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SUPPLEMENTARY DATA

Appendix 1

Introduction

AP: A recent 10-year review found a 93.5% increase in the number of hospitalized elderly patients diagnosed with AP while other types of pneumonia in the elderly decreased [1].

We have recently found that OD is a highly prevalent and independent risk factor in most older patients with community-acquired pneumonia (CAP) [17,18]. Other studies found that oropharyngeal aspiration was associated with a 5.6-7-fold increase in risk for pneumonia [2] and that OD was a major risk factor for readmission for pneumonia in frail elderly patients [6].



Oral health: The health status of older patients is often affected by concomitant chronic diseases which increase the risk of mortality. [8]. Diabetes contributes to, and is negatively impacted by, poor oral health [3]. Furthermore, periodontal pathogens can induce inflammation not only locally but at distant sites [4] and increase the risk of cardiovascular disease [5].
Methods

Oral examinations

The assessment of the OHI-S, periodontal diseases and caries was only performed in dentate patients. Oral examinations were conducted with the aid of mouth mirrors (Proclínic SA, Hospitalet del Llobregat, Spain) and periodontal probes (PCP-UNC 15®, Hu-Friedy, Chicago, IL, USA). The clinical examination included measurements of clinical attachment loss (CAL), probing pocket depth (PPD), bleeding on probing (BOP), and tooth mobility. We explored two buccal sites per tooth (mesio-buccal and mid-buccal), excluding third molars.

Oral hygiene habits questionnaire was answered by 39 patients.
EAT-10

The EAT-10 (Eating Assessment Tool) [9] is a symptom-specific questionnaire for dysphagia. It is composed of 10 questions which evaluate specific OD symptoms. The maximum score per question is 4 points; patients who score more than 3 points are at risk of OD and further assessment is needed. This questionnaire was given to all the patients as an OD screening.


VFS

Performance: patients were studied during the deglutition of series of 5 mL, 10 mL and 20 mL boluses with nectar, liquid, and pudding viscosity using a previously described algorithm for VFS studies [7]. Liquid viscosity was obtained by mixing 1:1 mineral water and the X-ray contrast Gastrografin (Berlimed SA, Madrid, Spain) at room temperature; nectar viscosity, by adding 2.4g of thickener Resource ThickenUp Clear (Nestlé Healthcare Nutrition, Vevey, Switzerland) to liquid solution, and pudding by adding 5.4 g of the thickener [9]. VFS signs of impaired safety or efficacy of deglutition were diagnosed according to accepted definitions [10,6].
Results

Chewing capacity: 20/50 patients with OD used dentures. These were edentulous patients that used complete dentures to eat with. Up to 9/50 patients needed dietary adjustments for impaired chewing. Up to 38/50 patients with OD presented alterations in oral phase. Taken together, these results suggest that prevalence of chewing difficulties among our patients with OD was high.
Diseases: Patients with OD presented many comorbidities (n=50): 43 presented cardiovascular diseases (37, arterial hypertension; 16, arrhythmia; 6, ischemic heart disease); 41, central nervous system; 26, metabolic; 23, musculoskeletal; 21, respiratory; 20, uro-genital; 19, gastrointestinal; 19, endocrinal (14, diabetes mellitus II); 13, ophthalmologic; 10, otorhinolaryngological; 9, hepatic and 4, skin diseases.
Medication: patients with OD (n=50) took several drugs for cardiovascular (43) and nervous system (38) diseases, thrombosis (26), gastro-oesophageal reflux disease (proton pump inhibitors) (40), and diabetes (8, oral hypoglycaemic and 2, insulin). In addition, 17 patients took sedatives and 18 patients received medication for depression; 6, for epilepsy; 4, for Parkinson; 1, for dizziness and 1, for dementia with potential effects on swallow response.
Penetration-aspiration severity: Penetration into the laryngeal vestibule during the pharyngeal phase (Rosenbek level 3-5) was the most prevalent cause of unsafe deglutition and was observed in 24/44 of patients when swallowing liquid boluses according to our VFS protocols [11]. Increasing viscosity to nectar reduced prevalence to 12/50 , and further increase to pudding viscosity reduced prevalence to 5/50 (p=0.002). Aspirations (Rosenbek 6-8) were present in 6/44 patients during liquid series, 2/50 patients at nectar and 1/50 patient during pudding viscosity (p<0.05) [11]. However, oral residue was present in 5/44 patients during liquid series, 5/50 patients during nectar series and 11/50 patients during pudding series. Pharyngeal residue was observed in 6/44 patients during liquid series and 11/50 patients during both nectar and pudding viscosity series.

Appendix 2
(2/50)
(19/50)
(2/50)
(2/50)

(2/50)
(6/50)

(4/50)
26%
(13/50)



Figure 2. Safety of swallow among older patients with oropharyngeal dysphagia: prevalence of patients with several levels of videofluoroscopic signs of impaired safety of swallow according to the Rosenbek Penetration-Aspiration Scale [11].

Appendix 3


ORAL HEALTH

 

 

 













 

OD Patients

Controls

P-value

N

50

15

 

Age

79.7±6.64

77.09±4.51

0.1922

Edentulism

40% (20/50)

6.7% (1/15)

0.0249

nº teeth (dentate patients)

17±8.3

18.1±8.8

0.5123

OHI-S

3.86±1.5

3.25±1.35

0.2869

Oral Health Status




 

 

Health

0% (0/30)

7.14%(1/14)

0.4375

Gingivitis

6.67% (2/30)

0% (0/14)

1

Periodontitis

93.3% (28/30)

92.86% (13/14)

1

MP

20% (6/30)

50% (7/14)

0.0821

MOP

36.7% (11/30)

21.43% (3/14)

0.3133

SP

36.7% (11/30)

21.43% (3/14)

0.3133

Caries

59.3% (16/27)

21.43% (3/14)

0.0456

% Teeth

23.05±0.16

7.63±3.5

0.022

% Surface (CI)

8.2±5.13

2.71±2.44

0.1032

Clinical assessment







 

Charlson

2.98±1.83

1.4±1.12

0.0023

EAT-10

10.5±7.6

0.23±0.6

<0.0001

EAT-10 ≥3

84% (42/50)

0% (0/30)

<0.0001


Table 1. Oral health status between elderly patients with OD and elderly controls (MP: mild periodontitis; MOP: moderate periodontitis; SP: severe periodontitis). OHI-S and prevalence of periodontal diseases and caries results are based on the dentate patients.


Appendix 4 (Additional references from appendix 1 not in the main text (not in bold))

[1] Baine WB, Yu W, Summe JP. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia, 1991-1998. Am J Public Health 2001; 91(7):1121-3.


[2] Schmidt J, Holas M, Halvorson K, Reding M. Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia 1994; 9:7–11.
[3] Yoon, A. J., B. Cheng, et al. (2012). "Inflammatory biomarkers in saliva: Assessing the strength of association of diabetes mellitus and periodontal status with the oral inflammatory burden." Journal of Clinical Periodontology 39(5): 434-440.
[4] Hayashi, C., C. V. Gudino, et al. (2010). "Pathogen-induced inflammation at sites distant from oral infection: Bacterial persistence and induction of cell-specific innate immune inflammatory pathways." Molecular Oral Microbiology 25(5): 305-316.
[5] de Oliveira, C, Watt R, Hamer M. Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey. BMJ 2010; 340 (Clinical research ed.).
[6] Clavé P, de Kraa M, Arreola V et al. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Aliment Pharmacol Ther 2006; 1; 24(9):1385-94.


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