Dry mouth and its effects on the oral health of elderly people pptx

Background. The objective of this literature
review is to summarize information about the eti-
ology, diagnosis, oral sequelae and treatment of dry
mouth in elderly patients.
Types of Studies Reviewed. The authors con-
ducted a comprehensive review of the English-based scientific literature
from the past 10 years. They selected the studies on the basis of
clinical investigations to provide an objective assessment of dry mouth
problems among older people.
Results. Dry mouth (salivary hypofunction, xerostomia) is a common
problem among older people. It causes significant oropharyngeal disorders,
pain and an impaired quality of life. Dry mouth has many causes, from
local salivary disorders to a plethora of medications and medical condi-
tions. Treatments are designed to correct the underlying cause and/or to
enhance salivation with topical and systemic stimulants. Early interven-
tion for dry mouth problems helps prevent the deleterious consequences of
this disorder in elderly people.
Clinical Implications. Clinicians must be aware of dry mouth prob-
lems in older patients, and they should be prepared to provide a diagnosis
and administer treatment to protect a patient’s oropharyngeal health and
quality of life.
Key Words. Xerostomia; aging; saliva; salivary glands; Sjögren’s
syndrome; cancer; radiotherapy; medications.
JADA 2007;138(9 supplement):15S-20S.
S
aliva plays a critical role
in the preservation of
oropharyngeal health.
Complaints of a dry
mouth (xerostomia) and
diminished salivary output are

common in older populations, which
can result in impaired food and bev-
erage intake, host defense and com-
munication. Persistent xerostomia
and salivary dysfunction can pro-
duce significant and permanent oral
and pharyngeal disorders and can
impair a person’s quality of life.
Salivary function remains
remarkably intact in healthy older
people, yet a plethora of systemic
diseases (such as Sjögren’s syn-
drome [SS]), medications (such as
anticholinergics) and head and neck
radiotherapy (such as for cancer)
cause xerostomia, particularly in
elderly patients. Treatment strate-
gies include salivary replacement
therapies, as well as use of gusta-
tory, masticatory and pharmacolog-
ical stimulants.
EPIDEMIOLOGY OF DRY
MOUTH IN ELDERLY PEOPLE
Estimates of xerostomia and sali-
vary gland hypofunction are diffi-
cult to obtain owing to the limited
number of epidemiological studies
ABSTRACT
A
R

T
I
C
L
E
2
Dr. Turner is an assistant professor, Department of Oral and Maxillofacial Surgery, New York University
College of Dentistry, New York City.
Dr. Ship is a professor, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, New
York University College of Dentistry; a professor, Department of Medicine, New York University School
of Medicine; and director, Bluestone Center for Clinical Research, New York University College of
Dentistry, 421 First Ave., 2nd Floor, New York, N.Y. 10010-4086, e-mail “”.
Address reprint requests to Dr. Ship.
J
A
D
A
C
O
N
T
I
N
U
I
N
G
E
D
U

C
A
T
I
O
N
✷
✷
®
Dry mouth and its effects on the oral health
of elderly people
Michael D. Turner, DDS, MD; Jonathan A. Ship, DMD, FDS RCS (Edin)
JADA, Vol. 138 September 2007 15S
Copyright ©2007 American Dental Association. All rights reserved.
that have been conducted; however, Ship and col-
leagues
1
estimated that approximately 30 percent
of the population 65 years and older experience
these disorders. Drug-induced dry mouth is the
most common cause, because the vast majority of
older adults are being treated with at least one
medication that causes salivary hypofunction.
The prevalence of xerostomia is nearly 100 per-
cent among patients with SS,
2
and head and neck
radiation for the treatment of cancer causes per-
manent xerostomia.
3

Dry mouth in elderly people. Many older
adults experience dry mouth for a variety of rea-
sons.
4,5
Interestingly, output from the major sali-
vary glands does not undergo clinically significant
decrements in healthy older people.
6
Some data
show age-related changes in salivary con-
stituents, but other evidence shows
age-stable production of salivary
electrolytes and proteins in the
absence of major medical problems
and medication use. Clinicians
should not attribute complaints of a
dry mouth and findings of salivary
hypofunction in an older person to
his or her age; an appropriate diag-
nosis is required.
Salivary disorders in the aging
population usually are caused by
systemic diseases and their treat-
ments (for example, anticholinergic medications or
radiation therapy). Numerous medical conditions
(such as SS, diabetes, Alzheimer’s disease, dehy-
dration), medications (both prescription and non-
prescription), head and neck irradiation and
chemotherapy can cause or contribute to salivary
gland diseases.

1-3,5
Furthermore, evidence suggests
that salivary glands are vulnerable to the delete-
rious effects of all of these conditions in elderly
people,
7
which may contribute to the increased
prevalence of salivary problems with age.
Medications. The most common cause of sali-
vary disorders is the use of prescription and non-
prescription medications. For example, Sreebny
and Schwartz
8
reported that 80 percent of the
most commonly prescribed medications cause
xerostomia, with more than 400 medications asso-
ciated with salivary gland dysfunction as an
adverse side effect. Because elderly people are
more likely than the rest of the population to take
medications and are more vulnerable to their side
effects, medication-induced xerostomia is
common.
4,9,10
Drugs with anticholinergic effects are the most
likely to produce complaints of dry mouth and
diminished salivary output. Furthermore, drugs
that inhibit neurotransmitters from binding to
salivary gland membrane receptors, or that per-
turb ion transport pathways in the acinar cell,
may affect adversely the quality and quantity of

salivary output. Common categories of these
drugs include tricyclic antidepressants, sedatives
and tranquilizers; antihistamines; antihyperten-
sives (α and β blockers, diuretics, calcium channel
blockers, angiotensin-converting enzyme
inhibitors); cytotoxic agents; and anti-
Parkinsonism and antiseizure drugs.
Chemotherapeutic agents also have been asso-
ciated with salivary disorders.
11
After completing
therapy, most patients experience a return of sali-
vary function to prechemotherapy
levels; however, long-term changes
in salivary function have been
reported.
12
Radioactive iodine
(I-131), which is used to treat thy-
roid malignancies, damages sali-
vary tissues in a dose-dependent
fashion, primarily affecting the
parotid glands.
5,13
Radiation therapy. A common
therapy for head and neck cancers
is external beam radiation, which
causes severe and permanent sali-
vary hypofunction and results in persistent com-
plaints of xerostomia.

3
Radiation-induced destruc-
tion of the serous-producing salivary cells occurs
via a process termed “apoptosis.” Within one week
of the start of irradiation (after 10 grays of radia-
tion have been delivered), a patient’s salivary
output declines by 60 to 90 percent, with no
recovery occurring unless the total dose to sali-
vary tissues is less than 25 Gy.
14
Most patients
receive therapeutic dosages that exceed 60 Gy,
and their salivary glands undergo atrophy and
become fibrotic. These patients experience a
plethora of oral and pharyngeal side effects as a
result of the salivary dysfunction (Box).
SS. SS is one of the most frequently encoun-
tered chronic autoimmune connective-tissue dis-
orders, and it is the most common systemic condi-
tion associated with xerostomia and salivary
dysfunction. SS occurs in primary and secondary
16S JADA, Vol. 138 September 2007
Drugs with
anticholinergic effects
are the most likely to
produce complaints
of dry mouth and
diminished salivary
output.
ABBREVIATION KEY. Anti-Ro/SSA: Anti-Ro/Sjögren’s

Syndrome A autoantibodies. SS: Sjögren’s syndrome.
Copyright ©2007 American Dental Association. All rights reserved.
forms. Patients with primary SS have salivary
and lacrimal gland involvement, with an asso-
ciated decreased production of saliva and tears.
In secondary SS, the disorder occurs with other
autoimmune diseases, such as rheumatoid
arthritis, systemic lupus erythematosus, sclero-
derma, polymyositis and polyarteritis nodosa.
2,15
The onset of the disease often is insidious;
accordingly, diagnosis may be delayed for many
years. The female-to-male ratio has been esti-
mated to be 9:1, although reported ratios vary
considerably. The prevalence of primary SS
varies from 0.05 to 4.8 percent,
16
with approxi-
mately 1 million people in the United States esti-
mated to have the disease.
The pathogenesis of SS remains unclear.
2
Environmental agents (for example, viruses) may
trigger events in a genetically susceptible host.
Hormonal factors may play a role in the patho-
genesis, because SS occurs predominantly in
women. SS probably has a genetic component,
because SS autoantibodies (for example, anti-
Ro/Sjögren’s Syndrome A autoantibodies [anti-
Ro/SSA]) are higher in family members of

patients with the disease than they are in the
general population.
17
Typical oral findings in patients with SS and
xerostomia are described below for other xeros-
tomic patients (Box). In addition, diminished tear
production causes punctuate ulcerations of the
ocular surface termed “keratoconjunctivitis
sicca.” Other systemic findings include synovitis,
neuropathy, vasculitis and disorders of the skin,
thyroid gland, urogenital system and respiratory
and gastrointestinal tracts. Most serious is the
estimated 44-fold increase in the prevalence of
B-cell lymphomas among patients with SS.
18
Lab-
oratory test results frequently will be positive for
rheumatoid factor (90 percent of cases), anti-
Ro/SSA or anti-La/Sjögren’s Syndrome B auto-
antibodies (50 to 90 percent of cases), with the
presence of increased serum immunoglobulins.
19
CLINICAL FINDINGS OF XEROSTOMIA
AND SALIVARY HYPOFUNCTION
Saliva is essential for the preservation of oropha-
ryngeal health, and it serves many functions in
the oral and gastrointestinal environment. Saliva
aids in swallowing, oral cleansing, speech, diges-
tion and taste. When salivary hypofunction and
xerostomia occur, transient and permanent oral

and extraoral disorders can develop (Figure 1).
Patients with salivary hypofunction experience
numerous oral symptoms. Nighttime xerostomia
is common in these patients, because salivary
output typically reaches its lowest circadian
levels during sleep, and the problem may be exac-
erbated by mouth breathing. Taste may be dis-
turbed, as saliva stimulates gustatory receptors
located on the taste buds and delivers tastants
directly to the taste buds. Patients with chronic
xerostomia secondary to SS, head and neck radio-
therapy and other conditions experience a dimin-
ished ability to detect and recognize many gusta-
tory stimuli.
20
Saliva also is necessary to prepare food for
digestion and deglutition. Patients with low sali-
vary flow have difficulty masticating and swal-
lowing, particularly dry foods, and they may need
liquids to swallow food (Box). These problems can
lead to changes in food and fluid selection that
may compromise nutritional status. They also can
lead to an increased susceptibility to aspiration
pneumonia, with consequent colonization of the
lungs with gram-negative anaerobes from the gin-
gival sulcus.
21
Dentures. The lack of saliva and lubrication in
the denture-mucosal interface can produce den-
ture sores, and retention of prostheses may be

JADA, Vol. 138 September 2007 17S
BOX
Oral and pharyngeal effects
of salivary hypofunction.
dDental caries
dDry lips
dDry mouth
dDysgeusia
dDysphagia
dGingivitis
dHalitosis
dMastication problems
dMucositis
dOropharyngeal
candidiasis
dPoorly fitting
prostheses
dSleeping difficulty
dSpeech difficulty
dTraumatic oral lesions
Figure 1. Plaque and calculus accumulations in a patient with
severe salivary hypofunction and xerostomia.
Copyright ©2007 American Dental Association. All rights reserved.
reduced when the salivary film is inadequate.
Subjective complaints of halitosis, stomatodynia
(burning mouth and tongue) and intolerance to
acidic and spicy foods also have been reported.
22
Oral mucosal surfaces (that is, tongue, buccal
mucosa, floor of the mouth, palate, posterior oral

pharynx) become desiccated and friable. The sub-
sequent speech and eating difficulties that may
develop can impair social interactions and may
cause some patients to avoid social engagements.
Patients with salivary hypofunction are more
susceptible to developing mucosal candidiasis,
which can present with a pseudomembrane, ery-
thema of the underlying tissues and/or a burning
sensation of the tongue or other intraoral soft tis-
sues (Figure 2). Fungus-associated denture stom-
atitis usually is diagnosed on the basis of clinical
findings, although microscopy can confirm the
clinical diagnosis via the observation of mycelia
or pseudohyphae in a direct smear. Candida may
colonize the corners of the mouth extraorally
(angular cheilitis) in the areas where the lips are
cracked and dry.
Dental caries. A second frequently occurring
infection is new and recurrent dental caries
(Figure 3). This condition is particularly common
among older adults, many of whom now have
more retained natural teeth, a high number of
previously restored dental surfaces and gingival
recession predisposing teeth to root-surface
caries. Without sufficient saliva to restore the
oral pH and regulate bacterial populations, the
mouth is colonized rapidly with caries-associated
microorganisms.
Visible and palpable enlarged major salivary
glands develop if salivary glands are infected or

obstructed, such as in bacterial parotitis or
mumps. Patients with SS may develop salivary
enlargements, with or without an accompanying
infection. A swollen parotid gland can displace
the earlobe and extend inferiorly over the angle of
the mandible, whereas an enlarged sub-
mandibular gland is palpated medial to the pos-
teroinferior border of the mandible.
TREATING PATIENTS WITH XEROSTOMIA
The first step in treating patients with xero-
stomia is establishing a diagnosis. This fre-
quently involves a multidisciplinary team of
health care practitioners among whom communi-
cation is critical, because many older people have
concomitant medical problems and polypharma-
ceutical complications. The second step is to
schedule frequent dental evaluations to assess
patients for oral complications of low salivary
output.
22,23
A low-sugar diet and daily use of top-
ical fluorides and antimicrobial mouthrinses are
critical to help prevent dental caries (Table
24
).
Dry mucosal surfaces and dysphagia are treated
with oral moisturizers and lubricants, artificial
salivas and nighttime use of bedside humidifiers.
Clinicians must instruct patients to drink fluids
while eating, particularly if foods are dry and

rough.
For patients with remaining viable salivary
gland tissue, stimulation techniques are helpful.
Sugar-free chewing gum, candies and mints can
stimulate salivary output. The U.S. Food and
Drug Administration has approved two
18S JADA, Vol. 138 September 2007
Figure 2. Pseudomembraneous candidiasis plaques on the tongue
of a patient with salivary hypofunction and xerostomia.
Figure 3. New and recurrent dental caries in a patient who
received head and neck radiotherapy for a squamous cell carcinoma
of the tongue. The patient experienced permanent loss of salivary
function and xerostomia.
Copyright ©2007 American Dental Association. All rights reserved.
secretagogues, pilo-
carpine
25,26
and
cevimeline,
27,28
for the
treatment of xero-
stomia and salivary
hypofunction. These
drugs are effective in
increasing secretions
and diminishing
xerostomic complaints
in patients with suffi-
cient exocrine tissue.

Pilocarpine is a non-
selective muscarinic
agonist, whereas
cevimeline reportedly
has a higher affinity
for M1 and M3 mus-
carinic receptor sub-
types. Because M2
and M4 receptors are
located on cardiac and
lung tissues, cevime-
line treatment, in
theory, should
enhance salivary
secretions while
diminishing adverse
effects on pulmonary
and cardiac function.
Oral candidiasis is
a frequent complica-
tion of dry mouth and
most commonly is
treated with topical
antifungal agents
(Table). Oral rinses,
ointments, pastilles
and troches are effec-
tive for most forms of
oral candidiasis, and
systemic antifungal

therapy (for example, ketoconazole, fluconazole)
should be reserved for refractory disease and for
patients who are immunocompromised. Dentures
may harbor fungal infections and thus require
immersion once or twice daily in solutions con-
taining benzoic acid, 0.12 percent chlorhexidine
or 1 percent sodium hypochlorite. Daily denture
hygiene and use of topical antifungal ointment
also are helpful. Clinicians should treat patients
who have angular cheilitis with a combination of
antifungal and anti-inflammatory agents.
Drug substitutions may help reduce the
adverse side effects of medications that produce
xerostomia if similar drugs are available that
have fewer xerostomic side effects. For example,
Scully
29
reported that selective serotonin reuptake
inhibitors cause less dry mouth than do tricyclic
antidepressants.
If an older patient can take anticholinergic
medications during the daytime, nocturnal xero-
stomia can be diminished, because salivary
output is lowest at night.
8
In addition, if a patient
JADA, Vol. 138 September 2007 19S
TABLE
Treatment of xerostomia-associated problems.*
XEROSTOMIA-ASSOCIATED

PROBLEM
TREATMENT STRATEGY
* Source: Ship.
24
Dental Caries
Dry Mouth
Dysgeusia
Dysphagia
Oral Candidiasis
Bacterial Infections
Poorly Fitting Prostheses
dDaily use of fluoridated dentifrice (0.05 percent
sodium fluoride)
dDaily use of prescription fluoride gel (1.0 percent
sodium fluoride, 0.4 percent stannous fluoride)
dApplication of 0.5 percent sodium fluoride varnish
to teeth
dDental examinations at least every six months and
bitewing radiographs every 12 months for early
diagnosis
dOral moisturizers/lubricants, mouthwashes
and sprays
dSugar-free gums, mints, lozenges
dArtificial salivary replacements
dPrescription sialogogues: pilocarpine (5 milligrams
three times per day and at bedtime); cevimeline
(30 mg three times per day)
dLubricants on lips every two hours
dUse of bedside humidifier during sleeping hours
dDrinking of fluids while eating

dCareful eating, with fluids
dCopious use of fluids during meals
dAvoidance of dry, hard, sticky and difficult-to-
masticate foods
dAntifungal rinses: nystatin oral suspension
(100,000 units/milliliter), rinse four times per day
dAntifungal ointments: nystatin ointment applied
four times per day
dAntifungal lozenges dissolved in mouth four times
per day, nystatin pastilles (200,000 units),
clotrimazole troches (10 mg), nystatin vaginal
suppositories
dDenture antifungal treatment (daily hygiene): soak
prosthesis for 30 minutes in benzoic acid,
0.12 percent chlorhexidine or 1 percent sodium
hypochlorite
dSystemic antibiotic therapy for 10 days: amoxicillin
with clavulanate (500 mg every eight hours);
clindamycin (300 mg three times per day);
cephalexin (500 mg every six hours)
dIncrease in hydration
dSalivary stimulation with sugar-free gums, mints,
lozenges
dSoft- and hard-tissue relines by dentist
dUse of denture adhesives
Copyright ©2007 American Dental Association. All rights reserved.
can divide his or her drug dosages, he or she may
be able to avoid the side effects caused by a large
single dose. A dentist’s scrutiny of drug side
effects can assist in diminishing the xerostomic

potential of many pharmaceuticals used by elderly
patients.
CONCLUSION
Complaints of a dry mouth (xerostomia) and
diminished salivary output (salivary hypofunc-
tion) are common in elderly people as a result of a
plethora of salivary gland disorders, medication
use and medical disorders. Dry mouth problems
have a clinically significant deleterious impact on
oropharyngeal health. Clinicians must be able to
diagnose dry mouth disorders in their elderly
patients and provide preventive and interven-
tional treatments to reduce the impact of these
disorders on an older person’s quality of life. ■
1. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric
patient. J Am Geriatr Soc 2002;50(3):535-43.
2. Fox PC. Autoimmune diseases and Sjögren’s syndrome: an autoim-
mune exocrinopathy. Ann N Y Acad Sci 2007;1098:15-21.
3. Shiboski CH, Hodgson TA, Ship JA, Schiodt M. Management of
salivary hypofunction during and after radiotherapy. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2007;103(supplement 1):S66-S73.
4. Bergdahl M. Salivary flow and oral complaints in adult dental
patients. Community Dent Oral Epidemiol 2000;28(1):59-66.
5. von Bultzingslowen I, Sollecito TP, Fox PC, et al. Salivary dysfunc-
tion associated with systemic diseases: systematic review and clinical
management recommendations. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;103(supplement 1):S57-S65.
6. Ghezzi EM, Wagner-Lange LA, Schork MA, et al. Longitudinal
influence of age, menopause, hormone replacement therapy, and other
medications on parotid flow rates in healthy women. J Gerontol A Biol

Sci Med Sci 2000;55(1):M34-M42.
7. Ghezzi EM, Ship JA. Aging and secretory reserve capacity of major
salivary glands. J Dent Res 2003;82(10):844-8.
8. Sreebny LM, Schwartz SS. A reference guide to drugs and dry
mouth: 2nd edition. Gerodontology 1997;14(1):33-47.
9. Närhi TO. Prevalence of subjective feelings of dry mouth in the
elderly. J Dent Res 1994;73(1):20-5.
10. Thomson WM, Chalmers JM, Spencer AJ, Slade GD. Medication
and dry mouth: findings from a cohort study of older people. J Public
Health Dent 2000;60(1):12-20.
11. Epstein JB, Tsang AH, Warkentin D, Ship JA. The role of salivary
function in modulating chemotherapy-induced oropharyngeal
mucositis: a review of the literature. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2002;94(1):39-44.
12. Meurman JH, Laine P, Lindqvist C, Teerenhovi L, Pyrhonen S.
Five-year follow-up study of saliva, mutans streptococci, lactobacilli
and yeast counts in lymphoma patients. Oral Oncol 1997;33(6):439-43.
13. Allweiss P, Braunstein GD, Katz A, Waxman A. Sialadenitis fol-
lowing I-131 therapy for thyroid carcinoma: concise communication.
J Nucl Med 1984;25(7):755-8.
14. Eisbruch A, Ten Haken RK, Kim HM, Marsh LH, Ship JA. Dose,
volume, and function relationships in parotid salivary glands following
conformal and intensity-modulated irradiation of head and neck cancer.
Int J Radiat Oncol Biol Phys 1999;45(3):577-87.
15. Vitali C, Bombardieri S, Jonsson R; European Study Group on
Classification Criteria for Sjögren’s Syndrome, et al. Classification cri-
teria for Sjögren’s syndrome: a revised version of the European criteria
proposed by the American-European Consensus Group. Ann Rheum
Dis 2002;61(6):554-8.
16. Pillemer SR, Matteson EL, Jacobsson LT, et al. Incidence of

physician-diagnosed primary Sjögren syndrome in residents of Olmsted
County, Minnesota. Mayo Clinic Proc 2001;76(6):593-9.
17. Fox RI, Stern M, Michelson P. Update in Sjögren syndrome. Curr
Opin Rheumatol 2000;12(5):391-8.
18. Kassan SS, Thomas TL, Moutsopoulos HM, et al. Increased risk of
lymphoma in sicca syndrome. Ann Intern Med 1978;89(6):888-92.
19. Bell M, Askari A, Bookman A, et al. Sjögren’s syndrome: a critical
review of clinical management [published correction appears in
J Rheumatol 1999;26(12):2718]. J Rheumatol 1999;26(9):2051-61.
20. Spielman AI, Ship JA. Taste and smell. In: Miles TS, Nauntofte
B, Svensson P, eds. Clinical oral physiology. Copenhagen, Denmark:
Quintessence; 2004:53-70.
21. Loesche WJ, Bromberg J, Terpenning MS, et al. Xerostomia, xero-
genic medications and food avoidances in selected geriatric groups.
J Am Geriatr Soc 1995;43(4):401-7.
22. Atkinson JC, Wu A. Salivary gland dysfunction: causes, symp-
toms, treatment. JADA 1994;125(4):409-16.
23. Fox PC. Management of dry mouth. Dent Clin North Am
1997;41(4):863-76.
24. Ship JA. Diagnosing, managing, and preventing salivary gland
disorders. Oral Dis 2002;8(2):77-89.
25. Johnson JT, Ferretti GA, Nethery WJ, et al. Oral pilocarpine for
post-irradiation xerostomia in patients with head and neck cancer.
N Engl J Med 1993;329(6):390-5.
26. Vivino FB, Al-Hashimi I, Khan Z, et al. Pilocarpine tablets for the
treatment of dry mouth and dry eye symptoms in patients with Sjögren
syndrome: a randomized, placebo-controlled, fixed-dose, multicenter
trial. P92-01 Study Group. Arch Intern Med 1999;159(2):174-81.
27. Petrone D, Condemi JJ, Fife R, Gluck O, Cohen S, Dalgin P. A
double-blind, randomized, placebo-controlled study of cevimeline in

Sjögren’s syndrome patients with xerostomia and keratoconjunctivitis
sicca. Arthritis Rheum 2002;46(3):748-54.
28. Fife RS, Chase WF, Dore RK, et al. Cevimeline for the treatment
of xerostomia in patients with Sjögren syndrome: a randomized trial.
Arch Intern Med 2002;162(11):1293-300.
29. Scully C. Drug effects on salivary glands: dry mouth. Oral Dis
2003;9(4):165-76.
20S JADA, Vol. 138 September 2007
Copyright ©2007 American Dental Association. All rights reserved.