Abstract
Purpose
Oral conditions are established complications in terminally-ill cancer patients. Yet despite significant morbidity, the characteristics and impact of oral conditions in these patients are poorly documented. The study objective was to characterize oral conditions in terminally-ill cancer patients to determine the presence, severity, and the functional and social impact of these oral conditions.
Methods
This was an observational clinical study including terminally-ill cancer patients (2.5–3 week life expectancy). Data were obtained via the Oral Problems Scale (OPS) that measures the presence of subjective xerostomia, orofacial pain, taste change, and the functional/social impact of oral conditions and a demographic questionnaire. A standardized oral examination was used to assess objective salivary hypofunction, fungal infection, mucosal erythema, and ulceration. Regression analysis and t test investigated the associations between measures.
Results
Of 104 participants, most were ≥50 years of age, female, and high-school educated; 45% were African American, 43% Caucasian, and 37% married. Oral conditions frequencies were: salivary hypofunction (98%), mucosal erythema (50%), ulceration (20%), fungal infection (36%), and other oral problems (46%). Xerostomia, taste change, and orofacial pain all had significant functional impact; p<.001, p=.042 and p<.001, respectively. Orofacial pain also had a significant social impact (p<.001). Patients with oral ulcerations had significantly more orofacial pain with a social impact than patients without ulcers (p=.003). Erythema was significantly associated with fungal infection and with mucosal ulceration (p<.001).
Conclusions
Oral conditions significantly affect functional and social activities in terminally-ill cancer patients. Identification and management of oral conditions in these patients should therefore be an important clinical consideration.
Keywords: Terminally-ill, Cancer, mouth diseases, pain, functional and social impact, hospice, palliative care
Introduction
Terminally-ill cancer patients suffer with progressive advanced disease that affects quality of life (QOL). Oral health plays an essential role in QOL because oral conditions contribute to symptoms that affect oral and oropharyngeal function as well as social interaction and may impact the management of medical problems [20, 22, 34]. However, the extent of oral care needed among terminally-ill patients who are receiving hospice or palliative care is frequently underestimated because patients may not complain of what they believe to be inevitable discomfort in their mouths, or they may be physically or cognitively unable to do so. Under-reporting may contribute to failure by some health-care givers, health-care providers, and hospice administrators to fully appreciate the problems [16].
Oral conditions such as salivary hypofunction, fungal and viral infections, erythema, ulceration, and dental disease can contribute to orofacial pain, denture instability, dysphagia, esthetic loss, taste disturbances, compromised oral intake and speech [1, 3, 4, 7, 13, 17, 19, 33]. These problems can lead to unnecessary pain and may compromise QOL [38]. The clinical significance of compromised oral health in patients with terminal cancer is illustrated by the finding that xerostomia is ranked as the third-most distressing symptom after lack of energy and pain [10]. The dry oral environment caused by salivary hypofunction may contribute to mucositis, tissue irritation and ulceration, and dental caries, and increase the risk of candidiasis, which has prevalence as high as 30% in palliative care patients [3, 7–9].
Despite the significant morbidity caused by oral conditions, the impact of oral complaints for terminally-ill cancer patients is not well-documented and few studies have characterized the presence, severity, and functional/social impact of oral conditions in terminally-ill cancer patients undergoing hospice or palliative care [1, 16, 18, 28, 33]. We conducted a prospective study to characterize oral conditions in terminally-ill cancer patients undergoing hospice or palliative care to determine the presence, severity, and the functional/social impact of the oral conditions, all of which affect QOL. We present quantitative results after standardized oral examination by a dental health professional and from subjective patient self-report.
Patients and Methods
Study design/setting
This was a cross-sectional, observational, clinical study conducted in the homes of patients in collaboration with the Horizon Hospice and Palliative Care and Rainbow Hospice and Palliative Care programs. The Institutional Review Board at the University of Illinois at Chicago approved the study.
Patients
One-hundred and four terminally-ill cancer patients receiving home-care level hospice or palliative care service were enrolled. Patients had a life expectancy of 2.5–3 weeks at the time of study enrollment based on a palliative performance scale score of ≥30 [2, 37]. Eligible patients were ≥18 years of age, with a primary caregiver who cared for the patient at least 5 days/week for 6 hours/day and was ≥18 years of age. All participating patients completed informed consent. Patients were seen for one visit in their homes by an oral medicine professional and a research assistant.
Study measures
Study measures included patient self-report tools and a standardized oral examination. Patient demographic data were obtained via questionnaire.
The Oral Problems Scale (OPS) was used to determine the presence of subjective xerostomia, taste change, orofacial pain, and the functional/social impact of oral conditions. The OPS is composed of 20 questions, 16 of which have a 0–4 Likert-type response format, where 0 represents “never” and 4 represents “always,” and 4 of which are 11-point scales that range from 0–10. Most of the OPS items were adapted from other valid and reliable measures as indicated in the following list:
Xerostomia was assessed using 3 Likert-type questions modified from previous studies of xerostomia that relate to salivary output [14, 15, 23, 26, 29]. Also, one question was adapted from the Brief Pain Inventory (BPI) [5] to measure the patient's assessment of xerostomia on an 11-point scale with 0 representing “no dry mouth” and 10 representing “dry mouth as much as can be.”
Orofacial pain was assessed with 4 Likert-type questions modified from the physical pain subscale of the Oral Health Impact Profile (OHIP) [21, 30] and the mouth and face pain subscale of the Oral Symptom and Function Scale [12]. Also, the severity of orofacial pain was rated with an 11-point scale with 0 indicating “no pain” and 10 indicating “pain as bad as it can be.”
Taste change was assessed with one Likert-type question from the mouth function subscale of the Oral Symptom and Function Scale [12].
Impact on functions related to xerostomia and orofacial pain was evaluated with 4 Likert-type questions from the mouth function subscale of the Oral Symptom and Function Scale [12] along with two 11-point scales adapted from the BPI [5] assessing the severity of the functional impact of xerostomia and orofacial pain, respectively. For the functional impact items, the impact on daily life was measured with 0 representing “no interference” and 10 corresponding to “completely interferes”.,
Social impact of xerostomia and orofacial pain was evaluated with two Likert-type questions about psychological discomfort modified from the psychological discomfort subscale of the OHIP [21, 30] and 2 Likert-type questions assessing the social and global impact of oral conditions from the handicap subscale of the OHIP [21, 30].
A standardized oral examination was used to assess perioral and oral tissues for the objective presence of salivary hypofunction, fungal infection, erythema, and ulceration/pseudomembrane formation. Clinical correlates of salivary hypofunction included lip dryness, buccal mucosa dryness, and the absence of a salivary pool on the floor of the mouth, adapted from Navazesh and colleagues [24]. Lip dryness was measured by a 4-point scale, with 0 indicating “normal condition,” 1 indicating “dry vermillion border,” 2 indicating “dry, chapped and/or fissured tissue,” and 3 indicating “angular cheilitis, redness or fissuring at the commissure.” Similarly, buccal mucosa dryness was measured by a 4-point scale and was assessed using a dry tongue blade, with 0 indicating “normal condition,” 1 indicating “looks dry, but tissue does not stick to tongue blade,” 2 indicating “looks dry, and tissue sticks to tongue blade,” and 4 indicating “looks dry, tissue sticks to the tongue blade, and the location of one or both parotid ducts is not apparent” [24]. A binary variable was used to indicate the presence/absence of salivary pool. Fungal infection was defined by the clinical presentation of pseudomembraneous, erythematous, hyperplastic, and/or chronic fungal infection and was confirmed by fungal culture, quantifying the presence of moderate/heavy fungal colony-forming units on selective medium. Evaluation of erythema and ulceration/pseudomembrane formation was adapted from the Oral Mucositis Assessment Scale, developed for patients who developed oral complications of cancer therapy [32]. Binary variables were used to indicate the presence/absence of fungal infection, erythema, and ulceration.
Statistical analysis
Data were entered into excel spreadsheets by two independent persons and then imported into statistical software R for analysis [35]. Statistical analysis revealed that 65 entries were missing, constituting 2% of the OPS and oral examination data used in the analysis. Out of these missing entries, at least 46 were missing at random (new questions added after the first 6 subjects; researchers conducting the examination missed entries). The remaining missing entries showed no apparent pattern. These entries constituted less than 1% of the data and the impact of any potential non-random absence on our analysis based on multiple imputations was considered negligible [6].
After data cleaning, the psychometric properties of the measures were assessed and descriptive statistics (mean, standard deviation [SD], frequencies, and percentages) were computed to document the occurrence of oral conditions. The summary scores of the 5 subscales of the OPS were computed by rescaling each component score to a range of 0 to 10, summing the component scores, and then normalizing the sums that ranged from 0 to 10. The summary for salivary hypofunction was obtained by adding the scores for salivary pool, lip dryness, and buccal mucosa dryness. Regression analysis and t test were used to investigate the associations between oral conditions and functional/social impact.
Results
Patient demographics are shown in Table 1. The 104 patients ranged in age from 29 to 112 years (mean age 66 years, SD: 16.3 years). Most patients (83%) were 50 years of age or older, female (59%), and high-school educated or higher (83%). Predominately, the patents were African American (45%) or Caucasian (43%) and married (37%).
Table 1.
Frequency of patient demographics and oral conditions
| Demographics | Patients N=104 n (%) |
|---|---|
| Age group | |
| 29–49 | 16 (15%) |
| 50–64 | 30 (29%) |
| 65–74 | 24 (23%) |
| 75–84 | 17 (16%) |
| 85–112 | 15 (14%) |
| Unknown | 2 (2%) |
| Gender | |
| Male | 42 (40%) |
| Female | 61 (59%) |
| Unknown | 1 (1%) |
| Race/Ethnicity | |
| Native American | 1 (1.0%) |
| Asian/Pacific Islander | 2 (2.0%) |
| African American | 47 (45%) |
| Caucasian | 45 (43%) |
| Hispanic | 5 (5%) |
| Other | 2 (2%) |
| Unknown | 2 (2%) |
| Education | |
| Grade 1–11 | 18 (17%) |
| High School/GED | 32 (31%) |
| Some College | 31 (30%) |
| Bachelor's Degree | 9 (9%) |
| Advanced Degree | 14 (13%) |
| Marital Status | |
| Married | 38 (37%) |
| Live with Partner | 5 (5%) |
| Widowed | 32 (31%) |
| Divorced or Separated | 11 (11%) |
| Never Married | 17 (16%) |
| Unknown | 1 (1%) |
| Oral Condition and Severity | |
| Salivary hypofunction * | |
| None | 2 (2%) |
| Mild | 38 (37%) |
| Moderate | 42 (40%) |
| Severe | 22 (21%) |
| Fungal infection | |
| Present | 37 (36%) |
| Absent | 67 (64%) |
| Erythema | |
| Present | 52 (50%) |
| Absent | 52 (50%) |
| Ulceration | |
| Present | 21 (20%) |
| Absent | 83 (80%) |
| Other | |
| Present | 48 (46%) |
| Absent | 56 (54%) |
none (score of 0); mild (score >0 to 3); moderate (score >3 to 6); severe (score >6).
The frequencies of observed oral conditions are shown in Table 1. Nearly all patients (98%) presented with salivary hypofunction with over 60% of patients having moderate to severe salivary hypofunction. Clinical examination revealed erythema in half of all patients (50%), ulceration, in 20% of patients, fungal infection in 36% of patients, and other oral conditions in almost half of the patients (46%), such as pallor of intraoral tissues, mucosal atrophy, fissured tongue or coated tongue.
The prevalence and mean patient scores for the OPS and standardized oral examination are shown in Tables 2 and 3. Nearly all patients (98%) presented with clinical indicators of salivary hypofunction, with over half of these patients being categorized as having moderate to severe hyposalivation. Subjective reports of xerostomia illustrated that this complaint occurred frequently (5.8 ± 2.5 on 0 to 10 scale) and with moderate severity (5.0 ± 3.1 on 0 to 10 scale) (Table 2). The subjective components of the OPS (xerostomia, orofacial pain, taste change, functional/social impact) and the objective oral examination (salivary hypofunction) were organized into subscales. The subscales were tested for internal consistency using descriptive statistics, including Cronbach's alpha, which provides a measure of internal consistency for subscales consisting of more than one item. We observed that all subscales, with the exception of taste change that consists of only one item, had an alpha of at least .70, indicating acceptable reliability (Table 2).
Table 2.
Summary of patient scores for the items of Oral Problems Scale and oral examination subscale
| Scale | Subscale | Components of scale (0–4 unless indicated otherwise) | Prevalence* | Mean Score | SD | Cronbach's Alpha |
|---|---|---|---|---|---|---|
| Oral Problems Scale | Xerostomia | Thirst frequency | 94% | 2.39 | 1.14 | .86 |
| Dry lips frequency | 92% | 2.53 | 1.20 | |||
| Dry mouth frequency | 91% | 2.41 | 1.17 | |||
| Average severity of dryness (0–10) | 91% | 5.02 | 3.07 | |||
| Orofacial pain | Facial pain frequency | 23% | 0.51 | 1.06 | .84 | |
| Intraoral pain frequency | 52% | 1.11 | 1.27 | |||
| Frequency of mouth sores | 34% | 0.69 | 1.13 | |||
| Sharp or shooting facial/intraoral pain frequency | 19% | 0.38 | 0.92 | |||
| Average pain severity (0–10) | 48% | 2.01 | 2.57 | |||
| Taste change | Frequency of taste change when not eating | 71% | 1.78 | 1.44 | N/A | |
| Functional impact | Frequency of swallowing difficulty | 61% | 1.28 | 1.22 | .80 | |
| Frequency of speaking difficulty | 57% | 1.13 | 1.22 | |||
| Frequency of eating difficulty | 55% | 1.25 | 1.38 | |||
| Frequency of food restriction | 50% | 1.06 | 1.26 | |||
| From dryness (0–10) | 66% | 3.10 | 3.07 | |||
| From pain (0–10) | 44% | 1.89 | 2.81 | |||
| Social impact | Worried frequency | 51% | 1.11 | 1.28 | .81 | |
| Bothered frequency | 51% | 0.95 | 1.10 | |||
| Frequency of not wanting people around you | 22% | 0.43 | 0.93 | |||
| Life less satisfying frequency | 36% | 0.76 | 1.22 | |||
| Oral examination † | Salivary hypofunction | Absence of salivary pool (0–1) | 44% | 0.44 | 0.50 | .70 |
| Lip dryness severity (0–3) | 96% | 1.41 | 0.67 | |||
| Buccal mucosa dryness severity (0–3) | 87% | 1.29 | 0.71 |
score > 0
Binary coding used for other oral examination items
Table 3.
Summary of patient scores for Oral Problems Scale and oral examination subscales*
| Scale | Subscale | Mean Score | SD | Median |
|---|---|---|---|---|
| Oral Problems Scale | Xerostomia | 5.84 | 2.49 | 6.06 |
| Orofacial pain | 1.75 | 2.12 | 1.00 | |
| Taste change | 4.45 | 3.60 | 5.00 | |
| Functional impact | 2.79 | 2.18 | 2.50 | |
| Social impact | 2.03 | 2.25 | 1.59 | |
| Oral examination † | Salivary hypofunction | 4.48 | 2.12 | 4.29 |
Subscale scores rescaled and normalized to range from 0 to 10
Binary coding used for other oral examination items
To determine whether ulceration affected other oral conditions and/or had a functional/social impact, we stratified patients by the presence/absence of ulceration and analyzed OPS scores. Patients with ulcers had higher mean scores on all five OPS subscales than those without ulcers (Table 4). However, only score differences in orofacial pain and social impact were statistically significant (p=.003 and p=.048, respectively). The mean OPS score for patients with ulceration was twice that of the mean OPS for patients without ulcers (p=.003).
Table 4.
Association of ulceration with subjective xerostomia, taste change, orofacial pain, and functional/social impact
| Oral complaint or functional/social impact | Oral Problems Scale Score | p value | |
|---|---|---|---|
| With Ulceration N = 21 | Without Ulceration N = 83 | ||
| Xerostomia | 6.00 ± 2.37 | 5.80 ± 2.53 | .738 |
| Taste change | 5.36 ± 3.38 | 4.22 ± 3.64 | .197 |
| Orofacial pain | 2.97 ± 2.57 | 1.44 ± 1.89 | .003 |
| Functional impact | 3.40 ± 1.89 | 2.64 ± 2.24 | .157 |
| Social impact | 2.91 ± 2.76 | 1.81 ± 2.07 | .048 |
Mean ± standard deviation shown.
To assess the functional and social impact of subjective oral problems, we performed linear regressions using the scores for xerostomia, taste change, and orofacial pain. Xerostomia, taste change, and orofacial pain had significant functional impact on patient activities; p<.001, <.042 and p<.001, respectively. However, only orofacial pain had a significant association with social impact (p<.001) (Table 5).
Table 5.
Association of salivary hypofunction with Oral Problems Scale components and association of functional and social impact with subjective xerostomia, taste change, and orofacial pain
| Estimate | Standard Error | t value | p value | |
|---|---|---|---|---|
| Salivary hypofunction | ||||
| Xerostomia | 0.46 | 0.11 | 4.26 | <.001 |
| Taste change | 0.15 | 0.17 | 0.88 | .38 |
| Orofacial pain | 0.08 | 0.10 | 0.84 | .41 |
| Functional impact | 0.39 | 0.10 | 4.10 | <.001 |
| Social impact | 0.23 | 0.10 | 2.22 | .03 |
| Functional impact | ||||
| Xerostomia | 0.32 | 0.07 | 4.81 | <.001 |
| Taste change | 0.10 | 0.05 | 2.06 | .04 |
| Orofacial pain | 0.49 | 0.08 | 6.55 | <.001 |
| Social impact | ||||
| Xerostomia | 0.06 | 0.08 | 0.74 | .46 |
| Taste change | 0.07 | 0.06 | 1.35 | .18 |
| Orofacial pain | 0.60 | 0.09 | 6.73 | <.001 |
Finally, we determined whether salivary hypofunction was associated with the subjective patient assessments of xerostomia, taste change, and orofacial pain from the OPS. Salivary hypofunction was significantly associated with xerostomia (p<.001) but salivary hypofunction was not significantly associated with taste change or orofacial pain. There was a significant association between salivary hypofunction and functional impact (p<.001), and an association between salivary hypofunction and social impact (p<.028) (Table 5).
Fungal infection may correlate with erythematous oral tissues in close proximity to the infection. Similarly, ulcerated tissues in various phases of development or healing may be associated with tissue erythema. We found that erythema was significantly associated (both statistically and clinically) with fungal infection (p<.001) and ulceration (p<.001). The association between fungal infection and ulceration showed a trend towards statistical significance (p<.08) (Table 6). We found no significant association between fungal infection and ulceration in the presence or absence of erythema (data not shown).
Table 6.
Association of tissue erythema with fungal infection or ulceration/pseudomembrane
| Erythema versus Fungal Infection | Erythema | Unadjusted Odds Ratio [95% CI] | P value | ||
|---|---|---|---|---|---|
| Present | Absent | ||||
| Fungal Infection | Present | 33 | 4 | 20.1 [6.0, 89.0] | <.001 |
| Absent | 19 | 48 | |||
| Erythema versus Ulceration/Pseudomembrane | Erythema | ||||
| Present | Absent | ||||
| Ulceration/Pseudomembrane | Present | 19 | 2 | 14.1 [3.1, 132.7] | <.001 |
| Absent | 33 | 50 | |||
| Fungal Infection versus Ulceration/Pseudomembrane | Fungal Infection | ||||
| Present | Absent | ||||
| Ulceration/Pseudomembrane | Present | 11 | 10 | 2.4 [0.8, 7.2] | .08 |
| Absent | 26 | 57 | |||
Discussion
Evaluation of oral conditions in terminally-ill patients is not routine in hospice and palliative care, despite the potential negative impact of these conditions on function and social interaction that affect QOL. In our study, we identified oral conditions affecting a group of patients undergoing palliative or hospice care and showed that specific oral conditions in these terminally-ill cancer patients have a significant impact upon oral function and social interaction.
Our finding of the high prevalence of moderate to severe salivary hypofunction is not surprising, as hydration status and medications utilized for comfort care including opioids contribute to salivary hypofunction [29, 31, 36]. We also found that salivary hypofunction significantly affected oral function and social interaction. Further, subjective reports of xerostomia indicate that this complaint occurred frequently and with moderate severity. Xerostomia has previously been identified as a major distressing symptom in terminally-ill patients and a significant ongoing problem in palliative care patients [1, 16, 18, 28, 33]. Gordon et al. reported that almost two-thirds of patients (62%) experienced dry mouth in a series of 31 hospice patients receiving palliative care for terminal cancer [16]. Aldred et al. studied 20 terminally-ill hospice patients and over half of the patients (58%) reported oral dryness [1]. Jobbins et al. identified over three quarters of patients in their large series of 197 terminally-ill cancer patients with xerostomia (77%) [18]. The dry oral environment caused by salivary hypofunction may increase the risk for developing oral conditions including candidiasis and dental caries and may contribute to oral functional complaints, such as dysphagia and chewing difficulty. Moreover, hyposalivation may be related to nutrition intake and hydration status in patients at their end of life [11, 27]. Orofacial pain assessment included self-report of facial pain, intraoral pain, mouth sores, and shooting or sharp extraoral/intraoral pains. While the mean orofacial pain frequency and severity were low, it significantly affected oral function. This finding may be partly explained by the presence of ulcerations, which were diagnosed in 20% of patients in our study. Patients with ulcers had significantly higher mean scores on all five OPS orofacial pain subscales than those without ulcers. Other investigators have also reported oral pain and ulceration as complaints by terminally-ill patients [1, 16, 18, 28, 33]. In the series by Gordon et al, over half the patients studied experienced oral pain [16], while Jobbins et al reported that one third of patients experienced oral pain, and 12% had ulceration [18]. Orofacial pain was also significantly associated with social impact, suggesting that the orofacial pain experienced by terminally-ill patients was worrisome and affected social interaction at this life stage.
In our study, many patients (71%) experienced taste change when not eating and with moderate frequency (4.5 ± 3.6 on 0 to 10 scale). These taste alterations affected oral function, possibly related to food enjoyment, but were not reported to have a significant social impact. The presence of ulcerations and salivary hypofunction did not have a significant association with taste change. Other investigators have reported taste alterations in terminally-ill patients, suggesting that it is not an uncommon complaint [16, 25]. In particular, a study of mixed advanced cancer patients followed in an outpatient nutrition-fatigue clinic, reported taste and smell alterations to be the most frequent nutrition impacting symptom (27%), and was significantly greater compared to a control mixed cancer population without nutrition-fatigue symptoms [25]. Consequently, taste change is an important finding in advanced cancer patients and has the potential to contribute to nutritional compromise and affecting QOL.
The frequency of oral mucosal abnormalities diagnosed in our study population was relatively high, with 50% of patients experiencing erythema, 36% presenting with fungal infection (candidiasis), and 20% having ulceration. The prevalence of clinical and microbiologic evidence of oral candidiasis in our study was similar to that of previous studies in advanced cancer patients [3, 8, 9, 33]. Oral fungal infection is often associated with salivary hypofunction, antibiotic use and may contribute to taste change. Further, yeast resistance to azole antifungal drugs has been reported in advanced cancer patients and may present a clinical challenge [3, 7]. While tissues with fungal infection and ulceration may be erythematous, erythema independent of these oral conditions is a clinical indicator of mucosal inflammation and may contribute to oral sensitivity and/or pain, which can impact oral function. Consequently, identification of oral conditions in patients at the end of life may offer additional strategies for management, improving patient care.
Conclusions
Our study showed that oral conditions in terminally-ill patients are clinically significant and affect QOL-related functional and social activities. We used a research-driven approach combining a statistically-validated oral symptom questionnaire with excellent internal consistency (Cronbach α ≥.70), standardized oral examination by an oral health professional, and laboratory confirmation of oral samples for microbiologic confirmation of fungal species overgrowth. These findings suggest that there is an important role for the health care team in identification and management of oral complaints, such as salivary hypofunction, orofacial pain, taste change and oral mucosal abnormalities in patients with advanced cancer. These oral conditions may be inter-related, may impact social and oral function, and may contribute to nutrition and hydration needs in patients at their end of life. The importance of establishing clinical protocols and setting standards of care to identify and manage oral conditions in the terminally-ill patient population is clearly warranted given the significant clinical burden of these problems.
Acknowledgements
The authors thank Jan Durham from Horizon Hospice & Palliative Care and Hope Engeseth and Julie Vecchio from University of Illinois at Chicago for subject referral and data collection. We also thank Nicola Solomon, PhD from the City of Hope National Medical Center for assistance writing and editing the manuscript. We are grateful to the leadership and staff of Horizon Hospice & Palliative Care and Rainbow Horizon Hospice and Palliative Care for their support of this research and to patients who participated.
Conflict of interest The authors do not have a financial relationship with the National Institutes of Health, National Institute of Nursing Research, the organization that sponsored the research. DW serves as a grant reviewer for NIH and DF now works at NIH, National Institute of Dental and Craniofacial Research (NIDCR), but this employment started after the data were collected. We have full control of all primary data and agree that the journal can have access to review our data if requested.
Funding: This publication was made possible by Grant Number P30 NR010680 (DJW) from the National Institutes of Health, National Institute of Nursing Research (NINR). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NINR.
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