Art-6-Konstantopoulou
GERODONTOLOGY www.stomaeduj.com
MECHANISMS LINKING ORAL HEALTH AND FRAILTY
Review Article
IN OLDER ADULTS: A NARRATIVE REVIEW
Kalliopi Konstantopoulou1a* , Anastassia Kossioni1b
¹Department of Prosthodontics, Dental School, National and Kapodistrian University of Athens, Athens, Greece
a
DaDDS, MSc; e-mail: kakonsta@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0002-4314-9222
b
DDS, MSc, PhD, Professor; e-mail: akossion@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0003-0610-6984
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(3).art.6
Background Frailty is a geriatric syndrome in which multiple systems lose their physiological reserves
resulting in increased vulnerability to stressors and risk of adverse health-related outcomes. There is an
increasing number of studies discussing the association of oral health with frailty through several pathways.
Objective The aim of this review was to describe the possible mechanisms linking oral health and frailty.
Data Sources A narrative review was performed with literature search in PubMed, Google Scholar and
ScienceDirect electronic databases. Reference lists from relevant studies and cited papers were also
investigated.
Study Selection The review included full papers of any study design, published in peer-reviewed journals
in English until July 2021.
Data Extraction Current literature indicates four possible mechanisms linking oral health and frailty.
Data Synthesis The first mechanism refers to the nutritional pathway. It is reported that poor oral health
negatively affects protein and vitamins intake. Malnutrition and decreased energy intake have a dominant
role in frailty onset. Inflammation is another mechanism. Periodontal disease causes a systemic increase of
pro-inflammatory biomarkers which in turn may lead to muscle strength deterioration. Furthermore, oral
health can be related to frailty through neural mechanisms. Specifically, occlusion and proprioception from
the periodontal ligament contribute to the control of body balance. Finally, the mechanisms include the
psychological pathway, since poor oral health may lead to social isolation and depression which increase the
risk of negative general health outcomes. More studies are necessary to clarify the previous associations and
reveal any causative effects.
KEYWORDS
Oral Health; Frailty; Malnutrition; Inflammation; Depression.
1. INTRODUCTION common clinical manifestations of frailty are falls,
confusion, functional decline and several non-specific
One of the dominant characteristics of the older signs and symptoms, such as unintentional weight
population is heterogeneity, therefore overall health loss, extreme fatigue and frequent infections. Genetic
and function can vary substantially among individu- and environmental factors combined with epigenetic
als of the same chronological age. The concept of mechanisms are closely associated to the cumulative
frailty has come to the forefront of research interest molecular and cellular damage, and pathophysiology
in Geriatric Medicine as a geriatric syndrome charac- of frailty.
As frailty is considered a dynamic and modifiable
terized by multiple functional impairments trying
condition exercise (aerobic, balance and resistance-
to explain this diversity among older people [1,2,3].
based), caloric and protein support, vitamin D intake
Frailty is defined as a clinical state of increased vulne-
and reducing polypharmacy seem to be effective
rability related to ageing in which multiple systems strategies in its prevention or even reversion [4].
lose their physiological reserves and the homeostatic Prevalence of frailty among community-dwelling
balance is disrupted, resulting in an increased risk of older adults and nursing home residents is estimated
adverse health-related outcomes, including functi- to be approximately 16.7% [5] and 52.3% respectively
onal impairment, dependency, hospital admission, [6]. Regarding the assessment of frailty, a total of 67
institutionalization, reduced quality of life and morta- instruments are available in the literature [7]. The
lity, even after exposure to a minor stressor, such as a Physical Frailty Phenotype has been identified as the
viral infection or the use of a new drug [2,4]. The most most widely used instrument [7].
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Konstantopoulou K, Kossioni A. Mechanisms linking oral health and frailty in older adults: a narrative review. Stoma Edu J.2021;8(3):195-204.
Received: August 19, 2021; Revised: September 19, 2021; Accepted: September 23, 2021; Published: September 27, 2021
*Corresponding author: Dr. Kalliopi Konstantopoulou; Department of Prosthodontics, School of Dentistry, National and Kapodistrian University
of Athens, Thivon 2 str. 11527 Goudi, Athens, Greece
Tel./Fax: +302107461212; e-mail: kakonsta@dent.uoa.gr
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
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Konstantopoulou K, et al.
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According to this instrument, frailty is diag- mutual clinical features with frailty and may serve as a
Review Articles nosed when at least three of the following precursor of frailty [15,16].
components are met: unintentional weight Apart from the various individual oral health indica-
loss, self-reported exhaustion, low physical tors that have been investigated in relation to frailty,
activity, weak hand grip strength and slow gait speed, the term “oral frailty” has been introduced by the
while pre-frailty is defined by the presence of one or Japanese Society describing a condition of decreased
two of these criteria [8]. Moreover, the Clinical Frailty articulation, slight choking, or spillage while eating
Scale and the Frailty Index of Accumulative Deficits and increased number of unchewable foods [17]. A
are among the nine most-referenced frailty instru- longitudinal study in Japanese community-dwelling
ments [7]. It was developed as a 7-point ordinal scale older adults, describing oral frailty as the presence of
and has been modified as a 9-point scale from one at least three of the following parameters: less than
(very fit) to nine (terminally ill with a life expectancy 21 natural teeth, decreased masticatory performance,
of less than six months) based on information about decreased oral diadochokinesis for the syllable “ta”,
health status derived from medical history and clini- decreased tongue pressure, subjective difficulties
cal examination; a score of 5 or more indicates frailty in eating tough foods and swallowing tea or soup
[9]. The Frailty Index of Accumulative Deficits is based showed that it may predict new onsets of frailty as
on the multi-dimensional nature of frailty and is defined by the Physical Frailty Phenotype and morta-
expressed as a ratio of various accumulated health lity [18].
deficits [10]. As an increasing number of studies has shown an
Frailty has come to the forefront of the research inte- association between oral health and frailty, the pur-
rest in the dental field as well. Poor oral health has a pose of the present narrative review was to describe
high prevalence among older adults and there is an the possible linking mechanisms.
increasing number of studies which demonstrate
cross-sectional, as well as longitudinal associations 2. METHODOLOGY
of oral health indicators with frailty or its compo-
nents through several suggested pathways [11-13]. A A literature search in PubMed, Google Scholar and
systematic review showed a relationship between as- ScienceDirect electronic databases was performed.
pects of oral health, such as number of teeth, need for The following keywords were used: (oral health OR
and use of dental prostheses, and frailty or pre-frailty, oral function) AND (frailty) AND (linking mechanisms
and suggested the existence of various mediators of OR linking pathways). In addition, reference lists from
this association which should be further investigated relevant studies and cited papers were investigated.
[11]. In a systematic review of longitudinal studies, The titles and abstracts of the retrieved articles were
the number of teeth, oral function, accumulation screened to decide whether full-text reading was re-
of oral health problems and number of dry mouth quired, and full texts were retrieved for the selected
symptoms were identified as predictors of frailty [12]. articles. Included studies should have been published
The evident associations between oral health and in peer-reviewed journals in English language, while
frailty status among older people suggest that the no limits were set on the study design and the year
integration of frailty assessment into dental treat- of publication. Articles published until July 2021 were
ment planning might be useful in providing the most included in the present review.
appropriate dental care and preventive strategies to
older adults who are at a state of increasing vulnera- 3. RESULTS
bility [13]. Moreover, oral health, and particularly
occlusal force and mastication, have been associated Current literature indicates four possible mechanisms
with sarcopenia [14], a muscle disease characterized through which oral health is associated to frailty: a)
by decreased muscle strength and muscle mass, and/ nutritional pathway, b) inflammation, c) neural mech-
or reduced physical performance, which has many anisms and d) psychological pathway (Fig. 1).
Tooth loss Dysphagia Poor diet quantity and
Malnutrition
Dysgeusia quality
Systemic increase of Decreased muscle strength
Periodontal disease
inflammatory mediators and muscle mass
Poor oral
health Frailty
Poor oral health related General health
quality of life Depression and well-being
Social isolation
Edentulism Denture problems deterioration
Loss of proprioceptive sensation from the periodontal
ligament Postural instability and falls
Occlusal instability
Figure 1. Screening process.
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3.1. Nutritional pathway associated with poorer nutritional status, while eden-
Review Articles
The first linking mechanism refers to the nutritional tulism and the presence of a prosthesis were not
pathway and there is an interesting discussion on the found to have a statistically significant effect on mal-
association between oral health and nutrition. nutrition in older adults [35].
Malnutrition is associated with frailty [19,20]. A meta- However, a systematic review of longitudinal stud-
analysis revealed that a total of 68% of community- ies has shown that the evidence of a causative ef-
dwelling older adults with malnutrition had frailty fect between tooth loss and nutritional status and
[21]. nutrient intake was minor [36]. Also, the results of
Another meta-analysis demonstrated the substan- a randomized controlled trial indicated that both
tial association between malnutrition and frailty or removable partial dental prostheses and the short-
sarcopenia, with the co-occurrence of two or all the ened dental arch concept generated equal improve-
afore-mentioned conditions in about 50% of the hos- ment in partially dentate older adults’ masticatory
pitalized older adults [22]. performance, but the masticatory performance
There are indications that energy intake, as well could not predict nutritional status, due to their
as nutrient quality have an important role in the weak association [37]. Impaired masticatory per-
onset of frailty and the pathogenesis of sarcope- formance in older adults is affected by a variety of
nia [23]. Deficiencies in nutrients have been as- factors and may lead to alteration of dietary choices
sociated with mitochondrial dysfunction which and, subsequently, to malnutrition [38]. Better mas-
in turn may cause fatigue and weakness, two ticatory performance among functionally indepen-
elements of Physical Frailty Phenotype [24,25]. dent older adults, was independently associated with
Furthermore, a decreased amount of protein intake higher adherence to the Mediterranean Diet, in con-
possibly contributes to the pathogenesis of frailty trast to other dental indicators such as the number
findings, based on a meta-analysis of observational of natural teeth and use of removable prostheses
studies suggesting an association between an increa- [39], while older Greeks were more adherent to the
sed intake of dietary protein and a lower prevalence components of the Mediterranean Diet compared
of frailty (OR=0.67) [26]. In addition to the quantity to younger ones disregarding their dental status
of proteins, other parameters, such as protein source [40]. The enhancement of the maximum bite force
and protein distribution across meals, may also have and masticatory performance has been viewed as a
an impact on the development and progression of prerequisite for a normal nutritional status in older
frailty in older people [18]. people [41,42]. Nevertheless, the prosthetic rehabili-
Diet quality overall has been associated with a lower tation of missing teeth does not seem sufficient for
incidence of frailty in older adults [27,28]. Regarding the treatment of malnutrition, and should be accom-
the eating patterns in older adults, higher adherence panied by nutritional advice, as this combination has
to the Mediterranean Diet, which is characterized been shown to lead to alterations in the food intake
by a high intake of plant foods and olive oil and low such as fruits and vegetables and to improvement of
consumption of red meats, have been inversely corre- older adults’ nutritional status [41-44].
lated to the loss of muscle mass, sarcopenia and frailty Regarding dysgeusia, taste alteration leads to a dimi-
[29]; a meta-analysis demonstrated the protective role nution of food enjoyment, which in turn may decrease
of the Mediterranean Diet against physical disability appetite and result in malnutrition [45]. Dysphagia
(OR=0.75) and frailty (OR=0.42) [30]. It is hypothesized (swallowing problems), which is highly prevalent in
that the Mediterranean Diet has a protective action on older individuals, can alter the oral intake of foods
skeletal muscle health (myoprotective effect), since and liquids and, thus, serves as a risk factor of mal-
it is regarded as a source of bioactive nutrients and nutrition [46-48]. According to a systematic review,
has anti-oxidative and anti-inflammatory properties chewing and swallowing problems were among the
[31]. On the other hand, Westernised dietary patterns, factors which were consistently associated with poor
characterized by high consumption of refined cere- nutrition in nursing home residents [31,49]. Further-
als, whole dairy products, and processed meat, have more, high Xerostomia Index scores in older adults
a direct relationship with the increased risk of deve- have been associated with the selective avoidance of
loping several components of physical frailty pheno- foods including raw carrots, whole apples and nuts,
type, namely weight loss and slow gait speed [32]. lettuce, corn and grilled or fried meats [50].
Poor dentition, dysphagia and dysgeusia are consid- In a cross-sectional study, community dwelling older
ered to be among the nine common risk factors (the adults with oral frailty (based on the definition pro-
nine d’s) of malnutrition in older adults [33], but more posed by Tanaka et al.) were found to have a great-
research is necessary to clarify any causative effects er possibility of more severe malnutrition assessed
and the role of individual contributors. using the Mini Nutritional Assessment – Short Form
Edentulism and the presence of less than 21 natural (OR=2.17) and the level of serum albumin (OR=1.59)
teeth have been associated with the decreased intake [51].
of fruits, vegetables and proteins and the increased Also, a two-year longitudinal study demonstrated
consumption of carbohydrates [34]. A meta-analysis that oral frailty was associated with an increased risk
showed that a lower number of remaining teeth was of deterioration of nutritional status (OR=2.24) [52].
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There are indications that oral health status is mainly in the liver in various inflammatory cytokines,
Review Article
independently associated with malnutrition [53]. are elevated in patients with periodontitis [62].
However, the findings of a systematic review of
prospective studies regarding dental status and 3.3. Psychological pathway
swallowing function as determinants of malnutrition Late-life depression and frailty have been described
in older adults were inconsistent, while moderate as comorbid geriatric syndromes [63]. A meta-
quality evidence proposed that periodontal diseases, analysis supported a reciprocal relationship
oral pain and difficulties in mastication are not between depression and frailty in older adults
determinants of malnutrition [54]. Therefore, [64]. A systematic review suggested the strong
mastication seems to explain only part of variance in prospective relationship between the presence of
the intake of food and/or nutrients in independent depression and greater risk of incident frailty among
older adults [41], and more high-quality studies are community-dwelling older adults [65]. Also, a strong
necessary. correlation between depression and risk of frailty
was found in a meta-analysis and this risk was higher
3.2. Inflammation for older men compared to older women (OR=4.76
The term “inflammaging” describes an age- and OR=2.25 respectively) [66]. The findings of
related state of low-grade chronic inflammation. another meta-analysis revealed a weak negative
It is characterized by both increased levels of correlation between depressive symptomatology
proinflammatory cytokines, such as CRP and and handgrip strength [67]. Furthermore, the results
IL-6 and acute phase proteins, such as CRP, and of a longitudinal study demonstrated that both
decreased concentrations of IL-10, which lead to loneliness and social isolation were independently
deterioration of immunological homeostasis [55, associated with incident frailty [68]. Another pros-
56]. Thus, inflammaging has been assumed as an pective cohort study showed a negative association
underlying mechanism of frailty. Proinflammatory between frequency of laughter and risk of functional
biomarkers, principally interleukin 6 (IL-6) and tumor disability among older individuals [69].
necrosis factor-α (TNF-α) can have an effect on the On the other hand, a longitudinal study showed
onset of frailty [57]. The results of a meta-analysis that high levels of loneliness were associated with
demonstrated a cross-sectional association between increased risk of incident physical frailty, but no
higher concentrations of CRP and IL-6, and frailty relationship was found between loneliness and
and pre-frailty, while no statistically significant social isolation, and rate of change in frailty index
longitudinal relationship emerged [58]. Another [70]. Also, the results of a population-based cohort
meta-analysis revealed a cross-sectional quantitative study suggested that depression does not act as a
relationship between immunological biomarkers risk factor for the onset of frailty in older people [71].
and frailty among older adults assessed with Physical The bidirectional association between depression
Frailty Phenotype, which was stronger for CRP and and frailty is questioned, but it is indicated that they
IL-6 and weaker for TNF-α [56]. share some common risk factors in the short and
In a prospective cohort study, elevated serum levels long term [72].
of IL-6 acted as a predictor of walking speed decline Oral health has an effect on various aspects of older
among community-dwelling older adults [59]. Also, adults’ quality of life among which are appearance
the findings of a meta-analysis suggested that and socializing [73]. Poor oral health may have
higher levels of circulating CRP, IL-6 and TNF-α were negative consequences on social interaction and
significantly associated with lower handgrip strength self-esteem and may lead to depression, which has
and knee extension strength, and CRP levels were an adverse effect on general health and wellbeing
significantly inversely correlated to skeletal muscle [74,75]. Cross-sectional as well as longitudinal
mass [60]. A meta-analysis of cross-sectional studies associations between oral health related quality
showed that serum levels of CRP were elevated in of life and loneliness in older adults have been
people with sarcopenia compared to controls, while identified [76].
no statistically significant associations were found Tooth loss can negatively affect speech and appearance,
between serum IL-6 levels and TNF-α levels, and while denture problems may result in embarrassment
sarcopenia [61]. due to dislodgement, pain and discomfort [38,77].
There is evolving evidence of strong associations Older adults with fewer natural teeth and those who
between periodontitis, low-grade inflammation do not use dentures may have a greater possibility of
and systemic health. The accumulation of social isolation [78]. In addition, tooth loss and self-
periodontopathogenic bacteria into the gingival reported dry mouth were found to be associated with
sulcus stimulates a local inflammatory response and a higher risk of developing depression among older
pro-inflammatory mediators such as interleukin 6 (IL- adults in a longitudinal study [79]. Tooth loss and self-
6) and tumor necrosis factor α (TNF-α) are produced reported oral health problems, such as difficulty in
in periodontal lesions, which may move into the chewing tough foods, may be longitudinally corre-
systemic circulation. Also, serum levels of C-reactive lated to development or worsening of depression in
protein (CRP), an acute phase reactant produced older adults [80].
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Also, a significant association was found with one-leg standing time among men aged 85
Review Article
between lower GOHAI (Geriatric Oral Health and older [96]. The results of a cohort study showed
Assessment Index) scores and depression a strong relationship between occlusal status and
in Greek community-dwelling older adults postural stability [97]. According to a prospective
[81]. A meta-analysis revealed a positive cohort study, older adults with fewer than 20 teeth
association of edentulism (OR=1.28) and those not using dentures were at higher risk for
and periodontal disease (HR=1.73) with incident falls (OR=2.5) [98].
depression in adults and older people [82]. Also, the presence of teeth (OR=0.59) and dentures
A population-based cross-sectional study indicated (OR=0.66) was significantly associated with
a bidirectional association between the number decreased risk of falls in older adults with dementia
of remaining teeth and the frequency of laughter [99]. On the other hand, the findings of a cross-
among community-dwelling older adults [83]. sectional study demonstrated that the use of
Moreover, the results of a nationwide population- dentures was correlated to decreased balance in
based cohort study demonstrated that periodontitis both static and dynamic conditions and the duration
was associated with the increased risk of subsequent of denture use was negatively asso-ciated with
depression [84]. dynamic balance [100].
On the other hand, a study in older Greeks has shown
that the frequency of eating out was not affected 4. DISCUSSION
by the dental status, but other biological and social
factors played a more significant role indicating the Current evidence supports both the cross-sectional
multifactorial nature of human behaviour [85]. and the longitudinal association between oral health
and frailty [11-13], but more studies are necessary
3.4. Neural mechanisms to confirm the evidence and clarify any causative
The deterioration of body balance control is one effects. The majority of studies investigating this
of the most common causes of falls among older relationship were conducted in community dwelling
people [86]. Evidence has shown the existence of older adults in Japan and the most commonly used
a positive association between postural instability frailty assessment instrument was the Physical
and frailty or pre-frailty [87,88]. In a meta-analysis, an Frailty Phenotype. This review has also identified
association between falls and frailty (OR=1.80) was four potential pathways which may link oral health
found [89]. Moreover, a systematic review and meta- and frailty that also need further investigation: the
analysis provided a significant association between nutritional pathway, inflammation, the psychological
frailty and the future risk of falls among community- pathway and neural mechanisms.
dwelling older adults, greater in males [90]. Another Oral health indicators, such as the number of teeth,
systematic review and meta-analysis with similar masticatory performance, swallowing problems and
findings showed that community-dwelling older dysgeusia seem to contribute to the nutritional status
adults with frailty and prefrailty were at higher risk in older adults [33-35,38,45-52]. However, robust
for falls and, also, those with frailty were more prone evidence on the association between oral health and
to recurrent falls [91]. malnutrition is still lacking as various confounding
Oral health may be related to postural stability factors are implicated [41,42,54]. Malnutrition and
through neural mechanisms. The stomatognathic decreased energy intake, in turn, are considered to
system plays a role in the control of body posture have a dominant role in the onset of frailty and the
[92]. Dental occlusion, trigeminal afferents and pathogenesis of sarcopenia [23-26]. The multifactorial
proprioception from the periodontal ligament nature of nutritional status and food choices has
may contribute to the control of postural stability, been acknowledged, therefore, the interdisciplinary
therefore tooth loss is a possible risk factor for collaboration between dental professionals, dietetics
postural instability [92,93]. practitioners, and primary care providers is necessary
A case-control study showed that edentulous older for treatment and prevention of malnutrition [42].
adults had statistically significantly less body balance Regarding the pathway of inflammation, periodontitis
activity and higher body oscillation compared to may lead to systemic increase of inflammatory
those who maintained their dentition, while the mediators, which may serve as an underlying
use of complete denture(s) was not associated with mechanism of frailty. Nevertheless, the findings
body balance control [93]. However, in another regarding the association of periodontitis with frailty
study, complete dentures were found to have a are contradictory and evidence which supports
positive effect on static and dynamic stability among inflammation as a linking mechanism between oral
edentulous older individuals [94]. In a longitudinal health and frailty is weak [12].
study, the complete loss of occlusion with natural There are indications that poor oral health, namely
teeth (Eichner index C) was associated with decrea- tooth loss, periodontitis and self-assessed oral health
sed one-leg standing time with eyes open (OR=4.27) status negatively influences older adults’ quality of life
[95]. Furthermore, a prospective study disclosed an and is associated with an increased risk of depression
independent association of maximum occlusal force in older adults [78-82,84].
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Reciprocal, as well as prospective associations and marker of frailty. Moreover, more studies
Review Article between depre-ssive symptomatology and frailty in are necessary to explore the potential linking
older adults havebeen reported [64,65], while it is mechanisms including nutrition, inflammation,
suggested that depression and frailty are affected psychological and neural pathways. Studies in
by common causes such as biological, psychosocial, community-dwelling older individuals and nursing
behavioral, and environmental factors [72]. home residents should also examine the possible
As far as the neural mechanisms are concerned, the protective effect of systematic oral care provision
literature supports the existence of a relationship against frailty. Statistically significant results on these
between the stomatognathic system and body parameters may lead to the integration of markers
posture; the loss of proprioception from periodontal of oral health in the frailty assessment instruments
ligament may have a negative impact on the head and to the development of appropriate preventive
position and contribute to postural instability [92,93]. strategies in the context of oral health promotion.
posture; the loss of proprioception from periodontal
ligament may have a negative impact on the head 5. CONCLUSIONS
position and contribute to postural instability [92,93].
Deterioration in control of body balance is one of Oral health and frailty may be linked through
the leading causes of falls in older people nutritional, inflammatory, psychological and neural
[86]. Falls, in turn, are associated with frailty mechanisms. Further studies are necessary to
[87-89] and are among the most common thoroughly elucidate the role of these pathways as
clinical manifestations of frailty [90,91]. mediators of the latter association and, subsequently,
This narrative review has revealed the need for to determine the most effective preventive strategies.
further research including case-control and
randomized controlled trials to thoroughly explore AUTHOR CONTRIBUTIONS
the association between oral health and frailty and KK: protocol, data gathering, data analysis, authoring the draft.
also the specific role of oral health as a predictor AK: concept, protocol, critically revising the manuscript.
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Kalliopi KONSTANTOPOULOU
DDS, MSc
Department of Prosthodontics
School of Dentistry
National and Kapodistrian University of Athens
CV Athens, Greece
Kalliopi Konstantopoulou graduated from the Dental School of National and Kapodistrian University of Athens, Athens, Greece
in 2016. In 2019, she obtained her master’s degree in Health Promotion and Education from the Medical School of National
and Kapodistrian University of Athens and is currently a postgraduate student at the Department of Prosthodontics, Dental
School, National and Kapodistrian University of Athens, Athens, Greece. She is also a Board member at the European College of
Gerodontology.
Stoma Edu J. 2021;8(3):195-204 pISSN 2360-2406; eISSN 2502-0285 203
Konstantopoulou K, et al.
www.stomaeduj.com
Questions
Review Article
1. The most widely used instrument to assess frailty is:
qa. Physical Frailty Phenotype;
qb. Frailty Index;
qc. Clinical Frailty Scale;
qd. Short Physical Performance Battery.
2. Oral health is linked to frailty through:
qa. Nutrition;
qb. Inflammation;
qc. Psychological and neural pathways;
qd. All of the above are correct.
3. Which of the following sentences is correct?
qa. Oral health is the dominant determinant of malnutrition;
qb. Nutritional status and food selection have a multifactorial nature;
qc. Malnutrition can be reversed solely by prosthodontic rehabilitation;
qd. Westernized dietary patterns may prevent frailty.
4. Which of the following sentences is correct?
qa. No prospective associations exist between depression and frailty;
qb. No reciprocal associations exist between depression and frailty;
qc. Depression and frailty seem to be affected by common causes;
qd. None of the above.
https://www.adfcongres.com/en/the-conference/the-scientific-programme
204 Stoma Edu J. 2021;8(3):195-204 pISSN 2360-2406; eISSN 2502-0285