Oral frailty and heart failure: a screening challenge in the practice and in hospital

Chronic heart failure (CHF) is not limited to the cardiovascular system; it is frequently accompanied by malnutrition, sarcopenia, and impaired oral function. However, while oral frailty (OF) — this cumulative decline in masticatory structures and functions — is documented in community-dwelling older adults, data are lacking regarding patients hospitalised for CHF. These patients are nevertheless vulnerable: treatments with diuretics, ACE inhibitors, or beta-blockers often induce severe xerostomia, while reduced physical capacities and nutritional restrictions complicate the maintenance of optimal oral function.

The study presented here specifically addresses this gap. Conducted on 343 elderly hospitalised patients in Mianyang (China) between May and November 2025, it aimed to establish the prevalence of oral frailty in this specific context and to identify its clinical determinants. The objective was to construct and validate a visual prediction model (nomogram) to enable the early identification of high-risk patients. The tested hypothesis is based on the significant influence of factors such as advanced age, smoking, physical frailty, malnutrition, polypharmacy and oral health self-efficacy on the onset of this syndrome.

Study design and population

This cross-sectional survey was conducted using convenience sampling among 343 hospitalised patients (out of 350 initially recruited, representing a 98% response rate) at a tertiary care centre in Mianyang, China, between May and November 2025. The participants, aged 60 years or older, were all diagnosed with chronic heart failure (CHF) and presented a stable clinical condition allowing for assessment.

Oral frailty assessment

The primary endpoint, oral frailty, was measured using the OFI-8 (Oral Frailty Index-8). A cut-off score ≥ 4 was used to identify clinical cases, ensuring a sensitivity and specificity of 80%.

Analysed variables and measurement tools

The study explored several clinical and psychosocial dimensions using validated tools:

• Clinical indicators: Demographic data, indicators related to cardiac function, duration of CHF, polypharmacy, xerostomia and chewing difficulties.
• Systemic frailty and nutrition: Fried Frailty Phenotype (FP) and Mini Nutritional Assessment–Short Form (MNA-SF).
• Psychological dimensions: Geriatric Depression Scale–Short Form (GDS-SF) and oral health-related self-efficacy scale (GSEOH).
• Quality of life: Geriatric Oral Health Assessment Index (GOHAI).

Statistical analyses

Researchers used logistic regression to identify independent predictive factors. A visual prediction model (nomogram) was developed in R. The model's performance was rigorously tested using a ROC curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, internal validation via Bootstrap (C-index) and a decision curve analysis (DCA) to measure the net clinical benefit.

An alarming prevalence of oral frailty

Among the 343 elderly patients hospitalised for chronic heart failure (CHF) included in the study (response rate of 98.0%), 176 cases of oral frailty were identified. This represents a prevalence of 51.3%, confirming that more than one in two patients suffering from CHF presents a significant impairment of oral functions.

Determinants of oral frailty (Logistic regression analysis)

Multivariate analysis identified six statistically significant independent predictors (p < 0.05). The risk of oral frailty is closely associated with the following factors:

Performance and validation of the predictive model

The prediction model (nomogram) developed from these variables demonstrates robust metrological qualities:

• Discrimination: The area under the curve (AUC) is 0.857, indicating the model's excellent ability to distinguish at-risk patients.
• Calibration: The Hosmer-Lemeshow test (χ² = 4.696, p = 0.790) shows a satisfactory fit between the predicted probabilities and the actual observations.
• Internal validation: After Bootstrap resampling, the corrected concordance index (C-index) remains at 0.845.

Decision curve analysis (DCA) confirms that the use of this model provides a high net clinical benefit for early screening in a hospital setting.

Oral frailty and heart failure: a major clinical link

The results of this cross-sectional study conducted on 343 hospitalised patients reveal an alarming prevalence of oral frailty (51.3%). This figure highlights that more than half of elderly patients suffering from chronic heart failure (CHF) present a cumulative decline in oral functions. Logistic regression analysis identifies clear predictors: advanced age, smoking, physical frailty, malnutrition (MNA-SF < 11), polypharmacy, and low oral health self-efficacy. The link with polypharmacy is particularly critical for the practitioner, as classic CHF treatments (diuretics, angiotensin-converting enzyme inhibitors, beta-blockers) exacerbate xerostomia, a driver of functional decline.

Model accuracy and study limitations

The developed predictive model (nomogram) displays excellent discrimination with an area under the curve (AUC) of 0.857. This performance suggests high reliability for early screening in a hospital setting. However, the study presents methodological limitations: convenience sampling in a single hospital centre in Mianyang and a cross-sectional design that prevents establishing a direct causal link between ICC and oral frailty. Furthermore, the use of self-administered questionnaires may introduce reporting bias, although the tools used (OFI-8, GOHAI) are scientifically validated.

Implications for daily practice

This study demonstrates that oral frailty is not a clinical isolate but a component of the overall frailty spectrum. For the dental surgeon, these results mean that the follow-up of a cardiac patient cannot be limited to the management of infectious risk. The systematic assessment of masticatory function and nutritional status is essential to prevent irreversible deterioration. The potential reversibility of oral frailty in the early stages offers a concrete window for therapeutic intervention to improve the overall prognosis of these frail patients.

Summary of results

This cross-sectional study conducted on 343 hospitalised patients reveals a prevalence of oral frailty of 51.3% among seniors with chronic heart failure (CHF). The developed predictive model (AUC 0.857) identifies advanced age (≥ 80 years), smoking, malnutrition (MNA-SF < 11), physical frailty and polypharmacy as major clinical predictors of this functional decline.

In practical terms, for the practitioner:

• Targeted screening: Integrate the OFI-8 index into the assessment of your cardiac patients over 80 years of age, as the risk of oral frailty is doubled in this specific population.
• Iatrogenic vigilance: In cases of polypharmacy (diuretics, beta-blockers), systematically assess xerostomia and hyposalivation, aggravating factors of masticatory function loss in CHF patients.
• Multidisciplinary coordination: In the presence of oral frailty, request a nutritional assessment and an evaluation of physical frailty, as these three components are intrinsically linked in the overall health prognosis of the elderly patient.

Technical glossary of the study

Chronic Heart Failure (CHF): A common chronic condition in the elderly, often associated in this study with malnutrition, sarcopenia and dysphagia.

Oral Frailty (OF): Cumulative age-related decline of oral structures and functions, primarily manifested by tooth loss, poor oral hygiene and impaired masticatory function.

OFI-8 (Oral Frailty Index-8): Oral function assessment index used to screen for functional decline and identify hospitalised patients at high risk of frailty.

Frailty Phenotype (FP): Clinical assessment model used to quantify overall physical frailty based on physical capacity and energy expenditure criteria.

MNA-SF (Mini Nutritional Assessment–Short Form): Rapid screening tool used to assess nutritional status and identify malnutrition in elderly patients.

GOHAI (Geriatric Oral Health Assessment Index): Multidimensional index assessing the impact of oral health on quality of life across physical, psychosocial and pain dimensions.

Polypharmacy: Concomitant use of multiple medications, identified here as a significant predictive factor associated with the prevalence of oral frailty.

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