SYSTEMATIC REVIEW

Association of oral healtherelated quality of life and Alzheimer

disease: A systematic review
Yung Ming, MSN,a Shang-Wei Hsu, PhD,b Yea-Yin Yen, MPH, PhD,c and Shou-Jen Lan, DDS, PhDd

ABSTRACT
Statement of problem. Oral healtherelated quality of life (OHRQoL) is a subjective measure that assesses a person’s perception of oral health.
Patients with Alzheimer disease (AD) suffer from impaired cognitive function and a compromised ability to perform activities of daily living.
Further exploration is needed to clarify whether OHRQoL is negatively impacted by cognitive degeneration and oral health conditions among
patients with AD.
Purpose. The purpose of this systematic review was to increase understanding of OHRQoL among patients with AD and explore factors that
may affect OHRQoL.
Material and methods. Searches were conducted in PubMed, the Cochrane Library database, Medline, EBSCO, ProQuest, and EMBASE until
August 30, 2018, with no date restrictions. The initial search targeted quantitative observational studies published in English that included the
keywords AD, oral, prosthesis, and OHRQoL. Data extraction was independently conducted by 2 reviewers. OHRQoL was investigated as the
outcome. Cognitive status and oral health conditions were treated as exposures. Tools used to measure OHRQoL included the Geriatric Oral
Health Assessment Index (GOHAI) and the Oral Health Impact Profile. The research adhered to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses guidelines.
Results. Six studies were included. The sample sizes ranged from 30 to 226 participants, 5 studies used cross-sectional designs, and 1 was a
nonrandomized controlled trial. Three studies reported higher OHRQoL scores among participants with AD than those among controls, but only
1 study showed a statistically significant difference. A statistical analysis was conducted with 4 studies that reported GOHAI scores, and no
significant differences were found in GOHAI scores between participants with AD and controls (standard mean difference: 0.09; 95% confidence
interval: −0.66 to 0.85). All studies that explored factors affecting OHRQoL showed different associations between cognitive impairment, oral
health conditions, and OHRQoL. One study showed that cognitive impairment was negatively associated with OHRQoL. Three studies found oral
health conditions (including periodontitis, gingival bleeding, probing depth >4 mm, and number of natural teeth) impaired the OHRQoL of
participants with AD. Three studies reported that prosthetic type and quality positively affected OHRQoL among participants with AD.
Conclusions. OHRQoL may not fully represent actual oral health problems of patients with AD. Clinical dentists should evaluate oral problems
in this population, preferably by using both subjective and objective examinations, including oral and dental conditions. This will ensure oral
problems among patients with AD can be detected early and timely treatment provided. (J Prosthet Dent 2019;-:---)

Alzheimer disease (AD) is a neurodegenerative disorder
and accounts for 60% to 80% of all dementias among
the elderly.1,2 The pathophysiology of AD has been
associated with the extracellular deposition of amyloid-
b protein in brain tissues, resulting in disrupted synaptic
connectivity and tau protein hyperphosphorylation,
which in turn leads to intracellular neurofibrillary
tangles.2,3 The resultant pathophysiological changes
cause neuronal loss and progressive atrophy of cortical
areas (including hippocampus, entorhinal cortex, and
amygdala).4,5 The degree of impairment tends to dete-
riorate as AD progresses and is primarily expressed as
reduced cognitive and physical abilities in daily
activities.6

a
Graduate student, Department of Healthcare Administration, Asia University, Taichung City, Taiwan, Republic of China.
b
Associate Professor, Department of Healthcare Administration, Asia University, Taichung City, Taiwan, Republic of China.
c
Associate Professor, Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan, Republic of China.
d
Professor, Department of Healthcare Administration, Asia University, Taichung City, Taiwan, Republic of China.

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Clinical Implications
Patients with AD are presumed to have higher
OHRQoL scores. Tests derived from oral function
examinations have revealed that the oral health
condition of patients with AD is worse than that of
their non-AD counterparts. In general, most patients
with AD do not report relevant oral health
complaints. Clinical dentists, long-term care
specialists, and caregivers should pursue proactive
follow-up to avoid deteriorated nutritional status
and accelerated cognitive decline among patients
with AD.
Currently, no curative therapies exist for AD or the
broader category of dementia. Therefore, the primary
goal of treatment is to maximize quality of life (QoL) by
ameliorating functional and cognitive performance,
delaying decline in activities of daily living, and assisting
patients and caregivers to obtain the necessary care and
services.7 The World Health Organization defined QoL
as “individuals’ position in life in the context of culture
and value systems in which they live and in relation to
their goals, expectations, standards, and concerns.”8 Oral
healtherelated quality of life (OHRQoL) refers to a per-
son’s perception of their oral health and is significantly
related to the individual’s overall QoL.9-11 OHRQoL
underlines interactions among conditions of oral cavity
health, general state of health, and QoL.9-12 When pa-
tients with neuromuscular and cognitive limitations
become less capable of performing oral hygiene proced-
ures, they are not able to remove food debris or recognize
caries and primary signs related to periodontal diseases
(manifested primarily through bleeding, deep probing, or
mobility).2,3,12-16 Periodontal disease, tooth loss, and the
use of inappropriate prostheses lead to limitations in
mastication and speech and can affect an individual’s
social life and acquired nutrition.17-25 Reduced overall
oral health status may affect OHRQoL and deteriorate
patients’ cognitive status.10-14,19,20,25-27
OHRQoL indicators offer an excellent way to measure
patients’ satisfaction and abilities through self-report.10
The Geriatric Oral Health Assessment Index (GOHAI)
is a straightforward, widely used, and scientifically tested
instrument specially designed for the aged population.28-30
The GOHAI provides reliable evidence of self-perceived
OHRQoL regarding oral function, pain, and discom-
fort.11,26,27 The Oral Health Impact Profile (OHIP)-14 is a
simplified version of the OHIP-49 with 7 dimensions:
functional limitation, physical pain, psychological
discomfort, physical disability, psychological disability,
social disability, and handicaps.30 Clinical signs alone
cannot comprehensively determine an individual’s
THE JOURNAL OF PROSTHETIC DENTISTRY
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satisfaction or ability to perform daily activities. There-
fore, evaluating the impact of oral health on QoL among
older adult patients with AD is important. Further
exploration is also needed to clarify whether subjective
perceptions of OHRQoL are consistent with actual oral
health in the context of cognitive impairment among
patients with AD. Most previous systematic reviews of
OHRQoL have focused on adults and older adults or
have been used to explore correlations between problems
such as the oral cavity and OHRQoL.14,19,31 Few sys-
tematic reviews have explored OHRQoL among patients
with cognitive impairment (such as AD). The present
study therefore aimed to clarify whether OHRQoL
among patients with AD was worse than that among
those without AD and what factors relating to oral health
conditions affected OHRQoL among patients with AD.
MATERIAL AND METHODS
The present study involved a methodological assessment
of journal articles that summarized OHRQoL among
participants with AD, along with factors that impacted
their OHRQoL. This research adhered to the Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines for conducting and re-
porting systematic reviews.32
This review included descriptive and experimental
studies that measured OHRQoL at baseline and inter-
vened with prosthesis use. The present study assessed
prospective observational studies, as well as control
groups from controlled intervention studies focused on
AD. Published articles were excluded from the research
if they were not written in English, full text was not
available, or professional data or letters were not
available. The search was not limited by year of publi-
cation. Studies that included participants with
Alzheimer-type dementia diagnosed by neurologists or
psychologists were included in this research; any degree
of cognitive impairment was included. Participants in
the included studies were not limited to a specific de-
mographic or ethnic group. Subjective perceptions of
OHRQoL among participants with AD were assessed by
using questionnaires such as the GOHAI and the OHIP,
and factors affecting OHRQoL related to oral health
conditions (including periodontal disease, tooth loss,
caries, and use of prostheses) were examined by clinical
dentists and measured by any tools. Any of these con-
ditions were included in this analysis.
A 3-step search strategy was used in the review
processes to find as many qualified published studies as
possible. Initially, articles listed in PubMed, MEDLINE,
EMBASE, CINAHL, Cochrane Library database, and
ProQuest were searched. Text words contained in the
titles and abstracts and index terms used to describe the
articles were analyzed. A second search phase using all
Ming et al
- 2019 3

Literature database search (n=54)

(JBI) Meta-Analysis of Statistics Assessment and Review
PubMed (n=11), Cochrane Library database (n=1), Instrument.33,34 For health management strategies, the
Identification

MEDLINE (n=10), EBSCO (n=5), JBI classifies grade A recommendations as “strong” and
ProQuest (n=17), Embase (n=10) grade B as “weak.”35 The statistical analysis of standard
mean difference (SMD) of OHRQoL between partici-
pants with AD and non-AD controls was the primary
Duplicate articles (n=39)
measure of effect. Statistical analyses were performed by
using a statistical software program (Stata version 13.0;
StataCorp LLC).

Articles excluded (n=8):

Screening

OHRQoL not outcome variable RESULTS

(n=1)
Titles/abstracts
Patients with other disorders
The electronic database search retrieved 54 records, of
reviewed (n=15) which 39 were duplicate records and excluded. Eight of
(n=6)
(Reviewers: Ming, Yen)
Participants and measurement the remaining 15 records were also excluded; 1 study did
tools not meeting the inclusion not use OHRQoL as the outcome variable, 6 studies
criteria (n=1) involved participants who did not have AD, and 1 study
did not qualify because the measurement tools and
Eligibility

participants did not meet the inclusion criteria for the

Full-text articles Inclusion criteria not clearly present review. Of the remaining 7 studies, 1 study was
screened (n=7) defined (n=1) excluded because the AD diagnosis was not clearly
defined. After this multistage screening and selection
process, 6 of the 54 initially retrieved records qualified
Articles met the inclusion criteria for the and were included in the final review (Fig. 1). Of these, 1
literature review (n=6) study was conducted in the United States, 1 in Italy, 1 in
Articles met inclusion criteria when article Germany, and 3 in Brazil. Five studies used cross-
Included

references searched (n=0) sectional designs, and 1 was a nonrandomized, single-

Articles included for systematic review (n=6)
Figure 1. Flow diagram of records identified through database
searching.
identified keywords and index terms was then under-
taken across these databases. Additionally, reference lists
of all identified articles were searched for additional
qualified studies. Search terms used were [Dementia or
cognitive impair* or Alzheimer*]; and [oral or dental;
prosthesis* or Implant*]; and [GOHAI or OHRQoL or
OHIP].
Duplicated studies were removed by using a reference
management software program (EndNote X8; Clarivate
Analytics). Two authors (Y.M., Y.-Y.Y.) independently
read the titles, abstracts, and full text of identified articles
and eliminated irrelevant reports. Any disagreements in
the initial search and duplicate screening stages were
discussed with a third reviewer (S.-J.L.). All studies
identified as potentially relevant were then retrieved and
read in full to determine eligibility for inclusion in
this review. Quality assessment of the selected studies
was performed by the 3 authors who independently
assessed individual study designs with respect to meth-
odological quality by adopting standardized critical
appraisal instruments from the Joanna Briggs Institute
center controlled trial (Table 1).
The included studies used the Decayed, Missing, and
Filled Teeth (DMFT) index and clinical inspection to
evaluate participants’ cavities and probing depth. Other
parameters including gingival bleeding, biofilm index,
and the degree of tooth mobility test were also recorded
(Table 1). Three studies found fewer natural teeth among
patients with AD. These studies used the DMFT index to
assess participants’ oral conditions, with the index scores
reported as 23.56 ±2.78, 25.8 ±4.6, and 28
(Table 2).10,11,25 One study indicated that participants
with AD presented with fewer natural teeth (P<.001) and
higher values for both the DMFT (P<.001) and Oral
Hygiene Index (OHI; P=.002) than controls (Table 2).25
One study reported that participants who had about
87.2% of their teeth remaining (on average 12.21 ±3.77
teeth) had periodontal disease (confirmed by a probing
depth of 4 mm or more); on average, 9.15 of injured
periodontal teeth had gingival bleeding (about 75%), and
37.34% of periodontally diseased teeth were in a severe
stage of mobility.10 Only 1 study found that participants
with AD had lower masticatory efficiency than the con-
trol group before and after the insertion of new remov-
able prostheses (Table 2).7
One study used the OHIP-14 to assess OHRQoL
among participants with AD, with the highest score
range being 29 to 42 points (65.2%).10 Five studies used
the GOHAI, with 2 of these studies using a 5-point

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Table 1. Description of each study

Measurements
Study Population
Author (Year) Country Study Design and Characteristics Subjective Assessment Objective Assessment JBI Quality
Campos Brazil Nonrandomized, 32 older adults: mild AD (n=16), GOHAI (3-point scoring ME, using the sieving Strong
et al (2018)7 single-center, age 76.7 ±6.3 y; without AD (n=16) scale), before and 2 mo after method
controlled clinical age 75.2 ±4.4 y the prosthetic treatment
trial
Klotz Germany Cross-sectional 169 participants from nursing GOHAI (5-point scoring Record: natural teeth, type Strong
et al (2017)26 study homes: scale) of denture, and denture-
124 AD (male=47, female=77), age related treatment needs
83.1 ±8.9 y; 45 non-AD (male=8, Revised Oral Assessment
female=37), age 82.3 ±8.9 y Guide
Campos Brazil Cross-sectional 16 patients with AD, age 76.7 ±6.3 y; GOHAI (3-point scoring DMFT index Strong
et al (2016)11 study 16 patients’ caregivers without AD, scale) Assessing oral health, clinical
age 51.7 ±11.1 y examinations
RISE index (quality of
prostheses)
Cicciu Italy Cross-sectional 158 patients with AD, 57 males OHIP-14 DMFT index Strong
et al (2013)10 study (36%), 101 females (64%); age 74.37 Tooth mobility degree test
±5.38 y Clinical investigation
Excluded patients with complete Biofilm index
edentulous
Lee United States Cross-sectional 226 community-living residents: 38 GOHAI (5-point scoring Oral evaluations: 3 dentists Strong
et al (2013)27 study CIND; 19 MD; 169 NCF scale) and 1 dental hygienist
Age  70 y
Ribeiro Brazil Cross-sectional 30 subjects with AD (mild=11, GOHAI (3-point scoring DMFT index Strong
et al (2012)25 study moderate=12, severe=7), aged 78 scale) OHI
y (range: 68.0-89.0 y)
30 subjects without AD (controls)
age 66 y (range: 59.0-81.0 y)

AD, Alzheimer disease; CIND, cognitive impairment non-dementia; DMFT, Decayed Missing Filled Teeth; GOHAI, Geriatric Oral Health Assessment Index; JBI, Joanna Briggs Institute; MD,
mild dementia; ME, masticatory efficiency; NCF, normal cognitive function; OHI, Oral Hygiene Index; OHIP-14, Oral Health Impact Profile.

scoring scale26,27 and 3 using a 3-point scoring
scale.7,10,11 The studies that used a 3-point scoring scale
showed that participants with AD had higher GOHAI
scores than controls.7,11,25 One study7 reported that
participants with AD had significantly higher GOHAI
scores than the control group (34.56 ±2.00 versus 30.56
±4.49, P<.05), and the GOHAI scores after prosthetic
treatment for both groups were significantly higher than
those before treatment (34.56 ±2.00 versus 35.58 ±0.61;
30.56 ±4.49 versus 34.69 ±1.49, P<.05). However, the
impact on OHRQoL after treatment in participants with
AD was less than that among controls (Table 2).7 The
other 2 studies showed that the scores of patients with
AD were not significantly higher than those of the
controls (34.4 ±2.3 versus 32.9 ±3.5, P=.26; 33 versus 32,
P=.102).11,25 A study using a 5-point scoring scale found
that the GOHAI scores of participants with AD were not
statistically different from those of the control group
(48.6 ±8.6 versus 50.3 ±8.4, P=.234).26 Another study
found that those with normal cognitive function had
higher GOHAI total scores than participants with AD
with mild dementia (55.1 ±4.7 versus 51.0 ±4.8, P=.02)
(Table 2).27
In Table 2, OHRQoL among participants with AD
differed between each study.7,10,11,25-27 Four studies that
used the GOHAI were analyzed statistically to estimate
an overall summary effect size for the difference between
participants with AD and controls. No significant differ-
ences were found in GOHAI scores between participants
with AD and controls (SMD: 0.09; 95% CI: −0.66 to 0.85)
(Fig. 2).
Three studies mentioned a relationship between
cognitive status and OHRQoL.25-27 One study showed
that cognitive status could predict OHRQoL among 7%
of patients with AD (P<.05).27 Absence of teeth was a
significant characteristic in patients with AD.11 Three
studies found that the number of natural teeth (fewer
than 5 natural teeth)26 or decayed coronal surfaces (more
than 2 molar teeth)11,27 and probing depth >4 mm10
significantly impacted OHRQoL among patients with
AD (Table 2). One study performed an adjusted analysis
for key confounding factors such as age, sex, and
cognitive status. Patients with AD with fewer than 5
teeth had a 2-fold risk for lower OHRQoL (odds ratio
[OR]: 2.0, P=.036, 95% confidence interval [CI]: 1 to 4).25
Another study showed that periodontal pathology
(including periodontitis and gingival bleeding) also
negatively affected OHRQoL among participants with
AD (Table 2).10 Three studies indicated that the condition
of dentures was a major factor that influenced OHRQoL
among participants with AD. Furthermore, 1 study sug-
gested that OHRQoL was seriously affected in edentu-
lous participants with AD without any types of prosthetic
restorations (OR: 6.5, 95% CI: 1.3 to 32.4, P=.023).25
Denture-related treatment needs (OR: 2.4, 95% CI: 1.1
to 5, P=.024) were also factors that significantly affected
OHRQoL (Table 2).25 Only 1 study mentioned GOHAI
and masticatory efficiency and reported a significant

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Table 2. Results of oral health conditions, oral healtherelated quality of life score, influencing factors, and comparisons with controls
Oral Health Condition OHRQoL Score Influencing Factors
Author (Year) Results and Main Findings Results and Main Findings Results and Main Findings
Campos Patients with AD vs control group Patients with AD vs control group Before and after PT, intragroup
et al (2018)7 Salivary flow rate: 0.73 ±0.52 vs 1.19 ±0.65 (P<.05) GOHAI score: GOHAI score: AD, 34.56 vs 35.58 (P<.05);
AD group had significantly lower salivary flow Baseline: 34.56 vs 30.56 (P<.05) controls, 30.56 vs 34.49 (P<.05)
rate than controls before PT After PT: 35.58 vs 34.49 (P<.05) GOHAI score significantly improved after PT
ME: AD group had significantly higher GOHAI in both groups, but AD group was still higher
Baseline: 3.13 vs 15.12 (P<.05) score than controls before and after PT than controls
After PT: 9.54 vs 25.85 (P<.05) ME: AD, 3.13 vs 9.54 (P<.05);
AD group had significantly lower masticatory controls, 15.12 vs 25.85 (P<.05)
efficiency than controls before and after PT Masticatory efficiency significantly improved
after PT in both groups, but AD group was
still weaker than controls
Klotz Patients with AD vs non-AD number of natural GOHAI of AD group vs non-AD: 48.6 (8.3) vs Main factors affecting OHRQoL
et al (2017)26 teeth: 8.3 (8.9) vs 8.1 (9.0) (P=.861) 50.3 (8.4) (P=.234) Multivariate logistic regression model
Number of natural teeth did not significantly GOHAI score of AD group was lower than adjusted for age, gender, and cognitive
differ between the AD and non-AD groups that of control group, but no statistical status:
Type of denture: significance Number of teeth (<5 natural teeth):
FDP: 25% vs 16%, RDP: 21% vs 24%; CD: 53% Type of denture: OR=2.0 (P=.036, 95% CI: 1 to 4);
vs 53%, ENP: 7% vs 3% FDP (53 ±6.6), RDP (49.8 ±8.2), CD (48.3 Type of prosthetic status: OR=6.5 (P=.023,
90% of participants wore CD. ±8.2), ENP (41.3 ±8.4) (P<.001) 95% CI: 1.3 to 32.4)
Denture condition: Types of denture were significantly Denture-related treatment needs: OR=2.4
Sufficient: 34% vs 42% associated with GOHAI (P=.024, 95% CI: 1.1 to -5)
Insufficient: 66% vs 58% Denture condition: Number of teeth, type of prosthetic status,
64% of participants needed dental-related Sufficient (50.8 ±6.7), insufficient (47.2 and denture-related treatment needs were
treatment ±8.8) (P=.013) the main factors affecting OHRQoL
Denture conditions were significantly Cognitive impairment was not associated
associated with GOHAI with OHRQoL (P=.073)
Campos Number of teeth: AD group vs caregivers No correlations between GOHAI scores and
et al (2016)11 AD vs caregivers: 4.3 ±6.8 vs 20.8 ±9.9 GOHAI scores: 34.4 ±2.3 vs 32.9 ±3.5 (P=.26) prostheses quality (P>.05)
DMFT index: GOHAI score of the AD group was higher
AD vs caregivers: 25.8 ±4.6 vs 15.8 ±6.4 than that of the caregiver group, but not
Denture status: AD vs caregivers statistically significant
Edentulous, 68% vs 12.3%
Partially edentulous, 1.3% vs 31.3%
Fully dentate, 0 vs 56.3%
Cicciu DMFT index 23.56 ±2.78: OHIP-14: Main factors affecting OHRQoL:
et al (2013)10 Decayed 6.89 ±3.02 0-14 points (1.9%) Periodontitis (P<.001)
Missing 14.04 ±4.39 15-28 points (26.45%) Missing filled teeth (P<.013)
Filled teeth 2.62 ±1.79 29-42 points (65.2%)43-56 points Gingival bleeding (P=.001)
87.2% of remaining teeth (12.21 ±3.77) had (16.45%) Probing depth >4 mm (P=.012)
periodontal disease OHRQoL was negatively affected by poor oral
9.15 periodontal of damageable teeth had health including fewer teeth, gingival
gingival bleeding bleeding, probing depth >4 mm, and
37.34% of periodontal teeth were a severe stage periodontal disease
of mobility (grade 3)
Lee Number of decayed coronal surfaces: mild AD vs GOHAI score: Clinical predictors:
et al (2013)27 NCF vs CIND MD vs CIND vs NCF Model 1: cognitive status, R2=7% (P<.001)
1.0 ±1.6 vs 0.8 ±2.1 vs 1.4 ±3.2 51.0 ±4.8 vs 52.3 ±6.5 vs 55.1 ±4.7 Model 2: Model 1 and sociodemographic
Number of decayed root surface: mild AD vs NCF (P<.001) characteristics, health status, medical
vs CIND NCF vs CIND (b= -.38, P=.02) conditions, R2=28% (P=.17)
1.8 ±3.6 vs 0.5 ±1.1 vs 0.8 ±2.2 (P=.004) NCF vs MD (b= -.31, P=.02) Model 3: Model 2 and clinical dental
Number of missing teeth: mild AD vs NCF vs GOHAI score with MD, NCF, and CIND were status, R2=47% (P=.03)
CIND significantly different The more decayed coronal surfaces, the
10.2 ±7.5 vs 12.7 ±7.6 vs 12.7 ±8.0 (P=.40) lower GOHAI scores (b=-0.31, P=.04)
Poor cognitive status and clinical dental
status could predict the OHRQoL of the AD
group, especially a greater number of
decayed coronal surfaces
Riberio AD group vs control group: AD group vs control group: Difference of AD stage vs controls: mild vs
et al (2012)25 Number of natural teeth GOHAI score: 33 (22.0-36.0) vs 32.0 (17.0- moderate vs severe vs controls
1 (0-22) vs 13.5 (0-28) (P<.001); 36.0) (P=.102) 33.0 (22.0-36.0) vs 32.5 (25.0-36.0) vs 34.0
DMFT 28 (22-28) vs 25.5 (12-28) (P=.002); GOHAI scores of the AD group were not (25.0-34.0) vs 32.0 (17.0-36.0) (P=.413)
OHI 4.5 (1.7-10) vs 2.2 (0.5-8.0) (P=.002); significantly different from those of controls GOHAI score of severity of AD was not
Patients with AD showed significant differences different.
in number of natural teeth, DMFT, and OHI Removable prosthetic conditions between
compared with controls presence of oral pathology and AD revealed
a significant association (P=.006)

AD, Alzheimer disease; CD, complete denture; CDP, complete denture prosthesis; CI, confidence interval; CIND, cognitive impairment non-dementia; DMFT Index, Decayed Missing Filled
Teeth; ENP, edentulous without teeth replacement; FDP, fixed denture prosthesis; GOHAI, Geriatric Oral Health Assessment Index; MD, mild dementia; ME, masticatory efficiency; NCF,
normal cognitive function; OHI, Oral Hygiene Index; OHIP-14, Oral Health Impact Profile; OHRQoL, oral health-related quality of life; OR, odds ratio; PT, prosthetic treatment; RPD, removable
partial denture.

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Author_Year
Lee, 2013
Campus, 2016
Kiotz, 2017
Campus, 2018
Overall (I-squared=87.2%, P=.000)
NOTE: Weights are from random effects analysis
–1.9
Figure 2. Comparison of Geriatric Oral Health Assessment Index scores in Alzheimer disease and control groups.
difference (P<.05) between measurements (before and
after prosthetic insertion) and groups (participants with
AD and controls) (Table 2).7
DISCUSSION
The purpose of this systematic review was to answer the
question “Is the OHRQoL of patients with AD worse
than that of non-AD persons?” The study revealed that
GOHAI scores tended to be higher among patients with
AD than among those without AD. The OHRQoL scores
of patients with AD varied across the included studies,
with some studies reporting that subjective OHRQoL
was higher among patients with AD than that of control
groups.7,11,25 This finding suggests that patients with AD
with impaired cognitive abilities have reduced ability to
identify pain or discomfort associated with periodontitis,
gingival bleeding, missing teeth, and decay and may not
report relevant oral health complaints. Cognitive status
could predict 7% of OHRQoL, and when demographic
characteristics, health status, medical condition, and
clinical dental status were added, the predictive power
increased to 47%. In particular, clinical dental status
increased the predictive power by 19%.27 One study has
further identified that a high plaque index may indicate
decreased cognitive function among patients with AD
because tooth brushing practices among those patients
tend to be irregular.10
OHRQoL is a subjective assessment tool for people
with cognitive impairment but may best be used as a
reference. Patients with AD should regularly receive oral
examinations and treatment to maintain good OHRQoL.
Absence of or fewer teeth is a major factor affecting
the OHRQoL of patients with AD.11 Tooth loss was a
significant risk factor for dementia and has been re-
ported to be more prevalent among elders with de-
mentia.10,11,25 Tooth loss may be the strongest
predictive indicator of cognitive status among patients
THE JOURNAL OF PROSTHETIC DENTISTRY
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%
SMD (95% CI) Weight
–0.87 (–1.35, –0.39) 26.22
0.51 (–0.20, 1.21) 23.35
–0.20 (–0.55, 0.14) 27.71
1.15 (0.40, 1.90) 22.71
0.09 (–0.66, 0.85) 100.00
0 1.9
with AD,25 as patients who had lost 5 to7 teeth were at a
4.16 times greater risk for having cognitive decline.16
Experimental studies on animals have identified that
pyramidal cells in hippocampus and gyrus dentatus
decline in number over time after tooth loss,36 leading
to damaged spatial learning and memory.37 The studies
included in this review also reported that the loss of
more than 2 molar teeth could decrease masticatory
ability and affect overall QoL.10,11 The choice of food
consistency has been reported to be correlated with
dental status, whereas alimentation status was strongly
compromised in patients with fewer than 5 teeth.11,22
This suggests a need for comprehensive examinations
to assist patients in recovering from their tooth loss and
improving their mastication abilities.
The present study revealed that the absence of teeth
could affect patients’ masticatory efficiency, with 1 study
reporting lower masticatory efficiency in those with AD
than in controls.7 The same study further reported that
reduced masticatory efficiency in patients with AD may
be enhanced after delivery of prostheses. However, the
masticatory efficiency among patients with AD after the
prostheses was still less than that of counterparts in the
control group. This may be related to the neurological
degeneration of patients with AD. El Osta et al28 reported
similar results indicating that participants with fewer
than 4 functional units were found to have an altered oral
function status. Affected participants often reported dif-
ficulties in mastication or swallowing, and tended to
avoid hard foods.21 Consequently, these individuals may
be at a greater risk of malnutrition, which in turn may
affect their general health and reduce life expectancy.21,36
Masticatory efficiency appears to be more strongly
related to cognitive impairment than the number of
teeth38 and was found to be associated with various
cognitive functions such as episodic memory, verbal
fluency, and psychomotor performance. These cognitive
functions are controlled in a distinct portion of the
Ming et al
- 2019
cerebral cortex and hippocampus.38-40 Studies that used
functional magnetic resonance imaging and positron
emission topography technologies reported that masti-
cation was connected to an increase in cortical blood
flow.4,38,39 A lower cerebral blood flow was reported to be
associated with faster progression in cognitive
decline.40,41 Theoretically, mastication may contribute to
long-term positive effects on the cerebral nervous system
and be helpful in preventing or delaying the degradation
of brain function.39-41 Brain degeneration caused by AD
can also reduce sensations of smell and taste and affect
salivary flow, appetite, and motor function, which in turn
impairs masticatory function.38,42 Impaired masticatory
function can in turn limit eating and social life activities
and negatively affect OHRQoL.1,7
The oral health conceptual model proposed by Locker
and Slade18 described the relationship among 5 oral
health states that usually interact in a specific order: oral
impairment that causes functional limitation and pain or
discomfort that further affects physical, psychological,
and social health status, ultimately resulting in hand-
icap.18 The present study explored factors including
dental caries, loss of teeth, periodontal problems, den-
tures, and mastication that could affect OHRQoL among
patients with AD. Medical and dental professionals and
caregivers are advised to recognize this phenomenon
associated with patients with AD3 and initiate proactive
dental interventions or treatments as early as possible to
prevent or mitigate the vicious cycle among cognitive
abilities, mastication, and nutrition.
Limitations of this systematic review included that
only studies published in English were evaluated, the
study outcomes were evaluated by using 2 OHRQoL
instruments, which were scaled in different ways, the
majority of reviewed literature was cross-sectional, and
the included studies used small sample sizes and were
localized. A well-designed, longitudinal study with a
large sample size is required to explore the effects of oral
health condition among patients with AD. In addition,
this review found that prosthetic status may be an
important factor that affects OHRQoL among patients
with AD, especially those with a fewer number of natural
teeth or an edentulous condition. High-quality ran-
domized control trials are needed to confirm the effec-
tiveness of prosthetic treatment.
CONCLUSIONS
Based on the findings of this systematic review, the
following conclusions were drawn:
1. OHRQoL may not fully represent actual oral health
problems among patients with AD.
2. Dentists should comprehensively evaluate oral
health conditions of patients with AD by using both
subjective and objective examinations.
Ming et al
7
3. Dentists should actively manage problems associ-
ated with insufficient mastication capacity and oral
discomfort to prevent or delay the potential vicious
cycle of inadequate nutrition and to mitigate the
accelerated cognitive degradation among patients
with AD.
4. Health professionals should educate caregivers to
improve their knowledge and skills relating to oral
health care and support early detection and timely
treatment of oral problems among patients with
AD.
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Corresponding author:
Dr Shou-Jen Lan
Department of Healthcare Administration
Asia University
No. 500, Lioufeng Road
Wufeng District
Taichung City 41354
Taiwan
REPUBLIC OF CHINA
Email: shoujenlan@gmail.com or sjlan@asia.edu.tw
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.08.015
Ming et al