International Journal of Cardiology 179 (2015) 52–54
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Hypertension, diabetes and poor mental health are associated with dissatisfaction of teeth appearance: Scottish Health Survey, 2012 Ivy Shiue ⁎ School of Energy, Geoscience, Infrastructure & Society, Heriot-Watt University, UK Owens Institute for Behavioral Research, University of GA, USA
a r t i c l e
i n f o
Article history: Received 6 October 2014 Accepted 19 October 2014 Available online 24 October 2014 Keywords: Epidemiology Risk factor Oral health Hypertension Diabetes Mental health Self-rated health
Dental health has been one of the health concerns in humans for centuries. With an advancing age, teeth could become with a mottled appearance ranging from white, yellow to brown-black that might require mouth rehabilitation. Previously, clinicians and researchers observed that among the elderly people, the predictors of self-rated oral health were “worry about teeth” and “appearance of teeth” followed by total missing teeth, race, education and depression scores while self-rated general health was also related to self-rated oral health [1]. Self-rated oral health could be affected by oral disease and tissue damage, oral pain and discomfort, oral functional limitation, and oral disadvantage [2]. However, it is not known whether and how other physical health concerns might be related. Therefore, it was aimed to examine the associations between common chronic diseases and self-rated teeth appearance in adults in a country-wide and population-based setting. As described elsewhere in detail [3], Scottish Health Survey (http:// www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-healthsurvey) has been a country-wide, population-based, multi-year study. It provides a detailed picture of the health of the Scottish population in private households and is designed to make a major contribution to the monitoring of health in Scotland. It is essential for the Scottish Government's forward planning, for identifying gaps in health services provision and for identifying which groups are at particular risk of fu-
⁎ Heriot-Watt University, Riccarton, EH14 4AS Edinburgh, Scotland, UK. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2014.10.079 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
ture ill-health. For more survey design details including sample size estimation, they can be found here: http://www.scotland.gov.uk/Topics/ Statistics/Browse/Health/scottish-health-survey/SurveyDesignContent. In the current analysis, the most recent study wave in 2012 with available data on demographics, lifestyle factors, self-reported ever chronic diseases and current self-rated teeth appearance in adults aged 16 and above which was obtained by household interview was included. Study exposure variables were ever common chronic diseases (e.g. high blood pressure) while the study outcome was current self-rated teeth appearance (question: How happy or unhappy are you with the appearance of your teeth at present?). Covariates that could have an impact on self-rated oral appearance including age, sex, education level, deprivation level, marital status, smoking status (current, past, or never), alcohol status (yes or no), toothache and the survey design were adjusted. In the first step, examination on associations between common chronic diseases and self-rated teeth appearance was carried out. In the second step, associations between mental health status by using the 12-item General Health Questionnaire and self-rated teeth appearance were examined as well. Effects were estimated by using odds ratios (OR) and 95% confidence intervals (CI), with P b 0.05 considered statistically significant. Statistical software STATA version 13.0 (STATA, College Station, Texas, USA) was used to perform all the analyses. Since it is only a secondary data analysis in the present study, no further ethics approval was required. Of 4815 adults (aged 16–99) included in the study cohort, 4179 with valid data on all exposures and outcomes were eligible for statistical analysis. The mean age was 51.5 (SD 18.2). At present, 859 people (20.6%) reported their unhappiness about their teeth appearance. Table 1 shows associations between common chronic diseases and self-rated teeth appearance. People with high blood pressure (OR 1.36, 95% CI 1.10 to 1.68, P = 0.004), diabetes (OR 1.21, 95% CI 1.0004 to 1.46, P = 0.050) or depression (OR 1.43, 95% CI 1.17 to 1.73, P b 0.001) tended to be unhappy about their teeth appearance. In addition, people with poor self-rated health were also dissatisfied with their teeth appearance at present (OR 1.42, 95% CI 1.05 to 1.94, P = 0.024). Table 2 presents associations between mental health status by each item of the General Health Questionnaire and self-rated teeth appearance. Clearly, almost all the items were significantly associated with self-rated teeth appearance, except for “felt capable of making decisions” (OR 1.24, 95% CI 0.89 to 1.72, P = 0.208). The statistical insignificance might be due to the small number of events (n b 100) recorded and included in the modelling.
I. Shiue / International Journal of Cardiology 179 (2015) 52–54
53
Table 1 Associations of chronic diseases and dissatisfaction of teeth appearance.
Self-rated health Good Poor High blood pressure No Yes Angina No Yes Heart attack No Yes Heart murmur No Yes Stroke No Yes Diabetes No Yes COPD No Yes Depression No Yes a
Happy with teeth appearance (n = 3320, 79.4%)
Unhappy with teeth appearance (n = 859, 20.6%)
OR (95% CI)a
3109 (80.8%) 210 (64.0%)
741 (19.3%) 118 (36.0%)
1.00 1.42 (1.05–1.94)
0.024
2479 (80.6%) 839 (76.2%)
596 (19.4%) 262 (23.8%)
1.00 1.36 (1.10–1.68)
0.004
3201 (79.7%) 118 (73.3%)
816 (20.3%) 43 (26.7%)
1.00 0.99 (0.80–1.22)
0.934
3238 (79.6%) 81 (75.0%)
832 (20.4%) 27 (25.0%)
1.00 0.95 (0.71–1.26)
0.714
3194 (79.6%) 126 (75.5%)
817 (20.4%) 41 (24.6%)
1.00 1.11 (0.88–1.39)
0.378
3253 (79.7%) 66 (70.2%)
831 (20.4%) 28 (29.8%)
1.00 1.11 (0.80–1.56)
0.527
3166 (20.0%) 153 (69.2%)
791 (20.0%) 68 (30.8%)
1.00 1.21 (1.0004–1.46)
0.050
3223 (79.8%) 97 (69.8%)
817 (20.2%) 42 (30.2%)
1.00 1.02 (0.80–1.31)
0.851
2032 (82.2%) 983 (73.6%)
439 (17.8%) 352 (26.4%)
1.00 1.43 (1.17–1.73)
b0.001
P value
Adjusting for age, sex, education, deprivation level, marital status, smoking, alcohol, toothache and survey weighting.
Table 2 Associations of mental health status and dissatisfaction of teeth appearance.
Able to concentrate Normal Less than usual Lost sleep over worry Normal More than usual Felt playing useful part in things Normal Less than usual Felt capable of making decisions Normal Less than usual Felt constantly under strain Normal More than usual Felt couldn't overcome difficulties Normal More than usual Able to enjoy day-to-day activities Normal Less than usual Been able to face problems Normal Less than usual Been feeling unhappy and depressed Normal More than usual Been losing confidence in self Normal More than usual Been thinking of self as worthless Normal More than usual Been feeling reasonably happy Normal Less than usual a
Happy with teeth appearance (n = 3320, 79.4%)
Unhappy with teeth appearance (n = 859, 20.6%)
OR (95% CI)a
2808 (80.5%) 248 (66.7%)
680 (19.5%) 124 (33.3%)
1.00 1.51 (1.14–1.99)
0.004
2645 (81.0%) 416 (69.1%)
619 (19.0%) 186 (30.9%)
1.00 1.61 (1.25–2.07)
b0.001
2845 (80.7%) 211 (63.6%)
682 (19.3%) 121 (36.5%)
1.00 1.68 (1.27–2.24)
b0.001
2879 (79.9%) 178 (69.3%)
725 (20.1%) 79 (30.7%)
1.00 1.24 (0.89–1.72)
0.208
2516 (81.1%) 541 (71.3%)
587 (18.9%) 218 (28.7%)
1.00 1.40 (1.11–1.78)
0.005
2827 (80.8%) 232 (63.2%)
670 (19.2%) 135 (36.8%)
1.00 1.69 (1.27–2.24)
b0.001
2647 (80.7%) 394 (70.5%)
635 (19.4%) 165 (29.5%)
1.00 1.38 (1.09–1.76)
0.009
2866 (80.8%) 175 (59.5%)
681 (19.2%) 119 (40.5%)
1.00 1.97 (1.43–2.73)
b0.001
2643 (81.2%) 400 (68.0%)
612 (18.8%) 188 (32.0%)
1.00 1.61 (1.25–2.07)
b0.001
2729 (81.3%) 312 (64.7%)
629 (18.7%) 170 (35.3%)
1.00 1.80 (1.39–2.34)
b0.001
2867 (80.6%) 176 (62.0%)
691 (19.4%) 108 (38.0%)
1.00 1.76 (1.29–2.42)
b0.001
2778 (80.7%) 262 (66.0%)
665 (19.3%) 135 (3.40%)
1.00 1.59 (1.20–2.11)
0.001
Adjusting for age, sex, education, deprivation level, marital status, smoking, alcohol, toothache and survey weighting.
P value
54
I. Shiue / International Journal of Cardiology 179 (2015) 52–54
In the present country-wide, population-based, cross-sectional study, it was observed that adults reported ever high blood pressure, diabetes, depression, poor self-rated health and poor mental heath status were dissatisfied with their current teeth appearance. A few case reports have described an uncommon association between diabetes insipidus and dental fluorosis, but no assessment on oral appearance was performed [4–6]. In animal research, however, there was an observation on how type 1 diabetes might have been a contributing factor to the appearance of tooth decay [7]. Moreover, in Japanese civil service officers (n = 1381), associations between mental health by the General Health Questionnaire and self-rated oral health were insignificant in men (P = 0.169) but significant in women (P = 0.004) [8]. On the other hand, there seems to be no sound empirical evidence on the potential relationship of hypertension and self-rated teeth appearance, although a clinical study showed a potential linkage in patients with severe secondary hyperparathyroidism in chronic renal failure [9]. The linkage of poor mental health such as distress or depression and selfrated teeth appearance could be via the mechanism of low selfcompetence and appreciation [10]. The strengths of conducting this present study lie in its very large and representative study sample (country-wide and populationbased) and in the very recent years. This is also the first time analysing the relationships of chronic diseases and self-rated oral appearance in Scotland. However, the causality cannot be established due to the cross-sectional study design in nature. Future studies overcoming the limitation would be suggested. In sum, this is the first observation on how hypertension, diabetes and poor self-rated general and mental health could have been associated with oral appearance using a large human sample that is country-wide and population-based. Intervention and nursing research looking into dental and mental health care should be paid more attention at a national level, in particular among patients with any historical health event.
Conflict of interest None. Acknowledgements IS is supported by the Global Platform for Research Leaders scheme. References [1] R.E. Matthias, K.A. Atchison, J.E. Lubben, F. De Jong, S.O. Schweitzer, Factors affecting self-ratings of oral health, J. Public Health Dent. 55 (1995) 197–204. [2] G.H. Gilbert, R.P. Duncan, M.W. Heft, T.A. Dolan, W.B. Vogel, Multidimensionality of oral health in dentate adults, Med. Care 36 (1998) 988–1001. [3] Scottish Health Survey, The Scottish Government, 1995. [4] H. Klein, Dental fluorosis associated with hereditary diabetes insipidus, Oral Surg. Oral Med. Oral Pathol. 40 (1975) 736–741. [5] W.K. Seow, M.J. Thomsett, Dental fluorosis as a complication of hereditary diabetes insipidus: studies of six affected patients, Pediatr. Dent. 16 (1994) 128–132. [6] R. Bansal, A. Jain, S. Mittal, T. Kumar, Full mouth rehabilitation in a medically compromised patient with fluorosis, J. Clin. Diagn. Res. 8 (2014) ZD22–ZD24. [7] I. Gutowska, I. Baranowska-Bosiacka, M. Rybicka, I. Noceń, W. Dudzińska, M. Marchlewicz, B. Wiszniewska, D. Chlubek, Changes in the concentration of microelements in the teeth of rats in the final stage of type 1 diabetes, with an absolute lack of insulin, Biol. Trace Elem. Res. 139 (2011) 332–340. [8] R. Ide, T. Hoshuyama, D. Wilson, K. Takahashi, T. Higashi, Association of psychological well-being with oral conditions in Japanese workers, J. Occup. Health 48 (2006) 487–493. [9] Y. Sagliker, M. Balal, P. Sagliker Ozkaynak, S. Paydas, C. Sagliker, H. Sabit Sagliker, N. Kiralp, S. Mumin Adam, I. Tuncer, G. Gonlusen, M. Esenturk, E. Gocmez, H. Taskapan, M. Yeksan, E. Kobaner, O. Ozkaya, M. Yuksekgonul, I. Emir, N. Cengiz, I. Onder Isik, O. Bilginer, T. Guler, H. Yakar, N. Sarsmaz, S. Dilaver, B. Akoglu, M. Basgumus, E. Chirik, Sagliker syndrome: uglifying human face appearance in late and severe secondary hyperparathyroidism in chronic renal failure, Semin. Nephrol. 24 (2004) 449–455. [10] A.L. Dumitrescu, C. Toma, V. Lascu, Self-liking, self-competence, body investment and perfectionism: associations with oral health status and oral-health-related behaviours, Oral Health Prev. Dent. 7 (2009) 191–200.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Hypertension, diabetes and poor mental health are associated with dissatisfaction of teeth appearance: Scottish Health Survey, 2012 Ivy Shiue ⁎ School of Energy, Geoscience, Infrastructure & Society, Heriot-Watt University, UK Owens Institute for Behavioral Research, University of GA, USA
a r t i c l e
i n f o
Article history: Received 6 October 2014 Accepted 19 October 2014 Available online 24 October 2014 Keywords: Epidemiology Risk factor Oral health Hypertension Diabetes Mental health Self-rated health
Dental health has been one of the health concerns in humans for centuries. With an advancing age, teeth could become with a mottled appearance ranging from white, yellow to brown-black that might require mouth rehabilitation. Previously, clinicians and researchers observed that among the elderly people, the predictors of self-rated oral health were “worry about teeth” and “appearance of teeth” followed by total missing teeth, race, education and depression scores while self-rated general health was also related to self-rated oral health [1]. Self-rated oral health could be affected by oral disease and tissue damage, oral pain and discomfort, oral functional limitation, and oral disadvantage [2]. However, it is not known whether and how other physical health concerns might be related. Therefore, it was aimed to examine the associations between common chronic diseases and self-rated teeth appearance in adults in a country-wide and population-based setting. As described elsewhere in detail [3], Scottish Health Survey (http:// www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-healthsurvey) has been a country-wide, population-based, multi-year study. It provides a detailed picture of the health of the Scottish population in private households and is designed to make a major contribution to the monitoring of health in Scotland. It is essential for the Scottish Government's forward planning, for identifying gaps in health services provision and for identifying which groups are at particular risk of fu-
⁎ Heriot-Watt University, Riccarton, EH14 4AS Edinburgh, Scotland, UK. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2014.10.079 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
ture ill-health. For more survey design details including sample size estimation, they can be found here: http://www.scotland.gov.uk/Topics/ Statistics/Browse/Health/scottish-health-survey/SurveyDesignContent. In the current analysis, the most recent study wave in 2012 with available data on demographics, lifestyle factors, self-reported ever chronic diseases and current self-rated teeth appearance in adults aged 16 and above which was obtained by household interview was included. Study exposure variables were ever common chronic diseases (e.g. high blood pressure) while the study outcome was current self-rated teeth appearance (question: How happy or unhappy are you with the appearance of your teeth at present?). Covariates that could have an impact on self-rated oral appearance including age, sex, education level, deprivation level, marital status, smoking status (current, past, or never), alcohol status (yes or no), toothache and the survey design were adjusted. In the first step, examination on associations between common chronic diseases and self-rated teeth appearance was carried out. In the second step, associations between mental health status by using the 12-item General Health Questionnaire and self-rated teeth appearance were examined as well. Effects were estimated by using odds ratios (OR) and 95% confidence intervals (CI), with P b 0.05 considered statistically significant. Statistical software STATA version 13.0 (STATA, College Station, Texas, USA) was used to perform all the analyses. Since it is only a secondary data analysis in the present study, no further ethics approval was required. Of 4815 adults (aged 16–99) included in the study cohort, 4179 with valid data on all exposures and outcomes were eligible for statistical analysis. The mean age was 51.5 (SD 18.2). At present, 859 people (20.6%) reported their unhappiness about their teeth appearance. Table 1 shows associations between common chronic diseases and self-rated teeth appearance. People with high blood pressure (OR 1.36, 95% CI 1.10 to 1.68, P = 0.004), diabetes (OR 1.21, 95% CI 1.0004 to 1.46, P = 0.050) or depression (OR 1.43, 95% CI 1.17 to 1.73, P b 0.001) tended to be unhappy about their teeth appearance. In addition, people with poor self-rated health were also dissatisfied with their teeth appearance at present (OR 1.42, 95% CI 1.05 to 1.94, P = 0.024). Table 2 presents associations between mental health status by each item of the General Health Questionnaire and self-rated teeth appearance. Clearly, almost all the items were significantly associated with self-rated teeth appearance, except for “felt capable of making decisions” (OR 1.24, 95% CI 0.89 to 1.72, P = 0.208). The statistical insignificance might be due to the small number of events (n b 100) recorded and included in the modelling.
I. Shiue / International Journal of Cardiology 179 (2015) 52–54
53
Table 1 Associations of chronic diseases and dissatisfaction of teeth appearance.
Self-rated health Good Poor High blood pressure No Yes Angina No Yes Heart attack No Yes Heart murmur No Yes Stroke No Yes Diabetes No Yes COPD No Yes Depression No Yes a
Happy with teeth appearance (n = 3320, 79.4%)
Unhappy with teeth appearance (n = 859, 20.6%)
OR (95% CI)a
3109 (80.8%) 210 (64.0%)
741 (19.3%) 118 (36.0%)
1.00 1.42 (1.05–1.94)
0.024
2479 (80.6%) 839 (76.2%)
596 (19.4%) 262 (23.8%)
1.00 1.36 (1.10–1.68)
0.004
3201 (79.7%) 118 (73.3%)
816 (20.3%) 43 (26.7%)
1.00 0.99 (0.80–1.22)
0.934
3238 (79.6%) 81 (75.0%)
832 (20.4%) 27 (25.0%)
1.00 0.95 (0.71–1.26)
0.714
3194 (79.6%) 126 (75.5%)
817 (20.4%) 41 (24.6%)
1.00 1.11 (0.88–1.39)
0.378
3253 (79.7%) 66 (70.2%)
831 (20.4%) 28 (29.8%)
1.00 1.11 (0.80–1.56)
0.527
3166 (20.0%) 153 (69.2%)
791 (20.0%) 68 (30.8%)
1.00 1.21 (1.0004–1.46)
0.050
3223 (79.8%) 97 (69.8%)
817 (20.2%) 42 (30.2%)
1.00 1.02 (0.80–1.31)
0.851
2032 (82.2%) 983 (73.6%)
439 (17.8%) 352 (26.4%)
1.00 1.43 (1.17–1.73)
b0.001
P value
Adjusting for age, sex, education, deprivation level, marital status, smoking, alcohol, toothache and survey weighting.
Table 2 Associations of mental health status and dissatisfaction of teeth appearance.
Able to concentrate Normal Less than usual Lost sleep over worry Normal More than usual Felt playing useful part in things Normal Less than usual Felt capable of making decisions Normal Less than usual Felt constantly under strain Normal More than usual Felt couldn't overcome difficulties Normal More than usual Able to enjoy day-to-day activities Normal Less than usual Been able to face problems Normal Less than usual Been feeling unhappy and depressed Normal More than usual Been losing confidence in self Normal More than usual Been thinking of self as worthless Normal More than usual Been feeling reasonably happy Normal Less than usual a
Happy with teeth appearance (n = 3320, 79.4%)
Unhappy with teeth appearance (n = 859, 20.6%)
OR (95% CI)a
2808 (80.5%) 248 (66.7%)
680 (19.5%) 124 (33.3%)
1.00 1.51 (1.14–1.99)
0.004
2645 (81.0%) 416 (69.1%)
619 (19.0%) 186 (30.9%)
1.00 1.61 (1.25–2.07)
b0.001
2845 (80.7%) 211 (63.6%)
682 (19.3%) 121 (36.5%)
1.00 1.68 (1.27–2.24)
b0.001
2879 (79.9%) 178 (69.3%)
725 (20.1%) 79 (30.7%)
1.00 1.24 (0.89–1.72)
0.208
2516 (81.1%) 541 (71.3%)
587 (18.9%) 218 (28.7%)
1.00 1.40 (1.11–1.78)
0.005
2827 (80.8%) 232 (63.2%)
670 (19.2%) 135 (36.8%)
1.00 1.69 (1.27–2.24)
b0.001
2647 (80.7%) 394 (70.5%)
635 (19.4%) 165 (29.5%)
1.00 1.38 (1.09–1.76)
0.009
2866 (80.8%) 175 (59.5%)
681 (19.2%) 119 (40.5%)
1.00 1.97 (1.43–2.73)
b0.001
2643 (81.2%) 400 (68.0%)
612 (18.8%) 188 (32.0%)
1.00 1.61 (1.25–2.07)
b0.001
2729 (81.3%) 312 (64.7%)
629 (18.7%) 170 (35.3%)
1.00 1.80 (1.39–2.34)
b0.001
2867 (80.6%) 176 (62.0%)
691 (19.4%) 108 (38.0%)
1.00 1.76 (1.29–2.42)
b0.001
2778 (80.7%) 262 (66.0%)
665 (19.3%) 135 (3.40%)
1.00 1.59 (1.20–2.11)
0.001
Adjusting for age, sex, education, deprivation level, marital status, smoking, alcohol, toothache and survey weighting.
P value
54
I. Shiue / International Journal of Cardiology 179 (2015) 52–54
In the present country-wide, population-based, cross-sectional study, it was observed that adults reported ever high blood pressure, diabetes, depression, poor self-rated health and poor mental heath status were dissatisfied with their current teeth appearance. A few case reports have described an uncommon association between diabetes insipidus and dental fluorosis, but no assessment on oral appearance was performed [4–6]. In animal research, however, there was an observation on how type 1 diabetes might have been a contributing factor to the appearance of tooth decay [7]. Moreover, in Japanese civil service officers (n = 1381), associations between mental health by the General Health Questionnaire and self-rated oral health were insignificant in men (P = 0.169) but significant in women (P = 0.004) [8]. On the other hand, there seems to be no sound empirical evidence on the potential relationship of hypertension and self-rated teeth appearance, although a clinical study showed a potential linkage in patients with severe secondary hyperparathyroidism in chronic renal failure [9]. The linkage of poor mental health such as distress or depression and selfrated teeth appearance could be via the mechanism of low selfcompetence and appreciation [10]. The strengths of conducting this present study lie in its very large and representative study sample (country-wide and populationbased) and in the very recent years. This is also the first time analysing the relationships of chronic diseases and self-rated oral appearance in Scotland. However, the causality cannot be established due to the cross-sectional study design in nature. Future studies overcoming the limitation would be suggested. In sum, this is the first observation on how hypertension, diabetes and poor self-rated general and mental health could have been associated with oral appearance using a large human sample that is country-wide and population-based. Intervention and nursing research looking into dental and mental health care should be paid more attention at a national level, in particular among patients with any historical health event.
Conflict of interest None. Acknowledgements IS is supported by the Global Platform for Research Leaders scheme. References [1] R.E. Matthias, K.A. Atchison, J.E. Lubben, F. De Jong, S.O. Schweitzer, Factors affecting self-ratings of oral health, J. Public Health Dent. 55 (1995) 197–204. [2] G.H. Gilbert, R.P. Duncan, M.W. Heft, T.A. Dolan, W.B. Vogel, Multidimensionality of oral health in dentate adults, Med. Care 36 (1998) 988–1001. [3] Scottish Health Survey, The Scottish Government, 1995. [4] H. Klein, Dental fluorosis associated with hereditary diabetes insipidus, Oral Surg. Oral Med. Oral Pathol. 40 (1975) 736–741. [5] W.K. Seow, M.J. Thomsett, Dental fluorosis as a complication of hereditary diabetes insipidus: studies of six affected patients, Pediatr. Dent. 16 (1994) 128–132. [6] R. Bansal, A. Jain, S. Mittal, T. Kumar, Full mouth rehabilitation in a medically compromised patient with fluorosis, J. Clin. Diagn. Res. 8 (2014) ZD22–ZD24. [7] I. Gutowska, I. Baranowska-Bosiacka, M. Rybicka, I. Noceń, W. Dudzińska, M. Marchlewicz, B. Wiszniewska, D. Chlubek, Changes in the concentration of microelements in the teeth of rats in the final stage of type 1 diabetes, with an absolute lack of insulin, Biol. Trace Elem. Res. 139 (2011) 332–340. [8] R. Ide, T. Hoshuyama, D. Wilson, K. Takahashi, T. Higashi, Association of psychological well-being with oral conditions in Japanese workers, J. Occup. Health 48 (2006) 487–493. [9] Y. Sagliker, M. Balal, P. Sagliker Ozkaynak, S. Paydas, C. Sagliker, H. Sabit Sagliker, N. Kiralp, S. Mumin Adam, I. Tuncer, G. Gonlusen, M. Esenturk, E. Gocmez, H. Taskapan, M. Yeksan, E. Kobaner, O. Ozkaya, M. Yuksekgonul, I. Emir, N. Cengiz, I. Onder Isik, O. Bilginer, T. Guler, H. Yakar, N. Sarsmaz, S. Dilaver, B. Akoglu, M. Basgumus, E. Chirik, Sagliker syndrome: uglifying human face appearance in late and severe secondary hyperparathyroidism in chronic renal failure, Semin. Nephrol. 24 (2004) 449–455. [10] A.L. Dumitrescu, C. Toma, V. Lascu, Self-liking, self-competence, body investment and perfectionism: associations with oral health status and oral-health-related behaviours, Oral Health Prev. Dent. 7 (2009) 191–200.
