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Mastication and oral healtherelated quality of life in

removable denture wearers with Alzheimer disease
Camila H. Campos, DDS, MS,a Giselle R. Ribeiro, DDS, MS,b and Renata C. M. Rodrigues Garcia, PhDc

Progressive and degenerative ABSTRACT

Alzheimer disease (AD) affects Statement of problem. Alzheimer disease (AD) can affect masticatory function, affecting oral
the central nervous system healtherelated quality of life (OHRQoL). Whether oral rehabilitation with conventional removable
and causes cognitive impair- prostheses can restore masticatory function and improve OHRQoL in these individuals is unknown.
ment, including memory loss,
Purpose. The purpose of this clinical study was to evaluate the influence of oral rehabilitation with
communication problems, loss removable prostheses on masticatory efficiency and OHRQoL in elders with and without AD.
of time and space orientation,
and inability to acquire new Material and methods. Thirty-two elders with mild AD (n=16, mean age=76.7 ±6.3 years) or
without AD (n=16, mean age=75.2 ±4.4 years) were recruited. All participants first underwent
learning.1,2 Mastication has
masticatory efficiency and OHRQoL evaluations, and 2 months after insertion of new removable
been reported as a way to prostheses, the variables were reassessed. Masticatory efficiency was determined using the sieving
improve cognitive function by method, and OHRQoL was measured by applying the Geriatric Oral Health Assessment Index
enhancing cerebral cortex ac- (GOHAI). The data from the baseline and after insertion of the new removable prostheses were
tivity and increasing cortical compared by paired t test. Group differences at each time point were assessed by t test (a=.05).
blood flow.3,4 Mastication may Results. After insertion of the new removable prostheses, masticatory efficiency and OHRQoL
lead to long-term effects on improved in both the elders with AD and the control. At baseline, elders with AD had lower
the cerebral nervous system masticatory efficiency and higher OHRQoL than controls (P<.05). After removable prosthesis
and be helpful in preventing insertion, elders with AD continued to show lower masticatory efficiency values than controls, but
the degradation of brain func- their OHRQoL was similar.
tions.3,5,6 In addition, epide- Conclusions. Oral rehabilitation with new removable prostheses improved the masticatory effi-
miologic studies have reported ciency and OHRQoL of elders with and without AD, although masticatory efficiency did not reach
that tooth loss is a significant control levels in elders with AD. (J Prosthet Dent 2017;-:---)
risk factor for dementia or
AD5,7,8 and that tooth loss is more prevalent in elders appetite, and motor function and thereby impairing
with dementia.9,10 Animal experiments have identified masticatory function.13-19 Impaired masticatory function
tooth loss as impairing spatial learning and memory also can limit eating and social life, negatively affecting
because the number of pyramidal cells in the hippo- oral healtherelated quality of life (OHRQoL).20
campus and the gyrus dentatus decrease with time after In spite of the significant increase in the elderly
tooth loss.11,12 Thus, evidence exists that chronic masti- population and as a consequence the incidence of AD,
catory dysfunction may affect neurobiology of the brain. the effects of the disease on masticatory function and
Brain damage caused by AD can also reduce the OHRQoL are not clear.21-23 Although Rolim et al24 re-
sensations of smell and taste, affecting salivary flow,
ported improvements in OHRQoL after general dental

Supported by the National Counsel of Technological and Scientific Development (grant 48.090.3/2013-1); and the São Paulo Research Foundation (grant 2013/10200-7).
Postgraduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School (UNICAMP), University of Campinas, São Paulo, Brazil.
Postgraduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School (UNICAMP), University of Campinas, São Paulo, Brazil.
Professor, Department of Prosthodontics and Periodontology, Piracicaba Dental School (UNICAMP), University of Campinas, São Paulo, Brazil.


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AD as diagnosed by a neurologist using the International

Clinical Implications Classification of Diseases (ICD-10), Diagnostic and Sta-
Oral rehabilitation with removable prostheses tistical Manual of Mental Disorders (DSM-IV), Mini-
Mental State Examination (MMSE), and Clinical
improves oral healtherelated quality of life and
Dementia Rating scale (CDR).26 To be part of the control
mastication in elders with Alzheimer disease (AD).
group, elders had to be free of AD or any other type of
However, masticatory difficulties remain. Clinicians
dementia. Also excluded were individuals with severe
should be aware of the masticatory impairment of
periodontal disease, temporomandibular disorders,
elders with AD when proposing rehabilitative
cognitive impairment, and major depression or other
therapies and adjustments in diet.
mood disorders.25
In addition to matching by age, groups were also
matched by sex (8 men and 8 women in each group) and
treatment, the authors are unaware of reports that show
dental status, with each group presenting 11 completely
whether removable prostheses would improve mastica-
edentulous and 5 partially edentulous participants.25 The
tion or OHRQoL in elderly people with AD.
MMSE26 was applied by a single calibrated researcher
Therefore, the purpose of this clinical study was to
(C.H.C.) for participants in both groups, and cutoffs were
compare the masticatory function and OHRQoL of
applied for the control group selection.27
elderly people with mild AD with a control group of el-
During clinical examination, stimulated salivary flow rate
ders without cognitive impairment before and after oral
was estimated using a 0.02-mm thick piece of plastic paraffin
rehabilitation with removable partial dentures (RPDs)
film (Parafilm M; Bemis Co Inc). The participant was
and/or complete dentures (CDs). The null hypotheses
instructed to masticate the piece for 5 minutes, expectorating
were that those with AD and the controls would not
the produced saliva into a preweighed container. Salivary
differ in masticatory function and OHRQoL, and that
flow rate (g/min) was then calculated by subtracting the
oral rehabilitation with removable prostheses would not
initial weight from the final weight of the container.28
improve masticatory function and OHRQoL.
After receiving general dental treatment,25 all partic-
ipants underwent baseline assessment of OHRQoL and
masticatory efficiency. New CDs and/or RPDs were then
This was a nonrandomized, single-center, controlled processed and delivered. After a 2-month adaptation
clinical trial that compared mastication and OHRQoL period, OHRQoL and masticatory efficiency were
between individuals with and without AD. Additionally, reassessed.
a paired design was used to compare the same variables Patient-based assessment of OHRQoL was evaluated
before and after the use of new RPDs and/or CDs. using the validated Portuguese-language version of
Masticatory function was evaluated by measuring GOHAI.29 A single examiner (C.H.C.) asked the partici-
masticatory efficiency, and OHRQoL was measured by pants about 12 GOHAI items in reference to the previous
applying the Geriatric Oral Health Assessment Index 3 months. They were asked to respond using a 3-point
(GOHAI). The assessments were performed before and 2 scoring scale (always, sometimes, or never). The final
months after the prosthetic treatment. GOHAI score was calculated as previously described by
Thirty-two partially or completely edentulous elderly Atchison and Dolan.30 The GOHAI score could range
individuals who had participated in a previous study25 between 12 and 36 and was classified as high if the scores
and who used removable prostheses were assigned to 2 ranged between 34 and 36, moderate if between 31 and
groups: with AD (n=16, aged 76.7 ±6.3 years) and 33, and low if less than 30. Participants presenting high
without AD (n=16, aged 75.2 ±4.4 years). Details about GOHAI scores indicated that they had a positive
the participants of this study have been previously perception of their oral health, and those with lower
described.25 The ethics committee of Piracicaba Dental GOHAI scores had more self-reported oral health
School, University of Campinas, approved this study problems and were expected to have poorer oral health
(protocol 043/2013). The study was also registered in the conditions.30 To improve the reliability of self-reporting,
Brazilian Registry of Clinical Trials database active listening and slow speech were used while
(RBR_5v5bvw), which is linked to the International applying the questionnaire to the elders with AD.31,32
Clinical Trials Registration Platform (ICTRP/World Masticatory efficiency was evaluated using an artificial
Health Organization). Participation in this study was test material composed of 5.6×5.6×5.6 mm Optocal33
voluntary, and participants and their families or legal cubes. Portions containing 17 cubes of Optocal (3.7 g in
representatives provided signed written informed con- weight) were given to each participant, who masticated
sent before enrollment. them for 40 cycles; they were monitored by a single
According to the earlier report,25 to be included in the calibrated operator (C.H.C.). The comminuted particles
experimental group, elders had to be in the mild stage of were collected in a paper filter, dried for 1 week at room


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Table 1. Two-way ANOVA for GOHAI and masticatory efficiency among Table 2. Masticatory efficiency (mean ±SD) of AD and control groups
groups and before and after prosthetic treatment before and after prosthetic treatment
Sum of Mean AD (n=16) Control (n=16)
Source Squares df Squares F P
Characteristic Before PT After PT Before PT After PT
ME (%) 3.13 ±6.62Aa 9.54 ±13.41Ab 15.12 ±9.90Ba 25.85 ±16.28Bb
Groups 10.11 1 10.11 7.69 .007
GOHAI 34.56 ±2.00Aa 35.58 ±0.61Ab 30.56 ±4.49Ba 34.69 ±1.49Bb
Prosthetic treatment 1.67 1 1.67 46.63 <.001
AD, Alzheimer disease; GOHAI, Geriatric Oral Health Assessment Index; ME, masticatory
Group×Prosthetic <.001 efficiency; PT, prosthetic treatment. Different superscript uppercase letters represent
treatment interaction differences between groups (P<.05). Different superscript lowercase letters represent
GOHAI intragroup differences (P<.05).
Groups 97.52 1 97.52 13.60 <.001
Prosthetic treatment 112.89 1 112.89 15.75 <.001
Group×Prosthetic <.001 Table 3. AD and control groups in each GOHAI category before and after
treatment interaction prosthetic treatment
ME, masticatory efficiency; GOHAI, Geriatric Oral Health Assessment Index. AD (n=16), Controls (n=16),
n (%) n (%)
GOHAI Category Before PT After PT Before PT After PT
temperature, and vibrated in a sieving machine (elec-
High 13 (81.25) 16 (100) 5 (31.25) 12 (75.00)
tromagnetic vibrator; Bertel Indústria Metalúrgica Ltd) Moderate 1 (6.25) 0 5 (31.25) 4 (25.00)
through a stack of 10 sieves with mesh varying between Low 2 (12.50) 0 6 (37.50) 0
0.5 and 5.6 mm.34 Materials retained on the sieves were
AD, Alzheimer disease; GOHAI, Geriatric Oral Health Assessment Index; PT, prosthetic
weighed on a 0.001-g analytic balance (Mark, BEL En- treatment.
gineering), and the masticatory efficiency was calculated
as the percentage weight of the comminuted material
that passed through the 2.8-mm sieve.34 is presented in Table 1. GOHAI and masticatory effi-
After baseline evaluations, all participants received ciency were significantly influenced (P<.05) by the 2
new CDs or RPDs for both maxillary and mandibular times (before and after prosthetic insertion) and by group
arches. These were fabricated by a single experienced (AD and controls) factors.
dental technician with heat-polymerized acrylic resin Masticatory efficiency was impaired in patients with
(Vipi Cril Flash; Dental Vipi) and by following conven- AD compared with the control group both before and
tional techniques.35 As in the prior study,36 RPD frame- after prosthetic treatment (P<.05). Both groups benefited
works were composed of cobalt-chromium alloy from treatment, which increased the masticatory effi-
(Dentorium) and were designed to accommodate the ciency values (P<.05) (Table 2).
anatomy of the supporting tissues and remaining teeth. After rehabilitation with new removable prostheses,
They consisted of a major bar, rests, and clasp retainers. both the AD and control groups presented higher
Both maxillary and mandibular prostheses were delivered GOHAI values, demonstrating improvement in OHR-
and adjusted for a bilateral balanced occlusal scheme. QoL (P<.05) (Table 2). However, comparisons between
After 2 months of using the new prostheses, OHRQoL groups showed that GOHAI values were significantly
and masticatory efficiency were reevaluated. higher for the AD group than for the control group in
The data were evaluated by statistical software (SAS both analyzed times (P<.05), showing less impact of oral
v9.3; SAS Institute Inc) (a=.05). Shapiro-Wilk tests for health on quality of life of patients with AD (Table 2).
each group at baseline and after insertion of the remov- Table 3 shows the distribution of patients in GOHAI
able prostheses revealed normal distributions for salivary categories (high, moderate, and low) before and after
flow rate and GOHAI. A nonparametric distribution was prosthetic treatment. After prosthetic treatment, neither
detected for masticatory efficiency, which underwent a group presented patients in the low GOHAI category,
logarithmic transformation. Data on masticatory efficiency and the number of patients in the high GOHAI category
and GOHAI were submitted to a 2-way ANOVA and the increased, showing improvement in OHRQoL. The
Tukey Studentized range post hoc test, considering time Fisher test revealed P=.02 before prosthetic treatment
(before and after prosthetic insertion) and group (AD and and P=.05 after prosthetic treatment.
controls) as factors. The Fisher test was applied to analyze
the GOHAI category difference between groups. DISCUSSION
This clinical study showed that individuals with AD had
reduced masticatory efficiency and less improvement in
The salivary flow rate was lower (P<.05) in the AD group OHRQoL compared with controls, rejecting the null
(0.73 ±0.52) than in the control group (1.19 ±0.65). The hypothesis. Oral rehabilitation with removable prosthe-
2-way ANOVA for GOHAI and masticatory efficiency ses improved mastication and OHRQoL in both groups.
among groups and before and after prosthetic treatment However, mastication remained impaired for participants


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with AD even after prosthetic treatment, suggesting that controls. However, Ribeiro et al2 found no difference
AD was responsible for the masticatory impairment between AD and control groups. These contrasting re-
rather than the prosthesis insertion. sults may be elucidated by the severity level of AD in our
Salivary flow rate was lower in the AD group than in participants. Unlike our study, which evaluated only
the control group. These data confirm previous find- elderly individuals with mild AD, the latter study2
ings16,17,19 and indicate an increased risk of caries, assessed elderly individuals at different levels of AD.
mucosal inflammation, and reduced food bolus lubrica- Nevertheless, Lee et al21 found lower GOHAI values for
tion in those with the disease.13 Submandibular gland the AD group than for the control group; however, their
function is impaired in those with AD.13,15 In addition, patients with AD had fewer teeth and more oral health
many of the medications taken by elders with AD have problems than their controls. Because our study groups
anticholinergic effects that result in reduced salivary had similar oral characteristics, this may explain the
flow.15 Although no consensus has been reached in the difference.
literature regarding the influence of salivary flow rate in In general, our findings showed that new and better-
mastication,14 it may be an additional factor in the fitted removable prostheses had positive effects on
impaired mastication of those with AD. OHRQoL for both AD and controls. Although we are
Although the dental condition between the AD and unaware of previous research on oral rehabilitation in
control groups was matched, masticatory efficiency was elderly patients with AD, Rolim et al24 found improve-
significantly lower in patients with mild AD before and ment in OHRQoL after providing general dental treat-
after insertion of the new prostheses. Data from the ment for elders with AD.
controls were consistent with those from a previous study The gains in masticatory efficiency and OHRQoL
involving elderly individuals.34 On the basis of the lower emphasize the importance of dental treatment and
number of teeth present in cognitively impaired elders, prosthetic rehabilitation in elders with AD. Because AD is
previous reports9,10 have estimated that this group have still a disease with no cure, efforts should be made to
worse masticatory function compared with controls. maintain or improve the quality of life of the affected
Although a study19 has verified reduced masticatory individuals. In addition, although patients with AD are
efficiency in elderly individuals with other types of thought to require special attention by dental pro-
dementia by comparing controls with balanced oral fessionals, we found no difficulties in treating patients
characteristics, the authors are unaware of a prior study with mild AD. Furthermore, adaptation to the new
on elderly individuals with AD using matched groups. dentures was similar for both AD and control partici-
The masticatory efficiency results suggest that masti- pants. Thus, dentists and researchers should be encour-
catory function is not only related to the presence of aged to attend to this group of special-needs patients.
natural teeth but also depends on sensory feedback and
motor coordination among the masticatory muscles, lips, CONCLUSIONS
cheeks, and tongue.18,19 As dementia, even in an early
On the basis of the findings from this clinical study, the
stage, is associated with impaired motor skill,1 this un-
following conclusions were drawn:
derlying pathology might directly contribute to the lower
masticatory efficiency observed in the present study. 1. Oral rehabilitation with new removable dental
In addition, some studies3,4 have found reduced ce- prostheses improves the OHRQoL and masticatory
rebral blood flow in individuals with impaired mastica- efficiency of elders with and without AD.
tion, making mastication a risk factor for developing 2. However, masticatory efficiency in elders with AD
dementia.5 However, AD affects brain regions related to remained below control levels.
mastication,3 which could negatively affect this function.
Thus, dementia impairs mastication and motor skills, and REFERENCES
lack of mastication accelerates dementia by reducing
cerebral blood flow and brain activity.8 1. Ghezzi E, Ship J. Dementia and oral health. Oral Surg Oral Med Oral Pathol
Oral Radiol 2000;89:2-5.
Regarding the subjective assessments, differences 2. Ribeiro GR, Costa JLR, Ambrosano GMB, Garcia RCMR. Oral health of the
elderly with Alzheimer’s disease. Oral Surg Oral Med Oral Pathol Oral Radiol
were observed between the AD and control elders in the 2012;114:338-43.
GOHAI values before oral rehabilitation. The GOHAI 3. Onozuka M, Fujita M. Mapping brain region activity during chewing: a
functional magnetic resonance imaging study. J Dent Res 2002;81:743-6.
values were considered high for the AD group and 4. Ono Y, Yamamoto T, Kubo K, Onozuka M. Occlusion and brain function:
moderate for the control group. Although there are few mastication as a prevention of cognitive dysfunction. J Oral Rehabil 2010;37:
reports on subjective assessments of individuals with AD, 5. Gatz M, Mortimer JA, Fratiglioni L, Johansson B, Berg S, Reynolds CA, et al.
the results of the present study agree with those found by Potentially modifiable risk factors for dementia in identical twins. Alzheimers
Dement 2006;2:110-7.
Warren et al,23 which demonstrated that participants 6. Momose T, Nishikawa J, Watanabe T, Sasaki Y, Senda M, Kubota K, et al.
with AD reported better self-perceived oral health than Effect of mastication on regional cerebral blood flow in humans examined by


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positron-emission tomography with O-labelled water and magnetic reso- 24. Rolim TDS, Fabri GMC, Nitrini R, Anghinah R, Teixeira MJ, de Siqueira JTT,
nance imaging. Arch Oral Biol 1997;42:57-61. et al. Evaluation of patients with Alzheimer’s disease before and after dental
7. Okamoto N, Morikawa M, Tomioka K, Yanagi M, Amano N, Kurumatani N. treatment. Arq Neuropsiquiatr 2014;72:919-24.
Association between tooth loss and the development of mild memory 25. Campos CH, Ribeiro GR, Costa JLR, Rodrigues Garcia RCM. Correlation of
impairment in the elderly: the Fujiwara-kyo study. J Alzheimers Dis 2015;44: cognitive and masticatory function in Alzheimer’s disease. Clin Oral Investig
777-86. 2017;21:573-8.
8. Weijenberg RAF, Scherder EJA, Lobbezoo F. Mastication for the mind-the 26. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State.” A practical
relationship between mastication and cognition in ageing and dementia. method for grading the cognitive state of patients for the clinician. J Psychiatr
Neurosci Biobehav Rev 2011;35:483-97. Res 1975;12:189-98.
9. Miura H, Kariyasu M, Yamasaki K, Arai Y, Sumi Y. Relationship between 27. Uhlmann RF, Larson EB. Effect of education on the Mini-Mental State
general health status and the change in chewing ability: a longitudinal study examination as a screening test for dementia. J Am Geriatr Soc 1991;39:
of the frail elderly in Japan over a 3-year period. Gerodontology 2005;22: 876-80.
200-5. 28. van der Bilt A. Assessment of mastication with implications for oral reha-
10. Kondo K, Niino M, Shido K. A case-control study of Alzheimer’s disease in bilitation: a review. J Oral Rehabil 2011;38:754-80.
Japan-significance of life-styles. Dementia 1994;5:314-26. 29. de Souza RF, Terada ASSD, Vecchia MPD, Regis RR, Zanini AP,
11. Hirano Y, Obata T, Kashikura K, Nonaka H, Tachibana A, Ikehira H, et al. Compagnoni MA. Validation of the Brazilian versions of two inventories for
Effects of chewing in working memory processing. Neurosci Lett 2008;436: measuring oral health-related quality of life of edentulous subjects. Ger-
189-92. odontology 2012;29:e88-95.
12. Onozuka M, Watanabe K, Mirbod SM, Ozono S, Nishiyama K, Karasawa N, 30. Atchison KA, Dolan TA. Development of the Geriatric Oral Health Assess-
et al. Reduced mastication stimulates impairment of spatial memory and ment Index. J Dent Educ 1990;54:680-7.
degeneration of hippocampal neurons in aged SAMP8 mice. Brain Res 31. Egan M, Bérubé D, Racine G, Leonard C, Rochon E. Methods to enhance
1999;826:148-53. verbal communication between individuals with Alzheimer’s disease and
13. Matsuo R, Yamauchi Y, Morim-Oto T. Role of submandibular and sublingual their formal and informal caregivers: a systematic review. Int J Alzheimers Dis
saliva in maintenance of taste sensitivity recorded in the chorda tympani of 2010;2010:1-12.
rats. J Physiol 1997;498:797-807. 32. Campos CH, Ribeiro GR, Rodrigues Garcia RCM. Oral health-related quality
14. Engelen L, Fontijn-Tekamp A, van der Bilt A. The influence of product and of life in mild Alzheimer: patient versus caregiver perceptions. Spec Care
oral characteristics on swallowing. Arch Oral Biol 2005;50:739-46. Dentist 2016;36:271-6.
15. Ship J, Pilliner S, Baum B. Xerostomia and the geriatric patient. J Am Geriatr 33. Pocztaruk RDL, Frasca LCDF, Rivaldo EG, Fernandes EDL, Gavião MBD.
Soc 2002;50:535-43. Protocol for production of a chewable material for masticatory function tests
16. Ellefsen B, Holm-Pedersen P, Morse DE, Schroll M, Andersen BB, (Optocal-Brazilian version). Braz Oral Res 2008;22:305-10.
Waldemar G. Caries prevalence in older persons with and without dementia. 34. Goncalves TMSV, Campos CH, Goncalves GM, de Moraes M, Rodrigues
J Am Geriatr Soc 2008;56:59-67. Garcia RCM. Mastication improvement after partial implant-supported
17. Vergona KD. A self-reported survey of Alzheimer’s centers in southwestern prosthesis use. J Dent Res 2013;92:189S-94S.
Pennsylvania. Spec Care Dentist 2005;25:164-70. 35. Carr AB, Brown DT. McCracken’s removable partial prosthodontics. 13th ed.
18. Lund JP. Mastication and its control by the brain stem. Crit Rev Oral Biol St Louis: Mosby/Elsevier; 2015:392.
Med 1991;2:33-64. 36. Campos CH, Ribeiro GR, Stella F, Rodrigues Garcia RCM. Mandibular
19. Elsig F, Schimmel M, Duvernay E, Giannelli SV, Graf CE, Carlier S, et al. movements and bite force in Alzheimer’s disease before and after new
Tooth loss, chewing efficiency and cognitive impairment in geriatric patients. denture insertion. J Oral Rehabil 2017;44:178-86.
Gerodontology 2015;32:149-56.
20. Fueki K, Yoshida E, Igarashi Y. A structural equation model relating objective
and subjective masticatory function and oral health-related quality of life in Corresponding author:
patients with removable partial dentures. J Oral Rehabil 2011;38:86-94. Dr Renata Cunha Matheus Rodrigues Garcia
21. Lee KH, Wu B, Plassman BL. Cognitive function and oral health-related Department of Prosthodontics and Periodontology
quality of life in older adults. J Am Geriatr Soc 2013;61:1602-7. Piracicaba Dental School (UNICAMP)
22. Cicciù M, Matacena G, Signorino F, Brugaletta A, Cicciù A, Bramanti E. University of Campinas
Relationship between oral health and its impact on the quality life of Alz- Avenida Limeira, 901
heimer’s disease patients: a supportive care trial. Int J Clin Exp Med 2013;6: Piracicaba, São Paulo, 13414-903
766-72. BRAZIL
23. Warren JJ, Chalmers JM, Levy SM, Blanco VL, Ettinger RL. Oral health of Email:
persons with and without dementia attending a geriatric clinic. Spec Care
Dent 1997;17:47-53. Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.