Understanding rapid oral health deterioration and its associated factors among older adults: A scoping review

Background Understanding the pivotal interplay between systemic and oral health is paramount to ensuring holistic care, particularly among the aging demographic. Therefore, this review article aims to explore the emerging concept of Rapid Oral Health Deterioration (ROHD) by reviewing the current knowledge base among older adults and identifying knowledge gaps in this area of research. Methods This scoping review was conducted in line with Arksey and O’Malley’s framework between December 2023 and March 2024 and reported while adhering to the PRISMA-ScR guidelines. A systematic database search was performed across three databases i.e. PubMed, Scopus, and EMBASE to collate the existing literature published in English between January 2013 and February 2024 addressing ROHD among older adults. After data charting, a critical appraisal of the selected studies was followed by qualitative thematic analysis. Results Among the 12 papers in this scoping review, 10 were cross-sectional studies, with one each of retrospective cohort and case-control studies. The qualitative thematic analysis of the selected articles resulted in the emergence of four main themes: risk factors for ROHD, attributes related to ROHD, challenges encountered in the management of ROHD, and management approaches for ROHD among older adults. Conclusions This scoping review provides an overview of the rapid deterioration of oral health among older adults. Age-related dental disease harms the quality of life and overall health. To avoid dental disorders and to maintain and improve oral health in older adults, an integrated and multidisciplinary approach is essential. If ROHD is not treated, it may lead to poor health, a lower quality of life, and in severe cases, systemic infections that increase hospitalizations and possibly cause death.


Introduction
The aging demographic is an enduring worldwide phenomenon, with projections indicating that by 2050, one out of every six individuals globally will be aged 65 or above, compared to one in ten in 2021. 1 As individuals age, they become more vulnerable to a variety of systemic illnesses, with the older adults exhibiting a significantly higher prevalence of chronic and non-communicable diseases compared to the younger demographic. 2It is often suggested that the condition of the oral cavity reflects a person's general health. 3,4Oral diseases, particularly periodontal disease, have been linked to various non-communicable conditions like diabetes, cardiovascular diseases, cancer, cognitive decline, among others. 5,6Therefore, recognizing the vital relationship between overall health and oral health is essential for safeguarding an individual's overall well-being, as general health status significantly influences oral health outcomes. 3though the complete loss of teeth may be declining, gradual tooth loss remains a significant indicator of poor oral health in older adults with dental caries continuing to be the most prevalent oral condition among older individuals. 5,6Hence, early detection and treatment of oral health issues in older adult patients can mitigate oral health complications, particularly in those with chronic illnesses, and contribute to enhancing overall Oral Health-Related Quality of Life. 7e care needs of older individuals are diverse and intricate, which is highlighted by the emergence of medical and dental specializations that prioritize patient-centered care.Programs in geriatric dentistry specifically aim to understand the interplay between oral health conditions, socioeconomic factors, and systemic health issues in this demographic. 8ommon chronic systemic disorders diagnosed in older individuals include arthritis, hypertension, diabetes, depression, neurodegenerative conditions, dementia, and stroke.Recognizing potential interactions between oral health factors and these systemic health events is crucial for addressing the poor oral health encountered in this age-group.This serves as the foundational premise of the systematic framework outlined in the Rapid Oral Health Deterioration (ROHD) concept, aiding dental professionals in assessing the probability of progressive oral health deterioration among older adult patients. 6,9derstanding the potential the concept of ROHD holds in alleviating the oral disease burden among older adults, the aim of this scoping review was to explore the existing literature on ROHD in older adults, an area that has received relatively limited attention in research.The objective was to compile and analyze the literature while also pinpointing and comprehending the existing knowledge gaps in this realm of research.

Methods
The time frame for this scoping review ranged between December 2023 and March 2024 following the framework outlined by Arksey and O'Malley, 10 to address the research question "What is known about rapid oral health deterioration among older adults in the existing literature?"A review protocol was not registered for this scoping review, and the findings are presented in accordance with the PRISMA-ScR checklist. 11igibility criteria This scoping review included articles focusing on one or more facets of oral health deterioration in older adults, published in English between January 2013 and February 2024 reflecting on the heightened awareness around oral health needs of the geriatric population.Review articles, letters to editors, and other papers with missing full-text formats, such as conference proceedings, were excluded from this scoping review.

Information sources and search strategy
A systematic search was conducted across three databases i.e.PubMed, Scopus, EMBASE, where the last search was performed in February 2024.The search strategy involved using key terms such as 'older adults', 'older adults', 'aged', 'clinical deterioration' and 'rapid oral health deterioration', along with Boolean operators 'OR' and 'AND'.The detailed search strategy across the databases has been provided in Table 1.

Selection process
The initial database search was conducted by one author (RR) using the search strategy, followed by the removal of duplicates.Title and abstract screening were independently performed by two investigators (RR and RS), with each article categorized as "Yes", "No", or "Maybe".Subsequently, the articles selected during title and abstract screening underwent full-text review by the two investigators independently.Disagreements were resolved through discussion at each stage, leading to consensus.The articles which fulfilled the eligibility criteria were included in this scoping review for data extraction and critical appraisal.

Data charting process
One author (RR) charted the data from the selected full-text articles using a predetermined format, which was followed by random verification by another author (RS).The predetermined format encompassed the following headings: title of the study and the authors, year of publication, purpose of theoretical and conceptual orientation, research questions and/or hypothesis, sample description, methods and analysis, key measures, main findings or results, author(s) stated limitations of the study, additional limitations of the study, strength and importance of the study.

Critical appraisal of articles
The Crowe Critical Appraisal Tool (CCAT) 12 was employed to assess the quality of the available evidence and accurately identify the research gaps in the literature.CCAT enables the critical assessment of various research methodologies and evaluates each article in eight categories i.e. preliminaries, introduction, design, sampling, data collection, ethical issues,       Based on the CCAT scores, articles with a score of 35 or more were labelled as high quality, scores from 25 to 34 were deemed medium quality while articles with scores less than 25 were considered as low quality. 13The critical appraisal was executed by one author (RR), with a subset of articles randomly selected for reassessment by another author (RS) to ensure accuracy.

Synthesis of results
The findings of this scoping review were synthesized through qualitative thematic analysis of each selected article.Two authors (RR and PDB) independently conducted the coding process for thematic analysis, where the appropriate segments of the selected articles pertaining to the research question on rapid oral health deterioration among older adults were identified and initially coded using Atlas.tiMac 14 (Version 23.2.1).Subsequently, both authors deliberated on the initial codes to arrive at the final codes and at this juncture, a third author (RS) joined the discussion for further refinement of the codes and through comprehensive discussion, the main themes emerging from the selected articles addressing the research question were identified and organized into main themes and subthemes for enhanced clarity and comprehension.

Results
A total of 86 articles were selected after the initial search based on title screening, of which 27 duplicates were eliminated.Subsequently, this was followed by a title and abstract screening of the remaining 59 articles, of which 39 were considered for a comprehensive full-text review.Based on the eligibility criteria, finally 12 articles were deemed suitable for inclusion in this scoping review.The selection process of the articles is illustrated in Figure 1 with a PRISMA flow diagram. 15aracteristics and quality of sources of evidence Among the 12 papers included in this scoping review, ten were cross-sectional studies, with one each of retrospective cohort and case-control studies.These papers were mostly published within the last ten years, as per the eligibility criteria which included articles from 2013 onwards.Table 2 offers a comprehensive overview of the characteristics of the articles selected for this scoping review, along with the data extracted from these sources.
CCAT was used to conduct a quality appraisal of the selected sources of evidence, and the detailed scores for each paper across all domains are presented in Table 3.According to the CCAT scores, eleven papers included in the review were deemed as medium quality, while one was labelled as low quality based on the CCAT scores.

Synthesis of results
The qualitative thematic analysis of the selected articles resulted in the emergence of four main themes namely: risk factors for ROHD, attributes related to ROHD, challenges encountered in managing ROHD and management approaches for ROHD among older adults.The details of the main and sub-themes are provided in Table 4.
Risk factors for ROHD included systemic, socioeconomic factors and oral factors.Systemic factors included a wide array of systemic conditions mainly dementia, schizophrenia, and cardiovascular disorders among others.Oral factors included Table 4. Main themes and sub-themes emerging from qualitative analysis.
The next two themes were related to the challenges encountered in the management of ROHD and the potential solutions which could be implemented in the management of ROHD among older adults.

Discussion
This scoping review intended to examine the available evidence on the rapid deterioration of oral health in the older population, with a special emphasis on identifying the research gaps.Additionally, the findings relating to the qualitative thematic analysis shed light on potentially promising approaches which could be imbibed into everyday interprofessional medical practices to better manage ROHD among older adults, thereby enhancing OHRQoL.

Systemic conditions and oral health
There is a strong relationship between oral diseases and systemic diseases, with research demonstrating a robust connection between dental health and noncommunicable diseases such as cancer, neurodegenerative disorders, diabetes, heart disease, depression, inflammatory bowel disease, rheumatic diseases, obesity, stomach helicobacter pylori, and asthma. 7It is important to note that the prevalence of several chronic medical disorders rises with age. 8mentia emerged as an important condition affecting the oral health condition among older adults in this scoping review.Poor oral hygiene in older people with dementia is caused by a number of variables, including behavioural issues, deteriorating cognitive function, degree of dementia and insufficient dental staff nursing education. 19,22Similarly, neuropsychatric disorders like schizophrenia have a significant negative effect on people's health.These patients have poor dental hygiene, which lowers their quality of life and raises their risk of systemic illnesses. 24stemic health and oral health share a bi-directional relationship with each other as can be observed in the available evidence, where oral health also tends to adversely affect the general health of individuals.The importance of regular dental check-ups in preventing acute hospitalization occurring due to diseases like pneumonia, cerebrovascular disease and urinary tract infections, has been highlighted by a retrospective study conducted in Japan on older adults included in this review. 26The studies on diabetes and oral health has been always focused on the periodontal tissues and maintenance of glycemic control. 28This is in line with evidence which suggests that early detection and treatment of oral health issues could avert poor oral health and a reduction in OHRQoL particularly in older adult patients with chronic illnesses. 7 Nutrition and oral health There is a reciprocal and dynamic relationship between dental health and nutrition.Poor dental health may increase an older adult person's risk of malnourishment or malnutrition, particularly if they are institutionalized. 21,23This further magnifies the importance of including oral health indicators in geriatric examinations. 21Evidence suggests that a risk of nutritional deficiency was substantially correlated with a negative self-perception of oral status; however, this correlation vanished when socioeconomic level, neurosensory impairments, and chronic illnesses were taken into account. 18ble 4. Continued

Main themes Sub-themes
Management approaches for ROHD Need for specific dental protocols in residential care institutions 19 Oral health indicators to be included in routine geriatric assessments 21 Routine dental visits, scaling and cleaning 19,26 Dental care against periodontal disease 24,26 Specific training for nursing staff for oral health maintenance 17,19,24 Attention to nutrition in orally frail individuals 23 Teaching Tool for dental students 20 Training to caregivers to identify oral pain-related signs and behavioural changes 16,22 Frailty and oral health Reduced stress tolerance, elevated susceptibility, and compromised functioning are all considered indicators of frailty.It raises the possibility of hospitalization, disability, falls, and death.Oral Frailty (OFr), which is defined in the literature as "weakness and fatigue of the oral muscles," contains elements including poor oral health, impaired muscle performance, the possibility of weight loss, issues with chewing and swallowing, changes in the food's composition, trouble speaking, and tongue or tooth pain.One of the included studies suggested that protection against OFr may come from maintaining one's natural teeth, maintaining good oral health throughout one's life, and preventing oral illnesses. 27nagement approaches for ROHD in older adults Institutionalized older adults need assistance in doing oral hygiene activities 17 and usage of various oral hygiene aids such as adaptive toothbrush handles, collis-curve brushes, triple-headed toothbrushes, water flossers, interdental brushes of different diameters, floss holders/single-use floss picks, and other oral hygiene products like electric toothbrushes help these people remove plaque more effectively and help with physical adaptations. 6,9 Among other potential approaches to manage ROHD in older adults, the need for specific dental protocols to be followed in residential care institutions along with training for nursing staff to cater to oral health maintenance and empowering caregivers in identifying oral pain-related signs were highlighted in the included articles.In particular, attention to nutritional needs in orally frail individuals as well as providing adequate dental care against periodontal disease emerged as important approaches.Another study discussed a simple yet effective teaching tool for dental students to provide care to the geriatric population and people with special needs. 20

Future directions
The findings of the present review warrant more high quality research in this important area with rising geriatric population worldwide.This research also lays down potentially promising approaches, which can be researched as well as implemented with regards to the management of ROHD among aging adults.

Conclusion
Age-related dental disease has a negative effect on overall health and quality of life.In order to avoid dental disorders and to maintain and improve oral health in older adults, an integrated and multidisciplinary approach is essential.If ROHD is not treated, it may lead to poor health, a lower quality of life, and in severe cases, systemic infections that increase hospitalizations and possibly cause death.

Open Peer Review
Current Peer Review Status: What constitutes "deterioration" and the time frame for such change can vary from person to person but it can be agreed that oral disease negatively impacts the frail older adult's quality of life.It is imperative to address dental caries, periodontal disease as needs arise to avoid undesired sequelae.In this article, Ranjith and colleagues provide a detailed review of emerging thought about oral health deterioration seen in medically frail older adults.Their approach seems to be methodologically robust and reproducible, and care has been taken at every step to ensure inclusion of the best available literature that pertains to their specific topic of interest.Table 4 neatly summarizes the key themes that one might encounter when dealing with patients who are either at risk for, are experiencing or have experienced ROHD.
Although we may accept a general association between oral and systemic disease as proposed here, the issue is a rather complex one.As suggested by Philstrom et al, it is sufficient to promote good oral health as a benefit in and of itself rather than because it carries a specific systemic health benefit [Ref-1].The current article might present a more balanced view if it referenced controversies in this area and the limitations inherent in studying associations between oral and systemic health.
Overall, a very good report .

Are sufficient details of the methods and analysis provided to allow replication by others? Yes
Is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.Specifying the limitations of the scoping review process may be considered.3.

Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes
Are sufficient details of the methods and analysis provided to allow replication by others?Yes

Are the conclusions drawn adequately supported by the results presented in the review? Yes
If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified?('Living Systematic Review' or a variation of this term should be included in the title.)Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Dentistry, oral health, geriatric health, dental caries, oral cancer We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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Figure 1 .
Figure 1.PRISMA flow diagram depicting the selection of articles.
. Each category is scored between from 0-5 and with a possibility of the maximum total score of 40.

Version 1 Reviewer
Report 31 May 2024 https://doi.org/10.5256/f1000research.163534.r272000© 2024 Nair R.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Rohit Nair Department of Preventive and Community Dentistry, The University of Iowa College of Dentistry and Dental Clinics, Iowa City, IA, USA As a clinical concept, Rapid Oral Health Deterioration (ROHD) is tangible but difficult to define.

Table 1 .
The detailed search strategy across the databases.

Table 2 .
Charted data from the included studies.

Table 3 .
Crowe's critical appraisal scores of the included studies.

the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.) Not applicable Competing Interests:
An article that I co-authored was cited in this paper.Reference #6 -Desai JP, Nair RU: Oral health factors related to rapid oral health deterioration among older adults: a narrative review.J. Clin.Med.2023 Apr 29; 12(9): 3202 Reviewer Expertise: Geriatric Dentistry, Dentistry for Adults with Special Health Care Needs I

confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
Reviewer Report 28 May 2024 https://doi.org/10.5256/f1000research.163534.r271999