- Email: [email protected]
SELECTIONS FROM THE CURRENT LITERATURE
ORIGINAL CONTRIBUTIONS
JOURNALSCAN SELECTIONS FROM THE CURRENT LITERATURE Compiled by Bruce Lee Pihlstrom, DDS, MS
EFFECT OF IMPLANT-SUPPORTED OVERDENTURES ON DIET
Hamdan NM, Gray-Donald K, Awad MA, et al. Do implant overdentures improve dietary intake? A randomized clinical trial. J Dent Res 2013;9(12) (suppl):146S-153S. doi:10.1177/0022034513504948. Background. Dental implants often are used to support mandibular full dentures because they have several advantages over nonimplant-supported dentures, including increased oral health quality of life, greater patient satisfaction and better chewing ability. However, few investigators have studied the effect of implantsupported overdentures on dietary intake. The purpose of this randomized clinical trial was to evaluate the effects of mandibular implant-supported overdentures on the nutritional status of elderly people. Methods. The authors conducted a randomized clinical trial among people who were living independently in Montreal, Quebec, Canada, were at least 65 years of age and had been edentulous for a minimum of five years. Hamdan and colleagues randomly assigned 255 participants to receive either a conventional mandibular complete denture (n = 128) or an implant-supported complete denture (n = 127); each participant received a conventional maxillary full denture. Trained dietitians used a telephone interview to assess the participants’ dietary intake in terms of dietary fiber, calories, macronutrients (proteins, fats, carbohydrates) and nine micronutrients (vitamins A, B6, B12, C and D and thiamine, riboflavin, folate and niacin). They conducted the dietary assessments on three separate occasions (twice on weekdays and once on a weekend) at baseline and 12 months after delivery of the dentures. Results. The investigators reported that one year after participants received the dentures, there were no differences in any of the dietary measures between people who received conventional mandibular complete dentures and those who received implant-supported mandibular complete dentures. Why is this study important? This is an important study because, to the knowledge of the authors, it was the first randomized clinical trial with a sample size that was sufficiently large to enable them to study differences in dietary intake between people who wear conventional dentures and those who wear implant-supported overdentures. The authors acknowledged that there were several possible limitations of their study that could have
affected the results, including a possible reporting bias because of the self-reported 24-hour recall of dietary intake and the fact that foods may have been prepared and eaten in different ways by people who had the two types of dentures. For example, people who had conventional complete dentures may have consumed similar types and amounts of food as those who had implant-supported dentures, but they may have eaten their food more slowly or in smaller bites than did those with implantsupported dentures. RETROSPECTIVE, LONG-TERM, PRACTICEBASED STUDY OF DENTAL IMPLANTS
Dhima M, Paulusova V, Lohse C, Salinas TJ, Carr AB. Practice-based evidence from 29-year outcome analysis of management of the edentulous jaw using osseointegrated dental implants (published online ahead of print July 26, 2013). J Prosthodont. doi:10.1111/jopr.12084. Background. The authors of this article point out that clinical trials have provided important information about the outcome of treatment with dental implants. However, it is widely recognized that the results of highly controlled clinical trials in a specialty or academic environment may not be generalizable to everyday practice. The purpose of this retrospective study was to summarize the outcomes of osseointegrated implants that were placed in dental practice. Methods. Dhima and colleagues used dental records to assess treatment outcomes for 255 patients at the Mayo Clinic in Rochester, Minn., who each had received an implant-supported prosthesis according to the original Brånemark protocol1,2 during the years 1983 to 1991. Results. The investigators reported that the mean age of the patients when the implants were first placed was 56.4 years and that 75 percent were female and 25 percent were male. They reported that most patients (97 percent) underwent surgical implant and prosthesis placement at the Mayo Clinic, and the mean duration of follow-up was 13.0 years (range, 0.3-28 years). The authors reported that the 255 patients had received a total of 1,325 implants (1,089 in the mandible and 236 in the maxilla). They reported that the overall 20-year survival rate of implants was 86 percent and that the survival rate of implants without any prosthetic or biological adverse events was 51 percent at five years and 11 percent at 20 years. Prosthetic adverse events such as fractured screws, fractured abutment and wear occurred three times more often than did biological adverse events such as gingival hyperplasia, implant mobility and infection. The most common prosthetic adverse event was the fracture of gold implant screws and the most common biological adverse event was peri-implant gingival hyperplasia. Why is this study important? Although this was a
JADA 145(3)
http://jada.ada.org
March 2014
287
ORIGINAL CONTRIBUTIONS
retrospective study of patient records and was not a prospective randomized controlled trial, it provides important data that complement findings from clinical trials. It is important because it provides real-life, long-term data about the success, failure and complications of dental implants and associated prostheses in dental practice. 1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Maxillofac Surg 1981;10(6):387-416. 2. Attard NJ, Zarb GA. Long-term treatment outcomes in edentulous patients with implant overdentures: the Toronto study. Int J Prosthodont 2004;17(4):425-433.
MICROBIOLOGICAL AND IMMUNOLOGICAL ASPECTS OF PERI-IMPLANT DISEASE
Belibasakis GN. Microbiological and immunopathological aspects of peri-implant diseases (published online ahead of print Oct. 9, 2013). Arch Oral Biol. doi:10.1016/j.archoralbio.2013.09.013. Background. As noted by the author of this article, peri-implant diseases are a group of infections resulting in inflammation and destruction of tissues that support osseointegrated dental implants. This article is a narrative review of the infectious etiology and immunological processes involved in the pathogenesis of peri-implant diseases. The author also discussed the similarities and differences between peri-implant disease and inflammatory periodontal disease. Methods. Belibasakis reviewed the published literature about the clinical, microbiological and immunological features of peri-implant diseases. Results. The author noted that the risk factors for peri-implantitis are similar to those for periodontitis, including poor oral hygiene, smoking, diabetes, genetic susceptibility, possibly alcohol consumption and a history of periodontitis. Belibasakis pointed out that, in contrast to the presence of a periodontal ligament and of Sharpey’s fibers in the cementum of natural teeth, the fundamental anatomical difference between implants and natural teeth is that implants do not have a periodontal ligament and collagen fibers that are incorporated into their surface. He reported that this has several disadvantages for implants, including an absence of a physical barrier against bacterial invasion of tissue, a restricted blood supply because of the absence of a periodontal ligament, and reduced ability to withstand and adapt to occlusal and masticatory forces. The author noted that as with natural teeth, biofilms can form on implant surfaces, resulting in inflammation and destruction of the surrounding tissues. Belibasakis reported that the microbial composition of the peri-implantitis biofilm appears to be similar to that of periodontal disease, but that initial microbial colonization on implants appears to be slower than that on natural teeth and that certain organisms such as staphylococci, peptostreptococci, enteric
288
JADA 145(3)
http://jada.ada.org
March 2014
bacteria and Candida organisms may be present more frequently in higher numbers in peri-implant disease than in periodontal disease. He also noted that although the immunopathological events that lead to periodontitis and peri-implantitis appear to be similar and are characterized by neutrophils, macrophages and T- and B-cells, the inflammatory tissue destruction in periimplantitis appears to be more rapid and extensive. He also noted that more research is needed to understand the peri-implant diseases and that use of molecular markers of inflammation obtained from peri-implant crevicular fluid may be useful for diagnosing periimplant diseases and modulating their treatment. Why is this study important? This is an important study because it helps to explain some of the reasons why patients who have dental implants need to control risk factors and receive periodic preventive maintenance. It also is important because it outlines the fundamental similarities and differences between periodontitis and peri-implantitis. Dentists who place implants, who are involved in prosthetic dental restoration involving implants and who see patients with implants in their practices need to be aware of the microbiological features and pathogenesis of peri-implant disease. EARLY DENTAL OFFICE VISITS AND CHILDHOOD DENTAL CARIES
Beil H, Rozier RG, Preisser JS, Stearns SC, Lee JY. Effects of early dental office visits on dental caries experience (published online ahead of print Oct. 17, 2013). Am J Public Health. doi:10.2105/ AJPH.2013.301325. Background. As noted by the authors, dental caries during early childhood is the most common chronic disease. It can be a devastating and costly disease, but it also can be prevented and even reversed in its early stages. As the authors also noted, whereas early childhood dental visits are widely recommended, it is unclear whether children who have had early dental visits have different dental disease than do children who have their first dental visits later in childhood. The purpose of this study was to estimate the effect of timing of the first dental visit on dental disease among kindergarten students in North Carolina. Methods. The authors used North Carolina Medicaid claims from 1999 to 2006 that were linked to state oral health surveillance data to evaluate dental caries among 11,394 children who had a dental visit before 5 years of age. Results. The authors reported that children who had their first dental visit at age 37 to 48 months and at age 49 to 60 months had significantly less dental caries than did those who had their first dental visit by age 24 months. In the overall sample of 35,943 kindergarten children who were enrolled in Medicaid before 5 years of age,
ORIGINAL CONTRIBUTIONS
54 percent had untreated dental disease. Moreover, only 7 percent had received a preventive dental visit before they were 3.5 years of age, and children in areas with limited access to dental care and higher numbers of children enrolled in Medicaid had higher rates of untreated dental disease. Why is this study important? This is an important study because it involved a large sample of patients and because it linked Medicaid claims to state oral health surveillance information. The authors stated that their finding of an association of early dental care with increased dental disease indicated that children in this Medicaid population went to the dentist when they had pain or obvious dental disease. Therefore, children who most needed care were the most likely to visit a dentist and receive care. Although these results could be viewed as positive, the results also reinforce the need for early preventive care in children who are at the highest risk of experiencing dental caries. DENTAL HEALTH OF PATIENTS WITH HEAD AND NECK CANCER RECEIVING RADIATION
Duarte VM, Liu YF, Rafizadeh S, Tajima T, Nabili V, Wang MB. Comparison of dental health of patients with head and neck cancer receiving IMRT vs conventional radiation (published online ahead of print Oct. 21, 2013). Otolaryngol Head Neck Surg. doi:10.1177/0194599813509586. Background. As summarized by the authors of this study, patients who receive a diagnosis of head and neck cancer frequently are treated with radiation therapy, which is associated with complications that can have a profound effect on quality of life. These adverse effects are difficult to manage and include xerostomia, dental caries, periodontal disease, mucositis, osteoradionecrosis, trismus and dysphagia. One way to reduce damage caused by radiation therapy is to reduce the amount of tissue that is exposed to radiation. The use of intensitymodulated radiation therapy (IMRT) is one way of reducing radiation exposure. IMRT aims thin beams of radiation at tumors in three dimensions from many angles and, therefore, reduces damage to nearby healthy tissue.1 The purpose of this study was to perform a retrospective comparison of the oral health of patients who received conventional radiation therapy with that of patients who
received IMRT for head and neck cancers. Methods. The authors included in their study 158 patients (157 men and one woman) who received either conventional radiation therapy (99 patients) or IMRT (59 patients) at the West Los Angeles, Calif., Veterans Affairs hospital. As part of their usual care at the hospital, all patients received a complete dental evaluation before radiation therapy, any necessary dental care and extraction of teeth as needed to minimize postradiation oral complications of radiation therapy and to prepare them for future dental rehabilitation. All patients also received education in toothbrushing and the use of dental floss and were prescribed daily use of high-concentration topical fluoride (1.1 percent neutral sodium fluoride). One month after radiation therapy, patients were assessed for the incidence of Candida infection, dental caries, mucositis, xerostomia, periodontitis, edentulism, extractions, presence of osteoradionecrosis and use of fluoride. The investigators used these data from patients’ records to compare the adverse effects of conventional radiation therapy with those of IMRT. Results. Three complications of radiation therapy occurred more frequently among patients who had been treated with conventional radiation therapy compared with those who were treated with IMRT: xerostomia, 46.5 percent versus 16.9 percent (P < .001); mucositis, 46.5 percent versus 16.9 percent (P < .001); and osteoradionecrosis, 10.1 percent versus 0 percent (P < .02). Why is this study important? The oral complications of radiation therapy for head and neck cancers can have a profound negative effect on quality of life. Although this was not a randomized clinical trial and the follow-up time of one month was relatively short, this study’s findings support the use of IMRT for head and neck cancer. Q doi:10.14219/jada.2013.38 1. National Institutes of Health, National Cancer Institute. NCI dictionary of terms. www.cancer.gov/dictionary?cdrid=335073. Accessed Nov. 20, 2013. Dr. Pihlstrom is a professor emeritus, Department of Surgical and Developmental Sciences, School of Dentistry, University of Minnesota, Minneapolis. He also is the associate editor, Research, for The Journal of the American Dental Association, as well as an independent oral health research consultant. Disclosure. Dr. Pihlstrom did not report any disclosures.
JADA 145(3)
http://jada.ada.org
March 2014
289
JOURNALSCAN SELECTIONS FROM THE CURRENT LITERATURE Compiled by Bruce Lee Pihlstrom, DDS, MS
EFFECT OF IMPLANT-SUPPORTED OVERDENTURES ON DIET
Hamdan NM, Gray-Donald K, Awad MA, et al. Do implant overdentures improve dietary intake? A randomized clinical trial. J Dent Res 2013;9(12) (suppl):146S-153S. doi:10.1177/0022034513504948. Background. Dental implants often are used to support mandibular full dentures because they have several advantages over nonimplant-supported dentures, including increased oral health quality of life, greater patient satisfaction and better chewing ability. However, few investigators have studied the effect of implantsupported overdentures on dietary intake. The purpose of this randomized clinical trial was to evaluate the effects of mandibular implant-supported overdentures on the nutritional status of elderly people. Methods. The authors conducted a randomized clinical trial among people who were living independently in Montreal, Quebec, Canada, were at least 65 years of age and had been edentulous for a minimum of five years. Hamdan and colleagues randomly assigned 255 participants to receive either a conventional mandibular complete denture (n = 128) or an implant-supported complete denture (n = 127); each participant received a conventional maxillary full denture. Trained dietitians used a telephone interview to assess the participants’ dietary intake in terms of dietary fiber, calories, macronutrients (proteins, fats, carbohydrates) and nine micronutrients (vitamins A, B6, B12, C and D and thiamine, riboflavin, folate and niacin). They conducted the dietary assessments on three separate occasions (twice on weekdays and once on a weekend) at baseline and 12 months after delivery of the dentures. Results. The investigators reported that one year after participants received the dentures, there were no differences in any of the dietary measures between people who received conventional mandibular complete dentures and those who received implant-supported mandibular complete dentures. Why is this study important? This is an important study because, to the knowledge of the authors, it was the first randomized clinical trial with a sample size that was sufficiently large to enable them to study differences in dietary intake between people who wear conventional dentures and those who wear implant-supported overdentures. The authors acknowledged that there were several possible limitations of their study that could have
affected the results, including a possible reporting bias because of the self-reported 24-hour recall of dietary intake and the fact that foods may have been prepared and eaten in different ways by people who had the two types of dentures. For example, people who had conventional complete dentures may have consumed similar types and amounts of food as those who had implant-supported dentures, but they may have eaten their food more slowly or in smaller bites than did those with implantsupported dentures. RETROSPECTIVE, LONG-TERM, PRACTICEBASED STUDY OF DENTAL IMPLANTS
Dhima M, Paulusova V, Lohse C, Salinas TJ, Carr AB. Practice-based evidence from 29-year outcome analysis of management of the edentulous jaw using osseointegrated dental implants (published online ahead of print July 26, 2013). J Prosthodont. doi:10.1111/jopr.12084. Background. The authors of this article point out that clinical trials have provided important information about the outcome of treatment with dental implants. However, it is widely recognized that the results of highly controlled clinical trials in a specialty or academic environment may not be generalizable to everyday practice. The purpose of this retrospective study was to summarize the outcomes of osseointegrated implants that were placed in dental practice. Methods. Dhima and colleagues used dental records to assess treatment outcomes for 255 patients at the Mayo Clinic in Rochester, Minn., who each had received an implant-supported prosthesis according to the original Brånemark protocol1,2 during the years 1983 to 1991. Results. The investigators reported that the mean age of the patients when the implants were first placed was 56.4 years and that 75 percent were female and 25 percent were male. They reported that most patients (97 percent) underwent surgical implant and prosthesis placement at the Mayo Clinic, and the mean duration of follow-up was 13.0 years (range, 0.3-28 years). The authors reported that the 255 patients had received a total of 1,325 implants (1,089 in the mandible and 236 in the maxilla). They reported that the overall 20-year survival rate of implants was 86 percent and that the survival rate of implants without any prosthetic or biological adverse events was 51 percent at five years and 11 percent at 20 years. Prosthetic adverse events such as fractured screws, fractured abutment and wear occurred three times more often than did biological adverse events such as gingival hyperplasia, implant mobility and infection. The most common prosthetic adverse event was the fracture of gold implant screws and the most common biological adverse event was peri-implant gingival hyperplasia. Why is this study important? Although this was a
JADA 145(3)
http://jada.ada.org
March 2014
287
ORIGINAL CONTRIBUTIONS
retrospective study of patient records and was not a prospective randomized controlled trial, it provides important data that complement findings from clinical trials. It is important because it provides real-life, long-term data about the success, failure and complications of dental implants and associated prostheses in dental practice. 1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Maxillofac Surg 1981;10(6):387-416. 2. Attard NJ, Zarb GA. Long-term treatment outcomes in edentulous patients with implant overdentures: the Toronto study. Int J Prosthodont 2004;17(4):425-433.
MICROBIOLOGICAL AND IMMUNOLOGICAL ASPECTS OF PERI-IMPLANT DISEASE
Belibasakis GN. Microbiological and immunopathological aspects of peri-implant diseases (published online ahead of print Oct. 9, 2013). Arch Oral Biol. doi:10.1016/j.archoralbio.2013.09.013. Background. As noted by the author of this article, peri-implant diseases are a group of infections resulting in inflammation and destruction of tissues that support osseointegrated dental implants. This article is a narrative review of the infectious etiology and immunological processes involved in the pathogenesis of peri-implant diseases. The author also discussed the similarities and differences between peri-implant disease and inflammatory periodontal disease. Methods. Belibasakis reviewed the published literature about the clinical, microbiological and immunological features of peri-implant diseases. Results. The author noted that the risk factors for peri-implantitis are similar to those for periodontitis, including poor oral hygiene, smoking, diabetes, genetic susceptibility, possibly alcohol consumption and a history of periodontitis. Belibasakis pointed out that, in contrast to the presence of a periodontal ligament and of Sharpey’s fibers in the cementum of natural teeth, the fundamental anatomical difference between implants and natural teeth is that implants do not have a periodontal ligament and collagen fibers that are incorporated into their surface. He reported that this has several disadvantages for implants, including an absence of a physical barrier against bacterial invasion of tissue, a restricted blood supply because of the absence of a periodontal ligament, and reduced ability to withstand and adapt to occlusal and masticatory forces. The author noted that as with natural teeth, biofilms can form on implant surfaces, resulting in inflammation and destruction of the surrounding tissues. Belibasakis reported that the microbial composition of the peri-implantitis biofilm appears to be similar to that of periodontal disease, but that initial microbial colonization on implants appears to be slower than that on natural teeth and that certain organisms such as staphylococci, peptostreptococci, enteric
288
JADA 145(3)
http://jada.ada.org
March 2014
bacteria and Candida organisms may be present more frequently in higher numbers in peri-implant disease than in periodontal disease. He also noted that although the immunopathological events that lead to periodontitis and peri-implantitis appear to be similar and are characterized by neutrophils, macrophages and T- and B-cells, the inflammatory tissue destruction in periimplantitis appears to be more rapid and extensive. He also noted that more research is needed to understand the peri-implant diseases and that use of molecular markers of inflammation obtained from peri-implant crevicular fluid may be useful for diagnosing periimplant diseases and modulating their treatment. Why is this study important? This is an important study because it helps to explain some of the reasons why patients who have dental implants need to control risk factors and receive periodic preventive maintenance. It also is important because it outlines the fundamental similarities and differences between periodontitis and peri-implantitis. Dentists who place implants, who are involved in prosthetic dental restoration involving implants and who see patients with implants in their practices need to be aware of the microbiological features and pathogenesis of peri-implant disease. EARLY DENTAL OFFICE VISITS AND CHILDHOOD DENTAL CARIES
Beil H, Rozier RG, Preisser JS, Stearns SC, Lee JY. Effects of early dental office visits on dental caries experience (published online ahead of print Oct. 17, 2013). Am J Public Health. doi:10.2105/ AJPH.2013.301325. Background. As noted by the authors, dental caries during early childhood is the most common chronic disease. It can be a devastating and costly disease, but it also can be prevented and even reversed in its early stages. As the authors also noted, whereas early childhood dental visits are widely recommended, it is unclear whether children who have had early dental visits have different dental disease than do children who have their first dental visits later in childhood. The purpose of this study was to estimate the effect of timing of the first dental visit on dental disease among kindergarten students in North Carolina. Methods. The authors used North Carolina Medicaid claims from 1999 to 2006 that were linked to state oral health surveillance data to evaluate dental caries among 11,394 children who had a dental visit before 5 years of age. Results. The authors reported that children who had their first dental visit at age 37 to 48 months and at age 49 to 60 months had significantly less dental caries than did those who had their first dental visit by age 24 months. In the overall sample of 35,943 kindergarten children who were enrolled in Medicaid before 5 years of age,
ORIGINAL CONTRIBUTIONS
54 percent had untreated dental disease. Moreover, only 7 percent had received a preventive dental visit before they were 3.5 years of age, and children in areas with limited access to dental care and higher numbers of children enrolled in Medicaid had higher rates of untreated dental disease. Why is this study important? This is an important study because it involved a large sample of patients and because it linked Medicaid claims to state oral health surveillance information. The authors stated that their finding of an association of early dental care with increased dental disease indicated that children in this Medicaid population went to the dentist when they had pain or obvious dental disease. Therefore, children who most needed care were the most likely to visit a dentist and receive care. Although these results could be viewed as positive, the results also reinforce the need for early preventive care in children who are at the highest risk of experiencing dental caries. DENTAL HEALTH OF PATIENTS WITH HEAD AND NECK CANCER RECEIVING RADIATION
Duarte VM, Liu YF, Rafizadeh S, Tajima T, Nabili V, Wang MB. Comparison of dental health of patients with head and neck cancer receiving IMRT vs conventional radiation (published online ahead of print Oct. 21, 2013). Otolaryngol Head Neck Surg. doi:10.1177/0194599813509586. Background. As summarized by the authors of this study, patients who receive a diagnosis of head and neck cancer frequently are treated with radiation therapy, which is associated with complications that can have a profound effect on quality of life. These adverse effects are difficult to manage and include xerostomia, dental caries, periodontal disease, mucositis, osteoradionecrosis, trismus and dysphagia. One way to reduce damage caused by radiation therapy is to reduce the amount of tissue that is exposed to radiation. The use of intensitymodulated radiation therapy (IMRT) is one way of reducing radiation exposure. IMRT aims thin beams of radiation at tumors in three dimensions from many angles and, therefore, reduces damage to nearby healthy tissue.1 The purpose of this study was to perform a retrospective comparison of the oral health of patients who received conventional radiation therapy with that of patients who
received IMRT for head and neck cancers. Methods. The authors included in their study 158 patients (157 men and one woman) who received either conventional radiation therapy (99 patients) or IMRT (59 patients) at the West Los Angeles, Calif., Veterans Affairs hospital. As part of their usual care at the hospital, all patients received a complete dental evaluation before radiation therapy, any necessary dental care and extraction of teeth as needed to minimize postradiation oral complications of radiation therapy and to prepare them for future dental rehabilitation. All patients also received education in toothbrushing and the use of dental floss and were prescribed daily use of high-concentration topical fluoride (1.1 percent neutral sodium fluoride). One month after radiation therapy, patients were assessed for the incidence of Candida infection, dental caries, mucositis, xerostomia, periodontitis, edentulism, extractions, presence of osteoradionecrosis and use of fluoride. The investigators used these data from patients’ records to compare the adverse effects of conventional radiation therapy with those of IMRT. Results. Three complications of radiation therapy occurred more frequently among patients who had been treated with conventional radiation therapy compared with those who were treated with IMRT: xerostomia, 46.5 percent versus 16.9 percent (P < .001); mucositis, 46.5 percent versus 16.9 percent (P < .001); and osteoradionecrosis, 10.1 percent versus 0 percent (P < .02). Why is this study important? The oral complications of radiation therapy for head and neck cancers can have a profound negative effect on quality of life. Although this was not a randomized clinical trial and the follow-up time of one month was relatively short, this study’s findings support the use of IMRT for head and neck cancer. Q doi:10.14219/jada.2013.38 1. National Institutes of Health, National Cancer Institute. NCI dictionary of terms. www.cancer.gov/dictionary?cdrid=335073. Accessed Nov. 20, 2013. Dr. Pihlstrom is a professor emeritus, Department of Surgical and Developmental Sciences, School of Dentistry, University of Minnesota, Minneapolis. He also is the associate editor, Research, for The Journal of the American Dental Association, as well as an independent oral health research consultant. Disclosure. Dr. Pihlstrom did not report any disclosures.
JADA 145(3)
http://jada.ada.org
March 2014
289