In light of the increase in life expectancy, aging is "on the verge of becoming one of the most significant social transformations of the twenty-first century”1. In Spain, people over 65 represent 19.2% of the total population2, a figure that will reach 25.2% in 20333.
This makes it necessary to reconsider the way in which we attend and treat elderly patients in society4, not just those who have sufficient personal autonomy but also those, estimated to represent around 3% of the elderly5, 6, who live in institutions and need some kind of specific care. Despite this need, there are few studies that describe the situation in which this population group find themselves and which might contribute to improving the attention given to them and therefore increase their quality of life. For example, in Spain there are no studies published in which the physical, medical and psychological conditions of the institutionalized elderly population are evaluated 5.
The progress and improvements that have been made in dentistry, as well as new patterns of care and prevention, have meant that it is increasingly possible to reach elderly people with a large number of teeth and in a better state of dentition than ever before 7, 8 although there is still a tendency for the elderly to be vulnerable to caries and periodontitis 8. Oral pathologies can significantly affect health and general welfare of the population, and lead to alterations in speech, the poor pronunciation of certain words, or deficient food intake, raising the risk of malnutrition 9 due to problems with chewing or swallowing. Moreover, oral health can have a negative effect on facial aesthetics, lowering self-esteem and harming the psychosocial well-being of the individual 10,11,12. Numerous studies have described the relationship between poor oral health and the emergence of systemic diseases, ranging from heart disease or Diabetes Mellitus to respiratory diseases, such as pneumonia 8, 10, 13, 14.
Diseases such as Parkinson's or Alzheimer's, or neuromuscular disorders, are some of the reasons that many are no longer able to carry out oral care tasks, due to a loss of manual dexterity, basically because of a loss of motor and cognitive skill, or because they do not remember how to brush their teeth or are not able to follow the instructions on how to do so themselves 11.
In the case of geriatric patients, the frequent coexistence of several diseases and disorders in the same patient must also be taken into account. Comorbidity in this population makes them especially susceptible to oral pathologies, often as a result of the medication they are taking, which increase the risk of tooth decay through alterations in saliva flow 10. In addition, some disorders may give rise to physical, cognitive or even motivational limitations that interfere with the development and habit of practising good oral hygiene 11, 15, 16.
Added to the vulnerability of geriatric patients in this respect, other factors may limit their access to oral attention, such as an inability to assume the costs of treatment, reduced physical mobility, the lack of transport or the absence of caregivers or family members who can accompany them. In addition, the work they used to do, their social environment or their own idiosyncrasies may mean the person lacks the ability to recognize the need for an a dental examination or treatment 10.
Despite the high prevalence of oral health problems in this group of patients, little or no importance is given to this problem 10, leading the World Health Organization (WHO) to advise on the need to increase awareness, on a social, cultural and medical level, of oral health as a major component of overall health and quality of life 15. The organization strongly recommends that countries develop programmes to meet the needs of their elderly citizens in this respect and to research the problem of oral care in the elderly, due to an increase in the overall incidence of non-transmissible diseases17. A survey of the oral health of elderly patients carried out by the WHO revealed that oral health programmes targeting this population group are very rare17, and that dental intervention tends to be therapeutic rather than (ideally) preventive. That is why hospitalization or long stays in care centres present a good opportunity for providing dental assistance that would otherwise not be offered to the general elderly population 10.
The removal of bacterial plaque at least twice a day (morning and evening) is essential for maintaining oral health, especially in dependent older people. However, despite the important role that staff in hospitals and other long stay centers such as nursing homes, could play in maintaining and influencing oral health, they do not know what care and oral hygiene protocols should be followed with the elderly, except those patients who are at risk of pneumonia associated with mechanical ventilation 11.
Although oral pathologies are among the most common chronic diseases and represent an important public health problem due to their prevalence and the expense of treatment15, there is a general but erroneous belief that oral hygiene and care are unimportant11. When patients, for different reasons, reject oral care, staff simply accept their refusal. However, refusing treatment would not be tolerated in other interventions - for example, measuring the level of glucose in the blood or the blood pressure of a patient. This situation is doubly severe in elderly patients with dementia who are reluctant to be cared for by third parties, Moreover, care providers may not be in a position to offer proper care, either because the patient refuses or because they are overworked and decide not to assist them. For all of the above, these patients can be considered extremely vulnerable and are at higher risk than the general elderly population11.
Bilder et al.15 describes how poor oral health and limited access to oral care for adults in long-term care centres, as well as the lack of detailed guidelines, are a reflection of insufficient scientific evidence concerning the dental care support techniques that can be offered11. This clearly does not help when attempts are made to reverse this situation. However, problems of oral health, ranging from dental caries to chewing problems or pain, constitute the most frequent treatment needs and are among the least successfully resolved health problems in the population group consisting of older people and the disabled15.
For all these reasons, we think that the lack of information, documentation and prevention concerning the oral health of elderly patients can have an advese impact on health, i.e., on the state of complete physical, mental and social well-being.
Our main objective, then, was to conduct a systematic review to ascertain the state of oral health of elderly patients in an institution for a long period of time, analysing those parameters that could reveal their current oral situation. Secondary objectives were: to see whether any deterioration of oral health detected in these patients is affected by their being in a hospital or residence; to ascertain whether a standard protocol exists concerning the oral health care of these patients; to compare the information obtained with published scientific literature, and, if no relevant information exists, to propose a line of research to establish a prevention-based protocol for oral care in the elderly population, especially those in long stay facilities.
The literature search strategy followed in making this systematic review was in accordance with the PICOS framework18. The focus question was: What is the state of oral health of institutionalized elderly patients?