Findings in Oral Health: Attitudes and Quality of Life Among Patients Experiencing Homelessness

Hazem Seirawan, DDS, MPH, MS, is a clinical associate professor and the section chair of the CHAMP project in the division of dental public health and pediatric dentistry at the Herman Ostrow School of Dentistry of USC. He is a practicing pediatric dentist and a diplomate of the American Academy of Pediatric Dentistry. Conflict of Interest Disclosure: None reported.

Laura Elizondo, DDS, is an associate professor of clinical dentistry at the Herman Ostrow School of Dentistry of USC and the director of the USC Dental Clinic at the Union Rescue Mission. Conflict of Interest Disclosure: None reported.

Niel Nathason, MPH, MA, is an associate professor emeritus of clinical dentistry at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

Roseann Mulligan DDS, MS, is the Charles M. Goldstein professor of community oral health and an associate dean of community health programs and hospital affairs at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.

ABSTRACT

Background: The goal of this study was to evaluate access to dental care, oral health attitudes, oral health-related quality of life (OHRQoL) and satisfaction with received dental care among people experiencing homelessness (PEH) who are receiving dental services from a safety net program in downtown Los Angeles.

Methods: The subjects were read the study questions in two separate interviews at baseline and follow-up assessing health attitudes and OHRQoL.

Results: The study recruited 80 subjects. OHRQoL average scores improved from 35 to 26 points over the study period. The program resulted in a statistically significant reduction in the extent and prevalence of the OHRQoL scores with an improvement of 46.9% and 26.1% respectively. Subjective saliva indicators were statistically significantly associated with poorer total and partial scores of the Oral Health Impact Profile (OHIP-14). The subjects were satisfied with the providers and the services they received.

Conclusions: The study found that providing adequate access to oral health care for PEH should reduce the severity of their oral health diseases and thus reduce the associated negative impacts on their OHRQoL.

Practical implications: Community and private clinics should be supported in providing better access to oral health care for PEH and educated about the role of this access on employability, acceptability, rehabilitation and reintegration of PEH in our society.

Key words: Oral health, quality of life, homelessness

The highly diverse U.S. population experiencing homelessness continues to increase in number. [1] It is estimated that while there are over 57,000 individuals without housing in Los Angeles County at any one time, there are over 190,000 people experiencing homelessness (PEH) per year. [2] Access to health care is vital to an individual’s well-being. While many Los Angeles County residents struggle with the high costs of health care, those without housing are particularly vulnerable to multiple unique challenges regarding their health. About a quarter (24%) are unable to receive needed medical care with nearly half (48%) visiting hospital emergency rooms and 52% suffering from depression. [3] Clearly, the accessibility of safety net programs is suboptimum. [4]

Good general and oral health is considered an essential factor in helping PEH return to the workforce and resume productive roles in society. [1] Yet published studies describing their poor oral health conditions, lack of access to dental care and the associated burden on the quality of life are scarce. [1,5–10] To help PEH in their rehabilitation and to reduce the impact of poor oral health conditions on their quality of life, the Herman Ostrow School of Dentistry of USC and the Union Rescue Mission (URM) established a community dental clinic in 1999 to provide comprehensive oral health care and thereby improve and maintain the oral health of PEH in downtown Los Angeles.

The authors previously described the development of the USC+URM Dental Clinic in downtown Los Angeles, illustrating its success as a model of a community-campus partnership developed to improve the access of dental care among those without housing, and reported on the high prevalence of oral health disease among PEH including untreated caries (58%) with a mean of 6.3 decayed teeth at baseline. [11] In this study, we evaluated access to dental care, attitudes toward oral health and dental care, oral health-related quality of life (OHRQoL) status and satisfaction with received dental care among PEH treated at this dental clinic.

PEH who were first-time visitors to the USC+URM Dental Clinic and who were enrolled in a rehabilitation program were eligible for the study and were invited to participate by bilingual staff (English/Spanish). This group represents a convenience sample recruited over a three-month period. During the first interview (baseline), participants were asked questions about their access to dental care, OHRQoL, attitudes toward oral health and dental care. The second interview (followup) occurred about six months after the first dental appointment and again asked questions about their OHRQoL, attitudes toward oral health and dental care and satisfaction with the dental care they received. The study obtained approval and satisfied the University of Southern California Institutional Review Board (UP-06-00279).

The questions asked during the interviews were adapted from previously published questionnaires. For example, access to dental care was evaluated using the Association of State and Territorial Dental Directors questionnaire instrument. [12] The short version of the Oral Health Impact Profile instrument (OHIP-14) was used for the OHRQoL. [13] This instrument is composed of 14 questions with a five-point Likert scale response system. Attitudes toward oral health and dental care were also evaluated using a structured questionnaire designed by the World Health Organization Collaborating Centre (WHO CC) for Community Oral Health Programs and Research [14] where a five-point Likert scale ranging from “strongly agree” to “strongly disagree” was used. Other questions were added about the subjective feeling of the amount of saliva in the mouth (based on the subjective parameters develop by Fox et al. [15] ), smoking habits, consumption of alcohol and satisfaction with received dental services. Responses to the satisfaction questions were also recorded on a five-point Likert scale ranging from “very satisfied” to “very dissatisfied.”

Descriptive statistics from the questionnaire were generated for all study variables. OHRQoL questions were coded from 0 to 4 where 0 indicated never and 4 indicated very often. The overall weighted sum of scores of OHRQoL questions and the partial scores by domains were calculated to measure OHRQoL severity. OHRQoL prevalence was calculated as the proportion of people reporting at least one answer as fairly often or very often. The number of questions answered by a subject as fairly often or very often is the subject’s OHRQoL extent. [16] The attitude variables from the WHO CC instrument were dichotomized as strongly agree versus all other categories. The satisfaction variables were dichotomized as very satisfied versus all other categories. The independent variables were age, gender, race/ethnicity, length of homelessness, saliva indicators and currently smoking. General linear models were used to quantify the association between OHRQoL and the independent variables.

The study recruited 80 consecutive subjects for the baseline interview. All subjects invited to join the study agreed to participate. The majority were males (78.8.%), with 45.0% being 40–49 years of age and most commonly African American (48.7%). Twenty-nine subjects (36.3%) were available for the follow-up interview. The follow-up sample was not significantly different in terms of age, gender or race/ ethnicity compared to the baseline sample. More than half of the baseline sample of subjects (52.1%) were newly lacking a home (less than six months). About onethird of them reported the sensation of a dry mouth when eating (32.1%) or needed to sip water to aid in swallowing dry food (33.8%) with greater than half of them being current smokers (63.3%) (TABLE 1). Just over half (52.6%) recalled a toothache during the last six months and 53.3% had unmet dental needs in the last year. Only two African American women were enrolled in the state Medicaid program (Denti-Cal) (TABLE 2). The reader is advised to review the authors’ earlier publication about the USC+URM Dental Clinic for more in-depth analyses of the oral health conditions of the clinic’s target population. [11]

TABLE 3 describes the attitudes of the study subjects toward oral health (measured by the WHO CC instrument 14 ). With the exception of the attitude statement about the focus of dentists being on treatment more than prevention, at the baseline interview more than half of the subjects strongly agreed with all the different attitude statements. Over half of the subjects at the baseline strongly agreed about the importance of the appearance of teeth (77.5%) and that going to the dentist solves oral health problems (66.3%). At the follow-up interview, subjects had even more favorable attitudes toward dentists than during the baseline interview, with a statistically significant improvement being seen for the two attitudes: dentists explaining problems (an improvement of 63.6% (p < .01) and dentists devoting attention to patients (an improvement of 61.5% (p < .05). An interesting attitude statement that received a lower score than expected was related to sugar consumption with only 61.3% (baseline) and 79.3% (follow-up) of the subjects strongly agreeing that sweet products were bad for teeth. The strongest favorable changes in attitudes between the two interviews were in the effect of brushing on periodontal health and the role of dentists in solving problems with all subjects who did not strongly agree with these statements during the baseline interview strongly agreeing with them at the follow-up interview.

TABLE 4 describes the OHRQoL of the study subjects with lower scores being better. At baseline, the subjects scored 34.9 points or 63% of the maximum score possible, which would equal the worst OHRQoL. The worst partial scores were in psychological discomfort (8.0) followed by the psychological disability (6.4) dimensions of the instrument. The best partial scores were in the functional limitation (2.2) and physical disability (3.8) dimensions of the instrument. OHRQoL scores were improved when measured at the second interview with an average total score of 26.1 points or 46% of the maximum score possible. Follow-up partial scores had the same patterns of the baseline partial scores with subjects scoring the highest in the psychological discomfort (6.7) and psychological disability (4.2) dimensions and the lowest in the functional limitation (2.3) and physical disability (2.1) dimensions. Changes in total OHRQoL scores and in the partial scores of the physical pain, physical disability, psychological disability and handicap dimensions were statistically significant and in the desirable direction. The strongest improvement was in the scores of the physical disability and handicap dimensions, which both increased by 44.5% and 38.0% respectively at the follow-up interview. The weakest improvement was 19.3% in the psychological discomfort dimension (TABLE 4). Total OHRQoL scores at baseline were not explained by age, gender or race/ethnicity except that participants in the age group 40–49 had the highest mean total score of 42.9 compared to 18.7 and 35.4 in the age groups 18–39 and 50-plus respectively (p = 0.004) (data not shown). Nor were changes in OHRQoL scores explained by age, gender and ethnicity except that psychological discomfort was found to be statistically significantly different by the age groups after adjusting for baseline scores (p = 0.028); participants in the age group 40–49 had an increased score of 0.15 of a point in psychological discomfort between the two interviews compared to decreases of 3.52 and 2.67 points in the age groups 18–39 and 50-plus respectively (data not shown). The USC+URM program resulted in a statistically significant reduction in the extent and prevalence of the poor OHRQoL scores with an improvement of 46.9% (in 69% of the subjects) and 26.1% respectively.

TABLE 5 further describes the OHRQoL of the study subjects by their subjective saliva indicators. Both measures of “dry mouth when eating a meal” and “needs to sip liquids when swallowing dry foods” were statistically significantly associated with poorer total and partial scores of OHRQoL. Participants whose mouths felt dry when eating had more than double the OHIP-14 scores of those who did not (54.1 versus 25.9, p < 0.001); and participants who needed liquids when swallowing had almost double the scores of those who did not (50.1 versus 27.1, p < 0.001). The pattern was similar for all partial OHRQoL scores. Participants who did not notice that their saliva was “too much” or “too little” also had significantly better total and partial scores except in the area of social disability, where the trend did not reach significance. When the extent and prevalence measures of OHRQoL were calculated by saliva indicators, statistically significant higher OHRQoL scores were found for those with dry mouth or needing to sip liquids when eating (TABLE 5). Length of homelessness did not seem to have an effect on OHRQoL scores, but smokers seem to have poorer total scores by 13.4 points with a p = 0.025 (data not shown).

Overall, the subjects were very satisfied with the providers and services they received at the follow-up interview. Over 93% were very satisfied with the staff services (front desk and chairside) and over 86% were very satisfied with the dentist. About two-thirds of the subjects (69%) were very satisfied with their smiles and 62% were very satisfied with their quality of life subsequent to treatment. The majority of the subjects believed that their new smiles helped them become more employable (86%) and socially acceptable (93%) (data not shown).

Homelessness is more than just a lack of safe and secure housing. It results in social isolation and vulnerability to risky health behaviors and chronic health problems. [17] Our study is the first U.S. study to use the OHIP-14 — a validated and known instrument — to better understand the OHRQol of PEH in the U.S. Our study is also the first to study their OHRQoL at two points of time over a timespan of six months. The response rate to our follow-up study was 36%, which is a reasonable outcome given the transient nature of our subjects and their complex social and psychosocial challenges.

PEH experience a burden of medical conditions and poorer oral health than the general public. [16] The authors have reported in a previous publication about the community health project USC+URM Dental Clinic and concluded that PEH visiting the clinic are in great need of restorative, surgical and periodontal procedures. The findings were consistent with other U.S. and international studies describing the high rates of dental diseases among PEH. [11] For example, 41% of PEH in the U.S. were found to have unmet dental needs. [18] The number of decayed teeth among PEH was estimated to be seven teeth in Stockholm, Sweden, [8] four in Belfast, Ireland, [19] three in Hong Kong [9] and 5.8 in Boston, [6] which was similar to our study of 6.[3]. The results are consistent with the World Health Organization Report and the U.S. surgeon general report that the burden of oral diseases is the greatest among disadvantaged groups such as PEH. [20,21] The USC+URM Dental Clinic continues to be a successful oral health care delivery model for PEH. It is deeply incorporated in the rehabilitation programs of the URM main facility programs and other local rehabilitating agencies that refer PEH for comprehensive care. [11]

Previous oral health research on PEH in the U.S. has tended to focus on their clinical oral conditions. However, the psychosocial and social impacts of diseases are as important as the classic epidemiological measures. [22] One study in the U.S. by Conte et al. found in a sample of 46 PEH subjects participating in a homeless service day in New Jersey that the majority reported one or more negative oral health impacts. Eating difficulty was reported by 42% of the subjects followed by unease or difficulty in smiling (33%), concentration (18%) and talking (16%). The study concluded that the negative impact of oral health on daily activities was higher than expected and typically unreported. [10] In this study, we focus on the impact of oral health on the quality of life in our target population.

There are several studies about the OHRQoL of PEH in the U.K. and Australia. Daly et al. studied a convenience sample of 93 PEH subjects drawn from eight facilities in South East London who were invited to participate in an oral health assessment in an outreach dental clinic. The study used the OHIP-14 instrument and found poor OHRQoL with an overall mean impact (severity) score of 32 compared to our study of 34.9 at baseline and 26.1 at follow-up. [23] Another study in the U.K. by Richard et al. studied 100 vulnerable PEH subjects who were using the services of a community center in Swansea, South Wales. The subjects were invited to complete the OHIP-14 instrument. The study found an overall mean impact score of 21.8 with the most common impacts being related to toothache, discomfort (physical pain), ability to relax and feeling ashamed regarding the appearance of teeth (psychological disability). [22]

In our study, psychological disability and psychological discomfort were the strongest adverse impacts at both baseline and follow-up, rather than physical pain. While Ford et al. theorized that PEH might be more accepting of greater levels of oral pain because of the small difference (1.0 point) in OHRQoL found between the general population and PEH in the psychological domain (smaller than any other domains), [16] we propose that our subjects’ recent access to dental care that may have alleviated any possible pain complaints might explain the moderate impact of physical pain seen in our study (1.0 point or 21.8%). The South Wales study also found that homeless status and tooth loss were the strongest predicting factors of poorer OHIP-14 scores with rough sleeping (sleeping outside because the individual has no home) and those with less than 19 teeth being more likely to be in this category. [22] It should be mentioned that the OHIP-14 was administered in the Adult Dental Health Survey of the U.K. in 1998 with a resulting overall mean impact score of 5.1 for the general population. [24] Another study in Brisbane, Australia, examined the adverse impact of oral health problems and quality of life of a convenience sample of urban adult PEH subjects using the OHIP-14 instrument. In this study, the oral health impact on quality of life was significantly greater across all measures when compared with the general Australian population by a magnitude of three times greater than the general population with the overall mean impact score at 28.6 compared to 7.5 in the Australian population. In this Australian study, the authors chose to combine the domains of physical pain and physical disability in one domain and did the same for the domains of psychological discomfort and physiological disability, [16] thus we could not compare our partial scores.

In the U.S., there is no national survey that employs OHIP-14 among adult Americans. The 2003–2004 NHANES employed a shorter version, comprised of only seven questions from the OHIP- 14 instrument. In the NHANES study, the prevalence of OHRQoL was 15.3% with a mean impact score of 2.81, [25] compared to our study with a prevalence of 75.6 and a mean of 5.2 at baseline. The large difference in the mean scores is due to the NHANES being based on the sum of seven items and the OHIP- 14 having 14 items. [25] Our finding is still alarming given that the prevalence in our sample at follow-up is almost four times (58.6%) what is reported in the U.S. population (15.3%) and the services provided at the USC+URM Dental Clinic resulted in significant reduction in the severity, extent and prevalence of OHRQoL measures.

Our study also sheds light on the high prevalence of subjectively assessed salivary gland dysfunction among PEH. In our relatively young sample (age range 18–62), about one-third of the subjects were affected by a subjective feeling of xerostomia, and these results correlated with a significant impact in all dimensions of their OHRQoL. Other authors have published about the effect of xerostomia on OHRQoL among general adult populations in the U.S. and found that a feeling of mouth dryness while eating was a strong risk factor associated with poor OHRQoL. It was the third most important risk factor for poor OHRQoL in a multivariate analysis after perceived needs to relieve pain and to have a denture respectively (OR of 2.2). [26] This effect seems to be as significant among our PEH sample with a feeling of dry mouth resulting in about double the OHRQoL scores compared to those without this feeling at baseline. The effects of xerostomia on OHRQoL have been documented among people with burning mouth syndrome, [27] Sjogren’s syndrome, [28] oral cancer [29] and Type 1 diabetes. [30] It is likely that our sample subjects may also be suffering from other medical conditions with oral symptoms. Further investigation of the systemic and oral health of PHE and their OHRQoL is recommended.

Oral health care provided by the USC+URM Dental Clinic resulted in the majority of PEH subjects in the sample perceiving themselves as more employable and socially acceptable at the end of the study. This is in spite of the fact that only 62% of them were satisfied with their quality of life in general. It is important to remind the reader that the participants in our study were part of a rehabilitation program that helped them tackle their intertwined and complex social and health problems at the same time they were receiving dental care.

We recognize that there are some limitations to our study. Although our sample does not represent all PEH in Los Angeles, it represents those who were enrolled in local rehabilitation programs and thus had access to oral health care through the USC+URM Dental Clinic. Our sample is not a probability-based sample, but it represents a diverse group of individuals in terms of age, gender and race/ethnicity.

In conclusion, the oral health of PEH is quite poor and has negative impacts on their quality of life. Providing adequate access to oral health care for PEH should reduce the severity of their oral health diseases and thus reduce the associated negative effects on their OHRQoL. Furthermore, better access to oral health care should contribute to improving their employability, acceptability and satisfaction of PEH, with the goal being to contribute to their rehabilitation and reintegration as productive members of society.

This study was funded by the Herman Ostrow School of Dentistry of USC and received approval from the USC’s Institutional Review Board (USC IRB UP-09-00020). All procedures performed in this study were in accordance with the ethical standards of the USC IRB. Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors.

REFERENCES

1. King TB, Gibson G. Oral health needs and access to dental care of homeless adults in the United States: A review. Spec Care Dentist Jul–Aug 2003;23(4):143–7. doi: 10.1111/j.1754-4505.2003.tb00301.x.

2. The Los Angeles Homeless Services Authority. 2013 Greater Los Angeles Homeless Count. Los Angeles: The Los Angeles Homeless Services Authority; 2014.

3. The Los Angeles Homeless Services Authority. 2007 Greater Los Angeles Homeless Count. Los Angeles: The Los Angeles Homeless Services Authority; 2007.

4. Kertesz SG, McNeil W, Cash JJ, et al. Unmet need for medical care and safety net accessibility among Birmingham’s homeless. J Urban Health 2014 Feb;91(1):33–45. doi: 10.1007/s11524-013-9801-3.

5. Gelberg L, Linn LS, Rosenberg DJ. Dental health of homeless adults. Spec Care Dentist Jul–Aug 1988;8(4):167–72. doi: 10.1111/j.1754-4505.1988. tb00725.x.

6. Kaste LM, Bolden AJ. Dental caries in homeless adults in Boston. J Public Health Dent Winter 1995;55(1):34–6. doi: 10.1111/j.1752-7325.1995.tb02328.x.

7. Gibson G, Rosenheck R, Tullner JB, et al. A national survey of the oral health status of homeless veterans. J Public Health Dent Winter 2003;63(1):30–7. doi: 10.1111/j.1752-7325.2003.tb03471.x.

8. De Palma P, Frithiof L, Persson L, et al. Oral health of homeless adults in Stockholm, Sweden. Acta Odontol Scand 2005 Feb;63(1):50–5. doi: 10.1080/00016350510019658.

9. Luo Y, McGrath C. Oral health status of homeless people in Hong Kong. Spec Care Dentist Jul–Aug 2006;26(4):150–4. doi: 10.1111/j.1754-4505.2006. tb01716.x.

10. Conte M, Broder HL, Jenkins G, et al. Oral health, related behaviors and oral health impacts among homeless adults. J Public Health Dent Fall 2006;66(4):276–8. doi: 10.1111/j.1752-7325.2006.tb04082.x.

11. Seirawan H, Elizondo LK, Nathason N, et al. The oral health conditions of the homeless in downtown Los Angeles. J Calif Dent Assoc 2010 Sep;38(9):681–8.

12. Association of State and Territorial Dental Directors. Basic screening surveys: An approach to monitoring community oral health. 2003.

13.Slade GD, Strauss RP, Atchison KA, et al. Conference summary: Assessing oral health outcomes — measuring health status and quality of life. Community Dent Health 1998 Mar;15(1):3–7.

14. Petersen PE, Aleksejuniene J, Christensen LB, et al. Oral health behavior and attitudes of adults in Lithuania. Acta Odontol Scand 2000 Dec;58(6):243–8. doi: 10.1080/00016350050217073.

15. Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia and objective measures of salivary gland performance. J Am Dent Assoc 1987 Oct;115(4):581–4. doi: 10.1016/s0002-8177(87)54012-0.

16. Ford PJ, Cramb S, Farah CS. Oral health impacts and quality of life in an urban homeless population. Aust Dent J 2014 Jun;59(2):234–9. doi: 10.1111/adj.12167.

17. Kermode M, Crofts N, Miller P, et al. Health indicators and risks among people experiencing homelessness in Melbourne, 1995–1996. Aust N Z J Public Health 1998 Jun;22(4):464–70. doi: 10.1111/j.1467-842x.1998. tb01415.x.

18. Baggett TP, O’Connell JJ, Singer DE, et al. The unmet health care needs of homeless adults: A national study. Am J Public Health 2010 Jul;100(7):1326–33. doi: 10.2105/ AJPH.2009.180109. Epub 2010 May 13.

19. Collins J, Freeman R. Homeless in North and West Belfast: An oral health needs assessment. Br Dent J 2007 May;202(12):E31. doi: 10.1038/bdj.2007.473.

20. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. 2000.

21. Petersen PE. World Health Organization global policy for improvement of oral health — World Health Assembly 2007. Int Dent J 2008 Jun;58(3):115–21. doi: 10.1111/j.1875-595x.2008.tb00185.x.

22. Richards W, Keauffling J. Homeless who accessed a healthy living centre in Swansea, South Wales: An assessment of the impact of oral illhealth. Prim Dent Care 2009 Jul;16(3):94–8. doi: 10.1308/135576109788634287.

23. Daly B, Newton T, Batchelor P, et al. Oral health care needs and oral health-related quality of life (OHIP-14) in homeless people. Community Dent Oral Epidemiol 2010 Apr;38(2):136–44. doi: 10.1111/j.1600- 0528.2009.00516.x. Epub 2010 Jan 14.

24. Steele JG, Sanders AE, Slade GD, et al. How do age and tooth loss affect oral health impacts and quality of life? A study comparing two national samples. Community Dent Oral Epidemiol 2004 Apr;32(2):107–14. doi: 10.1111/j.0301-5661.2004.00131.x.

25. Sanders AE, Slade GD, Lim S, et al. Impact of oral disease on quality of life in the U.S. and Australian populations. Community Dent Oral Epidemiol 2009 Apr;37(2):171–81. doi: 10.1111/j.1600- 0528.2008.00457.x. Epub 2009 Jan 17.

26. Seirawan H, Sundaresan S, Mulligan R. Oral health-related quality of life and perceived dental needs in the United States. J Public Health Dent Summer 2011;71(3):194–201.

27. Lopez-Jornet P, Juan H, Alvaro PF. Mineral and trace element analysis of saliva from patients with BMS: A crosssectional prospective controlled clinical study. J Oral Pathol Med 2014 Feb;43(2):111–6. doi: 10.1111/jop.12105. Epub 2013 Jul 19.

28. Mumcu G, Bicakcigil M, Yilmaz N et al. Salivary and serum B-cell activating factor (BAFF) levels after hydroxychloroquine treatment in primary Sjögren’s syndrome. Oral Health Prev Dent 2013;11(3):229–34. doi: 10.3290/j.ohpd.a30172.

29. Li W, Yang Y, Xu Z, et al. Assessment of quality of life of patients with oral cavity cancer who have had defects reconstructed with free anterolateral thigh perforator flaps. Br J Oral Maxillofac Surg 2013 Sep;51(6):497–501. doi: 10.1016/j.bjoms.2012.09.005. Epub 2012 Oct 26.

30. Busato IM, Ignacio SA, Brancher JA, et al. Impact of xerostomia on the quality of life of adolescents with Type 1 diabetes mellitus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009 Sep;108(3):376–82. doi: 10.1016/j. tripleo.2009.05.005.

THE CORRESPONDING AUTHOR, Hazem Seirawan, DDS, MPH, MS, can be reached at mhseirawan@gmail.com.