Evolving aspects of oral care in older adults: a systematic review and Meta-synthesis

Abstract

Background

The global aging population has heightened the need for comprehensive oral care in older adults, yet evolving aspects such as preventive strategies, technological advancements, and interdisciplinary approaches remain underexplored. This systematic review and qualitative meta-synthesis aimed to synthesize qualitative evidence on perceptions, experiences, barriers, facilitators, and impacts of oral care in older adults, guided by the Socio-Ecological Model.

Methods

Following PRISMA and ENTREQ guidelines, a systematic search was conducted in MEDLINE (PubMed), Embase, CINAHL, PsycINFO, Scopus, and Web of Science for qualitative studies published from January 2000 to December 2025. Eligibility criteria were defined using the SPIDER framework, focusing on older adults (aged ≥ 60) and stakeholders. Two reviewers independently screened records, extracted data, and appraised quality using CASP. Thematic synthesis was performed using NVivo to generate higher-order themes.

Results

From 1,416 records, 49 studies were included, involving diverse participants from multiple countries. Four overarching themes emerged: [1] Meaning-Making and Beliefs Surrounding Oral Health (e.g., cognitive biases, links to general health, responsibility); [2] Barriers to Accessing and Maintaining Oral Care (e.g., financial, physical, systemic); [3] Facilitators, Strategies, and Ethical Considerations in Oral Care Delivery (e.g., interprofessional collaboration, education, autonomy); and [4] Oral Health as a Determinant of Quality of Life and Human Dignity (e.g., functional, psychosocial, broader implications). A conceptual model illustrated the cyclical evolution of oral care.

Conclusions

Oral health in older adults is influenced by multifaceted perceptions and systemic factors, impacting well-being. Findings advocate for interprofessional models, policy reforms, and education to address gaps and promote equitable, holistic care. Future research should explore digital interventions and multilingual syntheses.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12903-026-09781-7.

Background

The global population is aging at an unprecedented rate, with the number of individuals aged 65 years and older projected to double by 2050, reaching over 1.5 billion people worldwide. This demographic shift poses significant challenges to healthcare systems, particularly in the domain of oral health, where older adults face unique vulnerabilities due to physiological changes, comorbidities, and socioeconomic factors [1]. In the United States alone, the proportion of older adults is expected to rise, amplifying the demand for specialized geriatric dental services. Oral care in this population has evolved from a focus on basic hygiene and denture management to a more comprehensive, interdisciplinary approach that integrates preventive, restorative, and palliative strategies [2]. This evolution reflects advances in dental technology, improved preventive practices, and a growing recognition of the interplay between oral and systemic health [3]. However, despite these advancements, oral health disparities persist, underscoring the need for systematic reviews to synthesize evidence and guide future interventions [4].

Older adults are particularly susceptible to a range of oral health issues that can compromise their quality of life. Common conditions include xerostomia (dry mouth), which affects up to 30% of seniors and is often exacerbated by polypharmacy, radiation therapy, or autoimmune disorders like Sjögren’s syndrome [5]. Dental caries, especially root caries due to gingival recession, remain prevalent, with nearly one-third of older adults experiencing untreated tooth decay [6]. Periodontal disease affects as many as 64% of this demographic, leading to tooth mobility, abscesses, and eventual edentulism. Oral cancer risk also increases with age, compounded by factors such as tobacco use and alcohol consumption [7]. These problems are not isolated; they often intersect with age-related changes like reduced manual dexterity, cognitive impairment, and diminished salivary flow, making daily oral hygiene challenging [8]. For instance, individuals with dementia may forget routines or resist assistance, leading to neglected care and accelerated deterioration. Moreover, institutional settings like nursing homes amplify these issues, where staff shortages and inadequate training result in suboptimal oral care practices [9].

The linkage between oral health and systemic well-being in older adults is well-established and multifaceted. Poor oral hygiene can contribute to aspiration pneumonia, a leading cause of mortality in frail elders, as oral bacteria enter the respiratory tract [10]. Periodontal pathogens have been implicated in exacerbating cardiovascular diseases, with inflammation from gum disease potentially promoting atherosclerosis and stroke [11]. Diabetes management is similarly affected; uncontrolled periodontitis can worsen glycemic control, creating a bidirectional relationship. Emerging evidence also connects tooth loss and masticatory dysfunction to cognitive decline, including Alzheimer’s disease, possibly through nutritional deficiencies or chronic inflammation. In a study of older adults, those with fewer than 20 teeth showed greater disability and cognitive impairment [12]. Furthermore, systemic conditions prevalent in aging—such as rheumatoid arthritis or osteoporosis—can manifest orally, with medications causing xerostomia or gingival overgrowth [13]. These associations highlight that oral health is not merely a local concern but a critical component of holistic geriatric care, influencing nutritional status, social interactions, and overall mortality [14].

Maintaining optimal oral health in older adults is paramount for preserving independence and enhancing life quality. Effective oral care prevents pain, facilitates proper nutrition, and reduces the risk of malnutrition, which affects up to 50% of institutionalized seniors [15]. It also supports social well-being by enabling clear speech and confident smiling, countering isolation often linked to edentulism. From a public health perspective, investing in geriatric oral care can alleviate healthcare burdens, as untreated issues lead to costly emergency interventions [16]. Yet, barriers abound: limited dental insurance coverage, transportation difficulties, and rural-urban disparities result in low utilization rates, with only about 60% of adults aged 65–74 visiting a dentist annually. Socioeconomic factors further exacerbate inequities, particularly among minority and low-income groups [17, 18].

Despite the increasing recognition of oral health’s role in geriatric well-being, evidenced by numerous systematic reviews on specific issues such as oral health inequalities, caregiver education, root caries progression, and motivational interventions, as well as qualitative meta-syntheses on topics like tooth loss consequences and oral care challenges in mental illness [19–24], no related qualitative meta-synthesis and systematic review has been conducted on the evolving aspects of oral care in older adults.

In this study, the term “evolving” is operationalized in three interconnected senses: (1) evolution within the individual life course, as oral care needs, capabilities, and priorities shift with advancing age, frailty, and cognitive decline [25]; (2) evolution at the health systems level, as preventive strategies, technological advancements, and interdisciplinary models of care develop over time; and [26] evolution across the care trajectory, wherein the dynamic interplay between barriers, facilitators, and outcomes continuously shapes the quality of life of older adults [27]. This tripartite conceptualization moves beyond static descriptions of barriers and facilitators to capture the temporal and adaptive nature of oral care in aging populations.

Existing literature often focuses on isolated conditions or interventions, such as dysphagia-related oral health or nursing home practices [28, 29], without synthesizing the broader evolutionary trends in preventive strategies, technological advancements, and interdisciplinary approaches tailored to this demographic. This gap hinders the development of cohesive guidelines and highlights the need for a comprehensive synthesis to address the dynamic nature of geriatric oral care.

This study is guided by the Socio-Ecological Model (SEM) as a conceptual framework to explore the evolving aspects of oral care in older adults. The SEM posits that health behaviors and outcomes are influenced by multiple interconnected levels: individual (e.g., personal beliefs and physical capabilities), interpersonal (e.g., relationships with caregivers and professionals), organizational (e.g., healthcare systems and institutional practices), community (e.g., socioeconomic and cultural contexts), and policy (e.g., access to services and regulations) [30]. This multilevel approach is particularly apt for geriatric oral health, as it accounts for the complex interplay between age-related vulnerabilities, systemic barriers, and interprofessional dynamics, allowing for a holistic synthesis of qualitative data that transcends isolated individual experiences to reveal broader structural influences on oral care evolution [31].

This systematic review and qualitative meta-synthesis aims to consolidate qualitative evidence on perceptions, experiences, barriers, facilitators, and impacts of oral care in older adults, identifying evolving trends, gaps, and recommendations. By synthesizing diverse perspectives—from patients to healthcare professionals—it will inform policy, education, and practice, ultimately promoting healthier aging. No quantitative meta-analysis was conducted, as the focus of this synthesis was interpretive and thematic rather than aggregative.

Methods

Study design

This study employed a systematic review and qualitative meta-synthesis approach to synthesize and interpret findings from existing qualitative research on the evolving aspects of oral health and care among older adults. Meta-synthesis is a rigorous method for integrating qualitative data to generate new interpretive insights beyond those achievable through individual studies, particularly suited to exploring complex, subjective experiences such as perceptions, barriers, and facilitators in healthcare contexts [32]. By focusing on thematic synthesis, we aimed to develop higher-order constructs that illuminate the dynamic interplay between individual attitudes, systemic factors, and holistic well-being in aging populations. This approach aligns with recommendations for synthesizing qualitative evidence in health sciences [33] and adheres to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines for transparent reporting [34], supplemented by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the systematic search and selection process [35] (See supplement S1 for more details). As well, the protocol was registered in PROSPERO (ID: CRD420261277302). This review was retrospective in design, as it synthesized already published qualitative studies identified through systematic literature searching rather than prospectively collecting primary data.

Search strategy

A comprehensive systematic search was conducted across multiple electronic databases to identify relevant qualitative studies published between January 2000 and December 2025, capturing contemporary perspectives on oral care evolution amid global aging trends. Databases included MEDLINE (via PubMed), Embase, CINAHL, PsycINFO, Scopus, and Web of Science, selected for their coverage of health sciences, nursing, dentistry, and social sciences literature. Search terms were developed iteratively using a combination of MeSH terms, free-text keywords, and Boolean operators, encompassing concepts related to the population (e.g., “older adults,” “elderly,” “aged,” “geriatric”), intervention/exposure (e.g., “oral health,” “oral care,” “dental hygiene,” “gerodontology”), and qualitative methodology (e.g., “qualitative,” “interview,” “focus group,” “thematic analysis”). The full search string for PubMed, for example, was: (“older adults” OR “elderly” OR “aged” OR “geriatric”) AND (“oral health” OR “oral care” OR “dental care” OR “gerodontology”) AND (“qualitative research” OR “phenomenology” OR “grounded theory” OR “thematic analysis” OR “narrative”). No language restrictions were initially applied, but only English-language publications were included post-screening due to resource constraints. Hand-searching of reference lists of included studies and relevant reviews yielded an additional 52 records, and forward citation tracking using Google Scholar identified 29 records. Details for search strategy in each database is provided as supplementary file (See Supplement S2).

Eligibility criteria

This review employed the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework [36] to define inclusion criteria, which is particularly suitable for qualitative and mixed-methods evidence syntheses exploring experiences and perceptions.

• Sample (S): Studies involving older adults (aged 60 years or older) as primary participants, or key stakeholders directly involved in their oral health and care, including informal caregivers (e.g., family members), formal caregivers (e.g., nurses, nursing assistants), healthcare professionals (e.g., dentists, dental hygienists, district nurses, general practitioners), and institutional staff. Studies focusing exclusively on professionals were included only if their perspectives explicitly addressed the oral health experiences, needs, or care provision for older adults.

• Phenomenon of Interest (PI): Perceptions, attitudes, experiences, barriers, facilitators, management practices, or impacts related to oral health and oral care in older adults. This encompassed daily oral hygiene, access to dental services, preventive and restorative care, interprofessional roles, and the broader implications of oral health on well-being.

• Design (D): Qualitative research designs (e.g., interviews, focus groups, ethnography, grounded theory, phenomenology) or mixed-methods studies with a substantial qualitative component that reported extractable qualitative findings (e.g., themes, narratives, direct participant quotes).

• Evaluation (E): Subjective experiences, views, beliefs, attitudes, behaviors, challenges, strategies, or outcomes as reported by participants through qualitative data collection and analysis.

• Research type (R): Qualitative or mixed-methods studies published in peer-reviewed journals. Quantitative-only studies, grey literature, reviews, editorials, and commentaries were excluded.

No restrictions were placed on country or setting (e.g., community-dwelling, residential care, hospitals) to capture diverse global perspectives. Studies published in languages other than English were excluded due to resource limitations.

Study selection

The search yielded 1,330 records after deduplication using EndNote X9 software. Titles and abstracts were independently screened by two reviewers against inclusion criteria, with discrepancies resolved through discussion with a third reviewer. Full-text assessment was conducted on 135 potentially eligible articles, resulting in the inclusion of 49 studies. The selection process is detailed in a PRISMA flow diagram (Fig. 1).

Fig. 1.

PRISMA Flowchart of selected studies

Data extraction and quality appraisal

Data were extracted independently by two reviewers using a standardized form capturing study characteristics (e.g., author, year, country, design, sample size, population demographics) and key qualitative findings (e.g., themes, sub-themes, direct quotes). For quality appraisal, we applied the Critical Appraisal Skills Programme (CASP) Qualitative Checklist [37], assessing aspects such as methodological rigor, ethical considerations, and reflexivity. Studies were not excluded based on quality scores to preserve a comprehensive synthesis, but limitations in lower-quality studies (e.g., small samples, n = 3) were noted during interpretation. Inter-rater reliability was high (kappa = 0.87), with consensus achieved via team discussion. The results of quality appraisal are provided as a supplementary file (See supplement S3).

Data synthesis

Thematic synthesis was performed following Thomas and Harden’s (2008) three-stage process [33]. First, findings from each study were coded line-by-line using NVivo 12 software to identify initial descriptive themes, drawing directly on participants’ quotes and authors’ interpretations. Second, these codes were organized into analytic themes and sub-themes through constant comparison, grouping similar concepts (e.g., financial barriers across studies) while attending to contextual nuances (e.g., cultural variations in attitudes). Third, higher-order themes were developed inductively to generate novel insights, such as the “evolving” nature of oral care influenced by frailty and interprofessional dynamics. Synthesis was iterative, with regular team meetings to refine themes and ensure reflexivity regarding our positions as researchers (e.g., dental public health backgrounds). No quantitative meta-analysis was conducted, as the focus was interpretive rather than aggregative.

Results

This systematic review and meta-synthesis integrates qualitative findings from 49 studies published between 2003 and 2025, exploring perceptions, experiences, barriers, facilitators, and systemic issues related to oral health and care among older adults aged 60 years and older. The included studies originated from diverse geographical contexts, including Europe (n = 28, primarily Sweden and the Netherlands), Asia (n = 9, including China, South Korea, and Iran), North America (n = 5, USA and Canada), Oceania (n = 6, Australia and New Zealand), South America (n = 2, Brazil and Chile), and other regions (n = 1, Cambodia). A detailed geographical mapping of all included studies by country and World Bank income classification is provided in Fig. 2. Study designs predominantly involved semi-structured interviews (n = 35), focus groups (n = 8), or mixed qualitative approaches (n = 6), with sample sizes ranging from 8 to 320 participants (median = 19). Key stakeholders encompassed older adults (n = 22 studies), healthcare professionals such as nurses, dentists, and caregivers (n = 20), and mixed groups including policymakers and family members (n = 7). The table of overall characteristics of included studies is provided as supplementary file (See Supplement S4).

Fig. 2.

Geographical distribution of included studies

Meta-synthesis findings

This meta-synthesis integrates qualitative findings from 49 studies exploring the perceptions, experiences, barriers, facilitators, and systemic issues surrounding oral care in older adults. Through thematic synthesis, four overarching themes emerged: (1) Meaning-Making and Beliefs Surrounding Oral Health; (2) Barriers to Accessing and Maintaining Oral Care; (3) Facilitators, Strategies, and Ethical Considerations in Oral Care Delivery; and (4) Oral Health as a Determinant of Quality of Life and Human Dignity. These themes reflect the evolving nature of oral care, influenced by aging populations, interprofessional dynamics, and societal shifts towards holistic health integration. The synthesis draws on diverse participant voices, including older adults, caregivers, nurses, dentists, and other professionals, highlighting the multifaceted challenges and opportunities in this domain.

Theme 1: meaning-making and beliefs surrounding oral health

Perceptions of oral health among older adults and healthcare professionals were shaped by deeply rooted beliefs, lived experiences, and sociocultural norms. While oral health was often acknowledged as an important component of overall well-being, it was frequently deprioritized in practice due to cognitive biases, normalization of decline, and limited awareness of preventability. Attitudes toward oral care were not static but influenced by aging experiences, health literacy, and perceived responsibility. This theme captures how misconceptions, health beliefs, and professional boundaries collectively shaped engagement with oral health, influencing both preventive behaviors and care-seeking practices.

Sub-theme 1.1: cognitive biases and misconceptions

Participants commonly demonstrated cognitive biases that framed oral health problems as an inevitable consequence of aging rather than a preventable or treatable condition. Such beliefs minimized the perceived seriousness of symptoms and contributed to delayed or absent care-seeking behaviors. These misconceptions were often reinforced through social narratives, past experiences, and limited access to accurate information, leading to normalization of discomfort and deterioration. Oral health problems were frequently trivialized unless they caused acute pain or functional impairment, resulting in an underestimation of long-term consequences [38–46]. Participants often regarded tooth loss or oral decline as a natural part of aging, rather than a health issue requiring intervention: “It’s normal for your teeth to fail as you get older, it’s not a serious illness, don’t worry about it” [38]. Dismissal of preventive procedures like scaling was common, exemplified by another participant: “I’ve heard that scaling can make the gaps in your teeth bigger, so that’s not good” [46]. Ignoring common symptoms like gum bleeding was prevalent: “My gums bleed, sometimes they bleed when I brush my teeth, it happens a lot and I don’t take it seriously” [40]. These individual perceptions reflected broader systemic misconceptions, as illustrated by observations of widespread untreated conditions: “There are deplorable conditions. toothlessness, decay, and gum infection are rampant” [39]. Additionally, physical decline was seen as reducing care priority, which was noted in a study: “You become shaky and has bad sight, you don’t care in the same way as you get older” [41]. However, social confidence tied to oral health reflected broader attitudinal biases, as described in: “Good oral health as a basis for satisfaction and social confidence” [45].

Sub-theme 1.2: link between oral and general health

Many participants acknowledged the interconnectedness of oral health with systemic health, nutrition, and overall quality of life. However, this awareness was uneven and often conflicted with persistent misconceptions that oral problems were secondary or unavoidable. Healthcare professionals, in particular, recognized that poor oral health could exacerbate broader health conditions, yet institutional and educational gaps limited consistent integration of oral care into holistic health management [47–58]. Nurses linked poor oral conditions to broader health deterioration, as one of them said: “I think there is a connection between oral problems and general condition and, if the condition of the oral cavity is poor, other diseases can primarily be affected negatively .but we don’t focus on the oral problems” [47]. As well, the functional importance of oral health for nutrition and daily living was repeatedly highlighted: “You have to think it all the way through . You can’t chew if you don’t have teeth” [49]. Beyond physical function, oral health was linked to psychosocial well-being and dignity: “Oral health has such broad connotations: to dare to laugh in the company of others, important for social interaction and of course for nutrition, yes it has to do with quality of life” [59]. The centrality of the mouth to personal integrity was expressed: “The mouth is something that feels very central in the face, and I think most people want the teeth to be fairly intact. This thing with bad teeth characterizes the whole person […]. My mouth has to do with my integrity” [57]. Besides, a simple holistic view was captured in by a participant: “Healthy teeth make for a healthy body” [58]. Doubts about care staff’s ability to address this link were raised in: “I seriously wonder whether they are able to deliver a good service to the people that they care for” [56].

Sub-theme 1.3: personal and professional responsibility

Responsibility for oral health was negotiated between individuals and care providers, often creating tension between autonomy, professional boundaries, and ethical obligations. Older adults frequently emphasized self-reliance and personal accountability, while professionals expressed uncertainty about the extent of their role in oral care promotion. This dynamic shaped engagement, sometimes reinforcing gaps in care [41, 42, 51, 58, 60–70]. Self-responsibility was strongly valued, with participants emphasizing autonomy and proactive information-seeking: “I think you have to find out things for yourself. There are newspaper and the internet, it’s up to you. you can’t expect things to fall in your lap” [41]. At the same time, healthcare professionals described discomfort and role ambiguity when addressing oral health, particularly in private or home settings: “This has not been a nurse’s job. when you come into someone’s home it feels insulting to say, ‘Can I get a look in your mouth?‘” [51]. However, building trust through relationships was key, exemplified by: “The relationship means that you create something—a security that I know that I get good support from you and that you are a good person who does not want to [harm me]. You wish me well, so to speak” [67]. Educational gaps were identified as structural contributors to uncertainty, prompting calls for interprofessional learning: “Dental students… are not well trained in caring for older people… side-by-side training at the beginning… breaks down barriers between dentists and DCPs” [65]. Notably, pride in self-care was evident among participants: “I try to rely on care as little as possible. I try to look after myself as well as I can for as long as I can. It is also part of your own pride to take good care of yourself” [58]. As well, financial influences on responsibility were noted in: “Those decisions will very likely be money driven. … If I am 80 years old and broke—then I am not going to do much” [68].

Theme 2: barriers to accessing and maintaining oral care

Barriers to oral care were multidimensional and interconnected, encompassing financial constraints, physical limitations, and systemic shortcomings. These barriers often accumulated with age and dependency, compounding vulnerability and limiting timely access to preventive and restorative services. The findings illustrate how structural inequities and organizational fragmentation contribute to unmet oral health needs among older adults.

Sub-theme 2.1: financial and economic barriers

Economic constraints were among the most frequently cited obstacles, disproportionately affecting individuals on fixed or limited incomes. High treatment costs, insufficient insurance coverage, and rising prices of dental materials discouraged care-seeking and fostered avoidance behaviors [39, 40, 50, 56, 63, 68, 71–76]. Rising costs of dental materials impacted affordability, as one of the participants mentioned: “Dental services are relatively expensive in the country, which is partly due to the high cost of the equipment and essentials and at the end of 2019, the prices of consumables required for conventional dental services increased several times” [39]. Also, pensioners felt burdened by treatment expenses, exemplified by another participant: “If you’ve got fillings and x-rays you are paying quite a bit of money and as I said when you are a pensioner.it’s not that I haven’t got anything .I get two pensions.so therefore I don’t get any benefits” [71]. Saving money by enduring issues was common, as seen in: “The main reason is that I don’t have any money. so let’s save as much as we can and just put up with it” [72]. Cumulative challenges in aging compounded financial issues, noted in: “It kind of just all compounds in this age group” [56]. However, insurance limitations deterred care, as one said: “I’ve checked out a few that I’ve gotten in the mail… But a lot of them have limitations where they won’t do anything for two, three, up to five years if you’ve got an existing condition” [68]. Notably, socioeconomic struggles led to avoidance, with a participant mentioning: “In this neighbourhood, a lot of people are struggling. And the dental costs are a big problem. They simply don’t go to the dentist to save money” [75].

Sub-theme 2.2: physical and accessibility barriers

Physical limitations, reduced mobility, and transportation challenges significantly restricted access to dental services, particularly for frail or dependent older adults. Geographic distance, complex healthcare navigation, and reliance on others further compounded these barriers [41, 48, 49, 56, 58, 66, 71, 72, 76–78]. Distance and complex processes hindered visits, which was noted by one of the participants: “It’s far from home, it’s a long drive. and the processes in the hospital are troublesome” [38]. Additionally, preference for nearby services due to travel limitations was expressed in: “I want a dentist where I can get to easily because I can’t travel too far” [71]. Meanwhile, impossibility of transport for dependent individuals was highlighted in: “Getting them to the dentist was pretty much impossible in most cases” [56]. Sensory and mobility declines complicated access, as seen in: “You’re a bit shaky and don’t see well.you have to book transport or ask someone to drive, it gets complicated with everything.there is a lot of factors to take into account” [41]. Unrealistic expectations for older adults were noted in: “Well the only place in Perth where you can get emergency treatment straight away is Suburb1… and I have to walk about three quarters of a kilometre to the clinic… totally unrealistic for an older person” [66]. Reliance on others for basic care added barriers, as exemplified by a participant: “Look at my teeth. You always have to rely on someone … Sometimes they come immediately, sometimes it takes half an hour. I prefer to do it myself” [58].

Sub-theme 2.3: systemic and organizational barriers

System-level shortcomings—including fragmented care structures, unclear professional roles, and competing priorities—emerged as major obstacles to consistent oral healthcare delivery. Oral health was frequently deprioritized within busy care environments, leading to fragmented responsibility and inconsistent follow-up [42, 47, 49, 51, 59, 64, 65, 67, 73, 75, 79, 80]. In this line, fragmented systems between sectors were criticized: “We have the problem of different principals, different legislation and different economic pre requisites between medicine, dental care and care for the elderly who still live in their own homes” [47]. As well, professional boundaries led to neglect, as addressed by one of the participants: “Oral care falls away in some way. Because it’s a different profession” [49]. Time constraints overlooked oral exams and was introduced as another systemic barrier: “The pace is quite hectic so we have to prioritize. One has to be content with examining the rest of the body and so it’s easy to overlook things like the mouth” [59]. Uncertainty about tools like oral care cards was evident in words of a participant: “Who looks at the oral cards and does anybody read them? What are they for?” [64]. Ultimately, the lack of routine integration into daily care routines was repeatedly emphasized: “Very few people are being looked after in that sense, in the same way as they may be clothed and fed and even washed, the mouths aren’t being cleaned” [56].

Theme 3: Facilitators, Strategies, and Ethical Considerations in Oral Care Delivery

Facilitators and strategies for oral care emphasize collaborative, adaptive, and ethically grounded approaches that evolve to address older adults’ unique needs, promoting autonomy and interprofessional integration. This theme explores how relationships, education, and customized interventions enhance care delivery.

Sub-theme 3.1: interprofessional collaboration and support

Interprofessional collaboration emerged as a cornerstone of effective oral care, emphasizing shared responsibility, mutual trust, and coordinated action among caregivers, healthcare professionals, and family members. Participants described how structured teamwork and clear communication pathways facilitated continuity of care and enabled early identification of oral health issues. Collaboration allowed oral health to be embedded within broader care discussions, reinforcing its legitimacy as part of holistic health assessment [43, 48, 49, 51, 64, 65, 67, 69, 71, 72, 75, 76, 81]. The presence of supportive networks also empowered caregivers to act proactively and confidently, reducing isolation in decision-making. As one participant noted: “It’s a team that works together. Everyone has a duty and we are united. We have to be united to do the job because it’s impossible for me to carry out a task alone. I need help” [48]. Interdisciplinary dialogue further normalized oral health as part of whole-person care, as illustrated by a participant: “Well, it’s the whole person we discuss there … And that very much includes the mouth” [49]. Home care services were seen as strategic entry points for oral health monitoring, particularly for individuals with limited access to dental services. Their proximity to daily life enabled early detection and referral, expanding the scope of preventive care: “This is a unique way to approach the older people through the home care organization. There could be added value if they not only do wound care, but could also play a signalling role in oral health care; that could be very positive” [75]. Greater involvement in care processes was also valued, as it fostered attentiveness to subtle changes in health status: “You would like to have more control and be more involved in the care. You see a lot more, discover things like how they are, and how they walk and eat and take care of themselves, take their medication” [67]. Finally, referral pathways to specialized professionals were viewed as essential for comprehensive care, particularly when time constraints or expertise limited routine providers: “Many older people… might be happier being referred to a therapist or hygienist who may have a bit more time for them” [65].

Sub-theme 3.2: education, knowledge, and adaptive strategies

Education emerged as a key enabler of effective oral care, enhancing caregivers’ confidence, competence, and responsiveness to the complex needs of older adults. Participants emphasized that tailored education—both for professionals and older individuals—was essential for overcoming practical barriers and fostering informed engagement. Adaptive strategies, including personalized care plans and flexible communication approaches, were particularly important in addressing physical, cognitive, and motivational challenges associated with aging [39, 41, 46, 47, 51–53, 55, 62, 63, 66, 67, 77, 78, 82–84]. However, gaps in health literacy and professional training limited effective implementation. Older adults reported difficulties understanding written educational materials, highlighting accessibility issues: “The pamphlets issued by this hospital. I can’t read or understand” [46]. At the professional level, insufficient curricular emphasis on geriatric oral health constrained preparedness: “There is no separate course unit for geriatric dentistry in dental schools” [39]. Similarly, staff acknowledged limited formal training in oral health, despite recognizing its importance for overall wellbeing: “All understood that oral health could influence general health. The staff had received very little education about oral health and related issues in their training” [83]. Targeted educational interventions were perceived as transformative, enhancing awareness and practical skills: “…it made the team extra aware of oral care and we received new tips and tricks, that they can also pass on to older people“ [76]. Care strategies were often adapted to respect resistance or cognitive decline, with gentle persuasion replacing directive approaches: “I usually just say something like ‘Let’s go to bed, and then we’ll brush our teeth’…because if you ask, it’s usually a no…” [67].

Sub-theme 3.3: ethical dilemmas and autonomy

Ethical considerations permeated oral care delivery, particularly when cognitive impairment, dependency, or end-of-life care complicated decision-making. Care providers frequently navigated tensions between respecting autonomy and ensuring health protection, especially when interventions risked being perceived as intrusive or undignified. The intimacy inherent in oral examinations heightened these ethical sensitivities, requiring emotional labor and moral judgment [44, 49, 51, 55, 57, 58, 64, 70, 71, 80]. Some caregivers described discomfort associated with close physical inspection, even when clinically justified: “Sometimes I can find that it becomes very intimate and unpleasant to look closely at someone else’s mouth [with ROAG-J]. But then you have to do it for the other person’s good” [49]. Another participant reflected on the moral boundaries of professional roles, particularly in private settings such as the home: “This has not been a nurse’s job. when you come into someone’s home it feels insulting to say, ‘Can I get a look in your mouth?‘” [51]. Preserving autonomy and dignity remained central values, especially among older adults who strongly identified with independence and self-care: “I try to rely on care as little as possible. I try to look after myself as well as I can for as long as I can. It is also part of your own pride to take good care of yourself” [58]. Rather than coercion, ethical care involved persistence grounded in respect, encouragement, and choice: “Though you know you’re not supposed to impose yourself. we must not give up either, but the whole time offer, offer” [51]. Supporting participation in care was viewed as a means of empowering older adults and preserving dignity: “We shouldn’t take that away from them so they can participate in taking care of their teeth” [64].

Theme 4: oral health as a determinant of quality of life and human dignity

Oral health emerged as a central determinant of older adults’ quality of life, influencing not only physical functioning but also emotional well-being, social participation, and overall life satisfaction. Across studies, participants described oral health as deeply intertwined with daily living, identity, and dignity. Deterioration in oral health often triggered a cascade of functional limitations and psychosocial consequences, underscoring the interconnectedness of oral, physical, and emotional health. This theme illustrates how oral conditions extend beyond the mouth, shaping nutritional intake, self-esteem, social relationships, and perceptions of aging and health.

Sub-theme 4.1: functional and physical impacts

Functional impairment emerged as one of the most immediate and tangible consequences of poor oral health. Difficulties with chewing, speaking, and swallowing frequently disrupted daily routines and compromised nutritional intake. For many older adults, oral discomfort or poorly fitting dentures directly limited food choices, leading to dietary modifications, weight loss, and reduced enjoyment of meals. These functional challenges often accumulated over time, diminishing independence and increasing vulnerability [40, 43, 48, 50, 55, 57, 66, 69, 80, 84]. Participants described the physical instability of dentures and its impact on eating: “If I move my mouth, they just come out, can’t eat with them. I’ve lost over a stone in weight because I can’t eat any proper food” [50]. In some cases, unresolved oral problems necessitated urgent dental interventions, further disrupting daily life: “Those [teeth] needs to come out’ but it was at the back, so she would need to go in [Name of Hospital]” [50]. Caregivers often prioritized caloric intake over nutritional quality when oral discomfort limited eating, reflecting a shift from optimal to pragmatic care goals: “Yes, the thing is we’ve got to the point now where we’re just grateful that she eats anything. I know she doesn’t have the greatest diet, but I just want her to eat. she’s always had a sweet tooth. I know it’s full of sugar, but she enjoyed it. I really don’t care” [40]. For some older adults, dentures themselves became a source of discomfort or risk, leading to their removal and subsequent nutritional compromise: “When they get very old, sometimes the dentures even hurt. We sometimes take them out because they’re risky. They get thinner and get troublesome, so we take them out. They don’t eat properly when they’re in” [48]. To maintain autonomy, individuals often adapted their eating practices by modifying food textures and preparation methods: “I can eat softer foods. I can cook things a little bit longer” [68].

Sub-theme 4.2: psychosocial and emotional impacts

Beyond physical limitations, oral health exerted a profound influence on emotional well-being, self-esteem, and social engagement. Visible dental problems frequently elicited feelings of shame, embarrassment, and social withdrawal, reinforcing stigma and self-consciousness. Participants often linked their oral appearance to identity, dignity, and perceived social worth [40, 41, 50, 55, 68, 77, 85, 86]. Concerns about dental appearance were closely tied to self-image and confidence: “I had two very prominent teeth here, rabbit teeth. that’s why it’s so important your teeth, for your own self-image. to me, they were ugly” [50]. Social judgments—both internalized and perceived—intensified emotional distress, as reflected in compassionate yet stigmatizing observations: “She has such awful teeth, poor thing, but your teeth get more brown with age.they simply don’t brush their teeth” [41]. Shame and embarrassment led some individuals to withdraw from social interactions altogether: “I was very ashamed when they (natural teeth) were broken and stuff–didn’t smile in pictures or anything like that” [68]. Poor oral condition was also associated with feelings of uncleanliness and diminished self-worth: “I think it is ugly, I think it exhibits to other people that, perhaps, I am not a clean person, or I’m not careful, or concerned about my look, or something. I hate it! I don’t even like to look in the mirror” [55]. Conversely, maintaining natural teeth was a source of pride and confidence, reinforcing a positive self-concept: “I haven’t got a false tooth in my mouth… all of my teeth are mine” [86].

Sub-theme 4.3: Broader health and well-being implications

Oral health was repeatedly linked to broader health outcomes, functioning as both a marker and determinant of overall well-being. Participants and caregivers recognized that oral deterioration could exacerbate existing conditions, compromise nutrition, and accelerate functional decline, particularly among individuals with cognitive impairment or chronic illness [39, 42, 48, 54, 56, 57, 59, 69, 75]. High prevalence of tooth loss underscored the magnitude of the issue at a population level: “More than 50% of Iranian aging people are toothless” [39]. Cognitive decline further complicated oral care, often leading to reduced intake and health deterioration: “The oral health of the old person I care for is quite poor because the old don’t help us because of dementia. This can have several consequences … the most serious is loss of appetite, especially when their mouth is in a bad shape” [48]. Loss of cognitive function also impaired basic understanding of oral hygiene practices: “[…] say that you get a dementia disease, it is not certain that you know what a toothbrush should be for. It could be that they think they should clean the sink or something like that instead” [57]. Participants highlighted how poor baseline oral health could rapidly worsen after institutionalization: “If you went into aged care with an already debilitated dentition, it’s going to go downhill in a big way” [56]. Conversely, integration of oral health into chronic disease management frameworks improved awareness and prioritization: “With diabetic care, there are structured visits (…) with test results and even more questionnaires. So, oral health became part of the conversation” [75].

Table 1 show the details on themes, sub-theme and illustrative quotes in this study.

Table 1.

Themes, sub-themes, and illustrative quotes

Theme	Sub-themes	Related Quotes
Theme 1: Meaning-Making and Beliefs Surrounding Oral Health	Sub-theme 1.1: Cognitive Biases and Misconceptions	Ignoring common symptoms like gum bleeding was prevalent, as in: “My gums bleed, sometimes they bleed when I brush my teeth, it happens a lot and I don’t take it seriously” [38]; Reports of widespread poor oral conditions highlighted systemic misconceptions, such as: “There are deplorable conditions… toothlessness, decay, and gum infection are rampant” [39]; Physical decline was seen as reducing care priority, noted in: “You become shaky and has bad sight, you don’t care in the same way as you get older” [41]
	Sub-theme 1.2: Link Between Oral and General Health	The integral role of teeth in nutrition was emphasized by: “You have to think it all the way through … You can’t chew if you don’t have teeth” [49]; A simple holistic view was captured in: “Healthy teeth make for a healthy body” [58]; Doubts about care staff’s ability to address this link were raised in: “I seriously wonder whether they are able to deliver a good service to the people that they care for” [56].
	Sub-theme 1.3: Personal and Professional Responsibility	Self-reliance in seeking information was stressed in: “I think you have to find out things for yourself. There are newspaper and the internet, it’s up to you… you can’t expect things to fall in your lap” [41]; Nurses felt intrusive when addressing oral health, as in: “This has not been a nurse’s job… when you come into someone’s home it feels insulting to say, ‘Can I get a look in your mouth?‘” [51]; Building trust through relationships was key, exemplified by: “The relationship means that you create something—a security that I know that I get good support from you and that you are a good person who does not want to [harm me]. You wish me well, so to speak” [57]
Theme 2: Barriers to Accessing and Maintaining Oral Care	Sub-theme 2.1: Financial and Economic Barriers	Insurance limitations deterred care, as in: “I’ve checked out a few that I’ve gotten in the mail… But a lot of them have limitations where they won’t do anything for two, three, up to five years if you’ve got an existing condition” [68]; Socioeconomic struggles led to avoidance, captured in: “In this neighbourhood, a lot of people are struggling. And the dental costs are a big problem. They simply don’t go to the dentist to save money” [75].
	Sub-theme 2.2: Physical and Accessibility Barriers	Sensory and mobility declines complicated access, as seen in: “You’re a bit shaky and don’t see well…you have to book transport or ask someone to drive, it gets complicated with everything…there is a lot of factors to take into account” [41]; Unrealistic expectations for older adults were noted in: “Well the only place in Perth where you can get emergency treatment straight away is Suburb1… and I have to walk about three quarters of a kilometre to the clinic… totally unrealistic for an older person” [66]; Reliance on others for basic care added barriers, exemplified by: “Look at my teeth. You always have to rely on someone … Sometimes they come immediately, sometimes it takes half an hour. I prefer to do it myself” [58].
	Sub-theme 2.3: Systemic and Organizational Barriers	Fragmented systems between sectors were criticized in: “We have the problem of different principals, different legislation and different economic pre requisites between medicine, dental care and care for the elderly who still live in their own homes” [59]; Professional boundaries led to neglect, as in: “Oral care falls away in some way… Because it’s a different profession” [49]; Time constraints overlooked oral exams, noted in: “The pace is quite hectic so we have to prioritize. One has to be content with examining the rest of the body and so it’s easy to overlook things like the mouth” [59]
Theme 3: Facilitators, Strategies, and Ethical Considerations in Oral Care Delivery	Sub-theme 3.1: Interprofessional Collaboration and Support	Home care’s signaling role enhanced access, exemplified by: “This is a unique way to approach the older people through the home care organization. There could be added value if they not only do wound care, but could also play a signalling role in oral health care; that could be very positive” [75]; Increased involvement in care was desired, as in: “You would like to have more control and be more involved in the care. You see a lot more, discover things like how they are, and how they walk and eat and take care of themselves, take their medication” [67]; Referral to supportive professionals was suggested in: “Many older people… might be happier being referred to a therapist or hygienist who may have a bit more time for them” [65].
	Sub-theme 3.2: Education, Knowledge, and Adaptive Strategies	Curriculum gaps in geriatric dentistry were noted in: “There is no separate course unit for geriatric dentistry in dental schools” [39]; Limited training for staff was acknowledged in: “All understood that oral health could influence general health. The staff had received very little education about oral health and related issues in their training” [83]; Sessions improved awareness and skills, as in: “…it made the team extra aware of oral care and we received new tips and tricks, that they can also pass on to older people” [76]
	Sub-theme 3.3: Ethical Dilemmas and Autonomy	Pride in independence was a core value, as in: “I try to rely on care as little as possible. I try to look after myself as well as I can for as long as I can. It is also part of your own pride to take good care of yourself” [58]; Persistent offering without coercion was advocated in: “Though you know you’re not supposed to impose yourself… we must not give up either, but the whole time offer, offer” [51]; Promoting participation respected autonomy, noted in: “We shouldn’t take that away from them so they can participate in taking care of their teeth” [64].
Theme 4: Oral Health as a Determinant of Quality of Life and Human Dignity	Sub-theme 4.1: Functional and Physical Impacts	Urgent extractions due to issues were described in: “Those [teeth] needs to come out’ but it was at the back, so she would need to go in [Name of Hospital]” [50]; Nutritional compromises for enjoyment were noted in: “Yes, the thing is we’ve got to the point now where we’re just grateful that she eats anything… I know she doesn’t have the greatest diet, but I just want her to eat… she’s always had a sweet tooth… I know it’s full of sugar, but she enjoyed it… I really don’t care” [40]; Adaptive eating strategies were employed, exemplified by: “I can eat softer foods. I can cook things a little bit longer” [68].
	Sub-theme 4.2: Psychosocial and Emotional Impacts	Prominent teeth affected self-image, as in: “I had two very prominent teeth here, rabbit teeth… that’s why it’s so important your teeth, for your own self-image… to me, they were ugly” [50]; Perceived uncleanliness from poor teeth caused distress, exemplified by: “I think it is ugly, I think it exhibits to other people that, perhaps, I am not a clean person, or I’m not careful, or concerned about my look, or something. I hate it! I don’t even like to look in the mirror” [68]; Pride in natural teeth boosted confidence, as in: “I haven’t got a false tooth in my mouth… all of my teeth are mine” [86].
	Sub-theme 4.3: Broader Health and Well-Being Implications	High toothlessness rates affected well-being, as in: “More than 50% of Iranian aging people are toothless” [39]; Dementia-related oral issues led to appetite loss, noted in: “The oral health of the old person I care for is quite poor because the old don’t help us because of dementia. This can have several consequences … the most serious is loss of appetite, especially when their mouth is in a bad shape” [48]; Cognitive decline impaired hygiene understanding, as in: “[…] say that you get a dementia disease, it is not certain that you know what a toothbrush should be for. It could be that they think they should clean the sink or something like that instead” [57]

Conceptual model

The conceptual model was constructed through a three-phase iterative process. In Phase 1, the four meta-synthesis themes were positioned as interconnected conceptual domains, with preliminary directional relationships hypothesized based on recurrent patterns observed across included studies. In Phase 2, these hypothesized relationships were tested and refined through constant comparison with the extracted data, ensuring that each pathway in the model was grounded in empirical qualitative evidence rather than imposed a priori. In Phase 3, the model was reviewed and revised through team consensus discussions, during which the cyclical feedback loops—specifically the pathway from quality-of-life impacts back to meaning-making beliefs—were identified as the core dynamic mechanism distinguishing this model from linear frameworks.

Drawing from the meta-synthesis findings, a conceptual model emerges that illustrates the dynamic evolution of oral care in older adults as a cyclical process centered on four interconnected domains: perceptions and beliefs (Theme 1), barriers (Theme 2), facilitators and strategies (Theme 3), and impacts on quality of life and dignity (Theme 4). This model explicitly aligns with the Socio-Ecological Model by situating each domain across multiple levels of influence. At the individual (intrapersonal) level, cognitive biases and personal responsibility beliefs shape meaning-making (Theme 1) and influence how older adults perceive the necessity of care-seeking. At the interpersonal level, relationships with caregivers and professionals mediate the effectiveness of facilitators such as collaboration and trust-building (Theme 3, Sub-theme 3.1). At the organizational level, institutional practices and interprofessional structures determine the extent to which systemic barriers (Theme 2, Sub-theme 2.3) impede or enable consistent care delivery. At the community level, socioeconomic conditions and cultural norms influence financial barriers (Theme 2, Sub-theme 2.1) and the psychosocial impacts of poor oral health (Theme 4, Sub-theme 4.2). At the policy level, insurance coverage and reimbursement structures shape access to services across all barrier and facilitator domains. At the core is the individual’s meaning-making of oral health, which influences and is influenced by barriers such as financial and physical constraints, while facilitators like interprofessional collaboration and education serve as mediators to mitigate these challenges. The model depicts quality of life as both an outcome and a feedback loop, where functional, psychosocial, and broader health implications reinforce or reshape initial beliefs, fostering adaptive evolution in care practices over time. This cyclical structure captures the tripartite operationalization of “evolving” articulated in this study: individual life-course changes are reflected in shifting meaning-making and impacts; health systems evolution is embedded in facilitators and systemic barriers; and care-trajectory dynamics are represented by the continuous feedback between quality-of-life outcomes and subsequent perceptions. This model highlights the non-linear, iterative nature of oral care, emphasizing the need for targeted interventions at multiple levels to break negative cycles and promote positive trajectories in geriatric well-being (Fig. 3).

Fig. 3.

Conceptual model

Discussion

The findings from this meta-synthesis illuminate the multifaceted and evolving nature of oral health and care among older adults, drawing on qualitative insights from 49 studies to reveal four overarching themes: perceptions and attitudes towards oral health, barriers to accessing and maintaining oral care, facilitators, strategies, and ethical considerations in oral care delivery, and the impact of oral health on quality of life and overall well-being. These themes underscore the interplay between individual experiences, systemic challenges, and broader health implications, highlighting how oral health extends beyond dental concerns to encompass psychosocial, functional, and holistic dimensions of aging. By synthesizing diverse participant voices—including older adults, caregivers, nurses, dentists, and other professionals—this review advances understanding of why oral health often remains undervalued and underprioritized in geriatric care, despite its profound effects on well-being.

The term “evolving” was operationalized in three senses—life-course changes, health systems development, and care-trajectory dynamics—and the meta-synthesis findings demonstrate evolution across all three dimensions. Life-course evolution is evident in how cognitive biases (Theme 1) shift as individuals experience functional decline, altering their perceived responsibility and care priorities [87]. Health systems evolution is reflected in the identified facilitators (Theme 3), where emerging interprofessional models and educational interventions represent ongoing systemic adaptations to bridge historical divides between medicine and dentistry [88]. Care-trajectory evolution is captured by the conceptual model’s feedback loop, wherein quality-of-life impacts (Theme 4) continuously reshape individual beliefs and care-seeking behaviors, creating adaptive spirals that can be either virtuous or vicious depending on the balance of barriers and facilitators present [89]. Thus, while individual sub-themes may reflect established barriers and facilitators, their dynamic interaction—as synthesized through this meta-synthesis—reveals an evolving system rather than a static landscape.

A central finding was the prevalence of cognitive biases and misconceptions that frame oral health issues as inevitable consequences of aging, often leading to passive attitudes and delayed care-seeking. Participants frequently normalized tooth loss, gum bleeding, and pain as “normal” for older age, rooted in hearsay or limited knowledge, which undermines preventive behaviors. This aligns with another research where fatalistic beliefs about tooth decay and edentulism were common, viewing them as unavoidable rather than preventable through routine hygiene [90]. Similarly, another exploration revealed that rural older adults often internalized myths about oral health deterioration, attributing it to genetics or lifestyle rather than modifiable factors [57], which echoes our sub-theme on misconceptions and parallels the dismissal of symptoms seen in our synthesis.

The recognized link between oral and general health emerged as a pivotal attitude shift, with participants acknowledging impacts on nutrition, systemic conditions, and quality of life, yet awareness gaps persisted. This is consistent with quantitative evidence from systematic reviews, which quantified how poor oral health exacerbates chronic diseases like diabetes and cardiovascular issues in the elderly, though our qualitative lens adds depth to the subjective undervaluation [91]. Furthermore, a mixed-methods study highlighted how cultural perceptions influence this link, with immigrant older adults prioritizing aesthetics over systemic health, a nuance that complements our emphasis on integrity and social connotations [92].

Personal and professional responsibility attitudes revealed a tension between autonomy and duty, with older adults valuing self-care pride and professionals grappling with role ambiguity. This resonates with research identifying dentists’ ambivalence in geriatric care due to unclear scopes, similar to our sub-theme on nurses feeling intrusive in oral assessments [93]. Overall, these perceptions evolve with education and experience, suggesting that targeted interventions could shift fatalistic views towards proactive ones, as evidenced in intervention studies where awareness programs improved attitudes among elders [94].

Financial and economic barriers were prominently synthesized, with high costs, inadequate insurance, and socioeconomic disparities deterring access, particularly for pensioners. This finding extends beyond our included studies, aligning with global systematic reviews estimating that out-of-pocket dental expenses exacerbate health inequities among older adults in low- and middle-income countries, leading to untreated conditions [95]. Moreover, European cohort analyses quantified how economic barriers correlate with increased edentulism rates, reinforcing our qualitative insights on cumulative aging compounds [96].

Physical and accessibility barriers, including mobility limitations and transport dependencies, highlighted the vulnerability of frail or institutionalized older adults. External literature, such as a scoping review, identified geographic isolation in rural areas as a key impediment, with homebound elders facing compounded risks, akin to our synthesis of “unrealistic” clinic distances [97]. Another research delved into sensory declines (e.g., vision, dexterity) as underrecognized barriers, echoing our findings on shaky hands and poor sight complicating self-care [98]. Additionally, a Canada-based ethnographic study on dementia patients underscored dependency on caregivers for transport, often leading to missed appointments, which mirrors our sub-theme’s emphasis on reliance adding layers of complexity [99].

Interprofessional collaboration surfaced as a key facilitator, with teamwork and signaling roles enhancing access and holistic discussions. A randomized trial demonstrated that multidisciplinary teams reduce oral pain in nursing homes, supporting our emphasis on unity and signaling [100]. Moreover, an evidence synthesis on inter-professional education initiatives highlighted how collaborative training fosters mutual trust, echoing our findings on holistic person-centered discussions [101].

Education and adaptive strategies were pivotal, with training boosting confidence and tools like personalized plans addressing frailty. This aligns with a study on oral health education for non-dental professionals, showing improved knowledge and attitudes post-intervention, showing improved knowledge and attitudes post-intervention [102], similar to our noted tips and tricks dissemination. On the other hand, ethical dilemmas, particularly balancing autonomy and integrity, were prominent, with intimacy concerns in assessments and respect for preferences guiding care. This resonates with bioethical analyses emphasizing dignity in oral interventions for cognitively impaired elders, paralleling our intrusive feelings [103].

Functional and physical impacts, such as dietary restrictions and weight loss from poor dentition, underscored oral health’s role in daily living. A study linked tooth loss to malnutrition and frailty, quantifying risks that our qualitative data humanize through adaptive eating narratives [104]. Another cohort study associated denture discomfort with reduced food intake, echoing our risky denture removals [105].

Psychosocial and emotional impacts revealed embarrassment and social withdrawal from aesthetic concerns, affecting self-image. This is supported by a research where elders described poor teeth as stigmatizing, leading to isolation, similar to our shame from broken teeth [106]. Another study validated the Oral Health Impact Profile (OHIP) in measuring these effects, reinforcing our pride in natural teeth [107].

The findings of this meta-synthesis map systematically onto all five levels of the Socio-Ecological Model, extending beyond the general theme-level analysis presented earlier. At the intrapersonal level, Sub-themes 1.1 (Cognitive Biases and Misconceptions) and 1.3 (Personal and Professional Responsibility) operate primarily through individual knowledge, attitudes, and self-efficacy beliefs. Fatalistic attitudes toward tooth loss as an inevitable consequence of aging [35, 37, 38] represent intrapersonal cognitive barriers that directly undermine preventive behaviors, a pattern consistent with the Health Belief Model’s construct of perceived susceptibility, which has been shown to predict oral health behaviors in older adults [84]. At the interpersonal level, Sub-theme 3.1 (Interprofessional Collaboration and Support) and Sub-theme 3.3 (Ethical Dilemmas and Autonomy) are embedded within relational dynamics between older adults, caregivers, and healthcare professionals. The trust-building relationships described in included studies [54, 64] exemplify how interpersonal rapport can mediate resistance to oral care, functioning as a relational facilitator that operates through social cognitive mechanisms of modeling and reinforcement [87]. At the organizational level, Sub-theme 2.3 (Systemic and Organizational Barriers)—including fragmented care systems, time constraints, and unclear professional roles [44, 46, 56]—reflects institutional structures that deprioritize oral health within healthcare delivery. These findings align with organizational behavior research demonstrating that without dedicated protocols and accountability mechanisms, oral care becomes marginalized in settings where competing clinical demands dominate [94]. At the community level, Sub-theme 2.1 (Financial and Economic Barriers) and Sub-theme 4.2 (Psychosocial and Emotional Impacts) intersect with socioeconomic conditions, cultural norms, and community resources. The shame and social withdrawal associated with poor oral appearance [52, 65] reflect community-level stigma processes, while neighborhood-level socioeconomic disadvantage directly constrains access to care [72], consistent with area-based studies of oral health inequality [89]. At the policy level, Sub-theme 2.1 (Financial and Economic Barriers) is fundamentally shaped by national health financing structures, insurance coverage limitations [65], and reimbursement policies that exclude adult dental care from universal health coverage frameworks in many countries. These policy-level determinants create structural conditions that either enable or constrain all other levels of the SEM, underscoring the need for upstream interventions.

Geographic distribution and generalizability

The geographic distribution of the included studies warrants careful consideration when assessing the generalizability of the synthesized themes. The majority of studies originated from high-income European countries (n = 28), particularly Sweden and the Netherlands, where publicly subsidized dental systems provide varying degrees of coverage for older adults. This concentration may limit the transferability of findings—particularly Theme 2 (Barriers to Accessing and Maintaining Oral Care)—to low- and middle-income countries where out-of-pocket payment models predominate and the severity of financial barriers may be substantially greater than reported here. For instance, financial barriers described in the included European studies [68, 72] reflect partial coverage systems where cost-sharing remains a burden, whereas in settings without any public dental coverage—which characterizes many countries in Africa, South Asia, and Latin America not represented in this synthesis—financial barriers may constitute absolute rather than relative obstacles to care. Similarly, systemic barriers related to interprofessional fragmentation (Sub-theme 2.3) are embedded within the organizational structures of highly formalized health systems, and may manifest differently in settings where informal care networks and traditional healers play more prominent roles. Conversely, themes related to meaning-making and psychosocial impacts (Themes 1 and 4) may have greater cross-contextual resonance, as they reflect more fundamental human experiences of aging, embodiment, and social identity. The geographical mapping figure (Fig. 2) allows readers to assess the applicability of findings to their own contexts by identifying the distribution of included studies across regions and income classifications.

Implications for practice, policy, and education

These findings have profound implications. For practice, enhancing interprofessional models could address barriers, as piloted in initiatives integrating oral health into nursing. Policy-wise, advocating for Medicare dental inclusions could alleviate financial burdens. Educationally, incorporating geriatric modules would build responsibility and reduce biases.

Strengths and limitations

While this meta-synthesis focused exclusively on English-language studies to ensure feasibility and depth in analysis, this approach may have introduced selection bias by systematically excluding qualitative research published in local languages from countries represented in our sample, such as Iran, China, Brazil, and Chile. Studies published in English from these regions may reflect authors with greater access to international funding or collaborative networks, potentially overlooking culturally specific perceptions, barriers, and care practices documented in non-English journals. This limitation may affect the transferability of our findings to non-English-speaking settings and underscores the need for caution when applying these results globally. Future multilingual syntheses that include locally published qualitative work are essential to enhance global representativeness and capture the full spectrum of evolving oral care dynamics. Furthermore, this systematic review and meta-synthesis was retrospective in design, synthesizing previously published studies rather than prospectively collecting primary data. According to CASP and ENTREQ guidelines, prospective designs are considered an indicator of methodological rigor, as they allow for a priori specification of synthesis methods and reduce the risk of selective reporting. The retrospective nature of this synthesis means that the scope and quality of findings are constrained by the methodological decisions, population characteristics, and contextual factors of the original studies, and emerging themes could not be explored further through additional data collection. Future prospective qualitative evidence syntheses, including living systematic reviews that iteratively update findings as new evidence emerges, would enhance confidence in the evolving themes identified here. Although the included studies exhibited heterogeneity in methodological quality and contexts—ranging from community-dwelling to institutionalized settings—this diversity enriched the interpretive breadth, allowing for a nuanced understanding of evolving oral care dynamics and highlighting avenues for standardized quality assessments in subsequent reviews. Additionally, the geographic concentration of studies in high-income European countries, as detailed in Supplement S5 and discussed above, limits the generalizability of findings, particularly for financial and systemic barrier themes that are contingent on health system structures. The reliance on published peer-reviewed literature, while ensuring rigor, might exclude emerging grey literature or unpublished findings, yet this selective scope facilitated a focused synthesis on established evidence, paving the way for integrative reviews incorporating diverse data sources to broaden perspectives. Finally, the interpretive nature of meta-synthesis introduces potential researcher bias in theme development, but rigorous team-based reflexivity and adherence to ENTREQ guidelines mitigated this, fostering trustworthy insights and encouraging replicative studies to validate and expand our themes.

Conclusion

Beyond the specific thematic findings reported above, this meta-synthesis offers a higher-level interpretive insight: oral health in older adulthood represents a site where structural ageism, fragmented health systems, and the subjective experience of bodily decline converge. The recurrent finding that oral health problems are normalized as “inevitable” consequences of aging is not merely a cognitive bias but reflects a broader societal failure to recognize oral health as a fundamental component of dignity and quality of life in later years. This epistemic injustice—wherein the oral health needs of older adults are systematically minimized—is perpetuated across all levels of the Socio-Ecological Model, from individual fatalism through institutional deprioritization to policy-level exclusion from universal health coverage frameworks. Addressing oral health inequities in aging populations therefore requires not only practical interventions such as interprofessional collaboration and education (Theme 3) but also a fundamental reconceptualization of oral care as a human rights issue integral to aging with dignity.

The conceptual model developed through this synthesis captures this reconceptualization by illustrating that oral care in older adults is not a static set of practices but an adaptive spiral in which meaning-making, barriers, facilitators, and quality-of-life outcomes continuously interact across the life course, health systems, and care trajectories. Breaking negative cycles—where fatalistic beliefs lead to care avoidance, which worsens oral health, which reinforces fatalism—requires multilevel interventions that simultaneously target individual beliefs, interpersonal support, organizational protocols, community resources, and policy structures. As global demographics continue to age, these findings advocate for integrated interprofessional models that address financial and accessibility gaps, fostering equitable oral care systems resilient to frailty and cognitive challenges. Future research should explore digital interventions and longitudinal designs to track attitude evolutions, and multilingual syntheses to ensure global representativeness, ensuring that oral care evolves in tandem with societal needs and technological advancements for a healthier aging society.

Authors' contributions

A.N., A.R., and N.F.A.: conception or design of the work. M.P., Z.A., and S.N.: literature review, quality assessment, data extraction, data analysis. A.R., N.F.A., and M.P.: quality assessment, interpretation, and drafting of the manuscript. All authors: critically reviewing and editing the manuscript. All authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

AI Declarations

The authors declare that no generative or large language model was used to generate the content of this manuscript. AI tools were only used for minor language and grammar checking, under the authors’ supervision. All ideas, analyses, and references are entirely the authors’ own work.