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 .
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  and that OD was a major risk factor for readmission for pneumonia in frail elderly patients .
Oral health: The health status of older patients is often affected by concomitant chronic diseases which increase the risk of mortality. . Diabetes contributes to, and is negatively impacted by, poor oral health . Furthermore, periodontal pathogens can induce inflammation not only locally but at distant sites  and increase the risk of cardiovascular disease .
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.
The EAT-10 (Eating Assessment Tool)  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.
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 . 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 . VFS signs of impaired safety or efficacy of deglutition were diagnosed according to accepted definitions [10,6].
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 . 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) . 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)
(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 .
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))
 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.
 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.
 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.
 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.
 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.).
 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.