Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues
Identifieur interne : 000E26 ( Pmc/Corpus ); précédent : 000E25; suivant : 000E27Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues
Auteurs : Suzanne Delwel ; Tarik T. Binnekade ; Roberto S. G. M. Perez ; Cees M. P. M. Hertogh ; Erik J. A. Scherder ; Frank LobbezooSource :
- Clinical Oral Investigations [ 1432-6981 ] ; 2016.
Abstract
The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia.
A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS).
The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without.
Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia.
The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.
Url:
DOI: 10.1007/s00784-016-1934-9
PubMed: 27631597
PubMed Central: 5203832
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PMC:5203832Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues</title><author><name sortKey="Delwel, Suzanne" sort="Delwel, Suzanne" uniqKey="Delwel S" first="Suzanne" last="Delwel">Suzanne Delwel</name><affiliation><nlm:aff id="Aff1">Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Faculty of Dentistry, Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Binnekade, Tarik T" sort="Binnekade, Tarik T" uniqKey="Binnekade T" first="Tarik T." last="Binnekade">Tarik T. Binnekade</name><affiliation><nlm:aff id="Aff1">Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Perez, Roberto S G M" sort="Perez, Roberto S G M" uniqKey="Perez R" first="Roberto S. G. M." last="Perez">Roberto S. G. M. Perez</name><affiliation><nlm:aff id="Aff3">Department of Anesthesiology, EMGO+ Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Hertogh, Cees M P M" sort="Hertogh, Cees M P M" uniqKey="Hertogh C" first="Cees M. P. M." last="Hertogh">Cees M. P. M. Hertogh</name><affiliation><nlm:aff id="Aff4">Faculty of Medicine, Department of Elderly Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Scherder, Erik J A" sort="Scherder, Erik J A" uniqKey="Scherder E" first="Erik J. A." last="Scherder">Erik J. A. Scherder</name><affiliation><nlm:aff id="Aff1">Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Lobbezoo, Frank" sort="Lobbezoo, Frank" uniqKey="Lobbezoo F" first="Frank" last="Lobbezoo">Frank Lobbezoo</name><affiliation><nlm:aff id="Aff2">Faculty of Dentistry, Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27631597</idno><idno type="pmc">5203832</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5203832</idno><idno type="RBID">PMC:5203832</idno><idno type="doi">10.1007/s00784-016-1934-9</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000E26</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000E26</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues</title><author><name sortKey="Delwel, Suzanne" sort="Delwel, Suzanne" uniqKey="Delwel S" first="Suzanne" last="Delwel">Suzanne Delwel</name><affiliation><nlm:aff id="Aff1">Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Faculty of Dentistry, Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Binnekade, Tarik T" sort="Binnekade, Tarik T" uniqKey="Binnekade T" first="Tarik T." last="Binnekade">Tarik T. Binnekade</name><affiliation><nlm:aff id="Aff1">Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Perez, Roberto S G M" sort="Perez, Roberto S G M" uniqKey="Perez R" first="Roberto S. G. M." last="Perez">Roberto S. G. M. Perez</name><affiliation><nlm:aff id="Aff3">Department of Anesthesiology, EMGO+ Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Hertogh, Cees M P M" sort="Hertogh, Cees M P M" uniqKey="Hertogh C" first="Cees M. P. M." last="Hertogh">Cees M. P. M. Hertogh</name><affiliation><nlm:aff id="Aff4">Faculty of Medicine, Department of Elderly Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Scherder, Erik J A" sort="Scherder, Erik J A" uniqKey="Scherder E" first="Erik J. A." last="Scherder">Erik J. A. Scherder</name><affiliation><nlm:aff id="Aff1">Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</nlm:aff></affiliation></author><author><name sortKey="Lobbezoo, Frank" sort="Lobbezoo, Frank" uniqKey="Lobbezoo F" first="Frank" last="Lobbezoo">Frank Lobbezoo</name><affiliation><nlm:aff id="Aff2">Faculty of Dentistry, Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands</nlm:aff></affiliation></author></analytic><series><title level="j">Clinical Oral Investigations</title><idno type="ISSN">1432-6981</idno><idno type="eISSN">1436-3771</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia.</p></sec><sec><title>Methods</title><p>A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS).</p></sec><sec><title>Results</title><p>The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without.</p></sec><sec><title>Conclusions</title><p>Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia.</p></sec><sec><title>Clinical relevance</title><p>The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Petersen, Pe" uniqKey="Petersen P">PE Petersen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rodriguez Rodero, S" uniqKey="Rodriguez Rodero S">S Rodríguez-Rodero</name></author><author><name sortKey="Fernandez Morera, Jl" uniqKey="Fernandez Morera J">JL Fernández-Morera</name></author><author><name sortKey="Menendez Torre, E" uniqKey="Menendez Torre E">E Menéndez-Torre</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Petersen, Pe" uniqKey="Petersen P">PE Petersen</name></author><author><name sortKey="Yamamoto, T" uniqKey="Yamamoto 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Clin Oral Investig</journal-id><journal-id journal-id-type="iso-abbrev">Clin Oral Investig</journal-id><journal-title-group><journal-title>Clinical Oral Investigations</journal-title></journal-title-group><issn pub-type="ppub">1432-6981</issn><issn pub-type="epub">1436-3771</issn><publisher><publisher-name>Springer Berlin Heidelberg</publisher-name><publisher-loc>Berlin/Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27631597</article-id><article-id pub-id-type="pmc">5203832</article-id><article-id pub-id-type="publisher-id">1934</article-id><article-id pub-id-type="doi">10.1007/s00784-016-1934-9</article-id><article-categories><subj-group subj-group-type="heading"><subject>Review</subject></subj-group></article-categories><title-group><article-title>Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">http://orcid.org/0000-0002-6836-5394</contrib-id><name><surname>Delwel</surname><given-names>Suzanne</given-names></name><address><email>s.delwel@vu.nl</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Binnekade</surname><given-names>Tarik T.</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Perez</surname><given-names>Roberto S. G. M.</given-names></name><xref ref-type="aff" rid="Aff3">3</xref></contrib><contrib contrib-type="author"><name><surname>Hertogh</surname><given-names>Cees M. P. M.</given-names></name><xref ref-type="aff" rid="Aff4">4</xref></contrib><contrib contrib-type="author"><name><surname>Scherder</surname><given-names>Erik J. A.</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Lobbezoo</surname><given-names>Frank</given-names></name><xref ref-type="aff" rid="Aff2">2</xref></contrib><aff id="Aff1"><label>1</label>Faculty of Behavioral and Movement Sciences, Department of Clinical Neuropsychology, VU University, Amsterdam, The Netherlands</aff><aff id="Aff2"><label>2</label>Faculty of Dentistry, Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands</aff><aff id="Aff3"><label>3</label>Department of Anesthesiology, EMGO+ Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands</aff><aff id="Aff4"><label>4</label>Faculty of Medicine, Department of Elderly Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands</aff></contrib-group><pub-date pub-type="epub"><day>8</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="pmc-release"><day>8</day><month>9</month><year>2016</year></pub-date><pub-date pub-type="ppub"><year>2017</year></pub-date><volume>21</volume><issue>1</issue><fpage>17</fpage><lpage>32</lpage><history><date date-type="received"><day>26</day><month>5</month><year>2016</year></date><date date-type="accepted"><day>3</day><month>8</month><year>2016</year></date></history><permissions><copyright-statement>© The Author(s) 2016</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold> This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.</license-p></license></permissions><abstract id="Abs1"><sec><title>Objective</title><p>The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia.</p></sec><sec><title>Methods</title><p>A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS).</p></sec><sec><title>Results</title><p>The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without.</p></sec><sec><title>Conclusions</title><p>Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia.</p></sec><sec><title>Clinical relevance</title><p>The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Dementia</kwd><kwd>Elderly</kwd><kwd>Aged</kwd><kwd>Gerodontology</kwd><kwd>Facial pain</kwd><kwd>Oral health</kwd><kwd>Stomatognathic disease</kwd></kwd-group><funding-group><award-group><funding-source><institution>Fonds NutsOhra (NL)</institution></funding-source><award-id>1130-046</award-id><principal-award-recipient><name><surname>Scherder</surname><given-names>Erik J. A.</given-names></name></principal-award-recipient></award-group><award-group><funding-source><institution>Alzheimer Nederland</institution></funding-source><award-id>WE.09-2012-02</award-id><principal-award-recipient><name><surname>Scherder</surname><given-names>Erik J. A.</given-names></name></principal-award-recipient></award-group><award-group><funding-source><institution>Amstelring</institution></funding-source><award-id>RVB U-9107-2013/HM/wb</award-id><principal-award-recipient><name><surname>Scherder</surname><given-names>Erik J. A.</given-names></name></principal-award-recipient></award-group><award-group><funding-source><institution>Roomsch Catholijk Oude Armen Kantoor (RCOAK)</institution></funding-source><award-id>U-9128-2012 HM/lw</award-id><principal-award-recipient><name><surname>Scherder</surname><given-names>Erik J. A.</given-names></name></principal-award-recipient></award-group><award-group><funding-source><institution>Stichting Beroepsopleiding Huisartsen (SBOH)</institution></funding-source></award-group><award-group><funding-source><institution>Stichting Henriëtte Hofje</institution></funding-source></award-group></funding-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© Springer-Verlag Berlin Heidelberg 2017</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Introduction</title><p>During recent decades, an improvement in oral health care was seen, and consequently, an increase in the number of remaining teeth at higher ages [<xref ref-type="bibr" rid="CR1">1</xref>]. Aging is an important risk factor in the development of medical conditions [<xref ref-type="bibr" rid="CR2">2</xref>], and general health has a wide-ranging interaction with oral health [<xref ref-type="bibr" rid="CR3">3</xref>–<xref ref-type="bibr" rid="CR12">12</xref>]. Therefore, with the aging of the population, an increase in oral health problems is to be expected.</p><p>Oral health in older people has been described in several studies, examining the number of teeth present, dentures, oral disease, and caries. Edentulousness is prevalent among older people all over the world and is highly associated with socio-economic status [<xref ref-type="bibr" rid="CR1">1</xref>]. Dentures are particularly frequent among older people in the developed countries [<xref ref-type="bibr" rid="CR4">4</xref>]. In these countries, full dentures in both the upper and lower jaw are worn by one third to half of the older population, while partial dentures or full dentures in one jaw are worn by three quarters of the older population [<xref ref-type="bibr" rid="CR3">3</xref>]. Dental caries is highly prevalent in older people in several countries, such as Australia and the USA [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>] and is closely associated with social and behavioral factors [<xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR7">7</xref>]. More specifically, caries tends to be more prevalent in people with low income, irregular dentist visits, lower frequency of brushing teeth, and high sugar consumption [<xref ref-type="bibr" rid="CR7">7</xref>–<xref ref-type="bibr" rid="CR9">9</xref>]. The caries increments of older people (between 0.8 and 1.2 newly affected tooth surfaces per year) exceed that of adolescents (between 0.4 and 1.2 newly affected tooth surfaces per year) [<xref ref-type="bibr" rid="CR6">6</xref>]. Altogether, older people have more oral health problems than younger adults, and also orofacial pain is considered to increase with age in the general population [<xref ref-type="bibr" rid="CR10">10</xref>].</p><p>Oral health problems become even more prevalent in older people with dementia; as the disorder progresses, cognition, motor skills, and self-care decline, increasing the risk of oral health problems [<xref ref-type="bibr" rid="CR11">11</xref>, <xref ref-type="bibr" rid="CR12">12</xref>]. Even though an increasing interest in oral health in older people with dementia is seen in recent years, an up-to-date review of literature, comparing oral health in older people with and without dementia, is lacking. Furthermore, a review of orofacial pain in older people with dementia is lacking entirely, while oral health problems can be an important cause of orofacial pain and discomfort. Consequently, the aim of this review was to provide a systematic overview including a quality assessment of studies about the oral health and orofacial pain of older people with dementia, compared to older people without dementia. For this review, the focus was on health of dental hard tissues and orofacial pain, representing the following available data: percentages of people with orofacial pain, edentulousness and dentures, the Decayed Missing Filled Index, number of teeth present and retained roots, and number of teeth with coronal and root caries. The health of oral soft tissues will be reviewed in a separate article.</p></sec><sec id="Sec2" sec-type="materials|methods"><title>Methods</title><sec id="Sec3"><title>Search, study selection, and quality assessment</title><p>A literature search was performed on March 31, 2016 in the following electronic databases: PubMed, CINAHL, and the Cochrane Library. In PubMed, the following search query was used: ((((“Oral Health”[Mesh] OR “Oral Health” [tiab])) OR (“Stomatognathic Diseases”[Mesh])) AND ((“Dementia”[Mesh] OR “Dementia”[tiab])). In CINAHL and the Cochrane Library, the same search terms were used, with database queries adjusted to the specific database. No restrictions with regard to language, year of publication, or methodology were applied during the search in order to maximize the inclusion of appropriate articles. Articles published in languages other than Dutch, English, and German were assessed by native speakers with dental knowledge for that particular language. Next, the titles, abstracts, and full texts were reviewed according to inclusion and exclusion criteria. The inclusion criteria were as follows: older people with dementia, oral health, stomatognathic disease, facial pain, and useable data. Exclusion criteria were as follows: age below 60, no dementia, not about oral health or stomatognathic disease, case report, review, and no useable data (e.g., no quantitative data).</p><p>The screening of the titles, abstracts, and full texts, as well as the assessment of the quality of the Dutch, English, and German studies, was done independently by a dentist (SD) and a neuropsychologist (TB). The criteria were formulated in advance, and disagreements between reviewers were resolved by consensus. Articles published in other languages were screened and assessed by a native speaker (for the particular language) with a background in dentistry. The reference lists of the included articles were scanned for complementary studies. If full texts were not available, or the dementia diagnosis or oral health data was unclear, the original authors were contacted up to a maximum of three times. If the dementia diagnosis or oral health data remained unclear, the article was excluded. The quality of the remaining articles, including risk of bias, was assessed with the Newcastle-Ottawa Scale (NOS), using a maximum score of 9 [<xref ref-type="bibr" rid="CR13">13</xref>]. In this review, a NOS quality score of 7 (=78 % of the maximum score) or more, was considered a high score.</p></sec><sec id="Sec4"><title>Data extraction</title><p>Although the search focused on oral health in general, this review only discusses the dental hard tissue variables. The oral soft tissue variables will be reported in a separate review. The division between dental hard and soft tissues is often seen in articles that report oral health in older people with dementia [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR14">14</xref>–<xref ref-type="bibr" rid="CR16">16</xref>]. The first review author (SD) extracted the data from the included studies, and the second (TB) and last author (FL) checked the extracted data. The following data were extracted from the included articles: (1) study design (e.g., cross-sectional, case-control, cohort study); (2) participant characteristics (including age, dementia diagnosis, subtype, and severity); and (3) outcome measures, including orofacial pain, dentures, edentulousness, number of teeth present [<xref ref-type="bibr" rid="CR17">17</xref>], decayed missing filled teeth (DMFT) index [<xref ref-type="bibr" rid="CR18">18</xref>], coronal caries, root caries, and retained roots. If a study published baseline and follow-up data within the same article, only the baseline data was used. The principal summary measures used were percentages and means, including standard deviation. The heterogeneity of the data was checked.</p></sec></sec><sec id="Sec5" sec-type="results"><title>Results</title><sec id="Sec6"><title>Study selection, characteristics, and participants</title><p>The search yielded 577 studies, up to publication year 2016. After the duplicates had been removed, 527 studies remained. The titles and abstracts of the remaining studies were screened, leading to the exclusion of 428 studies because they did not meet the inclusion criteria. The 99 remaining full text articles were then examined for eligibility, of which 62 were then excluded because they did not meet the inclusion criteria. Only one study was added through scanning the reference lists of the included articles [<xref ref-type="bibr" rid="CR19">19</xref>]. Thereafter, the quality of the 37 included studies was assessed. The flowchart of search is presented in Fig. <xref rid="Fig1" ref-type="fig">1</xref>. During the review process, 11 authors were contacted for further information of which seven replied. Additional information about the dementia diagnosis was given by Chen et al. and Del Brutto et al. [<xref ref-type="bibr" rid="CR20">20</xref>–<xref ref-type="bibr" rid="CR23">23</xref>] and additional data was provided by authors of Bomfim et al., Fjeld et al., Kersten et al., Lee et al., and Stewart et al. [<xref ref-type="bibr" rid="CR24">24</xref>–<xref ref-type="bibr" rid="CR27">27</xref>].<fig id="Fig1"><label>Fig. 1</label><caption><p>Flow chart of the literature search</p></caption><graphic xlink:href="784_2016_1934_Fig1_HTML" id="MO1"></graphic></fig></p><p>Of the final 37 included studies (Table <xref rid="Tab1" ref-type="table">1</xref>), 11 were cohort studies, 6 were case-control studies, 19 were cross-sectional studies, and 1 had an randomized controlled trial (RCT) design. Most of the studies were in English; the articles of Nishiyama et al. and Sumi et al. were in Japanese [<xref ref-type="bibr" rid="CR50">50</xref>, <xref ref-type="bibr" rid="CR55">55</xref>]. The relevant information of these two Japanese studies was extracted by a native Japanese speaker with dental knowledge; the study of Nishiyama et al. was excluded for not involving older people with dementia.<table-wrap id="Tab1"><label>Table 1</label><caption><p>Overview of studies about the health of dental hard tissues in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Study</th><th>Design</th><th>Dementia group (=<italic>N</italic>)</th><th>Mean age In years (SD)</th><th>Control group (=<italic>N</italic>)</th><th>Mean age in years (SD)</th><th>Dementia measure</th><th>Oral health measure hard dental tissues</th></tr></thead><tbody><tr><td>Adam and Preston [<xref ref-type="bibr" rid="CR28">28</xref>], UK</td><td>Cross-sectional</td><td>81 MoD-SeD</td><td>80.8 (7.63)</td><td>54 ND or MiD</td><td>85.5 (7.56)</td><td>Abbreviated Mental Test</td><td>Orofacial pain, dentures, edentulousness, DMFT</td></tr><tr><td>Bomfim et al. [<xref ref-type="bibr" rid="CR24">24</xref>], Brazil</td><td>Cross-sectional</td><td>mv</td><td>mv</td><td>mv</td><td>mv</td><td>MMSE, chart, ADL</td><td>Present teeth, dentures</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR14">14</xref>], Australia</td><td>Longitudinal cohort</td><td>116</td><td><79: 78.4 %<break></break>80+: 21.6 %</td><td>116</td><td><79: 78.4 %<break></break>80+: 21.6 %</td><td>MMSE</td><td>Present teeth, DMFT, root caries</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR15">15</xref>], Australia</td><td>Longitudinal cohort</td><td>103</td><td><79: 79.6 %<break></break>80+: 20.4 %</td><td>113</td><td><79: 77.9 %<break></break>80+: 22.1 %</td><td>MMSE</td><td>Present teeth, dentures, DMFT, coronal caries, root caries</td></tr><tr><td>Chapman and Shaw [<xref ref-type="bibr" rid="CR30">30</xref>], Australia</td><td>Cross-sectional</td><td>85 AD</td><td>74.9</td><td>–</td><td>–</td><td>Not described</td><td>Present teeth, dentures, DMFT</td></tr><tr><td>Chen et al. [<xref ref-type="bibr" rid="CR22">22</xref>], USA</td><td>Cross-sectional</td><td>51 community<break></break>18 assisted living<break></break>501 NHR</td><td>79.3 (8.0)<break></break>80.9 (12.6)<break></break>82.6 (9.6)</td><td>–</td><td>–</td><td>Chart, ICD-9</td><td>Present teeth, decay or retained roots</td></tr><tr><td>Chu et al. [<xref ref-type="bibr" rid="CR32">32</xref>], China</td><td>Case-control</td><td>59</td><td>79.8 (7.4)</td><td>59</td><td>79.8 (7.4)</td><td>Chart</td><td>DMFT</td></tr><tr><td>Cohen-Mansfield [<xref ref-type="bibr" rid="CR33">33</xref>], USA</td><td>Cross-sectional</td><td>21</td><td>88.0 (mv)</td><td>–</td><td>–</td><td>MMSE, MDS-COGS</td><td>Broken or fractured teeth, caries, dentures, retained roots</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>], Brazil</td><td>Case-control</td><td>29</td><td>75.2 (6.7)</td><td>30</td><td>61.2 (11.2)</td><td>NINCDS-ADRDA for AD, MMSE</td><td>Orofacial pain, DMFT</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>], Brazil</td><td>Case-control</td><td>29</td><td></td><td>–</td><td>–</td><td>NINCDS-ADRDA for AD, MMSE</td><td>Orofacial pain, DMFT</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR35">35</xref>], Denmark</td><td>Cross-sectional (baseline)</td><td>61 AD<break></break>26 OD</td><td>82.8 (5.7)<break></break>81.5 (4.8)</td><td>19</td><td>79.8 (7.3)</td><td>ICD-10</td><td>Coronal caries, root caries</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR36">36</xref>], Denmark</td><td>Cohort (baseline, follow-up)</td><td>49 AD<break></break>15 OD</td><td>83.6 (5.5)<break></break>81.3 (4.0)</td><td>13</td><td>79.9 (7.7)</td><td>ICD-10</td><td>Present teeth, DMFT, CCI, NCI, ADJCI</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR38">38</xref>], Denmark</td><td>Cross-sectional (follow-up)</td><td>61 AD</td><td>82.8 (5.7)</td><td>–</td><td>–</td><td>ICD-10</td><td>Present teeth, DMFT, coronal caries, root caries</td></tr><tr><td>Elsig et al. [<xref ref-type="bibr" rid="CR39">39</xref>], Switzerland</td><td>Cross-sectional</td><td>29</td><td>82.5 (6.3)</td><td>22</td><td>81.9 (6.5)</td><td>NP, MMSE, CERAD, CDR</td><td>Present teeth</td></tr><tr><td>Eshkoor et al. [<xref ref-type="bibr" rid="CR40">40</xref>] Malaysia</td><td>Cross-sectional</td><td>1210</td><td>71.0 (7.38)</td><td>–</td><td>–</td><td>MMSE</td><td>Presences of teeth or dentures</td></tr><tr><td>Fjeld et al. [<xref ref-type="bibr" rid="CR25">25</xref>], Norway</td><td>RCT</td><td>159</td><td>85.5 (7.7)</td><td>43</td><td>88.5 (6.6)</td><td>Evaluated by physician</td><td>Present teeth</td></tr><tr><td>Furuta et al. [<xref ref-type="bibr" rid="CR41">41</xref>], Japan</td><td>Cross-sectional</td><td>143 MiD-MoD<break></break>61 SeD</td><td></td><td>82</td><td></td><td>CDR</td><td>Present teeth, dentures</td></tr><tr><td>Hatipoglu et al. [<xref ref-type="bibr" rid="CR42">42</xref>], Turkey</td><td>Prospective cohort</td><td>31 AD</td><td>67.6 (9.14)</td><td>47</td><td>65.3 (7.0)</td><td>MMSE</td><td>Dentures, DMFT</td></tr><tr><td>Jones et al. [<xref ref-type="bibr" rid="CR43">43</xref>], USA</td><td>Cohort</td><td>23</td><td>67.4 (7.5)</td><td>46</td><td>66.1 (6.9)</td><td>Longitudinal study of dementia</td><td>Present teeth, CCI, RCI</td></tr><tr><td>Kossioni et al. [<xref ref-type="bibr" rid="CR44">44</xref>], Greece</td><td>Case-control</td><td>27</td><td>76.5 (6.8)</td><td>84</td><td></td><td>DSM-IV</td><td>Present teeth, DMFT</td></tr><tr><td>Lee et al. [<xref ref-type="bibr" rid="CR26">26</xref>], USA</td><td>Cross-sectional</td><td>19 MiD</td><td>MiD<break></break>83.9 (7.9)</td><td>169</td><td>77.4 (5.8)</td><td>MCI, MiD: DSM-IV</td><td>Missing teeth, coronal caries, root caries</td></tr><tr><td>Luo et al. [<xref ref-type="bibr" rid="CR45">45</xref>], China</td><td>Cross-sectional</td><td>120</td><td>80.9 (7.4)</td><td>2389</td><td>70.0 (7.7)</td><td>DSM-IV</td><td>Missing teeth</td></tr><tr><td>Minakuchi et al. [<xref ref-type="bibr" rid="CR46">46</xref>], Japan</td><td>Cross-sectional</td><td>155</td><td></td><td>50</td><td></td><td>COD by MHLW JP</td><td>Present teeth, dentures</td></tr><tr><td>Nordenram et al. [<xref ref-type="bibr" rid="CR47">47</xref>], Sweden</td><td>Case-control</td><td>40</td><td>87.0 (7.0)</td><td>40</td><td>87.0 (6.6)</td><td>DSM-III-R, MMSE</td><td>Present teeth, dentures</td></tr><tr><td>Philip et al. [<xref ref-type="bibr" rid="CR16">16</xref>], Australia</td><td>Cross-sectional</td><td>84</td><td>85.7 (9.6)</td><td>102</td><td>84.3 (9.9)</td><td>Chart, ADLOH</td><td>DMFT, retained roots</td></tr><tr><td>Ribeiro et al. [<xref ref-type="bibr" rid="CR48">48</xref>], Brazil</td><td>Cross-sectional</td><td>30</td><td>79.1 (5.6)</td><td>30</td><td>67.8 (5.5)</td><td>ICD-10, DSM-IV, MMSE, CDR</td><td>Present teeth, DMFT, dentures</td></tr><tr><td>Ship and Puckett [<xref ref-type="bibr" rid="CR12">12</xref>], USA</td><td>Cohort</td><td>21</td><td>64.0 (9.0)</td><td>21</td><td>65.0 (12)</td><td>NINCDS-ADRDA<break></break>CT, MRI, PET, NP</td><td>Present teeth, DMFT</td></tr><tr><td>Srilapanan et al.[<xref ref-type="bibr" rid="CR50">50</xref>], Thailand</td><td>Cross-sectional</td><td>69</td><td>75.5 (7.0)</td><td>0</td><td>–</td><td>Chart, MMSE</td><td>Dental habits, present teeth, dentures, DMFT, caries</td></tr><tr><td>Sumi et al. [<xref ref-type="bibr" rid="CR50">50</xref>], Japan</td><td>Cohort</td><td>10</td><td>77.7 (5.9)</td><td>0</td><td>–</td><td>NINCDS-ADRDA, MMSE</td><td>Present teeth, DMFT</td></tr><tr><td>Syrjala et al. [<xref ref-type="bibr" rid="CR51">51</xref>], Finland</td><td>Cross-sectional</td><td>49 AD<break></break>16 VaD<break></break>11 OD</td><td>84.8 (5.6)<break></break>82.2 (4.7)<break></break>85.3 (4.8)</td><td>278</td><td>81.4 (4.6)</td><td>DSM-IV, McKeith, DSM-III-R</td><td>Present teeth, dentures</td></tr><tr><td>Warren et al. [<xref ref-type="bibr" rid="CR52">52</xref>], USA</td><td>Case-control</td><td>45 AD<break></break>52 OD</td><td>81.6 (6.9)<break></break>81.4 (7.3)</td><td>133</td><td>80.3 (6.8)</td><td>MMSE, chart, NT, scans</td><td>Dental habits, present teeth, dentures, coronal caries, root caries</td></tr><tr><td>Zenthöfer et al. [<xref ref-type="bibr" rid="CR53">53</xref>], Germany</td><td>Case-control</td><td>57</td><td>83.1 (10.6)</td><td>36</td><td>82.6 (9.0)</td><td>MMSE, medical chart</td><td>Decayed and missing teeth</td></tr><tr><td>Zenthöfer et al. [<xref ref-type="bibr" rid="CR54">54</xref>], Germany</td><td>Cohort</td><td>33</td><td>81.7 (9.0)</td><td>60</td><td>83.4 (10.4)</td><td>MMSE, medical chart</td><td>Missing teeth</td></tr></tbody></table><table-wrap-foot><p><italic>AD</italic> Alzheimer dementia, <italic>ADJCI</italic> adjusted caries increments, <italic>ADL</italic> Activities of Daily Living, <italic>CASI</italic> Cognitive Abilities Screening Instrument, <italic>CCI</italic> crude caries increment, <italic>CDR</italic> Clinical Dementia Rating, <italic>CERAD</italic> Consortium to Establish a Registry for Alzheimer’s Disease, <italic>COD</italic> classification of dementia, <italic>CT</italic> computer tomography, <italic>DMFT</italic> decayed missing filled teeth, <italic>DQ</italic> Dementia Questionnaire, <italic>DSM</italic> Diagnostic and Statistical Manual of Mental Disorders, <italic>GOHAI</italic> Geriatric Oral Health Assessment Index, <italic>ICD</italic> International Classification of Diseases, <italic>McKeith</italic> consensus criteria for Dementia with Lewy Bodies by McKeith, <italic>MDS-COGS</italic> Minimum Data Set Cognition Scale, <italic>MHLW</italic> Ministry of Health, Labour, and Welfare, <italic>MiD</italic> mild dementia, <italic>MoD</italic> moderate dementia, <italic>MMSE</italic> Mini Mental State Examination, <italic>MRI</italic> Magnetic Resonance Imaging, <italic>mv</italic> missing value, <italic>NCI</italic> net caries increment, <italic>ND</italic> no dementia, <italic>NINCD-ADRDA</italic> National Institute of Neurological Disorders and Stroke Alzheimer’s Disease and Related Disorders Association, <italic>NOS</italic> Newcastle-Ottawa Scale, <italic>NP</italic> Neuropsychological Examination, <italic>NT</italic> Neurological Testing, <italic>OD</italic> other dementia, <italic>PCR</italic> Plaque Control Record, <italic>PET</italic> Positron Emission Tomography, <italic>SeD</italic> severe dementia, <italic>VaD</italic> vascular dementia</p></table-wrap-foot></table-wrap></p><p>Altogether, the included studies about dental hard tissues involved 3770 participants with dementia and 4036 participants without dementia. The mean age of the participants with dementia was 78.18, and the mean age of the participants without dementia was 74.0 years. The reported method to classify the group of people with dementia varied. Seven studies specified the dementia subtype: Alzheimer’s disease, vascular dementia, and other types of dementia, such as Lewy bodies [<xref ref-type="bibr" rid="CR30">30</xref>, <xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR36">36</xref>, <xref ref-type="bibr" rid="CR38">38</xref>, <xref ref-type="bibr" rid="CR42">42</xref>, <xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR52">52</xref>]. Three studies divided the group according to dementia severity [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR41">41</xref>]. Four studies were about nursing home residents (Table <xref rid="Tab2" ref-type="table">2</xref>), without separate data about older people with and without dementia [<xref ref-type="bibr" rid="CR29">29</xref>, <xref ref-type="bibr" rid="CR56">56</xref>–<xref ref-type="bibr" rid="CR58">58</xref>]. The authors of these studies (Chalmers et al. and Hopcraft et al.) were contacted, but it was impossible to obtain separate data for the participants with and without dementia.<table-wrap id="Tab2"><label>Table 2</label><caption><p>Overview of studies about the oral health in nursing home residents, including people with dementia, without subdivision in people with dementia and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th>Study</th><th>Design</th><th>NHR (=N)</th><th>Mean age</th><th>Percentage dementia</th><th>Dementia</th><th>Oral health</th></tr></thead><tbody><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR29">29</xref>]</td><td>Cross-sectional (baseline)</td><td>224</td><td>83.2</td><td>75.0 %</td><td>MMSE</td><td>Dental habits, present teeth, dentures, DMFT, coronal caries, root caries, retained roots</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR56">56</xref>]</td><td>Longitudinal cohort (follow-up)</td><td>224</td><td>83.2</td><td>>65.0 %</td><td>MMSE</td><td>Orofacial pain, dental habits, present teeth, DMFT, coronal caries, root caries, retained roots</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR57">57</xref>]</td><td>Longitudinal cohort (comparison)</td><td>224</td><td>83.6</td><td>63.4 %</td><td>MMSE</td><td>Orofacial pain, dental habits, CCI, NCI, ADJCI</td></tr><tr><td>Hopcraft et al. [<xref ref-type="bibr" rid="CR58">58</xref>]</td><td>Cross-sectional</td><td>510</td><td>mv</td><td>38.0 %</td><td>Chart</td><td>Present teeth, DMFT, coronal caries, retained roots</td></tr></tbody></table><table-wrap-foot><p><italic>ADJCI</italic> Adjusted caries and filling increments, <italic>ADSNH</italic> Adelaide Dental Study of Nursing Homes, <italic>CCI</italic> crude caries increment, <italic>DMFT</italic> decayed missing filled teeth, <italic>MMSE</italic> Mini Mental State Examination, <italic>mv</italic> missing value, <italic>NCI</italic> net caries increment, <italic>NHR</italic> nursing home residents</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec7"><title>Group and outcome variables</title><p>Dementia was classified (Table <xref rid="Tab1" ref-type="table">1</xref>) with the Diagnostic and Statistical Manual of Mental Disorders (DSM-III or IV) [<xref ref-type="bibr" rid="CR60">60</xref>, <xref ref-type="bibr" rid="CR61">61</xref>] or International Classification of Disease (ICD-10) [<xref ref-type="bibr" rid="CR62">62</xref>]; National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s disease and Related Disorders Association (NINCDS-ADRDA) [<xref ref-type="bibr" rid="CR63">63</xref>, <xref ref-type="bibr" rid="CR64">64</xref>]; computed tomography (CT); Magnetic Resonance Imaging (MRI); Positron Emission Tomography (PET) [<xref ref-type="bibr" rid="CR65">65</xref>]; Clinical Dementia Rating (CDR) [<xref ref-type="bibr" rid="CR66">66</xref>]; classification of dementia by the Ministry of Health, Labour, and Welfare (MHLW) of Japan [<xref ref-type="bibr" rid="CR46">46</xref>]; and/ or the existing medical chart of the participant. In addition to dementia diagnosis, measurements for cognitive status were used, such as the Abbreviated Mental Test (AMT) [<xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR67">67</xref>], Mini-Mental State Examination (MMSE) [<xref ref-type="bibr" rid="CR68">68</xref>], or Minimum Data Set Cognitive Score (MDS-COGS) [<xref ref-type="bibr" rid="CR33">33</xref>, <xref ref-type="bibr" rid="CR69">69</xref>]. Additionally, functional measures (e.g., Activities of Daily Living) were used.</p><p>The studies showed a variety of outcome measures concerning dental hard tissues (Table <xref rid="Tab1" ref-type="table">1</xref>). The most used measures were number of teeth present [<xref ref-type="bibr" rid="CR17">17</xref>], DMFT index [<xref ref-type="bibr" rid="CR70">70</xref>–<xref ref-type="bibr" rid="CR72">72</xref>], number of retained roots, and number of teeth with coronal and root caries. The development of dental caries was measured using the following outcome measures: crude caries increment (CCI) [<xref ref-type="bibr" rid="CR18">18</xref>, <xref ref-type="bibr" rid="CR36">36</xref>], root caries index (RCI) [<xref ref-type="bibr" rid="CR3">3</xref>], net caries increment (NCI) [<xref ref-type="bibr" rid="CR18">18</xref>, <xref ref-type="bibr" rid="CR36">36</xref>], and adjusted caries and filling increments (ADJCI) [<xref ref-type="bibr" rid="CR18">18</xref>, <xref ref-type="bibr" rid="CR36">36</xref>]. The use of prosthetics was reported by percentages of edentulousness and presence of removable prosthetics.</p></sec><sec id="Sec8"><title>Quality assessment</title><p>An overview of the results of the quality assessment with the Newcastle-Ottawa Scale [<xref ref-type="bibr" rid="CR13">13</xref>] is presented in Tables <xref rid="Tab3" ref-type="table">3</xref>, <xref rid="Tab4" ref-type="table">4</xref>, <xref rid="Tab5" ref-type="table">5</xref>, and <xref rid="Tab6" ref-type="table">6</xref>. The NOS scores of the assessed articles ranged from 1 to 9; the median score was 5 and the mean was 4.9 (SD 2.2). Of the 37 studies, 9 studies had an NOS score of 7 or higher.<table-wrap id="Tab3"><label>Table 3</label><caption><p>Methodological quality assessment of the included cohort studies with the Newcastle-Ottawa Scale</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th colspan="4">Selection</th><th colspan="2">Comparability</th><th colspan="3">Outcome</th><th>Score</th></tr><tr><th>Cohort study</th><th>Representativeness of cases</th><th>Selection of controls</th><th>Ascertainment of exposure</th><th>Demonstration outcome of interest not present at start of study</th><th>Age</th><th>Gender</th><th>Assessment of oral health</th><th>Follow up long enough</th><th>Adequacy of follow up</th><th>Total</th></tr></thead><tbody><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR14">14</xref>]</td><td><italic>+</italic></td><td><italic>−</italic></td><td><italic>−</italic></td><td><italic>−</italic></td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>5</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR15">15</xref>]</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>7</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR56">56</xref>] NHR</td><td>+</td><td>−</td><td>−</td><td>−</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>3</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR57">57</xref>] NHR</td><td>+</td><td>−</td><td>−</td><td>?</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>3</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>+</td><td>−</td><td>+</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>3</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR36">36</xref>, <xref ref-type="bibr" rid="CR37">37</xref>]</td><td>+</td><td>+</td><td>+</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>7</td></tr><tr><td>Hatipoglu et al. [<xref ref-type="bibr" rid="CR42">42</xref>]</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>?</td><td>3</td></tr><tr><td>Jones et al. [<xref ref-type="bibr" rid="CR43">43</xref>]</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>6</td></tr><tr><td>Ship and Puckett [<xref ref-type="bibr" rid="CR12">12</xref>]</td><td>+</td><td>+</td><td>+</td><td>−</td><td>+</td><td>−</td><td>+</td><td>+</td><td>−</td><td>6</td></tr><tr><td>Sumi et al. [<xref ref-type="bibr" rid="CR50">50</xref>]</td><td>+</td><td>−</td><td>+</td><td>−</td><td>−</td><td>−</td><td>+</td><td>+</td><td>?</td><td>4</td></tr><tr><td>Zenthöfer et al. [<xref ref-type="bibr" rid="CR54">54</xref>]</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>9</td></tr></tbody></table><table-wrap-foot><p><italic>+</italic> met, <italic>−</italic> unmet, <italic>?</italic> unclear</p></table-wrap-foot></table-wrap><table-wrap id="Tab4"><label>Table 4</label><caption><p>Methodological quality assessment of the included case-control studies with the Newcastle-Ottawa Scale</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th colspan="4">Selection</th><th colspan="2">Comparability</th><th colspan="3">Exposure</th><th>Score</th></tr><tr><th>Case-control study</th><th>Definition of cases</th><th>Representativeness of cases</th><th>Selection of controls</th><th>Definition of controls</th><th>Age</th><th>Gender</th><th>Assessment of oral health</th><th>Same method cases and controls</th><th>Non-response rate</th><th>Total</th></tr></thead><tbody><tr><td>Chu et al. [<xref ref-type="bibr" rid="CR32">32</xref>]</td><td><italic>−</italic></td><td><italic>+</italic></td><td><italic>−</italic></td><td><italic>+</italic></td><td>+</td><td>+</td><td>+</td><td>−</td><td>−</td><td>5</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>8</td></tr><tr><td>Kossioni et al. [<xref ref-type="bibr" rid="CR44">44</xref>]</td><td>+</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>6</td></tr><tr><td>Nordenram et al. [<xref ref-type="bibr" rid="CR47">47</xref>]</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>8</td></tr><tr><td>Warren et al. [<xref ref-type="bibr" rid="CR52">52</xref>]</td><td>+</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>7</td></tr><tr><td>Zenthöfer et al. [<xref ref-type="bibr" rid="CR53">53</xref>]</td><td>−</td><td>−</td><td>+</td><td>−</td><td>+</td><td>−</td><td>+</td><td>+</td><td>−</td><td>4</td></tr></tbody></table><table-wrap-foot><p><italic>+</italic> met, <italic>−</italic> unmet, <italic>?</italic> unclear</p></table-wrap-foot></table-wrap><table-wrap id="Tab5"><label>Table 5</label><caption><p>Methodological quality assessment of the included cross-sectional studies with the Newcastle-Ottawa Scale</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Cross-sectional study</th><th colspan="4">Selection</th><th colspan="2">Comparability</th><th colspan="3">Exposure</th><th>Score</th></tr><tr><th>Definition of cases</th><th>Representativeness of cases</th><th>Selection of controls</th><th>Definition of controls</th><th>Age</th><th>Gender</th><th>Assessment of oral health</th><th>Same method cases and controls</th><th>Non-response rate</th><th>Total</th></tr></thead><tbody><tr><td>Adam and Preston [<xref ref-type="bibr" rid="CR28">28</xref>]</td><td>−</td><td>+</td><td>+</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>?</td><td>3</td></tr><tr><td>Bomfim et al. [<xref ref-type="bibr" rid="CR24">24</xref>]</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>−</td><td>?</td><td>−</td><td>?</td><td>1</td></tr><tr><td>Chalmers et al. NHR [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR29">29</xref>]</td><td>−</td><td>+</td><td>+</td><td>−</td><td>−</td><td>−</td><td>+</td><td>+</td><td>?</td><td>4</td></tr><tr><td>Chapman and Shaw [<xref ref-type="bibr" rid="CR30">30</xref>]</td><td>−</td><td>+</td><td>−</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>2</td></tr><tr><td>Chen et al. [<xref ref-type="bibr" rid="CR22">22</xref>, <xref ref-type="bibr" rid="CR31">31</xref>]</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>6</td></tr><tr><td>Cohen-Mansfield [<xref ref-type="bibr" rid="CR33">33</xref>]</td><td>−</td><td>−</td><td>−</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>1</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR35">35</xref>]</td><td>+</td><td>+</td><td>+</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>7</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR38">38</xref>]</td><td>+</td><td>+</td><td>+</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>7</td></tr><tr><td>Elsig et al. [<xref ref-type="bibr" rid="CR39">39</xref>]</td><td>+</td><td>+</td><td>+</td><td>−</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>5</td></tr><tr><td>Eshkoor et al. [<xref ref-type="bibr" rid="CR40">40</xref>]</td><td>−</td><td>+</td><td>−</td><td>−</td><td>−</td><td>−</td><td>−</td><td>−</td><td>−</td><td>1</td></tr><tr><td>Furuta et al. [<xref ref-type="bibr" rid="CR41">41</xref>]</td><td>−</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>5</td></tr><tr><td>Hopcraft et al. NHR [<xref ref-type="bibr" rid="CR58">58</xref>]</td><td>−</td><td>+</td><td>+</td><td>−</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>4</td></tr><tr><td>Lee et al. [<xref ref-type="bibr" rid="CR26">26</xref>]</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>+</td><td>+</td><td>?</td><td>5</td></tr><tr><td>Luo et al. [<xref ref-type="bibr" rid="CR45">45</xref>]</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>+</td><td>−</td><td>+</td><td>+</td><td>7</td></tr><tr><td>Minakuchi et al. [<xref ref-type="bibr" rid="CR46">46</xref>]</td><td>+</td><td>+</td><td>−</td><td>+</td><td>+</td><td>−</td><td>+</td><td>+</td><td>−</td><td>6</td></tr><tr><td>Philip et al. [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR16">16</xref>]</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>3</td></tr><tr><td>Ribeiro et al. [<xref ref-type="bibr" rid="CR48">48</xref>]</td><td>+</td><td>+</td><td>−</td><td>+</td><td>−</td><td>−</td><td>+</td><td>+</td><td>−</td><td>5</td></tr><tr><td>Srisilapanan et al. [<xref ref-type="bibr" rid="CR49">49</xref>]</td><td>−</td><td>+</td><td>−</td><td>−</td><td>−</td><td>−</td><td>+</td><td>−</td><td>−</td><td>2</td></tr><tr><td>Syrjala et al. [<xref ref-type="bibr" rid="CR51">51</xref>]</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>+</td><td>−</td><td>8</td></tr></tbody></table><table-wrap-foot><p><italic>+</italic> met, <italic>−</italic> unmet, <italic>?</italic> unclear</p></table-wrap-foot></table-wrap><table-wrap id="Tab6"><label>Table 6</label><caption><p>Methodological quality assessment of the included randomized clinical trial with the Newcastle-Ottawa Scale</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">RCT</th><th colspan="4">Selection</th><th colspan="2">Comparability</th><th colspan="3">Exposure</th><th>Score</th></tr><tr><th>Definition of cases</th><th>Representativeness of cases</th><th>Selection of controls</th><th>Definition of controls</th><th>Age</th><th>Gender</th><th>Assessment of oral health</th><th>Same method cases and controls</th><th>Non-response rate</th><th>Total</th></tr></thead><tbody><tr><td>Fjeld et al. [<xref ref-type="bibr" rid="CR25">25</xref>]</td><td>+</td><td>−</td><td>+</td><td>+</td><td>?</td><td>?</td><td>+</td><td>+</td><td>+</td><td char="." align="char">7</td></tr></tbody></table><table-wrap-foot><p><italic>+</italic> met, <italic>−</italic> unmet, <italic>?</italic> unclear</p></table-wrap-foot></table-wrap></p><p>In 14 (=53.8 %) of the non-cohort the studies, the DSM, ICD, or NINCDS-ADRDA was used for the classification of the dementia diagnosis. For 30 (=81.1 %) studies, the participants demonstrated good representativeness of the classification “older people with dementia.” Controls, in this case older people without dementia, often (=54.1 %) came from other sources than the cases. In only 11 (=29.7 %) of the non-cohort studies, it was explicitly stated that the controls had no history of dementia. Of all 37 studies, 51.4 % had comparable age and 37.8 % had comparable gender between cases and controls. Almost all studies (=91.9 %) used a standardized, structured method for the dental examination. Only 3 studies (=18.2 % of the non-cohort studies) described the non-response rate [<xref ref-type="bibr" rid="CR25">25</xref>, <xref ref-type="bibr" rid="CR45">45</xref>, <xref ref-type="bibr" rid="CR52">52</xref>]. For most of the 11 cohort studies (=90.9 %), the follow-up period was longer than 3 months. At the same time, the number of subjects lost to follow-up was reported in only two (=22.2 %) of the cohort studies.</p></sec><sec id="Sec9"><title>Results for each outcome variable</title><p>With respect to edentulousness, a wide range of percentages between studies was seen among older people with and without dementia (Table <xref rid="Tab7" ref-type="table">7</xref>). For people without dementia, percentages varied from 14.0 to 70.0 % [<xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR32">32</xref>] and for older people with dementia from 11.6 to 72.7 % [<xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR49">49</xref>].<table-wrap id="Tab7"><label>Table 7</label><caption><p>Edentulousness in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Study</th><th colspan="2">Number of participants<break></break>Mean age in years (SD)</th><th colspan="2">Edentulousness</th><th rowspan="2">Specification</th></tr><tr><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th></tr></thead><tbody><tr><td>Adam and Preston [<xref ref-type="bibr" rid="CR28">28</xref>]</td><td>54 ND-MiD<break></break>85.5 (7.6)</td><td>81 MoD-SeD<break></break>80.8 (7.6)</td><td>ND-MiD 70.0 %</td><td>MoD-SeD 63.0 %</td><td>Not dentate</td></tr><tr><td>Bomfim et al. [<xref ref-type="bibr" rid="CR24">24</xref>]</td><td>mv</td><td>mv</td><td>46.7 %</td><td>40.0 %</td><td>No specification</td></tr><tr><td>Chapman and Shaw [<xref ref-type="bibr" rid="CR30">30</xref>]</td><td>0</td><td>85 AD<break></break>74.9</td><td>–</td><td>AD 64.7 %</td><td>No teeth, with and without dentures</td></tr><tr><td>Chu et al. [<xref ref-type="bibr" rid="CR32">32</xref>]</td><td>59<break></break>79.8 (7.4)</td><td>59<break></break>79.8 (7.4)</td><td>14.0 %</td><td>17.0 %</td><td>Not dentate</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>30<break></break>61.2 (11.2)</td><td>29<break></break>75.2 (6.7)</td><td>43.3 %</td><td>32.3 %</td><td><italic>p</italic> = .614</td></tr><tr><td>Elsig et al. [<xref ref-type="bibr" rid="CR39">39</xref>]</td><td>22<break></break>81.9 (6.5)</td><td>29<break></break>82.5 (6.3)</td><td>54.6 %</td><td>62.1 %</td><td><italic>p</italic> = .774</td></tr><tr><td>Kossioni et al. [<xref ref-type="bibr" rid="CR44">44</xref>]</td><td>84</td><td>27<break></break>76.5 (6.8)</td><td>–</td><td>62.9 %</td><td>No teeth, with and without dentures</td></tr><tr><td>Nordenram et al. [<xref ref-type="bibr" rid="CR47">47</xref>]</td><td>40<break></break>87 (6.6)</td><td>40 AD<break></break>87 (7.0)</td><td>43.0 %</td><td>MoD 36.0 %<break></break>SeD 45.0 %</td><td>No teeth, with and without dentures</td></tr><tr><td>Srisilapanan et al. [<xref ref-type="bibr" rid="CR49">49</xref>]</td><td>0</td><td>69<break></break>75.5 (7.0)</td><td>–</td><td>11.6 %</td><td>No teeth</td></tr><tr><td rowspan="3">Syrjala et al. [<xref ref-type="bibr" rid="CR51">51</xref>]</td><td rowspan="3">278<break></break>81.4 (4.6)</td><td>49 AD<break></break>84.8 (5.6)</td><td>44.6 %</td><td>AD 63.3 %</td><td rowspan="3">No teeth, with and without dentures</td></tr><tr><td>16 VaD<break></break>82.2 (4.7)</td><td></td><td>VaD 68.8 %</td></tr><tr><td>11 OD<break></break>85.3 (4.8)</td><td></td><td>OD 72.7 %</td></tr><tr><td>Warren et al. [<xref ref-type="bibr" rid="CR52">52</xref>]</td><td>133 ND<break></break>80.3 (6.8)</td><td>45 AD<break></break>81.6 (6.9)<break></break>52 OD<break></break>81.4 (7.3)</td><td>31.6 %</td><td>AD 40.0 %<break></break>OD 32.0 %</td><td>No specification</td></tr></tbody></table><table-wrap-foot><p><italic>AD</italic> Alzheimer dementia, <italic>Dem</italic> dementia, <italic>DQ</italic> Dementia Questionnaire, <italic>MiD</italic> mild dementia, <italic>MoD</italic> moderate dementia, <italic>mv</italic> missing value, <italic>ND</italic> no dementia, <italic>OD</italic> other dementia, <italic>SeD</italic> severe dementia, <italic>VaD</italic> vascular dementia</p></table-wrap-foot></table-wrap></p><p>In terms of denture utilization, there was also a great variation among older people with and without dementia (Table <xref rid="Tab8" ref-type="table">8</xref>). For older people without dementia, percentages ranged from 17.0 to 81.8 % [<xref ref-type="bibr" rid="CR47">47</xref>, <xref ref-type="bibr" rid="CR73">73</xref>]; for older people with dementia, this number ranged from 5.0 to 100.0 % [<xref ref-type="bibr" rid="CR42">42</xref>, <xref ref-type="bibr" rid="CR47">47</xref>]. The lowest percentage (5.0 %) was seen in a group of people with severe dementia (MMSE score below 10) [<xref ref-type="bibr" rid="CR47">47</xref>].<table-wrap id="Tab8"><label>Table 8</label><caption><p>Dentures in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Study</th><th colspan="2">Number of participants<break></break>Mean age in years (SD)</th><th colspan="2">Dentures</th></tr><tr><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th></tr></thead><tbody><tr><td>Bomfim et al. [<xref ref-type="bibr" rid="CR24">24</xref>]</td><td>mv</td><td>mv</td><td>20.0 %</td><td>20.0 %</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR15">15</xref>]</td><td>113<break></break><79: 88<break></break>80+: 25</td><td>103<break></break><79: 82<break></break>80+: 21</td><td>27.6–30.1 %</td><td>20.7–23.3 %</td></tr><tr><td>Chapman and Shaw [<xref ref-type="bibr" rid="CR30">30</xref>]</td><td>0</td><td>85 AD<break></break>74.9 (mv)</td><td>–</td><td>59.0 %</td></tr><tr><td rowspan="3">Chen et al. [<xref ref-type="bibr" rid="CR22">22</xref>, <xref ref-type="bibr" rid="CR31">31</xref>]</td><td rowspan="3">–</td><td>51 community living<break></break>79.3 (8.0)</td><td rowspan="3">–</td><td>Community living 48.0 %</td></tr><tr><td>18 assisted living<break></break>80.9 (12.6)</td><td>Assisted living 38.9 %</td></tr><tr><td>501 nursing home residents<break></break>82.6 (9.6)</td><td>Nursing home residents 47.1 %</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>30<break></break>61.17 (11.2)</td><td>29<break></break>75.17 (6.7)</td><td>43.3 %</td><td>25.8 %</td></tr><tr><td>Eshkoor et al. [<xref ref-type="bibr" rid="CR40">40</xref>]</td><td>71 (mv)</td><td>1210</td><td>81.8 %</td><td>86.2 %</td></tr><tr><td>Hatipoglu et al. [<xref ref-type="bibr" rid="CR42">42</xref>]</td><td>47<break></break>65.3 (7.0)</td><td>31 AD<break></break>67.6 (9.1)</td><td><italic>Maxillary</italic><break></break>57.0 %<break></break><italic>Mandibular</italic><break></break>55.0 %</td><td><italic>Maxillary</italic><break></break>AD 97.0 %<break></break><italic>Mandibular</italic><break></break>AD 100.0 %</td></tr><tr><td>Kim et al. [<xref ref-type="bibr" rid="CR59">59</xref>]</td><td>919</td><td>0</td><td>53.0 %</td><td>–</td></tr><tr><td>Nordenram et al. [<xref ref-type="bibr" rid="CR47">47</xref>]</td><td>40<break></break>87 (6.6)</td><td>40 AD<break></break>87.0 (7.0)</td><td>17.0 %</td><td>MoD 7.0 %<break></break>SeD 5.0 %</td></tr><tr><td>Ship and Puckett [<xref ref-type="bibr" rid="CR12">12</xref>]</td><td>21<break></break>65 (12)</td><td>21 AD<break></break>64.0 (9.0)</td><td>43.0 %</td><td>AD 40.0–67.0 %</td></tr><tr><td>Srisilapanan et al. [<xref ref-type="bibr" rid="CR49">49</xref>]</td><td>0</td><td>69<break></break>75.5 (7.0)</td><td>–</td><td>40.6 %</td></tr><tr><td rowspan="3">Syrjala et al. [<xref ref-type="bibr" rid="CR51">51</xref>]</td><td rowspan="3">278 ND<break></break>81.4 (4.6)</td><td>49 AD<break></break>84.8 (5.6)</td><td rowspan="3">73.7 %</td><td>AD 75.5 %</td></tr><tr><td>16 VaD<break></break>82.2 (4.7)</td><td>VaD 68.6 %</td></tr><tr><td>11 OD<break></break>85.3 (4.8)</td><td>OD 72.2 %</td></tr></tbody></table><table-wrap-foot><p><italic>AD</italic> Alzheimer’s disease, <italic>Dem</italic> dementia, <italic>MoD</italic> moderate dementia, <italic>mv</italic> missing value, <italic>ND</italic> no dementia, <italic>NHR</italic> nursing home residents, <italic>OD</italic> other dementia, <italic>SeD</italic> severe dementia, <italic>VD</italic> vascular dementia</p></table-wrap-foot></table-wrap></p><p>The number of teeth present was the most commonly used indicator for dental health, and there was a wide range within both groups (Table <xref rid="Tab9" ref-type="table">9</xref>). For people without dementia, it varied between 2.0 and 20.2 [<xref ref-type="bibr" rid="CR24">24</xref>, <xref ref-type="bibr" rid="CR37">37</xref>], and for people with dementia, it varied between 1.7 and 20.0 [<xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR49">49</xref>].<table-wrap id="Tab9"><label>Table 9</label><caption><p>Number of present teeth in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Study</th><th colspan="2">Number of participants<break></break>Mean age in years (SD)</th><th colspan="2">Number of present teeth</th><th rowspan="2">No dementia vs dementia<break></break><italic>p</italic> value</th></tr><tr><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th></tr></thead><tbody><tr><td>Bomfim et al. [<xref ref-type="bibr" rid="CR24">24</xref>]</td><td>mv</td><td>mv</td><td>2.0 (8.5)</td><td>3.0 (3.7)</td><td>mv</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR15">15</xref>]</td><td>116<break></break><79: 78.4 %<break></break>80+: 21.6 %</td><td>116<break></break><79: 78.4 %<break></break>80+: 21.6 %</td><td>17.2 (mv)</td><td>18.0</td><td>>.05</td></tr><tr><td>Chapman and Shaw [<xref ref-type="bibr" rid="CR30">30</xref>]</td><td>–</td><td>85 AD<break></break>74.9</td><td>–</td><td>12.8</td><td>n/a</td></tr><tr><td rowspan="3">Chen et al. [<xref ref-type="bibr" rid="CR31">31</xref>]</td><td rowspan="3">–</td><td>51 community<break></break>79.3 (8.0)</td><td rowspan="3">–</td><td>Community living<break></break>18.2 (7.2)</td><td rowspan="3">n/a</td></tr><tr><td>18 assisted<break></break>80.9 (12.6)</td><td>Assisted living<break></break>19.3 (6.8)</td></tr><tr><td>501 NHR<break></break>82.6 (9.6)</td><td>Nursing home residents<break></break>17.4 (7.9)</td></tr><tr><td rowspan="2">Ellefsen et al. [<xref ref-type="bibr" rid="CR36">36</xref>]</td><td rowspan="2">13<break></break>79.9 (7.7)</td><td>49 AD<break></break>83.6 (5.5)</td><td rowspan="2">20.2 (8.9)</td><td>AD 17.3 (7.4)<sup>a</sup></td><td rowspan="2">≤.001 for AD</td></tr><tr><td>15 OD<break></break>81.3 (4.0)</td><td>OD 16.1 (9.0)</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR38">38</xref>]</td><td>–</td><td>61 AD<break></break>82.8 (5.7)</td><td>–</td><td>AD 16.5 (7.4)</td><td>n/a</td></tr><tr><td>Elsig et al. [<xref ref-type="bibr" rid="CR39">39</xref>]</td><td>22<break></break>81.9 (6.5)</td><td>29<break></break>82.5 (6.3)</td><td>6.5 (8.8)</td><td>4.9 (8.3)</td><td>.533</td></tr><tr><td>Fjeld et al. [<xref ref-type="bibr" rid="CR25">25</xref>]</td><td>43<break></break>88.5 (6.6)</td><td>159<break></break>85.5 (7.7)</td><td>20.1 (6.1)</td><td>20.0 (5.8)</td><td>mv</td></tr><tr><td>Hopcraft et al. [<xref ref-type="bibr" rid="CR58">58</xref>]</td><td></td><td>510 NHR<break></break>194 Dem</td><td>14.6 (0.7)</td><td>(0.7)</td><td>>.05</td></tr><tr><td>Jones et al. [<xref ref-type="bibr" rid="CR43">43</xref>]</td><td>46<break></break>66.1 (6.9)</td><td>23<break></break>67.4 (7.5)</td><td>18.2 (7.5)</td><td>AD 17.9 (8.1)</td><td>.90</td></tr><tr><td>Kossioni et al. [<xref ref-type="bibr" rid="CR44">44</xref>]</td><td>84</td><td>27<break></break>76.5 (6.8)</td><td>–</td><td>4.4 (7.2)</td><td>n/a</td></tr><tr><td>Ribeiro et al. [<xref ref-type="bibr" rid="CR48">48</xref>]</td><td>30<break></break>67.8 (5.4)</td><td>30<break></break>79.1 (5.6)</td><td>Median 13.5<sup>a</sup> (0.0–28.0)</td><td>Median 1.0<sup>a</sup> (0.0–22.0)</td><td>.0004</td></tr><tr><td>Srisilapanan et al. [<xref ref-type="bibr" rid="CR49">49</xref>]</td><td>–</td><td>69<break></break>75.5 (7.0)</td><td>–</td><td>19.5 (8.4)</td><td>n/a</td></tr><tr><td>Sumi et al. [<xref ref-type="bibr" rid="CR50">50</xref>]</td><td>–</td><td>10<break></break>77.7 (5.9)</td><td>–</td><td>12.7</td><td>n/a</td></tr><tr><td rowspan="3">Syrjala et al. [<xref ref-type="bibr" rid="CR51">51</xref>]</td><td rowspan="3">278<break></break>81.4 (4.6)</td><td>49 AD<break></break>84.8 (5.6)</td><td rowspan="3">15.0 (8.2)</td><td>AD 10.9 (7.0)</td><td rowspan="3"></td></tr><tr><td>16 VaD<break></break>82.2 (4.7)</td><td>VaD 7.8 (3.8)</td></tr><tr><td>11 OD<break></break>85.3 (4.8)</td><td>OD 1.7 (1.2)</td></tr><tr><td rowspan="2">Warren et al. [<xref ref-type="bibr" rid="CR52">52</xref>]</td><td rowspan="2">133<break></break>80.3 (6.8)</td><td>45 AD<break></break>81.6 (6.9)</td><td rowspan="2">13.0 (10.8)</td><td>AD 10.0 (10.1)</td><td rowspan="2"><italic>p</italic> > .05</td></tr><tr><td>52 OD<break></break>81.4 (7.3)</td><td>OD 13.0 (10.6)</td></tr></tbody></table><table-wrap-foot><p><italic>AD</italic> Alzheimer dementia, <italic>ADS NH</italic> Adelaide Dental Study of Nursing Homes, <italic>Dem</italic> dementia, <italic>MiD</italic> mild dementia, <italic>MoD</italic> moderate dementia, <italic>mv</italic> missing value, <italic>N/A</italic> not applicable, <italic>ND</italic> no dementia, <italic>NHR</italic> nursing home residents, <italic>OD</italic> other dementia, <italic>OH CLOAD</italic> oral health of community-living older adults with dementia, <italic>SeD</italic> severe dementia, <italic>VaD</italic> vascular dementia</p><p><sup>a</sup>Significant difference between groups</p></table-wrap-foot></table-wrap></p><p>The DMFT index (Table <xref rid="Tab10" ref-type="table">10</xref>) was 19.7 to 26.1 in people without dementia [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR42">42</xref>], and 14.9 to 28.0 [<xref ref-type="bibr" rid="CR48">48</xref>, <xref ref-type="bibr" rid="CR49">49</xref>] in people with dementia. The lowest DMFT was 14.9, which was derived from a cross-sectional study from Thailand examining older people with dementia without using a control group [<xref ref-type="bibr" rid="CR49">49</xref>]. Only five studies compared older people with and without dementia, and just one study found a significant difference between the two groups; DMFT 25.5 in people without and DMFT 28.0 in people with dementia [<xref ref-type="bibr" rid="CR48">48</xref>].<table-wrap id="Tab10"><label>Table 10</label><caption><p>Decayed, missing, and filled teeth and DMFT index in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Study</th><th colspan="2">Number of participants<break></break>Mean age in years (SD)</th><th colspan="2">Decayed</th><th colspan="2">Missing</th><th colspan="2">Filled</th><th colspan="2">DMFT</th></tr><tr><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th></tr></thead><tbody><tr><td>Adam and Preston [<xref ref-type="bibr" rid="CR28">28</xref>]</td><td>54 ND-MiD<break></break>85.5 (7.6)</td><td>81 MoD-SeD<break></break>80.8 (7.6)</td><td>1.1 (3.4)</td><td>0.80 (1.9)</td><td>28.2 (6.6)</td><td>27.3 (7.7)</td><td>ND-MiD 0.7 (1.3)</td><td>0.90 (2.4)</td><td></td><td></td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR14">14</xref>]</td><td>116<break></break><79 years: 91<break></break>80+: 25</td><td>116<break></break><79: 91<break></break>80+: 25</td><td>0.0–0.4</td><td>0.5–1.6*</td><td>–</td><td>–</td><td>24.7–25.7</td><td>22.1–23.9</td><td>–</td><td>–</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR15">15</xref>]</td><td>113<break></break><79 years: 88<break></break>80+: 25</td><td>103<break></break><79: 82<break></break>80+: 21</td><td>0.0–0.1</td><td>0.3–1.3*</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Chapman and Shaw [<xref ref-type="bibr" rid="CR30">30</xref>]</td><td>0</td><td>85 AD 74.9</td><td>–</td><td>1.4 (0.3)</td><td>–</td><td>17.8 (1.0)</td><td>–</td><td>6.4 (0.7)</td><td>–</td><td>25.6 (0.7)</td></tr><tr><td rowspan="3">Chen et al. [<xref ref-type="bibr" rid="CR22">22</xref>, <xref ref-type="bibr" rid="CR31">31</xref>]</td><td rowspan="3">–</td><td>51 community<break></break>79.3 (8.0)</td><td rowspan="3">–</td><td>Community<break></break>5.5 (5.4)</td><td rowspan="3">–</td><td rowspan="3">–</td><td rowspan="3">–</td><td>Community<break></break>10.4 (6.3)</td><td rowspan="3">–</td><td rowspan="3">–</td></tr><tr><td>18 assisted<break></break>80.9 (12.6)</td><td>Assisted<break></break>5.3 (4.1)</td><td>Assisted<break></break>10.9 (6.0)</td></tr><tr><td>501 NHR<break></break>82.6 (9.6)</td><td>NHR<break></break>6.0 (5.2)</td><td>NHR<break></break>8.7 (6.3)</td></tr><tr><td>Chu et al. [<xref ref-type="bibr" rid="CR32">32</xref>]</td><td>59<break></break>79.8 (7.4)</td><td>59<break></break>79.8 (7.4)</td><td>0.8 (1.4)</td><td>1.2 (1.9)</td><td>18.3 (8.9)</td><td>18.9 (9.4)</td><td>2.4 (2.5)</td><td>2.5 (3.3)</td><td>21.5 (8.2)</td><td>22.3 (8.2)</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>30<break></break>61.2 (11.2)</td><td>29<break></break>75.2 (6.7)</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td></td><td>27.2 (5.7)<break></break>Range 11–32</td></tr><tr><td>Hatipoglu et al. [<xref ref-type="bibr" rid="CR42">42</xref>]</td><td>47<break></break>65.3 (7.0)</td><td>31 AD<break></break>67.6 (9.1)</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>19.7 (9.5)</td><td>24.2 (6.8)</td></tr><tr><td>Hopcraft et al. [<xref ref-type="bibr" rid="CR58">58</xref>]</td><td>316 of 510 NHR</td><td>194 of 510 NHR</td><td>2.9 (0.4)</td><td>2.4 (0.3)</td><td>17.4 (0.7)</td><td>17.9 (0.7)</td><td>4.8 (0.6)</td><td>4.8 (0.6)</td><td>25.0 (0.4)</td><td>25.0 (0.5)</td></tr><tr><td>Kossioni et al. [<xref ref-type="bibr" rid="CR44">44</xref>]</td><td>Other psychotic diagnosis</td><td>27<break></break>76.5 (6.8)</td><td>–</td><td>1.8 (2.9)</td><td>–</td><td>–</td><td>–</td><td>0.9 (1.5)</td><td>–</td><td>–</td></tr><tr><td>Lee et al. [<xref ref-type="bibr" rid="CR26">26</xref>]</td><td>169<break></break>77.4 (5.8)</td><td>19 MiD<break></break>83.9 (7.9)</td><td>CC + RC</td><td>CC + RC</td><td>12.7 (7.6)</td><td>10.2 (7.5)</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Luo et al. [<xref ref-type="bibr" rid="CR45">45</xref>]</td><td>2389<break></break>70.0 (7.7)</td><td>120<break></break>80.9 (7.4)</td><td>–</td><td>–</td><td>9.3</td><td>18.7**</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Philip et al. [<xref ref-type="bibr" rid="CR5">5</xref>]</td><td>102<break></break>84.3 (9.9)</td><td>84<break></break>85.7(9.6)</td><td>2.9 (3.0)</td><td>3.0 (3.9)</td><td>18.0 (7.1)</td><td>17.4 (7.3)</td><td>5.0 (4.8)</td><td>5.3 (5.0)</td><td>26.1 (4.2)</td><td>25.9 (4.5)</td></tr><tr><td>Ribeiro et al. [<xref ref-type="bibr" rid="CR48">48</xref>]</td><td>30<break></break>67.8 (5.5)</td><td>30<break></break>79.1 (5.6)</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>–</td><td>25.5 (12.0–28.0)*</td><td>28.0 (22.0–28.0)*</td></tr><tr><td>Srisilapanan et al. [<xref ref-type="bibr" rid="CR49">49</xref>]</td><td>0</td><td>69<break></break>75.5 (7.0)</td><td>–</td><td>1.5 (2.3)</td><td>–</td><td>12.6 (8.4)</td><td>–</td><td>0.8 (1.9)</td><td>–</td><td>14.9 (9.2)</td></tr><tr><td>Zenthöfer et al. [<xref ref-type="bibr" rid="CR53">53</xref>]</td><td>36<break></break>82.6 (9.0)</td><td>57<break></break>83.1 (10.6)</td><td>0.7 (1.4)</td><td>0.6 (1.3)</td><td>19.9 (9.1)</td><td>20.8 (8.5)</td><td>–</td><td>–</td><td>–</td><td>–</td></tr><tr><td>Zenthöfer et al. [<xref ref-type="bibr" rid="CR54">54</xref>]</td><td>60<break></break>83.4 (10.4)</td><td>33<break></break>81.7 (9.0)</td><td>–</td><td>–</td><td>20.5 (8.5)</td><td>20.5 (9.2)</td><td>–</td><td>–</td><td>–</td><td>–</td></tr></tbody></table><table-wrap-foot><p><italic>AD</italic> Alzheimer’s disease, <italic>CC</italic> coronal caries, <italic>D</italic> decayed, <italic>Dem</italic> dementia, <italic>DMFT</italic> decayed missing filled teeth, <italic>F</italic> filled, <italic>M</italic> missing, <italic>MoD</italic> moderate dementia, <italic>ND</italic> no dementia, <italic>NHR</italic> nursing home residents, <italic>OD</italic> other dementia, <italic>RC</italic> root caries, <italic>SeD</italic> severe dementia, <italic>VaD</italic> vascular dementia</p><p>*<italic>p</italic> < .05, **<italic>p</italic> < .001</p></table-wrap-foot></table-wrap></p><p>Taking the DMFT categories separately, “decay” varied from 0.0 to 2.9 in the group of older people without dementia [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR58">58</xref>] and 0.3 to 6.0 in the group of older people with dementia [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR31">31</xref>], “missing” from 9.3 to 28.2 in the group without dementia [<xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR45">45</xref>] and 10.2 to 27.3 in the group with dementia [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR28">28</xref>], and “filled” from 0.7 to 25.7 in the group without dementia [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR28">28</xref>] and 0.8 to 23.9 in the group with dementia [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR49">49</xref>].</p><p>The reviewed studies showed that older people with dementia had more coronal caries (0.1–2.9) [<xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR38">38</xref>, <xref ref-type="bibr" rid="CR52">52</xref>] than older people without dementia (0.0–1.0) [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR38">38</xref>]. In addition, older people with dementia had more root caries (0.6–4.9) [<xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR38">38</xref>, <xref ref-type="bibr" rid="CR52">52</xref>] than people without dementia (0.3–1.7) [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR35">35</xref>, <xref ref-type="bibr" rid="CR38">38</xref>]. Furthermore, retained roots were more common in people with dementia (0.2–10) [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR35">35</xref>] than in people without dementia (0.0–1.2) [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR35">35</xref>]. (Table <xref rid="Tab11" ref-type="table">11</xref>).<table-wrap id="Tab11"><label>Table 11</label><caption><p>Retained roots, root caries, and coronal caries in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Study</th><th colspan="2">Number of participants<break></break>Mean age in years (SD)</th><th colspan="2">Coronal caries<break></break>Mean number (SD)</th><th colspan="2">Root caries<break></break>Mean number (SD)</th><th colspan="2">Retained roots<break></break>Mean number (SD)</th></tr><tr><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th></tr></thead><tbody><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR14">14</xref>]<break></break>Chalmers et al. [<xref ref-type="bibr" rid="CR15">15</xref>]</td><td>116<break></break><79: 91<break></break>80+: 25</td><td>116<break></break><79: 91<break></break>80+: 25</td><td>0.0*</td><td>0.5*</td><td>0.3*</td><td>0.8*</td><td><italic>Decayed</italic><break></break>0.0*<break></break><italic>Sound</italic><break></break>0.1</td><td><italic>Decayed</italic><break></break>0.3*<break></break><italic>Sound</italic><break></break>0.2</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>30<break></break>61.2 (11.2)</td><td>29<break></break>75.2 (6.7)</td><td>3.4 %</td><td>6.8 %</td><td>–</td><td>–</td><td>10.2 %</td><td>6.8 %</td></tr><tr><td>Ellefsen et al. [<xref ref-type="bibr" rid="CR35">35</xref>]<break></break>Ellefsen et al. [<xref ref-type="bibr" rid="CR38">38</xref>]</td><td>19<break></break>79.8 (7.3)</td><td>61 AD<break></break>82.8 (5.7)</td><td>1.0*</td><td>2.9*</td><td>1.7*</td><td>AD 4.9*</td><td>0.0*</td><td><italic>AD 10.0*</italic></td></tr><tr><td></td><td></td><td>26 OD<break></break>81.5 (4.8)</td><td></td><td></td><td></td><td>OD 2.3*</td><td></td><td>OD 0.5*</td></tr><tr><td>Jones et al. [<xref ref-type="bibr" rid="CR43">43</xref>]</td><td>46<break></break>66.1 (6.9)</td><td>23 AD<break></break>67.4 (7.5)</td><td>0.8</td><td>1.4</td><td>0.4</td><td>1.8</td><td>–</td><td>–</td></tr><tr><td>Lee et al. [<xref ref-type="bibr" rid="CR26">26</xref>]</td><td>169<break></break>77.4 (5.8)*</td><td>19 MiD<break></break>83.9 (7.9)*</td><td>0.8 (2.1)</td><td>1.0 (1.6)</td><td>0.5 (1.1)*</td><td>1.8 (3.6)*</td><td>–</td><td>–</td></tr><tr><td>Philip et al. [<xref ref-type="bibr" rid="CR5">5</xref>]</td><td>102<break></break>84.3 (9.9)</td><td>84<break></break>85.7 (9.6)</td><td>–</td><td>–</td><td>–</td><td>–</td><td>1.2<break></break>D 0.9</td><td>1.8<break></break>D 1.4</td></tr><tr><td>Warren et al. [<xref ref-type="bibr" rid="CR52">52</xref>]</td><td>133 ND<break></break>80.3 (6.8)</td><td>45 AD<break></break>81.6 (6.9)<break></break>52 OD<break></break>81.4 (7.3)</td><td>0.4</td><td>AD 0.1<break></break>OD 0.4</td><td>0.8</td><td>AD 0.6<break></break>OD 0.6</td><td>–</td><td>–</td></tr></tbody></table><table-wrap-foot><p><italic>AD</italic> Alzheimer’s disease, <italic>D</italic> decayed, <italic>Dem</italic> dementia, <italic>MiD</italic> mild dementia, <italic>ND</italic> no dementia, <italic>OD</italic> other dementia, <italic>VaD</italic> vascular dementia</p><p>*<italic>p</italic> < .05</p></table-wrap-foot></table-wrap></p><p>Although dental hard tissues can be an important source of orofacial pain, only seven of the included studies published data about the presence of orofacial pain [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR19">19</xref>, <xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR33">33</xref>, <xref ref-type="bibr" rid="CR34">34</xref>, <xref ref-type="bibr" rid="CR44">44</xref>, <xref ref-type="bibr" rid="CR74">74</xref>]. The presence of reported dental pain in older people with dementia varied between 7.4 and 21.7 %. Only in the study of Cohen-Mansfield and Lipson, pain with dental etiology was the central research question [<xref ref-type="bibr" rid="CR33">33</xref>]. In this study, 60.0 % of the assessed participants were considered to have a dental pain-causing condition (Table <xref rid="Tab12" ref-type="table">12</xref>). For older people without dementia, the orofacial pain prevalence was 6.7–18.5 % [<xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR34">34</xref>].<table-wrap id="Tab12"><label>Table 12</label><caption><p>Orofacial pain in older people with and without dementia</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Study</th><th colspan="2">Number of participants<break></break>Mean age in years (SD)</th><th colspan="2">Orofacial pain</th><th rowspan="2">Pain measurement</th></tr><tr><th>No dementia</th><th>Dementia</th><th>No dementia</th><th>Dementia</th></tr></thead><tbody><tr><td>Adam and Preston [<xref ref-type="bibr" rid="CR28">28</xref>]</td><td>54 ND-MiD<break></break>85.5 (7.6)</td><td>81 MoD-SeD<break></break>80.8 (7.6)</td><td>18.5 %</td><td>7.4 %</td><td>Questionnaire: presence or absence of pain in the last 4 weeks, asked to individuals and/ or caregivers; nearly 60 % of the responses attained from caregivers</td></tr><tr><td>Chalmers et al. [<xref ref-type="bibr" rid="CR15">15</xref>]</td><td>113<break></break><79: 88<break></break>80+: 25</td><td>103<break></break><79: 82<break></break>80+: 21</td><td>11.2–11.5 %</td><td>18.4–19.0 %</td><td>Questionnaire: current pain or discomfort. Asked to guardian/caregiver if necessary</td></tr><tr><td>Cohen-Mansfield [<xref ref-type="bibr" rid="CR33">33</xref>]</td><td>–</td><td>21<break></break>88.0 (mv)</td><td>–</td><td>60.0 %</td><td>Dental exam: considered to have pain-causing conditions according to dentist</td></tr><tr><td>De Souza Rolim et al. [<xref ref-type="bibr" rid="CR34">34</xref>]<break></break>De Souza Rolim et al. Evaluation<sup>a</sup> [<xref ref-type="bibr" rid="CR34">34</xref>]</td><td>30<break></break>61.17 (11.2)</td><td>29<break></break>75.17 (6.7)</td><td>6.7 %</td><td>20.7 %</td><td>Questionnaire and dental exam: orofacial pain characteristics and Visual Analog Scale, McGill Pain Questionnaire</td></tr><tr><td>Kossioni et al. [<xref ref-type="bibr" rid="CR44">44</xref>]</td><td>–</td><td>23<break></break>76.3 (7.1)</td><td>–</td><td>21.7 %</td><td>Questionnaire: pain when chewing</td></tr></tbody></table><table-wrap-foot><p><italic>Dem</italic> dementia, <italic>MiD</italic> mild dementia, <italic>MoD</italic> moderate dementia, <italic>mv</italic> missing value, <italic>SeD</italic> severe dementia</p><p><sup>a</sup>Same data as de Souza Rolim [34]</p></table-wrap-foot></table-wrap></p><p>The heterogeneity, specifically the clinical and methodological variability, between the studies was considered too large to perform a meta-analysis.</p></sec></sec><sec id="Sec10" sec-type="discussion"><title>Discussion</title><p>This is the first systematic review with a quantitative overview of oral health variables in older people with dementia, compared to older people without dementia. Several qualitative reviews already stated the importance of good oral health in older people with dementia [<xref ref-type="bibr" rid="CR75">75</xref>–<xref ref-type="bibr" rid="CR83">83</xref>]. This review summarizes that the number of teeth present is comparable between older people with dementia and cognitively intact older people [<xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR25">25</xref>, <xref ref-type="bibr" rid="CR39">39</xref>, <xref ref-type="bibr" rid="CR43">43</xref>, <xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR52">52</xref>, <xref ref-type="bibr" rid="CR58">58</xref>]. The number of teeth present was the most commonly used measure for dental health, presumably because of its simplicity.</p><p>Studies that compare older people with and without dementia, showed similar, high DMFT scores for both groups [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR32">32</xref>, <xref ref-type="bibr" rid="CR42">42</xref>, <xref ref-type="bibr" rid="CR48">48</xref>, <xref ref-type="bibr" rid="CR58">58</xref>]. Although the DMFT index gives an indication of the dental caries history as a whole, it does not distinguish between decayed, missing, and filled teeth separately. To get a better indication of disease and treatment need, the presence of caries should be assessed individually. Dental decay can be divided in coronal and root caries, which is a valuable distinction, considering the etiology and treatment methods of these types of caries. Coronal caries and root caries are significantly more common in older people with dementia than in those without dementia. This difference can be explained by cognitive, medical, and functional changes in people with dementia. For example, agitated behavior, characteristic for dementia, may complicate oral care [<xref ref-type="bibr" rid="CR84">84</xref>], resulting in increased plaque accumulation and higher risk of caries [<xref ref-type="bibr" rid="CR14">14</xref>]. In addition, reduced cooperation with dental treatment may constrain the possibilities of dental treatment [<xref ref-type="bibr" rid="CR85">85</xref>]. The risk of caries increases even further, as a result of decreased submandibular saliva flow rates in people with Alzheimer’s disease [<xref ref-type="bibr" rid="CR86">86</xref>], and changes in food composition (e.g., more sticky, grinded, and cariogenic food), which are often seen in people with dementia [<xref ref-type="bibr" rid="CR39">39</xref>, <xref ref-type="bibr" rid="CR58">58</xref>]. Furthermore, functional changes in dementia, like declined handgrip and motor skills, play a role in the caries risk [<xref ref-type="bibr" rid="CR39">39</xref>, <xref ref-type="bibr" rid="CR48">48</xref>]. More specifically, the decline in motor coordination might result in more difficulty performing oral care [<xref ref-type="bibr" rid="CR48">48</xref>] and lower chewing and swallowing efficiency [<xref ref-type="bibr" rid="CR39">39</xref>]. Remarkably, studies looking at coronal and root caries separately show significantly more caries in older people with dementia. One explanation is that some studies did not include root caries as decay in the DMFT index, as this was not mentioned in all articles [<xref ref-type="bibr" rid="CR28">28</xref>, <xref ref-type="bibr" rid="CR42">42</xref>, <xref ref-type="bibr" rid="CR48">48</xref>, <xref ref-type="bibr" rid="CR87">87</xref>].</p><p>Retained roots are more present in older people with dementia than older people without dementia. This may be a result of the higher caries prevalence, fewer dental checks, resistance-to-care behavior, and decreased verbal communication skills [<xref ref-type="bibr" rid="CR88">88</xref>, <xref ref-type="bibr" rid="CR89">89</xref>]. Lee and colleagues stated that, in the USA, people with dementia are less likely to visit the dentist regularly and the last visit to the dentist was a longer time ago, compared to older people without cognitive impairment [<xref ref-type="bibr" rid="CR88">88</xref>]. Furthermore, an article about the barriers to good oral hygiene in nursing homes pointed out that resistance-to-care behavior is a major threshold in providing good oral care, which can be overcome by education of health workers and more time to provide oral care [<xref ref-type="bibr" rid="CR90">90</xref>]. Additionally, verbal communication about dental problems and pain can be complicated in people with dementia, because of the short-term memory loss and language disturbances, like aphasia [<xref ref-type="bibr" rid="CR91">91</xref>].</p><p>For edentulousness, the wide range in percentages might have been related to cultural differences [<xref ref-type="bibr" rid="CR92">92</xref>, <xref ref-type="bibr" rid="CR93">93</xref>] and the small number of studies and participants. For instance, people in different countries have different diets, oral hygiene habits, and access to professional dental care [<xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR94">94</xref>].</p><p>Dentures were worn by approximately the same percentage of older people either with or without dementia [<xref ref-type="bibr" rid="CR12">12</xref>, <xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR51">51</xref>]. However, one study examined people in different stages of dementia and found lower percentages of denture use in people with more severe dementia [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR47">47</xref>]. Adam and Preston suggest that “the high rate of not wearing dentures in the moderate/severe dementia group may in part be due to the dementia itself” [<xref ref-type="bibr" rid="CR28">28</xref>]. A decrease of denture use with the progress of dementia could be explained by the lower tolerance of dentures, decreased control of oral musculature, decreased quality and quantity of saliva, and/ or higher risk of denture loss [<xref ref-type="bibr" rid="CR85">85</xref>, <xref ref-type="bibr" rid="CR95">95</xref>]. Additionally, as people are edentulous for a longer time, the processus alveolaris resorbs more, resulting in a decrease of denture retention, especially in the lower jaw [<xref ref-type="bibr" rid="CR96">96</xref>]. This increases the risk of aspiration of the lower dentures, particularly in older people with dementia, who are at increased risk of aspiration of foreign material [<xref ref-type="bibr" rid="CR97">97</xref>].</p><p>Strikingly, orofacial pain in older people with dementia (7.4–21.7 %) was rarely studied [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR33">33</xref>]. This is interesting, because this particular group seems to be at higher risk for this type of pain, considering the higher prevalence of oral health problems and the loss of verbal communication skills as the dementia progresses. Even more so, because being free of pain is considered an important factor in quality of life [<xref ref-type="bibr" rid="CR1">1</xref>].</p><sec id="Sec11"><title>Strengths and limitations</title><p>The main strengths of this review are its systematic approach, the quality assessment of the articles, the quantitative overview of the dementia and oral health variables, and the involvement of a multidisciplinary team, including a neuropsychologist, dentists, and a pain specialist. For the search, there were no language limitations. Next to the described search, additional searches were done with the search terms facial pain, dental pain, DMFT, caries, and teeth present, in combination with dementia, to check the completeness of the results of the original search. Regarding the quality of the studies, most have a good, representative selection of cases and controls, a good comparability between the groups, and a systematic approach of the dental examination.</p><p>Limitations of this review are that the included studies showed a variety in outcome measures, not all included studies reported the standard deviations of the published mean values, and some studies about nursing home residents did not distinguish between older people with and without dementia. In addition, the number of RCTs was small, the number of high quality studies was low, and the heterogeneity was too large to perform a meta-analysis. Within the studies, the non-response and follow-up rate of the participants was often insufficiently described. In order to enable a better interpretation, it is important that these results are published. Despite the mentioned limitations, in this review the outcome measures, standard deviations and means, classification of dementia, and NOS scores of the studies are represented in a systematic manner to enhance a better interpretation of the different studies.</p><p>When looking at the effect of the quality on the studies, the main thing that strikes is the higher amount of coronal and root caries in older people without dementia in high quality studies [<xref ref-type="bibr" rid="CR52">52</xref>], compared to all studies. Furthermore, the amount of retained roots in older people with dementia is the highest in the only high-quality study that compares retained roots in older people with and without dementia [<xref ref-type="bibr" rid="CR35">35</xref>]. When only the high-quality studies are considered, the percentage of orofacial pain in older people with dementia is higher [<xref ref-type="bibr" rid="CR15">15</xref>]. The ranges of outcome values get smaller when solely looking at the higher quality studies, especially for edentulousness [<xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR52">52</xref>], denture use [<xref ref-type="bibr" rid="CR47">47</xref>, <xref ref-type="bibr" rid="CR51">51</xref>], and the number of teeth present [<xref ref-type="bibr" rid="CR37">37</xref>, <xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR52">52</xref>]. This seems logical, considering the smaller amount of studies involved.</p></sec><sec id="Sec12"><title>Considerations and suggestions</title><p>This study shows a broad range of methods to classify the group of people with dementia. The MMSE is most commonly used, even though it is only a short cognitive screening instrument and not suitable for dementia diagnosis [<xref ref-type="bibr" rid="CR98">98</xref>]. The advantages of the MMSE are its easy and quick application and the possibility of using this tool in moderate stages of dementia (from MMSE 14), where more extensive neuropsychological testing is no longer possible [<xref ref-type="bibr" rid="CR68">68</xref>]. To diagnose dementia, extensive diagnostic examination should take place, and structural classification with systems like the ICD and DSM are preferred [<xref ref-type="bibr" rid="CR61">61</xref>, <xref ref-type="bibr" rid="CR99">99</xref>, <xref ref-type="bibr" rid="CR100">100</xref>]. To distinguish between dementia subtypes, neuroimaging is a valuable addition [<xref ref-type="bibr" rid="CR101">101</xref>].</p><p>For oral health, a broad range of methods is also seen, with the number of teeth present being the most common variable studied. While the number of teeth present is easy to measure and compare between studies, it does not specify the state of the teeth. The DMFT also provides information about the presence of caries and fillings in the teeth and is a widely used method, which enables comparing results between studies [<xref ref-type="bibr" rid="CR102">102</xref>]. However, the method was developed in 1930 for epidemiological research in children [<xref ref-type="bibr" rid="CR103">103</xref>] and seems unsuitable for present-day dentistry in people, which includes implants, crowns, and bridges. Further limitations of the DMFT are that teeth can be lost for reasons other than caries; it cannot be used to assess root caries; and it gives equal weight to decayed, missing, and filled teeth [<xref ref-type="bibr" rid="CR104">104</xref>]. There is a need for an international, standardized method for dental examination in (older) people, dealing with the limitations stated above. Suggested items for the examination of dental hard tissues are the number of teeth present and the presence of implants, crowns, bridges, fillings, coronal caries, root caries, and retained roots. To investigate the chewing efficiency, Elsig and colleagues also suggested to include a chewing efficiency test into a standard examination [<xref ref-type="bibr" rid="CR39">39</xref>]. In addition, the soft tissues should be examined. Suggestions for the examination of the dental soft tissues are beyond the scope of this article and will be discussed in a separate review.</p><p>With regard to oral health in older people with dementia, Chalmers and colleagues already suggested to examine the possible relationship between dental problems, dental pain, and challenging behavior in older people with dementia [<xref ref-type="bibr" rid="CR14">14</xref>]. As of yet, this relationship is still scarcely studied, although dental discomfort might be an underlying cause of behavioral problems [<xref ref-type="bibr" rid="CR105">105</xref>, <xref ref-type="bibr" rid="CR106">106</xref>]. This issue may even be more urgent for people with vascular dementia, in whom the pain experience is suggested to be increased, due to the presence of white matter lesions [<xref ref-type="bibr" rid="CR107">107</xref>, <xref ref-type="bibr" rid="CR108">108</xref>]. However, the prevalence of orofacial pain in dementia subtypes has not been studied yet and is a suggested subject for future research.</p></sec></sec><sec id="Sec13" sec-type="conclusion"><title>Conclusion</title><p>In conclusion, this systematic review found that older people with dementia have worse overall oral health than older people without dementia, including coronal caries, root caries, and retained roots. In contrast, they had an equivalent number of teeth present, similar rate of edentulousness, and equivalent decayed missing filled teeth index. Unfortunately, few studies have focused on orofacial pain in older people with dementia. Oral health, and specifically orofacial pain in older people with dementia, is in dire need of further attention.</p></sec></body><back><ack><p>We thank Dr. Eiko Yoshida of the Tokyo Medical and Dental University (TMDU), Tokyo, Japan for her help with the assessment of the Japanese articles.</p></ack><notes notes-type="COI-statement"><title>Compliance with ethical standards</title><sec id="FPar1"><title>Conflict of interest</title><p>The authors declare that they have no conflict of interest.</p></sec><sec id="FPar2"><title>Funding</title><p>The work was supported by Alzheimer Nederland, Amstelring, Fonds NutsOhra, Roomsch Catholijk Oude Armen Kantoor (RCOAK), Stichting Beroepsopleiding Huisartsen (SBOH), and Stichting Henriëtte Hofje.</p></sec><sec id="FPar3"><title>Ethical approval</title><p>This article does not contain any studies with human participants or animals performed by any of the authors.</p></sec><sec id="FPar4"><title>Informed consent</title><p>For this type of study, formal consent is not required.</p></sec></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Petersen</surname><given-names>PE</given-names></name></person-group><article-title>The World Oral Health Report 2003: continuous improvement of oral health in the 21st century—the approach of the WHO Global Oral Health Programme</article-title><source>Community Dent Oral Epidemiol</source><year>2003</year><volume>31</volume><fpage>3</fpage><lpage>24</lpage><pub-id pub-id-type="doi">10.1046/j..2003.com122.x</pub-id><pub-id pub-id-type="pmid">15015736</pub-id></element-citation></ref><ref id="CR2"><label>2.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rodríguez-Rodero</surname><given-names>S</given-names></name><name><surname>Fernández-Morera</surname><given-names>JL</given-names></name><name><surname>Menéndez-Torre</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Aging genetics and aging</article-title><source>Aging Dis</source><year>2011</year><volume>2</volume><fpage>186</fpage><lpage>195</lpage><pub-id pub-id-type="pmid">22396873</pub-id></element-citation></ref><ref id="CR3"><label>3.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Petersen</surname><given-names>PE</given-names></name><name><surname>Yamamoto</surname><given-names>T</given-names></name></person-group><article-title>Improving the oral health of older people: the approach of the WHO Global Oral Health Programme</article-title><source>Community Dent Oral Epidemiol</source><year>2005</year><volume>33</volume><fpage>81</fpage><lpage>92</lpage><pub-id pub-id-type="doi">10.1111/j.1600-0528.2004.00219.x</pub-id><pub-id pub-id-type="pmid">15725170</pub-id></element-citation></ref><ref id="CR4"><label>4.</label><mixed-citation publication-type="other">Petersen PE, Bourgeois D, Bratthall D, Ogawa H (2005) Oral health information systems—towards measuring progress in oral health promotion and disease prevention. 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