Introduction: Understanding and anticipating oral health deterioration in older adults requires more than describing their current oral and general health. Risk factors arising from oral, systemic and social domains strongly influence disease progression, care complexity and the ability to maintain function over time. We aimed to establish a framework for staging and grading oral health and disease in older adults, with grading systematically assessing and describing determinants of oral health deterioration. The developed framework is intended to support care planning, education, research and health-service policy.

Methods: Eight reviews examining oral, systemic and social risk factors for worsening oral health in older adults informed framework development. Additional existing reviews were also considered. A 2.5-day international workshop involving 31 experts from 13 countries was conducted, during which structured subgroup discussions and Delphi-style anonymous voting were used to refine and agree on the framework. Consensus was predefined at 75% agreement, and that was subsequently reached for all statements in a single voting round. The current paper presents the grading aspect of the developed framework; it should be used jointly with the paper on staging oral health in older adults.

Results: Grading encompasses three levels of risk factors: (1) oral-level factors such as dental caries risk, periodontitis risk and risks associated with the maintenance of existing dental prostheses; (2) systemic-level factors including xerostomia, multimorbidity, polypharmacy and nutritional aspects and (3) social-level factors such as social status and social support. Together, these domains reflect the likelihood of oral health deterioration, the intensity and frequency of required supportive care and the potential complexity of clinical management. Grading complements staging-which describes the current oral health status-by identifying the underlying risks shaping each older adult's oral health trajectory.

Conclusion: Grading provides a structured, evidence-based method for assessing risk and care complexity in older adults. When combined with staging, it should enable clinicians, caregivers and policymakers to classify cases comprehensively, tailor preventive and supportive interventions, and inform resource planning, surveillance, research and education. Future work should focus on validating, disseminating and implementing the framework across diverse care settings.