Oral health status of nursing home residents in Flanders, Belgium: a cross-sectional study

Oral health status of nursing home residents in Flanders, Belgium: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Oral health status of nursing home residents in Flanders, Belgium: a cross-sectional study Patricia Ann Ivonne Vandenbulcke, Johanna de Almeida Mello, Emilie Schoebrechts, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4950980/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Feb, 2025 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Background A decline in self-care due to deteriorating general health presents a challenge for oral health in care-dependent older people. The most recently published data on the oral health of nursing home residents in Flanders, as assessed by oral health professionals, dates from 2010 to 2012. This study aimed to update the condition on the current oral health status of nursing home residents in Flanders. Methods In this cross-sectional study, the oral health of nursing home residents was evaluated by oral health professionals using the Oral Health Section as developed for use within the interRAI Suite of Instruments (OHS-interRAI). Validated dental indices were used to provide more detailed information about the condition of oral hygiene, gums, and teeth. Bivariate analyses were performed to investigate associations between oral health items and participants’ clinical characteristics. Results A total of 458 residents participated in the study with a mean age of 82.7 (± 7.8) years (70.3% female). For people with natural teeth (53.9%), the most prevalent oral health problems were insufficient oral hygiene (75.7%), and poor condition of teeth (56.6%) and gums (49.9%). High levels of dental plaque resulted in a mean Oral Hygiene Index of 4.5 (± 2.6). About 44.0% of the participants had at least one tooth with untreated caries affecting the nerve. The mean Modified Gingival Index was 1.8 (± 1.2), indicating mild inflammation of the entire gingiva. Denture hygiene was insufficient in 68.5% of the cases. Self-reported oral health problems were mainly related to dry mouth (32.8%) and chewing difficulty (23.4%). Strongest correlations were found between oral hygiene and gum condition (r = .324, p < .0001) and chewing difficulty and pain (r = .247, p < .0001). Furthermore, cognitive impairment showed strongest correlation with the level of oral hygiene and gingival health. Conclusion Despite the advances in dentistry, the oral health of nursing home residents still remains poor. Oral health of people with cognitive decline or functional impairment needs more attention. The regular oral health assessment with the OHS-interRAI by healthcare providers without a dental background has the potential to facilitate the early detection and prevention of oral health problems. Trial registration ClinicalTrials.gov NCT06536322- Retrospectively registered July 23rd, 2024. Health sciences/Diseases Health sciences/Health care Health sciences/Health occupations Aged Epidemiology Geriatric assessment interRAI Long-Term Care Oral Health Oral Hygiene Oral Health Assessment Patient Care Planning Public Health Introduction/ Background In Belgium, nearly 20% of the population is aged over 65, which is expected to rise to over 25% by 2050 [ 1 ]. In Flanders (largest region in Belgium), the share of people over 65 already increased to 21% in 2023, with approximately 8% receiving nursing care at home, and 5% residing in long-term care facilities [ 2 ]. In recent years, due to improved oral care, older people maintain their natural dentition into their later years [ 3 , 4 ]. This achievement has positive effects on their ability to chew and on their nutritional status [ 3 ]. However, a decline in self-care due to deteriorating general health, cognitive impairment or physical limitations presents a challenge for oral health in care-dependent older people [ 5 , 6 ]. Care dependency is defined as a decrease in functional ability and can be measured through activities of daily living (ADLs). Personal hygiene, including oral hygiene, is often among the first activities to be affected. Research in short-term care has shown that older people who require assistance with self-care, such as oral hygiene, have a significantly higher risk of experiencing oral health issues, particularly poor oral hygiene and broken teeth [ 7 ]. In older adults, the most common oral health problems are dental caries including root caries, periodontal disease, edentulism, dry mouth/xerostomia, and oral cancer [ 8 ]. Systemic diseases and care dependency, combined with the natural ageing process, may contribute to poor oral health among nursing home residents [ 9 ]. Oral health is part of and related to overall health and well-being [ 10 ]. The most well-documented link is between periodontal disease and cardiovascular disease and diabetes [ 11 ]. More specifically in older people, research has shown links between oral health and aspiration pneumonia [ 12 , 13 ], malnutrition [ 14 , 15 ], cognition [ 16 ], frailty [ 17 – 19 ] and polypharmacy [ 20 , 21 ], especially among nursing home residents. Additionally, oral health has been extensively linked to quality of life and well-being [ 5 , 22 – 25 ]. The most recently published data on oral health among nursing home residents in Flanders were collected between 2010 and 2012 [ 26 , 27 ]. The national survey conducted on behalf of the National Institute for Health and Disability Insurance (NIHDI) in 2010 revealed that 77% of individuals with natural teeth had an objective treatment need, primarily due to tooth decay and periodontal inflammation [ 26 ]. Additionally, approximately 50% of the denture wearers also required treatment. Plaque levels were high for natural teeth and dentures. Also, mucosal lesions were prevalent in nearly one in four participants, mainly related to ill-fitting or inadequately maintained removable dentures [ 26 ]. About 36% of the nursing home residents were edentulous, compared to 64% in another study. De Visschere et al. (2016) concluded that care-dependent older people in Flanders had a very poor oral health status. The goal of the present study is to map and update the condition on the current oral health status of nursing home residents in Flanders, as assessed by oral health professionals. Methods Study design This cross-sectional study was conducted between April and October 2022 in nursing homes in Flanders, Belgium. This study is part of a longitudinal cluster randomised controlled trial to evaluate the implementation of the OHS-interRAI in nursing homes. The OHS-interRAI is an oral health screening instrument for use by non-dental caregivers within the interRAI instruments [ 28 , 29 ]. This study presents the oral health status of older people before any intervention took place in the trial. Reporting of the study methods and results follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [ 30 , 31 ]. Details about the checklist are included in Additional file 1. This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium (B3222021000650). Setting All nursing homes in Flanders were invited and encouraged by e-mail to participate in this study. The managing board of the nursing homes received a comprehensive information note on the study and signed an informed consent. First criterium for eligibility of nursing homes was using the interRAI Long Term Care Facilities (LTCF) assessment instrument embedded in a specific software program. This tool allows caregivers to assess several domains related to residents’ health and care, including their degree of dependency, their mental and physical capacities, and their care needs [ 32 ]. This assessment will be named BelRAI LTCF from now on, as the validated Belgian version was used in this study. In Flanders, two projects to improve oral health of nursing home residents are ongoing: the Oral Health Care Track [ 33 ] and the Gerodent project [ 34 ]. To avoid bias, nursing homes participating in these projects were excluded from this study. Participants Two-stage sampling was performed, first at the level of nursing homes and secondly at the level of the individual participants. In the included nursing homes, residents were recruited for voluntary participation from January 2022 until July 2022. They received comprehensive information about the study and, in case of incapability, the legally authorized representative was approached for consent. Eligibility criteria were being 65 or older and having a permanent residence in a nursing home. Furthermore, the answer to the question 'Terminal stage of disease, 6 months or less to live' in BelRAI LTCF had to be negative as it was the intention to include people in the cluster randomised controlled trial for a period of 24 months. In the course of this recruitment procedure, the medical director of the nursing home was consulted and apprised of the residents who wanted to participate. The medical director then informed the general practitioner of the resident about the study and their participation. Should either have any objections to the resident's participation, they were instructed to report this to the researchers. Participants had the option to withdraw from participation or to revise their consent during the study, they also had the right to consult, correct or have their personal data deleted. Sample size calculation Sample size calculation was performed to allow for longitudinal research over two years in a cluster randomized controlled trial. The calculation was based on a Chi-squared test and considering a three parallel groups design, a power of 80%, significance level of 0.05 and an estimated effect size of 0.2. This resulted in a total sample of 184 participants (residents) for a regular RCT study. Because of the clustering of participants in nursing homes, this sample size had to be multiplied with a design factor of 1.95 (based on cluster size of 20 participants per nursing home and an intracluster correlation coefficient of 0.05). This resulted in a total sample for cluster randomized controlled trial of 359 participants. Furthermore, a dropout of 35–50% over the period of 24 months was considered, leading to the objective of recruiting between 552 and 718 participants. Outcomes The oral health status of the nursing home residents was assessed using the following measures. OHS-interRAI The OHS-interRAI, is a validated oral health instrument developed for use within the interRAI instruments and to be filled out by non-dental caregivers [ 28 , 29 ]. It contains three self-reported items concerning chewing, pain and dry mouth, next to six items that require inspection of the mouth: denture hygiene, oral hygiene, teeth, gums, tongue, and soft tissues (palate, inner surface of cheeks and lips). All items can be scored dichotomously as acceptable/ healthy or not, with the possibility of scoring ‘not applicable’ or ‘not possible to assess’ when appropriate (e.g. when the resident is uncooperative or unable to participate in the assessment). The assessment utilises trigger algorithms that result in Collaborative Action Points (CAPs) indicating the need for referral to the dentist (CAP Referral to a dentist) or for improvement of oral hygiene (CAP Oral hygiene). Dental indices For people with natural teeth, additional dental information was collected, such as the number of teeth and root remnants, as well as the following dental indices: The Modified Gingival Index (MGI) [ 35 ]: index to assess gingival health. This is a non-invasive assessment, developed for research that allows for repeated measurements. The MGI has a range of 0–4 and is interpreted as follows: 0.1-1.0 = Mild inflammation of any portion of the gingiva; 1.1-2.0 = Mild inflammation of the entire gingiva; 2.1-3.0 = Moderate inflammation; and 3.1-4.0 = Severe inflammation[ 36 ]. The Oral Hygiene Index (OHI) [ 37 ]: index to assess oral hygiene that consists of two components: the Debris Index (DI) and the Calculus Index (CI), which represent the amount of plaque and calculus on the tooth surfaces, respectively. The DI and CI both range from 0–6 and the OHI is calculated by summing the DI and CI, with a total range of 0–12. It is interpreted as follows: 0–2 = acceptable oral hygiene; 2.1–5.9 = moderate oral hygiene; ≥6 = poor oral hygiene[ 38 ]. The PUFA-index [ 39 ]: index to assess the presence of oral conditions resulting from untreated caries. This index ranges from 0–32 and the higher the number, the worse the condition of the teeth. The MGI and PUFA-index were especially designed to be assessed without using dental instruments. The OHI was scored visually using a mirror, without using a probe. Krausch-Hofmann et al. (2020) found that without mirror and probe about 6% less non-acceptable conditions were detected by dentists[ 40 ]. Additional information concerning the used indices and the formulas to calculate them are included in Additional file 2. Related variables Sociodemographic and clinical characteristics from the participants were obtained by means of their most recent BelRAI LTCF assessment, filled out by their caregivers: age, gender, self-care capacities, cognitive performance, symptoms of depression, health stability, dental check-up in the last year, number of medications and smoking behaviour. Self-care capacities were measured using the Activities of Daily Living Hierarchy Scale of the interRAI LTCF (ADL-H), ranging from 0 (independent) to 6 (total dependence) [ 41 ]. This validated scale measures the extent to which persons are self-reliant for personal hygiene, toilet use, locomotion, and eating. Cognitive performance was assessed using the Cognitive Performance Scale (CPS), ranging from 0 (intact) to 6 (very severe impairment) [ 42 ]. Symptoms of depression were measured with the Depression Rating Scale (DRS) which was developed for use in nursing homes [ 43 ]. This validated scale ranges from 0 (no mood symptoms) to 14 (all mood symptoms present in the last 3 days). Health instability was measured with the Changes in Health, End-Stage Disease, Signs, and Symptoms scale (CHESS), ranging from 0 (no health instability) to 5 (very high health instability)[ 44 ]. Data collection Data collection was carried out by seven dentists and one dental hygienist who were specifically trained to perform the assessments. To avoid potential bias, they cooperated as volunteers in the research project and had no other interest or involvement in the study. The training consisted of a webinar (1.5 hours), a written manual as well as a face-to-face training and calibration session prior to the start of the data collection. A key card with the core information regarding the indices to be scored was available during the assessments. The first author and an additional volunteer dentist assisted the dental professionals with recording the data. Appointments for visits to the nursing homes were previously planned. All assessments were completed in the residents’ rooms to ensure privacy, and in accordance with the guidelines for infection prevention. During the assessment, a headlight (Bo-Camp Headlamp 150 lumen) was used. The OHS-interRAI assessments were conducted without dental instruments, conform to the general guidelines. For the assessment of all dental indices, a disposable dental mirror (Flecta disposable mirrors Pulpdent) was used. Analysis All 9 items of the OHS-interRAI were dichotomized (0/1) and were analysed for the people for whom the items could be assessed. Responses to items that were scored ‘not applicable’ or ‘not possible to assess’ were omitted. All scores of the interRAI scales were dichotomized using their validated cut-off values. For the interRAI ADLH scale, a score of 3 or higher indicates a need for at least extensive assistance for activities of daily living (ADL) [ 41 ]. A cut-off of 3 on the interRAI CPS scale indicates moderate cognitive impairment [ 42 ]. A score of 3 on the interRAI scale represents minor depressive disorders [ 43 ] and the cut-off of 3 on the interRAI CHESS scale denotes that the resident has at least moderate health instability [ 44 ]. Statistical analysis All analyses were performed with software SAS Enterprise Guide for Windows, version 8.1 update 1. First, descriptive statistics were used to identify the population’s characteristics and the most prevalent oral health problems. The Chi-Square test was used to test for significant differences in the prevalence of oral health problems. Subsequently, bivariate analyses were performed to investigate associations between oral health items and the clinical characteristics of their most recent BelRAI LTCF assessment. Results Participants A total of 489 residents from 11 Flemish nursing homes consented to participation. After examination of eligibility, eleven participants were excluded because they did not meet the inclusion criteria (according to age 65 or older and long-stay in the nursing home). A total of 478 participants were included in the study, with a total of 22 to 73 residents per nursing home. The oral health assessment could be performed in 462 participants. Reasons for the lack of assessment were death, refusal, absence in the nursing home, and medical conditions. Data were analysed for a total of 458 participants. The mean age of the participants was 82.7 (± 7.8) years and the majority was female (70.3%). Their sociodemographic characteristics are presented in Table 1. About 68% of the participants needed extensive assistance for activities of daily living and 49% had moderate cognitive impairment. Table 1: Sociodemographic characteristics of the participants Variables N (%) Mean (± SD) Total 458 (100) Female 322 (70.3) Age 82.7 (± 7.8) CPS score (≥ 3) 188/381 (49.3) ADL score (≥ 3) 259/380 (68.2) DRS score (≥ 3) 144/382 (37.7) CHESS score (≥ 3) 43/369 (11.7) Dental visit last year 110/374 (29.4) Number of medications 8.4 ± 3.7 < 4 29/378 (7.7) 4–8 169/378 (44.7) ≥ 9 180/378 (47.6) Smokers 35/381 (9.2) Abbreviations: CPS, Cognitive Performance Scale; ADL, Activities Daily Living; DRS, Depression Rating Scale; CHESS, Changes in Health, End-Stage Disease and Sign and Symptoms Scale Outcome data Oral health based on OHS-interRAI The prevalence of oral health problems recorded with the OHS-interRAI is represented in Table 2 . Insufficient oral (75.7%) and denture (68.5%) hygiene were the most prevalent problems. Most oral health problems were observed in people with natural teeth and were related to teeth (56.6%) and gums (49.9%). Soft tissue lesions of palate and inner surfaces of cheeks and lips were recorded in 19.9% of the participants. Self-reported oral health problems were mainly related to dry mouth (32.8%) and chewing difficulty (23.4%). The oral health data retrieved from the screening indicated a need for referral to a dentist in 75% of the participants (CAP Referral to a dentist). Table 2 Prevalence of oral health problems or deficiencies, registered with the OHS-interRAI for all subjects (total sample N = 458) OHS-interRAI Assessed subjects*, n Number of residents with problems or deficiencies, n Prevalence, % Self-reported oral problems OHS-interRAI, n (%) Chewing difficulty 431 101 23.4 Pain in the mouth 434 39 9.0 Dry mouth 433 142 32.8 Observed oral problems OHS-interRAI, n (%) Denture hygiene 260 178 68.5 Oral hygiene 255 193 75.7 Teeth 241 137 56.9 Gums 445 222 49.9 Tongue 427 32 7.5 Palate, lips and cheeks 437 87 19.9 CAP Oral Hygiene, n (%) 454 315 69.4 CAP Referral to a dentist, n (%) 452 339 75.0 *Number of participants for whom the item could be assessed, excluding answer options ‘not applicable’ and ‘could not be assessed’. Abbreviations: OHS-interRAI, Oral Health Section for use within the interRAI suite of instruments; CAP, Collaborative Action Point Oral health based on dental indices For the participants with natural teeth (54% of the sample), additional dental indices were assessed. These results are presented in Table 3 . The mean number of visible teeth or tooth remnants was 12.8 (± 7.3). When excluding tooth remnants, the mean number of teeth was 11.5 (± 7.3). Only 9.2% of the participants had at least 20 teeth. Over 44% of the people with natural teeth had untreated tooth decay with at least pulpal involvement. The mean OHI was 4.5 (± 2.6), indicating moderate oral hygiene [ 38 ]. A proportion of 17.6% of the participants had an OHI-score ≤ 2, which is acceptable according to Mühlemann, and 26.2% had an OHI-score of 6 or higher, which indicates poor oral hygiene. Only 9.4% (22/233) of the participants with natural teeth had a DI-score ≤ 1.0, representing an acceptable amount of plaque, whereas 48.7% (113/232) had a CI-score ≤ 1.0, meaning that the calculus level was acceptable. The mean MGI of the residents was 1.8 (SD 1.2), indicating mild inflammation of the entire gingiva[ 36 ]. About 28.6% of the participants had an MGI-score ≤ 1.0, indicating mild inflammation of any portion of the gingiva. A total of 41.0% had an MGI-score of 2.1 and higher, indicating moderate to severe inflammation of the gingiva. Overall, removable dentures were worn by 59.9% (272/454) of the participants. Table 3 Participants’ oral health status and dental indices scores (total sample N = 458) Assessed in subjects (N = 458), n (%) Mean (± SD) Dentates - Number of visible teeth or tooth remnants 247/458 (53.9) 12.8 (± 7.3) Dentates with root remnants - Number of root remnants 97/241 (40.3) 3.3 (± 3.2) Dental indices OHI 233 4.5 (± 2.6) DI 233 2.9 (± 1.4) CI 232 1.6 (± 1.5) MGI 234 1.8 (± 1.2) PUFA > 0 - Number of PUFA 106 (44.2) 2.9 (± 2.9) Removable dentures, n (%) 102/247 (41.3) Edentulous persons 211/458 (46.0) Removable dentures Full dentures 170/207 (82.3) None 37/207 (17.8) Abbreviations: OHI, Oral Hygiene Index; DI, Debris Index; CI, Calculus Index; MGI, Modified Gingival Index; PUFA, Pulp Ulceration Fistel Abscess index OHS-interRAI associations Correlations were explored between different aspects of oral health. These are shown in Table 4 . The strongest correlation is found between the condition of the gums and oral hygiene (r = .324, p < .0001), followed by an association of chewing difficulty with pain (r = .247, p < .0001). Dry mouth is correlated with pain (r = .195, p < .0001) and with chewing difficulty (r = .183, p = .0002). Denture hygiene is correlated with mucosal problems of the palate, cheeks and lips (r = .169, p = .0067) and with gum condition (r = .158, p = .01). Weaker positive correlations were found for the item oral hygiene and teeth (r = .127, p = .05) and also for the item palate, cheeks and lips with pain (r = .107, p = .03) and gum condition (r = .104, p = .03). Weak negative correlations were found for dry mouth with denture hygiene (r=-.135, p = .03) and gum condition (r=-.113, p = .02). Denture hygiene shows weaker results and no statistical significance with oral hygiene (r = .153, p = .11) and teeth (r = .145, p = .16). The condition of the tongue showed no statistically significant correlation with any of the other items. Table 4 Pearson Correlation Coefficients between the different oral health items of the OHS-interRAI, Pain Dry mouth Denture hygiene Oral hygiene Teeth Gums Tongue Palate, cheeks and lips Chewing difficulty 0.24669*** < .0001 426 0.18257*** 0.0002 424 -0.05307 0.40 251 0.07712 0.23 241 0.08558 0.20 227 -0.02862 0.56 424 -0.02576 0.60 414 -0.08890 0.07 419 Pain 0.19494*** < .0001 429 0.00985 0.88 254 0.03724 0.56 242 0.04781 0.47 229 0.01261 0.80 426 0.00000 1.00 416 0.10732* 0.03 422 Dry mouth -0.13460* 0.03 253 -0.04112 0.52 243 -0.04169 0.53 229 -0.11334* 0.02 425 0.00343 0.94 417 -0.03771 0.44 423 Denture hygiene 0.15280 0.11 110 0.14513 0.16 96 0.15811** 0.01 255 0.04239 0.50 255 0.16873** 0.0067 257 Oral hygiene 0.12683* 0.05 236 0.32361*** |r| under H0: Rho = 0 Number of Observations p ≤ 0.001*** - p ≤ 0.01** - p ≤ 0.05* Associations between oral health and sociodemographic and clinical characteristics Table 5 Pearson Correlation Coefficients between the oral health related information and participants’ characteristics, Prob > |r| under H0: Rho = 0, Number of Observations CPS ≥ 3 ADL ≥ 3 Extensive support for personal hygiene DRS ≥ 3 CHESS ≥ 3 Dental visit Poly-pharmacy ≥ 9 drugs Smoking Chewing difficulty 0.00567 0.91 360 0.07170 0.18 359 0.08060 0.13 360 0.07612 0.15 361 -0.01619 0.76 348 0.00639 0.90 353 0.23029*** < .0001 356 -0.04262 0.42 359 Pain -0.13295** 0.01 362 -0.03298 0.53 361 -0.01749 0.74 362 0.07087 0.18 363 0.03411 0.52 351 -0.06755 0.20 355 0.14847** 0.005 358 0.01929 0.71 361 Dry mouth -0.22706*** < .0001 362 -0.00565 0.91 361 0.01408 0.79 362 0.11842* 0.02 363 0.06941 0.20 350 -0.09307 0.08 355 0.20842*** < .0001 358 -0.05778 0.27 361 Denture hygiene 0.13791* 0.04 214 0.12723 0.06 214 0.11494 0.09 215 -0.01006 0.88 214 0.00000 1.0000 207 -0.09230 0.18 208 0.03072 0.66 210 -0.12381 0.07 213 Oral hygiene 0.10795 0.12 214 0.15172* 0.03 212 0.16679** 0.01 213 0.04816 0.48 215 0.02005 0.78 204 -0.14467* 0.04 210 0.05426 0.43 211 -0.00019 0.10 214 Teeth 0.05790 0.41 204 -0.06098 0.39 202 -0.05569 0.43 203 0.11130 0.11 205 -0.08398 0.24 196 0.02259 0.75 200 0.07192 0.31 201 -0.02290 0.75 204 Gums 0.19872*** 0.0001 372 0.12490* 0.02 371 0.10731* 0.04 372 0.03392 0.51 373 0.02623 0.62 360 0.01374 0.79 365 -0.05473 0.30 368 -0.10954* 0.03 371 Tongue 0.01809 0.73 356 -0.03392 0.52 355 -0.02203 0.68 356 0.13776** 0.01 357 0.12828* 0.02 344 0.01703 0.75 349 0.06969 0.19 352 0.05029 0.34 355 Palate, cheeks and lips -0.04644 0.38 365 -0.00577 0.91 364 -0.00807 0.88 365 -0.02901 0.58 366 0.01399 0.79 353 -0.01067 0.84 358 0.01945 0.71 361 0.02321 0.66 364 CAP Oral hygiene 0.06195 0.23 378 0.07514 0.15 377 0.08707 0.09 378 0.02072 0.69 379 -0.01607 0.76 366 -0.06065 0.24 371 -0.03397 0.51 375 -0.07383 0.15 378 CAP Referral to a Dentist 0.13939** 0.01 375 0.09008 0.08 374 0.10075* 0.05 375 0.06415 0.21 376 0.06812 0.20 363 0.07382 0.16 368 0.04741 0.36 372 -0.16052** 0.002 375 DI ≥ 1 0.31329*** < .0001 196 0.14294 0.06 194 0.11320 0.12 195 0.11204 0.12 197 0.07656 0.30 188 -0.10127 0.16 192 -0.02153 0.77 193 0.09862 0.17 196 CI ≥ 1 0.17687** 0.01 195 0.14642* 0.04 193 015377* 0.03 194 -0.00869 0.90 196 0.10000 0.17 187 -0.21164** 0.003 191 0.00923 0.90 192 0.02408 0.74 195 OHI ≥ 2 0.29945*** < .0001 196 0.16929* 0.02 194 0.17217* 0.02 195 0.15342* 0.03 197 0.10082 0.47 188 -0.16017* 0.03 192 -0.01123 0.88 193 0.03899 0.59 196 MGI ≥ 1 0.38932*** < .0001 197 0.16810* 0.02 195 0.18160** 0.01 196 0.03447 0.63 198 0.07198 0.33 189 -0.19062** 0.008 193 -0.05045 0.48 194 -0.04469 0.53 197 MGI ≥ 2 0.32117*** < .0001 197 0.20913** 0.003 195 0.22094** 0.002 196 0.06612 0.35 198 0.08172 0.26 189 -0.19597** 0.006 193 -0.04371 0.54 194 -0.03595 0.62 197 PUFA ≥ 1 0.07569 0.28 202 -0.02886 0.69 200 -0.04109 0.56 201 0.01906 0.79 203 -0.04373 0.54 194 0.02152 0.76 198 0.06153 0.39 199 0.04715 0.51 202 Edentulous -0.10929* 0.03 381 -0.02942 0.57 380 -0.00700 0.89 381 -0.01318 0.80 382 -0.01176 0.82 369 -0.08250 0.11 374 0.13417** 0.01 378 0.07497 0.14 381 Dentures -0.18548*** 0.0003 378 -0.06610 0.20 377 -0.03654 0.48 378 -0.03894 0.45 379 -0.03115 0.55 366 -0.05558 0.29 371 0.01517 0.77 375 0.11171* 0.03 378 p ≤ 0.001*** - p ≤ 0.01** - p ≤ 0.05* Associations were investigated between oral health and participants’ sociodemographic and clinical characteristics. These are presented in Table 5 . Moderate to severe cognitive impairment (CPS score ≥ 3) showed the strongest correlations with various aspects of oral health, mainly related to gingival health and oral hygiene. The strongest positive correlation was seen with an MGI score greater than 1.0 (r = .389, p < .0001), indicating at least mild inflammation of the entire gingiva. There was also a positive correlation with an MGI score greater than 2.0 (r = .321, p < .0001), indicating moderate to severe gingival inflammation. The correlation between cognitive impairment and gingival health is also reflected in the OHS-interRAI item gums, although slightly weaker (r = .199, p = .0001). For oral hygiene, cognitive impairment shows a positive correlation with a DI score greater than or equal to 1.0 (r = .313, p < .0001), a CI score greater than or equal to 1.0 (r = .177, p = .01) and an OHI score greater than or equal to 2.0 (r = .299, p < .0001). This correlation is not reflected in the item oral hygiene of the OHS-InterRAI. However, there is a weak positive correlation with the item for denture hygiene (r = .138, p = .04). Cognitive impairment is also positively correlated to the CAP Referral to a Dentist (r = .139, p = .01). Negative correlations were seen for cognitive impairment with the OHS-InterRAI items pain (r=-.133, p = .01) and dry mouth (r = .227, p < .0001), being edentulous (r=-.109, p = .03) and wearing dentures (r=-.185, p = .0003). Functional impairment (ADL score ≥ 3) and needing extensive assistance with personal hygiene showed positive correlations with items and indices related to oral hygiene and gingival health. For gingival health, the strongest correlation was seen with an MGI score greater than or equal to 2.0 (r = .209, p = .003 and r = .221, p = .002 respectively). For oral hygiene, the strongest correlation for both was found with the OHI score (r = .169, p = .02 and r = .172, p = .02 respectively), followed by that with the item oral hygiene of the OHS-interRAI (r = .152, p = .03 and r = .167, p = .01 respectively). Having depressive symptoms (DRS score ≥ 3) showed a weak positive correlation with the OHI score (r = .153, p = .03) and the OHS-interRAI items tongue (r = .137, p = .01) and dry mouth (r = .118, p = .02). Having had a dental visit in the 12 months prior to the oral health assessment showed only negative correlations. For oral hygiene-related outcomes, this was the case for the CI score (r=-.212, p = .003), the OHI score (r=-.160, p = .03) and the item oral hygiene (r=-.145, p = .04) of the OHS-InterRAI. For gingival health, this was the case for the MGI scores (r=-.196, p = .01 and r = .191, p = .01) For those taking 9 or more medications , positive correlations were seen for the self-reported items of the OHS-interRAI, namely chewing difficulty (r = .230, p < .0001), dry mouth (r = .208, p < .0001) and pain (r = .148, p = .005), as well as for being edentulous (r = .134, p = .01). Smoking showed negative correlations with the item gums (r=-.110, p = .03) of the OHS-interRAI and the CAP Referral to a Dentist (r=-.161, p = .002). A positive correlation was seen with wearing dentures (r = .112, p = .03). Discussion Key results This study aimed to update the condition of the oral health of nursing home residents in Flanders, as assessed by oral health professionals. Furthermore, the aim was to explore associations between oral health and clinical characteristics using the BelRAI LTCF instrument. The most recent national survey on the oral health of older adults in Belgium was conducted in 2010 and consisted of data from approximately 440 nursing home residents [ 26 ]. The study showed that care dependency was high, present in 62% of the nursing home residents, as determined using the Katz index [ 26 ]. This is comparable to the present study, in which about half of the residents showed at least moderate cognitive impairment, and 68% required extensive assistance with activities of daily living. The present study utilised the OHS-interRAI to map the oral health of older individuals. This oral health assessment instrument offers a comprehensive overview of all oral structures, including oral hygiene [ 28 , 29 ]. Furthermore, dental indices were used to provide a more detailed assessment of common oral problems such as tooth decay, gum problems, and oral hygiene. This information provides a general understanding of the care needs of this study group. Research has shown that a healthy lifestyle and prevention-oriented health care, with good oral hygiene and regular dental visits, are associated with tooth retention into later life [ 4 ]. Over half of the participants in the present sample still had a natural dentition with 13 visible teeth or tooth remnants. This is comparable to the results of Janssens (2017) in a study of 1226 Flemish nursing home residents reporting on oral health data which was collected from 2010 to 2012 [ 27 ]. They found a mean number of 12 teeth (SD 8.1) of which 1.9 were residual roots [ 27 ]. However, the number of participants diagnosed with edentulism in the present study (46%) is slightly higher than that reported by Janssens et al. (2017) (42%) [ 27 ]. It is also 10% higher compared to the national oral health survey of 2010 (35.7%) [ 26 ]. This trend aligns with the findings of the WHO’s Oral Health Status Report (2022), which indicates a 30% increase in edentulism in the European region between 1990 and 2019 [ 45 ]. A systematic review of clinical and subjective oral health in nursing home residents across Europe revealed that the prevalence of edentulism ranged from 40–60% in the majority of included studies [ 46 ]. Residents with natural teeth had a mean number of teeth ranging from 9.8 to 20.0 per person [ 46 ]. The WHO-goal is to retain at least 20 teeth at the age of 80 to have sufficient functional tooth units and chewing ability [ 47 – 49 ]. In the study by De Visschere et al. (2016), it was found that only 10% of nursing home residents had 21 teeth or more [ 26 ]. In the current study, only 9% had 20 teeth or more. In terms of self-reported oral problems, 23.4% of the participants indicated that they had experienced difficulty chewing during the past three days. In a recent study by Krausch-Hofmann et al. (2021), 55.8% of the nursing home residents reported difficulty chewing [ 29 ]. However, this discrepancy may be attributed to the fact that the item for chewing difficulty was formulated with greater rigour. The occurrence of chewing problems was recorded by taking into account the hardness of food, with examples including the ability to chew nuts, raw apples and steak [ 29 ]. This approach has been optimised in the Delphi study by Schoebrechts et al. (2023) [ 28 ]. The result of the current study aligns with the considerable variation in reported chewing problems (5–55%) observed in the systematic review by Janssens et al. (2023) [ 46 ]. Furthermore, it confirms the findings of Abreu et al. (2022), who concluded that 23% of nursing home residents had chewing difficulties based on a meta-analysis of studies with a sufficiently large sample size [ 50 ]. Tooth loss, musculoskeletal conditions, nutrition-related factors and cognitive decline are the main factors associated with chewing difficulties [ 51 , 52 ]. Regarding pain , 9% of participants in this study reported experiencing pain or discomfort in their mouth in the past three days. This result is comparable to the study by Krausch-Hoffmann et al. (2021), where 11.2% of participants reported pain [ 29 ]. Pain or discomfort were reported in 6.0–40.5% of the nursing home residents in Europe [ 46 ]. Orofacial pain is shown to be significantly more prevalent in residents with dementia [ 53 ]. Nevertheless, a study by Delwel on the use of an Orofacial Pain scale for Non-verbal Individuals as a screening tool revealed that individuals only reported pain in 0–10% of cases [ 54 ]. In another study conducted by Delwel, which combined self-reported pain with a more comprehensive oral examination, including neurosensory testing, mouth opening, and additional testing for caries profunda, 25% of participants reported pain in at least one of the aforementioned aspects [ 55 ]. This may explain the differences with the results of this study. Orofacial pain seems to be underestimated when relying only on self-reported pain. In the present study, cognitive impairment even showed a negative correlation for pain as well as for xerostomia and chewing difficulty, which may indicate that individuals with cognitive decline are unable to effectively communicate their pain and discomfort. Although research has shown that self-reporting is the gold standard and should be encouraged, it may lead to inadequate diagnosis and inappropriate treatment for people [ 56 ]. The self-reported item that scored highest in this study was xerostomia . Approximately one-third of the participants reported experiencing dry mouth in the past three days. In Krausch-Hofmann's study (2021), this percentage was even higher, at 40.8% [ 29 ]. These results are in line with Janssens et al. (2023) [ 46 ]. Their systematic review showed that xerostomia in most studies was reported by 35–50% of the nursing home residents [ 46 ]. Although many older people report the sensation of dry mouth, this does not necessarily imply they suffer from hyposalivation [ 57 , 58 ]. A cross-sectional study by Diep (2021) showed xerostomia in older people was correlated with medication use, rheumatic disease and radiotherapy in the head/neck region, while hyposalivation was associated with medication use and diabetes [ 58 ]. A systematic review showed an overall prevalence rate of hyposalivation in older people of 33.37%, showing higher rates in women and in institutionalised people [ 59 ]. Research has also shown that xerostomia is frequently associated with polypharmacy [ 21 ]. This association was also confirmed for the participants in the present study. Approximately half of the participants used at least nine medications which aligns with the findings of Janssens et al. (2017) [ 20 ]. Furthermore, polypharmacy was associated with chewing difficulty, pain in the mouth and being edentulous. A systematic review reporting on oral conditions associated with dry mouth in older adults with polypharmacy indicated that tooth loss and dental caries were the most commonly reported conditions [ 21 ]. However, among other associations, the included studies also observed an association with chewing difficulty and pain [ 21 ]. Apart from polypharmacy, the association between dry mouth with chewing difficulty and pain was also evident in the current study when exploring the associations within the items of the OHS-interRAI. The most prevalent issues identified among participants in this study were related to hygiene . However, no correlation could be seen between denture hygiene and oral hygiene. This may be due to the small number of participants with both dentures and natural teeth. Janssens et al. (2023) also found in their systematic review that both oral hygiene and denture hygiene were inadequate in nursing home residents, with high levels of plaque [ 46 ]. The current study demonstrated that in 68.5% of individuals with removable dentures, more than a third of the inner surface was covered with plaque or tartar. This is higher than in the study by Krausch-Hofmann et al. (2021), which showed a prevalence of 55%. Regarding oral hygiene in people with natural teeth, an even greater proportion of participants presented poor scores. In the current study, oral hygiene was inadequate in 75.7% of participants. In Stefanie Krausch-Hofmann et al. (2021), this figure was 84% [ 29 ]. A more detailed assessment of oral hygiene with the OHI indicated that overall oral hygiene was moderate. However, looking at the underlying Debris Index and Calculus Index, it is clear that plaque accumulation is the main problem. Only 9% of the participants had an acceptable amount of plaque, while for tartar this was acceptable for approximately half of the participants according to Mühlemann (1976) [ 38 ]. The most recent national oral health survey in 2010 by De Visschere et al. (2016) also concluded that a significant proportion of participants had inadequate denture hygiene and oral hygiene [ 26 ]. However, the different way of assessing and reporting on these problems makes a clear comparison impossible. Nevertheless, De Visschere et al. (2016) observed that individuals living in residential care facilities exhibited significantly elevated plaque levels compared to their counterparts living at home [ 26 ]. In the current study, 57% of participants with natural teeth exhibited visible breakdown, decay or a defective restoration in at least one tooth. The PUFA index, a measure of the severity of untreated caries, showed that 44% of these participants had caries extending to the nerve. In those diagnosed with this condition, the average number of occurrences was 3 per person. The systematic review by Janssens et al. (2023) reported a great variation in the prevalence of untreated caries in nursing home residents across Europe (23–82%), mentioning almost all studies reported active caries in more than half of the residents [ 46 ]. Although caries prevalence is high in the present study, it is lower than found by Krausch-Hofmann et al. (2021) and Janssens et al. (2017), reporting prevalences of 77% and 69.7% respectively [ 27 , 29 ]. Comparable to Krausch-Hofmann (2021), a non-acceptable gum condition in the present study was found in about half of the participants [ 29 ]. Using the OHS-interRAI, gum health was assessed for all participating residents, including edentulous individuals. In such cases, the mucosa of the alveolar ridge was evaluated for the presence of colour changes, swelling, or lesions. Consequently, it is not possible to infer any conclusions regarding the periodontal health of the participants based on this item. However, the modified gingival index in dentate participants showed that 71.4% of the participants had mild to severe inflammation of the entire gingiva. Nevertheless, as the MGI is assessed visually only using a disposable mirror, it is not possible to draw robust conclusions regarding the extent of periodontal problems. A systematic review revealed that periodontal health in nursing home residents varied considerably across Europe, gingivitis being prevalent in 51–78% of the residents with natural dentition [ 46 ]. Overall, an American report showed that about 60% of the older adults are affected with periodontitis [ 60 ]. In De Visschere et al. (2016) periodontal disease was diagnosed in 87% of the participants using a conventional periodontal probe for scoring the Dutch Periodontal Screening Index [ 26 ]. Krausch-Hofmann (2021) observed that dentists who assessed oral health with the OHS-interRAI without using a mouth mirror and probe identified approximately 6% fewer unacceptable conditions of oral hygiene, teeth and gums [ 29 ]. The strongest association observed within the items of the OHS-interRAI is the one between the condition of the gums and oral hygiene. A lack of adequate oral hygiene leads to an increase in the accumulation of oral biofilm, which in turn causes gum problems, initially gingivitis, which can evolve into periodontitis. This relationship has been extensively demonstrated in literature [ 61 ]. Furthermore, the condition of the gums showed to be associated with cognitive decline and to a lesser extent with functional impairment and the need for extensive support. Research has shown a correlation between these personal characteristics and a higher prevalence of poor oral and denture hygiene and periodontal disease [ 25 , 62 ]. As with Krausch-Hofmann (2021) [ 29 ], the lowest number of problems was observed in the tongue . In the current study, this only concerned 7.5% of the participants. This is comparable, but slightly less than the Krausch-Hofmann study (10%) [ 29 ]. The item tongue of the OHS-interRAI was also slightly adapted after the international Delphi by Schoebrechts et al. (2023) [ 28 ]. Previously, the condition of the tongue was determined by the presence or absence of moisture on the tongue, which is no longer the case. Disorders of the tongue are not frequently reported as a distinct category in studies. Instead, they are often grouped with other oral mucosal lesions [ 63 ]. Furthermore, epidemiologic studies concerning oral mucosal lesions are rather scarce compared to studies on caries and periodontitis [ 63 ]. However, the tongue is an item in other oral health assessment instruments, such as the Revised Oral Assessment Guide (ROAG) and the Oral Health Assessment Tool (OHAT). A study conducted by Zenthöfer (2014) in Germany utilizing the ROAG by dentists in an epidemiological study revealed a prevalence of 2.6% for the item tongue [ 64 ]. Another Swedish study using ROAG in a population of more than 2500 participants showed that 15.0% of participants with problems related to tongue [ 65 ]. As to oral mucosal lesions , in the OHS-interRAI the palate, and inner surface of cheeks and lips are inspected for colour changes, swelling, sores or patches. The present study showed a comparable amount of problems with these soft tissues with Krausch-Hofmann (2021), showing a prevalence of 20% and 23.4% respectively [ 29 ]. Most common oral lesions are denture-related[ 66 ]. Janssens et al. (2023) reported prevalence rates of 10–15% of denture stomatitis and 1.5–18.0% of pressure ulcers because of dentures in European nursing home residents [ 46 ]. De Visschere et al. (2016) reported at least one lesion in nearly 25% of all participants, with the highest prevalence for denture pressure ulcers (10%) [ 26 ]. Within the OHS-interRAI, poor denture hygiene was found to be associated with poor condition of the gums and palate, cheeks and lips. A systematic review by Wong et al. (2019) on the factors related to the oral health of nursing home residents reported a median of 21% of surveyed residents with some type of denture stomatitis [ 25 ]. Overall, the oral health problems as assessed by dentists with the OHS-interRAI in the present study align with the results of previous studies in Belgium [ 26 , 27 ] and Europe [ 46 ], showing the need for better oral hygiene and professional dental care. With the assessment of the OHS-interRAI, CAPs are triggered when oral hygiene is deficient or when a resident needs referral to a dentist. Comparable to Krausch-Hofmann (2021), in approximately 70% of the participants the CAP Oral hygiene was activated [ 29 ]. The CAP Referral to a Dentist was activated in 75% of the participants in the present study, whereas in the study of Krausch-Hofmann (2021), this was the case for about 91% of the participants [ 29 ]. The strength of oral health assessment with the OHS-interRAI is that it offers a comprehensive overview of all oral structures, including oral hygiene [ 28 , 29 ] and that it is embedded in a holistic BelRAI LTCF assessment, which provides a comprehensive overview of a resident's care needs and care preferences. Furthermore, dental indices were used to provide a more detailed assessment of common oral problems such as tooth decay, gum problems, and oral hygiene. This information provides a general understanding of the oral care needs of this study group. However, as a limitation, it is essential to acknowledge that despite the utilisation of indices, this study represents an underestimation of oral health issues. This is due, in part, to the fact that the dentists were not equipped with a comprehensive set of instruments and diagnostic options, as would be the case in a dental practice. Another limitation is that only nursing homes could be included that used a specific software package allowing the collection of data from BelRAI LTCF and OHS-interRAI. Therefore, despite the large sample size, the findings of this study cannot be generalized to the entire population of residents in nursing homes in Flanders. However, the results of this study confirm previous research in Belgium, Flanders and Europe. Conclusions Despite the advances in dentistry and the Belgian health care system in which all Belgians have a compulsory health insurance, the oral health of nursing home residents has not improved compared to previous studies for which oral health data were collected on a larger scale in 2010–2012 [ 26 , 27 ]. As oral health is strongly related to holistic health, and impacts quality of life [ 10 ], these findings indicate that continued attention is needed to the early detection and prevention of oral health problems in older people. The study also showed that the oral health of people with cognitive decline or functional impairment needs more attention. Their oral hygiene is often worse than that of people without cognitive or functional impairment. Good daily oral hygiene and regular dental visits are the foundation of good oral health [ 4 ]. In this study, about 30% of people had visited a dentist in the previous year, a figure that is lower than that reported by the Intermutualistic Agency (IMA atlas) for Flanders. The IMA atlas reports that in 2022, 58.1% of people aged 65–74 had visited a dentist, while 41.3% of people aged 70 and over had done so. However, nursing home residents face several barriers to accessing a dentist [ 67 ]. The dental hygienist, as a new oral health professional profile in Belgium since 2019, could potentially represent an important change here. Not only can dental hygienists enhance access to professional oral healthcare, but also to more effective daily oral care by empowering healthcare providers and residents. Oral health is determined by many factors. Flanders and Belgium have taken several measures that may imply we are at a tipping point for better oral health for care-dependent older people. From June 2023, the Belgian government has mandated the use of the BelRAI LTCF as the basis for care planning in nursing homes. The OHS-interRAI, an oral health assessment developed for healthcare providers without a dental background, is being implemented in BelRAI LTCF. This will support professional caregivers in monitoring and improving oral health. This not only offers the opportunity to integrate oral care into general care, but also provides the opportunity to monitor the oral health of residents in nursing homes in Belgium on a standardised and regular basis for epidemiological research purposes. Abbreviations ADL Activities of Daily Living ADL-H Activities of Daily Living Hierarchy Scale of the interRAI LTCF BelRAI LTCF Belgian version of the international Resident Assessment Instrument for use in Long Term Care Facilities CAP Collaborative Action Points CHESS Changes in Health, End-Stage Disease, Signs, and Symptoms scale CI Calculus Index CPS Cognitive Performance Scale DI Debris Index DRS Depression Rating Scale interRAI international Resident Assessment Instrument IMA Intermutualistic Agency LTCF Long Term Care Facilities MGI Modified Gingival Index NIHDI National Institute for Health and Disability Insurance (Belgium) OHAT Oral Health Assessment Tool OHI Oral Hygiene Index OHS-interRAI Oral Health Section for use within the interRAI Suite of Instruments PUFA Pulp Ulceration Fistel Abscess ROAG Revised Oral Assessment Guide STROBE Strengthening the Reporting of Observational Studies in Epidemiology Declarations Ethics approval and consent to participate This study has been conducted in accordance with the ethical standards set forth in the Declaration of Helsinki and received ethical approval on 29 November 2021 from the Ethics Committee Research UZ/KU Leuven, Belgium, with reference B3222021000650. The nursing home management teams were provided with a comprehensive information note on the study, and signed an informed consent form. Each individual participant, or their legally authorised representative, was given comprehensive information about the study and provided their written informed consent for participation. Consent for publication All participants or their legally appointed representatives provided written consent for the publication of data in an aggregated and unidentifiable format. Availability of data and materials The data that support the findings of this study are available from Pyxicare, Belgium. However, restrictions apply to the availability of these data, which were used under a GDPR licence for the current study. Consequently, the data are not publicly available; however, they can be assessed upon reasonable request and with permission from the Belgian Privacy Commission. For any data or queries pertaining to the study, please contact the corresponding author, Patricia Ann Ivonne Vandenbulcke ( [email protected] ). Competing interests The authors declare that they have no competing interests. Funding This work was funded by Research Foundation Flanders [TBM T003220N] and KU Leuven [C24M-20-063]. Acknowledgements The authors acknowledge the contributions of the dentists, dental hygienist and dental assistant in the oral health assessments of the participating residents on a voluntary basis: Bakelants L., De Meester J.-M., De Schepper W., De Schrijver M., Deceuninck M., Konings N., Morren J., Piccart F., Stinkens L., Van Bael T., Van Dessel H., Verschueren L. and Wauters E. The authors would like to express their gratitude to the nursing homes and caregivers who participated in the study and provided their cooperation. Authors’ information Authors’ ORCID ID Patricia A. I. Vandenbulcke: 0000-0002-8436-6784 Johanna de Almeida Mello: 0000-0002-1262-318X Emilie Schoebrechts: 0000-0002-7797-567X Jan De Lepeleire: 0000-0001-6152-2134 Anja Declercq: 0000-0003-3136-124X Dominique Declerck: 0000-0003-4637-0675 Joke Duyck: 0000-0002-8698-1692 Authors’ affiliations Department of Oral Health Sciences, Population Studies in Oral Health, KU Leuven, Kapucijnenvoer 7 Box 7001, 3000 Leuven, BELGIUM Patricia A. I. Vandenbulcke, Johanna de Almeida Mello, Emilie Schoebrechts, Dominique Declerck & Joke Duyck LUCAS, Centre for Care Research and Consultancy, KU Leuven, Minderbroedersstraat 8 Box 5310, 3000 Leuven, BELGIUM Johanna de Almeida Mello & Anja Declercq Department of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 blok H - Box 7001, 3000 Leuven, BELGIUM Jan De Lepeleire Centre for Sociological Research (CeSO), KU Leuven, Parkstraat 45 Box 3601, 3000 Leuven, BELGIUM Anja Declercq CRediT author statement Patricia A. I. Vandenbulcke: Conceptualisation, Methodology, Software, Validation, Formal analysis,Investigation,Resources,Data Curation,Writing - Original Draft,Writing - Review and Editing, Visualisation,Project administration Johanna de Almeida Mello: Conceptualisation, Methodology, Software, Validation,Formal analysis,Investigation,Resources, Data Curation,Writing - Original Draft,Writing - Review and Editing, Visualisation, Supervision,Project administration,Funding acquisition Emilie Schoebrechts: Validation, Writing - Review and Editing, Visualisation Jan De Lepeleire: Conceptualisation, Methodology, Validation, Writing - Review and Editing, Supervision Anja Declercq: Conceptualisation, Methodology, Validation, Writing - Review and Editing, Supervision Dominique Declerck: Conceptualisation, Methodology,Validation, Resources, Writing - Review and Editing, Visualisation, Supervision,Funding acquisition Joke Duyck : Conceptualisation, Methodology, Validation, Resources, Data Curation, Writing - Original Draft, Writing - Review and Editing, Visualisation, Supervision, Project administration, Funding acquisition All authors read and approved the final manuscript. 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Assoc. 61 (2), 172–179 (1960). Mühlemann, H. R. Introduction to Oral Preventive Medicine, A program for the first clinical experience. Quintessence Publishers, Berlin; ISBN 3 87652 591 8, 253 pages. (1976). Monse, B., Heinrich-Weltzien, R., Benzian, H., Holmgren, C. & van Palenstein Helderman, W. PUFA- An index of clinical consequences of untreated dental caries. Commun. Dent. Oral Epidemiol. 38 , 77–82 (2010). Krausch-Hofmann, S. et al. Assessment of oral health in older adults by non-dental professional caregivers—development and validation of a photograph-supported oral health–related section for the interRAI suite of instruments. Clin. Oral Invest. 25 (6), 3475–3486 (2021). Morris, J. N., Berg, K., Fries, B. E., Steel, K. & Howard, E. P. Scaling functional status within the interRAI suite of assessment instruments. BMC Geriatr. 13 (1), 128–128 (2013). Carpenter, I. & Hirdes, J. P. Using interRAI assessment systems to measure and maintain quality of long-term care 93–139 (OECD Publishing, 2013). Burrows, A. B., Morris, J. N., Simon, S. E., Hirdes, J. P. & Phillips, C. Development of a Minimum Data Set-based depression rating scale for use in nursing homes. Age ageing . 29 (2), 165–172 (2000). Hirdes, J. P., Frijters, D. H. & Teare, G. F. The MDS-CHESS Scale: A New Measure to Predict Mortality in Institutionalized Older People. J. Am. Geriatr. Soc. (JAGS) . 51 (1), 96–100 (2003). WHO. Global oral health status report: towards universal health coverage for oral health by 2030. In. Edited by IGO LCB-N-S. Geneva: WHO; (2022). Janssens, L., Petrauskiene, E., Tsakos, G. & Janssens, B. Clinical and Subjective Oral Health Status of Care Home Residents in Europe: A Systematic Review. J. Am. Med. Dir. Assoc. 24 (7), 1013–1019e1040 (2023). Petersen, P. E. & Yamamoto, T. Improving oral health of older people: the approach of the WHO Global Oral Health Programme. In., vol. 33; : 81–92. (2005). Naka, O., Anastassiadou, V. & Pissiotis, A. Association between functional tooth units and chewing ability in older adults: a systematic review. Gerodontology . 31 (3), 166–177 (2014). Borg-Bartolo, R. et al. Global prevalence of edentulism and dental caries in middle-aged and elderly persons: A systematic review and meta-analysis. J. Dent. 127 , 104335–104335 (2022). Abreu, M. H. D. et al. Prevalence of chewing difficulty in older people in long-term care: A systematic review and meta-analysis. Gerodontology (2022). Kojima, G., Taniguchi, Y., Iwasaki, M., Aoyama, R. & Urano, T. Associations between self-reported masticatory dysfunction and frailty: A systematic review and meta-analysis. PloS one . 17 (9), e0273812–e0273812 (2022). Lahoud, T., Yu, A. Y. D. & King, S. Masticatory dysfunction in older adults: A scoping review. J. Rehabil. 50 (8), 724–737 (2023). van de Rijt, L. J., Feast, A. R., Vickerstaff, V., Lobbezoo, F. & Sampson, E. L. Prevalence and associations of orofacial pain and oral health factors in nursing home residents with and without dementia. Age ageing . 49 (3), 418–424 (2020). Delwel, S. et al. Psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals as a screening tool for orofacial pain in people with dementia. Gerodontology . 35 (3), 200–213 (2018). Delwel, S., Binnekade, T. T., Perez, R. S. G. M., Scherder, M. H. C. M. P. & Lobbezoo, E. J. A. Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues. Clin. Oral Invest. 22 , 93–108 (2018). van der Steen, J. T. P. et al. Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis. J. Pain Symptom Manag. 50 (5), 659–675e653 (2015). van der Putten, G-J., Brand, H. S., Schols, J. M. G. A. & de Baat, C. The diagnostic suitability of a xerostomia questionnaire and the association between xerostomia, hyposalivation and medication use in a group of nursing home residents. Clin. Oral Invest. 15 (2), 185–192 (2011). Diep, M. T. et al. Xerostomia and hyposalivation among a 65‐yr‐old population living in Oslo, Norway. Eur. J. Oral. Sci. 129 (1), e12757–n (2021). /a Pina, G. M. S., Mota Carvalho, R. & Silva BSdF, Almeida, F. T. Prevalence of hyposalivation in older people: A systematic review and meta-analysis. Gerodontology . 37 (4), 317–331 (2020). Bethesda, MUDoHaHS & National Institutes of Health, National Institute of Dental and Craniofacial Research.. Oral Health in America: Advances and Challenges Available: (2024). https://www.ncbi.nlm.nih.gov/books/NBK576535/ . Accessed Feb 12. Chapple, I. L. C. et al. Primary prevention of periodontitis: managing gingivitis. J. Clin. Periodontol. 42 (S16), S71–S76 (2015). Borsa, L., Dubois, M., Sacco, G. & Lupi, L. Analysis the link between periodontal diseases and alzheimer’s disease: A systematic review. Int. J. Environ. Res. Public Health . 18 (17), 9312 (2021). Radwan-Oczko, M., Sokol, I., Babuska, K. & Owczarek-Drabinska, J. E. Prevalence and Characteristic of Oral Mucosa Lesions. Symmetry (Bandung) . 14 (2), 307 (2022). Zenthöfer, A., Rammelsberg, P., Cabrera, T. & Hassel, A. J. Increasing dependency of older people in nursing homes is associated with need for dental treatments. Neuropsychiatr. Dis. Treat. 10 (default), 2285–2290 (2014). Rantzow, V., Andersson, P. & Lindmark, U. Occurrence of oral health problems and planned measures in dependent older people in nursing care. J. Clin. Nurs. 27 (23–24), 4381–4389 (2018). Ewan, V. & Staines, K. Diagnosis and management of oral mucosal lesions in older people: a review. Reviews Clin. Gerontol. 18 (2), 115–128 (2008). Vandenbulcke, P. A. I. et al. Nursing home residents’ perspectives on oral health: An in-depth interview study. Int. J. Nurs. Stud. Adv. 6 , 100198–100198 (2024). Additional Declarations No competing interests reported. Supplementary Files Additionalfile1STROBE.pdf Additionalfile2indices.pdf Cite Share Download PDF Status: Published Journal Publication published 14 Feb, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 02 Dec, 2024 Reviews received at journal 29 Nov, 2024 Reviews received at journal 21 Nov, 2024 Reviewers agreed at journal 15 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviewers agreed at journal 22 Oct, 2024 Reviewers invited by journal 08 Sep, 2024 Editor assigned by journal 08 Sep, 2024 Editor invited by journal 03 Sep, 2024 Submission checks completed at journal 30 Aug, 2024 First submitted to journal 21 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4950980","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":353834199,"identity":"6b4a4167-cf51-4efa-8f21-90496ae9d627","order_by":0,"name":"Patricia Ann Ivonne Vandenbulcke","email":"data:image/png;base64,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","orcid":"","institution":"Department of Oral Health Sciences, Population Studies in Oral Health, KU Leuven","correspondingAuthor":true,"prefix":"","firstName":"Patricia","middleName":"Ann Ivonne","lastName":"Vandenbulcke","suffix":""},{"id":353834200,"identity":"d5e973dd-d611-43ef-8d9a-52f288b92f46","order_by":1,"name":"Johanna de Almeida 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16:14:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1773935,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4950980/v1/a04d4d42-6298-4c2a-9b70-4974fc81bc40.pdf"},{"id":65663090,"identity":"02eeb5b5-c6c0-42e6-9de8-dfa4221141ed","added_by":"auto","created_at":"2024-10-01 05:23:03","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":132499,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1STROBE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4950980/v1/9275a0f52f9fde2010cbf989.pdf"},{"id":65663091,"identity":"f51fe10b-ad42-4c46-a66d-f88207c77408","added_by":"auto","created_at":"2024-10-01 05:23:03","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":88620,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2indices.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4950980/v1/d7050460678eedb892a7cd70.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Oral health status of nursing home residents in Flanders, Belgium: a cross-sectional study","fulltext":[{"header":"Introduction/ Background","content":"\u003cp\u003eIn Belgium, nearly 20% of the population is aged over 65, which is expected to rise to over 25% by 2050 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Flanders (largest region in Belgium), the share of people over 65 already increased to 21% in 2023, with approximately 8% receiving nursing care at home, and 5% residing in long-term care facilities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In recent years, due to improved oral care, older people maintain their natural dentition into their later years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This achievement has positive effects on their ability to chew and on their nutritional status [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, a decline in self-care due to deteriorating general health, cognitive impairment or physical limitations presents a challenge for oral health in care-dependent older people [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Care dependency is defined as a decrease in functional ability and can be measured through activities of daily living (ADLs). Personal hygiene, including oral hygiene, is often among the first activities to be affected. Research in short-term care has shown that older people who require assistance with self-care, such as oral hygiene, have a significantly higher risk of experiencing oral health issues, particularly poor oral hygiene and broken teeth [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn older adults, the most common oral health problems are dental caries including root caries, periodontal disease, edentulism, dry mouth/xerostomia, and oral cancer [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Systemic diseases and care dependency, combined with the natural ageing process, may contribute to poor oral health among nursing home residents [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOral health is part of and related to overall health and well-being [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The most well-documented link is between periodontal disease and cardiovascular disease and diabetes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. More specifically in older people, research has shown links between oral health and aspiration pneumonia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], malnutrition [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], cognition [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], frailty [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e–\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and polypharmacy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], especially among nursing home residents. Additionally, oral health has been extensively linked to quality of life and well-being [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e–\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most recently published data on oral health among nursing home residents in Flanders were collected between 2010 and 2012 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The national survey conducted on behalf of the National Institute for Health and Disability Insurance (NIHDI) in 2010 revealed that 77% of individuals with natural teeth had an objective treatment need, primarily due to tooth decay and periodontal inflammation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, approximately 50% of the denture wearers also required treatment. Plaque levels were high for natural teeth and dentures. Also, mucosal lesions were prevalent in nearly one in four participants, mainly related to ill-fitting or inadequately maintained removable dentures [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. About 36% of the nursing home residents were edentulous, compared to 64% in another study. De Visschere et al. (2016) concluded that care-dependent older people in Flanders had a very poor oral health status. The goal of the present study is to map and update the condition on the current oral health status of nursing home residents in Flanders, as assessed by oral health professionals.\u003c/p\u003e \n\n \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e \n\n "},{"header":"Methods","content":"\u003ch3\u003eStudy design\u003c/h3\u003e\u003cp\u003eThis cross-sectional study was conducted between April and October 2022 in nursing homes in Flanders, Belgium. This study is part of a longitudinal cluster randomised controlled trial to evaluate the implementation of the OHS-interRAI in nursing homes. The OHS-interRAI is an oral health screening instrument for use by non-dental caregivers within the interRAI instruments [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This study presents the oral health status of older people before any intervention took place in the trial.\u003c/p\u003e\u003cp\u003eReporting of the study methods and results follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Details about the checklist are included in Additional file 1.\u003c/p\u003e\u003cp\u003e This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium (B3222021000650).\u003c/p\u003e\u003ch2\u003eSetting\u003c/h2\u003e\u003cp\u003eAll nursing homes in Flanders were invited and encouraged by e-mail to participate in this study. The managing board of the nursing homes received a comprehensive information note on the study and signed an informed consent. First criterium for eligibility of nursing homes was using the interRAI Long Term Care Facilities (LTCF) assessment instrument embedded in a specific software program. This tool allows caregivers to assess several domains related to residents’ health and care, including their degree of dependency, their mental and physical capacities, and their care needs [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This assessment will be named BelRAI LTCF from now on, as the validated Belgian version was used in this study.\u003c/p\u003e\u003cp\u003eIn Flanders, two projects to improve oral health of nursing home residents are ongoing: the Oral Health Care Track [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and the Gerodent project [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. To avoid bias, nursing homes participating in these projects were excluded from this study.\u003c/p\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eTwo-stage sampling was performed, first at the level of nursing homes and secondly at the level of the individual participants.\u003c/p\u003e\u003cp\u003eIn the included nursing homes, residents were recruited for voluntary participation from January 2022 until July 2022. They received comprehensive information about the study and, in case of incapability, the legally authorized representative was approached for consent. Eligibility criteria were being 65 or older and having a permanent residence in a nursing home. Furthermore, the answer to the question 'Terminal stage of disease, 6 months or less to live' in BelRAI LTCF had to be negative as it was the intention to include people in the cluster randomised controlled trial for a period of 24 months.\u003c/p\u003e\u003cp\u003eIn the course of this recruitment procedure, the medical director of the nursing home was consulted and apprised of the residents who wanted to participate. The medical director then informed the general practitioner of the resident about the study and their participation. Should either have any objections to the resident's participation, they were instructed to report this to the researchers.\u003c/p\u003e\u003cp\u003eParticipants had the option to withdraw from participation or to revise their consent during the study, they also had the right to consult, correct or have their personal data deleted.\u003c/p\u003e\u003ch2\u003eSample size calculation\u003c/h2\u003e\u003cp\u003eSample size calculation was performed to allow for longitudinal research over two years in a cluster randomized controlled trial. The calculation was based on a Chi-squared test and considering a three parallel groups design, a power of 80%, significance level of 0.05 and an estimated effect size of 0.2. This resulted in a total sample of 184 participants (residents) for a regular RCT study. Because of the clustering of participants in nursing homes, this sample size had to be multiplied with a design factor of 1.95 (based on cluster size of 20 participants per nursing home and an intracluster correlation coefficient of 0.05). This resulted in a total sample for cluster randomized controlled trial of 359 participants. Furthermore, a dropout of 35–50% over the period of 24 months was considered, leading to the objective of recruiting between 552 and 718 participants.\u003c/p\u003e\u003ch3\u003eOutcomes\u003c/h3\u003e\u003cp\u003eThe oral health status of the nursing home residents was assessed using the following measures.\u003c/p\u003e\u003ch2\u003eOHS-interRAI\u003c/h2\u003e\u003cp\u003eThe OHS-interRAI, is a validated oral health instrument developed for use within the interRAI instruments and to be filled out by non-dental caregivers [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. It contains three self-reported items concerning chewing, pain and dry mouth, next to six items that require inspection of the mouth: denture hygiene, oral hygiene, teeth, gums, tongue, and soft tissues (palate, inner surface of cheeks and lips). All items can be scored dichotomously as acceptable/ healthy or not, with the possibility of scoring ‘not applicable’ or ‘not possible to assess’ when appropriate (e.g. when the resident is uncooperative or unable to participate in the assessment). The assessment utilises trigger algorithms that result in Collaborative Action Points (CAPs) indicating the need for referral to the dentist (CAP Referral to a dentist) or for improvement of oral hygiene (CAP Oral hygiene).\u003c/p\u003e\u003ch2\u003eDental indices\u003c/h2\u003e\u003cp\u003eFor people with natural teeth, additional dental information was collected, such as the number of teeth and root remnants, as well as the following dental indices:\u003c/p\u003e\u003cp\u003eThe \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModified Gingival Index (MGI)\u003c/span\u003e [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]: index to assess gingival health. This is a non-invasive assessment, developed for research that allows for repeated measurements. The MGI has a range of 0–4 and is interpreted as follows: 0.1-1.0 = Mild inflammation of any portion of the gingiva; 1.1-2.0 = Mild inflammation of the entire gingiva; 2.1-3.0 = Moderate inflammation; and 3.1-4.0 = Severe inflammation[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOral Hygiene Index (OHI)\u003c/span\u003e [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]: index to assess oral hygiene that consists of two components: the Debris Index (DI) and the Calculus Index (CI), which represent the amount of plaque and calculus on the tooth surfaces, respectively. The DI and CI both range from 0–6 and the OHI is calculated by summing the DI and CI, with a total range of 0–12. It is interpreted as follows: 0–2 = acceptable oral hygiene; 2.1–5.9 = moderate oral hygiene; ≥6 = poor oral hygiene[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePUFA-index\u003c/span\u003e [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]: index to assess the presence of oral conditions resulting from untreated caries. This index ranges from 0–32 and the higher the number, the worse the condition of the teeth.\u003c/p\u003e\u003cp\u003eThe MGI and PUFA-index were especially designed to be assessed without using dental instruments. The OHI was scored visually using a mirror, without using a probe. Krausch-Hofmann et al. (2020) found that without mirror and probe about 6% less non-acceptable conditions were detected by dentists[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditional information concerning the used indices and the formulas to calculate them are included in Additional file 2.\u003c/p\u003e\u003ch2\u003eRelated variables\u003c/h2\u003e\u003cp\u003eSociodemographic and clinical characteristics from the participants were obtained by means of their most recent BelRAI LTCF assessment, filled out by their caregivers: age, gender, self-care capacities, cognitive performance, symptoms of depression, health stability, dental check-up in the last year, number of medications and smoking behaviour.\u003c/p\u003e\u003cp\u003eSelf-care capacities were measured using the Activities of Daily Living Hierarchy Scale of the interRAI LTCF (ADL-H), ranging from 0 (independent) to 6 (total dependence) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. This validated scale measures the extent to which persons are self-reliant for personal hygiene, toilet use, locomotion, and eating. Cognitive performance was assessed using the Cognitive Performance Scale (CPS), ranging from 0 (intact) to 6 (very severe impairment) [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Symptoms of depression were measured with the Depression Rating Scale (DRS) which was developed for use in nursing homes [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This validated scale ranges from 0 (no mood symptoms) to 14 (all mood symptoms present in the last 3 days). Health instability was measured with the Changes in Health, End-Stage Disease, Signs, and Symptoms scale (CHESS), ranging from 0 (no health instability) to 5 (very high health instability)[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eData collection was carried out by seven dentists and one dental hygienist who were specifically trained to perform the assessments. To avoid potential bias, they cooperated as volunteers in the research project and had no other interest or involvement in the study.\u003c/p\u003e\u003cp\u003eThe training consisted of a webinar (1.5 hours), a written manual as well as a face-to-face training and calibration session prior to the start of the data collection. A key card with the core information regarding the indices to be scored was available during the assessments. The first author and an additional volunteer dentist assisted the dental professionals with recording the data.\u003c/p\u003e\u003cp\u003eAppointments for visits to the nursing homes were previously planned. All assessments were completed in the residents’ rooms to ensure privacy, and in accordance with the guidelines for infection prevention. During the assessment, a headlight (Bo-Camp Headlamp 150 lumen) was used. The OHS-interRAI assessments were conducted without dental instruments, conform to the general guidelines. For the assessment of all dental indices, a disposable dental mirror (Flecta disposable mirrors Pulpdent) was used.\u003c/p\u003e\u003ch2\u003eAnalysis\u003c/h2\u003e\u003cp\u003eAll 9 items of the OHS-interRAI were dichotomized (0/1) and were analysed for the people for whom the items could be assessed. Responses to items that were scored ‘not applicable’ or ‘not possible to assess’ were omitted.\u003c/p\u003e\u003cp\u003eAll scores of the interRAI scales were dichotomized using their validated cut-off values. For the interRAI ADLH scale, a score of 3 or higher indicates a need for at least extensive assistance for activities of daily living (ADL) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. A cut-off of 3 on the interRAI CPS scale indicates moderate cognitive impairment [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A score of 3 on the interRAI scale represents minor depressive disorders [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] and the cut-off of 3 on the interRAI CHESS scale denotes that the resident has at least moderate health instability [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll analyses were performed with software SAS Enterprise Guide for Windows, version 8.1 update 1.\u003c/p\u003e\u003cp\u003eFirst, descriptive statistics were used to identify the population’s characteristics and the most prevalent oral health problems. The Chi-Square test was used to test for significant differences in the prevalence of oral health problems. Subsequently, bivariate analyses were performed to investigate associations between oral health items and the clinical characteristics of their most recent BelRAI LTCF assessment.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eA total of 489 residents from 11 Flemish nursing homes consented to participation. After examination of eligibility, eleven participants were excluded because they did not meet the inclusion criteria (according to age 65 or older and long-stay in the nursing home). A total of 478 participants were included in the study, with a total of 22 to 73 residents per nursing home. The oral health assessment could be performed in 462 participants. Reasons for the lack of assessment were death, refusal, absence in the nursing home, and medical conditions.\u003c/p\u003e\n\u003cp\u003eData were analysed for a total of 458 participants.\u003c/p\u003e\n\u003cp\u003eThe mean age of the participants was 82.7 (\u0026plusmn;\u0026thinsp;7.8) years and the majority was female (70.3%). Their sociodemographic characteristics are presented in Table\u0026nbsp;1. About 68% of the participants needed extensive assistance for activities of daily living and 49% had moderate cognitive impairment.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;Table 1: Sociodemographic characteristics of the participants\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Taba\" style=\"width: 319.477px;\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 34px;\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth style=\"width: 77px;\" align=\"left\"\u003e\n\u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e458\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e322\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(70.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e82.7 (\u0026plusmn;\u0026thinsp;7.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCPS score (\u0026ge;\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e188/381\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(49.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eADL score (\u0026ge;\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e259/380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(68.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eDRS score (\u0026ge;\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e144/382\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(37.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCHESS score (\u0026ge;\u0026thinsp;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e43/369\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(11.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eDental visit last year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e110/374\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(29.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eNumber of medications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e29/378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(7.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003e4\u0026ndash;8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e169/378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(44.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026ge;\u0026thinsp;9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e180/378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(47.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eSmokers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 46px;\" align=\"left\"\u003e\n\u003cp\u003e35/381\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 34px;\" align=\"left\"\u003e\n\u003cp\u003e(9.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 77px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: CPS, Cognitive Performance Scale; ADL, Activities Daily Living; DRS, Depression Rating Scale; CHESS, Changes in Health, End-Stage Disease and Sign and Symptoms Scale\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003eOutcome data\u003c/h2\u003e\n\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n\u003ch2\u003eOral health based on OHS-interRAI\u003c/h2\u003e\n\u003cp\u003eThe prevalence of oral health problems recorded with the OHS-interRAI is represented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Insufficient oral (75.7%) and denture (68.5%) hygiene were the most prevalent problems. Most oral health problems were observed in people with natural teeth and were related to teeth (56.6%) and gums (49.9%). Soft tissue lesions of palate and inner surfaces of cheeks and lips were recorded in 19.9% of the participants.\u003c/p\u003e\n\u003cp\u003eSelf-reported oral health problems were mainly related to dry mouth (32.8%) and chewing difficulty (23.4%). The oral health data retrieved from the screening indicated a need for referral to a dentist in 75% of the participants (CAP Referral to a dentist).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePrevalence of oral health problems or deficiencies, registered with the OHS-interRAI for all subjects (total sample N\u0026thinsp;=\u0026thinsp;458)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOHS-interRAI\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAssessed subjects*, n\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNumber of residents with problems or deficiencies, n\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrevalence, %\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSelf-reported oral problems OHS-interRAI, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChewing difficulty\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e431\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e101\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePain in the mouth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e434\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDry mouth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e433\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e142\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eObserved oral problems OHS-interRAI, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDenture hygiene\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e260\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e178\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e68.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOral hygiene\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e255\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e193\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e75.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTeeth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e241\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e137\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e56.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGums\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e445\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e222\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e49.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTongue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e427\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePalate, lips and cheeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e437\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAP Oral Hygiene, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e454\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e315\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e69.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAP Referral to a dentist, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e452\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e339\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e75.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Number of participants for whom the item could be assessed, excluding answer options \u0026lsquo;not applicable\u0026rsquo; and \u0026lsquo;could not be assessed\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eAbbreviations: OHS-interRAI, Oral Health Section for use within the interRAI suite of instruments; CAP, Collaborative Action Point\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n\u003ch2\u003eOral health based on dental indices\u003c/h2\u003e\n\u003cp\u003eFor the participants with natural teeth (54% of the sample), additional dental indices were assessed. These results are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean number of visible teeth or tooth remnants was 12.8 (\u0026plusmn;\u0026thinsp;7.3). When excluding tooth remnants, the mean number of teeth was 11.5 (\u0026plusmn;\u0026thinsp;7.3). Only 9.2% of the participants had at least 20 teeth. Over 44% of the people with natural teeth had untreated tooth decay with at least pulpal involvement. The mean OHI was 4.5 (\u0026plusmn;\u0026thinsp;2.6), indicating moderate oral hygiene [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e]. A proportion of 17.6% of the participants had an OHI-score\u0026thinsp;\u0026le;\u0026thinsp;2, which is acceptable according to M\u0026uuml;hlemann, and 26.2% had an OHI-score of 6 or higher, which indicates poor oral hygiene. Only 9.4% (22/233) of the participants with natural teeth had a DI-score\u0026thinsp;\u0026le;\u0026thinsp;1.0, representing an acceptable amount of plaque, whereas 48.7% (113/232) had a CI-score\u0026thinsp;\u0026le;\u0026thinsp;1.0, meaning that the calculus level was acceptable. The mean MGI of the residents was 1.8 (SD 1.2), indicating mild inflammation of the entire gingiva[\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. About 28.6% of the participants had an MGI-score\u0026thinsp;\u0026le;\u0026thinsp;1.0, indicating mild inflammation of any portion of the gingiva. A total of 41.0% had an MGI-score of 2.1 and higher, indicating moderate to severe inflammation of the gingiva.\u003c/p\u003e\n\u003cp\u003eOverall, removable dentures were worn by 59.9% (272/454) of the participants.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eParticipants\u0026rsquo; oral health status and dental indices scores (total sample N\u0026thinsp;=\u0026thinsp;458)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAssessed in subjects (N\u0026thinsp;=\u0026thinsp;458), n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMean (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDentates - Number of visible teeth or tooth remnants\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e247/458 (53.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e12.8 (\u0026plusmn;\u0026thinsp;7.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDentates with root remnants - Number of root remnants\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97/241 (40.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.3 (\u0026plusmn;\u0026thinsp;3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDental indices\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOHI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e233\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.5 (\u0026plusmn;\u0026thinsp;2.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e233\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.9 (\u0026plusmn;\u0026thinsp;1.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e232\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e1.6 (\u0026plusmn;\u0026thinsp;1.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMGI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e234\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e1.8 (\u0026plusmn;\u0026thinsp;1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePUFA\u0026thinsp;\u0026gt;\u0026thinsp;0 - Number of PUFA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e106 (44.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.9 (\u0026plusmn;\u0026thinsp;2.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRemovable dentures, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102/247 (41.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEdentulous persons\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e211/458 (46.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRemovable dentures\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFull dentures\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e170/207 (82.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37/207 (17.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: OHI, Oral Hygiene Index; DI, Debris Index; CI, Calculus Index; MGI, Modified Gingival Index; PUFA, Pulp Ulceration Fistel Abscess index\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n\u003ch2\u003eOHS-interRAI associations\u003c/h2\u003e\n\u003cp\u003eCorrelations were explored between different aspects of oral health. These are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. The strongest correlation is found between the condition of the gums and oral hygiene (r\u0026thinsp;=\u0026thinsp;.324, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), followed by an association of chewing difficulty with pain (r\u0026thinsp;=\u0026thinsp;.247, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). Dry mouth is correlated with pain (r\u0026thinsp;=\u0026thinsp;.195, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) and with chewing difficulty (r\u0026thinsp;=\u0026thinsp;.183, p\u0026thinsp;=\u0026thinsp;.0002). Denture hygiene is correlated with mucosal problems of the palate, cheeks and lips (r\u0026thinsp;=\u0026thinsp;.169, p\u0026thinsp;=\u0026thinsp;.0067) and with gum condition (r\u0026thinsp;=\u0026thinsp;.158, p\u0026thinsp;=\u0026thinsp;.01).\u003c/p\u003e\n\u003cp\u003eWeaker positive correlations were found for the item oral hygiene and teeth (r\u0026thinsp;=\u0026thinsp;.127, p\u0026thinsp;=\u0026thinsp;.05) and also for the item palate, cheeks and lips with pain (r\u0026thinsp;=\u0026thinsp;.107, p\u0026thinsp;=\u0026thinsp;.03) and gum condition (r\u0026thinsp;=\u0026thinsp;.104, p\u0026thinsp;=\u0026thinsp;.03). Weak negative correlations were found for dry mouth with denture hygiene (r=-.135, p\u0026thinsp;=\u0026thinsp;.03) and gum condition (r=-.113, p\u0026thinsp;=\u0026thinsp;.02).\u003c/p\u003e\n\u003cp\u003eDenture hygiene shows weaker results and no statistical significance with oral hygiene (r\u0026thinsp;=\u0026thinsp;.153, p\u0026thinsp;=\u0026thinsp;.11) and teeth (r\u0026thinsp;=\u0026thinsp;.145, p\u0026thinsp;=\u0026thinsp;.16).\u003c/p\u003e\n\u003cp\u003eThe condition of the tongue showed no statistically significant correlation with any of the other items.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePearson Correlation Coefficients between the different oral health items of the OHS-interRAI,\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePain\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDry mouth\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDenture hygiene\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOral hygiene\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTeeth\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGums\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTongue\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePalate, cheeks and lips\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eChewing difficulty\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.24669***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e426\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.18257***\u003c/p\u003e\n\u003cp\u003e0.0002\u003c/p\u003e\n\u003cp\u003e424\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.05307\u003c/p\u003e\n\u003cp\u003e0.40\u003c/p\u003e\n\u003cp\u003e251\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07712\u003c/p\u003e\n\u003cp\u003e0.23\u003c/p\u003e\n\u003cp\u003e241\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.08558\u003c/p\u003e\n\u003cp\u003e0.20\u003c/p\u003e\n\u003cp\u003e227\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02862\u003c/p\u003e\n\u003cp\u003e0.56\u003c/p\u003e\n\u003cp\u003e424\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02576\u003c/p\u003e\n\u003cp\u003e0.60\u003c/p\u003e\n\u003cp\u003e414\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.08890\u003c/p\u003e\n\u003cp\u003e0.07\u003c/p\u003e\n\u003cp\u003e419\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePain\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.19494***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e429\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00985\u003c/p\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003cp\u003e254\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03724\u003c/p\u003e\n\u003cp\u003e0.56\u003c/p\u003e\n\u003cp\u003e242\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04781\u003c/p\u003e\n\u003cp\u003e0.47\u003c/p\u003e\n\u003cp\u003e229\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01261\u003c/p\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003cp\u003e426\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00000\u003c/p\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003cp\u003e416\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10732*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e422\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDry mouth\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.13460*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e253\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04112\u003c/p\u003e\n\u003cp\u003e0.52\u003c/p\u003e\n\u003cp\u003e243\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04169\u003c/p\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003cp\u003e229\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.11334*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e425\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00343\u003c/p\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003cp\u003e417\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03771\u003c/p\u003e\n\u003cp\u003e0.44\u003c/p\u003e\n\u003cp\u003e423\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDenture hygiene\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15280\u003c/p\u003e\n\u003cp\u003e0.11\u003c/p\u003e\n\u003cp\u003e110\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.14513\u003c/p\u003e\n\u003cp\u003e0.16\u003c/p\u003e\n\u003cp\u003e96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15811**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e255\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04239\u003c/p\u003e\n\u003cp\u003e0.50\u003c/p\u003e\n\u003cp\u003e255\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.16873**\u003c/p\u003e\n\u003cp\u003e0.0067\u003c/p\u003e\n\u003cp\u003e257\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOral hygiene\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.12683*\u003c/p\u003e\n\u003cp\u003e0.05\u003c/p\u003e\n\u003cp\u003e236\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.32361***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e253\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01571\u003c/p\u003e\n\u003cp\u003e0.81\u003c/p\u003e\n\u003cp\u003e236\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02175\u003c/p\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003cp\u003e244\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTeeth\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.08634\u003c/p\u003e\n\u003cp\u003e0.18\u003c/p\u003e\n\u003cp\u003e240\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10135\u003c/p\u003e\n\u003cp\u003e0.13\u003c/p\u003e\n\u003cp\u003e223\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02494\u003c/p\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003cp\u003e232\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGums\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03661\u003c/p\u003e\n\u003cp\u003e0.45\u003c/p\u003e\n\u003cp\u003e422\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10378*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e433\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTongue\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03890\u003c/p\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003cp\u003e425\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003cp\u003eProb \u0026gt; |r| under H0: Rho\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\n\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n\u003cp\u003eNumber of Observations\u003c/p\u003e\n\u003cp\u003ep\u0026thinsp;\u0026le;\u0026thinsp;0.001*** - p\u0026thinsp;\u0026le;\u0026thinsp;0.01** - p\u0026thinsp;\u0026le;\u0026thinsp;0.05*\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n\u003ch2\u003eAssociations between oral health and sociodemographic and clinical characteristics\u003c/h2\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePearson Correlation Coefficients between the oral health related information and participants\u0026rsquo; characteristics, Prob \u0026gt; |r| under H0: Rho\u0026thinsp;=\u0026thinsp;0, Number of Observations\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCPS\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eADL\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eExtensive support for personal hygiene\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDRS\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCHESS\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDental visit\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePoly-pharmacy \u0026ge; 9 drugs\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSmoking\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eChewing difficulty\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00567\u003c/p\u003e\n\u003cp\u003e0.91\u003c/p\u003e\n\u003cp\u003e360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07170\u003c/p\u003e\n\u003cp\u003e0.18\u003c/p\u003e\n\u003cp\u003e359\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.08060\u003c/p\u003e\n\u003cp\u003e0.13\u003c/p\u003e\n\u003cp\u003e360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07612\u003c/p\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003cp\u003e361\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01619\u003c/p\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003cp\u003e348\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00639\u003c/p\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003cp\u003e353\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.23029***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e356\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04262\u003c/p\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003cp\u003e359\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePain\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.13295**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e362\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03298\u003c/p\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003cp\u003e361\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01749\u003c/p\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003cp\u003e362\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07087\u003c/p\u003e\n\u003cp\u003e0.18\u003c/p\u003e\n\u003cp\u003e363\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03411\u003c/p\u003e\n\u003cp\u003e0.52\u003c/p\u003e\n\u003cp\u003e351\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.06755\u003c/p\u003e\n\u003cp\u003e0.20\u003c/p\u003e\n\u003cp\u003e355\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.14847**\u003c/p\u003e\n\u003cp\u003e0.005\u003c/p\u003e\n\u003cp\u003e358\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01929\u003c/p\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003cp\u003e361\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDry mouth\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.22706***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e362\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.00565\u003c/p\u003e\n\u003cp\u003e0.91\u003c/p\u003e\n\u003cp\u003e361\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01408\u003c/p\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003cp\u003e362\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11842*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e363\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06941\u003c/p\u003e\n\u003cp\u003e0.20\u003c/p\u003e\n\u003cp\u003e350\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.09307\u003c/p\u003e\n\u003cp\u003e0.08\u003c/p\u003e\n\u003cp\u003e355\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.20842***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e358\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.05778\u003c/p\u003e\n\u003cp\u003e0.27\u003c/p\u003e\n\u003cp\u003e361\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDenture hygiene\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.13791*\u003c/p\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003cp\u003e214\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.12723\u003c/p\u003e\n\u003cp\u003e0.06\u003c/p\u003e\n\u003cp\u003e214\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11494\u003c/p\u003e\n\u003cp\u003e0.09\u003c/p\u003e\n\u003cp\u003e215\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01006\u003c/p\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003cp\u003e214\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00000\u003c/p\u003e\n\u003cp\u003e1.0000\u003c/p\u003e\n\u003cp\u003e207\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.09230\u003c/p\u003e\n\u003cp\u003e0.18\u003c/p\u003e\n\u003cp\u003e208\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03072\u003c/p\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003cp\u003e210\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.12381\u003c/p\u003e\n\u003cp\u003e0.07\u003c/p\u003e\n\u003cp\u003e213\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOral hygiene\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10795\u003c/p\u003e\n\u003cp\u003e0.12\u003c/p\u003e\n\u003cp\u003e214\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15172*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e212\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.16679**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e213\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04816\u003c/p\u003e\n\u003cp\u003e0.48\u003c/p\u003e\n\u003cp\u003e215\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02005\u003c/p\u003e\n\u003cp\u003e0.78\u003c/p\u003e\n\u003cp\u003e204\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.14467*\u003c/p\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003cp\u003e210\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.05426\u003c/p\u003e\n\u003cp\u003e0.43\u003c/p\u003e\n\u003cp\u003e211\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.00019\u003c/p\u003e\n\u003cp\u003e0.10\u003c/p\u003e\n\u003cp\u003e214\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTeeth\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.05790\u003c/p\u003e\n\u003cp\u003e0.41\u003c/p\u003e\n\u003cp\u003e204\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.06098\u003c/p\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003cp\u003e202\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.05569\u003c/p\u003e\n\u003cp\u003e0.43\u003c/p\u003e\n\u003cp\u003e203\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11130\u003c/p\u003e\n\u003cp\u003e0.11\u003c/p\u003e\n\u003cp\u003e205\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.08398\u003c/p\u003e\n\u003cp\u003e0.24\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02259\u003c/p\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003cp\u003e200\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07192\u003c/p\u003e\n\u003cp\u003e0.31\u003c/p\u003e\n\u003cp\u003e201\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02290\u003c/p\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003cp\u003e204\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGums\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.19872***\u003c/p\u003e\n\u003cp\u003e0.0001\u003c/p\u003e\n\u003cp\u003e372\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.12490*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e371\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10731*\u003c/p\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003cp\u003e372\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03392\u003c/p\u003e\n\u003cp\u003e0.51\u003c/p\u003e\n\u003cp\u003e373\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02623\u003c/p\u003e\n\u003cp\u003e0.62\u003c/p\u003e\n\u003cp\u003e360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01374\u003c/p\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003cp\u003e365\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.05473\u003c/p\u003e\n\u003cp\u003e0.30\u003c/p\u003e\n\u003cp\u003e368\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.10954*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e371\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTongue\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01809\u003c/p\u003e\n\u003cp\u003e0.73\u003c/p\u003e\n\u003cp\u003e356\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03392\u003c/p\u003e\n\u003cp\u003e0.52\u003c/p\u003e\n\u003cp\u003e355\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02203\u003c/p\u003e\n\u003cp\u003e0.68\u003c/p\u003e\n\u003cp\u003e356\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.13776**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e357\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.12828*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e344\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01703\u003c/p\u003e\n\u003cp\u003e0.75\u003c/p\u003e\n\u003cp\u003e349\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06969\u003c/p\u003e\n\u003cp\u003e0.19\u003c/p\u003e\n\u003cp\u003e352\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.05029\u003c/p\u003e\n\u003cp\u003e0.34\u003c/p\u003e\n\u003cp\u003e355\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePalate, cheeks and lips\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04644\u003c/p\u003e\n\u003cp\u003e0.38\u003c/p\u003e\n\u003cp\u003e365\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.00577\u003c/p\u003e\n\u003cp\u003e0.91\u003c/p\u003e\n\u003cp\u003e364\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.00807\u003c/p\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003cp\u003e365\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02901\u003c/p\u003e\n\u003cp\u003e0.58\u003c/p\u003e\n\u003cp\u003e366\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01399\u003c/p\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003cp\u003e353\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01067\u003c/p\u003e\n\u003cp\u003e0.84\u003c/p\u003e\n\u003cp\u003e358\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01945\u003c/p\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003cp\u003e361\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02321\u003c/p\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003cp\u003e364\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCAP Oral hygiene\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06195\u003c/p\u003e\n\u003cp\u003e0.23\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07514\u003c/p\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003cp\u003e377\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.08707\u003c/p\u003e\n\u003cp\u003e0.09\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02072\u003c/p\u003e\n\u003cp\u003e0.69\u003c/p\u003e\n\u003cp\u003e379\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01607\u003c/p\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003cp\u003e366\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.06065\u003c/p\u003e\n\u003cp\u003e0.24\u003c/p\u003e\n\u003cp\u003e371\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03397\u003c/p\u003e\n\u003cp\u003e0.51\u003c/p\u003e\n\u003cp\u003e375\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.07383\u003c/p\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCAP Referral to a Dentist\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.13939**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e375\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.09008\u003c/p\u003e\n\u003cp\u003e0.08\u003c/p\u003e\n\u003cp\u003e374\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10075*\u003c/p\u003e\n\u003cp\u003e0.05\u003c/p\u003e\n\u003cp\u003e375\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06415\u003c/p\u003e\n\u003cp\u003e0.21\u003c/p\u003e\n\u003cp\u003e376\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06812\u003c/p\u003e\n\u003cp\u003e0.20\u003c/p\u003e\n\u003cp\u003e363\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07382\u003c/p\u003e\n\u003cp\u003e0.16\u003c/p\u003e\n\u003cp\u003e368\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04741\u003c/p\u003e\n\u003cp\u003e0.36\u003c/p\u003e\n\u003cp\u003e372\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.16052**\u003c/p\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003cp\u003e375\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDI\u0026thinsp;\u0026ge;\u0026thinsp;1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.31329***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.14294\u003c/p\u003e\n\u003cp\u003e0.06\u003c/p\u003e\n\u003cp\u003e194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11320\u003c/p\u003e\n\u003cp\u003e0.12\u003c/p\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11204\u003c/p\u003e\n\u003cp\u003e0.12\u003c/p\u003e\n\u003cp\u003e197\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07656\u003c/p\u003e\n\u003cp\u003e0.30\u003c/p\u003e\n\u003cp\u003e188\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.10127\u003c/p\u003e\n\u003cp\u003e0.16\u003c/p\u003e\n\u003cp\u003e192\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02153\u003c/p\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003cp\u003e193\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.09862\u003c/p\u003e\n\u003cp\u003e0.17\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCI\u0026thinsp;\u0026ge;\u0026thinsp;1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.17687**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.14642*\u003c/p\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003cp\u003e193\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e015377*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.00869\u003c/p\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10000\u003c/p\u003e\n\u003cp\u003e0.17\u003c/p\u003e\n\u003cp\u003e187\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.21164**\u003c/p\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003cp\u003e191\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00923\u003c/p\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003cp\u003e192\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02408\u003c/p\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOHI\u0026thinsp;\u0026ge;\u0026thinsp;2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.29945***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.16929*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.17217*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15342*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e197\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10082\u003c/p\u003e\n\u003cp\u003e0.47\u003c/p\u003e\n\u003cp\u003e188\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.16017*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e192\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01123\u003c/p\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003cp\u003e193\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03899\u003c/p\u003e\n\u003cp\u003e0.59\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMGI\u0026thinsp;\u0026ge;\u0026thinsp;1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.38932***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e197\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.16810*\u003c/p\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.18160**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.03447\u003c/p\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003cp\u003e198\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07198\u003c/p\u003e\n\u003cp\u003e0.33\u003c/p\u003e\n\u003cp\u003e189\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.19062**\u003c/p\u003e\n\u003cp\u003e0.008\u003c/p\u003e\n\u003cp\u003e193\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.05045\u003c/p\u003e\n\u003cp\u003e0.48\u003c/p\u003e\n\u003cp\u003e194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04469\u003c/p\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003cp\u003e197\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMGI\u0026thinsp;\u0026ge;\u0026thinsp;2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.32117***\u003c/p\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n\u003cp\u003e197\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.20913**\u003c/p\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003cp\u003e195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.22094**\u003c/p\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003cp\u003e196\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06612\u003c/p\u003e\n\u003cp\u003e0.35\u003c/p\u003e\n\u003cp\u003e198\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.08172\u003c/p\u003e\n\u003cp\u003e0.26\u003c/p\u003e\n\u003cp\u003e189\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.19597**\u003c/p\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003cp\u003e193\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04371\u003c/p\u003e\n\u003cp\u003e0.54\u003c/p\u003e\n\u003cp\u003e194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03595\u003c/p\u003e\n\u003cp\u003e0.62\u003c/p\u003e\n\u003cp\u003e197\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePUFA\u0026thinsp;\u0026ge;\u0026thinsp;1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07569\u003c/p\u003e\n\u003cp\u003e0.28\u003c/p\u003e\n\u003cp\u003e202\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02886\u003c/p\u003e\n\u003cp\u003e0.69\u003c/p\u003e\n\u003cp\u003e200\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04109\u003c/p\u003e\n\u003cp\u003e0.56\u003c/p\u003e\n\u003cp\u003e201\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01906\u003c/p\u003e\n\u003cp\u003e0.79\u003c/p\u003e\n\u003cp\u003e203\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.04373\u003c/p\u003e\n\u003cp\u003e0.54\u003c/p\u003e\n\u003cp\u003e194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02152\u003c/p\u003e\n\u003cp\u003e0.76\u003c/p\u003e\n\u003cp\u003e198\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06153\u003c/p\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003cp\u003e199\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04715\u003c/p\u003e\n\u003cp\u003e0.51\u003c/p\u003e\n\u003cp\u003e202\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEdentulous\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.10929*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e381\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.02942\u003c/p\u003e\n\u003cp\u003e0.57\u003c/p\u003e\n\u003cp\u003e380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.00700\u003c/p\u003e\n\u003cp\u003e0.89\u003c/p\u003e\n\u003cp\u003e381\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01318\u003c/p\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003cp\u003e382\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.01176\u003c/p\u003e\n\u003cp\u003e0.82\u003c/p\u003e\n\u003cp\u003e369\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.08250\u003c/p\u003e\n\u003cp\u003e0.11\u003c/p\u003e\n\u003cp\u003e374\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.13417**\u003c/p\u003e\n\u003cp\u003e0.01\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07497\u003c/p\u003e\n\u003cp\u003e0.14\u003c/p\u003e\n\u003cp\u003e381\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDentures\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.18548***\u003c/p\u003e\n\u003cp\u003e0.0003\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.06610\u003c/p\u003e\n\u003cp\u003e0.20\u003c/p\u003e\n\u003cp\u003e377\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03654\u003c/p\u003e\n\u003cp\u003e0.48\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03894\u003c/p\u003e\n\u003cp\u003e0.45\u003c/p\u003e\n\u003cp\u003e379\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.03115\u003c/p\u003e\n\u003cp\u003e0.55\u003c/p\u003e\n\u003cp\u003e366\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.05558\u003c/p\u003e\n\u003cp\u003e0.29\u003c/p\u003e\n\u003cp\u003e371\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.01517\u003c/p\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003cp\u003e375\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11171*\u003c/p\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003cp\u003e378\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ep\u0026thinsp;\u0026le;\u0026thinsp;0.001*** - p\u0026thinsp;\u0026le;\u0026thinsp;0.01** - p\u0026thinsp;\u0026le;\u0026thinsp;0.05*\u003c/p\u003e\n\u003cp\u003eAssociations were investigated between oral health and participants\u0026rsquo; sociodemographic and clinical characteristics. These are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModerate to severe cognitive impairment\u003c/strong\u003e (CPS score\u0026thinsp;\u0026ge;\u0026thinsp;3) showed the strongest correlations with various aspects of oral health, mainly related to gingival health and oral hygiene. The strongest positive correlation was seen with an MGI score greater than 1.0 (r\u0026thinsp;=\u0026thinsp;.389, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), indicating at least mild inflammation of the entire gingiva. There was also a positive correlation with an MGI score greater than 2.0 (r\u0026thinsp;=\u0026thinsp;.321, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), indicating moderate to severe gingival inflammation. The correlation between cognitive impairment and gingival health is also reflected in the OHS-interRAI item gums, although slightly weaker (r\u0026thinsp;=\u0026thinsp;.199, p\u0026thinsp;=\u0026thinsp;.0001). For oral hygiene, cognitive impairment shows a positive correlation with a DI score greater than or equal to 1.0 (r\u0026thinsp;=\u0026thinsp;.313, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), a CI score greater than or equal to 1.0 (r\u0026thinsp;=\u0026thinsp;.177, p\u0026thinsp;=\u0026thinsp;.01) and an OHI score greater than or equal to 2.0 (r\u0026thinsp;=\u0026thinsp;.299, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). This correlation is not reflected in the item oral hygiene of the OHS-InterRAI. However, there is a weak positive correlation with the item for denture hygiene (r\u0026thinsp;=\u0026thinsp;.138, p\u0026thinsp;=\u0026thinsp;.04). Cognitive impairment is also positively correlated to the CAP Referral to a Dentist (r\u0026thinsp;=\u0026thinsp;.139, p\u0026thinsp;=\u0026thinsp;.01).\u003c/p\u003e\n\u003cp\u003eNegative correlations were seen for cognitive impairment with the OHS-InterRAI items pain (r=-.133, p\u0026thinsp;=\u0026thinsp;.01) and dry mouth (r\u0026thinsp;=\u0026thinsp;.227, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), being edentulous (r=-.109, p\u0026thinsp;=\u0026thinsp;.03) and wearing dentures (r=-.185, p\u0026thinsp;=\u0026thinsp;.0003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional impairment\u003c/strong\u003e (ADL score\u0026thinsp;\u0026ge;\u0026thinsp;3) \u003cstrong\u003eand needing extensive assistance with personal hygiene\u003c/strong\u003e showed positive correlations with items and indices related to oral hygiene and gingival health. For gingival health, the strongest correlation was seen with an MGI score greater than or equal to 2.0 (r\u0026thinsp;=\u0026thinsp;.209, p\u0026thinsp;=\u0026thinsp;.003 and r\u0026thinsp;=\u0026thinsp;.221, p\u0026thinsp;=\u0026thinsp;.002 respectively). For oral hygiene, the strongest correlation for both was found with the OHI score (r\u0026thinsp;=\u0026thinsp;.169, p\u0026thinsp;=\u0026thinsp;.02 and r\u0026thinsp;=\u0026thinsp;.172, p\u0026thinsp;=\u0026thinsp;.02 respectively), followed by that with the item oral hygiene of the OHS-interRAI (r\u0026thinsp;=\u0026thinsp;.152, p\u0026thinsp;=\u0026thinsp;.03 and r\u0026thinsp;=\u0026thinsp;.167, p\u0026thinsp;=\u0026thinsp;.01 respectively).\u003c/p\u003e\n\u003cp\u003eHaving \u003cstrong\u003edepressive symptoms\u003c/strong\u003e (DRS score\u0026thinsp;\u0026ge;\u0026thinsp;3) showed a weak positive correlation with the OHI score (r\u0026thinsp;=\u0026thinsp;.153, p\u0026thinsp;=\u0026thinsp;.03) and the OHS-interRAI items tongue (r\u0026thinsp;=\u0026thinsp;.137, p\u0026thinsp;=\u0026thinsp;.01) and dry mouth (r\u0026thinsp;=\u0026thinsp;.118, p\u0026thinsp;=\u0026thinsp;.02).\u003c/p\u003e\n\u003cp\u003eHaving had a \u003cstrong\u003edental visit\u003c/strong\u003e in the 12 months prior to the oral health assessment showed only negative correlations. For oral hygiene-related outcomes, this was the case for the CI score (r=-.212, p\u0026thinsp;=\u0026thinsp;.003), the OHI score (r=-.160, p\u0026thinsp;=\u0026thinsp;.03) and the item oral hygiene (r=-.145, p\u0026thinsp;=\u0026thinsp;.04) of the OHS-InterRAI. For gingival health, this was the case for the MGI scores (r=-.196, p\u0026thinsp;=\u0026thinsp;.01 and r\u0026thinsp;=\u0026thinsp;.191, p\u0026thinsp;=\u0026thinsp;.01)\u003c/p\u003e\n\u003cp\u003eFor those taking \u003cstrong\u003e9 or more medications\u003c/strong\u003e, positive correlations were seen for the self-reported items of the OHS-interRAI, namely chewing difficulty (r\u0026thinsp;=\u0026thinsp;.230, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), dry mouth (r\u0026thinsp;=\u0026thinsp;.208, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) and pain (r\u0026thinsp;=\u0026thinsp;.148, p\u0026thinsp;=\u0026thinsp;.005), as well as for being edentulous (r\u0026thinsp;=\u0026thinsp;.134, p\u0026thinsp;=\u0026thinsp;.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e showed negative correlations with the item gums (r=-.110, p\u0026thinsp;=\u0026thinsp;.03) of the OHS-interRAI and the CAP Referral to a Dentist (r=-.161, p\u0026thinsp;=\u0026thinsp;.002). A positive correlation was seen with wearing dentures (r\u0026thinsp;=\u0026thinsp;.112, p\u0026thinsp;=\u0026thinsp;.03).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eKey results\u003c/h2\u003e \u003cp\u003eThis study aimed to update the condition of the oral health of nursing home residents in Flanders, as assessed by oral health professionals. Furthermore, the aim was to explore associations between oral health and clinical characteristics using the BelRAI LTCF instrument.\u003c/p\u003e \u003cp\u003eThe most recent national survey on the oral health of older adults in Belgium was conducted in 2010 and consisted of data from approximately 440 nursing home residents [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The study showed that care dependency was high, present in 62% of the nursing home residents, as determined using the Katz index [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This is comparable to the present study, in which about half of the residents showed at least moderate cognitive impairment, and 68% required extensive assistance with activities of daily living.\u003c/p\u003e \u003cp\u003eThe present study utilised the OHS-interRAI to map the oral health of older individuals. This oral health assessment instrument offers a comprehensive overview of all oral structures, including oral hygiene [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, dental indices were used to provide a more detailed assessment of common oral problems such as tooth decay, gum problems, and oral hygiene. This information provides a general understanding of the care needs of this study group.\u003c/p\u003e \u003cp\u003eResearch has shown that a healthy lifestyle and prevention-oriented health care, with good oral hygiene and regular dental visits, are associated with tooth retention into later life [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Over half of the participants in the present sample still had a natural dentition with 13 visible teeth or tooth remnants. This is comparable to the results of Janssens (2017) in a study of 1226 Flemish nursing home residents reporting on oral health data which was collected from 2010 to 2012 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. They found a mean number of 12 teeth (SD 8.1) of which 1.9 were residual roots [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, the number of participants diagnosed with edentulism in the present study (46%) is slightly higher than that reported by Janssens et al. (2017) (42%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It is also 10% higher compared to the national oral health survey of 2010 (35.7%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This trend aligns with the findings of the WHO\u0026rsquo;s Oral Health Status Report (2022), which indicates a 30% increase in edentulism in the European region between 1990 and 2019 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A systematic review of clinical and subjective oral health in nursing home residents across Europe revealed that the prevalence of edentulism ranged from 40\u0026ndash;60% in the majority of included studies [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Residents with natural teeth had a mean number of teeth ranging from 9.8 to 20.0 per person [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The WHO-goal is to retain at least 20 teeth at the age of 80 to have sufficient functional tooth units and chewing ability [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In the study by De Visschere et al. (2016), it was found that only 10% of nursing home residents had 21 teeth or more [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the current study, only 9% had 20 teeth or more.\u003c/p\u003e \u003cp\u003eIn terms of self-reported oral problems, 23.4% of the participants indicated that they had experienced \u003cb\u003edifficulty chewing\u003c/b\u003e during the past three days. In a recent study by Krausch-Hofmann et al. (2021), 55.8% of the nursing home residents reported difficulty chewing [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, this discrepancy may be attributed to the fact that the item for chewing difficulty was formulated with greater rigour. The occurrence of chewing problems was recorded by taking into account the hardness of food, with examples including the ability to chew nuts, raw apples and steak [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This approach has been optimised in the Delphi study by Schoebrechts et al. (2023) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The result of the current study aligns with the considerable variation in reported chewing problems (5\u0026ndash;55%) observed in the systematic review by Janssens et al. (2023) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Furthermore, it confirms the findings of Abreu et al. (2022), who concluded that 23% of nursing home residents had chewing difficulties based on a meta-analysis of studies with a sufficiently large sample size [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Tooth loss, musculoskeletal conditions, nutrition-related factors and cognitive decline are the main factors associated with chewing difficulties [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding \u003cb\u003epain\u003c/b\u003e, 9% of participants in this study reported experiencing pain or discomfort in their mouth in the past three days. This result is comparable to the study by Krausch-Hoffmann et al. (2021), where 11.2% of participants reported pain [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Pain or discomfort were reported in 6.0\u0026ndash;40.5% of the nursing home residents in Europe [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Orofacial pain is shown to be significantly more prevalent in residents with dementia [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Nevertheless, a study by Delwel on the use of an Orofacial Pain scale for Non-verbal Individuals as a screening tool revealed that individuals only reported pain in 0\u0026ndash;10% of cases [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In another study conducted by Delwel, which combined self-reported pain with a more comprehensive oral examination, including neurosensory testing, mouth opening, and additional testing for caries profunda, 25% of participants reported pain in at least one of the aforementioned aspects [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. This may explain the differences with the results of this study. Orofacial pain seems to be underestimated when relying only on self-reported pain. In the present study, cognitive impairment even showed a negative correlation for pain as well as for xerostomia and chewing difficulty, which may indicate that individuals with cognitive decline are unable to effectively communicate their pain and discomfort. Although research has shown that self-reporting is the gold standard and should be encouraged, it may lead to inadequate diagnosis and inappropriate treatment for people [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe self-reported item that scored highest in this study was \u003cb\u003exerostomia\u003c/b\u003e. Approximately one-third of the participants reported experiencing dry mouth in the past three days. In Krausch-Hofmann's study (2021), this percentage was even higher, at 40.8% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These results are in line with Janssens et al. (2023) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Their systematic review showed that xerostomia in most studies was reported by 35\u0026ndash;50% of the nursing home residents [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Although many older people report the sensation of dry mouth, this does not necessarily imply they suffer from hyposalivation [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. A cross-sectional study by Diep (2021) showed xerostomia in older people was correlated with medication use, rheumatic disease and radiotherapy in the head/neck region, while hyposalivation was associated with medication use and diabetes [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. A systematic review showed an overall prevalence rate of hyposalivation in older people of 33.37%, showing higher rates in women and in institutionalised people [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch has also shown that xerostomia is frequently associated with polypharmacy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This association was also confirmed for the participants in the present study. Approximately half of the participants used at least nine medications which aligns with the findings of Janssens et al. (2017) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, polypharmacy was associated with chewing difficulty, pain in the mouth and being edentulous. A systematic review reporting on oral conditions associated with dry mouth in older adults with polypharmacy indicated that tooth loss and dental caries were the most commonly reported conditions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, among other associations, the included studies also observed an association with chewing difficulty and pain [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Apart from polypharmacy, the association between dry mouth with chewing difficulty and pain was also evident in the current study when exploring the associations within the items of the OHS-interRAI.\u003c/p\u003e \u003cp\u003eThe most prevalent issues identified among participants in this study were related to \u003cb\u003ehygiene\u003c/b\u003e. However, no correlation could be seen between denture hygiene and oral hygiene. This may be due to the small number of participants with both dentures and natural teeth. Janssens et al. (2023) also found in their systematic review that both oral hygiene and denture hygiene were inadequate in nursing home residents, with high levels of plaque [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The current study demonstrated that in 68.5% of individuals with removable dentures, more than a third of the inner surface was covered with plaque or tartar. This is higher than in the study by Krausch-Hofmann et al. (2021), which showed a prevalence of 55%. Regarding oral hygiene in people with natural teeth, an even greater proportion of participants presented poor scores. In the current study, oral hygiene was inadequate in 75.7% of participants. In Stefanie Krausch-Hofmann et al. (2021), this figure was 84% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A more detailed assessment of oral hygiene with the OHI indicated that overall oral hygiene was moderate. However, looking at the underlying Debris Index and Calculus Index, it is clear that plaque accumulation is the main problem. Only 9% of the participants had an acceptable amount of plaque, while for tartar this was acceptable for approximately half of the participants according to M\u0026uuml;hlemann (1976) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The most recent national oral health survey in 2010 by De Visschere et al. (2016) also concluded that a significant proportion of participants had inadequate denture hygiene and oral hygiene [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, the different way of assessing and reporting on these problems makes a clear comparison impossible. Nevertheless, De Visschere et al. (2016) observed that individuals living in residential care facilities exhibited significantly elevated plaque levels compared to their counterparts living at home [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the current study, 57% of participants with \u003cb\u003enatural teeth\u003c/b\u003e exhibited visible breakdown, decay or a defective restoration in at least one tooth. The PUFA index, a measure of the severity of untreated caries, showed that 44% of these participants had caries extending to the nerve. In those diagnosed with this condition, the average number of occurrences was 3 per person. The systematic review by Janssens et al. (2023) reported a great variation in the prevalence of untreated caries in nursing home residents across Europe (23\u0026ndash;82%), mentioning almost all studies reported active caries in more than half of the residents [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Although caries prevalence is high in the present study, it is lower than found by Krausch-Hofmann et al. (2021) and Janssens et al. (2017), reporting prevalences of 77% and 69.7% respectively [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComparable to Krausch-Hofmann (2021), a non-acceptable \u003cb\u003egum condition\u003c/b\u003e in the present study was found in about half of the participants [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Using the OHS-interRAI, gum health was assessed for all participating residents, including edentulous individuals. In such cases, the mucosa of the alveolar ridge was evaluated for the presence of colour changes, swelling, or lesions. Consequently, it is not possible to infer any conclusions regarding the periodontal health of the participants based on this item. However, the modified gingival index in dentate participants showed that 71.4% of the participants had mild to severe inflammation of the entire gingiva. Nevertheless, as the MGI is assessed visually only using a disposable mirror, it is not possible to draw robust conclusions regarding the extent of periodontal problems. A systematic review revealed that periodontal health in nursing home residents varied considerably across Europe, gingivitis being prevalent in 51\u0026ndash;78% of the residents with natural dentition [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Overall, an American report showed that about 60% of the older adults are affected with periodontitis [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. In De Visschere et al. (2016) periodontal disease was diagnosed in 87% of the participants using a conventional periodontal probe for scoring the Dutch Periodontal Screening Index [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Krausch-Hofmann (2021) observed that dentists who assessed oral health with the OHS-interRAI without using a mouth mirror and probe identified approximately 6% fewer unacceptable conditions of oral hygiene, teeth and gums [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe strongest association observed within the items of the OHS-interRAI is the one between the condition of the gums and oral hygiene. A lack of adequate oral hygiene leads to an increase in the accumulation of oral biofilm, which in turn causes gum problems, initially gingivitis, which can evolve into periodontitis. This relationship has been extensively demonstrated in literature [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Furthermore, the condition of the gums showed to be associated with cognitive decline and to a lesser extent with functional impairment and the need for extensive support. Research has shown a correlation between these personal characteristics and a higher prevalence of poor oral and denture hygiene and periodontal disease [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs with Krausch-Hofmann (2021) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], the lowest number of problems was observed in the \u003cb\u003etongue\u003c/b\u003e. In the current study, this only concerned 7.5% of the participants. This is comparable, but slightly less than the Krausch-Hofmann study (10%) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The item tongue of the OHS-interRAI was also slightly adapted after the international Delphi by Schoebrechts et al. (2023) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Previously, the condition of the tongue was determined by the presence or absence of moisture on the tongue, which is no longer the case. Disorders of the tongue are not frequently reported as a distinct category in studies. Instead, they are often grouped with other oral mucosal lesions [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Furthermore, epidemiologic studies concerning oral mucosal lesions are rather scarce compared to studies on caries and periodontitis [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. However, the tongue is an item in other oral health assessment instruments, such as the Revised Oral Assessment Guide (ROAG) and the Oral Health Assessment Tool (OHAT). A study conducted by Zenth\u0026ouml;fer (2014) in Germany utilizing the ROAG by dentists in an epidemiological study revealed a prevalence of 2.6% for the item tongue [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Another Swedish study using ROAG in a population of more than 2500 participants showed that 15.0% of participants with problems related to tongue [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs to \u003cb\u003eoral mucosal lesions\u003c/b\u003e, in the OHS-interRAI the palate, and inner surface of cheeks and lips are inspected for colour changes, swelling, sores or patches. The present study showed a comparable amount of problems with these soft tissues with Krausch-Hofmann (2021), showing a prevalence of 20% and 23.4% respectively [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Most common oral lesions are denture-related[\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Janssens et al. (2023) reported prevalence rates of 10\u0026ndash;15% of denture stomatitis and 1.5\u0026ndash;18.0% of pressure ulcers because of dentures in European nursing home residents [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. De Visschere et al. (2016) reported at least one lesion in nearly 25% of all participants, with the highest prevalence for denture pressure ulcers (10%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Within the OHS-interRAI, poor denture hygiene was found to be associated with poor condition of the gums and palate, cheeks and lips. A systematic review by Wong et al. (2019) on the factors related to the oral health of nursing home residents reported a median of 21% of surveyed residents with some type of denture stomatitis [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the oral health problems as assessed by dentists with the OHS-interRAI in the present study align with the results of previous studies in Belgium [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and Europe [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], showing the need for better oral hygiene and professional dental care. With the assessment of the OHS-interRAI, CAPs are triggered when oral hygiene is deficient or when a resident needs referral to a dentist. Comparable to Krausch-Hofmann (2021), in approximately 70% of the participants the CAP Oral hygiene was activated [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The CAP Referral to a Dentist was activated in 75% of the participants in the present study, whereas in the study of Krausch-Hofmann (2021), this was the case for about 91% of the participants [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe strength of oral health assessment with the OHS-interRAI is that it offers a comprehensive overview of all oral structures, including oral hygiene [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and that it is embedded in a holistic BelRAI LTCF assessment, which provides a comprehensive overview of a resident's care needs and care preferences. Furthermore, dental indices were used to provide a more detailed assessment of common oral problems such as tooth decay, gum problems, and oral hygiene. This information provides a general understanding of the oral care needs of this study group. However, as a limitation, it is essential to acknowledge that despite the utilisation of indices, this study represents an underestimation of oral health issues. This is due, in part, to the fact that the dentists were not equipped with a comprehensive set of instruments and diagnostic options, as would be the case in a dental practice. Another limitation is that only nursing homes could be included that used a specific software package allowing the collection of data from BelRAI LTCF and OHS-interRAI. Therefore, despite the large sample size, the findings of this study cannot be generalized to the entire population of residents in nursing homes in Flanders. However, the results of this study confirm previous research in Belgium, Flanders and Europe.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite the advances in dentistry and the Belgian health care system in which all Belgians have a compulsory health insurance, the oral health of nursing home residents has not improved compared to previous studies for which oral health data were collected on a larger scale in 2010\u0026ndash;2012 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. As oral health is strongly related to holistic health, and impacts quality of life [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], these findings indicate that continued attention is needed to the early detection and prevention of oral health problems in older people. The study also showed that the oral health of people with cognitive decline or functional impairment needs more attention. Their oral hygiene is often worse than that of people without cognitive or functional impairment. Good daily oral hygiene and regular dental visits are the foundation of good oral health [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this study, about 30% of people had visited a dentist in the previous year, a figure that is lower than that reported by the Intermutualistic Agency (IMA atlas) for Flanders. The IMA atlas reports that in 2022, 58.1% of people aged 65\u0026ndash;74 had visited a dentist, while 41.3% of people aged 70 and over had done so. However, nursing home residents face several barriers to accessing a dentist [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. The dental hygienist, as a new oral health professional profile in Belgium since 2019, could potentially represent an important change here. Not only can dental hygienists enhance access to professional oral healthcare, but also to more effective daily oral care by empowering healthcare providers and residents.\u003c/p\u003e \u003cp\u003eOral health is determined by many factors. Flanders and Belgium have taken several measures that may imply we are at a tipping point for better oral health for care-dependent older people. From June 2023, the Belgian government has mandated the use of the BelRAI LTCF as the basis for care planning in nursing homes. The OHS-interRAI, an oral health assessment developed for healthcare providers without a dental background, is being implemented in BelRAI LTCF. This will support professional caregivers in monitoring and improving oral health. This not only offers the opportunity to integrate oral care into general care, but also provides the opportunity to monitor the oral health of residents in nursing homes in Belgium on a standardised and regular basis for epidemiological research purposes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eADL \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Activities of Daily Living\u003c/li\u003e\n \u003cli\u003eADL-H \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Activities of Daily Living Hierarchy Scale of the interRAI LTCF\u003c/li\u003e\n \u003cli\u003eBelRAI LTCF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Belgian version of the international Resident Assessment Instrument for use in Long Term Care Facilities\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCAP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Collaborative Action Points\u003c/li\u003e\n \u003cli\u003eCHESS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Changes in Health, End-Stage Disease, Signs, and Symptoms scale\u003c/li\u003e\n \u003cli\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Calculus Index\u003c/li\u003e\n \u003cli\u003eCPS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Cognitive Performance Scale\u003c/li\u003e\n \u003cli\u003eDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Debris Index\u003c/li\u003e\n \u003cli\u003eDRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Depression Rating Scale\u003c/li\u003e\n \u003cli\u003einterRAI\u0026nbsp;international Resident Assessment Instrument\u003c/li\u003e\n \u003cli\u003eIMA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intermutualistic Agency\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLTCF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Long Term Care Facilities\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMGI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Modified Gingival Index\u003c/li\u003e\n \u003cli\u003eNIHDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Institute for Health and Disability Insurance (Belgium)\u003c/li\u003e\n \u003cli\u003eOHAT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Oral Health Assessment Tool\u003c/li\u003e\n \u003cli\u003eOHI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Oral Hygiene Index\u003c/li\u003e\n \u003cli\u003eOHS-interRAI \u0026nbsp; \u0026nbsp; \u0026nbsp;Oral Health Section for use within the interRAI Suite of Instruments\u003c/li\u003e\n \u003cli\u003ePUFA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pulp Ulceration Fistel Abscess\u003c/li\u003e\n \u003cli\u003eROAG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Revised Oral Assessment Guide\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSTROBE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Strengthening the Reporting of Observational Studies in Epidemiology\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study has been conducted in accordance with the ethical standards set forth in the Declaration of Helsinki and received ethical approval on 29 November 2021 from the Ethics Committee Research UZ/KU Leuven, Belgium, with reference B3222021000650.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe nursing home management teams were provided with a comprehensive information note on the study, and signed an informed consent form.\u0026nbsp;Each individual participant, or their legally authorised representative,\u0026nbsp;was given comprehensive information about the study and provided\u0026nbsp;their written informed consent for participation.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll participants or their legally appointed representatives provided written consent for the publication of data in an aggregated and unidentifiable format.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Pyxicare, Belgium. However, restrictions apply to the availability of these data, which were used under a GDPR licence for the current study. Consequently, the data are not publicly available; however, they can be assessed upon reasonable request and with permission from the Belgian Privacy Commission. For any data or queries pertaining to the study, please contact the corresponding author, Patricia Ann Ivonne Vandenbulcke ([email protected]).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis work was funded by Research Foundation Flanders [TBM T003220N] and KU Leuven [C24M-20-063].\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors acknowledge the contributions of the dentists, dental hygienist and dental assistant in the oral health assessments of the participating residents on a voluntary basis: Bakelants L., De Meester J.-M., De Schepper W., De Schrijver M., Deceuninck M., Konings N., Morren J., Piccart F., Stinkens L., Van Bael T., Van Dessel H., Verschueren L. and Wauters E.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their gratitude to the nursing homes and caregivers who participated in the study and provided their cooperation.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; ORCID ID\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatricia A. I. Vandenbulcke:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-8436-6784\"\u003e0000-0002-8436-6784\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eJohanna de Almeida Mello:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-1262-318X\"\u003e0000-0002-1262-318X\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eEmilie Schoebrechts:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-7797-567X\"\u003e0000-0002-7797-567X\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eJan De Lepeleire:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0001-6152-2134\"\u003e0000-0001-6152-2134\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eAnja Declercq:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0003-3136-124X\"\u003e0000-0003-3136-124X\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eDominique Declerck:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0003-4637-0675\"\u003e0000-0003-4637-0675\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eJoke Duyck:\u0026nbsp;\u003ca href=\"https://orcid.org/0000-0002-8698-1692\"\u003e0000-0002-8698-1692\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; affiliations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Oral Health Sciences, Population Studies in Oral Health, KU Leuven, Kapucijnenvoer 7 Box 7001, 3000 Leuven, BELGIUM\u003c/p\u003e\n\u003cp\u003ePatricia A. I. Vandenbulcke, Johanna de Almeida Mello, Emilie Schoebrechts, Dominique Declerck \u0026amp; Joke Duyck\u003c/p\u003e\n\u003cp\u003eLUCAS, Centre for Care Research and Consultancy, KU Leuven, Minderbroedersstraat 8 Box 5310, 3000 Leuven, BELGIUM\u003c/p\u003e\n\u003cp\u003eJohanna de Almeida Mello \u0026amp; Anja Declercq\u003c/p\u003e\n\u003cp\u003eDepartment of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 blok H\u0026nbsp;- Box 7001, 3000 Leuven, BELGIUM\u003c/p\u003e\n\u003cp\u003eJan De Lepeleire\u003c/p\u003e\n\u003cp\u003eCentre for Sociological Research (CeSO), KU Leuven, Parkstraat 45 Box 3601, 3000 Leuven, BELGIUM\u003c/p\u003e\n\u003cp\u003eAnja Declercq\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCRediT author statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatricia A. I. Vandenbulcke:\u0026nbsp;\u003c/strong\u003eConceptualisation, Methodology, Software, Validation, Formal analysis,Investigation,Resources,Data Curation,Writing - Original Draft,Writing - Review and Editing, Visualisation,Project administration\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJohanna de Almeida Mello:\u0026nbsp;\u003c/strong\u003eConceptualisation, Methodology, Software, Validation,Formal analysis,Investigation,Resources, Data Curation,Writing - Original Draft,Writing - Review and Editing, Visualisation, Supervision,Project administration,Funding acquisition\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmilie Schoebrechts:\u0026nbsp;\u003c/strong\u003eValidation, Writing - Review and Editing, Visualisation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJan De Lepeleire:\u0026nbsp;\u003c/strong\u003eConceptualisation, Methodology, Validation, Writing - Review and Editing, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnja Declercq:\u0026nbsp;\u003c/strong\u003eConceptualisation, Methodology, Validation, Writing - Review and Editing, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDominique Declerck:\u0026nbsp;\u003c/strong\u003eConceptualisation, Methodology,Validation, Resources, Writing - Review and Editing, Visualisation, Supervision,Funding acquisition\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJoke Duyck\u003c/strong\u003e: Conceptualisation, Methodology, Validation, Resources, Data Curation, Writing - Original Draft, Writing - Review and Editing, Visualisation, Supervision, Project administration, Funding acquisition\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZorg voor ouderen [\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gezondbelgie.be/nl/performantie-van-het-belgische-gezondheidssysteem/specifieke-zorgdomeinen/zorg-voor-ouderen#OLD1-2]\u003c/span\u003e\u003cspan address=\"https://www.gezondbelgie.be/nl/performantie-van-het-belgische-gezondheidssysteem/specifieke-zorgdomeinen/zorg-voor-ouderen#OLD1-2]\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Clinical and Subjective Oral Health Status of Care Home Residents in Europe: A Systematic Review. \u003cem\u003eJ. Am. Med. Dir. Assoc.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (7), 1013\u0026ndash;1019e1040 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetersen, P. E. \u0026amp; Yamamoto, T. Improving oral health of older people: the approach of the WHO Global Oral Health Programme. In., vol. 33; : 81\u0026ndash;92. (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaka, O., Anastassiadou, V. \u0026amp; Pissiotis, A. Association between functional tooth units and chewing ability in older adults: a systematic review. \u003cem\u003eGerodontology\u003c/em\u003e. \u003cb\u003e31\u003c/b\u003e (3), 166\u0026ndash;177 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorg-Bartolo, R. et al. 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Masticatory dysfunction in older adults: A scoping review. \u003cem\u003eJ. Rehabil.\u003c/em\u003e \u003cb\u003e50\u003c/b\u003e (8), 724\u0026ndash;737 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan de Rijt, L. J., Feast, A. R., Vickerstaff, V., Lobbezoo, F. \u0026amp; Sampson, E. L. Prevalence and associations of orofacial pain and oral health factors in nursing home residents with and without dementia. \u003cem\u003eAge ageing\u003c/em\u003e. \u003cb\u003e49\u003c/b\u003e (3), 418\u0026ndash;424 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelwel, S. et al. Psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals as a screening tool for orofacial pain in people with dementia. \u003cem\u003eGerodontology\u003c/em\u003e. \u003cb\u003e35\u003c/b\u003e (3), 200\u0026ndash;213 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelwel, S., Binnekade, T. T., Perez, R. S. G. M., Scherder, M. H. C. M. P. \u0026amp; Lobbezoo, E. J. A. Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues. \u003cem\u003eClin. Oral Invest.\u003c/em\u003e \u003cb\u003e22\u003c/b\u003e, 93\u0026ndash;108 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Steen, J. T. P. et al. Tools to Assess Pain or Lack of Comfort in Dementia: A Content Analysis. \u003cem\u003eJ. Pain Symptom Manag.\u003c/em\u003e \u003cb\u003e50\u003c/b\u003e (5), 659\u0026ndash;675e653 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan der Putten, G-J., Brand, H. S., Schols, J. M. G. A. \u0026amp; de Baat, C. The diagnostic suitability of a xerostomia questionnaire and the association between xerostomia, hyposalivation and medication use in a group of nursing home residents. \u003cem\u003eClin. Oral Invest.\u003c/em\u003e \u003cb\u003e15\u003c/b\u003e (2), 185\u0026ndash;192 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiep, M. T. et al. Xerostomia and hyposalivation among a 65‐yr‐old population living in Oslo, Norway. \u003cem\u003eEur. J. Oral. Sci.\u003c/em\u003e \u003cb\u003e129\u003c/b\u003e (1), e12757\u0026ndash;n (2021). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/a\u003c/span\u003e\u003cspan address=\"http:///a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePina, G. M. S., Mota Carvalho, R. \u0026amp; Silva BSdF, Almeida, F. T. Prevalence of hyposalivation in older people: A systematic review and meta-analysis. \u003cem\u003eGerodontology\u003c/em\u003e. \u003cb\u003e37\u003c/b\u003e (4), 317\u0026ndash;331 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBethesda, MUDoHaHS \u0026amp; National Institutes of Health, National Institute of Dental and Craniofacial Research.. Oral Health in America: Advances and Challenges Available: (2024). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK576535/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK576535/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed Feb 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapple, I. L. C. et al. Primary prevention of periodontitis: managing gingivitis. \u003cem\u003eJ. Clin. 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Treat.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e (default), 2285\u0026ndash;2290 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRantzow, V., Andersson, P. \u0026amp; Lindmark, U. Occurrence of oral health problems and planned measures in dependent older people in nursing care. \u003cem\u003eJ. Clin. Nurs.\u003c/em\u003e \u003cb\u003e27\u003c/b\u003e (23\u0026ndash;24), 4381\u0026ndash;4389 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEwan, V. \u0026amp; Staines, K. Diagnosis and management of oral mucosal lesions in older people: a review. \u003cem\u003eReviews Clin. Gerontol.\u003c/em\u003e \u003cb\u003e18\u003c/b\u003e (2), 115\u0026ndash;128 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandenbulcke, P. A. I. et al. Nursing home residents\u0026rsquo; perspectives on oral health: An in-depth interview study. \u003cem\u003eInt. J. Nurs. Stud. Adv.\u003c/em\u003e \u003cb\u003e6\u003c/b\u003e, 100198\u0026ndash;100198 (2024).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aged, Epidemiology, Geriatric assessment, interRAI, Long-Term Care, Oral Health, Oral Hygiene, Oral Health Assessment, Patient Care Planning, Public Health","lastPublishedDoi":"10.21203/rs.3.rs-4950980/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4950980/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA decline in self-care due to deteriorating general health presents a challenge for oral health in care-dependent older people. The most recently published data on the oral health of nursing home residents in Flanders, as assessed by oral health professionals, dates from 2010 to 2012. This study aimed to update the condition on the current oral health status of nursing home residents in Flanders.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn this cross-sectional study, the oral health of nursing home residents was evaluated by oral health professionals using the Oral Health Section as developed for use within the interRAI Suite of Instruments (OHS-interRAI). Validated dental indices were used to provide more detailed information about the condition of oral hygiene, gums, and teeth. Bivariate analyses were performed to investigate associations between oral health items and participants\u0026rsquo; clinical characteristics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 458 residents participated in the study with a mean age of 82.7 (\u0026plusmn;\u0026thinsp;7.8) years (70.3% female). For people with natural teeth (53.9%), the most prevalent oral health problems were insufficient oral hygiene (75.7%), and poor condition of teeth (56.6%) and gums (49.9%). High levels of dental plaque resulted in a mean Oral Hygiene Index of 4.5 (\u0026plusmn;\u0026thinsp;2.6). About 44.0% of the participants had at least one tooth with untreated caries affecting the nerve. The mean Modified Gingival Index was 1.8 (\u0026plusmn;\u0026thinsp;1.2), indicating mild inflammation of the entire gingiva. Denture hygiene was insufficient in 68.5% of the cases. Self-reported oral health problems were mainly related to dry mouth (32.8%) and chewing difficulty (23.4%). Strongest correlations were found between oral hygiene and gum condition (r\u0026thinsp;=\u0026thinsp;.324, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) and chewing difficulty and pain (r\u0026thinsp;=\u0026thinsp;.247, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). Furthermore, cognitive impairment showed strongest correlation with the level of oral hygiene and gingival health.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDespite the advances in dentistry, the oral health of nursing home residents still remains poor. Oral health of people with cognitive decline or functional impairment needs more attention. The regular oral health assessment with the OHS-interRAI by healthcare providers without a dental background has the potential to facilitate the early detection and prevention of oral health problems.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e\u003c/p\u003e \u003cp\u003eClinicalTrials.gov NCT06536322- Retrospectively registered July 23rd, 2024.\u003c/p\u003e","manuscriptTitle":"Oral health status of nursing home residents in Flanders, Belgium: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-01 05:22:48","doi":"10.21203/rs.3.rs-4950980/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-02T10:32:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-29T22:48:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-21T15:15:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127446342771409514094096206137875565029","date":"2024-11-15T10:43:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287548164179531090940191643338854745915","date":"2024-11-14T09:56:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276427876339886974672754036176401823297","date":"2024-10-22T21:28:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-08T21:56:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-08T21:55:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-09-03T05:31:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-30T12:41:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-08-21T10:44:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"097d1ed0-d3ae-4b63-a5b5-ee4fe58cf1c9","owner":[],"postedDate":"October 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":37607099,"name":"Health sciences/Diseases"},{"id":37607100,"name":"Health sciences/Health care"},{"id":37607101,"name":"Health sciences/Health occupations"}],"tags":[],"updatedAt":"2025-02-17T16:12:50+00:00","versionOfRecord":{"articleIdentity":"rs-4950980","link":"https://doi.org/10.1038/s41598-025-89910-4","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-02-14 15:57:11","publishedOnDateReadable":"February 14th, 2025"},"versionCreatedAt":"2024-10-01 05:22:48","video":"","vorDoi":"10.1038/s41598-025-89910-4","vorDoiUrl":"https://doi.org/10.1038/s41598-025-89910-4","workflowStages":[]},"version":"v1","identity":"rs-4950980","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4950980","identity":"rs-4950980","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}