June Sadowsky DDS MPH Associate Professor Dentist Geriatrician The University of Texas Health Science Center at Houston School of Dentistry General Practice and Dental Public Health 1 Dr June Sadowsky ID: 916341
Download Presentation The PPT/PDF document "Oral Health with a Focus on Disabilit..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Oral Health with a Focus on Disabilities
June Sadowsky, DDS, MPHAssociate Professor, Dentist GeriatricianThe University of Texas Health Science Center at HoustonSchool of DentistryGeneral Practice and Dental Public Health
1
Slide2Dr. June SadowskyDr. June Sadowsky was a member of the HRSA funded Houston Geriatric Education Center when this presentation was developed. Dr. Sadowsky has presented this work to interprofessional audiences. Please credit her for the work she provided in the development and updating of this presentation.
2
Slide3Funded ByThis project was funded by a grant from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The grant was initially funded in 2007 with renewed funding for five years beginning in 2010. (Grant #UB4HP19058). The grant was successfully completed in June, 2015.
Slide4Learning Objectives
Successful completion will allow the student to:Gain knowledge of the risk factors associated with oral health and disabilitiesPerceive the oral manifestations of systemic diseaseBe aware of the diseases and oral management
Understand some interventions to assist older adults
4
Slide55
School of Dentistry
7500 Cambridge, Houston, Texas 77054
Slide6Major Risk Factors
Periodontal diseaseCariesSocio-behavioral factorsEnvironmental factors Health status6
UT Health 2002
Slide7A Risk Factor for
Cardiovascular Disease7
Scannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic Diseases. JPeriodontal
. 1998 Jul;69(7)841-50.
and Association
between periodontitis and anti-
cardiolipin
antibodies in Buerger
disease. ChenYW etal ,J Clin Periodontol,
2009 Oct;36(10):
830-5.
Slide8Other Risk Factors
8
Genco RJ, Borgnakke WS. Risk
factors for periodontal disease. Periodontology 2000
Volume
62, Issue 1,
pages 59–94, June
2013
Medications which reduce saliva flow
Smoking
Diabetes
Cancer
Microsoft
Slide9Link
Between Heart Disease
and Gum Disease
Inflammation is a major risk factor for heart disease, and periodontal disease may increase the inflammation level throughout the body. Since several studies have shown that patients with periodontal disease have an increased risk for cardiovascular disease,
cardiologists
and
periodontis
ts
developed
clinical recommendations
and will
now see
joining
forces to help
patients.
British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81 showed that there was an unexpected correlation between dental disease and systemic disease (stroke, heart disease, diabetes).
9
A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The Online Versions Of Two Leading Publications, The
American Journal Of Cardiology
(AJC), A Publication Circulated To 30,000 Cardiologists, And The
Journal Of Periodontology
(JOP), The Official Publication Of The American Academy Or Periodontology (AAP). J Periodontol • July
2009. Jeffcoat
MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum,
Impact
of Periodontal Therapy on General Health
American Journal of Preventive
Medicine
Volume
47, Issue 2
, Pages 166–174, August 2014
Slide10Caries Risk
85% had coronal and/or root caries> 75% were taking medications with hyposalivary side effectsLack of fluoride in oral environmentSaliva very acidic
10
Caries Activity And Associated Risk Factors In Elderly Hospitalized
Population – 15-months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58
Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463.
Slide11Environmental FactorsSocietal healthcareCultural
valuesEducationHealth promotionLifestyle choicesStressWork–related environmentFluoridated water
Sugar consumptionAlcohol use
11
Slide1212
Environmental Quality
Built Environment
Environmental Factors
University of Wisconsin Population Health Institute Model 2012
Physical Environment 10%
Social and economic factors -40%
Health Behaviors – 30%
Clinical Care -20%
Mortality (length of life) 50%
Morbidity (quality of life) 50%
Tobacco use
Diet and exercise
Alcohol use
Sexual Activity
Access to Care
Quality of Care
Community Safety
Education
Employment
Family and Social Support
Income
Health Outcomes
Health Factors
Policies and Programs
Slide13Socio-Behavioral Risk FactorsHuman biology Vulnerability
Health care organization Public policy changesLifestyleDevelop personal skills to deal with lifeRecreationUse fluoride productsEnvironmentCreate more support for elderlyIncome inequality
13
1974, Marc Lalonde
Google.com/images
Slide1414The common risk factor approach (adapted from Petersen, 2003)
Petersen PE, Sociobehavioural risk factors in dental caries – international perspectives, Community Dentistry and Oral Epidemiology
Volume 33, Issue 4, pages 274–279, August 2005
Slide15Health Status
TobaccoAlcoholDiet – well balanced Decrease sugar intakeIncrease fruit and vegetableVitamin D deficiencyFluoride use and plaque removal twice per day
Regular dental checkups
15
Microsoft.com
Slide16Caries Management By
Risk Assessment
Caries
Risk Assessment
Treatment Plan
Caries Free
Education
16
http://ncpresby.pbworks.com/f/dental%2016.jpg
Slide17Chronic Diseases
Heart diseaseStrokeCancerChronic respiratory diseases DiabetesREPRESENT 60% OF DEATHS
17
chronicdiseases@who.int
Microsoft.com
Slide18Manifestations of Systemic Disease
18
Slide19GI Disease Oral manifestations
Crohn’s diseaseNoncaseating granulomasLip, mucosal swellingCobblestone-like gingivaMucosal tagsAngular chelitisDecreased saliva production and malabsorption may lead to dental caries
Ulcerative colitis
Areas of hemorrhage and ulcerationAphthous ulcers and chelitisGERD
Mouth pH – 5.5
Erosion
Sensitivity
Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohn’s Disease
N Engl J Med. June 1 200; 342(22):
1644
Beitman RG
, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 26, No.8 (August 1981
)
Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J
Gastroenterol
.Apr 2007;21(4):241-4
19
Slide20Chronic Liver Disease
Liver Dysfunction
Coagulation/Vitamin K deficiency
Gingival bleeding (in the absence of inflammation)
Petechiae
Jaundice (bilirubin
in submucosa
of soft palate)
Hepatitis
- lichen planus, xerostomia, sialadenitis, erosive lesions
ALD or Cirrhosis
20
Cruz-Pamplona M,
Margaix
-Muñoz M, Gracia
Sarrión
-Pérez
MG.
Dental
considerations in patients with liver disease. J Clin
Exp
Dent.2011;3(2
):e127-34
.
Microsoft.com
CD Johnson
Slide21Chronic Kidney Disease
Presence of kidney damage or decreased kidney functionChronic NSAID useOral symptomsAmmonia like taste and smell (urea in saliva) and frost on skinStomatitisGingivitisParotitisXerostomia
Decreased salivary flowAtrophic glossitisThirst
21
Little JW. Dental management of the
m
edically compromised patient. 2013 Elsevier/
Mosby
, St. Lous Mo. Cruz-Pamplona
M, Margaix-Muñoz M, Gracia Sarrión-Pérez
MG.
Dental
considerations in patients with liver disease. J Clin
Exp
Dent.2011;3(2
):e127-34
.
Google.com/images
Slide22Anemia
Occult Blood LossIron deficiency AnemiaChronic inflammationB-12 Deficiency (Pernicious Anemia)GastrectomyFolate DeficiencyOral ManifestationsPale gums
Glossitis (folate and Vitamin B-12 deficiency)Angular stomatitis (candida infection)Pica (desire to consume unusual substances, such as ice or dirt)
22
Spivak JL. Anemia In The Elderly: Time For New Blood In Old Vessels?.
Arch Intern Med
. Oct 24 2005;165(19):2187-9.
Slide23Connective Tissue Disorders
23
Porter S, Scully C
.
Connective tissue disorders and the mouth. Dent Update 2008
Jun;35(5):294-6, 298-300, 302
.
Klasser GD, Balasubramaniam R Epsein
J,Topical
review-connective tissue diseases: orofacial manifestations including pain.
J
Orofac
Pain .2007
Summer;21(3):171-84
.
Sjogren’s Syndrome
90% females over 50
Sicca syndrome – dry eyes and mouth
Xerostomia
Atrophy of papillae of tongue produces a cobblestone effect
Increased incidence of candida infection
Dental caries
Slide24Pulmonary Conditions
COPD90% caused by smokingAir pollutionIrreversible damage to the airways
Restricts movementCough and breathlessnessSoft palate irritation from inhaler useDry mucous membranes
Wegener’s granulomatosisNecrotizing vasculitisUlceration and hyperplastic gingival enlargement
24
Maclay
JD,
Rabinovich
RA,
MacNee
W. Update in chronic obstructive pulmonary disease 2008.
Am J
Respir
Crit
Care Med
. Apr 1 2009;179(7):
533-41 Stewart C, Cohen D,
etal. Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review.
J Am Dent Assoc.
2007 Mar;138(3):338-48; quiz 396,
398
Slide25Diabetes
Affects approximately one in four Americans age 60 and olderThe number of adults age 75+ with1 million in 2000 to more than 4 million in 205023.1% of patients 60+
OR one of every 4.2 patients you see over the age of 60!
5.7 million are undiagnosed
82%
of diabetic patients with severe periodontal disease have experienced one or more
Major cardiovascular
Cerebrovascular
Peripheral vascular events
Compared to only
21% of diabetics without periodontal disease
Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and worldwide.
MMWR
2003;52(06):101-106
Measley
BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus.
J Periodontol 2006
Aug;77(8):1289-130
25
http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages
Slide26Diabetes
Uncontrolled diabetics exhibit higher levels of collagenase that can degrade periodontal tissues(Ryan 2003, Salvi 1997)Periodontal disease results in higher pro-inflammatory cytikine TNF-
ﻪ that causes insulin resistance(Grossi 1998)
Diabetic patients who have full-mouth disinfections
every three months showed significant reductions in their HbA1c serum levels (blood glucose)
(Lang 2008)
26
Slide27ArthritisLeading cause of disability
Affects 8 millionSeverely limits ability to perform Activities of Daily Living (ADL’s) Loss of Range of Motion
StiffnessJoint DeformityOverweight, FatigueUnexplained fever
May affect TMJ (temporomandibular joint)
Rutger
Persson
G. Rheumatoid arthritis and periodontitis: inflammatory and infectious connections: review of the literature. J Oral Microbiol 2012; 4:10
.
27
Slide28ArthritisJoint Pain, tenderness and inflammation
CRP=C-Reactive Protein in blood serum produced in the liver during acute inflammation or infectionOsteoarthritis – commonRheumatoid - + RF in bloodGout – Uric acid
Beer, sardines, organ meats
Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:10–25
Eke
PI, Dye BA, Wei L,
et al
. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental Res 2012; 91:914–920
.
28
Slide29Arthritis and Periodontal Disease
Patients referred for periodontal treatmentprevalence of self-reported rheumatoid arthritis was 3.95% Significantly higher than that seen in patients not referred for periodontal treatment (0.66%)that reported in the general population (1%).
29
Demmer
RT,
Molitor
JA, Jacobs DR Jr,
Michalowicz
BS. Periodontal disease, tooth loss and incident rheumatoid arthritis: results from the First National Health and Nutrition Examination Survey and its epidemiological follow-up study. J Clin Periodontol 2011; 38:998–1006
Slide30Arthritis and Periodontal DiseaseOf those referred patients with rheumatoid arthritis, 62.5%
advanced forms of periodontal diseaseself-reported prevalence of cardiovascular disease and diabetes mellitus30
Arkema EV, Karlson
EW, Costenbader KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol
2010; 37:1800–1804
Slide31Arthritis and Periodontal DiseaseConclusions:
there is good evidence to suggest that individuals with moderate to severe periodontal disease are at higher risk of suffering from rheumatoid arthritis and vice versa.31
Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April
2000
Arkema
EV,
Karlson
EW,
Costenbader
KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J
Rheumatol
2010; 37:1800–1804
Slide32OsteoporosisPeople with osteoporosis are much more likely to lose their teeth due to bone loss in the jaw.Good homecare is even more important to help prevent tooth loss.
Osteoporosis TreatmentBone-replacing cells in bone are suppressed and if an extraction, bone may not heal.
Mattson JS1,
Cerutis DR,
Parrish
LC
.Osteoporosis
: a review and its dental implications.
Compend
Contin
Educ
Dent.
2002 Nov;23(11):1001-4
Dervis
E
. Oral implications of osteoporosis.
Oral
Surg
Oral Med Oral Pathol Oral
Radiol
Endod
.
2005 Sep;100(3):349-56.
32
Slide33Oral Manifestation of Viral Diseases
HerpesZoster (Shingles)
33
Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007
Slide34Oral Manifestation of Viral Diseases
Human papillomavirusSquamous cell papilloma and verruca vulgarisHuman immunodeficiency virus
Plantar warts on hands
34
Schubert MM. Oral manifestations of viral infections in immunocompromised patients. Curr
Opin
Dent 1991;1:384-97.
Bouquot
JE.Herpes Zoster, Texas Dental Journal, 2007
Slide35Head and Neck Cancer
Incidence oral and pharyngeal cancer in 2012 in the US 40,250 new cases (28,540 in men and 11,710 in women)Estimated Deaths in 20127,850 people (5,440 men and 2,410 women)Careful monitoring of the oral cavity with strict application of preventive measures
Lower radiation doses or intensity-modulated radiotherapy (IMRT) Use of shielding Reduction in the use of toxic drugs
Improved oral instructions and expectationsCompletion of dental treatment before beginning cancer care benefits the patient greatly
35
http://www.cancer.org/acs/groups/cid/documents/webcontent/003128-pdf.pdf
Slide36Drug Induced Oral Manifestations
Apthous stomatitisCanker soresLichen PlanusACE inhibitorsBeta-blockersNSAID’sDiureticshydroxychloroquin
eGingival Enlargement (hyperplasia)PhenytoinCa+ Channel Blockers
Cyclosporine
Dry Mouth/Xerostomia (hyposalivation)
Single most adverse effect
Anticholinergic effect
Alters taste
Difficulty eating , swallowing
Treatment
Increased hydration
Artificial saliva
Procholinergic agents
Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C Virus And Lichen Planus: A Case Control Study Of 340 Patients. J Am Acad Dermatol, Nov 1999;4195):787-9
Abdollahi
M,
Radfar
M; A review of drug induced manifestations, J
Contemp
Dent
Prac
, 2003(2)1:10-31
36
Slide37Dry Mouth
37
CD Johnson
Slide38Drug Induced Oral ManifestationsStevens-Johnson Syndrome
3 weeks after medsRash to purpuric macules50 % oralSulfonamidesPenicillin PhenytoinPhylbutazone
Drug -induced NeutropeniaUlcers on gingivaFungal Infections
RadiationChemotherapeuticsImmunosuppressives
Bologna JL, Jorizzo, JL, Papini, RP, Dermatology. Spain: Mosby 2003
38
Slide39Candidiasis
39
Slide40Diseases and Oral Management
40
Slide41Disease and Oral Management
Alzheimer’s/dementiaDental Management Of Patients With Alzheimer's Disease And Other Dementias (Ronald L Ettinger July 2000volume 17, Issue 1pages X–xi, 1–64)
Alzheimer's Disease And Dental Management
(Hümeyra Kocaelli Etal Oral Surg, Oral Med, Oral Path, Oral Rad and Endo Vol 93 5, May 2002, Pages 521-524)
Stroke
Movement disorders
Parkinson’s
Oral Health and Peripheral Arterial Disease.
Hung HC, Circulation. 2003; 107: 1152-1157
Oral care for patients with cardiovascular disease and stroke (
Louis F. Rose LF, Etal.
J Am Dent Assoc, Vol 133, No suppl1, 37S-44S. 2002)
Can’t do ADL’s
41
Slide42Disease and Oral Management
Continued growth of population over 65Globally oral health is poor in elderlyPrevention is not emphasizedThose in dependent situations have few oral caregiversMore people are keeping their teeth longer means more teeth at risk42
World Wide Public Health Of Elderly - Improving The Oral Health Of Older People: The Approach Of The WHO Global Oral Health Programme Poul Erik Petersen, Tatsuo Community Dentistry And Oral Epidemiology
Volume 33, Issue 2,
Pages 81–92, April 2005
Slide43Disease and Oral Management
Long –term carePatient consent issuesSeventy percent of patients in long-term care facilities had unacceptable levels of oral hygiene (Kiyak et al. 1987, McIntyre et al. 1986)lack of knowledge about oral careHomeboundHospiceOral Cancer patients
Majority elders
43
Kiyak HA. An explanatory model of older persons’ use of dental services: implications for health policy. Med Care 1987;25:936–52
.
MacEntee
MI, Weiss R,
Waxler
-Morrison NE, Morrison BJ. Factors influencing oral health in long term care facilities. Community Dent Oral Epidemiol 1987;15: 314–6
.
Slide44Other Barriers to Dental Care
AccessTransportationHousingLive in abandoned car LegalVA BenefitAlien status
44
Slide45Interventions to Assist Older Adults
45
Slide46Management OptionsEducationEntities caring for seniors
Students and faculty to retain patientsLinkage to Community ResourcesTransportationMental HealthLivingCaregivingOutreach to Seniors concerning dental needs
46
Slide47Management OptionsEducation
Caregiver training video designed for nursing homes, assisted living facilities, and
individuals.Make a donation of one to a
facility near you.
47
Slide48Dental Management
Make all offices elder friendlyLiteracy alert Bigger printLanguage easy to understandEducate caregivers
Alter toothbrushesForms for daily documentation of oral careMobile/portable dental teams
48
Slide49ReferencesScannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic Diseases J. Periodontal. 1998 Jul;69(7)841-50
ChenYW etal . Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. J Clin Periodontol, 2009 Oct;36(10):830-5.Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000
Volume 62, Issue 1, pages 59–94, June 2013A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The Online Versions Of Two Leading Publications, The
American Journal Of Cardiology (AJC), A Publication Circulated To 30,000 Cardiologists, And The
Journal Of Periodontology
(JOP), The Official Publication Of The American Academy Or Periodontology (AAP). J Periodontol • July
2009
Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum,
Impact
of Periodontal Therapy on General Health American Journal of Preventive
Medicine
Volume
47, Issue 2
, Pages 166–174, August 2014
British Medical Journal (BMJ), 1989 Mar 25;298(6676):
779-81
Caries Activity And Associated Risk Factors In Elderly Hospitalized Population – 15-months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58
Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463.
49
Slide50ReferencesUniversity of Wisconsin Population Health Institute Model
20121974, Marc Lalondechronicdiseases@who.intStricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohn’s Disease N Engl J Med. June 1 200; 342(22):1644Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 26, No.8 (August 1981)
Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J Gastroenterol .Apr 2007;21(4):241-4
Bagan JV, Aguirre JM etal; Oral lichen planus and chronic liver disease: A clinical and morphometric study of the oral lesions in relation to transaminase elevation; Oral Surgery, Oral Medicine, Oral
Pathology
Volume
78, Issue 3
, September 1994, Pages
337–342
Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.
Dental considerations in patients with liver disease. J Clin
Exp
Dent.2011;3(2):e127-34
.
Little JW. Dental management of the medically compromised patient. 2013 Elsevier/
Mosby
, St. Lous Mo.
Porter S, Scully C
.
Connective tissue disorders and the mouth. Dent Update 2008 Jun;35(5):294-6, 298-300, 302.
Klasser GD, Balasubramaniam R Epsein J, Topical review-connective tissue diseases: orofacial manifestations including pain. J Orofac Pain. 2007 Summer;21(3):171-84.
50
Slide51ReferencesMaclay
JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care Med. Apr 1 2009;179(7):533-41 Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review.
J Am Dent Assoc. 2007 Mar;138(3):338-48; quiz 396, 398
Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and worldwide. MMWR 2003;52(06):101-106 Measley
BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J Periodontol 2006 Aug;77(8):
1289-130
http://
diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages
The influence of diabetes on periodontal disease, Ryan ME,
Carnu
O,
Kamer
A. JADA, Vol. 34, (10): 34S-40S.
Salvi G,
Yalda
B, Collins J, et al. Inflammatory mediator response as a potential risk marker for periodontal diseases in insulin dependent diabetes mellitus patients. J Periodontol 1997;68(2):
127:35.
Grossi SG, Genco RJ: Periodontal disease and diabetes mellitus: a two-way relationship. Ann Periodontol 3:51–61,
1998
Lang NP, Tan WC,
Krahenmann
MA,
Zwahlen
M. A
systematic review of the effects of full-mouth debridement with and without antiseptics in patients with chronic periodontitis.
J Clin Periodontol.
2008 Sep;35(8 Suppl):8-21
.
51
Slide52ReferencesDye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:10–25
Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental Res 2012; 91:914–920.Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth loss and incident rheumatoid arthritis: results from the First National Health and Nutrition Examination Survey and its epidemiological follow-up study. J Clin Periodontol 2011;
38:998–1006Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000
Arkema EV, Karlson EW,
Costenbader
KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J
Rheumatol
2010;
37:1800–1804
Mattson JS,
Cerutis
DR, Parrish LC. Osteoporosis: a review and its dental implications.
Compend
Contin
Educ
Dent.
2002 Nov;23(11):1001-4
Dervis
E. Oral
implications of osteoporosis.
Oral
Surg
Oral Med Oral Pathol Oral
Radiol
Endod
.
2005 Sep;100(3):349-56
.
Zachariasen RD, Oral manifestations of menopause. Compendium, 1993, 14(12):1584, 1586-91
52
Slide53QuestionsJune M. Sadowsky, DDS, MPH
713-500-4064 June.Sadowsky@uth.tmc.eduImagesHoustonGEC would like to thank: Microsoft imagesGoogle.com imagesUTHEALTH School of Dentistry
New Patient Information UTHealth School of Dentistry
713-486-4000
53