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Involvement of ayurvedic practitioners in oral health care in the United States
RESEARCH
Involvement of ayurvedic practitioners in oral health care in the United States Bhupinder S. Brar, BAMS, MS, CCRC; Robert G. Norman, MS, PhD; Ananda P. Dasanayake, BDS, MPH, PhD
yurveda is an ancient medical science that originated in India more than 3,000 years ago. Ayurveda is a Sanskrit word made up of two words: “ayur,” which means life, and “veda,” which means science or knowledge. This science of life is a qualitative holistic science of health and longevity; a philosophy; and a system of healing the entire person in mind, body and spirit. Ayurveda is composed of elements of physiology, pathology, pharmacology, materia medica and surgery. Ancient ayurvedic textbooks consisted of 100 sections, each with 1,000 stanzas comprising up to 100,000 verses in eight books. Bin Mohammed and colleagues1 described how Charaka and Sushruta rearranged these books into chapters about surgery, nosology, anatomy, therapeutics, toxicology and local diseases. Ayurvedic treatment includes herbal medicines, massages with medicinal oils, dietary instructions, lifestyle instructions and bodypurification procedures. This traditional form of medicine also is practiced in Asian countries other than India and
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A B ST RACT Background. Ayurveda, an ancient medical science originating in India, also is practiced in the United States. The authors conducted a study primarily to explore the involvement of ayurvedic practitioners in treating oral diseases. Methods. Eighty-five practitioners participated in this cross-sectional survey. The authors obtained self-reported data on demographics of the practitioners, the general and oral health conditions they treated, and the treatment modalities used. They performed descriptive statistical and logistic regression analyses by using statistical software. Results. Participants predominantly were female and white or nonHispanic, as well as part-time practitioners. Their educational backgrounds ranged from a 51⁄2 -year bachelor’s degree in ayurveda to shortterm training. Of the 60 respondents who answered the question about treating oral diseases, 25 (42 percent) reported that they did so. Conditions treated were related to oral malodor, gingival or periodontal disease and toothache. Ayurvedic treatments administered for these conditions primarily were preventive in nature. Conclusions. Ayurvedic practitioners in the United States treat a variety of oral diseases by using predominantly preventive traditional care. Ayurvedic practitioners of Asian origin and those who practiced for a longer duration were more likely to report that they treated oral diseases. Larger, population-based studies are needed to understand more fully the current role of ayurvedic practitioners in oral health care. Ayurvedic treatment modalities aimed at oral diseases need to be evaluated through rigorous randomized controlled trials for safety and effectiveness. Practice Implications. Patients with limited or no access to oral health care might seek ayurvedic treatment, and those who have access to conventional oral health care might wish to complement it with ayurvedic treatment. Practitioners can incorporate preventive ayurvedic treatments, which are based mainly on natural products, into overall preventive care regimens, if proven safe and effective. Key Words. Ayurveda; ayurvedic; complementary medicine; alternative medicine. JADA 2012;143(10):1120-1126.
Dr. Brar is a junior research scientist, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, 250 Park Ave. South, 6th Floor, New York, N.Y. 10003, e-mail [email protected]. Address reprint requests to Dr. Brar. Dr. Norman is an associate professor, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York City. Dr. Dasanayake is a professor, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York City.
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is gaining acceptance in Western countries.2-5 An estimate from a 1994 national survey by the Robert Wood Johnson Foundation showed that about 10 percent of the U.S. population sought alternative therapies during that year, including ayurveda,6 and survey results from a nationally representative sample in 1997 showed that more than two-thirds of the U.S. population used complementary and alternative medicine (CAM) therapies at least once in their lives.7 In ayurveda, specific treatments and procedures are described for various oral diseases. Athavale8 described various diseases of gingivae and teeth. He also described ayurvedic treatments for dental diseases such as halitosis, caries, periodontal diseases, gingivitis, bleeding gingivae and tooth extraction.8 Today, ayurveda is practiced in almost every state in the United States, and ayurvedic institutions provide formal education and training. These include the Kripalu School of Ayurveda, Stockbridge, Mass.; California College of Ayurveda, Cerritos; Kerala Ayurveda Academy/Ayurvedic School, Seattle; and Maharishi University of Management, Fairfield, Iowa. Ayurvedic practitioners also have formed various organizations and associations in the United States, such as the Association of Ayurvedic Professionals of North America (AAPNA), Coopersburg, Pa.; the National Ayurvedic Medical Association, Santa Cruz, Calif.; the Washington Ayurvedic Medical Association, Seattle; and the Colorado Ayurvedic Medical Association, Boulder. We conducted a survey of ayurvedic practitioners in the United States with the primary objective of evaluating their role in treating patients with oral diseases. The specific aims of the study were as follows: dto assess the level of education of U.S.-based ayurvedic practitioners; dto estimate the mean number of patients with various diseases treated per year by U.S.-based ayurvedic practitioners; dto identify the ayurvedic specialties that are practiced in the United States (for example, herbal medicine, diet, massage, body purification); dto evaluate whether U.S.-based ayurvedic practitioners treat oral diseases, and, if so, to identify associated factors; dto estimate the mean number of patients with oral diseases treated annually by U.S.-based ayurvedic practitioners; dto identify the ayurvedic procedures that practitioners perform to treat oral diseases; dto determine whether practitioners identified
any adverse effects of ayurvedic treatments. METHODS
The institutional review board of the School of Medicine, New York University, New York City, approved the study protocol as an exempt study. One of us (B.S.B.), an ayurvedic practitioner, designed a 30-question survey with the help of an epidemiologist (A.P.D.) and a statistician (R.G.N.). We pretested the survey with two ayurvedic practitioners who did not participate in the main study. The survey included questions related to these five major areas: demographics, education, general ayurvedic practice, oral health care, and licensing and affiliations. Study participants and data collection. The population of interest was ayurvedic practitioners who were currently working in the United States. Because these practitioners were not registered as ayurvedic practitioners in the United States, it was difficult to obtain a complete list of, and contact information for, practitioners. However, lists of ayurvedic practitioners were available on Web sites of the ayurvedic organizations. We contacted two prominent organizations, and the AAPNA invited us to attend its third International Ayurveda Conference in Woburn, Mass., in August 2011. In addition, the organization allowed us to distribute our self-administered survey to the conference attendees. We e-mailed the survey to members who did not attend the conference by using an online survey link. Those who did not have email addresses received a hard copy of the survey via regular mail, along with return envelopes with prepaid postage. We also mailed the survey to those who did not respond to the online survey (a study flowchart is available as supplemental data to the online version of this article [available at http://jada.ada.org]). Data analysis. The principal investigator (B.S.B.) collected, managed and analyzed the data under the guidance of the other two investigators (R.G.N., A.P.D.). We used software (EpiData, version 3.1, EpiData Association, Odense, Denmark) to create a database and exported the data for further analysis (IBM SPSS, Armonk, N.Y.). We summarized data by using frequencies, cross-tabulations and other descriptive analyses. We used logistic regression analysis to identify the characteristics of practitioners who treated patients with oral diseases. We considABBREVIATION KEY. AAPNA: Association of Ayurvedic Professionals of North America. BAMS: Bachelor of ayurvedic medicine and surgery. CAM: Complementary and alternative medicine. JADA 143(10)
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RESEARCH TABLE
of the participants stated that they did not have any formal eduPractitioners’ use of ayurveda in oral health cation in ayurveda, and only 16 care, according to survey findings. (20 percent) had a bachelor of SURVEY ITEM NO. (%) OF PRACTITIONERS*† ayurvedic medicine and surgery (BAMS) degree, which is a Female Male TOTAL 51⁄2-year degree offered in India. Importance of Oral Health in Overall Health Forty-seven of 81 respondents Very important 33 (75) 9 (60) 42 (71) (58 percent) were certified Important 10 (23) 5 (33) 15 (25) ayurvedic specialists or had some Less important 1 (2) 0 (0) 1 (2) ayurvedic qualification other than Not important at all 0 (0) 1 (7) 1 (2) a BAMS. One-third of practiTOTAL 44 (100) 15 (100) 59 (100) tioners received their education in Ayurveda Useful in India, and two-thirds received Improving Oral Hygiene their education from ayurvedic Yes 39 (85) 16 (94) 55 (87) schools in the United States. The Maybe 6 (13) 1 (6) 7 (11) length of ayurvedic education— No 1 (2) 0 (0) 1 (2) including the BAMS—ranged TOTAL 46 (100) 17 (100) 63 (100) from one day to 72 months, with a Ayurveda Useful in mean of 33.5 months (SD, 22 Treating Oral Cancer months). According to respondYes 17 (38) 8 (47) 25 (40) ents, the mean length of ayurvedic Maybe 28 (62) 9 (53) 37 (60) programs offered in India was 66 No 0 (0) 0 (0) 0 (0) months, whereas the length of TOTAL 45 (100) 17 (100) 62 (100) courses offered in the United Treat Oral Diseases States ranged from one day (semYes 18 (40) 7 (47) 25 (42) inar training) to 30 months. No 27 (60) 8 (53) 35 58) Almost two-thirds of the TOTAL 45 (100) 15 (100) 60 (100) ayurvedic practitioners reported Patients Treated for Oral that they were working part time. Diseases per Month Mean number of patients 1.9 2.6 2.1 On average, they had been pracStandard deviation 1.4 2.5 1.8 ticing for nearly seven years and Minimum number of patients 0.0 0.0 0.0 treated about 35 patients a month. Maximum number of patients 5.0 7.0 7.0 The most commonly treated gen* Unless otherwise specified. eral conditions were loss of vigor † Not all respondents answered every question. and vitality (76 percent), obesity (64 percent), osteoarthritis (53 perered a type I error of 5 percent or less to be the cent), acid peptic disorders (51 percent), diabetes level of significance. (42 percent), rheumatoid arthritis (42 percent), asthma (41 percent) and other conditions (65 RESULTS percent). The last category included migraine, Eighty-five practitioners participated in this insomnia, infertility, menopausal syndrome, skin study. The response rate for the AAPNA conferdisorders, allergies, fibromyalgia, chronic pains, ence attendees was 65 percent and for the online hypertension, high cholesterol levels, constipaand regular mail recipients, 16 percent. The tion, anxiety, depression and emotional distress. mean age of participants was 49.2 years According to the survey responses, the most (standard deviation [SD], 10.2 years). Sixty-one common treatment modalities used were of the 85 respondents (72 percent) were female. healthy lifestyle instructions (89 percent), With regard to race, 46 of 80 participants (58 dietary instructions (81 percent), herbal medicapercent) were white, 25 (31 percent) were Asian, tions (74 percent), yoga (76 percent) and masone (1 percent) was African American, one sage (57 percent). Of the 58 respondents to the (1 percent) was Native Hawaiian or other Pacific question about adverse events, 28 (48 percent) Islander and seven (9 percent) were “other.” reported that ayurvedic treatment can cause Of the 77 participants who reported their serious adverse events, but they thought that educational level, 72 (94 percent) had at least a ayurvedic treatment is safer than the Western bachelor’s degree and 43 (56 percent) had a system of medicine. master’s degree or a doctoral degree. One-fifth The table shows the use of ayurveda in the 1122 JADA 143(10)
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RESEARCH
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treatment of oral diseases. 90 Twenty-five of 60 practitioners 80 Female (42 percent) reported that they 70 treated oral diseases, as well as a Male 60 mean of two patients with oral Total 50 diseases per month. The practitioner’s age, sex, educational 40 background or ayurvedic training 30 did not predict whether he or she 20 treated oral diseases. However, 10 Asian practitioners (odds ratio 0 [OR] = 5.6; 95 percent confidence interval [CI] = 1.4-23.2) and those who practiced for more than 6.5 years (OR = 4.5; 95 percent CI = 1.2-17.3) were more likely to ORAL DISEASE treat oral diseases; this finding Figure 1. Oral diseases treated by ayurvedic practitioners who reported that they remained statistically significant treat oral diseases (n = 25). Gingival diseases included bleeding gingivae, periodontitis even after we controlled for age, and gingivitis. Other oral diseases included numbness of the tongue or lips, temporosex, educational background and mandibular joint disorder, infections and injuries. full-time or part-time work status. Nearly all respondents also agreed that oral health is impor100 Female tant in maintaining good overall 90 health, and most considered Male 80 ayurveda to be useful in imTotal 70 proving oral hygiene. The 60 ayurvedic techniques used to 50 improve oral hygiene included 40 tongue scraping, use of sesame 30 oil as a mouthrinse (that is, oil 20 pulling), detoxification, use of 10 tooth powder (that is, a mixture 0 of dry herbs ground to a fine powder), use of herbal toothpaste, gingival massage with oils and herbs, and maintenance of a balanced diet. Oral cancer. As shown in the TREATMENT table, less than one-half of participants believed that ayurveda is Figure 2. Ayurvedic treatments used for oral diseases. Gandoosha and kavala graha useful in treating oral cancer. are oral cleansing techniques in which the patient holds medicinal fluid or oil in the Suggested approaches included mouth for about three to five minutes and then releases it. Other treatments included tongue scraping, sesame oil pulling and gum massage. detoxification, breathing exercises, ayurvedic diet (basically medicinal fluid or oil, holds the liquid in the vegetarian) and the use of ayurvedic medicamouth for about three to five minutes and then tions believed to heal oral cancer, such as releases it. Some respondents reported that kasamarda (Cassia occidentalis Linn.) and they believed ayurveda can be used as an mahalaxmi vilas ras. Among the other reported adjunct to conventional therapy to improve treatments were removal of “ama” (anything overall quality of life. that exists in a state of incomplete transformaFigure 1 shows the oral diseases treated by tion or a toxic byproduct generated as a result ayurvedic practitioners, according to our survey of improper or incomplete digestion9) by using appropriate herbs for the oral cavity and using findings. The most commonly treated oral disayurvedic oral cleansing techniques in which eases were halitosis, bleeding gingivae, ginthe patient fills the mouth completely givitis and mouth ulcers. Survey respondents (gandoosha) or partially (kavala graha) with rarely addressed dental caries or dental plaque. JADA 143(10)
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As shown in Figure 2, the most commonly used ayurvedic treatments for oral conditions were herbal toothpaste, dietary instructions, ayurvedic oral hygiene methods, herbal powder and gandoosha or kavala graha. Of the 25 practitioners who reported that they treated oral diseases, 16 (64 percent) stated that they used these treatments. DISCUSSION
In 1990, Americans made an estimated 425 million visits to providers of unconventional medical therapies.4 Eisenberg and colleagues3 concluded that use of alternative medicine and related expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking such therapies. Lin and colleagues10 conducted a telephone survey, the results of which showed a trend toward greater use of CAM therapy in tertiary pain management settings and a high prevalence of CAM therapy in pediatric pain management programs. McEachraneGross and colleagues5 conducted a crosssectional survey of veterans with cancer or chronic pain that focused on six common CAM treatments (herbs, dietary supplements, chiropractic care, massage therapy, acupuncture and homeopathy); they reported that 27.3 percent of patients had used CAM within the previous 12 months and 76 percent of those who did not use CAM reported that they would use it if offered at Veterans Affairs hospitals. Although researchers have addressed the role of both traditional Indian and Chinese therapies in dentistry,11,12 this study is one of the first designed specifically to evaluate the role of ayurvedic practitioners in providing oral health care in the United States. With more than 45 million people without dental insurance13 and an increasing immigrant population in this country, it is possible that dental patients may seek care from alternative sources. Because CAM is becoming more popular in the United States,3,4,10 our survey findings that some patients with oral health problems seek ayurvedic treatment is not surprising. Researchers have tested the effectiveness and safety of ayurvedic treatment modalities under controlled conditions, but only in relation to general health problems such as diabetes.14 In our study, we took a preliminary look at the use of ayurvedic treatment for oral health conditions. This group of predominantly female, white or non-Hispanic part-time practitioners had a varied educational background ranging from a rigorous 51⁄2-year BAMS degree program 1124 JADA 143(10)
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in India to short-term training in the United States. Investigators in future studies should examine this diverse training in more depth. The respondents had been in practice for a mean of seven years, treated about 35 patients a month and provided treatment for general conditions and oral diseases by providing lifestyle and dietary instructions, herbal medications, yoga instruction and massages. The study would have been more informative if we had had detailed information about patients and their conditions, as well as their satisfaction or dissatisfaction with the treatment. Although 25 of 60 practitioners (42 percent) treated oral diseases, the number of dental patients treated per month was too low to be informative. Nevertheless, respondents understood the importance of oral health and believed that ayurvedic treatment can be useful in improving oral hygiene and even in treating oral cancer. The use of tongue scraping and herbal toothpaste, as well as following a proper diet (that is, basically vegetarian and based on the patient’s body constitution), seem to be logical treatment modalities that are consistent with modern dental practices. The use of sesame oil as a mouthwash and detoxification method is not a well-understood concept and needs to be evaluated more carefully. The results of laboratory and clinical studies suggest that some ayurvedic herbal preparations may have anticancer properties.15-17 In ayurveda, the herbal preparation referred to as a “rasayana” is an elixir that works in a nonspecific fashion to improve human health and longevity. Researchers have reviewed the scientific basis of such preparations in relation to various disorders.18,19 However, researchers also have shown that some commercially produced ayurvedic medicinal products such as mahalaxmi vilas ras (used for oral cancer) contain high levels of lead, mercury or arsenic or a combination of the preceding.20 Most of the treatments provided by ayurvedic practitioners for oral diseases are preventive in nature. This makes sense, because most conventional treatments for oral diseases are mechanical or surgical in nature (for example, restorations, implants, endodontic treatment, tooth extractions) and should be administered only by trained and licensed dentists. Use of natural products to prevent caries, halitosis or gingival or periodontal disease may not be harmful. In ancient times, ayurvedic practitioners developed certain dietary and therapeutic measures to arrest or delay aging and to rejuvenate entire functional dynamics of the body by using a
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RESEARCH
group of plants now known to possess strong antioxidant18 and other properties.19 However, for clinicians to use these procedures widely, ethically and legally, scientifically based evidence is needed regarding their safety and efficacy in relation to oral diseases. If ayurveda is to be considered a CAM for oral health, it needs to be studied further, monitored and legally regulated. No licensing or registration process exists for ayurvedic practitioners in the United States. Among the 63 survey respondents who answered the question regarding licensing, 37 (59 percent) reported that they were not licensed as health care practitioners in the United States. According to our survey findings, additional online searches and communication with professional organizations such as the AAPNA, most ayurvedic practitioners in the United States are registered as massage therapists or yoga teachers. Some practitioners reported being registered as a naturopathic doctor and a few were U.S.-trained doctors of medicine who incorporate ayurveda into their practices. The scope of our study was limited and it was descriptive in nature. This was necessary because we could find no studies in the literature in which investigators addressed the use of ayurveda in oral health care in the United States. The study sample was not a representative random sample. We recruited participants primarily from one professional organization, and, as a result, the study has some potential selection bias. According to survey research experts such as Dillman,21 the length of the survey, incentives and personalized correspondence are important to attain an acceptable response rate, with token financial incentives almost as helpful as multiple mailings. We followed these guidelines and kept the survey short (the time required to complete the survey was less than 20 minutes), corresponded more than once with practitioners, received the support of a professional organization, and offered participants who attended the AAPNA conference an incentive package that included oral health care products. The self-reported nature of the data also may have introduced biases, but we selected and worded the questions carefully to minimize such errors; in addition, we pilot tested the survey. Researchers have used similar surveys successfully to obtain practitioners’ views about oral health care.22 Our cross-sectional study, which was based on a convenience sample, is a preliminary exploration of this important area of research and will pave the way for future studies.
CONCLUSIONS
The results of our survey show that ayurvedic practitioners are treating patients with oral diseases by using a variety of strategies, most of which are preventive in nature. However, some of these treatments might not be preventive and could be dangerous. Reliance on such treatments to the point of delaying or avoiding conventional dental therapy could be detrimental to the public. Consequently, larger, populationbased studies are needed for researchers to evaluate the use of ayurveda in the U.S. population. Sound randomized controlled trials are needed to evaluate the safety and effectiveness of various natural and commercially available ayurvedic products used in oral health care. Most importantly, ayurveda needs to be legally regulated and investigated to determine whether some of its therapies constitute the unauthorized practice of medicine or dentistry. In addition, guidelines are needed with regard to the ayurvedic educational curriculum to protect the U.S. population from any possible harm caused by undertrained ayurvedic practitioners or by potentially harmful ayurvedic products. ■ Disclosure. None of the authors reported any disclosures. This study was supported by a New York University College of Dentistry Dean’s Award. The authors acknowledge Dr. Joyti Bhatt and Dr. Swaranjit Brar, ayurvedic practitioners who helped pretest the questionnaire. They also thank the Association of Ayurvedic Professionals of North America for allowing them to collect data during a three-day conference in Woburn, Mass., in August 2011. 1. Bin Mohammed A, Abdul Raheem KP, Kaivalyam K. The role of traditional healers in the provision of health care and family planning services: Ayurveda and Sidda. Malays J Reprod Health 1985; 3(1 suppl):S95-S99. 2. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004(343):1-19. 3. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569-1575. 4. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993;328(4):246-252. 5. McEachrane-Gross FP, Liebschutz JM, Berlowitz D. Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey. BMC Complement Altern Med 2006;6:34. 6. Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to Care Survey. J Pain Symptom Manage 1997;13(2):83-89. 7. Kessler RC, Davis RB, Foster DF, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001;135(4):262-268. 8. Athavale VB. Danta-shastra: Dentistry in Ayurveda. Bombay, India: Pediatric Clinics of India; 1980. 9. Ayurveda Yoga Wellness Clinic. www.ayurvedayoga.com.au/ aboutus.php. Accessed Sept. 9, 2012. 10. Lin YC, Lee AC, Kemper KJ, Berde CB. Use of complementary and alternative medicine in pediatric pain management service: a survey. Pain Medicine 2005;6(6):452-458. 11. Amruthesh S. Dentistry and Ayurveda, IV: classification and management of common oral diseases. Indian J Dent Res 2008;
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19(1):52-61. 12. Surathu N, Kurumathur AV. Traditional therapies in the management of periodontal disease in India and China. Periodontol 2000 2011;56(1):14-24. 13. Bloom B, Cohen RA. Dental insurance for persons under age 65 years with private health insurance: United States, 2008. NCHS Data Brief. Hyattsville, Md.: National Center for Health Statistics; 2010. www.cdc.gov/nchs/data/databriefs/db40.htm. Accessed Sept. 9, 2012. 14. Hsia SH, Bazargan M, Davidson MB. Effect of pancreas tonic (an Ayurvedic herbal supplement) in type 2 diabetes mellitus. Metabolism 2004;53(9):1166-1173. 15. Balachandran P, Govindarajan R. Cancer: an Ayurvedic perspective. Pharmacol Res 2005;51(1):19-30. 16. American Cancer Society. Find support and treatment. Ayurveda. www.cancer.org/Treatment/TreatmentsandSideEffects/ ComplementaryandAlternativeMedicine/MindBodyandSpirit/
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ayurveda. Accessed Sept. 10, 2012. 17. Penza M, Montani C, Jeremic M, et al. MAK-4 and -5 supplemented diet inhibits liver carcinogenesis in mice. BMC Complement Altern Med 2007;7:19. 18. Govindarajan R, Vijayakumar M, Pushpangadan P. Antioxidant approach to disease management and the role of “Rasayana” herbs of Ayurveda. J Ethnopharmacol 2005;99(2):165-178. 19. Jung M, Park M, Lee HC, et al. Antidiabetic agents from medicinal plants. Curr Med Chem 2006;13(10):1203-1218. 20. Saper RB, Kales SN, Paquin J, et al. Heavy metal content of Ayurvedic herbal medicine products. JAMA 2004;292(23):2868-2873. 21. Dillman DA. Mail and Internet Surveys: The Tailored Design Method. New York City: Wiley; 2000. 22. Husein AB, Butterworth CJ, Ranka MS, Kwasnicki A, Rogers SN. A survey of general dental practitioners in the North West of England concerning the dental care of patients following head and neck radiotherapy. Prim Dent Care 2011;18(2):59-65.
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Involvement of ayurvedic practitioners in oral health care in the United States Bhupinder S. Brar, BAMS, MS, CCRC; Robert G. Norman, MS, PhD; Ananda P. Dasanayake, BDS, MPH, PhD
yurveda is an ancient medical science that originated in India more than 3,000 years ago. Ayurveda is a Sanskrit word made up of two words: “ayur,” which means life, and “veda,” which means science or knowledge. This science of life is a qualitative holistic science of health and longevity; a philosophy; and a system of healing the entire person in mind, body and spirit. Ayurveda is composed of elements of physiology, pathology, pharmacology, materia medica and surgery. Ancient ayurvedic textbooks consisted of 100 sections, each with 1,000 stanzas comprising up to 100,000 verses in eight books. Bin Mohammed and colleagues1 described how Charaka and Sushruta rearranged these books into chapters about surgery, nosology, anatomy, therapeutics, toxicology and local diseases. Ayurvedic treatment includes herbal medicines, massages with medicinal oils, dietary instructions, lifestyle instructions and bodypurification procedures. This traditional form of medicine also is practiced in Asian countries other than India and
A
A B ST RACT Background. Ayurveda, an ancient medical science originating in India, also is practiced in the United States. The authors conducted a study primarily to explore the involvement of ayurvedic practitioners in treating oral diseases. Methods. Eighty-five practitioners participated in this cross-sectional survey. The authors obtained self-reported data on demographics of the practitioners, the general and oral health conditions they treated, and the treatment modalities used. They performed descriptive statistical and logistic regression analyses by using statistical software. Results. Participants predominantly were female and white or nonHispanic, as well as part-time practitioners. Their educational backgrounds ranged from a 51⁄2 -year bachelor’s degree in ayurveda to shortterm training. Of the 60 respondents who answered the question about treating oral diseases, 25 (42 percent) reported that they did so. Conditions treated were related to oral malodor, gingival or periodontal disease and toothache. Ayurvedic treatments administered for these conditions primarily were preventive in nature. Conclusions. Ayurvedic practitioners in the United States treat a variety of oral diseases by using predominantly preventive traditional care. Ayurvedic practitioners of Asian origin and those who practiced for a longer duration were more likely to report that they treated oral diseases. Larger, population-based studies are needed to understand more fully the current role of ayurvedic practitioners in oral health care. Ayurvedic treatment modalities aimed at oral diseases need to be evaluated through rigorous randomized controlled trials for safety and effectiveness. Practice Implications. Patients with limited or no access to oral health care might seek ayurvedic treatment, and those who have access to conventional oral health care might wish to complement it with ayurvedic treatment. Practitioners can incorporate preventive ayurvedic treatments, which are based mainly on natural products, into overall preventive care regimens, if proven safe and effective. Key Words. Ayurveda; ayurvedic; complementary medicine; alternative medicine. JADA 2012;143(10):1120-1126.
Dr. Brar is a junior research scientist, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, 250 Park Ave. South, 6th Floor, New York, N.Y. 10003, e-mail [email protected]. Address reprint requests to Dr. Brar. Dr. Norman is an associate professor, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York City. Dr. Dasanayake is a professor, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York City.
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is gaining acceptance in Western countries.2-5 An estimate from a 1994 national survey by the Robert Wood Johnson Foundation showed that about 10 percent of the U.S. population sought alternative therapies during that year, including ayurveda,6 and survey results from a nationally representative sample in 1997 showed that more than two-thirds of the U.S. population used complementary and alternative medicine (CAM) therapies at least once in their lives.7 In ayurveda, specific treatments and procedures are described for various oral diseases. Athavale8 described various diseases of gingivae and teeth. He also described ayurvedic treatments for dental diseases such as halitosis, caries, periodontal diseases, gingivitis, bleeding gingivae and tooth extraction.8 Today, ayurveda is practiced in almost every state in the United States, and ayurvedic institutions provide formal education and training. These include the Kripalu School of Ayurveda, Stockbridge, Mass.; California College of Ayurveda, Cerritos; Kerala Ayurveda Academy/Ayurvedic School, Seattle; and Maharishi University of Management, Fairfield, Iowa. Ayurvedic practitioners also have formed various organizations and associations in the United States, such as the Association of Ayurvedic Professionals of North America (AAPNA), Coopersburg, Pa.; the National Ayurvedic Medical Association, Santa Cruz, Calif.; the Washington Ayurvedic Medical Association, Seattle; and the Colorado Ayurvedic Medical Association, Boulder. We conducted a survey of ayurvedic practitioners in the United States with the primary objective of evaluating their role in treating patients with oral diseases. The specific aims of the study were as follows: dto assess the level of education of U.S.-based ayurvedic practitioners; dto estimate the mean number of patients with various diseases treated per year by U.S.-based ayurvedic practitioners; dto identify the ayurvedic specialties that are practiced in the United States (for example, herbal medicine, diet, massage, body purification); dto evaluate whether U.S.-based ayurvedic practitioners treat oral diseases, and, if so, to identify associated factors; dto estimate the mean number of patients with oral diseases treated annually by U.S.-based ayurvedic practitioners; dto identify the ayurvedic procedures that practitioners perform to treat oral diseases; dto determine whether practitioners identified
any adverse effects of ayurvedic treatments. METHODS
The institutional review board of the School of Medicine, New York University, New York City, approved the study protocol as an exempt study. One of us (B.S.B.), an ayurvedic practitioner, designed a 30-question survey with the help of an epidemiologist (A.P.D.) and a statistician (R.G.N.). We pretested the survey with two ayurvedic practitioners who did not participate in the main study. The survey included questions related to these five major areas: demographics, education, general ayurvedic practice, oral health care, and licensing and affiliations. Study participants and data collection. The population of interest was ayurvedic practitioners who were currently working in the United States. Because these practitioners were not registered as ayurvedic practitioners in the United States, it was difficult to obtain a complete list of, and contact information for, practitioners. However, lists of ayurvedic practitioners were available on Web sites of the ayurvedic organizations. We contacted two prominent organizations, and the AAPNA invited us to attend its third International Ayurveda Conference in Woburn, Mass., in August 2011. In addition, the organization allowed us to distribute our self-administered survey to the conference attendees. We e-mailed the survey to members who did not attend the conference by using an online survey link. Those who did not have email addresses received a hard copy of the survey via regular mail, along with return envelopes with prepaid postage. We also mailed the survey to those who did not respond to the online survey (a study flowchart is available as supplemental data to the online version of this article [available at http://jada.ada.org]). Data analysis. The principal investigator (B.S.B.) collected, managed and analyzed the data under the guidance of the other two investigators (R.G.N., A.P.D.). We used software (EpiData, version 3.1, EpiData Association, Odense, Denmark) to create a database and exported the data for further analysis (IBM SPSS, Armonk, N.Y.). We summarized data by using frequencies, cross-tabulations and other descriptive analyses. We used logistic regression analysis to identify the characteristics of practitioners who treated patients with oral diseases. We considABBREVIATION KEY. AAPNA: Association of Ayurvedic Professionals of North America. BAMS: Bachelor of ayurvedic medicine and surgery. CAM: Complementary and alternative medicine. JADA 143(10)
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of the participants stated that they did not have any formal eduPractitioners’ use of ayurveda in oral health cation in ayurveda, and only 16 care, according to survey findings. (20 percent) had a bachelor of SURVEY ITEM NO. (%) OF PRACTITIONERS*† ayurvedic medicine and surgery (BAMS) degree, which is a Female Male TOTAL 51⁄2-year degree offered in India. Importance of Oral Health in Overall Health Forty-seven of 81 respondents Very important 33 (75) 9 (60) 42 (71) (58 percent) were certified Important 10 (23) 5 (33) 15 (25) ayurvedic specialists or had some Less important 1 (2) 0 (0) 1 (2) ayurvedic qualification other than Not important at all 0 (0) 1 (7) 1 (2) a BAMS. One-third of practiTOTAL 44 (100) 15 (100) 59 (100) tioners received their education in Ayurveda Useful in India, and two-thirds received Improving Oral Hygiene their education from ayurvedic Yes 39 (85) 16 (94) 55 (87) schools in the United States. The Maybe 6 (13) 1 (6) 7 (11) length of ayurvedic education— No 1 (2) 0 (0) 1 (2) including the BAMS—ranged TOTAL 46 (100) 17 (100) 63 (100) from one day to 72 months, with a Ayurveda Useful in mean of 33.5 months (SD, 22 Treating Oral Cancer months). According to respondYes 17 (38) 8 (47) 25 (40) ents, the mean length of ayurvedic Maybe 28 (62) 9 (53) 37 (60) programs offered in India was 66 No 0 (0) 0 (0) 0 (0) months, whereas the length of TOTAL 45 (100) 17 (100) 62 (100) courses offered in the United Treat Oral Diseases States ranged from one day (semYes 18 (40) 7 (47) 25 (42) inar training) to 30 months. No 27 (60) 8 (53) 35 58) Almost two-thirds of the TOTAL 45 (100) 15 (100) 60 (100) ayurvedic practitioners reported Patients Treated for Oral that they were working part time. Diseases per Month Mean number of patients 1.9 2.6 2.1 On average, they had been pracStandard deviation 1.4 2.5 1.8 ticing for nearly seven years and Minimum number of patients 0.0 0.0 0.0 treated about 35 patients a month. Maximum number of patients 5.0 7.0 7.0 The most commonly treated gen* Unless otherwise specified. eral conditions were loss of vigor † Not all respondents answered every question. and vitality (76 percent), obesity (64 percent), osteoarthritis (53 perered a type I error of 5 percent or less to be the cent), acid peptic disorders (51 percent), diabetes level of significance. (42 percent), rheumatoid arthritis (42 percent), asthma (41 percent) and other conditions (65 RESULTS percent). The last category included migraine, Eighty-five practitioners participated in this insomnia, infertility, menopausal syndrome, skin study. The response rate for the AAPNA conferdisorders, allergies, fibromyalgia, chronic pains, ence attendees was 65 percent and for the online hypertension, high cholesterol levels, constipaand regular mail recipients, 16 percent. The tion, anxiety, depression and emotional distress. mean age of participants was 49.2 years According to the survey responses, the most (standard deviation [SD], 10.2 years). Sixty-one common treatment modalities used were of the 85 respondents (72 percent) were female. healthy lifestyle instructions (89 percent), With regard to race, 46 of 80 participants (58 dietary instructions (81 percent), herbal medicapercent) were white, 25 (31 percent) were Asian, tions (74 percent), yoga (76 percent) and masone (1 percent) was African American, one sage (57 percent). Of the 58 respondents to the (1 percent) was Native Hawaiian or other Pacific question about adverse events, 28 (48 percent) Islander and seven (9 percent) were “other.” reported that ayurvedic treatment can cause Of the 77 participants who reported their serious adverse events, but they thought that educational level, 72 (94 percent) had at least a ayurvedic treatment is safer than the Western bachelor’s degree and 43 (56 percent) had a system of medicine. master’s degree or a doctoral degree. One-fifth The table shows the use of ayurveda in the 1122 JADA 143(10)
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treatment of oral diseases. 90 Twenty-five of 60 practitioners 80 Female (42 percent) reported that they 70 treated oral diseases, as well as a Male 60 mean of two patients with oral Total 50 diseases per month. The practitioner’s age, sex, educational 40 background or ayurvedic training 30 did not predict whether he or she 20 treated oral diseases. However, 10 Asian practitioners (odds ratio 0 [OR] = 5.6; 95 percent confidence interval [CI] = 1.4-23.2) and those who practiced for more than 6.5 years (OR = 4.5; 95 percent CI = 1.2-17.3) were more likely to ORAL DISEASE treat oral diseases; this finding Figure 1. Oral diseases treated by ayurvedic practitioners who reported that they remained statistically significant treat oral diseases (n = 25). Gingival diseases included bleeding gingivae, periodontitis even after we controlled for age, and gingivitis. Other oral diseases included numbness of the tongue or lips, temporosex, educational background and mandibular joint disorder, infections and injuries. full-time or part-time work status. Nearly all respondents also agreed that oral health is impor100 Female tant in maintaining good overall 90 health, and most considered Male 80 ayurveda to be useful in imTotal 70 proving oral hygiene. The 60 ayurvedic techniques used to 50 improve oral hygiene included 40 tongue scraping, use of sesame 30 oil as a mouthrinse (that is, oil 20 pulling), detoxification, use of 10 tooth powder (that is, a mixture 0 of dry herbs ground to a fine powder), use of herbal toothpaste, gingival massage with oils and herbs, and maintenance of a balanced diet. Oral cancer. As shown in the TREATMENT table, less than one-half of participants believed that ayurveda is Figure 2. Ayurvedic treatments used for oral diseases. Gandoosha and kavala graha useful in treating oral cancer. are oral cleansing techniques in which the patient holds medicinal fluid or oil in the Suggested approaches included mouth for about three to five minutes and then releases it. Other treatments included tongue scraping, sesame oil pulling and gum massage. detoxification, breathing exercises, ayurvedic diet (basically medicinal fluid or oil, holds the liquid in the vegetarian) and the use of ayurvedic medicamouth for about three to five minutes and then tions believed to heal oral cancer, such as releases it. Some respondents reported that kasamarda (Cassia occidentalis Linn.) and they believed ayurveda can be used as an mahalaxmi vilas ras. Among the other reported adjunct to conventional therapy to improve treatments were removal of “ama” (anything overall quality of life. that exists in a state of incomplete transformaFigure 1 shows the oral diseases treated by tion or a toxic byproduct generated as a result ayurvedic practitioners, according to our survey of improper or incomplete digestion9) by using appropriate herbs for the oral cavity and using findings. The most commonly treated oral disayurvedic oral cleansing techniques in which eases were halitosis, bleeding gingivae, ginthe patient fills the mouth completely givitis and mouth ulcers. Survey respondents (gandoosha) or partially (kavala graha) with rarely addressed dental caries or dental plaque. JADA 143(10)
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As shown in Figure 2, the most commonly used ayurvedic treatments for oral conditions were herbal toothpaste, dietary instructions, ayurvedic oral hygiene methods, herbal powder and gandoosha or kavala graha. Of the 25 practitioners who reported that they treated oral diseases, 16 (64 percent) stated that they used these treatments. DISCUSSION
In 1990, Americans made an estimated 425 million visits to providers of unconventional medical therapies.4 Eisenberg and colleagues3 concluded that use of alternative medicine and related expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking such therapies. Lin and colleagues10 conducted a telephone survey, the results of which showed a trend toward greater use of CAM therapy in tertiary pain management settings and a high prevalence of CAM therapy in pediatric pain management programs. McEachraneGross and colleagues5 conducted a crosssectional survey of veterans with cancer or chronic pain that focused on six common CAM treatments (herbs, dietary supplements, chiropractic care, massage therapy, acupuncture and homeopathy); they reported that 27.3 percent of patients had used CAM within the previous 12 months and 76 percent of those who did not use CAM reported that they would use it if offered at Veterans Affairs hospitals. Although researchers have addressed the role of both traditional Indian and Chinese therapies in dentistry,11,12 this study is one of the first designed specifically to evaluate the role of ayurvedic practitioners in providing oral health care in the United States. With more than 45 million people without dental insurance13 and an increasing immigrant population in this country, it is possible that dental patients may seek care from alternative sources. Because CAM is becoming more popular in the United States,3,4,10 our survey findings that some patients with oral health problems seek ayurvedic treatment is not surprising. Researchers have tested the effectiveness and safety of ayurvedic treatment modalities under controlled conditions, but only in relation to general health problems such as diabetes.14 In our study, we took a preliminary look at the use of ayurvedic treatment for oral health conditions. This group of predominantly female, white or non-Hispanic part-time practitioners had a varied educational background ranging from a rigorous 51⁄2-year BAMS degree program 1124 JADA 143(10)
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in India to short-term training in the United States. Investigators in future studies should examine this diverse training in more depth. The respondents had been in practice for a mean of seven years, treated about 35 patients a month and provided treatment for general conditions and oral diseases by providing lifestyle and dietary instructions, herbal medications, yoga instruction and massages. The study would have been more informative if we had had detailed information about patients and their conditions, as well as their satisfaction or dissatisfaction with the treatment. Although 25 of 60 practitioners (42 percent) treated oral diseases, the number of dental patients treated per month was too low to be informative. Nevertheless, respondents understood the importance of oral health and believed that ayurvedic treatment can be useful in improving oral hygiene and even in treating oral cancer. The use of tongue scraping and herbal toothpaste, as well as following a proper diet (that is, basically vegetarian and based on the patient’s body constitution), seem to be logical treatment modalities that are consistent with modern dental practices. The use of sesame oil as a mouthwash and detoxification method is not a well-understood concept and needs to be evaluated more carefully. The results of laboratory and clinical studies suggest that some ayurvedic herbal preparations may have anticancer properties.15-17 In ayurveda, the herbal preparation referred to as a “rasayana” is an elixir that works in a nonspecific fashion to improve human health and longevity. Researchers have reviewed the scientific basis of such preparations in relation to various disorders.18,19 However, researchers also have shown that some commercially produced ayurvedic medicinal products such as mahalaxmi vilas ras (used for oral cancer) contain high levels of lead, mercury or arsenic or a combination of the preceding.20 Most of the treatments provided by ayurvedic practitioners for oral diseases are preventive in nature. This makes sense, because most conventional treatments for oral diseases are mechanical or surgical in nature (for example, restorations, implants, endodontic treatment, tooth extractions) and should be administered only by trained and licensed dentists. Use of natural products to prevent caries, halitosis or gingival or periodontal disease may not be harmful. In ancient times, ayurvedic practitioners developed certain dietary and therapeutic measures to arrest or delay aging and to rejuvenate entire functional dynamics of the body by using a
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RESEARCH
group of plants now known to possess strong antioxidant18 and other properties.19 However, for clinicians to use these procedures widely, ethically and legally, scientifically based evidence is needed regarding their safety and efficacy in relation to oral diseases. If ayurveda is to be considered a CAM for oral health, it needs to be studied further, monitored and legally regulated. No licensing or registration process exists for ayurvedic practitioners in the United States. Among the 63 survey respondents who answered the question regarding licensing, 37 (59 percent) reported that they were not licensed as health care practitioners in the United States. According to our survey findings, additional online searches and communication with professional organizations such as the AAPNA, most ayurvedic practitioners in the United States are registered as massage therapists or yoga teachers. Some practitioners reported being registered as a naturopathic doctor and a few were U.S.-trained doctors of medicine who incorporate ayurveda into their practices. The scope of our study was limited and it was descriptive in nature. This was necessary because we could find no studies in the literature in which investigators addressed the use of ayurveda in oral health care in the United States. The study sample was not a representative random sample. We recruited participants primarily from one professional organization, and, as a result, the study has some potential selection bias. According to survey research experts such as Dillman,21 the length of the survey, incentives and personalized correspondence are important to attain an acceptable response rate, with token financial incentives almost as helpful as multiple mailings. We followed these guidelines and kept the survey short (the time required to complete the survey was less than 20 minutes), corresponded more than once with practitioners, received the support of a professional organization, and offered participants who attended the AAPNA conference an incentive package that included oral health care products. The self-reported nature of the data also may have introduced biases, but we selected and worded the questions carefully to minimize such errors; in addition, we pilot tested the survey. Researchers have used similar surveys successfully to obtain practitioners’ views about oral health care.22 Our cross-sectional study, which was based on a convenience sample, is a preliminary exploration of this important area of research and will pave the way for future studies.
CONCLUSIONS
The results of our survey show that ayurvedic practitioners are treating patients with oral diseases by using a variety of strategies, most of which are preventive in nature. However, some of these treatments might not be preventive and could be dangerous. Reliance on such treatments to the point of delaying or avoiding conventional dental therapy could be detrimental to the public. Consequently, larger, populationbased studies are needed for researchers to evaluate the use of ayurveda in the U.S. population. Sound randomized controlled trials are needed to evaluate the safety and effectiveness of various natural and commercially available ayurvedic products used in oral health care. Most importantly, ayurveda needs to be legally regulated and investigated to determine whether some of its therapies constitute the unauthorized practice of medicine or dentistry. In addition, guidelines are needed with regard to the ayurvedic educational curriculum to protect the U.S. population from any possible harm caused by undertrained ayurvedic practitioners or by potentially harmful ayurvedic products. ■ Disclosure. None of the authors reported any disclosures. This study was supported by a New York University College of Dentistry Dean’s Award. The authors acknowledge Dr. Joyti Bhatt and Dr. Swaranjit Brar, ayurvedic practitioners who helped pretest the questionnaire. They also thank the Association of Ayurvedic Professionals of North America for allowing them to collect data during a three-day conference in Woburn, Mass., in August 2011. 1. Bin Mohammed A, Abdul Raheem KP, Kaivalyam K. The role of traditional healers in the provision of health care and family planning services: Ayurveda and Sidda. Malays J Reprod Health 1985; 3(1 suppl):S95-S99. 2. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004(343):1-19. 3. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280(18):1569-1575. 4. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993;328(4):246-252. 5. McEachrane-Gross FP, Liebschutz JM, Berlowitz D. Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey. BMC Complement Altern Med 2006;6:34. 6. Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to Care Survey. J Pain Symptom Manage 1997;13(2):83-89. 7. Kessler RC, Davis RB, Foster DF, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001;135(4):262-268. 8. Athavale VB. Danta-shastra: Dentistry in Ayurveda. Bombay, India: Pediatric Clinics of India; 1980. 9. Ayurveda Yoga Wellness Clinic. www.ayurvedayoga.com.au/ aboutus.php. Accessed Sept. 9, 2012. 10. Lin YC, Lee AC, Kemper KJ, Berde CB. Use of complementary and alternative medicine in pediatric pain management service: a survey. Pain Medicine 2005;6(6):452-458. 11. Amruthesh S. Dentistry and Ayurveda, IV: classification and management of common oral diseases. Indian J Dent Res 2008;
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19(1):52-61. 12. Surathu N, Kurumathur AV. Traditional therapies in the management of periodontal disease in India and China. Periodontol 2000 2011;56(1):14-24. 13. Bloom B, Cohen RA. Dental insurance for persons under age 65 years with private health insurance: United States, 2008. NCHS Data Brief. Hyattsville, Md.: National Center for Health Statistics; 2010. www.cdc.gov/nchs/data/databriefs/db40.htm. Accessed Sept. 9, 2012. 14. Hsia SH, Bazargan M, Davidson MB. Effect of pancreas tonic (an Ayurvedic herbal supplement) in type 2 diabetes mellitus. Metabolism 2004;53(9):1166-1173. 15. Balachandran P, Govindarajan R. Cancer: an Ayurvedic perspective. Pharmacol Res 2005;51(1):19-30. 16. American Cancer Society. Find support and treatment. Ayurveda. www.cancer.org/Treatment/TreatmentsandSideEffects/ ComplementaryandAlternativeMedicine/MindBodyandSpirit/
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ayurveda. Accessed Sept. 10, 2012. 17. Penza M, Montani C, Jeremic M, et al. MAK-4 and -5 supplemented diet inhibits liver carcinogenesis in mice. BMC Complement Altern Med 2007;7:19. 18. Govindarajan R, Vijayakumar M, Pushpangadan P. Antioxidant approach to disease management and the role of “Rasayana” herbs of Ayurveda. J Ethnopharmacol 2005;99(2):165-178. 19. Jung M, Park M, Lee HC, et al. Antidiabetic agents from medicinal plants. Curr Med Chem 2006;13(10):1203-1218. 20. Saper RB, Kales SN, Paquin J, et al. Heavy metal content of Ayurvedic herbal medicine products. JAMA 2004;292(23):2868-2873. 21. Dillman DA. Mail and Internet Surveys: The Tailored Design Method. New York City: Wiley; 2000. 22. Husein AB, Butterworth CJ, Ranka MS, Kwasnicki A, Rogers SN. A survey of general dental practitioners in the North West of England concerning the dental care of patients following head and neck radiotherapy. Prim Dent Care 2011;18(2):59-65.
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