Across LTC settings, treatment needs and functional impairments remain high despite increasing dentition retention. In a Canadian national LTC survey (32 LTCF, n = 559), 79.6% of dentate residents had moderate or severe gingival inflammation in at least one tooth, 43.2% of edentulous residents had poor denture hygiene, and 9% of all residents required urgent dental treatment [5]. In five Austrian LTCFs, denture shortcomings, such as insufficient mandibular denture retention, were reported in 56.0% of lower dentures and chewing problems in 26.7% of denture wearers. Furthermore, 57.1% of dissatisfied denture wearers could not afford to replace their dentures, underscoring the socioeconomic barriers to dental care for LTC residents [6]. In Canadian LTCFs, although tooth retention has improved markedly over ten years, with dentate residents increasing from 56% to 76% and edentulism decreasing from 44% to 24%, new residents had higher dental treatment needs. Dental hygiene treatment needs surged from 43% to 69%, reaching 80% among newly admitted residents, signaling a shift from acute to preventive care and an increasingly dentate resident population [7]. Clinically estimated hyposalivation was also common, with a reported prevalence of 77% among LTCF residents in Finland. This was associated with higher odds of periodontitis (odds ratio [OR] 4.1), lip lesions (OR 2.5), and root caries (OR 1.3) [8]. Microbiome analyses among dentate LTC residents demonstrated a progressive shift toward dysbiotic oral microbiomes with an increasing oral disease burden [9].

A study of 14 Brazilian LTCFs reported that masticatory impairment was associated with adverse outcomes, including mortality and poor masticatory performance, and predicted all-cause mortality (hazard ratio 1.52) after adjustment [10]. Dysphagia risk was associated with dental and salivary factors among three Brazilian LTCFs, and xerostomia symptoms were associated with dysphagia (prevalence ratios 1.52, 2.86) [11]. A study conducted in nine LTCFs in Japan found that prospective evidence links routine oral assessment scores to better respiratory outcomes. Each 1-point increase in the Oral Assessment Guide (OAG) total scores, indicating poorer oral condition, was associated with a significantly higher risk of pneumonia (adjusted OR 2.29, 95% confidence interval [CI] 1.27-4.14) over 12 months [12]. In a six-month multicenter cohort (31 facilities; n = 1,785), the incidence rates of pneumonia and acute viral respiratory infection (AVRI) were 4.1% and 1.6%, respectively. Furthermore, dysphagia and malnutrition independently predicted pneumonia, while dry mouth and halitosis predicted AVRI [13]. Oral frailty and depressive symptoms have been proven to be associated, suggesting bidirectional interactions between oral dysfunction, mental health, and overall frailty trajectories in older adults [14]. Interventional studies further supported these findings, with a randomized trial demonstrating that combined oral functional exercise and psychological support improved oral frailty while concurrently reducing anxiety and depression in older adults [15]. Together, these findings indicate that oral conditions influence systemic vulnerability through nutritional, functional, and psychosocial pathways.

Oral symptoms in individuals receiving LTC in Helsinki (n = 2,401) showed consistent associations with malnutrition, lower body mass index, poorer physical function, and poorer perceived health-related quality of life after adjustment [16].

Facility leaders perceived a low organizational priority for oral care and cancer screening; limited resident, family, and staff knowledge; regulatory pressures; insurance barriers; and competing demands [17]. In Manitoba, Canada, dentists’ participation in LTC was found to be limited, with only 26.2% providing dental care to LTC residents; they cited barriers such as limited time (60%), lack of invitation from LTCFs (53%), and inadequate equipment (42.6%) [18]. Institutional ethnography across two LTCFs in Canada revealed that frontline oral care was discretionary and weakly guided by institutional protocols. Healthcare aides largely decided when and how to provide oral care based on personal experience rather than standardized instructions. Protocols focused narrowly on toothbrushing and denture cleaning, with little detail provided on disease indicators, referral criteria, or frequency of care [19].

A rapid review found that virtually none of the 59 COVID-19 LTC guidance documents screened contained actionable oral hygiene protocols [20]. Research on LTC faces gatekeeping, reliance on caregiver informants, and protocol burden, reflecting challenges that also affect quality improvement [21]. Population-level insurance claims data further indicate that the onset of the need for home care is associated with a reduction in dental services utilization, highlighting structural access barriers once functional decline occurs [22].

Personnel attitudes can be negative. For example, 60% of staff at three Finnish LTCFs reported reluctance to assist with daily oral hygiene, citing resident refusals and time pressure as reasons for this reluctance [23]. Cross-sectional surveys have shown gaps in oral-systemic knowledge among Portuguese LTC workers and New Zealand nursing graduates. Thus, there is an urgent need for updated oral-care protocols and enhanced training [24, 25].

Alzheimer's disease progression markedly increases behavioral barriers to oral care. The odds of oral care refusal and of dependence on full assistance in performing oral healthcare were shown to increase to 56.35 and 30.52, respectively, at the Functional Assessment Staging Tool stage 7 compared with stages 1-3, with plaque accumulation peaking at severe stages [26]. In Japan, denture non-use among LTC residents was common and independently associated with moderate dementia (OR 4.44, 95% CI 1.18–16.71) and impaired rinsing ability (OR 3.00, 95% CI 1.12–8.06), underscoring how cognitive and oral-motor decline limit denture use and oral-care engagement [27]. Video analyses from two Canadian LTCFs demonstrated that residents brushed for a mean of 60.3 seconds, with 66% omitting brushing of the lingual and occlusal surfaces. This underscores inadequate plaque control and the need for explicit coaching [28].

National Japanese data (170,874 residents) showed that enhanced oral care increased the odds of discharge to home (OR 1.07, 95% CI 1.02–1.12) [29]. Moreover, hygienist-led Oral Health Management (OHM) implemented across 25 LTCFs in 17 regions of Japan was associated with better eating function, expressed as twice the odds of maintaining/improving food form compared to those without OHM over one year (OR 2.01, 95% CI 1.03-3.90) [30]. However, a recent Cochrane review (6 randomized controlled trials; 6,244 participants) found insufficient evidence that professional oral care reduces the incidence of nursing home-acquired pneumonia, although low-certainty evidence suggested a 57% reduction in pneumonia-related mortality at 24 months (risk ratio 0.43, 95% CI 0.25–0.76) [31].

A 14-day quality improvement program implementing a standardized bedside oral-care protocol in a Mississippi LTCF improved staff knowledge (pre-post-test scores increased from 88.8% to 97.7%; p = 0.021) and resident oral health outcomes, as measured by the Oral Health Assessment Tool (p = 0.001). Evidence from a randomized clinical trial in a Swiss LTCF indicated that individualized, visually supported oral health instructions are associated with improved plaque control, denture cleanliness, and oral health-related quality of life among LTC residents, compared with standard verbal instruction alone [32]. Consistent checklist use and staff education led to better protocol adherence, supporting the effectiveness of structured nursing-led oral care models [33]. Recent qualitative evidence indicates that structured oral health assessment tools, such as the International Resident Assessment Instrument for long-term care facilities (interRAI LTCF), enable feasible, systematic oral health assessment by non-dental staff [34]. Interprofessional programs, such as Maine’s Oral Team-Based Initiative Vital Access to Education (MOTIVATE), can enhance staff confidence and increase the application of oral-care skills in nursing homes, leading to gains in knowledge and clinical competence [35]. A pragmatic cluster-randomized trial suggested that caregivers' use of digital tools such as SmartJournal may facilitate incremental improvements in oral hygiene among nursing home residents [36]. Promising expanded-practice hygienist models, such as the Kansas Extended Care Permit initiative, improved access but faced billing and sustainability barriers [37]. Upstream multidisciplinary community programs integrating exercise, oral instruction, and nutrition were found to improve oral diadochokinesis (i.e., motor function and coordination) and swallowing among community dwellers [38], underscoring the value of interprofessional educational initiatives.

Practical tools that nurses can use, such as the Oral Health Screening Tool for Nursing Personnel, have demonstrated good sensitivity (0.67 for nurses and 0.71 for caregivers) for natural teeth, dentures, and oral function categories, and adding simple referral rules increases sensitivity from 0.86 to 0.91 [39]. LTCFs that employ dental professionals rather than use private dentists as consultants were found to have higher facility income [40]. At the population level, dental care experience was associated with a 12.4% improvement in LTC dependency (adjusted OR 1.18) among 53,130 Korean LTC beneficiaries [41]. Furthermore, preventive dental visits were associated with lower cumulative LTC insurance costs in an 8-year cohort of 8,429 participants from the Japan Gerontological Evaluation Study, with a reported relative cost ratio of 0.82 (95% CI 0.71-0.95) [42].