The major findings of this study were as follows: 1) poor oral health, assessed using the ROAG score, is relatively common in elderly patients with acute HF, 2) patients with poor oral health had significantly more geriatric conditions than those with normal oral health, and 3) the ROAG score was independently correlated with changes in the BI during hospitalization in elderly patients with acute HF.
Oral health problems have been reported as common health conditions in older adults and hospitalized patients [17] [18] [27] [28]. Several points are known about the relationship between oral health problems and heart failure. Chronic inflammation caused by periodontal diseases is a risk factor for cardiac and cerebrovascular diseases, which are the most major comorbidities of HF [29] [30]. General fatigue, dyspnea, delirium, and sleep disturbance accompanied by decompensated HF might contribute to reducing adherence to oral hygiene. In addition, dry mouth is often a consequence of polypharmacy, particularly as a side effect of cardiovascular agents (angiotensin-converting enzyme inhibitors, beta-blockers, and diuretics) [31] [32]. However, oral health has been underrecognized in the assessment and management of patients with HF. Our data suggests the importance of oral assessment in the multidisciplinary management of elderly HF patients because poor oral health is highly prevalent and significantly associated with decline in physical function during hospitalization.
We have previously demonstrated that hospitalization for HF was significantly correlated with decreased BI as an assessment of ADL, and a decreased BI during hospitalization was associated with worse clinical outcomes [8]. It has also been reported that a decline in ADL due to acute HF is an independent risk factor of hospitalization for HF and mortality [33]. Therefore, it is important to identify predictors of ADL decline during hospitalization in patients with HF. It has been demonstrated in elderly patients and patients with HF that age and the nutritional index are associated with ADL decline during hospitalization [33] [34]. Our present study involving elderly patients with HF has shown that the ROAG score serves as a good predictor of changes in ADL, and its predictive ability is comparable to age, nutritional indices, and various other parameters. Therefore, oral assessment of patients with HF using the ROAG score to screen for poor oral health may allow us to provide comprehensive care and rehabilitation to patients with poor oral health at an earlier stage. This may help prevent ADL decline during hospitalization for HF, leading to a better prognosis.
In the present study, nutritional status, assessed by CONUT and GNRI, was worse in the poor oral health group than in the normal oral health group. Furthermore, patients with poor oral health had lower dietary energy intake. Previous studies have demonstrated that poor oral health is associated with periodontal disease, dental caries, hyposalivation, and tooth loss or edentulousness, which pose risks of chewing difficulties, decreased masticatory function, and dysphagia [35] [36]. These oral problems may induce a preference for soft and easily chewable food and a need for changes in food texture to prevent aspiration and choking, leading to poor nutritional intake and undernutrition, and finally to sarcopenia, frailty, and decreased physical function [17] [37] [38].
In the acute setting of decompensated HF, nurses have a pivotal role in oral assessment and care, because of the small number of dentists and oral hygienists. Several oral health assessment tools have been developed for non-dental health care professionals [21] [39] [40]. Among these indices, the ROAG is not only a simple and comprehensive assessment but it also has favorable validity and reliability [41]. Oral assessment in patients with acute HF might have several influences on multidisciplinary disease management. First, patients who require consultation with in-hospital or regional dental health care professionals are screened. Second, nurses receive feedback on oral care from their patients. Third, oral care is one of the fundamental self-care activities after discharge, and thus, the information that an oral assessment provides is useful for educating patients on dental health compliance. Forth, several management strategies could be considered for patients with poor oral health. Nutritionists and dietitians could help to increase the dietary intake of the patients by changing meal content and food texture. Doctors and pharmacists could choose orally disintegrating tablets for the ease of taking medicines. Although the efficacy of multidisciplinary interventions for patients with poor oral health has not been fully elucidated, we believe that oral assessment could provide useful information for the multidisciplinary management of elderly patients with HF.
The present study had several limitations. First, this was a single-center, retrospective study, and the sample size was relatively small. Future prospective studies are necessary with larger patient populations. Second oral health was assessed by only one certified dysphagia nurse. Hence, the results could not be generalized to the routine assessment by ward nurses.