Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2015 42; 40--48
Oral health-related quality of life of removable partial
denture wearers and related factors
S. SHAGHAGHIAN*, M. TAGHVA†, J. ABDUO‡ & R. BAGHERI§
ment, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, , †Prosthodontic Department, School of Dentistry, Shiraz University
of Medical Sciences, Shiraz, Iran, ‡Restorative Department, Melbourne Dental School, Melbourne University, Melbourne, Vic., Australia and
§
Dental Material Department and Biomaterial Research Centre, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
SUMMARY This study aims to investigate the oral
health-related quality of life (OHRQoL) in a group
of removable partial denture (RPD) wearers in
Shiraz (Iran), using the Persian version of the Oral
Health Impact Profile (OHIP-14). Two hundred
removable partial denture wearers had completed
a questionnaire regarding patients’ demographic
characteristics and denture-related factors. In
addition, the OHIP-14 questionnaire was filled out
by interviewing the patients. Two measures of
interpreting the OHIP-14 scales were utilised:
OHIP-14 sum and OHIP-14 prevalence. The
relationship of the patients’ demographic
characteristics and denture-related factors, with
their OHRQoL was investigated. The mean OHIP-
14 sum and OHIP-14 prevalence of RPD wearers
were 13
80 (10
08) and 44
5%, respectively. The
most problematic aspects of OHIP-14 were physical
disability and physical pain. Twenty-seven
percentage and 24% of participants had reported
Introduction
Tooth loss is the outcome of various factors such as
caries, periodontal disease, pulpal pathology, trauma
and oral cancer and may result in chewing difficulties
that affect general health and quality of life (1). Sev-
eral treatment options, such as implant, fixed or
removable prostheses, can be proposed to replace the
missing teeth. Although the interest in dental
implants is continuously growing, many edentulous
patients are still treated by conventional removable
prostheses. The removable partial denture (RPD) is
© 2014 John Wiley & Sons Ltd
*Oral Public Health Depart-
meal interruption and eating discomfort,
respectively. OHIP-14 prevalence and OHIP-14 sum
were found to be significantly associated with
factors representing RPD wearer’s oral health such
as self-reported oral health and frequency of
denture cleaning. Furthermore, OHIP-14
prevalence and OHIP-14 sum were significantly
associated with factors related to frequency of
denture use such as hours of wearing the denture
during the day and wearing the denture while
eating and sleeping. Therefore, it can be concluded
that the OHRQoL of the patients of the study was
generally not optimal and found to be strongly
associated with oral health.
KEYWORDS: oral health, quality of life, removable,
partial, denture
Accepted for publication 30 July 2014
selected by many partially edentulous patients
because it is conservative in nature, quickly provided
and economical (2).
Like other countries, Iran experienced improvement
in oral health parameters including reduction of eden-
tulous patients’ rate and, consequently, their need for
denture treatment. However, as the population is
growing in Iran, the number of edentulous patients
will increase. It has been estimated that by 2050, the
number of edentulous patients will increase by a fac-
tor of four in comparison with the edentulous
patients number reported in year 1975 (3). Therefore,
doi: 10.1111/joor.12221

it is important to consider edentulous patients’ need
and the factors that influence their quality of life.
It has been shown that many biological, mechani-
cal, aesthetic and psychological factors are related to
acceptance of prosthesis and success of treatment (2).
Of these factors, mastication and phonation were pro-
ven to be important factors while age, health and
hygiene were not found to be associated with satisfac-
tion (2). Mechanical factors such as denture fit, reten-
tion and number of missing teeth were also associated
with satisfaction in RPD wearers (4).
In many instances, patient’s satisfaction is subjec-
tive and varies from individual to individual. Further-
more, it was shown that clinicians’ evaluation of
removable prostheses differs from patients’ appraisal.
Variables such as survival rate, longevity of the pros-
theses and frequency of complications have been con-
sidered as the more important for clinicians; while the
social and psychological impacts of treatment and cost
effectiveness are more important factors from the
patient’s perspective (5). Oral health impact profile
(OHIP) assesses patients’ perceptions of oral health
which has been used for measuring OHRQoL of
removable denture users and proved to be a suitable
means of measurement (6).
The OHIP questionnaire is based on a model of oral
health adapted for dentistry by Locker (7). The origi-
nal OHIP questionnaire was developed by Slade and
Spencer (8) and had 49 items. OHIP-14 was devel-
oped as a modified and abbreviated version of the ori-
ginal OHIP and was selected as an instrument of
choice to assess OHRQoL in the elderly (9). To date,
effect of wearing RPD in the OHRQoL among Iranian
patients is lacking. Therefore, in this study, Persian
version of OHIP-14 was used to investigate OHRQoL
of a sample of RPD wearers in Iran.
Materials and methods
This cross-sectional study was conducted in 2012 in
Shiraz Dental School, the most important referral cen-
tre for patients in the southern part of Iran. The list of
all prosthodontic practitioners was obtained from Shi-
raz University of Medical Sciences (over all 17 special-
ists). Ethical approval was also obtained from the
Ethics Committee of the Shiraz Dental School (Appli-
cation # 4476). Convenience sampling was carried
out by selecting 253 patients from who referred to
Shiraz Dental School and all the prosthodontics
© 2014 John Wiley & Sons Ltd
ORAL HEALTH OF DENTURE WEARERS 41
practices. A package containing an information bro-
chure explaining the aims and a consent form was
given to the selected participants in the study. The
following were the inclusion criteria: Patients wearing
either double or single RPD for at least 8 weeks old
with or without complete dentures. Questionnaires
were filled by interviewing with each patient.
This questionnaire consisted of two parts. The first
part was comprised of patients’ demographic charac-
teristics (age, sex and self-reported oral health) and
denture-related factors (eight questions). The next
part consisted of all 14 questions of Persian version of
(OHIP-14) that has been validated by Navabi et al.
after translation into Persian and adaptation to the
Iranian culture. The authors speculated that it is a
precise, valid and reliable instrument for assessing oral
health-related quality of life among Iranian popula-
tion (10).
Each question of the OHIP-14 questionnaire was
scored between zero and four (0 = never, 1 = hardly
ever, 2 = occasionally, 3 = fairly often, 4 = very
often). Two measures of interpreting the OHIP-14
scales, OHIP-14 sum and OHIP-14 prevalence, were
utilised to describe RPD wearers’ OHRQoL. The OHIP-
14 sum was calculated as sum of the 14 questions
scores. The scores had a possible range of 0–56; the
higher scores representing the worse OHRQoL. OHIP-
14 prevalence was determined as the percentage of
people reporting one or more OHIP-14 items, with a
fairly often/very often response.
The collected data were analysed by adapting the
SPSS package (version 18*). The independent sample
t-test, one-way ANOVA (with Tukey post hoc test) and
chi-square test were used to assess the relationship of
patients’ demographic characteristics and denture-
related factors with their OHQoL. To control the effect
of possible confounding factors, the variables were
entered in a multiple logistic regression model with
OHIP-14 prevalence as the dependent variable. An
alpha level of 0
05 was regarded as statistical signifi-
cance.
Results
Of the 253 RPD wearers, who were invited for the
interview, 200 patients participated in the study
*SPSS Inc., Chicago, IL, USA.
42 S . S H A G H A G H I A N et al.

Table 1. Characteristics of studied partial removable denture Table 1. (continued)

wearers (N = 200)

Characteristics Number (%)

Characteristics Number (%)
Sometime stable 135 (67
5)
Sex Never stable 16 (8
0)
Male 78 (39
0)
Satisfaction of the denture
Female 122 (61
0) Yes 122 (61
0)
Age No 70 (35
0)
<50 years old 90 (45
0)
Not responding 8 (4
0)
≥50 years old 110 (55
0)
Number of arch
One partial denture 110 (55
0)
Two partial denture 84 (42
0) (acceptance rate = 79%). One hundred and ten par-
One partial and one 6 (3
0)
ticipants (55%) were 50 years old or older and 122
complete denture
Duration of denture (61%) were women. Almost half of them had used
experience their denture more than 1 year. Self-reported oral
≤1 year 102 (51
0) health of 43
5% of them was good and 61% were sat-
>1 year 98 (49
0) isfied with their dentures (Table 1).
Denture material
Only resin 76 (38
0)
Only Chrome–cobalt 110 (55
0) OHRQoL of RPD wearers
One resin and one 14 (7
0)
Chrome–cobalt A total of 89 participants answered at least one item
Hours of wearing per day as very often/fairly often, (OHIP-14 preva-
39 (19
5) lence = 44
5%). The aspects of OHIP-14 in which the
1
0–3 h day use
participants had problems very often/fairly often were
39 (19
5)
4–14 h day 1
use widely different. The most problematic aspects were
85 (42
5) physical disability and physical pain so that 27% and
1
15–23 h day use 24% of participants had interrupted meals and were
37 (18
5) uncomfortable to eat, respectively. On the contrary,
24 h day 1 use
the participants had little problem in handicap and
Wear when eating
Always 98 (49
0)
social disability aspects so that only 2
5% of them
Sometime 68 (34
0) were unable to function and a similar percentage had
Never 34 (17
0) difficulty doing jobs (Table 2). OHIP-14 sum for the
Wear when sleeping study participants was from 0 to 40 and the mean
Always 27 (13
5) was 13
80  10
08 (Fig. 1).
Sometime 52 (26
0)
Never 121 (60
5)
Cleaning frequency Relationship between patients’ characteristics and their
35 (17
5)
1
OHRQoL
0–1 time week
97 (48
5) There was not a statistically significant association of
1
2–7 time week
OHIP-14 sum and OHIP-14 prevalence with the fol-
68 (34
0)
lowing variables: sex, number of arches and duration
>7 time week 1
Self-reported oral health of partial removable denture use (Table 3). Two vari-
Good 87 (43
5) ables, age and denture material, were significantly
Fair 58 (29
0) related to OHIP-14 sum but not to OHIP-14 preva-
Poor 55 (27
5) lence. However, both OHIP-14 prevalence and OHIP-
Stability during chewing
14 sum were significantly associated with denture sta-
and speaking
Always stable 49 (24
5) bility. Patients whose dentures were always stable
during chewing and speaking had the lowest scores of
OHIP-14 prevalence (P < 0
001) and OHIP-14 sum

© 2014 John Wiley & Sons Ltd

 ORAL HEALTH OF DENTURE WEARERS 43

Table 2. Distribution of Oral Health Impact Profile-14(OHIP- (P = 0
013). Similarly, these two measures of OHR-
14) for each single item (N = 200) QoL were significantly associated with variables indi-
cating RPD wearers’ oral health, that is frequency of
Very often
denture cleaning and self-reported oral health.
& fairy Hardly
often Occasionally ever & never
There was a statistically significant relationship
OHIP-14 item N (%) N (%) N (%) between self-reported oral health and OHIP-14 preva-
lence and OHIP-14 sum so that the participants with
Functional limitation
good oral health had the lowest scores in both mea-
Trouble 15 (7
5) 25 (12
5) 160 (80
0)
pronouncing sures (improved OHRQoL) (P < 0
001). Likewise, a
words significant association was found between OHIP-14
Taste worse 15 (7
5) 38 (19
0) 147 (73
5) prevalence and OHIP-14 sum and frequency of den-
Physical pain ture cleaning (P < 0
001). The more the RPD wearer
Painful aching 38 (19
0) 50 (25
0) 112 (56
0)
cleaned the denture, the lower OHIP-14 scores (better
Uncomfortable 48 (24
0) 56 (28
0) 96 (48
0)
to eat OHRQoL) were detected.
Psychological All three factors indicating frequency of denture
discomfort use, such as hours of wearing denture in a day, wear-
Self-conscious 15 (7
5) 32 (16
0) 153 (76
5) ing dentures when eating and when sleeping, were
Tense 40 (20
0) 38 (19
0) 122 (61
0)
significantly associated with both measures of OHR-
Physical disability
QoL. With respect to hours of wearing denture, the
Diet unsatisfactory 47 (23
5) 34 (17
0) 119 (59
5)
Interrupt meals 54 (27
0) 67 (33
5) 79 (39
5) OHRQoL of the patients not using their dentures or
Psychological using it/them a few hours per day was the worst
disability (P < 0
001). This was also true for patients never
Difficult to relax 42 (21
0) 44 (22
0) 114 (57
0) wearing their dentures when eating (P < 0
001) and
Been embarrassed 7 (3
5) 24 (12
0) 169 (84
5)
when sleeping (P < 0
001).
Social disability
Irritable with others 7 (3
5) 19 (9
5) 174 (87
0) Logistic regression analysis showed a significant
Difficulty doing jobs 5 (2
5) 10 (5
0) 185 (92
5) association of OHIP-14 prevalence with the variable
Handicap indicating RPD wearers’ oral health, frequency of
Life unsatisfying 6 (3
0) 11 (5
5) 183 (91
5) denture cleaning, and one of the variables represent-
Unable to function 5 (2
5) 9 (4
5) 186 (93
0)
ing frequency of denture use, that is wearing denture

100

80

75 percentile
Cumulative percent

60

40

20 25 percentile

Fig. 1. Cumulative distribution of 0

Oral Health Impact Profile-14 scores
in removable denture wearers 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 35 37 40
(N = 200). Oral health impact profile-14 score

© 2014 John Wiley & Sons Ltd

44 S . S H A G H A G H I A N et al.

Table 3. Bivariate analysis showing factors affecting oral health-related quality of life of partial removable denture wearers (N = 200)

OHIP sum OHIP prevalence

Characteristics Mean  SD P-value N (%) P-value

Sex
Male 12
7  10
1 0
213* 32 (41) 0
429***
Female 14
5  10
0 57 (46
7)
Age
<50 years old 15
4  10
3 0
047* 45 (50) 0
157***
≥50 years old 12
5  9
7 44 (40)
Number of arches
One 14
2  10
6 0
793* 52 (47
3) 0
383***
Two 13
8  9
4 37 (41
1)
Duration of partial removable denture use
≤1 year 14
1  9
9 0
635* 48 (47
1) 0
458***
>1 year 13
4  10
3 41 (41
8)
Hours of wear
25
0  9
3a <0
001** 35 (89
7) <0
001***
1
0–3 h day use
16
6  7
5b 19 (48
7)
1
4–14 h day use
9
5  7
1c 23 (27
1)
1
15–23 h day use
8
8  8
8c 12 (32
4)
1
24 h day use
Denture material
Only resin 11
5  9
4a 0
030** 28 (36
8) 0
131***
Only Chrome–cobalt 15
5  10
5b 56 (50
9)
One resin and one Chrome–cobalt 13
1  8
7ab 5 (35
7)
Wear denture when eating
Always 8
2  7
1a <0
001** 21 (21
4) <0
001***
Sometime 15
8  8
3b 35 (51
5)
Never 26
1  8
2c 33 (97
1)
Wear denture when sleeping
Always 7
8  7
4a 0
001** 8 (29
6) <0
001***
Sometime 10
2  8
4a 113 (25
0)
Never 16
7  10
2b 68 (56
2)
Cleaning frequency
26
1  7
6a <0
001** 32 (91
4) <0
001***
1
0–1 time week
12
1  8
8b 37 (38
1)
1
2–7 time week
9
9  7
9b 20 (29
4)
>7 time week 1
Stability during chewing and speaking
Always stable 7
1  7
5a <0
001** 13 (26
5) 0
013***
Sometime stable 15
6  9
1b 67 (49
6)
Never stable 18
6  15
0b 9 (56
3)
Self-reported oral health
Good 8
1  6
3a <0
001** 12 (13
8) <0
001***
Fair 12
7  8
2b 28 (48
3)
Poor 24
0  8
9c 49 (89
1)

N, number; s.d., standard deviation.

Different letters show statistically significant differences.
*Independent sample t-test.
**One-way ANOVA.
***Chi-square test.

© 2014 John Wiley & Sons Ltd

 ORAL HEALTH OF DENTURE WEARERS 45

when eating (Table 4). Those participants who when eating. Odds ratio for patients never wearing or
cleaned their denture less than once per day were sometimes wearing their RPD when eating in compar-
three times more likely to frequently experience each ison with those always wearing it was 6
37 (95% CI:
problems mentioned in OHIP-14 questionnaire than 2
83–14
33).
those cleaning it/them once or more per day (95%
CI: 1
33–7
14). Despite the significant association
Discussion
between the OHIP-14 prevalence and all indicators of
frequency of denture use in univariate analysis, no For the majority of people, oral health has an impact
statistically significant association was found between on the quality of life as it could influence comfort,
the OHIP-14 prevalence and two items indicating fre- function and aesthetics. This study discloses some of
quency of denture use, that is hours of wearing den- the variables that affect the quality of life of patients
ture during the day and wearing dentures when treated with RPD. The duration of wearing RPD,
sleeping in multivariate analysis. However, there was denture cleaning frequency, denture stability and
a significant association between this measure of self-reported oral health were found to positively
OHRQoL (OHIP-14 prevalence), and the other item contribute to OHRQoL. On the other hand, sex, age,
indicating frequency of denture use, wearing dentures number of dentures, period of RPD wear and denture
material were found to minimally influence the
OHRQoL.
Overall, although the OHIP-14 values in this study
Table 4. Multiple logistic regression model with Oral Health indicated favourable OHRQoL for patients with RPDs,
Impact Profile-14 prevalence as the dependent variable
the prevalence of RPD-related problems was relatively
(N = 200)
considerable. This observation was in accordance with
Independent
several studies that utilised OHIP to measure OHRQoL
variables B SE OR 95% CI for OR P for patients with RPDs (11, 12) Patient’s dissatisfaction
with RPD could be related to the nature of the RPD
Sex (/male)
treatment. RPD treatment consumes more clinical
Female 0
65 0
38 1
91 0
91–4
03 0
086
Age (/≥50 years old) time, and the patients will require high maintenance
<50 years old 0
08 0
37 1
09 0
53–2
23 0
822 rate (13). This was found to contribute to poor satis-
Number of arches (/two) faction with RPD and loss of patient motivation (14).
One 0
28 0
36 1
33 0
65–2
71 0
434 This finding is in accordance with a Korean study that
Duration of partial removable denture use (/>1 year)
utilised OHIP and found the RPD users had higher
≤1 year 0
23 0
38 0
79 0
38–1
68 0
547
Denture material (/resin)
scores than complete denture users. Their participants
Chrome–cobalt 0
05 0
39 0
95 0
44–2
05 0
897 reported that the RPD was associated with more dis-
Hours of wear comfort, social limitations and cleaning difficulties (6).
(/24 h day 1) Likewise, a German study found that patients treated
0
48 0
68 0
62 0
16–2
37 0
486 with RPD tend to suffer from prosthesis related com-
Lower than
plaints for greater duration than patients treated with
24 h day 1
Wear when eating (/always) fixed dental prostheses (12). The most common com-
Never or 1
85 0
41 6
37 2
83–14
33 <0
001 plaints were sore spots, painful gums, denture-related
sometime discomfort and sore jaw (12). The results of our study
Wear when sleeping(/always) was comparable to that of Abuzar et al. (15); the
Never or 0
01 0
78 0
99 0
21–4
63 0
999
OHIP-14 prevalence in our study (44
5%) was slightly
sometime
Cleaning frequency (/once or more per day)
higher than the OHIP-14 prevalence obtained from
Lower than 1
27 0
43 3
09 1
33–7
14 0
008 Australian RPD wearers (43
1%) while the OHIP-14
once per day sum in this study (13
8) was slightly lower than that
Stability during chewing and speaking(/always) of Australian (14
8). Therefore, it is speculated that
Never or 0
37 0
45 1
45 0
60–3
50 0
404 the participants in Iran have similar reaction to RPD
sometime
in comparison with participants of some other studies
SE, standard error; OR, odds ratio; CI, confidence interval. (15).

© 2014 John Wiley & Sons Ltd

46 S . S H A G H A G H I A N et al.
This study indicates that 50-year old participants or
older have less scores of OHIP sum than younger par-
ticipants. In the literature, there is conflicting evi-
dence about the impact of patient age on the
acceptance of RPD. Similar to the current studies, Wa-
kabayashi et al. (16) found that younger patients
(<65 years) tend to be less aesthetically satisfied with
their denture than older patients. Likewise, Frank
et al. (17) found that younger patients (less 60) tend
be more dissatisfied about their denture treatment.
Kimura et al. found younger patients treated with
RPD have less OHRQoL. Such outcome could be
attributed to higher social demand and self-concerns
with aesthetics and oral function in comparison with
older patients (18). On the other hand, older patients
are more experienced to function with missing teeth
(19). On the contrary, Koyama et al. (20) found that
the older the patients (more than 65 years), the less
likely to wear their RPDs. They anticipated that older
individuals might have less aesthetic and social
demands and more impaired neuromuscular control,
which could make them more indifferent to the treat-
ment.
There are signs that patients wearing acrylic partial
denture ranked their OHRQoL higher than those
wearing metal partial denture. This observation is
opposite to what many specialists would regularly rec-
ommend. However, in removable prosthodontics, dis-
crepancies between clinician objective appraisal and
patient subjective preference is not uncommon (20).
Still, these results should be interpreted with caution.
In many instances, acrylic denture is indicated for
immediate aesthetic restorations, which can solve a
major patient concerns. Furthermore, acrylic dentures
are generally cheaper, require less treatment time and
are heavily used to restore missing anterior teeth.
These factors could explain why the reported OHR-
QoL by patients wearing acrylic partial denture
appears higher.
In addition, this study emphasises that drawbacks
of RPD are the physical problems such as pain and
lack of stability during chewing and speaking. This
could eventually influence patients’ comfort, eating
and meal interruption. The importance of RPD stabil-
ity has been confirmed by a Japanese study, which
found that patients with more stable RPD had lower
OHIP scores (21). On that basis, improving RPD qual-
ity is very desirable (21) Thus it could be speculated
that restoring stability-related function by RPD, such
as chewing, is unreliable and might not be to the
level of patients’ expectations (2). The physical prob-
lems and lack of stability of RPD could be due to mul-
tiple reasons such as differential support, material
bulkiness and occlusion instability. In a retrospective
study, Koyama et al. (20) reported that completely
tooth supported RPDs were more preferred by
patients than tooth and tissue-supported RPDs, which
could be attributed to the superior stability and sup-
port. In the same study, it was shown that the better
the design and distribution of supporting rests, the
greater the satisfaction with the RPD, which could
also be associated with less pain during function. To
overcome the classical RPD problems, several authors
recommended RPD treatment alternatives such as
fixed prosthesis or shortened dental arch (SDA). There
is consistent observation that patients receiving
removable prosthesis had poorer OHRQoL than those
receiving fixed treatment (11, 22). On the other hand,
good level of evidence supports that for patients with
SDA, the RPD was found not to improve oral function
or prevent craniomandibular disorder, occlusion insta-
bility and tooth wear (23). Moreover, the OHRQoL
did not differ significantly between RPD patients and
SDA patients (24).
Similar to the observations by other authors (25),
the results of the present study indicate that patients
who ranked their self-reported oral health as good
had better OHIP values than those who reported it as
fair or poor. Similarly, participants regularly wearing
their RPDs or frequently cleaning it had better OHR-
QoL. This confirms the finding of other reports that
found patients who continuously wear their RPDs
were more satisfied with their denture treatment and
had better OHRQoL (19, 25). This reflects that accep-
tance of RPD is enhanced by the positive patient atti-
tude towards his/her own oral health (2).
Philosophical patients might be more motivated about
the RPD treatment and will, eventually, be more sat-
isfied and appreciative of the outcome.
This study indicates that RPD-related problems are
relatively frequent. It appears that the duration of
wearing the RPD, denture cleaning frequency, den-
ture stability and self-reported oral health are posi-
tively associated with better OHRQoL. These factors
should be considered by the treating clinician and
explained to the patient when the RPD treatment is
planned and executed. Comparing the data of this
cross-sectional study with dental individuals might be
© 2014 John Wiley & Sons Ltd

beneficial or indicated in the future. Although the
number of teeth is an important physical characteris-
tic for dental patient populations, it was not consid-
ered in this study which in turn is one of our study
limitations.
Acknowledgments
The authors thank the Vice Chancellor of Shiraz Uni-
versity of Medical Sciences for supporting this
research (Grant # 4476).
Ethical considerations
The scientific and ethical aspects of the protocol were
reviewed and approved by the review board of the
Shiraz Dental School, the University of Medical Sci-
ences, Shiraz, Iran. Informed consent was obtained
from all participants.
Funding
This research was supported by Vice Chancellor of
Shiraz University of Medical Sciences.
Conflicts of interest
No conflict of interests declared.
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Correspondence: Rafat Bagheri, Dental Material Department and
Biomaterial Research Centre, Shiraz University of Medical Sciences,
Shiraz Dental School, Ghomabad, Ghasrodasht St, Shiraz, Iran.
E-mail: bagherir@unimelb.edu.au
© 2014 John Wiley & Sons Ltd