Dear Editor,
1.
We read with interest the study by Hernandez et al. [1] evaluating the Oral Frailty Index‐8 (OFI‐8) in healthy community‐dwelling older adults. The topic is clinically important, particularly as oral frailty is increasingly recognized as a multidimensional geriatric condition rather than an isolated dental problem [2]. Evidence also suggests that oral frailty may be associated with adverse outcomes in older adults [3]. Nevertheless, several methodological issues temper the interpretation of the findings.
First, the evidence for a three‐factor structure appears limited. The Kaiser–Meyer–Olkin statistic was only 0.569, and parallel analysis supported a two‐factor rather than a three‐factor solution. Retaining three factors because they were more interpretable is understandable, but the resulting structure should be framed as exploratory. The denture item also showed cross‐loading, while “going out less frequently” may overlap with mood, life‐space mobility, and frailty rather than purely measuring oral function. Contemporary measurement guidance would support confirmatory factor analysis and broader psychometric testing before treating this structure as established [4].
Second, the cultural adaptation of the hard‐food item may have altered item difficulty. A recent Singapore validation study reported only moderate reliability, poor confirmatory factor fit, and limited discriminative validity of the OFI‐8 cut‐off of 4 [5]. Applying Japanese cut‐offs without local recalibration may partly explain why the oral pre‐frailty group was small and showed no independent associations [6]. Reporting receiver operating characteristic analyses against objective oral measures, or modeling OFI‐8 as continuous and domain‐specific scores, would strengthen interpretation.
Third, the associations may be affected by residual confounding and criterion contamination. Age, education, and vascular risk factors differed across groups, while socioeconomic status, dental service access, denture fit, number of functional teeth, polypharmacy, xerostomia‐inducing medications, nutritional status, and social isolation were not fully addressed. These factors are clinically relevant because oral frailty has been linked with appetite and dietary variety, fall risk, and late‐life depression [7, 8, 9]. Adjustment for physical frailty is also conceptually complex: it may reduce confounding, but it may also adjust away part of the causal pathway from oral dysfunction to adverse outcomes.
Fourth, multiple dichotomized outcomes were tested in relatively small subgroups without event counts, missing‐data handling, or a multiple‐comparison strategy. Wide confidence intervals, particularly for mood and functional outcomes, suggest limited precision.
Finally, the cross‐sectional design and self‐reported STEADI, SNAQ, and GDS outcomes cannot establish temporality or support strong prevention language. Longitudinal evidence suggests that oral frailty may predict serious downstream outcomes [10], but such inference requires prospective validation in the population where the instrument is being applied. The present findings are therefore best viewed as hypothesis‐generating evidence that OFI‐8 may flag a cluster of nutritional, psychosocial, and falls‐risk vulnerability. Future studies should include clinical dental examination, objective oral function tests, test–retest reliability, confirmatory factor analysis, local cut‐off calibration, and longitudinal outcomes before OFI‐8 is promoted as a validated multidimensional screening tool in this population.
Author Contributions
Chenjie Qiu contributed to the conception, drafting, and final approval of this letter.
Funding
The author has nothing to report.
Ethics Statement
The author has nothing to report.
Conflicts of Interest
The author declares no conflicts of interest.
Acknowledgments
The author has nothing to report.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
References
- 1. Hernandez H. H. C., Lim C., Lim J. P., et al., “Oral Frailty Index‐8 (OFI‐8) in Healthy Community‐Dwelling Older Adults: Factor Structure and Association With Appetite, Muscle Health, Falls, Physical Function, Mood, and Quality of Life,” Geriatrics & Gerontology International 26, no. 8 (2026): e70699. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Tanaka T., Hirano H., Ikebe K., et al., “Consensus Statement on “Oral Frailty” From the Japan Geriatrics Society, the Japanese Society of Gerodontology, and the Japanese Association on Sarcopenia and Frailty,” Geriatrics & Gerontology International 24, no. 11 (2024): 1111–1119. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Dibello V., Lobbezoo F., Lozupone M., et al., “Oral Frailty Indicators to Target Major Adverse Health‐Related Outcomes in Older Age: A Systematic Review,” Geroscience 45, no. 2 (2023): 663–706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Gagnier J. J., de Arruda G. T., Terwee C. B., and Mokkink L. B., “COSMIN Reporting Guideline for Studies on Measurement Properties of Patient‐Reported Outcome Measures: Version 2.0,” Quality of Life Research 34, no. 7 (2025): 1901–1911. [DOI] [PubMed] [Google Scholar]
- 5. Natarajan K., Sim Y. F., Chen H., et al., “Reliability and Validity of Oral Frailty Index‐8: Findings Among Community‐Dwelling Adults in Singapore,” Journal of Oral Rehabilitation 53, no. 6 (2026): 1159–1168. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Tanaka T., Hirano H., Ohara Y., Nishimoto M., and Iijima K., “Oral Frailty Index‐8 in the Risk Assessment of New‐Onset Oral Frailty and Functional Disability Among Community‐Dwelling Older Adults,” Archives of Gerontology and Geriatrics 94 (2021): 104340. [DOI] [PubMed] [Google Scholar]
- 7. Lin Y. C., Huang S. S., Yen C. W., Kabasawa Y., Lee C. H., and Huang H. L., “Physical Frailty and Oral Frailty Associated With Late‐Life Depression in Community‐Dwelling Older Adults,” Journal of Personalized Medicine 12, no. 3 (2022): 459. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Nakagawa S., Miura K., Arai E., et al., “Oral Frailty, Appetite and Dietary Variety in Late‐Stage Older Adults: A Cross‐Sectional Study (The STudy of lAte‐Stage oldeR adulTs in Tottori; START Tottori),” Geriatrics & Gerontology International 24, no. 6 (2024): 626–633. [DOI] [PubMed] [Google Scholar]
- 9. Song H., Wei Y., Wang Y., and Zhang J., “The Mediating Effect of Nutrition on Oral Frailty and Fall Risk in Community‐Dwelling Elderly People,” BMC Geriatrics 24, no. 1 (2024): 273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Watanabe D., Yoshida T., Watanabe Y., et al., “Oral Frailty Is Associated With Mortality Independently of Physical and Psychological Frailty Among Older Adults,” Experimental Gerontology 191 (2024): 112446. [DOI] [PubMed] [Google Scholar]
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Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.