Walter J. Loesche

Predictors of aspiration pneumonia: how important is dysphagia?

Abstract. Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.

Periodontal Disease as a Specific, albeit Chronic, Infection: Diagnosis and Treatment

SUMMARY Periodontal disease is perhaps the most common chronic infection in adults. Evidence has been accumulating for the past 30 years which indicates that almost all forms of periodontal disease are chronic but specific bacterial infections due to the overgrowth in the dental plaque of a finite number of mostly anaerobic species such as Porphyromonas gingivalis, Bacteroides forsythus, and Treponema denticola. The success of traditional debridement procedures and/or antimicrobial agents in improving periodontal health can be associated with the reduction in levels of these anaerobes in the dental plaque. These findings suggest that patients and clinicians have a choice in the treatment of this overgrowth, either a debridement and surgery approach or a debridement and antimicrobial treatment approach. However, the antimicrobial approach, while supported by a wealth of scientific evidence, goes contrary to centuries of dental teaching that states that periodontal disease results from a “dirty mouth.” If periodontal disease is demonstrated to be a risk factor for cardiovascular disease and stroke, it will be a modifiable risk factor since periodontal disease can be prevented and treated. Since the antimicrobial approach may be as effective as a surgical approach in the restoration and maintenance of a periodontally healthy dentition, this would give a cardiac or stroke patient and his or her physician a choice in the implementation of treatment seeking to improve the patients periodontal condition so as to reduce and/or delay future cardiovascular events.

Aspiration Pneumonia: Dental and Oral Risk Factors in an Older Veteran Population

OBJECTIVES: To investigate the importance of medical and dental factors in aspiration pneumonia in an older veteran population.

The predominant cultivable flora of tooth surface plaque removed from institutionalized subjects

Sunnnary-Tooth surface plaque was removed from 11 institutional~ed individuats and cultured on agar plates in an anaerobic chamber. The recovery of organisms on a dilute trypticase yeast extract medium (MMIO), incubated anaerobically, averaged 33 & 26 per cent of the microscopic count. Growth on MMlO, under aerobicconditions averaged 8 i: 5 per cent. The anaerobe to aerobe recovery ratio on medium MM10 was about 4. Six hundred and seventy-one isoiates grew on subculture and were partially characterized. About half the isolates were not capable of lowering the pH in glucose broth below 5 * 5. Streptococci accounted for about 38 per cent of the isolates and were found in each subject. A sub-group of 15 strains grew in 40 per cent bile, formed NH3 from arginine, fermented salicin, but not inulin. These isolates possessed characteristics of Streptococcus sang& and Streptococcus mitis. Various Actinomyces species comprised about 14 per cent and Clo~tr~iam species accounted for 8 per cent of the cultivable flora. Bacteroides melaninogenicus, Fusobacterium species, and Veillonella species each were about 6 per cent of the isolates. The overall character of these plaque isolates suggested that a gingival crevice microflora containing several amino-acid fermenting species had colonized the tooth surfaces. These organisms would not be expected to produce a plaque capable of decalcifying enamel, which might explain why these subjects had a low caries experience.

Functional units, chewing, swallowing, and food avoidance among the elderly

PURPOSE The number of teeth in the dentition was compared with the number and types of dental functional units (opposing tooth pairs) to correlate the number of functional units with complaints about chewing and swallowing in the elderly. MATERIAL AND METHODS Complaints of oral pharyngeal function and food avoidance practices were compared with the number and types of functional units. A convenience sample of 602 elderly subjects (468 men, 134 women, mean age 70 years) were interviewed and examined dentally. RESULTS Functional unit measures, which included functional arrangement of the teeth and the number and type of teeth present, were found to be more discriminatory and descriptive of masticatory potential than the more number of teeth. Elderly persons (> or = 60 years of age) with reduced numbers of functional units tended to report difficulty chewing, avoidance of stringy foods (including meat), crunchy foods (including vegetables), and dry solid foods (including breads), and difficulty in swallowing. Removable prostheses did not appear to prevent these consequences and, at least in this elderly population, did not appear to be equivalent to natural teeth in terms of masticatory potential. CONCLUSIONS It is possible that compromised dental function results in the swallowing of poorly chewed food, food avoidance patterns, dietary inadequacies, and systemic changes favoring illness, reduced vigor, debilitation, and shortened life expectancy. Emphasis should be placed on maintaining natural teeth whenever possible.

Xerostomia, Xerogenic Medications and Food Avoidances in Selected Geriatric Groups

OBJECTIVE: To study the relationship between complaints of xerostomia and salivary performance and food avoidances in four geriatric groups chosen to reflect a broad spectrum of individuals along the health‐disease continuum. To determine whether xerogenic medications taken by these individuals could be associated with either complaints of xerostomia or with food avoidances.

Growth and acid tolerance of human dental plaque bacteria

Pure cultures of representative strains of cariogenic and non-cariogenic plaque bacteria were assessed for their ability to initiate and maintain growth in broths, adjusted to initial pH levels of 7.0, 5.5 or 5.0, and to produce lactic acid from sucrose or glucose in resting-cell suspensions at pH 6.5, 5.0, 4.5 and 4.0. Streptococcus mutans, Lactobacillus casei and Streptococcus faecalis showed greater acid tolerance than strains of Streptococcus sanguis, Streptococcus salivarius, Streptococcus mitis and Actinomyces viscosus. For all species, growth initiation in broth was more acid sensitive than lactic-acid production in resting-cell suspensions. These data confirm and extend previous observations that the species of plaque bacteria most closely associated with the initiation or progression of dental caries are more aciduric than non-cariogenic species.

Dental Flossing and Interproximal Caries: a Systematic Review

Our aim was to assess, systematically, the effect of flossing on interproximal caries risk. Six trials involving 808 subjects, ages 4 to 13 years, were identified. There were significant study-to-study differences and a moderate to large potential for bias. Professional flossing performed on school days for 1.7 years on predominantly primary teeth in children was associated with a 40% caries risk reduction (relative risk, 0.60; 95% confidence interval, 0.48–0.76; p-value, < 0.001). Both three-monthly professional flossing for 3 years (relative risk, 0.93; 95% confidence interval, 0.73–1.19; p-value, 0.32) and self-performed flossing in young adolescents for 2 years (relative risk, 1.01; 95% confidence interval, 0.85–1.20; p-value, 0.93) did not reduce caries risk. No flossing trials in adults or under unsupervised conditions could be identified. Professional flossing in children with low fluoride exposures is highly effective in reducing interproximal caries risk. These findings should be extrapolated to more typical floss-users with care, since self-flossing has failed to show an effect.

Effect of Sorbitol, Xylitol, and Xylitol/Sorbitol Chewing Gums on Dental Plaque

The effect of sorbitol (SOR), xylitol (XYL), and the mixture XYL/SOR in chewing gums on dental plaque was studied in three groups of 7 adults (mean age 22.5 years). A fourth group of habitual users of sucrose-containing gums was used as a control. The study involved a 2-week, no-gum period followed by the use of the polyol gums for 2 weeks (10 gums/day in 5 2-gum doses). The daily consumption of XYL and SOR in the XYL and SOR groups was 10.9 g, whereas in the XYL/SOR group, 8.5 and 2.4 g of these polyols were used per day. At the end of the gum period the acidogenic response of the 48-hour plaque was tested using a 10-ml mouthrinse containing the polyols (10% w/v) present in the experimental gums, followed by a 10-ml rinse of 10% (w/v) sucrose solution. The plaque of the subjects who used XYL and XYL/SOR gums showed a significantly better ability to resist pH drops induced by the sucrose rinse than the plaque in the SOR gum group. No changes in resting pH values were observed in the XYL and XYL/SOR groups, whereas the use of SOR gum was associated with significantly lower pH values. The amount of plaque decreased in the XYL/SOR (24.3%) and the XYL (29.4%) groups, but increased in the SOR (48.3%) group, the changes in the SOR group differing significantly from those found in the other groups. The plaque and saliva levels of Streptococcus mutans generally increased in the SOR group, but decreased in groups which used XYL.

Correlation between the BANA Test and Oral Malodor Parameters

The purpose of the present investigation was to test the association between the BANA test (Perioscan®, Oral-B), and oral malodor parameters. The subject population consisted of 52 Israeli adults, 43 of whom complained of oral malodor. Oral malodor measurements consisted of peak and steady-state volatile sulphide measurement by a portable sulphide monitor (Interscan Corp., model 1170), as well as organoleptic measurements of malodor from whole mouth, tongue, and saliva. Samples for the BANA test were obtained from four loci (shallow pocket, deep pocket, tongue dorsum, saliva); results were scored as negative (0), weak (1), or strong (2). BANA scores were significantly associated with odor-judge ratings, with the highest association obtained when BANA saliva scores and odor-judge saliva assessment were compared (r = 0.500; p < 0.001). BANA tests from the different loci were not significantly associated with sulphide monitor levels. Stepwise multiple-regression analysis of odor-judge measurements in terms of sulphide levels and average BANA scores showed that both log peak sulphide levels as well as BANA scores were significantly factored into the equations, yielding, in all cases, highly significant correlations (multiple r = 0.57, 0.50, and 0.59, respectively, with significance levels of 0.0001, 0.001, and < 0.0001, for whole mouth, tongue, and saliva malodor, respectively). The results suggest that the BANA scores are associated with a component of oral malodor which is independent of volatile sulphide measurements and suggest its use as an adjunct test to volatile sulphide measurement.