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Paz C, Glassey A, Frick A, Sattar S, Zaorsky NG, Blitzer GC, Kimple RJ. Cancer therapy-related salivary dysfunction. J Clin Invest 2024; 134:e182661. [PMID: 39225092 PMCID: PMC11364403 DOI: 10.1172/jci182661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Salivary gland dysfunction is a common side effect of cancer treatments. Salivary function plays key roles in critical daily activities. Consequently, changes in salivary function can profoundly impair quality of life for cancer patients. We discuss salivary gland anatomy and physiology to understand how anticancer therapies such as chemotherapy, bone marrow transplantation, immunotherapy, and radiation therapy impair salivary function. We discuss approaches to quantify xerostomia in the clinic, including the advantages and limitations of validated quality-of-life instruments and approaches to directly measuring salivary function. Current and emerging approaches to treat cancer therapy-induced dry mouth are presented using radiation-induced salivary dysfunction as a model. Limitations of current sialagogues and salivary analogues are presented. Emerging approaches, including cellular and gene therapy and novel pharmacologic approaches, are described.
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Affiliation(s)
- Cristina Paz
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Annemarie Glassey
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Abigail Frick
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sarah Sattar
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas G. Zaorsky
- University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Grace C. Blitzer
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Randall J. Kimple
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Gan RH, Lan LQ, Sun DN, Tang F, Niu G, Zheng DL, Wang B, Lu YG. Effect of different approaches of direct radiation on the surface structure and caries susceptibility of enamel. Sci Rep 2024; 14:20183. [PMID: 39215189 PMCID: PMC11364863 DOI: 10.1038/s41598-024-71277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
It is not clear whether different radiation methods have different effects on enamel. The purpose of this study was to compare the effects of single and fractionated radiation on enamel and caries susceptibility and to provide an experimental basis for further study of radiation‑related caries. Thirty-six caries-free human third molars were collected and randomly divided into three groups (n = 12). Group1 (control group) was not exposed to radiation. Group 2 received single radiation with a cumulative dose of 70 Gy. Group 3 underwent fractionated radiation, receiving 2 Gy/day for 5 days followed by a 2-day rest period, for a total of 7 weeks with a cumulative dose of 70 Gy. Changes in microhardness, roughness, surface morphology, bacterial adhesion and ability of acid resistance of each group were tested. Scanning electron microscope revealed that the enamel surface in both radiation groups exhibited unevenness and cracks. Compared with the control group, microhardness and acid resistance of enamel decreased, while roughness and bacterial adhesion increased in both the single radiation and fractionated radiation groups. Compared with the single radiation group, the enamel surface microhardness and acid resistance decreased in the fractionated radiation group, while roughness and bacterial adhesion increased. Both single radiation and fractionated radiation resulting in changes in the physical and biological properties of enamel, with these changes being more pronounced in the fractionated radiation group. Therefore, fractionated radiation is recommended as a more suitable method for constructing a radiation‑related caries model in vitro.
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Affiliation(s)
- Rui-Huan Gan
- Fujian Key Laboratory of Oral Diseases and Fujian Provincial Engineering Research Center of Oral Biomaterial and Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
- Department of Preventive Dentistry, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Li-Qing Lan
- Fujian Key Laboratory of Oral Diseases and Fujian Provincial Engineering Research Center of Oral Biomaterial and Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
- Department of Preventive Dentistry, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Dan-Ni Sun
- Department of Stomatology, San Ming First Hospital, San Ming, China
| | - Fan Tang
- Department of Radiotherapy, San Ming First Hospital, San Ming, China
| | - Gang Niu
- Fujian Key Laboratory of Oral Diseases and Fujian Provincial Engineering Research Center of Oral Biomaterial and Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Da-Li Zheng
- Fujian Key Laboratory of Oral Diseases and Fujian Provincial Engineering Research Center of Oral Biomaterial and Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Bin Wang
- Department of Stomatology, San Ming First Hospital, San Ming, China.
| | - You-Guang Lu
- Fujian Key Laboratory of Oral Diseases and Fujian Provincial Engineering Research Center of Oral Biomaterial and Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China.
- Department of Preventive Dentistry, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China.
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Karimi Afshar M, Behniafar M, Abbaszadeh E, Parizi MT, Karimi Afshar M. Knowledge about dental care in patients with head and neck cancer among senior dental school students: a cross-sectional descriptive study. BMC MEDICAL EDUCATION 2024; 24:776. [PMID: 39030591 PMCID: PMC11264978 DOI: 10.1186/s12909-024-05728-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/01/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The dentist's central role in treating head and neck cancer patients is to care for the patient's oral cavity before, during, and after radio/chemotherapy. This research aimed to determine dental students' knowledge about head and neck cancer patients' dental care. METHODS One hundred and four fifth and sixth-year dental students participated in this cross-sectional descriptive study. The data collection tool was a questionnaire that collected demographic information (gender, year of study) and four questions consisting of attendance to courses or workshops, passing a dedicated course at the university, willing to participate in a course or workshop on the treatment of head and neck cancer patients and self-evaluating information about the treatment of head and neck cancer patients. Final part 36 questions about oral and dental care for head and neck cancer patients before, after, and during treatment. The data were analyzed with SPSS 26 statistical software and using t-tests, ANOVA, and linear regression at the 0.05 significance level. RESULTS Most of the participants were in their sixth year (48.9%). A total of 48.1% of the people reported that their information about dental treatments in patients with head and neck cancer was bad. 85% of participants agreed with the necessity of evaluating the patient's mouth and teeth before starting the treatment. The lowest percentage of correct answers was related to the ideal duration of tooth extraction and a poor prognosis before the start of cancer treatment. The regression analysis revealed a significant relationship between years of education, willingness to participate in courses, and students' knowledge evaluation and knowledge. CONCLUSION The findings showed that students' awareness of oral and dental treatment and care for patients with head and neck cancer is insufficient. It is recommended that teaching staff pay more attention to the lack of knowledge and effort to educate students by holding special courses and workshops.
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Affiliation(s)
- Marzieh Karimi Afshar
- Orthodontics, Medical Education, Orthodontics Department, School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran
| | - Milad Behniafar
- Kerman University of Medical Sciences, Private Practice, Kerman, Iran
| | - Elham Abbaszadeh
- Oral Medicine, Oral Disease Department, School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran
| | - Molook Torabi Parizi
- Oral and Maxillofacial Pathology, Medical Education, Oral and Maxillofacial Department, School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehrnaz Karimi Afshar
- Prosthodontics, Medical Education, Prosthodontics Department, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran.
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Moore C, Donnelly M, Semple C, O'Neill C, McKenna G. Compliance with oral hygiene and dietary advice for the prevention of post-radiotherapy dental disease among head and neck cancer patients - a qualitative study. J Dent 2023; 138:104720. [PMID: 37741501 DOI: 10.1016/j.jdent.2023.104720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 09/25/2023] Open
Abstract
OBJECTIVES To elicit head and neck cancer (HANC) patients' views about their oral health and to identify potential issues regarding compliance with clinical oral hygiene and dietary advice for the prevention of post-radiotherapy dental disease. METHODS A purposive sample of twelve HANC patients between 6- and 12-months post-radiotherapy were recruited to undergo a semi-structured interview with a qualitative researcher. A pre-piloted topic guide was used to frame each interview. Qualitative data were analysed via thematic analysis. RESULTS Data were categorised into four main themes - 'How HANC patients perceive oral health', 'Cancer diagnosis and cancer care pathway', 'Impact of oncology treatment (radiotherapy, surgery, and chemotherapy)', and 'Post-oncology treatment recovery', with 14 subthemes. Oral health was viewed as an important component of HANC patients' overall physical and mental health post-treatment. Patients' non-compliance with adequate oral hygiene practice was related to oral mucositis, a "burning" sensation associated with high fluoride toothpaste, forgotten or inconsistent clinical advice, and an inadequate supply of preventive oral hygiene products. The potentially highly cariogenic nature of prescribed nutritional supplements for patients at risk of malnutrition did not tend to be communicated to patients in advance of their prescription. CONCLUSIONS Adequate oral health is essential for the overall physical and mental well-being of post-treatment HANC patients. Non-compliance with preventive clinical advice increases the risk of post-treatment oral health deterioration and was related to miscommunication, inadequate supplies of oral hygiene products, and treatment-related oral discomfort. CLINICAL SIGNIFICANCE Post-treatment HANC patients are at increased risk of dental disease. Educational and behavioural techniques should be employed to enhance patients' compliance with clinical oral hygiene and dietary advice for the prevention of post-radiotherapy dental disease. Patients should be informed about the potentially highly cariogenic nature of nutritional supplements, and these patients should undergo frequent dental recall. Clinical advice regarding oral hygiene and dietary practices needs to be given consistently to HANC patients by different specialists of the HANC multidisciplinary team.
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Affiliation(s)
- Ciaran Moore
- Restorative Dentistry Department, School of Dentistry, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland, BT12 6BA; Institute of Clinical Sciences, Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital site, Grosvenor Road, Belfast, Northern Ireland, BT12 6BA.
| | - Michael Donnelly
- Institute of Clinical Sciences, Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital site, Grosvenor Road, Belfast, Northern Ireland, BT12 6BA.
| | - Cherith Semple
- School of Nursing and Paramedic Science, Ulster University, Belfast Campus, York Street, Belfast, BT15 1AP.
| | - Ciaran O'Neill
- Institute of Clinical Sciences, Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital site, Grosvenor Road, Belfast, Northern Ireland, BT12 6BA.
| | - Gerald McKenna
- Restorative Dentistry Department, School of Dentistry, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland, BT12 6BA; Institute of Clinical Sciences, Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital site, Grosvenor Road, Belfast, Northern Ireland, BT12 6BA.
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Blitzer GC, Rogus‐Pulia NM, Paz C, Nickel KP, Cannaday VL, Kelm‐Nelson CA, Sudakaran S, Chappell RJ, Glazer T, Kimple RJ. Quantification of very late xerostomia in head and neck cancer patients after irradiation. Laryngoscope Investig Otolaryngol 2022; 7:1018-1024. [PMID: 36000048 PMCID: PMC9392383 DOI: 10.1002/lio2.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 06/23/2022] [Accepted: 06/29/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Radiation therapy (RT) for head and neck cancer (HNC) can result in severe xerostomia, or the subjective feeling of dry mouth. Characterizing xerostomia is critical to designing future clinical trials investigating how to improve HNC patients' quality of life (QoL). Few studies have investigated the very late (>5 years post-RT) effects of RT for HNC. We undertook preliminary studies quantifying very late xerostomia. Methods Six adults who underwent RT for HNC at least 5 years prior and reported xerostomia were enrolled. Five healthy adults without a self-reported history of HNC or xerostomia were enrolled as controls. All participants completed three validated surveys to measure xerostomia-related QoL. Salivary production rates were measured and compositional analysis of the saliva and oral microbiome was completed. Results The QoL survey scores for the HNC participants were significantly worse as compared to the control participants. The HNC participants produced less unstimulated saliva (p = .02) but not less stimulated saliva. The median salivary mucin significantly higher in HNC participants than in control participants (p = .02). There was no significant difference between the pH, amylase, or total protein. Microbiome analysis revealed alpha diversity to be significantly lower in the HNC participants. Conclusion In the survivors of HNC who suffer from late toxicities, multiple means of measuring toxicity may be useful. We found that in patients with radiation-induced xerostomia over 5 years after therapy, not only were the QoL surveys significantly worse, as expected, but other measurements such as mucin and oral microbiome diversity were also significantly different. Level of evidence 3.
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Affiliation(s)
- Grace C. Blitzer
- Department of Human OncologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Nicole M. Rogus‐Pulia
- Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Cristina Paz
- Department of Human OncologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Kwangok P. Nickel
- Department of Human OncologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Vanessa L. Cannaday
- Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Cynthia A. Kelm‐Nelson
- Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | | | - Richard J. Chappell
- Department of Biostatistics & Medical InformaticsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of StatisticsUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Tiffany Glazer
- Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Randall J. Kimple
- Department of Human OncologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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Almhöjd U, Cevik-Aras H, Karlsson N, Chuncheng J, Almståhl A. Stimulated saliva composition in patients with cancer of the head and neck region. BMC Oral Health 2021; 21:509. [PMID: 34627217 PMCID: PMC8501675 DOI: 10.1186/s12903-021-01872-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To analyse over time changes in stimulated whole saliva regarding total protein, Immunoglobulin A (IgA), and mucin type O-glycans (mostly MUC5B and MUC7) in head and neck cancer patients. METHODS 29 dentate patients (20 men and 9 women, 59 ± 8 years) treated with curative radiation therapy and chemotherapy for cancer of the head and neck region were included. The stimulated whole salivary secretion rate was determined and saliva collected at four time-points: at pretreatment, and at 6 months, 1 and 2 years post treatment. The total protein concentration was determined spectrophotometrically by using Bicinchoninic Acid assay and Immunoglobulin A (IgA) by using ELISA technique. Glycosylation pattern of salivary mucins was determined in samples collected pre- and post treatment by using LC/MS electrospray and mucin content quantified using SDS-AgPAGE gels and PAS staining. RESULTS Compared with pretreatment, the total protein concentration was increased already at 6 months post treatment (p < 0.01), and continued to increase up to 2 years post treatment (p < 0.001). During that period no significant changes in IgA concentration was detected. At pretreatment, the output/min of both total protein and IgA was significantly higher than at all time-points post treatment. Saliva from the cancer patients showed a low abundance/no detectable MUC7, while the MUC5B level remained, compared to saliva from a healthy control. The glycomic analysis showed that the percentage of core 2 O-glycans was increased as core 1, 3 and 4 O-glycans were decreased. The level of sialylation was higher at 6 months post treatment, while sulfation was lower. CONCLUSION A decreased output per minute of proteins at decreased salivary secretion rate, as well as reduced sulfation of MUC5B at 6 months post treatment tended to correlate with the patients' experience of sticky saliva and oral dryness. At 2 years post treatment, the decreased amount of IgA combined with a lowered salivary secretion rate indicate a reduced oral defense with increased risk of oral infections.
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Affiliation(s)
- Ulrica Almhöjd
- Department of Cariology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hulya Cevik-Aras
- Department of Oral Pathology and Medicine, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,NÄL Hospital, Trollhättan, Sweden
| | - Niclas Karlsson
- BioMS, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jin Chuncheng
- BioMS, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annica Almståhl
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Bohm N, Karlsson C, Skoogh Andersson J, Almståhl A. Variations in odontological care routines for patients undergoing treatment for head and neck cancer in county councils/regions of Sweden. Clin Exp Dent Res 2020; 6:3-15. [PMID: 32067404 PMCID: PMC7025979 DOI: 10.1002/cre2.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/11/2019] [Accepted: 08/02/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To investigate current odontological care routines for patients treated for head and neck cancers in the county councils/regions (C/Rs) of Sweden. METHODS An invitation to fill in a web-based questionnaire was sent to dentists/dental hygienists working in dental clinics in the 12 C/Rs, treating and responsible for the odontological care of patients undergoing treatment for cancer of the head and neck. The questionnaire started with two mandatory and one non-mandatory questions, followed by questions regarding routines before (n = 28), during (n = 23), and after (n = 9) treatment, plus two additional questions, totalling 65 questions. RESULTS Four dental hygienists and six dentists in 10 of the 12 C/Rs answered the questionnaire. Three C/Rs stated that they measure both the unstimulated and stimulated salivary secretion rate, and another C/R stated that they measure the stimulated secretion rate only. Similar recommendations were given regarding oral hygiene, salivary stimulants and substitutes, and extra fluoride. However, great variations were seen regarding recommendations for preventing and relieving oral mucositis. There were also discrepancies regarding information about the importance of avoiding smoking and alcohol. In seven C/Rs, patients visited the dental hygienist once a week during cancer treatment. CONCLUSION The results suggests that there are great variations in odontological care given to patients undergoing treatment for cancer of the head and neck region in different county councils/regions in Sweden. There is a need to develop and implement evidence-based guidelines to decrease the risk of oral complications and increase both the quality of life and the quality of care.
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Affiliation(s)
- Niklas Bohm
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Charlott Karlsson
- Clinic of Oral and Maxillofacial Surgery, Department of Orofacial Medicine, Institute of OdontologyJönköping UniversityJönköpingSweden
| | - Jessica Skoogh Andersson
- Department of Periodontology, Institute of Odontology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Annica Almståhl
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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Dental caries following radiotherapy for head and neck cancer: A systematic review. Oral Oncol 2020; 100:104484. [DOI: 10.1016/j.oraloncology.2019.104484] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023]
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Abed H, Reilly D, Burke M, Daly B. Patients with head and neck cancers' oral health knowledge, oral health‐related quality of life, oral health status, and adherence to advice on discharge to primary dental care: A prospective observational study. SPECIAL CARE IN DENTISTRY 2019; 39:593-602. [DOI: 10.1111/scd.12418] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/06/2019] [Accepted: 08/23/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Hassan Abed
- Department of Sedation and Special Care DentistryGuys and St Thomas' NHS Foundation Trust London UK
- Department of Basic and Clinical Oral SciencesFaculty of DentistryUmm Al‐Qura University Makkah Saudi Arabia
- Centre for OralClinical and Translational ScienceFaculty of Dentistry, Oral and Craniofacial Sciences, King's College London London UK
| | - Damien Reilly
- Department of Sedation and Special Care DentistryGuys and St Thomas' NHS Foundation Trust London UK
- Department of Special Care DentistrySurrey and Sussex Healthcare NHS Trust Redhill Surrey UK
| | - Mary Burke
- Department of Sedation and Special Care DentistryGuys and St Thomas' NHS Foundation Trust London UK
| | - Blánaid Daly
- School of Dental ScienceTrinity College Dublin and Dublin Dental University HospitalLincoln Place Dublin 2 Ireland
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