The role of salivary function on oropharyngeal colonization

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

Influence of Preoperative Oropharyngeal Microflora on the Occurrence of Postoperative Pneumonia and Survival in Patients Undergoing Esophagectomy for Esophageal Cancer

OBJECTIVE

The aim of this study was to clarify the correlation between oropharyngeal microflora and postoperative complications as well as long-term survival after esophagectomy.

BACKGROUND

Although the oral cavity is known to be a potential reservoir for pathogens, the influence of abnormal oropharyngeal microflora on the outcomes of patients undergoing esophagectomy remains unknown.

METHODS

This study included 675 patients who underwent esophagectomy between 2007 and 2014. Saliva samples from the oropharynx were collected 2 days before the operation. There were 442 patients with indigenous flora (Ind group) and 233 with allopatric flora. Among the patients with allopatric flora, 140 had antibiotic-sensitive microbes only (Allo-S group) while 93 had different types of antibiotic-resistant microbes (Allo-R group). We investigated the correlation between the types of oropharyngeal microflora and the incidence of postoperative complications as well as long-term outcomes.

RESULTS

Sixteen microbes could be cultivated from the saliva samples. The incidence of postoperative pneumonia in the Allo-S and Allo-R groups was significantly higher than in the Ind group (P < 0.001). In addition, acute respiratory distress syndrome was more often observed in the Allo-R group than in the other groups (P = 0.002). A significantly higher rate of antibiotic use and longer hospital stays were observed in the Allo-R group compared with the Ind group. Multivariate logistic regression analysis revealed that the presence of allopatric antibiotic-resistant microbes in the oropharynx was an independent risk factor for postoperative pneumonia (odds ratio, 3.93; 95% confidence interval, 2.41-6.42). The overall survival was significantly poorer in the Allo-R group than in the other groups.

CONCLUSIONS

Preoperative oropharyngeal culture is a simple and low-cost method that can predict both the occurrence of postoperative pneumonia and poor prognosis after esophagectomy.

Spontaneous and Dosing Route–related Lung Lesions in Beagle Dogs from Oral Gavage and Inhalation Toxicity Studies

This study was conducted to characterize lung microscopic lesions in control beagle dogs from inhalation and oral gavage toxicity studies, to determine differences associated with the route of administration, and to discuss distinguishing features from compound-induced lung lesions. Samples from 138 control dogs from oral gavage studies and 124 control dogs from inhalation (vehicle control) studies were evaluated microscopically. There was no significant sex-related difference in the incidence of all lesions. Perivascular mononuclear cell infiltration, centriacinar mixed cell infiltration, bronchopneumonia, subpleural septal fibrosis, and alveolar macrophage accumulation were the most common lesions. Aspiration pneumonia was more common in dogs from gavage studies, suggesting reflux after gavage dosing or accidental administration of test formulation as possible causes. Centriacinar mixed cell infiltration was more common in dogs from inhalation studies, suggesting mild irritation by the vehicles used. Vascular lesions, which included pulmonary arteriopathy and smooth muscle mineralization, were observed in a few animals. Some of the spontaneous lesions are similar to lesions induced by test compounds. Compared to spontaneous lesions, compound-induced lesions tend to be multifocal or diffuse, follow a pattern of distribution (e.g., centriacinar, perivascular, and interstitial), show a dose response in the incidence and severity, and may show cell-specific toxicity.

Sialometry: aspects of clinical interest

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mucus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration. Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glandular parenchyma by infectious processes, granulomatous diseases or autoimmune and inflammatory conditions (such as Sjogren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conventional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited. However, new alternatives have shown great perspective in the treatment of this disorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evaluation of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequences of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.

Oral health status in individuals with dementia living in special facilities

AIM

The aim of this review was to retrieve data describing the oral health status of individuals with dementia living in special facilities.

MATERIALS AND METHODS

A literature search on the MEDLINE database (Entrez PubMed) was performed. The literature search yielded 208 papers, of which seven publications were selected for evaluation.

RESULTS

From the available studies poorer oral hygiene, decreased saliva flow rates and a higher caries incidence were reported in individuals with dementia living in special facilities when compared with healthy individuals. Oral health problems were more pronounced in the severe stage of the disease.

CONCLUSIONS

There is limited scientific data describing the oral health status of individuals with dementia living in special facilities. However, available data indicate that individuals with dementia living in special facilities have more oral health problems than individuals without dementia.

Aspiration and infection in the elderly : epidemiology, diagnosis and management

Aspiration of the oropharyngeal or gastric contents by elderly persons often leads to lower respiratory tract infections, such as aspiration pneumonia or pneumonitis. The existence of dysphagia and aspiration in elderly patients are important factors in the occurrence of aspiration pneumonia, but are not sufficient to cause aspiration pneumonia in the absence of other risk factors. Salivary flow and swallowing can eliminate Gram-negative bacilli from the oropharynx in healthy persons. However, elderly persons may have diminished production of saliva as a result of medications and oral/dental disease, leading to poor oral hygiene and oropharyngeal colonisation with pathogenic organisms. When dysphagic patients aspirate pathogenic bacteria while swallowing food or liquids, they must also have decreased defences, such as impaired immunity or pulmonary clearance, in order to develop aspiration pneumonia.Elderly patients with cerebrovascular disease often have dysphagia that leads to an increased incidence of aspiration. It was previously reported that patients with silent cerebral infarction affecting the basal ganglia were more likely to experience subclinical aspiration and an increased incidence of pneumonia. Basal ganglia infarction leads to the impairment of dopamine metabolism and, as a consequence, a decrease of substance P in the glossopharyngeal nerve and sensory vagal nerves. Therefore, dysphagia and a decreased cough reflex may be induced by the impairment of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical agents which modulate dopamine metabolism may be able to improve swallowing and the cough reflex in patients with basal ganglia infarction. The main strategy for controlling aspiration and aspiration-related pulmonary infection in the elderly is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. Because aspiration pneumonia in the elderly is related to certain risk factors, including dysphagia and aspiration, effective preventive measures involve various approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and positioning.

Radiotherapy-induced salivary dysfunction

Dry mouth (xerostomia) is one of the most common complaints following radiation therapy (RT) for head and neck cancers. Notably, RT causes irreparable damage to salivary glands that increases the risk for severe and long-term oral and pharyngeal disorders. Several strategies in the treatment of head and neck cancers have been developed to prevent RT-induced salivary dysfunction while providing definitive oncologic therapy. These include salivary-sparing RT; cytoprotectants (such as amifostine); combination therapy of high-dose-rate intraoperative RT, external beam RT, plus a cytoprotectant; salivary gland surgical transfer; and gene therapy. Future research that incorporates biologic, pharmacologic, and technologic advancements that optimize therapeutic ratios and minimizes adverse oral sequelae is warranted.

The role of oral microbial colonization in ventilator-associated pneumonia

The present article reviews the association between microbial colonization of the oral cavity and the lungs in critically ill patients that develop ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) setting. The risk factors and microorganisms associated with VAP are presented. The role of oral colonization of VAP-associated pathogens (VAP-AP) in the development of VAP is examined. We explore the potential factors involved in oral colonization of VAP-AP, which are atypical bacteria for the oral cavity. Strategies for the prevention or moderation of oral colonization of VAP-AP have had limited success. We need a deeper understanding of the pathophysiology of VAP in order to reduce the morbidity, mortality, and cost from this common complication in ICU medicine and surgery.

Biochemical, immunological and enzymatic components of saliva in prolonged naso-gastric-fed elderly patients

BACKGROUND AND AIMS

We have previously shown that naso-gastric tube (NGT)-fed patients harbor pathogenic flora in their oropharynx. The purpose of this study was to examine comparatively the biochemical, immunological and enzymatic components of the saliva of these patients with that of orally-fed counterparts.

METHODS

The study group consisted of 19 elderly NGT-fed patients and 18 comparable patients on oral feeding. Unstimulated whole saliva was collected and analyzed according to accepted methods for sodium, potassium, chloride, uric acid, total protein, albumin, amylase, lysozyme, and immunoglobulins, IgM, IgG, IgA, as well as secretory IgA.

RESULTS

None of the above tested salivary components significantly differed between the two groups. Only uric acid levels were significantly lower (50%, p < 0.05) in NGT-fed patients.

CONCLUSIONS

Uric acid is the main antioxidant component of saliva and, as such, it may be related to pathogenic bacterial colonization of the oropharynx in NGT-fed patients, with the risk of aspiration pneumonia.

How can oral health care providers determine if patients have dry mouth?

BACKGROUND

Dentists recognize the importance of saliva in maintaining oral health and often are familiar with the clinical effects an insufficient salivary flow can have on oral tissues. A variety of medical conditions and medications can alter salivary secretion and composition. Typically, diagnosis of hyposalivation is made only after damage has occurred to the oral tissues.

OVERVIEW

The author describes a series of clinical steps that, if followed properly, may help in the early detection of salivary gland hypofunction and prevention of its severe complications. This four-step approach includes identifying a patient's chief complaint and the symptoms and duration of illness that brought the patient to the dentist, as well as any approaches the patient took to relieve symptoms; obtaining a medical history that includes a review of the body systems; performing a clinical evaluation that notes the patient's overall condition in addition to the health and functioning of the salivary glands and oral soft and hard tissues; and, when needed, conducting further diagnostic evaluations.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Oral health care providers will continue to face the challenges of treating new and recurrent carious lesions if the profession's approach to salivary hypofunction remains reactive rather than proactive. The recommendations in this article may enhance clinicians' awareness of the objective methods used to identify patients with salivary gland hypofunction or those at risk of developing it. It is hoped that early identification of asymptomatic patients at risk of developing hyposalivation, as well as symptomatic patients will lower the incidence and prevalence of dental caries and fungal infection in this population and ultimately enhance their quality of life.

Xerostomia and the geriatric patient

Saliva is essential for the preservation of oral-pharyngeal health, and disorders of salivary physiology are associated with numerous oral and pharyngeal problems, particularly in older people. Although salivary function is remarkably intact in healthy aging, medical problems, medications, and head and neck radiotherapy can cause salivary dysfunction and complaints of xerostomia among older people. Sjögren's syndrome, an autoimmune exocrinopathy, is the most common medical disease associated with salivary dysfunction. Medications with anticholinergic side effects will impair salivary output, and head and neck radiotherapy for cancer will cause permanent destruction of salivary glands. Treatments for salivary problems are based upon establishing a diagnosis, protecting oral and pharyngeal health, stimulating remaining glands, and replacing lost salivary fluids.

Oral clearance and pathogenic oropharyngeal colonization in the elderly

The elderly have an increased incidence of oropharyngeal colonization with respiratory pathogens, a well-known risk factor for the development of pneumonia. Changes in the oral milieu may occur secondary to decreased salivary production and abnormalities in swallowing. These abnormalities, common in the elderly, may result in impaired clearance of organisms, allowing pathogenic colonization. To test this hypothesis, we performed a prospective cross-sectional analysis of 75 elderly institutionalized patients and measured oral clearance using (99m)Tc-human serum albumin (HSA) administered to the oropharynx. Oropharyngeal cultures, salivary cell populations, elastase activity, and clinical parameters were measured simultaneously. Retention of radiolabel ranged from 100% to 2.3% over 120 min of observation. Clearance in the oropharynx was significantly decreased in those patients who had oropharyngeal colonization with gram-negative bacilli (GNB), Staphylococcus aureus (SA), or yeast compared with those demonstrating normal flora by 95% confidence intervals. Decreased clearance was also seen in patients on antidepressants by 95% confidence levels. The absolute number of salivary lymphocytes/ml and buccal cells/ml was increased in colonized patients versus noncolonized persons (mean +/- SEM, 128 x 10(3) +/- 49 x 10(3), 25.4 +/- 11.6 x 10(3)). Elastase activity was elevated in patients who had GNB compared with patients without GNB (mean +/- SEM, 10.6 nM +/- 5.7, versus 2.2 nM +/- 1.2, p = 0.036). We conclude that a decrease in salivary clearance of potentially pathogenic organisms may be a major risk factor for the development of colonization in the elderly.

Sensory and motor deficits in the elderly: impact on oral health

Hearing, vision, orthopedic, and speech disorders are the most common impairments in the elderly. Older adults experience other sensory impairments such as olfactory and gustatory dysfunction, as well as oral motor problems including difficulty with mastication, speech, and swallowing. These disorders can directly affect oral health and can impair dental treatment. Therefore, it is imperative that dental health practitioners be cognizant of these conditions and aware of the impact these conditions and their treatments can have on oral health and function. Dental professionals may need to use different communication techniques for patients with vision or hearing losses. Accommodations in the dental office and by dental professionals will help older patients who have sensory and/or motor impairments to preserve their oral health and function and receive dental treatments in a safe and efficacious manner. This paper reviews the most common causes of sensory and motor impairments and their implications for oral health care with treatment modification guidelines for the older patient.

Histatin 5 inhibits inflammatory cytokine induction from human gingival fibroblasts by Porphyromonas gingivalis

Porphyromonas gingivalis is a gram-negative rod associated with the progression of human periodontal disease. It has been demonstrated that outer-membrane proteins as well as lipopolysaccharides from P. gingivalis ATCC 53977 can induce interleukin 6 (IL-6) and IL-8 from the cells of the periodontium in vitro. But, they cannot induce IL-1 and tumor necrosis factor-alpha from the cells. In the present study, we studied the effects of salivary protein on cytokine induction from human gingival fibroblasts by P. gingivalis outer-membrane protein. Histatin 5 suppressed the IL-6 and IL-8 induction by P. gingivalis outer-membrane protein. This activity was more effective when outer-membrane protein was incubated with histatin 5 before addition to the cell culture. The present study indicates that histatin 5 restrains induction of inflammatory cytokines by periodontal pathogens and that histatin is one of the salivary proteins responsible for this activity.

Determination of variation of stimulated salivary flow rates

Salivary hypofunction is associated with oral and pharyngeal disorders and requires early diagnosis and intervention. Large variability in salivary flow rates within and between individuals has been reported, which has impaired the establishment of standard values. The objective of this study was to determine variations in stimulated parotid and submandibular flow rates over 6 hours and to define salivary hypofunction. Pooled mean, standard deviation, and coefficient of variation values for four collection time periods were obtained from 36 healthy males and females (18 young, ages 20-38; 18 older, ages 60-77). The results demonstrated 27-44% variation in salivary flow rates over time. Overall, there were no significant age or gender differences in variability between and within salivary flow rates at all collection time periods. The results suggest that a 45% range in salivary flow rates could be considered normal salivary variation, and values below 45% of normal levels could be used to define salivary hypofunction.

Implications of oral infections on systemic diseases in the institutionalized elderly with a special focus on pneumonia

Systemic infection in the elderly patient living in a chronic care setting presents a significant burden to the health care system. The extent to which oral organisms cause systemic infections through hematogenous dissemination in the institutionalized elderly is still unknown. A more likely and common route of systemic infection by oral microorganisms is through aspiration of oropharyngeal fluids containing oral pathogenic microorganisms, which colonize the lower respiratory tract and cause pneumonia. Respiratory pathogens emerge in the dental plaque of elderly patients with very poor oral hygiene and severe periodontal disease. In the chronic care setting, aspiration of oropharyngeal fluids contaminated with these bacteria occurs in patients with diminished host defenses, resulting in bacterial pneumonia. This is also a problem in intensive care units in the hospital setting. In one study, pre-rinsing with a 0.12% chlorhexidine gluconate mouthwash significantly lowered the mortality rate from postsurgical pneumonia in patients undergoing open heart surgery. Selective digestive decontamination, a technique involving the topical application of antimicrobials to reduce the risk of colonization of the respiratory tract, has been used to reduce the incidence of nosocomial pneumonia in the acute care setting of hospitals. This technique has not been employed in the nursing home setting. Whether improving oral hygiene would also lower the risk in either of these settings has not been studied. A number of obstacles must be overcome in designing studies to investigate the relationship between oral infections and lung infections in the institutionalized elderly. Ethical issues must be addressed, and full collaboration of the medical team is required. Future studies should establish whether reducing the risk for pneumonia in the institutionalized elderly is possible through improved oral health.

Geriatric oral health and its impact on eating

OBJECTIVE

Adequate food and fluid intake and nutritional health are requisites for sustaining life. The oral-pharyngeal region has evolved multiple, highly regulated processes to ensure that the intake, chewing, and swallowing of foods and beverages is maintained. The objective of this paper is to identify the independent and collective roles of oral health on eating in older people.

DESIGN

Research reports from peer-reviewed scientific journals. Hypothesis-driven research that objectively examined taste, smell, dental and oral mucosal health, dental prostheses, chewing, and swallowing in the context of aging.

DATA EXTRACTION AND SYNTHESIS

Data results were extracted independently by multiple observers. A qualitative synthesis of data results from independent studies was made in order to form conclusions regarding the role of oral health on eating in older people.

CONCLUSIONS

Many oral functions remain intact in healthy older adults. However, significant alterations arise from oral and systemic diseases and their treatments, and these may have a profound effect on eating, drinking, and the nutritional status of older individuals. The care of older persons with smell, taste, dental/alveolar, oral mucosal, chewing, and swallowing problems requires a multidisciplinary team of health care providers. Recognition of the interrelationship between oral, pharyngeal, and systemic physiological processes will help practitioners identify the etiology of these disorders and implement appropriate therapy.

The oral prevalence of aerobic and facultatively anaerobic gram-negative rods and yeasts in semi-recluse human vegetarians

Limited data exist on the oral ecology of vegetarians. Hence the dental and periodontal status, and the oral prevalence of aerobic and facultatively anaerobic Gram-negative rods (AGNR) and yeasts, were studied in 36 semi-recluse, vegetarian, Buddhist monks and nuns in Hong Kong. The oral prevalence of AGNR and yeasts was 61.1% and 33.3%. There was no correlation between the prevalence of AGNR and/or yeasts and the incidence of carious or filled teeth and the health status of the periodontium. Rather, the results of this study combined with those of previous studies suggest that increasing age and the consumption of food prepared in communal kitchens might be more important contributory factors in the oral prevalence of AGNR than the nature of the diet itself or the health of the dentition and periodontium.

Relationship of medical status, medications, and salivary flow rates in adults of different ages

Multiple systemic disorders and medications have been reported to cause xerostomia or salivary gland hypofunction. The purpose of this study was to evaluate the relationship among systemic disorders, medications, and salivary flow rates. Sixty-three ambulatory dental patients aged 23 to 82 years were randomly selected. The nature, duration, and number of systemic disorders and medications were documented. Repeated measurements of unstimulated whole, chewing-stimulated whole, acid-stimulated parotid, and candy-stimulated parotid salivary flow rates were obtained. Data were analyzed with the Wilcoxon rank-sum test, nonparametric multivariate analysis of variance, and Fisher's exact test. For persons with systemic disorders who were taking medication, all salivary flow rates were significantly (p = 0.03 - 0.001) lower than the flow rates in healthy persons. Among persons with at least one systemic disorder who were taking medication, those who had been taking medication for longer than 2 years had significantly lower unstimulated whole saliva (p = 0.002), chewing-stimulated whole saliva (p = 0.0004), and candy-stimulated parotid saliva (p = 0.02) flow rates than those who had been taking medication for 1 to 2 years. The number of systemic disorders significantly (p = 0.02) and negatively affected the acid-stimulated parotid salivary rates. The prevalence of salivary hypofunction determined on the basis of unstimulated whole saliva and acid-stimulated parotid saliva was significantly higher (p = < 0.001, p = 0.007) in the those persons with systemic disorders and taking medications. The results suggest that salivary secretion is affected by the number of systemic disorders and duration of the potentially xerogenic medications.

The importance of oral health in the older patient

Oral health is important to general health because stomatologic disease affects more than the mouth. Increasing preservation of teeth among present and future cohorts of older people has increased their risk for serious disease from oral pathogens. The intent of this paper is twofold: first, to alert non-dental health personnel to the significance of oral health and oral disease in the older adult; and second, to recruit the assistance of non-dental professionals in helping patients to achieve and maintain an optimal oral condition. Normative aging processes alone have little effect on the oral cavity, but common disease processes affecting oral health include tooth loss, dental caries, periodontal diseases, and oral mucosal diseases (including candidiasis and squamous cell carcinoma). Systemic diseases and their treatments frequently affect salivary, oral motor, and oral sensory functions. As a result of bacteremia or aspiration of oral contents, organisms of oral origin can be responsible for serious nonstomatological infections. Clinicians caring for older people need to recognize the importance of stomatological health, include an oral component in the multidisciplinary geriatric assessment, support the education of patients on aspects of dental health, and advocate the expansion of personal and public oral health benefits for older adults.

Oral and oropharyngeal prevalence of Enterobacteriaceae in humans: a review

Members of the Enterobacteriaceae family are widely distributed in nature and exhibit substantial diversity in ecology, host range and pathogenic potential for man. While wide discrepancies in methodology exist between epidemiological studies, the available data indicate an increased prevalence of oral and/or oropharyngeal Enterobacteriaceae carriage in patients with illnesses of varying severity compared with healthy subjects. This paper reviews the prevalence of Enterobacteriaceae in the oral and oropharyngeal region of healthy human subjects and those affected by different disease entities, and discusses the complexities associated with collating and interpreting such data. The effect of antimicrobials and antiseptics on oral and oropharyngeal Enterobacteriaceae has also been reviewed, while highlighting the gaps in knowledge and future research directions.

Longitudinal study on oral health in subjects with Alzheimer's disease

OBJECTIVE

To examine longitudinal oral health changes in unmedicated, generally healthy subjects with Alzheimer's disease (AD) and compare them to age- and gender-matched healthy, unmedicated control subjects.

DESIGN

Oral health parameters were evaluated over 2 to 3 years and the results compared between subjects with AD and controls.

SETTING

Clinical Center of the National Institutes of Health, Bethesda, Maryland.

PARTICIPANTS

Twenty-one community-dwelling subjects with a clinical diagnosis of AD and 21 age- and gender-matched control subjects. Neither population was being treated for any other systemic condition nor taking any prescription medications.

MEASUREMENTS

Unstimulated and stimulated major salivary gland flow rates were measured, and gingival, periodontal, dental, and oral mucosal tissues assessed.

MAIN RESULTS

In general, subjects with AD demonstrated decreased salivary flow rates and diminished oral health, but most longitudinal changes in oral health status were not significantly different than controls.

CONCLUSIONS

Patients with AD are susceptible to a variety of oral health problems, and progression of AD can lead to a deterioration in oral health and function. These patients require aggressive preventive care to maintain function for as long as possible, which necessitates close cooperation among numerous health care professionals.