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Liu BM, Kouladjian O'Donnell L, Redston MR, Fujita K, Thillainadesan J, Gnjidic D, Hilmer SN. Association of the Drug Burden Index (DBI) exposure with outcomes: A systematic review. J Am Geriatr Soc 2024; 72:589-603. [PMID: 38006299 DOI: 10.1111/jgs.18691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND The Drug Burden Index (DBI) measures an individual's total exposure to anticholinergic and sedative medications. This systematic review aimed to investigate the association of the DBI with clinical and prescribing outcomes in observational pharmaco-epidemiological studies, and the effect of DBI exposure on functional outcomes in pre-clinical models. METHODS A systematic search of nine electronic databases, citation indexes and gray literature was performed (April 1, 2007-December 31, 2022). Studies that reported primary data on the association of the DBI with clinical or prescribing outcomes conducted in any setting in humans aged ≥18 years or animals were included. Quality assessment was performed using the Joanna Briggs Institute critical appraisal tools and the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool. RESULTS Of 2382 studies screened, 70 met the inclusion criteria (65 in humans, five in animals). In humans, outcomes reported included function (n = 56), cognition (n = 20), falls (n = 14), frailty (n = 7), mortality (n = 9), quality of life (n = 8), hospitalization (n = 7), length of stay (n = 5), readmission (n = 1), other clinical outcomes (n = 15) and prescribing outcomes (n = 2). A higher DBI was significantly associated with increased falls (11/14, 71%), poorer function (31/56, 55%), and cognition (11/20, 55%) related outcomes. Narrative synthesis was used due to significant heterogeneity in the study population, setting, study type, definition of DBI, and outcome measures. Results could not be pooled due to heterogeneity. In animals, outcomes reported included function (n = 18), frailty (n = 2), and mortality (n = 1). In pre-clinical studies, a higher DBI caused poorer function and frailty. CONCLUSIONS A higher DBI may be associated with an increased risk of falls and decreased function and cognition. Higher DBI was inconsistently associated with increased mortality, length of stay, frailty, hospitalization or reduced quality of life. Human observational findings with respect to functional outcomes are supported by preclinical interventional studies. The DBI may be used as a tool to identify older adults at higher risk of harm.
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Affiliation(s)
- Bonnie M Liu
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia
- Aged Care Department, Royal North Shore Hospital, Sydney, Australia
| | - Lisa Kouladjian O'Donnell
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia
| | - Mitchell R Redston
- St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kenji Fujita
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia
| | - Janani Thillainadesan
- Department of Geriatric Medicine and Centre for Education and Research on Ageing, Concord Hospital, Sydney, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah N Hilmer
- Ageing and Pharmacology Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, Australia
- Aged Care Department, Royal North Shore Hospital, Sydney, Australia
- Clinical Pharmacology Department, Royal North Shore Hospital, Sydney, Australia
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Chung J, Tjia J, Zhang N, O'Connor BT. Anticholinergic Burden and Xerostomia in Critical Care Settings. Dimens Crit Care Nurs 2023; 42:310-318. [PMID: 37756502 DOI: 10.1097/dcc.0000000000000606] [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: 09/29/2023] Open
Abstract
BACKGROUND Although previous studies have established the association of medications with anticholinergic adverse effects and xerostomia, anticholinergic burden and xerostomia in critical care settings are poorly characterized. The objective of this study was to determine the impact of medication burdens associated with anticholinergic adverse effects, particularly the occurrence of xerostomia (dry mouth) in a critical care setting. In addition, this study explored the correlation between the timing of the first instance of xerostomia and the administration timing of medication known to have anticholinergic adverse effects. METHODS A retrospective case-control study was used with the MIMIC (Medical Information Mart for Intensive Care) III database. The MIMIC-III clinical database is a publicly available, deidentified, health-related database with more than 40 000 patients in critical care units from 2001 to 2012. Cases of xerostomia (n = 1344) were selected from clinical notes reporting "dry mouth," "xerostomia," or evidence of pharmacological treatment for xerostomia; control (n = 4032) was selected using the propensity analysis with 1:3 matching on covariates (eg, age, sex, race, ethnicity, and length of stay). The anticholinergic burden was quantified as the cumulative effect of anticholinergic activities using the Anticholinergic Burden Scale. RESULTS Anticholinergic burden significantly differed between xerostomia patients and control subjects (P = .04). The length of stay was a statistically significant factor in xerostomia. The probability of developing the symptom of xerostomia within 24 hours was .95 (95%) for patients of xerostomia. CONCLUSIONS Anticholinergic Burden Scale is associated with xerostomia in the critical care setting, particularly within 24 hours after admission. It is crucial to carefully evaluate alternative options for medications that may have potential anticholinergic adverse effects. This evaluation should include assessing the balance between the benefits and harms, considering the probability of withdrawal reactions, and prioritizing deprescribing whenever feasible within the initial 24-hour period.
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Tabrizi M, Lee WC. Linking current dental education to gerontological education to meet the oral health needs of growing aging populations. FRONTIERS IN ORAL HEALTH 2023; 4:1232489. [PMID: 37876529 PMCID: PMC10591445 DOI: 10.3389/froh.2023.1232489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023] Open
Abstract
Objective This study aimed to recognize the gaps in dental education by studying the current level of geriatric oral health training of recent graduated dentists who have been admitted into an Advanced Education in General Dentistry (AEGD) program. Methods The AEGD program was developed along with the Age-Friendly 4Ms model to enhance current dental education. We adopted the Rapid Cycle Quality Improvement model to test the effectiveness of the training for AEGD residents from 2019 to 2022. A total of 18 residents participated (6 residents each year). A 5-question survey was administered before and after the rotation and Wilcoxon signed-rank with Fisher Exact tests were conducted to compare pre- and post- rotation results. Results All 18 residents have completed pre- and post-program surveys. They self-reported minimal to no training in preparation to provide care to older adults with multiple chronic conditions. After the rotation, residents' confidence in treating older adults was significantly increased (p = 0.011). Meanwhile, residents gained knowledge to apply the 4Ms framework (what matters, medication, mentation, and mobility) to their practices (p = 0.015) and provide age-friendly care for older adults. Conclusion The study identified and addressed the missing link in dental education to gerontological and geriatrics education. More clinical rotations and didactic training to equip residents with competences of providing geriatric oral health are strongly recommended.
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Affiliation(s)
- Maryam Tabrizi
- School of Dental Medicine, University of Nevada, Las Vegas, NV, United States
| | - Wei-Chen Lee
- Department of Family Medicine, John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX, United States
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Chaffee BW, Halpern-Felsher B, Cheng J. E-cigarette, cannabis and combustible tobacco use: associations with xerostomia among California adolescents. Community Dent Oral Epidemiol 2023; 51:180-186. [PMID: 34927762 PMCID: PMC9207149 DOI: 10.1111/cdoe.12721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Xerostomia (subjective experience of dry mouth), while less common in younger populations, can contribute to caries and oral discomfort. Use of e-cigarettes and cannabis among adolescents is increasing and may be a xerostomia risk factor. This study evaluates xerostomia prevalence in an adolescent population, overall and by e-cigarette, cannabis and combustible tobacco use. METHODS Cross-sectional analyses of 12-month follow-up data (N=976; collected 2020-2021) from a cohort of adolescents recruited from public high schools in Northern California (USA) compared self-reported past 30-day e-cigarette, cannabis and other tobacco use and dry mouth (overall dry mouth experience; shortened xerostomia inventory, SXI). Dry mouth experience (never, occasionally, frequently/always) was modelled using ordered logistic regression with school-level clustering and adjustment for gender, race/ethnicity, alcohol use, asthma, physical activity and mutually for e-cigarette, cannabis and tobacco use. RESULTS Past 30-day use prevalence was 12% for e-cigarettes, 16% for cannabis and 3% for combustible tobacco. Occasional dry mouth experience (54%) was more common than frequent/always experience (5%). Frequent/always dry mouth was more prevalent among frequent (>5 days/month) e-cigarette (14%) and cannabis (19%) users and combustible tobacco users (19%) than non-users of those respective products (all comparisons p < 0.001). In covariable-adjusted models, frequent e-cigarette use was no longer significantly associated with dry mouth experience (OR: 1.40; 95% CI: 0.69, 2.84), while frequent cannabis use (OR: 3.17; 95% CI: 1.47, 6.82) and combustible tobacco use (OR: 1.92; 95% CI: 1.38, 2.68) were associated with greater odds of reporting more frequent dry mouth. Findings were qualitatively similar using the SXI. CONCLUSIONS In this study, xerostomia was not independently associated with e-cigarette use but was one potential health concern of adolescent cannabis and combustible tobacco use.
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Affiliation(s)
| | | | - Jing Cheng
- University of California, San Francisco, US
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Cheah H, Gray M, Aboelmagd S, Barmak AB, Arany S. Anticholinergic Medication and Caries Status Predict Xerostomia under 65. Dent J (Basel) 2023; 11:dj11040087. [PMID: 37185465 PMCID: PMC10136720 DOI: 10.3390/dj11040087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
The use of anticholinergic medications is increasing in younger ages, yet information about xerostomia, the most common anticholinergic side effect, is limited. This case–control retrospective study examines the relationship between anticholinergic medication-induced xerostomia and caries status among adults between 18 and 65 years of age. The study sample comprised 649 cases with xerostomia and 649 age- and gender-matched controls. The anticholinergic burden was estimated using the anticholinergic drug scale (ADS). Caries experience was recorded by calculating the Decayed, Missing, Filled Tooth (DMFT) index. Individuals with xerostomia had a higher mean DMFT index (16.02 ± 9.50), which corresponded with a higher level of anticholinergic exposure from medications (3.26 ± 2.81) compared to their age and gender-matched controls without xerostomia (13.83 + 8.83 and 1.89 ± 2.45, respectively). Logistic regression analysis verified the effects of DMFT, the total number of AC medications, and the ADS burden on xerostomia status. Comparing adults with or without xerostomia revealed statistical differences in several risk factors, such as smoking, diabetes, sleep apnea, and the utilization of anticholinergic medications. A personalized dental care plan should include the evaluation of the anticholinergic burden from medications regardless of the patient’s age to prevent increased caries severity.
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Alghamdi SA, Mugri MH, Elamin NMH, Kamil MA, Osman H, Eid BG, Shaik RA, Shaker SS, Alrafiah A. A Possible Novel Protective Effect of Piceatannol against Isoproterenol (ISO)-Induced Histopathological, Histochemical, and Immunohistochemical Changes in Male Wistar Rats. Curr Issues Mol Biol 2022; 44:2505-2528. [PMID: 35735612 PMCID: PMC9221942 DOI: 10.3390/cimb44060171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/14/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022] Open
Abstract
Dry mouth is characterized by lower saliva production and changes in saliva composition. In patients with some salivary gland function remaining, pharmaceutical treatments are not recommended; therefore, new, more effective methods of promoting saliva production are needed. Hence, this study aimed to provide an overview of the histological changes in the salivary gland in the model of isoproterenol (ISO)-induced degenerative changes in male Wistar rats and to evaluate the protective effect of piceatannol. Thirty-two male Wistar rats were randomly divided into four groups: the control group, the ISO group, and the piceatannol (PIC)-1, and -2 groups. After the third day of the experiment, Iso (0.8 mg/100 g) was injected intraperitoneally (IP) twice daily into the animals. PIC was given IP in different daily doses (20 and 40 mg/kg) for three days before ISO and seven days with ISO injection. The salivary glands were rapidly dissected and processed for histological, histochemical, immunohistochemical (Ki-67), and morphometric analysis. Upon seven days of treatment with ISO, marked hypertrophy was observed, along with an increased number of positive Ki-67 cells. Proliferation was increased in some endothelial cells as well as in ducts themselves. Despite the significant decrease in proliferation activity, the control group did not return to the usual activity level after treatment with low-dose PIC. Treatment with a high dose of PIC reduced proliferative activity to the point where it was substantially identical to the results seen in the control group. An ISO-driven xerostomia model showed a novel protective effect of piceatannol. A new era of regenerative medicine is dawning around PIC’s promising role.
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Affiliation(s)
- Samar A. Alghamdi
- Department of Oral Biology, Faculty of Dentistry, King AbdulAziz University, Jeddah 22254, Saudi Arabia;
| | - Maryam H. Mugri
- Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia; (M.H.M.); (N.M.H.E.)
| | - Nahid M. H. Elamin
- Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia; (M.H.M.); (N.M.H.E.)
| | - Mona Awad Kamil
- Department of Preventive Dental Science, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia; (M.A.K.); (H.O.)
| | - Hind Osman
- Department of Preventive Dental Science, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia; (M.A.K.); (H.O.)
| | - Basma G. Eid
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King AbdulAziz University, Jeddah 22254, Saudi Arabia; (B.G.E.); (R.A.S.)
| | - Rasheed A. Shaik
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, King AbdulAziz University, Jeddah 22254, Saudi Arabia; (B.G.E.); (R.A.S.)
| | - Soad S. Shaker
- Department of Histology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt;
| | - Aziza Alrafiah
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King AbdulAziz University, Jeddah 22254, Saudi Arabia
- Correspondence: ; Tel.: +966-0126401000 (ext. 23495); Fax: +966-0126401000 (ext. 21686)
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Villalba-Moreno AM, Galván-Banqueri M, Rodríguez-Pérez A, Toscano-Guzmán MD, López-Hermoso C, Sánchez-Fidalgo S, Santos-Ramos B, Alfaro-Lara ER. Chronic-pharma: New Platform for Chronic Patients Pharmacotherapy Optimization. J Med Syst 2022; 46:18. [PMID: 35226192 PMCID: PMC8885479 DOI: 10.1007/s10916-022-01808-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 02/12/2022] [Indexed: 11/25/2022]
Abstract
We describe the technological development of a web platform named CHRONIC-PHARMA that integrates three prescription support tools for patients with chronic diseases: Anticholinergic Burden Calculator (ABC), LESS-CHRON criteria and TRIGGER-CHRON. They focus on the optimization and evaluation of pharmacotherapy in patients with chronic diseases, resulting in a useful, single platform that can facilitate the review of pharmacotherapy and improve the safety of chronically ill patients. This is achieved by estimating and reducing the anticholinergic risk (ABC), detecting opportunities for deprescribing drugs and monitoring its success (LESS-CHRON criteria), as well as calculating the risk of adverse drug events (TRIGGER-CHRON). The platform is freely accessible online (https://chronic-pharma.com/) as well as through a mobile application, and therefore easily accessible among the healthcare community.
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Rosa LK, Costa FS, Hauagge CM, Mobile RZ, de Lima AAS, Amaral CDB, Machado RC, Nogueira ARA, Brancher JA, de Araujo MR. Oral health, organic and inorganic saliva composition of men with Schizophrenia: Case-control study. J Trace Elem Med Biol 2021; 66:126743. [PMID: 33740480 DOI: 10.1016/j.jtemb.2021.126743] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Schizophrenia (SCZ) presents complex challenges related to diagnosis and clinical monitoring. The study of conditions associated with SCZ can be facilitated by using potential markers and patterns that provide information to support the diagnosis and oral health. METHODS The salivary composition of patients diagnosed with SCZ (n = 50) was evaluated and compared to the control (n = 50). Saliva samples from male patients were collected and clinical parameters were evaluated. The concentration of total proteins and amylase were determined and salivary macro- and microelements were quantified by ICP OES and ICP-MS. Exploratory data analysis based on artificial intelligence tools was used in the investigation. RESULTS There was a significant increase in the salivary concentrations of Al, Fe, Li, Mg, Na, and V, higher prevalence of caries (p < 0.001), periodontal disease (p < 0.001), and reduced salivary flow rate (p = 0.019) in SCZ patients. Also, samples were grouped into six clusters. As, Co, Cr, Cu, Mn, Mo, Ni, Se, and Sr were correlated with each other, while Fe, K, Li, Ti, and V showed the highest concentrations in the samples distributed in the clusters with the highest association between SZC patients and controls. CONCLUSIONS The results obtained indicate changes in salivary flow, organic composition, and levels of macro- and microelements in SCZ patients. Salivary concentrations of Fe, Mg, and Na may be related to oral conditions, higher prevalence of caries, and periodontal disease. The exploratory analysis showed different patterns in the salivary composition of SCZ patients impacted by associations between oral health conditions and the use of medications. Future studies are encouraged to confirm the results investigated in this study.
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Affiliation(s)
- Letícia Kreutz Rosa
- Federal University of Paraná, Department of Stomatology, Curitiba, PR, 80210-170, Brazil
| | | | - Cecília Moraes Hauagge
- Federal University of Paraná, Department of Stomatology, Curitiba, PR, 80210-170, Brazil
| | - Rafael Zancan Mobile
- Federal University of Paraná, Department of Stomatology, Curitiba, PR, 80210-170, Brazil
| | | | - Clarice D B Amaral
- Federal University of Paraná, Department of Chemistry, Curitiba, PR, 81531-980, Brazil
| | - Raquel C Machado
- Federal University of São Carlos, Department of Chemistry, São Carlos, SP, 13565-905, Brazil
| | | | - João Armando Brancher
- Pontifícia Universidade Católica do Paraná, Escola de Ciências da Vida, Curitiba, PR, 80215-901, Brazil
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Tiisanoja A, Syrjälä AM, Anttonen V, Ylöstalo P. Anticholinergic burden, oral hygiene practices, and oral hygiene status-cross-sectional findings from the Northern Finland Birth Cohort 1966. Clin Oral Investig 2020; 25:1829-1837. [PMID: 32748073 PMCID: PMC7966223 DOI: 10.1007/s00784-020-03485-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 07/29/2020] [Indexed: 11/24/2022]
Abstract
Objectives To study the association between anticholinergic burden and oral hygiene practices and oral hygiene status among 46-year-old people. Materials and methods The study included 1945 participants from the Northern Finland Birth Cohort 1966 (NFBC1966), who had a complete dental status. The participants underwent clinical medical and dental examinations, and their medication data were gathered by combining self-reported drug use with information from the National Prescription Register. Anticholinergic burden was measured using nine previously published anticholinergic scales. Oral hygiene practices were assessed with toothbrushing frequency and oral hygiene status with the presence of visible dental plaque. Poisson regression with robust variance estimation and negative binomial regression models were used to estimate relative risks (RR). Results Thirty percent of the participants reported brushing their teeth twice a day and about 25% of their teeth had dental plaque on them. Fifteen percent of the participants used at least one anticholinergic drug or had an anticholinergic burden according to the nine anticholinergic scales. After adjustments for confounding factors, the RRs of anticholinergic burden varied between 0.95 and 1.11 for toothbrushing frequency. Anticholinergic burden (according to Anticholinergic Activity Scale, Anticholinergic Cognitive Burden, Chew’s scale) was associated statistically significantly with the number of teeth with dental plaque. For the three scales, RRs varied from 1.24 to 1.50. Conclusions Anticholinergic burden associated with poor oral hygiene. Clinical relevance The findings stress the importance of providing oral hygiene instructions and prophylactic measures to patients taking anticholinergic drugs. Electronic supplementary material The online version of this article (10.1007/s00784-020-03485-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antti Tiisanoja
- Periodontology and Geriatric Dentistry, Research Unit of Oral Health Sciences, University of Oulu, P.O BOX 5000, FI-90014, Oulu, Finland. .,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Anna-Maija Syrjälä
- Periodontology and Geriatric Dentistry, Research Unit of Oral Health Sciences, University of Oulu, P.O BOX 5000, FI-90014, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Vuokko Anttonen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Cariology, Endodontology and Paediatric Dentistry, Research Unit of Oral Health Sciences, University of Oulu, P.O BOX 5000, FI-90014, Oulu, Finland
| | - Pekka Ylöstalo
- Periodontology and Geriatric Dentistry, Research Unit of Oral Health Sciences, University of Oulu, P.O BOX 5000, FI-90014, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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