~ zhe ime r ' s disease (AD) is the most common form

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1 Longitudinal Study on Oral Health in Subjets with Alzheimer's Disease Jonathan A. Ship, DMD and SottA. Pukett, BS Objetive: To examine longitudinal oral health hanges in unmediated, generally healthy subjets with Alzheimer's disease (AD) and ompare them to age- and gender-mathed healthy, unmediated ontrol subjets. Design: Oral health parameters were evaluated over 2 to 3 years and the results ompared between subjets with AD and ontrols. Setting: Clinial Center of the National Institutes of Health, Bethesda, Maryland. Partiipants: Twenty-one ommunity-dwelling subjets with a linial diagnosis of AD and 21 age- and gender-mathed ontrol subjets. Neither population was being treated for any other systemi ondition nor taking any presription mediations. Measurements: Unstimulated and stimulated major salivary gland flow rates were measured, and gingival, periodontal, dental, and oral muosal tissues assessed. Main Results: In general, subjets with AD demonstrated dereased salivary flow rates and diminished oral health, but most longitudinal hanges in oral health status were not signifiantly different than ontrols. Conlusions: Patients with AD are suseptible to a variety of oral health problems, and progression of AD an lead to a deterioration in oral health and funtion. These patients require aggressive preventive are to maintain funtion for as long as possible, whih neessitates lose ooperation among numerous health are professionals. J Am Geriatr So 42:57-63,1994 zhe ime r ' s disease (AD) is the most ommon form of dementia among the elderly, aounting for about 5% to 6% of people with loss of ognitive funtion.' The inidene of AD inreases dramatially with age, from about.1 % at age 6 to 65 to as high as 47% at age It is a degenerative neurologial disorder haraterized by progressive impairments in a wide range of oitive abilities, from memory to abstrat reasoning." Behavioral and funtional symptoms often aompany the above-mentioned impairments, resulting in severe onsequenes to many organ systems." With the inreasing perentage of the population over age 65, the number of individuals with Alzheimer's disease will also grow. Presently, there is no known effetive treatment for the funtional and intelletual degeneration resulting from the disease proess. Most treatment efforts are generally are oriented, as opposed to ure oriented, and are direted to provide relief of physial, psyhologial, and emotional problems assoiated with the progressing disease.' The oral avity serves several essential funtions (deglutition, host defense, and ommuniation), yet frequently oral health is negleted in patients with terminal and inapaitating disorders. Although researh advanes have inreased the understanding of AD, there are few reports of the effets of AD and its progression on oral health. Previous ross-setional studies have demonstrated diminished salivary gland funtion and altered gingival and dental health in unmediated patients with AD. 5 6 Other reviews have reommended the establishment of early preventive and maintenane oral health regimens in patients with AD and other neurodegenerative disorders." 7-1 To our From the University of Mihigan Shool of Dentistry, Ann Arbor. Mihigan. Address orrespondene to Jonathan A. Ship, DMD, Department of Oral Mediine. Pathology, and Surgery, University of Mihigan Shool of Dentistry. 111 N. University. Room 21. Ann Arbor, MI knowledge, however, there have been no longitudinal studies published on oral health in patients with AD. These data would be useful to devise appropriate linial reommendations for the maintenane of oral health and funtion in these patients and to preserve their quality of life for as long as possible. Aordingly, the purpose of this investigation was to examine longitudinal hanges in salivary, gingival, periodontal, dental, and oral muosal parameters in unmediated, essentially healthy subjets with AD. MATERIALS AND METHODS Population Twenty-one ommunity dwelling subjets in middle soio-eonomi status (13 men, 8 women) with a linial diagnosis of AD were evaluated at the Clinial Center of the National Institutes of Health, Bethesda, Maryland, in a longitudinal study sponsored by the National Institute on Aging (Table 1). A diagnosis was made aording to NINCDS ADRDA riteria!' after subjets were sreened vigorously to exlude other medial, neurologial, and psyhiatri onditions. All subjets were extensively evaluated with diagnosti radiographs, omputed tomographi brain sans, magneti resonane imaging, positron emission tomoaphy, and neuropsyhologial and medial tests.f" 5 No subjet was taking any mediation for systemi disease, nor being treated for any other disorder. The Mini-Mental State Examination (MMSE)16 was administered to eah subjet at eah visit to estimate the severity of ognitive impairment (Table 1). The interval between visits for subjets with AD was 23 ± 11 months (mean ± SD). Twenty-one healthy subjets were seleted as ageand gender-mathed ontrol subjets (Table 1). All were volunteer partiipants in a normative aging program onduted by the National Institute on Aging. These subjets were ommunity dwelling, of middle soio-eonomi status, healthy, not being treated for JAGS 42:57-63, by theamerian Geriatris Soiety /94/$3.5

2 58 SHIP AND PUCKETT JAGS-JANUARY 1994-VOL. 42, NO. 1 Men Women Age (y) Age (range) (y) Interval (mas) MMSE soresf Visit 1 Visit 2 TABLE 1. STUDY POPULAnON* Control Subjets Alzheimer's Subjets (n = 21) (n = 21) ± ± ± ± ± ± ± ± 9.2 p** Values areexpressed as mean ± SD. t Statistial omparison between ontrol subjets and Alzheimer's subjets. Mini-mental state exam; Folstein et al.i. Signifiantly lower than visit 1 MMSE sores for Alzheimer's (P = ). any systemi disease nor taking any presription mediations, and underwent rigorous medial, neurologial, and laboratory sreening The interval between visits for ontrol subjets was 36 ± 1.5 months (mean ± SD) (Table 1). Oral Health Parameters All study subjets reeived an interview and intraoral/extraoral linial examinatiori'y'" by one investigator (J.A.S.). The examiner was not blinded to the status of the study subjet (AD vs ontrol), but was unaware of the level of dementia among AD subjets at the time of examination. Major salivary gland flow rates were determined aording to previously desribed riteria." All subjets refrained from eating, drinking, smoking, and oral hygiene for a minimum of 9 minutes before saliva olletion. Unstimulated and stimulated saliva was olleted from one parotid gland with the use of a modified Carlson-Crittenden up as desribed previously." For any subjet displaying no unstimulated parotid saliva prodution after 5 minutes, a retest was performed. Only after two negative unstimulated test results, plus positive evidene of a stimulated seretion, was a subjet onsidered to have an unstimulated flow rate of zero." Submandibular saliva was olleted from the orifie of Wharton's dut, as previously desribed.l" Salivary flow was stimulated by swabbing 2% itri aid on the dorsolateral surfaes of the tongue at 3 seond intervals." After olletion, the salivary volume was determined gravimetrially, assuming a speifi gravity of 1.. Submandibular saliva atually represents a ombined submandibular/sublingual seretion due to the frequent ommon exit of the gland duts, but will be referred to as submandibular saliva. An examination of dental, gingival, periodontal, and oral muosal tissues was performed on all subjets, aording to previously desribed riteria." The number of teeth (exluding third molars), deayed-missingfilled-teeth sore, and the number of teeth with ervial and oronal aries and restorations were reorded." The mesiobual, midbual, distobual, mesiolingual, midlingual, and distolingual surfaes of the six teeth proposed by Rarnfjord'" were examined for periodontal parameters" aording to National Institute of Dental Researh riteria." Briefly, the 36 tooth surfaes were assessed for the presene or absene of dental plaque, gingival bleeding, and supra- or subgingival alulus. The distane from the free gingival margin to the ementoenamel juntion and the distane from the free gingival margin to the bottom of the sulus or poket was measured with a National Institute of Dental Researh olor-oded periodontal probe. The perentage of tooth surfaes for eah subjet with dental plaque, gingival bleeding, and alulus was alulated and the amounts of gingival reession, poketing, and level of attahment (LOA) were reorded. In addition, the extent and severity of LOA were determined aording to riteria established by Carlos et al. 2S All intraoral strutures were assessed with a modified muosal rating sale." Normal muosal hanges (dry, pale, or glossy muosa and alterations in muosal topogrphy) were rated, and any moderate or severe onditions (erythemi or leukoplaki lesions, ulerations, and erosions) were rated Oral andidal lesions (atrophi, pseudomembranous, and denture stomatis) were diagnosed linially" and grouped together With a rating of 1. Statistial analysis Intraexaminer repliate examinations for periodontal poket depth (SD =.38 mm) and LOA (SD =.42 mm), and intralass orrelation oeffiients for unstimulated submandibular flow rate (.978) and stimulated submandibular flow rate (.984) were alulated on nine ontrol subjets. Data from the study were analyzed for differenes between men and women within eah group, and between subjets with AD and ontrol subjets for eah visit. The yearly hange in eah oral health parameter was determined: the hange from the first to last visit for eah subjet was divided by the number of months between visits, and then multiplied by 12 months. A Student's t test was used when mean values had a normal distribution, and a Mann-Whitnel U proedure was used for nonparametri values. X and two-way Fisher's Exat tests were performed for prevalene data. Correlation analyses were performed on subjets with AD to determine whether a relation existed between level of dementia (as determined from the MMSE sore) at eah visit and oral health parameters. Correlations were also determined on AD subjets for hanges in dementia over time (hange in MMSE sore) and hange in oral health parameters. To determine whether the relationship between age and hange in oral health was different between groups, regressions were alulated for longitudinal hange for eah oral health parameter and age at baseline, and ompared between the two groups. Data were analyzed using the RS1 software pakage (BBN Software Produts Corp, Boston, MA). A riterion of P <.5 was aepted for signifiane in all statistial tests. RESULTS Beause no gender differenes were observed for any of the linial parameters in either AD or ontrol populations, data for men and women were ombined in all subsequent analyses. In addition, regression analyses for longitudinal hanges in eah oral health parameter and age at baseline were not statistially different between the two groups.

3 JAGS-JANUARY 1994-VOL. 42, NO.1 ORAL HEALTH AND ALZHEIMER'S DISEASE 59 Major salivary gland flow rates in AD and ontrol groups at both visits are displayed in Figure 1. With the exeption of stimulated parotid flow rates at visit 1, subjets with AD had lower unstimulated and stimulated major salivary gland flow rates at both visits. Unstimulated (P =.2) and stimulated (P =.7) submandibular flow rates were lower in subjets with AD at visit 1, and unstimulated parotid (P =.5) and stimulated submandibular (P =.5) flow rates were lower at visit 2. Salivary flow rates inreased over the time interval in ontrol subjets, but were only signifiant for unstimulated parotid flow (P =.4). Unstimulated flow rates remained essentially stable in Alzheimer's subjets, whereas stimulated flow rates (parotid, P =.7; submandibular, P >.5) dereased over time. The average yearly hanges in unstimulated (P =.6) and stimulated (P =.7) parotid flow rates tended to be lower in subjets with AD ompared with ontrol subjets (Table 2). There were no signifiant differenes for average yearly hanges for submandibular flow rates between the two groups. Analyses were performed to determine if there was a relation between MMSE sores and salivary gland flow rates. There were.7 E.6 "".5 a.4 - r.3.4 T I. -",------,------,-----,-----r-----,------, , o P I Controls PI Alzheimer's 'V P2 Controls "" P2 Alzheimer's o S I Controls S 1 Alzheirners 'V 82 Controls Alzheimer's FIGURE 1. Longitudinal parotid (top panel) and submandibular (bottom panel) salivary gland flow rates in 21 unmediated AD and 21 healthy ontrol subjets. Results are expressed in milliliters per minute per gland (mean ± SE) for all flow rates. Values for AD subjets are extrapolated from the 1.9-year time point to the 3-year time point. PI denotes unstimulated parotid flow, P2 stimulated parotid, 51 unstimulated submandibular, and 52 stimulated submandibular. T I o ;;: t" M ;:-----y. --'--,----,----,----,----,-----r-----,..5 1, "" g I ;.2 T a '" o to a.1 a V1 I T J i positive orrelations with submandibular flow rates but none for parotid flow rates. With dereasing MMSE sores, unstimulated submandibular (visit 1, r =.42, P =.5; visit 2, r =.47, P <.5) and stimulated submandibular (visit 2, r =.37, P =.9) flow rates diminished. However, there were no signifiant orrelations between hanges in salivary flow rates over the time period and hanges in MMSE sores. Gingival health parameters were onsistently worse at both visits in subjets with AD ompared with ontrol subjets (Figure 2). This was signifiant for the perent of tooth surfaes with dental plaque (visit 1, P =.3; visit 2, P =.7) and gingival bleeding (visit 2, P = ). Gingival health in Alzheimer and ontrol subjets worsened over time (with the exeption of gingival bleeding in ontrols), but there were no statistial differenes between the two groups (Table 2). For ontrol subjets, perent plaque (P = ) and alulus (P =.1) inreased over the interval between visits, whereas only alulus signifiantly inreased for Alzheimer subjets (P =.3). In general, there were non-signifiant ross-setional and longitudinal trends of poorer gingival health with lower MMSE sores, with two exeptions. With dereasing MMSE sores, the perent of dental surfaes with gingival bleeding (visit 1, r = -.4, P =.6) and plaque (visit 2, r = -.52, P =.1) inreased. No statistial differenes were seen between ontrol and AD subjets for any of the periodontal parameters at visit 1 or at visit 2. In general, periodontal health remained stable or improved slightly in both groups over the time span. Poket depth dereased signifiantly over time in both ontrol (P = ) and AD subjets (P =.4), but there were no longitudinal differenes in the rate of derease between the two groups. LOA improved from visit 1 to visit 2 for ontrols (P = ) but not for subjets with AD; however, these differenes over time between both groups were not signifiant. The extent of teeth with LOA dereased signifiantly for ontrols (P =.2) and AD subjets (P =.6) over the time interval, and this improvement was greater in subjets with AD (P =.5). Furthermore, there were no signifiant orrelations between MMSE sores and periodontal parameters. The ross-setional and longitudinal analysis of total number of remaining teeth and surfaes with oronal and ervial aries revealed no statistial differenes between the two groups. The number of teeth with restored oronal (visit 1, P =.6; visit 2, P =.3) and ervial (visit I, P =.1; visit 2, P =.3) surfaes was onsistently higher in subjets with AD; however, the longitudinal hanges were not signifiant for either population nor between groups (Figure 3). Deayed-missing-filled-teeth sore levels in subjets with AD were signifiantly higher at visit 1 (P =.1) and visit 2 (P =.4), although there was no signifiant longitudinal hange within either population or between the two groups (Table 2). The only dental parameter whih was orrelated signifiantly with MMSE sores was the number of teeth with deayed oronal surfaes. A negative orrelation (r = -.4, P =.6) was found at visit 2 between oronal deay and MMSE sore.

4 6 SHIP AND PUCKETT JAGS-JANUARY 1994-VOL. 42, NO.1 TABLE MONTH CHANGE IN ORAL HEALTH PARAMETERS* Control Alzheimer's Parameter Subjets vs ** Subjets vs *** Controls vs Alzheimer's# Salivary (rnl/min- gland) Unstimulated parotid NS.6 Stimulated parotid.3 NS Unstim submandibular.7 NS.2 NS NS Stirn submandibular.4 NS -.27 NS NS Gingival (%) Dental plaque NS NS Bleeding -.72 NS 2.69 NS NS Calulus NS Peridontal (mm) Poket depth NS Reession.6 NS -.3 NS NS LOA## NS NS Extent LOA (%) Severity LOA -.9 NS -.4 NS NS Dental Number of teeth -.47 NS NS NS DMFT###.461 NS.347 NS NS Deayed oronal.112 NS.5 NS NS Deayed ervial -.21 NS -.27 NS NS Restored oronal -.3 NS -.66 NS NS Restored ervial. NS.1 NS NS Negative values denote a derease over time, positivevalues denote an inrease over time. P valuesfor statistial omparison of ontrol values versus no hange from baseline (). P valuesfor statistial omparison of Alzheimervalues versus no hange from baseline (). # P valuesfor statistial omparison of ontrol and Alzheimer values. ## Level of attahment. ### Deayed-missing-filled-teeth sore. Intraoral muosal examination showed no signifiant differenes between ontrol and AD groups at either visit. In addition, there were no signifiant hanges in oral muosal health over time within or between the two groups. Control (visits 1 and 2/ 43%) and AD (visit 1/4%; visit 2/ 67%) subjets with removable prostheses (full or partial dentures) were more likely to have linially detetable alterations in oral muosa. There was a signifiant negative orrelation between MMSE sores and oral muosal health among denture-wearing AD subjets (visit 2/ r = -.97/ P <.1)/ but not among non-denture-wearing subjets. The longitudinal analysis revealed that dereasing MMSE sores were orrelated with diminished muosal health for denture-wearing (r = -.62/ P <.1) and non-denture-wearing (r = -.43/ P =.6) AD subjets. DISCUSSION The results of this study demonstrate signifiant differenes in the oral health of unmediated subjets with Alzheimer's disease ompared to age- and gendermathed healthy, non-demented ontrol subjets. In general, these differenes were observed in both rosssetional analyses, but not onfirmed in the relatively short (2 to 3 years) longitudinal span of the study. Speifially, salivary gland flow rates (espeially submandibular) were onsistently lower in subjets with AD. There was a greater history of dental disease (inreased dental restorations), more gingival disease, but indistinguishable periodontal onditions in subjets with AD ompared with ontrols subjets. Oral muosal health was not different for the two groups; however, denture-wearing subjets in both groups showed altered muosal health. These ross-setional results are onsistent with previously reported findings of altered salivary gland funtion, gingival health, and differenes in dental findings using a similar population of subjets who were essentially healthy exept for AD. s.6 However, our longitudinal results overall did not reflet the rosssetional findings. Whereas stimulated salivary gland flow rates dereased and gingival health and overall dental disease worsened over the 2 to 3 years in subjets with AD, the remaining oral health parameters remained essentially stable. Nevertheless, many of the oral health parameters examined indiated onsistently greater impairment among subjets with AD. Analyses of rate of hange in these parameters (Figures 1 to 3) suggest that oral diseases will signifiantly impat on a person's systemi health and quality of life sooner in subjets with AD ompared with ontrol subjets. Furthermore/ it an be expeted that these subjets with AD will be treated eventually for medial onditions onomitant with the progression of AD and be presribed mediations, many of whih an have deleterious onsequenes to oral health." Some form of oral hygiene was performed in the AD subjets in this study beause not all dental surfaes

5 JAGS-JANUARY 1994-VOL. 42, NO. ORAL HEALTH AND ALZHEIMER'S DISEASE "" "" 7 i u Control Plaque Control Coronal Rest. Alzheimer Coronal Rest. Vl 5 ' 1 Alzheimer Plaque... i '. E 4 :> z ! i i "" " s '7 '7 Control Ging. Bleeding... 1; Alzheimer Ging. Bleeding Vl ' ' 1. 2 E :> z Control Cervial Rest. Alzheimer Cervial Rest "" 4 i 35 u 3 :; Vl ' 25 2 e,. o o Control Calulus Alzheimer Calulus FIGURE 2. Longitudinal gingival parameters in 21 unmediated AD and 21 healthy ontrol subjets. Gingival results are expressed as perent of tooth surfaes examined with dental plaque (top panel), gingival bleeding (middle panel), and alulus (bottom panel; mean ± SE). Values for AD subjets are extrapolated from the 1.9-year time point to the 3-year time point. I 22 2 "" i 18 t: '" C> o Control DMFT Alzheimer DMFT FIGURE 3. Longitudinal dental parameters in 21 unmediated AD and 21 healthy ontrol subjets. Results are expressed as number of teeth with oronal restorations (top panel), number of teeth with ervial restorations (middle panel), and the deayed-missing-filledteeth sore (DMFT) (bottom panel; mean ± SE). Values for AD subjets are extrapolated from the 1.9-year time point to the 3-year time point. were overed by dental plaque or had gingival bleeding (Figure 2). Oral hygiene tasks, however, will probably undergo signifiant hange in the ourse of the disease. These subjets were also ommunity dwelling; the extent of oral health are reeived by institutionalized persons is generally lower and less frequent ompared to are reeived by subjets in this study. It an be hypothesized that oral onditions of institutionalized patients with AD and other medial problems, taking numerous presription mediations, will deteriorate more rapidly due to inadequate oral health are. Therefore, the findings in this study of altered oral health in ommunity-dwelling, unmediated subjets with early AD may underestimate the eventual progression of oral disease and impairment. Saliva is essential for the maintenane of a healthy oral environment, and diminished output may predispose a person to multiple oral and systemi problems." For example, diminished salivary funtion an predispose a person to aspiration pneumonia." Major salivary gland flow rates were onsistently lower (with the exeption of stimulated parotid at visit 1), and stimulated funtion diminished over time in subjets with AD (Figure 1). These negative trends ould be aelerated if patients reeive psyhotropi or other antiholinergi drugs, whih are frequently assoiated with dereased salivary funtion." The mehanisms underlying the diminished salivary gland funtion in AD subjets are unlear. Seretion by these glands is stimulated by ativity of the salivatory nulei and is ontrolled by sympatheti and parasympatheti innervation. Parasympatheti stimulation inreases the volume of saliva sereted, whereas sympatheti stimulation has greater effets on salivary omposition and protein ontent.32 The superior and inferior saliva tory nulei are loated within the retiular formation near the pontomedullary juntion of the brainstem and are in lose proximity to the solitary nuleus, whih reeives input from afferent taste fibers.": 34 The salivatory nulei reeive innervation from the ortioretiular trat, projeting from higher ortial regions." whih in tum reeive most of their holinergi innervation from the nuleus basalis." Itis known that degeneration of the holinerir system and the nuleus basalis ours in AD,3.36 whih ould lead to the inhibition of stimulus transdution to lower levels of the brainstern, inluding the saliva tory and

6 62 SHIP AND PUCKETT JAGS-JANUARY 1994-VOL. 42, NO. 1 solitary nulei. It is interesting to note that hanges in salivary output over time in subjets with AD were more dramati for itrate-stimulated ompared with unstimulated seretions (Table 2), whih ould partially be due to onomitant alterations in gustatory funtion." Furthermore, there have beenreports of brainstem degeneration, even within the retiular formation." in patients with AD. These findings, however, are not onsistent within an individual and between persons with AD,45,46 and the heterogeneity of linial findings in these patients has been doumented." Therefore, the variable pattern of neuropathologial destrution ould aount for the variety of salivary gland findings in these individuals, The gingival health of AD subjets was onsiderably worse than that of ontrol subjets and deteriorated with inreased severity of dementia. Extrapolation of dental plaque findings in subjets with AD indiates that three-quarters of all tooth surfaes will be overed with plaque 3 years from baseline (Figure 2). Less attention is devoted to appearane and hygiene in patients with early AD,48 and with the onomitant deline in ognitive funtion, gingival health will probably ontinue to deteriorate, Gingivitis ould eventually have systemi impliations and predispose a person to aspiration pneumonia." In ontrast to the gingival findings, the periodontal results demonstrated no signifiant differenes between subjets with AD and ontrols. The six index teeth used in this study23 have been shown to provide an aurate indiation of gingival health,5 but they may underestimate periodontal disease progression." Perhaps the 2- to 3-year span of the study was insuffiient for gingivitis to inrease periodontitis markedly. Furthermore, there is evidene to suggest that gingivitis may not neessarily be a forerunner of periodontal diseases Nevertheless, the deterioration in gingival health eventually may lead to signifiant periodontal destrution and tooth loss. Dental onditions did not signifiantly worsen in subjets with AD over the 2- to 3-year interval, yet there was a onsistently higher history of dental disease among subjets with AD, as shown by higher deayedmissing-filled-teeth sores and greater numbers of teeth with restored oronal and ervial surfaes (Figure 3). The results also demonstrate that despite a greater dental disease history, subjets with AD were reeiving dental are. It an be speulated, however, that as ognitive and motor funtion deteriorate, and these patients eventually beome more impaired, they will probably be less likely to perform regular oral hygiene and seek dental treatment. Furthermore, the risk for developing new or reurrent dental aries is greatly inreased in these patients beause of diminished salivary gland output. It is unknown to what magnitude dental aries must extend to produe an absess, bateremia, or septiemia. Nevertheless, subjets with AD have experiened a greater amount of dental diseases ompared with ontrol subjets, despite similar geographial and soio-eonomi bakgrounds. With a onomitant derease in salivary gland funtion, they are at an inreased risk for developing aries and its sequelae. The overall ondition of oral muosal tissues was similar between Alzheimer's subjets and ontrol subjets throughout the study. For both subjet groups, the denture-wearing subjets were more likely to demonstrate linial alterations in oral muosa, whih is onsistent with previous reports. 56, 57 The presene of removable prostheses, rather than the diagnosis of AD, is probably a greater prognostiator for oral muosal disorders. A general trend was seen for dereased ognition and inreased oral muosal problems, whih indiates the need for are providers to remove patient's dentures at bedtime and to enourage routine oral home are. Preventive and treatment goals for individuals with AD are to preserve and maintain oral health and funtion for as long as possible.j'"? Manual or mehanial toothbrushing and flossing should be performed at least daily and preferably after eah meal, and dentures should be leaned and removed every night. Health are providers, relatives, and friends should assist in these measures if neessary, and an help identify new problems neessitating appropriate onsultation. Fluoridated dentifries, water supplies, mouth rinses, and topial gels are required to prevent dental aries, espeially in patients with diminished salivary output. These patients should also be enouraged to use sugarless andies, hewing gums and artifiial salivas, and should be monitored for oral fungal infetions. Finally, as long as a patient is able to ooperate during routine dental treatment, frequent reall visits to dental professionals are neessary to assist in the prevention of oral disease and to detet and treat problems before funtion is impaired. Reommendations for optimum oral health are in patients with AD inlude the neessity of establishing relationships among dentists, dental hygienists, physiians, nursing staff and other are-providers, as well as family members and appropriate friends involved in the regular are of the patient. This may inrease the likelihood of integrating daily oral health are into other servies provided by are-givers in ommunitydwelling patients, or subjets residing in long-term are failities. The multidisiplinary approah to are of all patients with dementia will assist both patients and are-providers in the assessment of funtional needs and treatment goals. A sientifi aount of the proess of aging requires a systemati approah to the role of disease in the explanatiori." Therefore, more extensive longitudinal studies involving subjets with well haraterized diseases are neessary to identify patients at risk for oral diseases, to antiipate diagnosti and management needs of the elderly, and to implement effetive remens to prevent the development of oral problems. ACKNOWLEDGMENTS We aknowledge the ontributions of Dr Brue Baum (National Institute of Dental Researh, NIH) for researh guidane at the NIH, and Dr Mark Supiano (University of Mihigan Shool of Mediine) and Dr Jed Jaobson (University of Mihigan Shool of Dentistry) for ritial review of the manusript. We are

7 JAGS-JANUARY 1994-VOL. 42, NO. 1 ORAL HEALTH AND ALZHEIMER'S DISEASE 63 indebted to the assistane of the National Institute on Aging staff, ontrol subjets, and subjets with Alzheimer's disease for their ooperation. REFERENCES 1. Katzman R. Medial progress: Alzheimer's disease. N Engl j Med 1986;315: Evans DA, Funkerstein H, Albert MS et al. Prevalene of Alzheimer's disease in a ommunity population of older persons. JAMA 1989;262: Montelaro S. Alzheimer's disease: A growing onern in geriatri dentistry. Gen Dent 1985;Nov-De: Fabiszewski Kj. Caring for the Alzheimer's patient. Gerodontology 1987;6: Ship ja. Oral health of patients with Alzheimer's disease. j Am Dent Asso 1992;123: Ship ja, DeCarli C, Friedland RP, Baum Bj. Diminished submandibular salivary flow in dementia of the Alzheimer type. j GerontoI199;45:M Niessen LC, jones [A, Zohi M, Gurian B. Dental are for the Alzheimer's patient. j Am Dent Asso 1985;11: Niessen LC, jones ja. 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