Abstract
Background
To compare the prevalence of oral mucosal lesions and oral health-related quality of life between nursing home residents (NHR) and community-dwelling older adults (CDA) in Türkiye.
Methods
This observational cross-sectional study included 639 individuals aged ≥ 65 years: 329 NHR from seven state-authorized nursing homes and 310 CDA attending a university dental clinic between July 2024 and January 2025. Demographics, systemic conditions, denture use, and dental visit history were recorded. Oral mucosal lesions were identified through standardized examinations by a blinded oral medicine specialist. Oral health-related quality of life was assessed using the validated Turkish version of the Geriatric Oral Health Assessment Index (GOHAI-TR). Group comparisons employed Chi-squared, Fisher’s exact, and Mann–Whitney U tests (p < 0.05).
Results
NHR had higher denture use (p = 0.001) and more Alzheimer’s and cerebrovascular disease, whereas CDA had more ischemic heart disease, smoking, and xerostomia (p < 0.05). Candidiasis and angular cheilitis were more common in NHR, while oral lichen planus, ulcerative lesions, and fissured tongue predominated in CDA. Red–blue lesions, particularly sublingual varicosities, were more frequent in CDA (41.6% vs. 31.6%, p = 0.009). CDA had higher GOHAI functional limitation scores (p = 0.001), indicating better self-perceived oral function, while NHR scored higher in pain/discomfort (p = 0.006). No significant differences were observed in psychological impact or total GOHAI scores.
Conclusion
NHR exhibited greater functional limitations and higher rates of infectious oral diseases. Personalized oral care strategies, including specialist-led assessments, targeted infection prevention, and structured caregiver training, are needed in long-term care to preserve oral function and quality of life in older adults.
Keywords: Oral mucosal lesions, Geriatric dentistry, Nursing home residents, Community-dwelling older adults, Geriatric Oral Health Assessment Index (GOHAI)
Introduction
The World Health Organization (WHO) emphasizes the importance of maintaining oral health as a fundamental component of healthy aging [1]. Oral health is closely associated with general health and overall quality of life. Poor oral health has been associated with malnutrition and serious systemic diseases that may increase mortality, particularly in older adults [2]. Among the elderly, the oral epithelium becomes thinner, keratinization is impaired, and collagen production in connective tissues is reduced [3]. These structural changes, compounded by decreased salivary flow and degeneration of taste receptors, result in diminished taste perception, as well as impaired chewing and swallowing efficiency [4, 5]. However, aging alone is not the sole determinant of oral mucosal health. Additional factors such as denture use, systemic diseases, polypharmacy, poor oral hygiene, and harmful habits (e.g., tobacco and alcohol consumption) significantly affect oral mucosal health [6].
In developed countries, older adults residing in nursing homes are routinely monitored by healthcare personnel, and their oral health is typically assessed by general practitioners or dentists. Such institutional care services play a vital role in maintaining the overall health of elderly residents. However, epidemiological studies have consistently reported a high prevalence of oral mucosal lesions among nursing home residents (NHR), alongside inadequate oral hygiene and limited implementation of individualized oral care protocols [7–9]. Common problems include xerostomia, sublingual varices, caries, periodontal disease, and ill-fitting dentures. While numerous studies have assessed oral mucosal lesions and oral hygiene practices among NHR across various countries, none have provided a direct comparative analysis with community-dwelling older adults (CDA) [7–9].
The present study comparatively assessed the prevalence of oral mucosal lesions and oral health-related quality of life among elderly individuals residing in nursing homes and those who independently sought care at a university dental clinic. Therefore, Geriatric Oral Health Assessment Index (GOHAI) scores and clinical oral examination findings were compared between the two groups. Specifically, our study tested the hypothesis that community-dwelling older adults would have better oral health, with a lower prevalence of oral mucosal lesions and higher GOHAI scores, compared to those residing in nursing homes living in institutional care settings.
Methods
Ethics committee approval and informed consent
This study was conducted under the ethical guidelines of the 2024 revision of the Declaration of Helsinki and received ethical approval from Istanbul University Faculty of Dentistry Clinical Research Ethics Committee, Istanbul, Türkiye (approval number 2644732). Written informed consent was obtained from all participants prior to enrolment.
Study design and setting
This observational cross-sectional study was conducted between July 2024 and January 2025 and enrolled geriatric individuals (aged ≥ 65 years) who either presented with dental complaints to the Istanbul University Faculty of Dentistry or resided in seven state-authorized nursing homes in Istanbul located in different districts of Istanbul. The inclusion of nursing homes from geographically and socioeconomically diverse areas allowed for broader representation of older adults from varying cultural and socioeconomic backgrounds. Selection criteria for nursing homes included a capacity of at least 50 residents, provision of 24-hour medical and nursing services, and operation by private companies under the authority and regular inspection of the Ministry of Family and Social Services. All selected facilities offered similar levels of geriatric care, including routine medical evaluations, basic dental services, and referral systems for specialized treatments when required.
To minimize disruption to the daily routines of NHR, oral screenings were scheduled between 10:00 a.m. and 12:00 p.m. All examinations adhered to strict infection control protocols, including the use of disposable gloves, surgical masks, and tongue depressors.
Upon receiving Ethics Committee approval, a standardized oral mucosal assessment form was developed by two experienced clinicians who also designed the study protocol. Data collected included demographic characteristics (age, sex), educational and employment status, smoking habits, comorbidities (e.g., hypertension, diabetes mellitus, cardiovascular disease), oral examination findings, presenting symptoms, denture use, last dental visit, and provisional clinical diagnoses. No invasive procedures were performed beyond routine intraoral examination.
After clinical evaluation, each participant was asked to complete the validated Turkish version of the Geriatric Oral Health Assessment Index (GOHAI-TR) through face-to-face interviews conducted by trained researchers who were blinded to the study’s null hypothesis to minimize potential bias [10]. Clarifications were provided when necessary to ensure response accuracy. To ensure diagnostic consistency and reduce interobserver variability, all intraoral examinations—both at the university dental clinic and in the nursing homes—were performed by an oral medicine specialist with over 20 years of clinical experience, who was also blinded to the study hypothesis.
Participants were categorized into two groups: NHR and CDA who independently sought care. NHR with clinically suspected pathological lesions were referred to the university dental clinic for further diagnostic evaluation and follow-up. The clinical characteristics of the participants were compared between the two groups to evaluate differences in the prevalence of oral mucosal lesions and in oral health-related quality of life as measured by GOHAI scores.
Outcomes
The primary outcome was to compare the prevalence of oral mucosal lesions among NHR and CDA. All assessments were conducted cross-sectionally, either during visits to the university dental clinic or through on-site screenings. No longitudinal follow-up was conducted. The secondary outcome was to assess differences in oral health-related quality of life between the two groups, as measured by total scores on the GOHAI. Higher scores indicated better self-perceived oral health status.
Study population and sampling
The study included a total of 639 participants: 329 elderly individuals residing in seven state-authorized nursing homes and 310 community-dwelling older adults who independently presented to the Istanbul University Faculty of Dentistry between July 2024 and January 2025. NHR were selected following institutional approval, whereas CDA were included among patients presenting to the university dental clinic. In the CDA group, oral examinations and GOHAI-TR assessments were performed at the initial visit, before any dental treatment was initiated. Community-dwelling older adults were included with the aim of achieving a broadly comparable age and sex distribution. This represented frequency matching at the group level rather than individual matching; therefore, the groups were analyzed as independent samples without post-matching statistical adjustment.
All individuals who met the inclusion criteria during the study period were enrolled. Patients under the age of 65 and those who refused to participate were excluded from the study. Individuals with an inability to communicate due to cognitive or physical impairment, as well as those diagnosed with severe psychiatric illness that interfered with participation, were excluded. Inclusion was limited to participants with early-stage Alzheimer’s disease, as defined by Reisberg’s Global Deterioration Scale (GDS stages 1–3) [11], who were both cooperative and communicative. In addition, patients with conditions that precluded intraoral examination, such as trismus or restricted mouth opening, or those receiving end-of-life or hospice care, were excluded. Finally, the study excluded individuals with temporary residency in a nursing facility for a period of less than three months. To ensure the independence of observations, each participant was enrolled only once.
Evaluation of oral health-related quality of life
The GOHAI was employed to assess the oral health-related quality of life in all participants. The GOHAI is a self-reported questionnaire specifically developed for older adults to assess the impact of oral conditions on daily functioning and well-being. The index consists of 12 items grouped into three dimensions: physical function (eating, speaking, swallowing), psychosocial function (worry, self-consciousness, social interaction), and pain or discomfort related to oral health.
Each item is evaluated using a 5-point Likert scale, with total scores ranging from 12 to 60. Higher scores indicate better perceived oral health and quality of life. In this study, we used the previously validated Turkish version of the Geriatric Oral Health Assessment Index (GOHAI-TR), which has demonstrated acceptable reliability and validity in older Turkish adults [10]. In the GOHAI-TR version used in this study, all items were phrased in a problem-oriented/negative format. Therefore, no item-specific reverse scoring was applied. All items were scored uniformly from 5 to 1 (never = 5, rarely = 4, sometimes = 3, often = 2, always = 1), so that higher total scores indicated better oral health-related quality of life. For clinical interpretation, GOHAI total scores were also categorized as poor (< 50), moderate (51–56), and good (57–60). The GOHAI-TR was administered through face-to-face interviews conducted by trained researchers. Clarifications were provided when necessary to ensure accurate and complete responses.
Statistical analysis
The sample size was determined via power analysis prior to data collection, based on previous studies [12, 13]. It was estimated that at least 310 individuals from each group—NHR and CDA presenting to the university dental clinic—would be required to detect statistically significant differences in the prevalence of oral mucosal lesions and GOHAI scores between the groups, at a power of 95% and a two-tailed α = 0.05.
Data were analyzed using SPSS 28.0 for Windows (IBM Corp., Armonk, NY, USA). Descriptive statistics included frequencies and percentages for categorical variables and means, standard deviations, and range for numerical variables. The distribution of variables was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Comparisons between groups (NHR vs. CDA) were performed using the Chi-squared test or Fisher’s exact test for categorical variables, and the Mann–Whitney U test for non-normally distributed continuous variables (e.g., age and GOHAI scores). To improve interpretability, effect size measures were also reported: odds ratios (ORs) with 95% confidence intervals (CIs) for 2 × 2 categorical comparisons, Cramér’s V for categorical variables with more than two categories, and effect size r for Mann–Whitney U comparisons. The threshold for statistical significance was set to p < 0.05.
This manuscript was prepared in accordance with the STROBE reporting guideline for cross-sectional studies.
Results
A total of 639 elderly individuals were included in the study, comprising 386 female (60.4%) and 253 male (39.6%). The mean age of the participants was 77.2 ± 6.7 years. Among them, 329 participants were nursing home residents, while 310 were community-dwelling older adults who independently sought dental care.
Table 1 summarizes the demographic and clinical characteristics between NHR and CDA. While age did not differ significantly between the two groups (p = 0.135), the sex distribution differed significantly, with a higher proportion of female participants in the NHR group than in the CDA group (p = 0.019). In both groups, the most common level of education was primary school graduation. However, the distribution of educational attainment differed significantly between the groups (p < 0.001). In contrast, no statistically significant differences were observed between the groups in terms of employment status (p = 0.062). CDA were far more likely to have visited a dentist within the past six months (85.2% vs. 24.9%), whereas NHR more frequently reported their last dental visit as 7–12 months prior (47.1% vs. 8.4%) or 13–24 months prior (26.1% vs. 5.5%) (p < 0.001).
Table 1.
Demographic characteristics of participants
| Nursing homes residents | Community-dwelling older adults | Effect Size / OR (95% CI) | ||
|---|---|---|---|---|
| (n = 329) | (n = 310) | p* | ||
| Age, mean ± SD | 77.7 ± 6.8 | 76.6 ± 6.5 | 0.135 | r = 0.059 |
| Sex, n (%) | 0.019 | OR = 0.68 (0.50–0.93) | ||
| Female | 197 (59.9) | 156 (50.3) | ||
| Male | 132 (40.1) | 154 (49.7) | ||
| Educational level, n (%) | < 0.001 | V = 0.178 | ||
| Less than school | 17 (5.2) | 33 (10.6) | ||
| Primary school | 171 (52.0) | 193 (62.3) | ||
| High school | 56 (17.0) | 34 (11.0) | ||
| College degree or more | 85 (25.8) | 50 (16.1) | ||
| Employment status, n (%) | 0.062 | V = 0.107 | ||
| Housewife | 146 (44.4) | 124 (40.0) | ||
| Worker | 52 (15.8) | 69 (22.3) | ||
| Officer | 93 (28.3) | 71 (22.9) | ||
| Self-employed | 38 (11.6) | 46 (14.8) | ||
| Last dental visit, n (%) | < 0.001 | V = 0.606 | ||
| 0–6 months | 82 (24.9) | 264 (85.2) | ||
| 7–12 months | 155 (47.1) | 26 (8.4) | ||
| 13–24 months | 86 (26.1) | 17 (5.5) | ||
| > 24 months | 6 (1.8) | 3 (1.0) | ||
| Chronic diseases, n (%) | ||||
| Hypertension | 190 (52.8) | 160 (51.6) | 0.119 | OR = 1.28 (0.94–1.75) |
| Diabetes mellitus | 92 (28.0) | 90 (29.0) | 0.765 | OR = 0.95 (0.67–1.34) |
| Alzheimer’s | 146 (44.4) | 11 (3.5) | < 0.001 | OR = 21.69 (11.44–41.12) |
| Cardiovascular heart disease | 22 (6.7) | 47 (15.2) | 0.001 | OR = 0.40 (0.24–0.68) |
| COPD | 28 (8.5) | 35 (11.3) | 0.239 | OR = 0.73 (0.43–1.23) |
| Cerebrovascular disease | 42 (12.8) | 18 (5.8) | 0.003 | OR = 2.37 (1.33–4.22) |
| History of malignancy | 25 (7.6) | 34 (11.0) | 0.141 | OR = 0.67 (0.39–1.15) |
| Other diseases | 79 (24.0) | 84 (27.1) | 0.371 | |
| Smoking, n (%) | 0.001 | OR = 0.41 (0.24–0.71) | ||
| No | 308 (93.6) | 266 (85.8) | ||
| Yes | 21 (6.4) | 44 (14.2) | ||
| Xerostomia, n (%) | 0.041 | OR = 0.71 (0.51–0.99) | ||
| No | 232 (70.5) | 195 (62.9) | ||
| Yes | 97 (29.5) | 115 (37.1) | ||
| Denture use, n (%) | 0.001 | OR = 1.74 (1.27–2.38) | ||
| No | 147 (44.7) | 181 (58.4) | ||
| Yes | 182 (55.3) | 129 (41.6) |
Data are expressed as mean ± SD or n (%)
Effect sizes are reported as Odds Ratios (OR) with 95% Confidence Intervals (CI) for 2x2 categorical variables, Cramer's V (V) for categorical variables with more than two groups, and effect size r for continuous non-normally distributed variables
Abbreviation: COPD Chronic obstructive pulmonary disease
* Intergroup comparisons were performed using chi-square tests for categorical variables (e.g., sex, educational and employment status, and last dental visits) and the Mann–Whitney U test for non-normally distributed continuous variables (e.g., age)
Alzheimer’s disease (OR 21.69, 95% CI 11.44–41.12) and cerebrovascular disease (OR 2.37, 95% CI 1.33–4.22) were more prevalent among NHR, whereas cardiovascular heart disease (OR 0.40, 95% CI 0.24–0.68), smoking (OR 0.41, 95% CI 0.24–0.71), and xerostomia (OR 0.71, 95% CI 0.51–0.99) were more common in CDA. Denture use was also significantly higher among NHR (OR 1.74, 95% CI 1.27–2.38).
Table 2 presents a comparative analysis of oral mucosal lesions observed in the two study groups. The prevalence of red and white lesions showed borderline statistical significance between the groups (p = 0.050), with candidiasis and angular cheilitis being most common in NHR, and candidiasis and oral lichen planus in CDA. Angular cheilitis was more common in NHR (OR 2.36, 95% CI 1.11–5.02), whereas oral lichen planus (OR 0.51, 95% CI 0.26–0.99), denture stomatitis (OR 0.24, 95% CI 0.10–0.61), and fissured tongue (OR 0.14, 95% CI 0.08–0.25) were more frequent in CDA. Red and blue lesions were identified in 31.6% of NHR and 41.6% of CDA. Sublingual varicosities were the most common red and blue lesion in both groups (17.6% vs. 33.9%, respectively). No significant differences were found in precancerous lesions, benign tumors, or oral cancer rates between the two groups (p > 0.05 for all).
Table 2.
Oral mucosal lesions in nursing home residents and community-dwelling older adults
| Nursing Homes Residents | Community-dwelling adults | OR (95% CI) | ||
|---|---|---|---|---|
| (n = 329) | (n = 310) | p | ||
| Red and white lesions | 0.050 | |||
| No | 218 (66.3) | 215 (69.4) | ||
| Candidiasis | 42 (12.8) | 27 (8.7) | 1.53 (0.92–2.56) | |
| Prosthesis-related reactive lesions | 21 (6.4) | 22 (7.1) | 0.89 (0.48–1.66) | |
| Oral lichen planus | 14 (4.3) | 25 (8.1) | 0.51 (0.26–0.99) | |
| Angular cheilitis | 24 (7.3) | 10 (3.2) | 2.36 (1.11–5.02) | |
| Denture stomatitis | 6 (1.8) | 22 (7.1) | 0.24 (0.10–0.61) | |
| Fibroepithelial polyp | 5 (1.5) | 9 (2.9) | 0.52 (0.17–1.56) | |
| Frictional keratosis | 3 (0.9) | 10 (3.2) | 0.28 (0.08–1.01) | |
| Lichenoid reaction | 1 (0.3) | 11 (3.5) | 0.08 (0.01–0.65) | |
| Leukoedema | 4 (1.2) | 0 (0.0) | 8.59 (0.46–160.13) | |
| Others | 0 (0.0) | 4 (1.3) | ||
| Red and blue lesions | 0.009 | |||
| No | 225 (68.4) | 181 (58.4) | ||
| Sublingual varicosities | 58 (17.6) | 105 (33.9) | 0.42 (0.29–0.60) | |
| Petechiae and ecchymosis | 54 (16.4) | 19 (6.1) | 3.01 (1.74–5.20) | |
| Smoker’s melanosis | 22 (6.6) | 15 (4.8) | 1.41 (0.72–2.77) | |
| Oral melanotic macule | 4 (1.2) | 9 (2.9) | 0.41 (0.13–1.35) | |
| Pyogenic granuloma | 1 (0.3) | 5 (1.6) | 0.19 (0.02–1.60) | |
| Peripheral giant cell granuloma | 0 (0.0) | 3 (1.0) | 0.13 (0.01–2.59) | |
| Precancerous Lesions | 0.540 | |||
| No | 319 (97.0) | 303 (97.7) | ||
| Leukoplakia | 4 (1.2) | 5 (1.6) | 0.75 (0.20–2.82) | |
| Actinic cheilitis | 5 (1.5) | 2 (0.6) | 2.38 (0.46–12.34) | |
| Erythroplakia | 1 (0.3) | 0 (0.0) | 2.84 (0.12–69.87) | |
| Ulcers | < 0.001 | |||
| No | 322 (97.9) | 284 (91.6) | ||
| Traumatic ulcer | 6 (1.8) | 21 (6.8) | 0.26 (0.10–0.64) | |
| RAS | 1 (0.3) | 8 (2.6) | 0.12 (0.01–0.93) | |
| Tongue Lesions | < 0.001 | |||
| No | 250 (76.0) | 192 (61.9) | ||
| Fissured tongue | 15 (4.6) | 79 (25.5) | 0.14 (0.08–0.25) | |
| Atrophic tongue | 48 (14.6) | 37 (11.9) | 1.26 (0.80–2.00) | |
| Black Hairy tongue | 11 (3.4) | 7 (2.3) | 1.50 (0.57–3.91) | |
| Geographic tongue | 9 (2.8) | 8 (2.6) | 1.06 (0.40–2.79) | |
| Benign Tumors | 0.715 | |||
| No | 320 (97.3) | 300 (96.8) | ||
| Hemangioma | 9 (2.8) | 8 (2.6) | 1.06 (0.40–2.79) | |
| Papilloma | 0 (0.0) | 2 (0.6) | 0.19 (0.01–3.92) | |
| Squamous cell carcinoma | 0.114 | |||
| No | 329 (100.00) | 307 (99.0) | ||
| Yes | 0 (0.0) | 3 (1.0) | 0.13 (0.01–2.59) |
Data are expressed as mean ± SD or n (%). Effect sizes for categorical variables are reported as Odds Ratios (OR) with 95% Confidence Intervals (CI)
Abbreviation: RAS Recurrent aphthous stomatitis, OR Odds ratio, CI Confidence interval
* Intergroup comparisons were performed using chi-square tests
Table 3 displays participants’ itemized responses to the GOHAI, while Table 4 summarizes the corresponding domain and total scores for both groups. CDA had significantly higher scores in the functional limitation component (p = 0.001), indicating better self-perceived ability to eat, chew, swallow, and speak without difficulty. Conversely, pain and discomfort scores were significantly higher in NHR than in CDA (p = 0.006), indicating a lower self-reported burden of pain and discomfort among nursing home residents. The between-group differences in GOHAI domain scores were of small magnitude, with effect sizes of r = 0.130 for functional limitation and r = 0.109 for pain/discomfort. Psychological impact and total scores did not differ significantly between groups (p = 0.169 and p = 0.925, respectively).
Table 3.
Participants’ responses to individual items of the GOHAI questionnaire
| GOHAI Items | Never | Rarely | Sometimes | Often | Always | |
|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | ||
| Functional limitation | ||||||
| Limit kinds or amounts of food | NHR | 110 (33.4) | 27 (8.2) | 30 (9.1) | 67 (20.4) | 95 (28.9) |
| CDA | 114 (36.8) | 63 (20.3) | 13 (4.2) | 70 (22.6) | 50 (16.1) | |
| Trouble biting/chewing food | NHR | 105 (31.9) | 19 (5.8) | 27 (8.2) | 58 (17.6) | 120 (36.5) |
| CDA | 97 (31.3) | 47 (15.2) | 10 (3.2) | 75 (24.2) | 81 (26.1) | |
| Uncomfortable to swallow | NHR | 184 (55.9) | 26 (7.9) | 30 (9.1) | 42 (12.8) | 47 (14.3) |
| CDA | 219 (70.6) | 46 (14.8) | 6 (1.9) | 27 (8.7) | 12 (3.9) | |
| Prevented from speaking | NHR | 164 (49.8) | 26 (7.9) | 41 (12.5) | 44 (13.4) | 54 (16.4) |
| CDA | 191 (61.6) | 60 (19.4) | 4 (1.3) | 43 (13.9) | 12 (3.9) | |
| Pain and discomfort | ||||||
| Discomfort when eating | NHR | 135 (41.0) | 25 (7.6) | 31 (9.4) | 69 (21.0) | 69 (21.0) |
| CDA | 128 (41.3) | 77 (24.8) | 8 (2.6) | 69 (22.3) | 28 (9.0) | |
| Use medication to relieve pain | NHR | 266 (80.9) | 17 (5.2) | 22 (6.7) | 14 (4.3) | 10 (3.0) |
| CDA | 156 (50.3) | 89 (28.7) | 12 (3.9) | 44 (14.2) | 9 (2.9) | |
| Teeth, gums, sensitive to hot/cold | NHR | 249 (75.7) | 26 (7.9) | 18 (5.5) | 14 (4.3) | 22 (6.7) |
| CDA | 184 (59.4) | 71 (22.9) | 6 (1.9) | 42 (13.5) | 7 (2.3) | |
| Psychological impacts | ||||||
| Limit contact with others | NHR | 184 (55.9) | 23 (7.0) | 33 (10.0) | 41 (12.5) | 48 (14.6) |
| CDA | 191 (61.6) | 59 (19.0) | 5 (1.6) | 43 (13.9) | 12 (3.9) | |
| Unhappy with appearance | NHR | 168 (51.1) | 24 (7.3) | 34 (10.3) | 59 (17.9) | 44 (13.4) |
| CDA | 122 (39.4) | 81 (26.1) | 9 (2.9) | 65 (21.0) | 33 (10.6) | |
| Worried or concerned | NHR | 172 (52.3) | 23 (7.0) | 33 (10.0) | 53 (16.1) | 48 (14.6) |
| CDA | 92 (29.7) | 99 (31.9) | 17 (5.5) | 82 (26.5) | 20 (6.5) | |
| Nervous or self-conscious | NHR | 184 (55.9) | 25 (7.6) | 29 (8.8) | 48 (14.6) | 43 (13.1) |
| CDA | 149 (48.1) | 91 (29.4) | 13 (4.2) | 48 (15.5) | 9 (2.9) | |
| Uncomfortable eating in front of | NHR | 201 (61.1) | 31 (9.4) | 25 (7.6) | 30 (9.1) | 42 (12.8) |
| people | CDA | 182 (58.7) | 79 (25.5) | 6 (1.9) | 33 (10.6) | 10 (3.2) |
Data are expressed as n (%)
Abbreviation: NHR Nursing homes residents, CDA Community-dwelling older adults
Table 4.
GOHAI scores in nursing home residents and community-dwelling older adults
| GOHAI scores | Nursing homes residents |
Community-dwelling older adults |
||
|---|---|---|---|---|
| Mean ± SD | Mean ± SD | p | Effect Size (r) | |
| Functional limitation | 13.2 ± 5.8 | 15.0 ± 4.2 | 0.001 | 0.130 |
| Pain and discomfort | 12.3 ± 2.9 | 12.0 ± 2.6 | 0.006 | 0.109 |
| Psychological impacts | 18.9 ± 6.8 | 19.7 ± 4.6 | 0.169 | 0.054 |
| Total scores | 44.4 ± 14.7 | 46.7 ± 9.7 | 0.925 | 0.004 |
Data are expressed as mean ± SD or n (%)
Effect sizes are reported as r for continuous variables
* Intergroup comparisons were performed using Mann–Whitney U-test
Discussion
Oral health is a critical yet often overlooked component of healthy aging, with direct implications for nutrition, overall health, and quality of life in older adults. While previous epidemiological studies have examined oral mucosal lesions in either institutionalized or community-dwelling elderly populations, few have directly compared these groups to assess the influence of living environments and healthcare delivery models on oral health outcomes. The present study addresses this gap by providing a direct comparison of oral mucosal status and oral health-related quality of life between NHR and CDA. Our findings reveal that, despite living in an institutional care setting, NHR exhibited significantly lower functional limitation scores on the GOHAI, suggesting greater difficulty with basic oral functions such as eating, chewing, swallowing, and speaking. Additionally, candidiasis and angular cheilitis were proportionally more prevalent in this group, indicating suboptimal oral hygiene despite regular care. These results highlight the importance of implementing personalized oral health care strategies in institutional settings to better address individual needs and improve outcomes.
A notable demographic pattern in our study was the significantly higher prevalence of Alzheimer’s disease and cerebrovascular conditions among nursing home residents, whereas cardiovascular diseases were more common in CDA. Consistent with our findings, Helvik et al. reported a marked increase in both the prevalence and severity of dementia among Norwegian nursing home residents over time [14]. Similarly, a comparative observational study from China by Yang et al. found dementia to be far more prevalent in institutionalized than in community-dwelling older adults, while also reporting a higher prevalence of cardiovascular diseases in the latter group—mirroring our results [15]. Such neurological conditions adversely affect cognitive and motor functions, thereby diminishing the capacity for self-care, including oral hygiene. Previous research indicates that up to 75% of stroke survivors are unable to brush their teeth independently, and most individuals with advanced dementia become completely reliant on caregivers for oral hygiene [16].
In contrast, smoking was significantly more common among CDA in our cohort. Yang et al. similarly reported higher rates of tobacco and alcohol use among community residents compared with NHR [15]. This phenomenon may be attributed to the more restricted access to smoking areas in institutional settings and caregiver-enforced limitations on tobacco use. Smoking is a well-established risk factor for a broad spectrum of oral mucosal lesions and periodontal disease, and it also serves as an independent risk factor for cardiovascular morbidity and mortality, potentially compounding the higher cardiovascular disease burden observed in community-dwelling individuals [17]. Denture use, on the other hand, was markedly higher among nursing home residents. While prosthetic rehabilitation can restore masticatory function and improve quality of life, inadequate maintenance—particularly when compounded by neurological impairments—creates a favorable environment for opportunistic infections such as denture stomatitis and oral candidiasis.
In our cohort, oral candidiasis was the most common red–white lesion in both groups, consistent with large multicenter studies indicating that Candida-related disease is the leading infectious oral condition in older adults [5]. In nursing homes, higher denture use and greater dependence on caregivers can impair denture hygiene and oral debridement, facilitating fungal colonization. Conversely, in CDA, increased xerostomia prevalence and behavioral factors such as higher smoking rates may contribute to mucosal dryness, biofilm shifts, and opportunistic infections. Clinically, these findings support routine antifungal risk screening in both settings and reinforce the need for structured denture-hygiene protocols and caregiver training in institutions, alongside behavioral counseling (e.g., smoking cessation) in the community.
Additionally, angular cheilitis was disproportionately more common in nursing home residents (NHR), while oral lichen planus was more prevalent in community-dwelling elderly (CDA). Angular cheilitis is often caused by chronic saliva accumulation at the corners of the mouth, Candida colonization, and nutritional deficiencies; these risk factors are more pronounced in edentulous or cognitively/motor individuals with reduced occlusal vertical dimension and inadequate denture maintenance. A meta-analysis by Clarin et al. reported that the prevalence of angular cheilitis in elderly individuals ranged from 1% to 46.66% [18]. Federico et al. reported that the prevalence of angular cheilitis in the general elderly population is approximately 11%, with a prevalence rate as high as 28% in denture users [19]. Delwel et al.‘s study also found that elderly individuals with dementia and those receiving institutional care had poorer oral hygiene and more frequent denture-related lesions (stomatitis, angular cheilitis, ulcers, and hyperplasia) compared to cognitively intact individuals [20]. In line with these findings, the higher prevalence of Alzheimer’s disease, cerebrovascular disorders, and denture use observed among nursing home residents in our study likely contribute to the increased incidence of angular cheilitis through pathways involving care dependency, suboptimal hygiene, and fungal or irritant-induced inflammation. By contrast, the higher frequency of oral lichen planus among CDA may reflect differential exposure to behavioral or pharmacologic triggers (e.g., polypharmacy profiles) and better detection in an actively clinic-seeking population. This pattern is consistent with the findings of Radwan-Oczko et al., who reported associations between oral lichen planus prevalence, medication use, and systemic health status in elderly individuals [4]. Nevertheless, causality cannot be inferred due to the cross-sectional nature of the study design.
Furthermore, red–blue lesions were significantly more prevalent in CDA (41.6% vs. 31.6%; p = 0.009), with sublingual varicosities being the predominant vascular finding in both groups. Sublingual varices increase with age due to mucosal thinning, diminished connective-tissue support, and loss of venous wall elasticity. Their higher prevalence in CDA —despite greater functional autonomy—may be attributed to the greater burden of coronary artery disease and more frequent long-term use of anticoagulant or antiplatelet therapy, both of which were significantly more common in this group. Consistently, Bozdemir et al., in a study of 709 geriatric volunteers, reported cardiovascular diseases as the most prevalent systemic condition in their cohort, with sublingual varicosities being the most common oral mucosal lesion [21]. Similarly, a meta-analysis by James et al. identified hypertension, cardiovascular diseases, smoking, and denture use as significant risk factors for sublingual varicosities [22].
Our findings indicate that CDA had better oral functional status on the GOHAI than NHR. This suggests greater limitations in chewing, speaking, and swallowing among institutionalized older adults. Similar trends have been observed in the literature. In a study conducted in Barcelona, approximately two-thirds of NHR were found to have poor oral health-related quality of life according to GOHAI scores, with the functional component also significantly lower than that of CDA [23]. Furthermore, research has shown that institutionalized individuals often experience greater functional impairment in oral health due to extensive tooth loss and insufficient prosthetic rehabilitation. For example, being functionally edentulous is strongly associated with poorer GOHAI outcomes. In a survey of NHR in France, those without teeth and dentures recorded the lowest functional domain scores, significantly lower than peers with some teeth or dentures [24]. Likewise, Klotz et al., in a cross-sectional study, reported that CDA had more natural teeth and better prosthetic status compared with NHR [25]. The higher prevalence of Alzheimer’s disease and cerebrovascular conditions among NHR in our study likely further contributes to functional decline by impairing motor control of mastication, swallowing, and oral coordination. Similarly, Lee et al. found that older adults with mild dementia reported significantly worse oral health-related quality of life on the GOHAI compared with cognitively intact peers [26]. Recent evidence from Türkiye also suggests that different oral conditions, including periodontal disease, may adversely affect oral health-related quality of life in older adults [27]. These combined effects of dental status and neurological impairment underscore the importance of maintaining natural teeth or providing proper dentures, alongside targeted neurorehabilitation and caregiver-assisted feeding strategies, to preserve oral function and quality of life in older adults.
Conversely, our study revealed that NHR reported less pain and discomfort (reflected by higher GOHAI pain/discomfort scores) in comparison to CDA. This paradoxical finding may be attributed to the high prevalence of edentulism in institutionalized elders, as the absence of natural teeth reduces the likelihood of toothache or masticatory pain. A study conducted in Southern Italy similarly reported that oral pain and discomfort in the elderly—such as tooth sensitivity, toothache, or loose teeth—significantly contributes to the negative impact of oral health on daily life [28]. CDA, who are more likely to retain natural teeth, may therefore experience more frequent pain. In contrast, NHR frequently undergo extractions to address dental pain. Consistent with this pattern, Schnabl et al., in their comparative analysis of dental treatments under general anesthesia in Austria, reported that residents of nursing homes underwent significantly more tooth extractions and fewer restorative procedures than those living in private homes [29]. This finding may also be partly related to the higher prevalence of neurological conditions, such as Alzheimer’s disease and cerebrovascular disease, in the NHR group, which may affect pain perception, symptom recognition, or the ability to report oral discomfort accurately. This is supported by the findings of Pringle et al., who reported in their systematic scoping review that pain in nursing home residents with dementia is frequently under-reported or remains undetected by care staff [30]. Our findings also revealed that dental visits in the past six months were markedly less frequent among NHR compared to CDA, a pattern indicative of a largely reactive rather than preventive approach to oral care in institutionalized settings. Consistent with this, Tynan et al., in their study of residential aged care facilities in Australia, reported that dental evaluations in many nursing homes are typically initiated only in response to acute complaints—such as oral pain, eating difficulties, or denture-related issues—rather than as part of routine preventive care [31]. This phenomenon diminishes opportunities for the early detection of subclinical oral disease. This reactive care model may partly explain the combination of significantly lower functional, yet higher pain/discomfort GOHAI scores observed in NHR. It is probable that pain or discomfort in these contexts is frequently managed with palliative measures, such as analgesics, which suppress symptoms without addressing underlying causes. Consequently, this approach may result in poorer oral function alongside a reduced perception of pain or discomfort. To improve outcomes, nursing home oral health programs should incorporate personalized care plans, specialist-led assessments, and etiologically targeted interventions rather than solely palliative symptom control. Such strategies—ranging from preventive prosthetic adjustments to tailored periodontal or mucosal disease management—could help preserve oral function, enhance comfort, and improve overall quality of life in institutionalized older adults.
Our study has several limitations that should be acknowledged. First, the study population included individuals from one university dental faculty; therefore, the findings may not be generalizable to all older adults in Türkiye or other cultural and healthcare settings. The community-dwelling older adults in this study were recruited from individuals presenting to a university dental clinic rather than from the general community. Therefore, this group may not fully represent the broader community-dwelling older adult population and may reflect a more care-seeking, health-aware, or orally symptomatic subgroup, which may have introduced selection bias and should be considered when interpreting the between-group comparisons. Second, although the examiner was blinded to the study hypothesis, complete blinding to group status may have been limited by the different examination settings and participants’ general appearance. Third, diagnoses of oral mucosal lesions were based solely on clinical examination without histopathological confirmation, which may have led to misclassification of lesions with similar clinical presentations. Fourth, although the GOHAI-TR questionnaire was administered through face-to-face interviews to minimize misunderstanding, it remains inherently subjective and self-reported, making it susceptible to recall bias or underreporting, particularly among participants with mild cognitive impairment. Finally, although the overall sample size was adequately powered, some subgroup analyses—especially for less prevalent lesion types—may have been underpowered, limiting the ability to detect smaller but clinically meaningful differences.
Conclusion
Our findings suggest that nursing home residents, despite living in an institutional care setting, experience greater functional limitations and higher rates of infectious oral diseases such as candidiasis and angular cheilitis. Alzheimer’s disease and cerebrovascular disease were also more prevalent in this group, and denture use was significantly higher compared with community-dwelling older adults.
These results have important implications for public health professionals, gerontologists, and dentists. The higher prevalence of neurodegenerative and vascular conditions may reduce residents’ ability to perceive or accurately report oral health problems, contributing to underdiagnosis and delayed intervention. Moreover, the combination of denture dependency and preventable infectious oral diseases underscores the need for personalized and specialized oral care in long-term care facilities. Generic and standardized approaches risk accelerating functional decline and perpetuating unresolved problems. Personalized care strategies should incorporate routine specialist-led dental assessments, individualized denture hygiene protocols, targeted prevention of opportunistic infections, and structured caregiver training. Embedding these measures into a multidisciplinary care framework could not only reduce the burden of oral disease but also help preserve oral function, comfort, and quality of life for institutionalized older adults.
Acknowledgements
Not applicable.
Abbreviations
- CDA
Community-dwelling older adults
- GDS
Global deterioration scale
- GOHAI
Geriatric oral health assessment index
- GOHAI-TR
Turkish version of the Geriatric oral health assessment index
- NHR
Nursing home residents
- WHO
World Health Organization
Authors’ contributions
Z.A.A.A., S.M., and A.S. contributed to study conception, literature search, data extraction, and statistics; A.S. and G.A. contributed to the assessment of bias; Z.A.A.A., G.A., and A.S. drafted the manuscript; and Z.A.A.A. and A.S. contributed to the critical review. All authors provided substantial review and feedback on the final version of the article. Z.A.A.A. takes responsibility for the paper.
Funding
The author(s) received no financial support for this work, authorship, and/or publication.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
Declarations
Ethics approval and consent to participate
The study was approved by the Istanbul University Faculty of Dentistry Clinical Research Ethics Committee, Istanbul, Türkiye (approval number 2644732).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article.