Abstract
Objectives
This study aimed to investigate the current situation of oral frailty (OF) in elderly patients with head and neck cancer (HNC) in China and analyse its influencing factors.
Methods
A total of 332 elderly patients with HNC were recruited from four tertiary hospitals in Jiangsu, China. Oral frailty was assessed using the Oral Frailty Index-8 (OFI-8). A general information questionnaire, the Frailty Screening Scale (FRAIL), Nutritional Risk Screening 2002 (NRS 2002), number of remaining natural teeth(TN), and the Simplified Nutritional Appetite Questionnaire (SNAQ) were used to investigate factors associated with oral frailty. A nomogram was constructed as a visual representation of the final multivariable logistic regression model.
Results
The prevalence of OF among elderly patients with HNC was 68.98%. Multivariate logistic regression analysis revealed that radiotherapy (OR = 3.163, 95% CI: 1.239–8.073), having three or more comorbidities (OR = 4.641, 95% CI: 2.055–10.481) and NRS 2002 score ≥ 3 (OR = 3.010, 95% CI: 1.037–8.735) were associated with a higher likelihood of oral frailty. In contrast, SNAQ score > 14 (OR = 0.303, 95% CI: 0.108–0.854), higher monthly income (≥ 6,000 yuan; OR = 0.211, 95% CI: 0.064–0.698) and having ≥ 20 remaining natural teeth (TN ≥ 20; OR = 0.052, 95% CI: 0.017–0.156) were associated with a lower likelihood of oral frailty.
Conclusion
Oral frailty is highly prevalent among elderly patients with HNC. The main associated factors include radiotherapy, appetite, nutrition status, number of remaining natural teeth, having three or more comorbidities, and income. Routine screening and multidisciplinary interventions targeting these modifiable factors may help prevent or delay OF in this vulnerable population.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12903-026-08741-5.
Keywords: Head and neck cancer, Elderly patients, Oral frailty, Influencing factors
Introduction
Head and neck cancer (HNC), a diverse group of tumors arising in the upper aerodigestive tract, is the seventh most common cancer worldwide [1]. According to GLOBOCAN 2022, HNC accounted for over 947,000 new cases and approximately 482,000 deaths globally [2]. China bears one of the heaviest HNC burdens and ranks second in terms of total incident cases, with more than 145,000 new diagnoses [3]. This number is expected to continue rising due to rapid population ageing and persistent exposure to major risk factors, highlighting the substantial global and national health burden posed by HNC [4].
HNC is prevalent among older adults [5], and is often accompanied by impairments in oral structure and function due to tumor invasion and treatment-related effects [6]. The head and neck region has a highly complex anatomy that is intimately involved in essential physiological functions such as eating, breathing, and interpersonal communication. Once HNC is diagnosed, patients frequently require multimodal treatment, including surgical resection, radiotherapy, and chemotherapy [7]. Although these comprehensive treatment strategies have substantially improved survival, they unavoidably lead to a range of treatment-related complications. Surgical resection of the pharynx or larynx alters normal anatomy, disrupting neuromuscular coordination and resulting in dysphagia [8]. Radiotherapy to the head and neck region commonly induces salivary gland hypofunction, xerostomia, mucositis, dysgeusia, and trismus, which further interfere with chewing, swallowing, speech articulation, and salivary clearance [8, 9]. Chemotherapy may exacerbate these problems through systemic fatigue, nausea, oral mucositis, and increased susceptibility to oral infections [10]. Together, these treatment-related effects can cause persistent difficulties in chewing, swallowing, speaking, salivation, and maintaining oral hygiene, thereby accelerating the decline in oral function and contributing to the development of oral frailty [11]. In elderly patients with HNC, these treatment-related impairments may be further compounded by age-related deterioration in oral health and oral function. Older adults are more likely to experience periodontal disease, dental caries, tooth loss, and inadequate prosthetic rehabilitation, all of which may compromise chewing ability, restrict food choices, and contribute to impaired nutritional status [12, 13]. This combined effect of ageing-related oral vulnerability and cancer-related oral burden may place elderly patients with HNC at particularly high risk of oral frailty.
Evidence from studies among older adults has shown that oral frailty is closely associated with malnutrition, sarcopenia, physical frailty, cognitive decline, hospitalization, and mortality [14–17]. Sociodemographic characteristics, dentition status, nutritional risk, systemic health conditions, and psychosocial factors have all been identified as potential contributors to the onset and progression of oral frailty [18]. However, most existing findings are derived from community-dwelling older adults. Elderly patients with HNC experience unique and substantially higher risks of oral functional decline due to combined effects of tumor-related destruction and treatment-induced damage, making them a particularly vulnerable population.
Despite this elevated vulnerability, research specifically focusing on oral frailty among elderly patients with HNC remains limited. In particular, little is known about how demographic characteristics, systemic frailty, nutritional risk, appetite, chronic disease burden, number of remaining natural teeth, and dentition, interact to influence oral frailty in older adults receiving care for head and neck cancer. A comprehensive understanding of oral frailty and its determinants in elderly patients with HNC is essential for informing early screening, multidisciplinary intervention, and supportive care strategies. Identifying modifiable factors could help optimize nutrition, reduce treatment-related complications, and improve treatment adherence and quality of life. Multicenter evidence is particularly needed to provide generalizable conclusions and guide clinical decision-making across diverse hospital settings.
Methods
Study design
This multicenter cross-sectional study recruited participants using convenience sampling and was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [19]. Participants were recruited by physicians and nurses at the participating hospitals. Eligible patients were invited to a quiet room within the hospital, where questionnaire administration and relevant assessments were conducted. Data were collected by professionally trained nurses who were also involved in the patients’ daily clinical care.
Setting and participants
From March 2025 to October 2025, a total of 332 elderly patients with HNC treated in the Departments of Oncology, Radiation Oncology, and Otolaryngology–Head and Neck Surgery of four tertiary hospitals in Jiangsu Province, China, were included in this study.
Recruitment and data collection
Participants were recruited by posting flyers in outpatient clinics, which included the study background, objectives, inclusion criteria, and contact information. Researchers reviewed electronic medical records (EMRs) daily to promptly identify participants who met the inclusion criteria. The researchers communicated with them to assess their willingness to participate. After obtaining informed consent, iPads were provided for participants to complete the online questionnaire. In principle, all questionnaires were completed independently by participants. For those with visual impairment or reading difficulties, trained researchers assisted by reading each item aloud using neutral, non-suggestive language and recording the participants’ responses. On average, participants spent approximately 20 min completing the questionnaires. Initially, the study approached 345 elderly patients with HNC. Among them, 11 patients declined to participate due to objections from their caregivers, and 2 invalid questionnaires due to abnormal response time. A total of 332 valid questionnaires were collected, resulting in a response rate of 96.23%.
Inclusion and exclusion criteria
The inclusion criteria were as follows: (1) age ≥ 60 years; (2) pathologically confirmed malignant head and neck cancer (including laryngeal cancer, hypopharyngeal cancer, nasopharyngeal cancer, tonsillar cancer, and thyroid cancer.); (3) no cognitive impairment and intact communication ability; and (4) willingness to participate and provision of signed informed consent. The exclusion criteria were: (1) severe mental illness or cognitive impairment that precluded cooperation; (2) a history of severe oral disease (e.g., previous oral cancer surgery); and (3) being in the acute phase of head and neck cancer.
Sample size calculation
Sample size was calculated using PASS V.15 (NCSS, Kaysville, Utah, USA). Considering the prevalence of oral frailty among cancer patients as 64.3% [20], we set α as 5%, confidence interval width as 0.06, and dropout rate as 10%, the minimum required sample size was estimated to be 301.
Data collection instruments
General information questionnaire
This questionnaire was self-developed based on a review of the literature and a preliminary survey (file 1). It included both sociodemographic and disease-related information. Sociodemographic variables comprised sex, age, educational level, monthly income, smoking status, drinking status, and marital status. Disease-related variables included history of radiotherapy and chemotherapy (included prior or ongoing), number of comorbidities (based on the International Classification of Diseases, 10th Revision (ICD-10) [21]), body mass index (BMI, kg/m²), serum albumin (ALB), blood glucose (BG), and TN.
Oral frailty index-8 (OFI-8)
The Oral Frailty Index-8 (OFI-8) is a self-reported screening questionnaire originally developed by Tanaka et al. [17] in Japan for older adults. The instrument includes eight items across five domains related to oral function, oral symptoms, social participation, and oral health behaviors. The total score ranges from 0 to 11, with a score of ≥ 4 indicating a high risk or presence of oral frailty; higher scores indicate poorer oral health status. In this study, we adopted the Chinese version translated and culturally adapted by Chen ZM et al. [22]. The Cronbach’s α coefficient is 0.934.
The frailty screening scale (FRAIL)
This FRAIL scale was developed by geriatric experts from the International Society for Nutritional Health and Ageing [23]. In this study, the Chinese version developed by Wei Y et al. [24] was adopted, which includes 5 items: fatigue, increased resistance/decreased endurance, decreased free activity, having more than 5 diseases, and weight loss. Each item is scored as 1 point, with a total score ranging from 0 to 5. A score of 0 indicates a healthy status, 1–2 points signify pre-frailty, and a score of ≥ 3 indicates frailty. The Cronbach’s α coefficient is 0.826.
Nutritional risk screening 2002 (NRS 2002)
The NRS 2002 is recommended by the European Society for Clinical Nutrition and Metabolism(ESPEN) guidelines for the nutritional screening of patients within 48 h of admission [25]. The NRS 2002 consists of three parts, including nutritional status assessment (based on weight loss, BMI and food intake), disease severity (stress metabolism due to the degree of disease) and age (whether ≥ 70 years old). The final score ranges from 0 to 7, with a score of ≥ 3 indicating a high nutritional risk [26]. NRS 2002 has been widely applied in the assessment of malignant tumors due to its simple operation, accuracy and reliability. The Cronbach’s α coefficient is 0.703.
Simplified nutritional appetite questionnaire (SNAQ)
The SNAQ, developed by Wilson et al. [27], comprises four items: appetite, satiety, food taste, and frequency of meals per day, and it uses a 5-point ordinal scale with a range of 1 to 5 points assigned to each item. The total score ranges from 4 to 20, with higher scores indicating greater appetite. A SNAQ score of ≤ 14 indicates loss of appetite. The Cronbach’s α coefficient is 0.658.
Statistical analysis
All statistical analyses were performed using SPSS 25.0 (IBM Corporation, Armonk, NY, USA). Continuous variables were presented as mean and standard deviation (SD), or median and interquartile range (IQR) based on the distribution of the quantitative variables. Categorical variables are presented as frequencies and percentages. Univariate analyses were conducted to screen variables associated with the presence of OF. Prior to multivariable logistic regression analysis, all candidate independent variables were examined for multicollinearity. Multivariable binary logistic regression analysis was then used to identify independent factors associated with oral frailty. Based on the final multivariable model, a nomogram was constructed using R 4.5.2 software (R Foundation for Statistical Computing, Vienna, Austria) to provide a visual representation of the final multivariable logistic regression model. All statistical analyses were two-tailed, a P-value of less than 0.05 was considered statistically significant.
Results
Characteristics of the participants
Among the 332 elderly patients with HNC, cancer types included laryngeal cancer, hypopharyngeal cancer, nasopharyngeal cancer, tonsillar cancer, and thyroid cancer. A total of 229 patients were classified as having oral frailty, corresponding to a prevalence of 68.98%. The median age of the participants was 68.0 years (IQR: 63.0–72.0). A majority were male (75.30%), and most had an educational level of middle school or below (67.47%). Additionally, 91.57% were married, 62.65% had a history of smoking, and 43.67% had a history of alcohol consumption. Regarding monthly household income, 57.23% earned less than 3,000 yuan, 34.04% earned between 3,000 and 6,000 yuan, and 8.73% earned 6,000 yuan or more. In terms of treatment history, 24.70% of the patients had a history of radiotherapy, and 33.13% had a history of chemotherapy. Concerning comorbidities, 120 patients (36.14%) had no other chronic diseases, 89 patients (26.81%) had one to two chronic diseases, and 123 patients (37.05%) had three or more chronic diseases.
Univariate analysis of the risk of developing oral frailty in elderly patients with head and neck cancer
Univariate analysis showed that age, sex, educational level, monthly income, smoke, drink, radiotherapy, chemotherapy, comorbidity, BMI, diagnosis, blood glucose, serum albumin, physical frailty, NRS 2002, SNAQ, and TN were associated with oral frailty (P < 0.05). These findings are illustrated in (Table 1).
Table 1.
Univariate analysis of the risk of developing oral frailty in elderly patients with head and neck cancer(n = 332)
| Variables | OF group (n = 229) | Non-OF group (n = 103) | χ2/Z | P |
|---|---|---|---|---|
| Age (years), number (%) | 36.969 | < 0.001 | ||
| 60–64 | 54(23.58) | 57(55.34) | ||
| 65–69 | 60(26.20) | 25(24.27) | ||
| ≥ 70 | 115(50.22) | 21(20.39) | ||
| Sex, number (%) | 5.546 | 0.019 | ||
| Male | 181(79.04) | 69(66.99) | ||
| Female | 48(20.96) | 34(33.01) | ||
| Educational level, number (%) | 21.679 | < 0.001 | ||
| Primary school or below | 85(37.12) | 26(25.24) | ||
| Middle school | 85(37.12) | 28(27.18) | ||
| High school | 47(20.52) | 29(28.16) | ||
| College degree or above | 12(5.24) | 20(19.42) | ||
| Marital status, number (%) | 5.950 | 0.051 | ||
| Married | 204(89.09) | 100(97.08) | ||
| Unmarried | 1(0.44) | 0(0) | ||
| Widowed/divorced | 24(10.48) | 3(2.91) | ||
| Monthly income (RMB) (%) | 37.314 | < 0.001 | ||
| < 3000 | 152(66.38) | 38(36.89) | ||
| 3000–6000 | 69(30.13) | 44(42.72) | ||
| > 6000 | 8(3.49) | 21(20.39) | ||
| Smoke, number (%) | 12.700 | < 0.001 | ||
| Yes | 158(69.00) | 50(48.54) | ||
| No | 71(31.00) | 53(51.46) | ||
| Drink, number (%) | 6.904 | 0.009 | ||
| Yes | 111(48.47) | 34(33.01) | ||
| No | 118(51.53) | 69(66.99) | ||
| Radiotherapy, number (%) | 18.041 | < 0.001 | ||
| Yes | 72(31.44) | 10(9.71) | ||
| No | 157(68.56) | 93(90.29) | ||
| Chemotherapy, number (%) | 10.947 | 0.001 | ||
| Yes | 89(38.86) | 21(20.39) | ||
| No | 140(61.14) | 82(79.61) | ||
| Comorbidity, number (%) | 37.479 | < 0.001 | ||
| 0 | 62(27.07) | 58(56.31) | ||
| 1–2 | 59(25.77) | 30(29.13) | ||
| ≥ 3 | 108(47.16) | 15(14.56) | ||
| BMI (kg/m²) | 22.99(20.69,25.28) | 23.50(21.87,25.61) | -2.543 | 0.011 |
| Diagnosis, number (%) | 21.182 | < 0.001 | ||
| Laryngeal cancer | 110(48.03) | 34(33.01) | ||
| Hypopharyngeal cancer | 30(13.10) | 9(8.74) | ||
| Tonsillar cancer | 10(4.37) | 4(3.88) | ||
| Thyroid cancer | 50(21.83) | 48(46.60) | ||
| Nasopharyngeal cancer | 29(12.66) | 8(7.77) | ||
| BG (mmol/L), number (%) | 4.162 | 0.041 | ||
| < 6 | 150(65.50) | 79(76.70) | ||
| ≥ 6 | 79(34.50) | 24(23.30) | ||
| Alb (g/L), number (%) | 17.874 | < 0.001 | ||
| < 35 | 34(14.85) | 2(1.94) | ||
| 35–40 | 89(38.86) | 32(31.07) | ||
| > 40 | 106(46.29) | 69(66.99) | ||
| Physical frailty, number (%) | 19.118 | < 0.001 | ||
| Yes | 54(23.58) | 4(3.88) | ||
| No | 175(76.42) | 99(96.12) | ||
| NRS 2002 (score), number (%) | 48.521 | < 0.001 | ||
| ≥ 3, nutrition risk | 102(44.54) | 6(5.83) | ||
| < 3, no nutrition risk | 127(55.46) | 97(94.17) | ||
| SNAQ (score), number (%) | 34.232 | < 0.001 | ||
| ≤ 14, loss of appetite | 84(36.68) | 6(5.83) | ||
| > 14 good appetite | 145(63.32) | 97(94.17) | ||
| TN, number (%) | 84.900 | < 0.001 | ||
| < 20 | 132(57.64) | 4(3.88) | ||
| ≥ 20 | 97(42.36) | 99(96.12) |
Multifactorial analysis of the risk of developing oral frailty in elderly patients with head and neck cancer
The Variance inflation factor (VIF) and tolerance were calculated for each variable; all VIF values were < 5 and tolerance values were > 0.2, indicating no significant multicollinearity among the included variables. To further explore factors associated with oral frailty, a multivariable binary logistic regression analysis was performed, with the presence of oral frailty as the dependent variable. Variables that were statistically significant in the univariate analysis were entered into the regression model, and a backward stepwise (conditional) procedure was used to identify independent predictors. The results indicated that radiotherapy (OR = 3.163, 95% CI: 1.239–8.073, P = 0.016) and NRS 2002 score ≥ 3 (OR = 3.010; 95% CI: 1.037–8.735; P = 0.043) were significantly associated with a higher likelihood of oral frailty in elderly patients with HNC. Conversely, having ≥ 20 remaining natural teeth (TN ≥ 20; OR = 0.052, 95% CI: 0.017–0.156, P < 0.001), a monthly income ≥ 6,000 RMB (OR = 0.211, 95% CI: 0.064–0.698, P = 0.011), and a SNAQ score > 14 (OR = 0.303, 95% CI: 0.108–0.854, P = 0.024) were significantly associated with a lower likelihood of oral frailty (Table 2; Fig. 1).
Table 2.
Multifactorial analysis of the risk of developing oral frailty in elderly patients with head and neck cancer (n = 332)
| Variables | β | SE | P | OR (95% CI) |
|---|---|---|---|---|
| SNAQ (ref: ≤ 14) | -1.193 | 0.528 | 0.024 | 0.303 (0.108–0.854) |
| Sex (ref: Male) | 0.997 | 0.563 | 0.076 | 2.710 (0.899–8.168) |
| Smoke (ref: No) | 0.933 | 0.517 | 0.071 | 2.542 (0.922–7.006) |
| Monthly income 3000–6000 (ref: < 3000) | -0.203 | 0.345 | 0.556 | 0.816 (0.415–1.601) |
| Monthly income > 6000 (ref: < 3000) | -1.558 | 0.612 | 0.011 | 0.211 (0.064–0.698) |
| Radiotherapy (ref: No) | 1.151 | 0.478 | 0.016 | 3.163 (1.239–8.073) |
| Comorbidity: 1–2 (ref:0) | 0.236 | 0.383 | 0.537 | 1.266 (0.598–2.682) |
| Comorbidity: ≥3 (ref:0) | 1.535 | 0.416 | < 0.001 | 4.641 (2.055–10.481) |
| NRS 2002 (ref: < 3) | 1.102 | 0.544 | 0.043 | 3.010 (1.037–8.735) |
| TN (ref: < 20) | -2.953 | 0.558 | < 0.001 | 0.052 (0.017–0.156) |
Abbreviations: SE standard error, OR odds ratio, 95% CI 95% confidence interval, ref reference group
Fig. 1.
Nomogram for oral frailty in elderly patients with head and neck cancer. Notes: The nomogram was constructed based on the multivariable logistic regression model. Each variable contributes points to the total score, and the corresponding probability of oral frailty is derived from the total points
Discussion
This multicenter cross-sectional study investigated the prevalence of oral frailty and its associated factors among elderly patients with HNC in China. We found that the prevalence of oral frailty in this vulnerable population was as high as 68.98%. Radiotherapy and high nutritional risk (NRS 2002 ≥ 3) were independently associated with a higher likelihood of oral frailty, whereas having ≥ 20 remaining natural teeth, a higher monthly income (≥ 6,000 yuan), and better appetite (SNAQ > 14) were associated with a lower likelihood of oral frailty. These findings highlight the complex interplay between tumor-directed treatment, nutritional status, oral health, and socioeconomic conditions in shaping oral frailty in elderly patients with HNC.
The prevalence of oral frailty observed in this study (68.98%) was higher than that reported in previous studies of patients receiving chemotherapy (57.58%) [28] and in hospitalized cancer patients overall (64.3%) [20], suggesting that older patients with head and neck cancer constitute a particularly high-risk group.
Although previous studies have shown that age is significantly associated with oral frailty, it did not emerge as an independent predictor in our model. Several reasons may account for this finding. First, our study specifically focused on older patients with head and neck cancer (≥ 60 years), resulting in a relatively narrow age range (median 68 years). Within this restricted age band, disease and treatment-related factors may exert a stronger impact on oral function than chronological age alone. Second, age is closely correlated with other variables included in the model, such as the number of comorbidities, income, nutritional risk, and dentition status. These variables may better capture the “biological” or “functional” ageing process than chronological age, and thus attenuate the apparent effect of age after adjustment. Third, in older patients with head and neck cancer, tumor location, radiotherapy-related damage, nutritional status, and TN may play a more direct role in determining oral functional decline. Therefore, in this high-risk clinical population, chronological age appears to act more as a background risk factor rather than a key discriminator of oral frailty risk once treatment-related and functional variables are taken into account.
Our findings also revealed sex-related differences in the distribution of oral frailty. In contrast to several studies conducted in community-dwelling older adults, which have reported a higher prevalence of oral frailty in women than in men [29, 30], the proportion of oral frailty in our sample was higher among male patients. This discrepancy may be partly explained by the disease profile and risk-factor distribution in older patients with head and neck cancer. In China, head and neck cancer is more prevalent in men, who are also more likely to have a history of heavy smoking and alcohol consumption [31], and poorer oral hygiene habits [32], all of which may contribute to the development of oral frailty. In the present study, sex was significantly associated with oral frailty in the univariate analysis but did not remain an independent predictor after adjustment for treatment-related factors, nutritional risk, and income. This suggests that the apparent sex difference may be mediated by the clustering of high-risk behaviors and clinical characteristics among male patients rather than by biological sex.
Radiotherapy was independently associated with oral frailty in elderly patients with head and neck cancer (OR = 3.163, P = 0.016).In patients with head and neck cancer undergoing radiotherapy, the radiation field typically encompasses the parotid glands, submandibular glands, oropharyngeal mucosa, soft palate, base of the tongue, as well as the teeth and periodontal tissues. Such exposure causes chronic salivary gland hypofunction and moderate to severe xerostomia, which impairs lubricating functions, food bolus formation, and swallowing efficiency [33, 34]. In addition, radiation-induced mucositis, ulcers, and pain often lead patients to avoid chewing and restrict oral intake, thereby reducing daily oral motor function. In the long term, this increases patients’ risk of developing radiation caries, periodontal tissue destruction, tooth mobility, and tooth loss, ultimately leading to a reduction in the number of functional teeth and impaired masticatory function [35, 36]. Taken together, these radiotherapy-related changes may be associated with persistent deterioration in oral function and a higher likelihood of oral frailty, even when the primary tumor is not located in the oral cavity.
High nutritional risk, indicated by an NRS 2002 score ≥ 3, was also associated with oral frailty (OR = 3.010, P = 0.043). Poor nutritional status may be associated with oral frailty through multiple pathways. Protein–energy malnutrition and weight loss are closely related to sarcopenia, including loss of masticatory and tongue muscle mass, which leads to decreased tongue pressure, impaired chewing efficiency, and fatigue during oral intake [37, 38]. In addition, deficiencies in protein, vitamins, and micronutrients impair oral mucosal repair and local immune defense, predisposing patients to mucositis, oral infections, periodontal disease, and tooth loss, thereby reducing the number of functional teeth and further compromising masticatory performance [39]. Poor nutrition may also aggravate xerostomia and systemic fatigue, resulting in reduced oral motor activity and suboptimal oral hygiene [40].
Having three or more comorbidities was also independently associated with a markedly increased risk of oral frailty in older patients with head and neck cancer (OR = 4.641, P < 0.001). This finding is consistent with the growing evidence that multimorbidity is closely linked to frailty, malnutrition, and functional decline in older adults [41–44]. In elderly patients with HNC, multiple chronic conditions, such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease, and cerebrovascular disease, may further compromise systemic physiological reserves and exacerbate age-related declines in muscle strength and physical performance. In addition, multimorbidity is frequently accompanied by polypharmacy, and many commonly prescribed medications can induce xerostomia, alter taste, or cause fatigue, thereby reducing oral intake, chewing efficiency, and motivation to perform oral self-care [45–48].These mechanisms suggest that multimorbidity and oral frailty may interact in a bidirectional and mutually reinforcing manner, highlighting the importance of comprehensive management of chronic diseases when designing interventions to prevent or mitigate oral frailty in this population.
Consistent with this, better appetite (SNAQ > 14) was associated with a lower likelihood of oral frailty(OR = 0.303, P = 0.024). Appetite is a key determinant of dietary intake and nutritional status in older adults. In patients with head and neck cancer, pain, dysphagia, changes in taste and smell, and psychological distress frequently lead to reduced appetite and food avoidance [36, 49, 50]. Conversely, maintaining a relatively good appetite may help patients sustain adequate energy and protein intake, support muscle mass, and preserve oral and systemic function. The relationship between appetite, nutrition, and oral function suggests that early identification and targeted management of appetite loss may be crucial for preventing or slowing the progression of oral frailty in this population.
Having ≥ 20 remaining natural teeth (TN ≥ 20) was strongly associated with a lower likelihood of oral frailty (OR = 0.052, P < 0.001). Retaining an adequate TN allows patients to maintain higher masticatory efficiency [51] and a more diversified dietary pattern, thereby supporting sufficient nutrient intake and the maintenance of overall nutritional status. Moreover, a greater TN promotes mastication and salivary secretion and provides rich oral sensory feedback, helping to preserve coordinated movements of the tongue, cheeks, and masticatory muscles and to reduce eating difficulties and swallowing impairment [52, 53]. In addition, among patients with head and neck cancer, a more complete dentition often reflects better previous oral hygiene practices and higher health literacy [54], which may enhance adherence to postoperative oral functional exercises and oral care. Thus, an adequate TN may mitigate the progression of oral functional decline through both physiological and behavioral pathways.
Higher income (monthly income ≥ 6,000 RMB) was also associated with a lower likelihood of oral frailty in the multivariable model (OR = 0.211, P = 0.011). A higher income level may reflect better access to nutritious food, dental and rehabilitative care, and a greater capacity to afford preventive and restorative oral health services. Patients with higher income are also more likely to maintain favorable oral self-care behaviors [55] and to adhere to postoperative oral functional exercises and follow-up, thereby supporting nutritional status, preserving masticatory and swallowing function [56], and ultimately mitigating the progression of oral frailty.
An important consideration when interpreting the findings is that oral frailty in this study was assessed using a screening-based instrument rather than objective functional measurements. Although the tool captures multidimensional aspects of oral health, including functional decline and related behaviors, it may not fully reflect underlying physiological impairments such as swallowing dysfunction, reduced tongue pressure, salivary hypofunction, or trismus. In elderly patients with head and neck cancer, oral function is influenced not only by ageing but also by treatment-related effects, which may overlap with or mimic features of oral frailty. Therefore, the absence of objective oral assessments may limit the precision of distinguishing oral frailty from treatment-related dysfunction. Future studies should incorporate objective oral functional measurements alongside screening tools to provide a more comprehensive and clinically meaningful evaluation of oral frailty.
Limitations
Several limitations of this study should be acknowledged: First, the cross-sectional design limits the ability to infer causality from the findings, the temporal relationships between the identified correlates and oral frailty cannot be determined, and reverse causation cannot be ruled out. Future research should employ longitudinal or qualitative studies with larger sample sizes and extended follow-up periods to thoroughly investigate the relevant influencing factors in greater depth. Second, key variables such as oral symptoms, health behaviors, and income were assessed using self-report questionnaires, which are subject to recall bias and social desirability bias; In addition, although dentition status was assessed by TN, information on prosthetic rehabilitation, such as full or partial denture use, was not collected. Because prosthetic rehabilitation may influence chewing function, food intake, and nutritional status, future studies should incorporate both this variable and objective indicators of oral function, such as masticatory performance, tongue pressure, and salivary flow rate, to provide a more comprehensive assessment. Third, although the overall sample size of approximately 330 patients provided adequate power for the main analyses, it was insufficient for more fine-grained subgroup analyses due to tumor site or time since treatment, which may have reduced the precision of some estimates and led to wide confidence intervals.
Conclusions
In this multicenter cross-sectional study, oral frailty was highly prevalent among elderly patients with HNC. Better appetite, higher income, and TN ≥ 20 were independently associated with a lower likelihood of oral frailty, whereas radiotherapy, having three or more comorbidities, and NRS 2002 ≥ 3 were associated with a higher likelihood of oral frailty. These findings support routine screening for oral frailty and indicate that interventions targeting appetite, nutrition, and preservation of functional dentition, together with comprehensive management of multimorbidity and reduction of radiotherapy-related oral damage, may help prevent or slow oral functional decline in this population.
Supplementary Information
Acknowledgements
We would like to express our sincere gratitude to the administrative staff, physicians, and nurses from the Departments of Oncology, Radiation Oncology, and Otolaryngology–Head and Neck Surgery of the four participating tertiary hospitals in Jiangsu Province for their support in participant recruitment and data collection. We also thank all elderly patients with head and neck cancer who volunteered to participate in this study, as well as their caregivers for their understanding and cooperation. We would like to express our sincere gratitude to Professor Shaowen Tang and Dr. Jin Liu for their statistical guidance.
Clinical trial number
Not applicable.
Abbreviations
- OFI-8
Oral Frailty Index-8
- FRAIL
Frailty Screening Scale
- NRS 2002
Nutritional Risk Screening 2002
- SNAQ
Simplified Nutritional Appetite Questionnaire
- TN
Number of Remaining Natural Teeth
- BMI
Body Mass Index
- ALB
Serum Albumin
- BG
Blood Glucose
- OR
Odds Ratio
- CI
Confidence Interval
- VIF
Variance Inflation Factor
Authors’ contributions
XQ and RL: Conception and design of the study, development of data collection instruments, supervision of data collection, and final approval of the manuscript. QYY, HT, and TZ: Data collection, organization of raw data, preliminary statistical analysis, and drafting of the manuscript. ZLH and SZ: Statistical analysis, interpretation of results, and critical revision of the manuscript for intellectual content. PL: Coordination of multicenter data collection, verification of data accuracy, and revision of the manuscript. YW: Literature review, refinement of the study framework, and critical revision of the manuscript. HXF: Overall responsibility for the study, final data interpretation, manuscript revision, and correspondence with the journal.
Funding
None.
Data availability
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Independent Ethics Committee for Clinical Research of Jiangsu Province Hospital (No. 2024-SR-1126). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants prior to enrollment.
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.
Xue Qin and Rui Lin contributed equally to this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets analyzed during the current study are available from the corresponding author on reasonable request.