DENTAL AND ORAL HEALTH

Oral Health Status Is Associated with Common Medical

Comorbidities in Older Hospital Inpatients
oin
ın, MD,*† Adrian Montalto, BOH,‡ Shahrzad Jahromi, MBBS,*
Danielle N
ı Chr

Nicholas Ingham, MBBS,* Alexander Beveridge, MBBS,* and Peter Foltyn, BDent§

analysis (Spearman rho = 0.19, P = .01) but not when

OBJECTIVES: To investigate oral health status and
abnormalities in older adults admitted acutely to the hos-
pital and explore the association with common medical
comorbidities.
DESIGN: Cross-sectional study.
SETTING: Hospital.
PARTICIPANTS: All individuals aged 70 and older (mean
age 84.4, 61.4% female) admitted to a geriatric service
over 3 months (N = 202).
MEASUREMENTS: In-person assessment using the Oral
Health Assessment Tool (OHAT) (range 0–2, 2 = poorest)
for lips, tongue, gums and soft tissue, saliva, teeth, den-
tures, oral cleanliness, and dental pain. Comorbidities and
medications were also recorded.
RESULTS: One hundred twenty-eight (63%) participants
had full or partial dentures, and 31 (15%) were edentu-
lous. Median OHAT score was 6 (interquartile range 5–8).
Of the eight domains, saliva scored worst, with 53% scor-
ing 2. On univariate analysis, the highest (poorest) tertile
of OHAT (score ≥8) was associated with dementia (odds
ratio (OR) = 2.41, 95% confidence interval (CI) = 1.13–
5.12, P = .02), moderate to severe renal impairment (esti-
mated glomerular filtration rate <30 mL/min per 1.73 m2
at discharge) (OR = 5.52, 95% CI = 1.54–19.69,
P = .009), recent anticholinergic medication burden
(P = .02), and low oral pH (P = .05). On multivariate
analysis adjusted for oral pH and anticholinergic medica-
tion burden, dementia (OR = 2.29, P = .02) and moderate
to severe renal impairment (OR = 5.64, P = .01) were
independently associated with the highest tertile of OHAT.
Charlson Comorbidity Index (includes renal disease,
dementia) was associated with OHAT on univariate
From the *Department of Geriatric Medicine, St. Vincent’s Hospital,
Darlinghurst, New South Wales, Australia; †Department of Geriatric
Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia;
‡ as enamel, dentine, and cementum contain mineral and
Oral Health Services, South East Sydney Local Health District, Sydney,
Australia; and §Department of Dentistry, St. Vincent’s Hospital,
Darlinghurst, New South Wales, Australia.
Address correspondence to Danielle N
ı Chr

oin
ın, Department of Geriatric
Medicine, Liverpool Hospital, Corner of Elizabeth and Goulburn Streets,
Liverpool, NSW 2170, Australia. E-mail: dmmnic@umail.ucc.ie
DOI: 10.1111/jgs.14247
adjusted for oral pH (P = .10).
CONCLUSION: Poorer oral health was not uncommon
and was associated with dementia and renal impairment
even after adjustment for anticholinergic medication and oral
pH. Oral health screening should be considered for vulnera-
ble populations. J Am Geriatr Soc 64:1696–1700, 2016.
Key words: oral health; dental care; elderly; dementia;
renal insufficiency; anticholinergics
O ral disease can have a large effect on the health and
well-being of older persons.1–3 Pain is common and
may present atypically, particularly in persons with demen-
tia. Oral disease may impair speech and contribute to lack
of oral intake and resultant malnutrition. Poor oral health
may increase risk of local abscesses, aspiration pneumonia,
and septicemia.1,3,4 Poor dentition may also negatively
affect cosmesis and affect self-esteem.3
Multiple factors may influence oral health. Comorbidi-
ties commonly seen in geriatric practice can affect saliva
production, nutritional status, dexterity, motivation, and
cognition, all of which may affect oral health status and
ability to manage oral hygiene. In the acute setting, fever,
acute infection, and stress may alter endogenous anticholin-
ergic activity. Many medications add to the risk by increas-
ing anticholinergic burden and affecting saliva production.
Polypharmacy exacerbates this, and the result may be
xerostomia, caries, and infection. Saliva acts as a buffer
during acid attacks that predispose to dental erosion,
enhances mineralization through its mineral content, and
facilitates formation of dental pellicle.5 Dental tissues such
organic matrix components. Multiple factors, including
chemical, such as pH and mineral saturation, and physical,
such as temperature, influence mineral dissolution.6 Because
of improvements in oral care, fluoridation, and dentistry,
people are more likely to be dentate than in the past, but
the quality of remaining dentition is often poor,

JAGS 64:1696–1700, 2016

© 2016, Copyright the Authors
Journal compilation © 2016, The American Geriatrics Society 0002-8614/16/$15.00
JAGS AUGUST 2016–VOL. 64, NO. 8 ORAL HEALTH AND COMMON MEDICAL COMORBIDITIES 1697

restorations and prostheses are complex, and oral health categorized as 5.5 or less, 6.0 to 6.5, 7.0 to 8.0, and 8.5
status is vulnerable to rapid deterioration.1,3 Older persons or greater. Edentulous was defined as no remaining natural
may also have difficulty accessing dental care when needed teeth. When oral disease was detected, participants were
for a variety of reasons, including inadequate finances, offered dental review, and their dentist was sent a letter.
mobility, transport, lack of caregiver resources, and simple Comorbidities and medications were recorded from
failure to recognize the need for dental examination.3,7 the medical notes (hard copy and electronic). A diagnosis
Despite the importance and likelihood of oral health of dementia included any subtype, confirmed by a geriatri-
problems in older people, little attention is paid to the cian, and by definition involving cognitive impairment
issue. Poor oral health is underrecognized in this popula- with accompanying functional impairment. Delirium was
tion, and because of a lack of routine screening and proac- identified according to documentation of the diagnosis by
tive orodental care planning, intervention is often reactive the treating geriatric team. Renal impairment was defined
rather than preventative.1,8 The limited existing literature according to estimated glomerular filtration rate (eGFR) at
that exists focuses largely on community dwellers and the time of discharge, when renal function may have been
those in residential care, yet individuals in the hospital more likely to have stabilized than earlier during hospital-
may be at high risk, oral disease may be a contributing ization. Moderate to severe renal impairment was defined
factor to the presenting complaint, and intervention may as an eGFR of less than 30 mL/min per 1.73 m2 using the
improve the individuals’s health status. Hospitalization Modification of Diet in Renal Disease formula, which the
may present an opportunity to provide oral assessment hospital laboratory routinely uses.9 Charlson Comorbidity
and management that might otherwise be neglected. Index, a weighted index of the number and gravity of
In this context, the aim of the current study was to medical comorbidities (total 19 categories), was calculated
investigate the oral health status of older adults admitted at admission.10 Current and recent anticholinergic medica-
acutely to the hospital and to explore the association tion burden (medications taken within the last 2 years)
between oral health and common medical comorbidities. was determined from the medical notes supplemented by
information from general practitioners. This allowed calcu-
lation of Anticholinergic Cognitive Burden (ACB) score,
METHODS
both current and extending to medications taken within
This was a cross-sectional study of all individuals aged 70 the last 2 years.11 The ACB scale assesses anticholinergic
and older admitted to an inpatient ward under the care of activity based on literature indicating in vitro or in vivo
geriatric medicine over a 3-month period (September 22– anticholinergic effects, with risk determined by an expert
December 29, 2014). Those who were dying, extremely panel. A score of 0 to 3 is afforded to each medication
agitated, or declined consent were excluded. In the case of included, based on probability of anticholinergic burden.
those who lacked capacity to provide informed consent, Ethics approval was obtained from the St. Vincent’s
consent was sought from the next of kin. Any individual Hospital human research ethics committee.
was eligible for inclusion only once, even if they had mul- Simple descriptive statistics were used to report demo-
tiple admissions. graphic characteristics and prevalence of comorbidities.
An oral health therapist conducted an oral examina- Highest tertile of Oral Health Assessment Tool (OHAT)
tion using the Oral Health Assessment Tool, which has was determined according to distribution of OHAT scores
previously been validated in older adults, specifically in within the study cohort. Univariate and multivariate logis-
those residing in aged care facilities.7 It is a screening tool tic regression analyses were used to explore associations
modified from the Brief Oral Health Status Examination between predictor variables and binomial dependent vari-
that includes eight domains (Table 1), each scored from 0 ables, and the Spearman test was used as a nonparametric
(best or normal) to 2 (worst).7 Oral pH was assessed using test of correlation between continuous and ordinal vari-
a simple pH strip (ChoiceLine, Roche, Germany) and ables. Factors that were significantly associated with poor
oral health on univariate analysis (P ≤ .05) were included
in multivariable modeling. Statistical tests were performed
Table 1. Oral Health Assessment Tool (OHAT) using Stata version 13.0 (StataCorp LP, College Station,
Domain Scores in the Cohort (N = 202) TX).
Score
RESULTS
0 1 2
Of the 312 potentially eligible individuals admitted during
Domain n (%) the study period, 202 (64.7%) were included. Reasons for
exclusion included impending death (n = 30), inability to
Lips 23 (11.4) 177 (87.6) 2 (1.0) give consent (n = 24), declined consent (n = 18), extreme
Tongue 41 (20.3) 160 (79.2) 1 (0.5) agitation (n = 10), discharge before recruitment (n = 9),
Gums 85 (42.1) 111 (55.0) 6 (3.0) and other (e.g., language barrier, infection control;
Saliva 28 (13.9) 67 (33.2) 107 (53.0) n = 19). Because each participant could be included only
Teeth 97 (49.2) 52 (26.4) 48 (24.4)
once, 46 readmitted individuals were not eligible for inclu-
Dentures 80 (64.0) 2 (1.6) 43 (34.4)
Cleanliness 55 (27.2) 71 (35.2) 76 (37.6) sion for their readmission. There were no missing data
Pain 172 (85.2) 24 (11.9) 6 (3.0) amongst the included variables.
Of the 202 included participants, mean age was
Total OHAT score for this cohort, median 6, interquartile range 5–8. 84.4  6.5, 61.4% were female, 7.4% were current
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smokers, and 4% had a recent alcohol intake of more than with 53% of participants (n = 107) scoring 2, indicative of
10 U/wk (Table 2). High rates of comorbidities, including parched, red tissues; little, no, or thick saliva; and symp-
dementia (17.8%), delirium (20.3%), diabetes mellitus tomatic xerostomia (Table 1). Thirty-eight percent
(23.9%), and renal impairment (41.1%; eGFR <60 mL/ (n = 76) scored 2 (poor) for oral cleanliness (food, tartar,
min per 1.73 m2 at discharge) were observed (Table 2). plaque on most of mouth and dentures), and 34.4% (69)
Other comorbidities, including stroke, osteoporosis, and scored 2 (poor) for dentures (≥1 broken areas or teeth;
chronic obstructive pulmonary disease, were also common, missing, nonadherent, unnamed (unlabeled) dentures).
and mean Charlson Comorbidity Index score was On univariate analysis, poor oral health (highest tertile
6.1  2.1. The commonest primary admission diagnoses of OHAT score) was associated with dementia (odds ratio
were falls (20.2%, n = 9), respiratory tract infection (OR) = 2.41, 95% confidence interval (CI) = 1.13–5.12,
(9.4%, n = 19), and nonfracture musculoskeletal pain P = .02) and moderate to severe renal impairment (esti-
(8.4%, n = 17) (Table S1). Five (2.5%) had an oral pH of mated glomerular filtration <30 mL/min per 1.73 m2 at
5.5 or less, 105 (52.0%) a pH of 6.0 to 6.5, 92 (45.5%) a discharge) (OR = 5.52, 95% CI = 1.54–19.69, P = .009)
pH of 7.0 to 8.0, and none an oral pH of 8.5 or greater. (Table 3). Other factors associated with poor oral health
The median ACB score for current medications was 1 (in- included stepwise worsening of renal disease (eGFR >60,
terquartile range (IQR) 0–3) and for recent medications
was 2 (IQR 1–4). The commonest medications (current
and recent) are shown in Table S2.
Table 3. Logistic Regression Analysis Investigating
In total, 63.3% had partial or full dentures, and
Factors Associated with Greater Likelihood of Oral
15.3% were edentulous. The median total OHAT score Health Assessment Tool (OHAT) Score in Highest Ter-
was 6 (IQR 5–8; maximum possible total score 16 tile (Poor Oral Health)
(8 9 2)), with the highest tertile of OHAT of 8 and
higher. A score of 0 to 2 was assigned to each of the eight Odds Ratio (95% P-
domains assessed, with 2 representing the worst possible Variable Confidence Interval) Value
score. Saliva had the highest proportion of poor scores,
Univariate analysis
Age (per year increase) 1.01 (0.96–1.06) .59
Male 1.61 (0.86–3.05) .14
Table 2. Participant Characteristics and Distribution Current smoking 1.02 (0.31–3.37) .97
Current alcohol >10 U/wk 1.25 (0.86–1.83) .25
of Comorbidities (N = 202)
Decreasing oral pH (according 1.82 (1.01–3.26) .05
Characteristic Value to change in category)
Delirium 1.62 (0.77–3.40) .20
Age, mean  SD 84.4  6.5 Dementia 2.41 (1.13–5.12) .02
Female, n (%) 124 (61.4) Ischemic heart disease 1.49 (0.77–2.89) .23
Current smoker, n (%) 15 (7.4) Heart failure 0.97 (0.76–1.25) .82
Alcohol intake, U/wk, n (%) Atrial fibrillation 0.75 (0.33–1.69) .49
0 92 (45.5) Moderate to severe renal 5.51 (1.54–19.69) .009
>10 8 (4.0) impairmenta
Delirium, n (%) 41 (20.3) Dyslipidemia 0.90 (0.47–1.73) .76
Dementia, n (%) 36 (17.8) Diabetes mellitus 1.37 (0.67–2.80) .38
Ischemic heart disease, n (%) 63 (31.2) Lack of mobility, falls 1.24 (0.63–2.42) .53
Heart failure, n (%) 48 (23.8) Osteoporosis 0.85 (0.39–1.88) .69
Atrial fibrillation, n (%) 41 (20.3) Current infection 0.72 (0.35–1.50) .38
Estimate glomerular filtration rate, mL/min per 1.73 m2, n (%) Chronic obstructive pulmonary 1.21 (0.59–2.50) .53
>60 119 (58.9) disease, asthma
30–59 68 (33.7) Stroke 1.12 (0.73–1.73) .58
<30 15 (7.4) Parkinson’s disease 1.51 (0.36–6.36) .57
Dyslipidemia, n (%) 76 (37.6) Depression 1.29 (0.61–2.71) .50
Diabetes mellitus, n (%) 48 (23.9) Anticholinergic Cognitive Burden score (per unit increase)
Reduced mobility or falls, n (%) 62 (31.2) Current 1.04 (0.87–1.23) .68
Osteoporosis, n (%) 42 (20.8) Recent 1.18 (1.03–1.35) .02
Current infection, n (%) 55 (27.2) Charlson Comorbidity Indexb 1.14 (0.98–1.32) .08
Urinary tract 19 (9.4) Multivariate modelc
Lower respiratory tract 20 (9.9) Dementia 2.29 (1.03–5.08) .02
Cellulitis 5 (2.5) Moderate to severe renal 5.64 (1.50–21.29) .01
Combined 6 (3.0) impairment
Other 5 (2.5) Recent Anticholinergic Cognitive 1.16 (1.01–1.34) .04
Chronic obstructive pulmonary disease, asthma, 48 (23.8) Burden score
n (%) Decreasing oral pH 0.58 (0.31–1.08) .08
Stroke, n (%) 28 (13.9)
a
Transient ischemic attack, n (%) 11 (5.5) Estimated glomerular filtration rate <30 mL/min per 1.73 m2 at dis-
Parkinson’s disease, n (%) 9 (5.7) charge.
b
Depression, n (%) 43 (21.3) Significantly associated with OHAT when analyzed as an ordinal vari-
Charlson Comorbidity Index, mean  SD 6.1  2.1 able, Spearman rho = 0.019, P = .02.
c
Includes factors significantly associated with poor oral health on univari-
SD = standard deviation. ate analysis.
JAGS AUGUST 2016–VOL. 64, NO. 8
30–59, <30 mL/min per 1.73 m2; P = .01, test for trend),
decreasing category of oral pH (P = .05), and recent ACB
score (P = .02). Current total medication ACB score was
not associated with poorer oral health, as indicated by
increasing OHAT score. Charlson Comorbidity Index,
which includes dementia and chronic kidney disease as
components, was associated with OHAT score (Spearman
rho = 0.019, P = .02) (Table 3). Age, sex, and other
comorbidities listed in Table 2 were not significantly asso-
ciated with OHAT score. No association was observed
between primary admission diagnosis and OHAT score,
including analysis of any infection, specific source of infec-
tion, and delirium as the primary diagnosis.
On multivariate analysis adjusted for oral pH and
anticholinergic medication burden, dementia (OR = 2.29,
P = .02) and moderate to severe renal impairment
(OR = 5.64, P = .01) were independently associated with
highest tertile of OHAT (indicative of poorer oral health;
Table 3), with a statistical trend observed for the association
between decreasing pH and poorer oral health status
(P = .08). When recent medication ACB score was excluded
from the model, the association between highest tertile of
OHAT and dementia (OR = 2.28, CI = 1.04–5.01,
P = 0.04) and moderate to severe renal impairment
(OR = 6.11, 95% CI = 1.64–22.67, P = .007) persisted,
and the association with oral pH was relatively unchanged
(OR = 0.57 per category decrease, 95% CI = 0.31–1.05,
P = .07). The association observed between Charlson
Comorbidity Index and OHAT score was no longer evident
when adjusted for oral pH (P = .10; in model adjusting for
oral pH and recent medication ACB score, P = .15).
DISCUSSION
A high rate of poor oral health status was found in a large
cohort of older acutely hospitalized adults. Dementia and
moderate to severe renal impairment, which are commonly
encountered in geriatric practice, were independently asso-
ciated with poorer oral health. This association remained
after adjustment for recent anticholinergic medication bur-
den, indicating that the anticholinergic effects of medica-
tion alone do not mediate the effect.
Previous authors have noted an association between
dementia and orodontal disease,1,2 although this has not
been a consistent finding in all studies.1,12 The evidence
has come mostly from residential care settings. There are
several reasons why individuals with dementia might be at
higher risk of poor oral health, including difficulties with
self-care, insufficient caregiver (or staffing) resources, mal-
nutrition, anticholinergic medications, intrinsic alterations
in salivary function with Alzheimer’s disease, and cario-
genic diet.1–3 Recently, inflammatory activation has been
suggested as a common mechanism that may account for
some of the association observed between cognitive decline
and dental disease.11
A relationship between renal impairment and oral dis-
ease has also been described, although often in the context
of end-stage renal disease with or without renal replace-
ment therapy and in younger cohorts.13–17 Abnormalities
described have included gingivitis, altered probing depth,
attachment loss, enamel hypoplasia, xerostomia, dental
pain, mucosal infection, and moderate to high rates of
ORAL HEALTH AND COMMON MEDICAL COMORBIDITIES 1699
decayed, missing, and filled teeth.13,14,17 There are multi-
ple mechanisms by which renal disease might impair oral
health status, including impaired mineralization, malnutri-
tion, impaired drug excretion, inflammation, and impaired
immunity due to the condition itself as well as direct
immunosuppressive therapy in some individuals.13–17
There has been some indication that moderate to severe
periodontal disease is associated with all-cause and cardio-
vascular mortality in such populations, although the
observed associations have most often not reached statisti-
cal significance.17
The current study found an association between oral
health status and the anticholinergic burden of medications
taken during the past 2 years. Conversely, no association
was observed between oral health and the ACB score of
current medications alone. It may be that the ACB, one of
many anticholinergic burden scores, incompletely captures
the oral effect of medications,18 yet the fact that a rela-
tionship was found with medications taken in the recent
past indicates that it is not an insensitive scale. The anti-
cholinergic effects of medications on oral health may have
a prolonged effect, lasting beyond the duration of therapy,
or build up over time. ACB score, like others, does not
account for serum levels or duration of therapy that may
affect orodontal outcomes. The true extent of “recent”
anticholinergic medication burden may have been underes-
timated, because medical notes and general practitioner
sources may not have fully identified all drugs taken in the
preceding 2 years, but the findings are hypothesis-generat-
ing and warrant further investigation.
A statistical trend for an association between oral pH
and OHAT score was also observed. Oral pH is particu-
larly important for preservation of mineral integrity in
dental tissues. The solubility of all dental minerals depends
strongly on pH. Most of the acids responsible for dental
erosion are weak acids, which dissociate as pH increases,6
but the erosive potential of a substance is not a factor just
of its acidity, but also other factors such as mineral con-
tent and presence of inhibitory factors (e.g., fluoride). The
effect of pH is most important below 5.5, at which point
proton-promoted dissolution occurs as surface H+ adsorp-
tion leads to weakening of Ca+2 bonds, and Ca+2 releases
into the surrounding solution.6 Although the effect of
physiological stressors on salivary pH has varied between
studies,19,20 foodstuffs, oral hygiene products, and medica-
tions also affect oral pH.21
Strengths of this study include the investigation of uns-
elected acutely hospitalized older adults, the investigation
of common comorbidities that may affect oral health sta-
tus, and the fact that no data from among the variables
investigated were missing. A simple screening tool was
used that nondental specialists have administered effec-
tively in residential populations.7
This study has limitations. It being a cross-sectional
study limited to a single point in time, causal inferences
cannot be drawn regarding the nature of any associations
observed. Individuals who were extremely agitated or who
declined consent were excluded. These may be a high-risk
group, but it was not possible to assess them. Only indi-
viduals admitted under the care of geriatric medicine were
included, and thus the findings cannot necessarily be
extrapolated to other older adults admitted to the hospital.
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Data were not collected regarding dementia severity or
nutrition status, both of which may influence oral health.
Finally, the numbers of participants with moderate to sev-
ere renal impairment (n = 15) were small, although an
association was observed between progressive renal
impairment and poor oral health status. The findings were
obtained in a single institution, and replication elsewhere
would help confirm the observations.
Oral disease is common in older hospitalized adults,
and specific comorbidities such as dementia and renal
impairment may confer particular vulnerability. This is
important, because poor orodontal health may impair
quality of life and health in older adults. Here in Australia,
the former Department of Health and Aging (now Depart-
ment of Health) has highlighted the importance of oral
care in residential facilities within a national framework
for facilitating high-quality care in residential aged care
(Natframe),22 but the matter has been largely neglected in
other geriatric care settings. Hospitalization may afford an
opportunity to institute and advocate for better oral assess-
ment and treatment of older adults and improved hospital
dental services. Practice guidelines that highlight the role
of oral health care in the management of older adults, in
acute hospital and community settings, are needed. Further
research investigating the effect of routinely using tools
such as the OHAT during acute hospitalization, targeted
interventions for particularly high-risk groups, and the
potential benefit (and costs) of any such practice guidelines
will help guide oral health management. In the interim, it
is hoped that studies such as this will raise awareness of
oral assessment as part of comprehensive care.
ACKNOWLEDGMENTS
We thank the participants and the Oral Health Services
division of South East Sydney Local Health District, which
provided an oral health therapist to assist with this study.
Conflict of Interest: The editor in chief has reviewed
the conflict of interest checklist provided by the authors
and has determined that the authors have no financial or
any other kind of personal conflicts with this paper.
Authors Contributions: N
ı Chr
oin
ın: study concept
and design, participant recruitment, data collection, statis-
tical analysis, drafting, revision and finalization of manu-
script. Jahromi, Ingham: participant recruitment, data
collection, critical revision of manuscript. Beveridge, Fol-
tyn: study concept and design, participant recruitment,
critical revision and finalization of manuscript.
Sponsor’s Role: None.
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SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Table S1. Commonest Primary Diagnoses (N = 202)
Table S2. Commonest Medications (N = 202)
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