[49] Oral frailty is still underexplored. In vulnerable elderly people, a high prevalence of xerostomia and salivary gland hypofunction has been found.[50] Risk of getting dry mouth was higher in the prefrail geriatric population.[45] The majority of dental professionals agreed that there are limited opportunities to refer the frail and elderly with complex oral health-care problems to a colleague with specific knowledge and skills.[51]

Oral frailty was significantly associated with physical frailty by 66.6% and sarcopenia by 72.7% according to a Japanese cross-sectional study.[29] In the Netherlands study, oral frailty was associated with physical frailty by 4%.[36] The tools for assessing oral and physical frailty were different in both studies. The first one used the fried phenotype, while the latter used the Gronington indicator. In the US cross-sectional study, the association was about 25%.[28] Similarly, oral frailty assessment tools also were different in both studies.

Covariates used in this study were similar; variations were mainly in the indicators used for assessing socioeconomic position and adjustment for chronic diseases. Most studies ignored the number of medications and cognition. Standardization of covariates should be considered in further studies. As animal studies suggest, it could be plausible that a reciprocal relationship between mastication and cognition exists, however, this relationship has not been sufficiently studied in human populations.[52] Hence, cognitive parameters also should be included in further studies.

A significant association was found between the presence of teeth and frailty. However, it fails to establish the temporal association due to the comorbidities. Furthermore, deterioration of oral health, tooth loss and dry mouth, and diadochokinesis could affect nutritional status which can lead to frailty.

The scoping review approach has several limitations. Scoping reviews do not formally evaluate the quality of evidence and often gather information from a wide range of study designs and methods. This scoping review do not provide a synthesized result or answer to a specific question but rather provide an overview of the available literature regarding the impact of oral frailty on general frailty in geriatric population.

  Conclusions Top

Oral frailty is a crucial aspect of general frailty. More cohort studies need to establish a causal relationship between oral and physical frailty. Medical–dental collaboration is inadequate and should be improved in geriatric medicine. While evaluating physical frailty, geriatric practitioners should consider oral frailty also.

Availability of data and detail

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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