*3.2.4 Cognitive and functional impairment, risk factors for oral care*

Although cognitive impairment has not yet met the diagnostic criteria for dementia, people with mild cognitive impairment have been found to have poorer oral hygiene, a high gingivitis score, and more impaired root surfaces than those with intact cognition [33]. Tooth loss was reported to be independently associated with the development of cognitive impairment among older people living in the community. This finding supports the hypothesis that tooth loss may be a predictor or risk factor for cognitive decline [34].

Frail older patients in hospitals and long-term care homes, who depend on others for oral hygiene care, are at risk of poor health due to impaired functional and cognitive abilities. They are at high risk for tooth decay because foods containing sugar and refined carbohydrates remain in contact with the teeth for long periods between brushing [35].

### *3.2.5 Xerostomia: risk of caries and chronic periodontitis*

One of the oral conditions that affect the quality of life of the older adults is xerostomia. A high prevalence of xerostomia and hypofunction of the salivary glands has been found in vulnerable older people. Etiologic factors include polypharmacy (especially with antihypertensives, antidepressants, and antipsychotics), poor general health, female sex, and advanced age. People with dry mouth require preventive measures against the consequences of the absence of saliva, including tooth decay, periodontal disease, and candidiasis [36].

### *3.2.6 Depression is a risk for oral care*

Older people with depressive symptoms are less likely to make self-care, including oral hygiene and preventive dental care, a priority - many older people experience a chronic course of depressive symptoms. Depression in old age and depressive symptoms may be associated with poor nutrition, decreased salivary flow, distorted taste, increased oral lactobacillus counts, dental caries, advanced periodontal disease, and oral discomfort [37]. Older people with tooth loss were shown to be at increased risk of depressive symptoms [38].

#### *3.2.7 Risk factors for oral cancer*

Oral cancer poses a great threat to the health of adults and the older adults in highand low-income countries [36]. Oral cavity cancer can be easily prevented and treated if it is diagnosed early [39].

It includes cancer of the lip, oral cavity, and pharynx, and is the eighth most common cancer worldwide. Incidence and mortality rates are higher in men than in women. The prevalence increases with advancing age, and oral cancer is of particular concern among people over 65 years of age. Variations between countries are attributable to differences in risk profiles and the availability and accessibility of health services, among others [36].

Oropharyngeal cancers, a subset of head and neck cancers, have the human papillomavirus (HPV) as a major risk factor. Modifiable lifestyle behaviors, such as smoking and alcohol use, are implicated in the etiology of oral cavity cancers. Previous studies demonstrated that smoking was associated with a 2-fold increased likelihood

of oral cavity cancers among those who had never drunk alcohol and binge drinking was associated with a higher likelihood of oral cancers among those who never had they had smoked [40].

Other risk factors are the consumption of betel quid and areca nuts, poor oral hygiene, poor nutrition, a weakened immune system, genetic and immune predisposition. In most cases, it is preceded by visible painless changes in the mouth known as precancerous lesions, such as a whitish (leukoplakia) or reddish (erythroplastic) discoloration of the mucosa, an ulcer, or a swelling. The self-examination of the mouth serves for prevention and early detection. It is an easy to perform, non-invasive method, and low-cost [39].
