Oral Health and Autism Spectrum Disorders: A Unique Collaboration between Dentistry and Occupational Therapy

Dominique H Como, Leah I Stein Duker, José C Polido, Sharon A Cermak, Dominique H Como, Leah I Stein Duker, José C Polido, Sharon A Cermak

Abstract

Children with autism spectrum disorders (ASD) are at risk for oral health disparities. With the dramatic rise in ASD prevalence to 1 in 54 children, it is likely that an increasing number of dental practitioners will encounter or be asked to treat children with ASD. This paper reviews explanations related to the increasing prevalence of ASD, provides reasons why children with ASD are at increased risk for poor oral health, and discusses unique interprofessional collaborations between dental practitioners and occupational therapists. Occupational therapists and dentists can work together to plan modifications to the dental environment or adapt dental protocols to reduce some of the barriers encountered by those with ASD, provide desensitization strategies before the clinic visit, or help a child with emotional regulation during clinical treatments.

Keywords: autism spectrum disorder; dentistry; interprofessional collaboration; occupational therapy; oral health.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

References

    1. Murthy V. Oral health in America, 2000 to present: Progress made, but challenges remain. Public Health Rep. 2014;131:224–225. doi: 10.1177/003335491613100202.
    1. Fisher-Owens S., Isong I.A., Soobader M., Gansky S.A., Weintraub J.A., Platt L.J., Newacheck P.W. An examination of racial/ethnic disparities in children’s oral health in the United States. J. Public Health Dent. 2013;73:166–174. doi: 10.1111/j.1752-7325.2012.00367.x.
    1. Koritsas S., Iacono T. Secondary conditions in people with developmental disability. Am. J. Intellect. Dev. Disabil. 2011;116:36–47. doi: 10.1352/1944-7558-116.1.36.
    1. Maenner M.J., Shaw K.A., Baio J., Washington A., Patrick M., DiRienzo M., Christensen D.L., Wiggins L.D., Pettygrove S., Andrews J.G., et al. Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 Sites, United States, 2016. MMWR Surveill. Summ. 2020;69:1–12. doi: 10.15585/mmwr.ss6904a1.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; Arlington, VA, USA: 2013.
    1. Lord C., Elsabbagh M., Baird G., Veenstra-Vanderweele J. Autism spectrum disorder. Lancet. 2018;392:508–520. doi: 10.1016/S0140-6736(18)31129-2.
    1. Masi A., De Mayo M., Glozier N., Guastella A. An overview of autism spectrum disorder, heterogeneity and treatment options. Neurosci. Bull. 2017;33:183–193. doi: 10.1007/s12264-017-0100-y.
    1. Solomon M., Iosif A.M., Reinhardt V.P., Libero L.E., Nordahl C.W., Ozonoff S., Rogers S.J., Amaral D.G. What will my child’s future hold? Phenotypes of intellectual development in 2–8-year-olds with autism spectrum disorder. Autism Res. 2018;11:121–132. doi: 10.1002/aur.1884.
    1. Lotter V. Epidemiology of autistic conditions in young children. Soc. Psychiatry. 1966;1:124–135. doi: 10.1007/BF00584048.
    1. Centers for Disease Control and Prevention Autism Spectrum Disorders: Data and Statistics (Prevalence). Autism and Developmental Disabilities Monitoring Network. [(accessed on 26 March 2020)]; Available online: .
    1. Feinstein A. A History of Autism Conversations with the Pioneers. Wiley-Blackwell; Chichester, UK: 2010.
    1. Kita Y., Hosokawa T. History of Autism Spectrum Disorders: Historical controversy over diagnosis. Hist. Controv. Diagn. 2011;59:147–166.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 1st ed. American Psychiatric Association; Washington, DC, USA: 1952.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. American Psychiatric Association; Washington, DC, USA: 1968.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. American Psychiatric Association; Washington, DC, USA: 1980.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Association; Washington, DC, USA: 1994.
    1. Lord C., Luyster R.J., Gotham K., Guthrie W. Autism Diagnostic Observation Schedule. 2nd ed. Western Psychological Services; Torrance, CA, USA: 2012. (ADOS-2) Manual (Part. II): Toddler Module.
    1. Lord C., Rutter M., DiLavore P.C., Risi S., Gotham K., Bishop S.L. Autism Diagnostic Observation Schedule. 2nd ed. Western Psychological Services; Torrance, CA, USA: 2012. (ADOS-2) Manual (Part. I): Modules 1–4.
    1. Bieleninik L., Posserud M.-B., Geretsegger M., Thompson G., Elefant C., Gold C. Tracing the temporal stability of autism spectrum diagnosis and severity as measured by the autism diagnostic observation schedule: A systematic review and meta-analysis. PLoS ONE. 2017;12:e0183160. doi: 10.1371/journal.pone.0183160.
    1. Falkmer T., Anderson K., Falkmer M., Horlin C. Diagnostic procedures in autism spectrum disorders: A systematic literature review. Eur. Child. Adolesc. Psychiatry. 2013;22:329–340. doi: 10.1007/s00787-013-0375-0.
    1. Ozonoff S., Goodlin-Jones B.L., Solomon M. Evidence-based assessment of autism spectrum disorders in children and adolescents. J. Clin. Child. Adolesc. Psychol. 2005;34:523–540. doi: 10.1207/s15374424jccp3403_8.
    1. Blacher J., Cohen S.R., Azad G. In the eye of the beholder: Reports of autism symptoms by anglo and latino mothers. Res. Autism Spectr. Disord. 2014;8:1648–1656. doi: 10.1016/j.rasd.2014.08.017.
    1. Zwaigenbaum L., Bauman M.L., Fein D., Pierce K., Buie T., Davis P.A., Newschaffer C., Robins D.L., Wetherby A., Choueiri R., et al. Early screening of autism spectrum disorder: Recommendations for practice and research. Pediatrics. 2015;136:S41–S59. doi: 10.1542/peds.2014-3667D.
    1. American Academy of Pediatrics Clinical report: Identification and evaluation of children with Autism Spectrum Disorders. Pediatrics. 2007;120:1183–1215. doi: 10.1542/peds.2007-2361.
    1. Healthy Children Public Health Minute: Early Identification of ASD. [(accessed on 23 November 2018)]; Available online: .
    1. Turner-Brown L., Baranek G., Reznick J., Watson L., Crais E. The First Year Inventory: A longitudinal follow-up of 12-month-old to 3-year-old children. Autism. 2012;17:527–540. doi: 10.1177/1362361312439633.
    1. Robins D.L., Casagrande K., Barton M., Chen C.M., Dumont-Mathieu T., Fein D. Validation of the modified checklist for autism in toddlers, revised with follow- up (M-CHAT-R/F) Pediatrics. 2014;133:37–45. doi: 10.1542/peds.2013-1813.
    1. Matson J.L., Kozlowski A.M. The increasing prevalence of autism spectrum disorders. Res. Autism Spectr. Disord. 2011;5:418–425. doi: 10.1016/j.rasd.2010.06.004.
    1. Centers for Disease Control and Prevention Community Report of Autism 2020. Autism and Developmental Disabilities Monitoring Network. [(accessed on 26 March 2020)]; Available online: .
    1. Interagency Autism Coordinating Committee IACC Strategic Plan for Autism Spectrum Disorder. [(accessed on 20 June 2019)]; Available online:
    1. Dworzynski K., Ronald A., Bolton P., Happe F. How different are girls and boys above and below the diagnostic threshold for autism spectrum disorders? J. Am. Acad. Child. Adolesc. Psychiatry. 2012;51:788–797. doi: 10.1016/j.jaac.2012.05.018.
    1. Halladay A.K., Bishop S., Constantino J.N., Daniels A.M., Koenig K., Palmer K., Messinger D., Pelphrey K., Sanders S.J., Singer A.T., et al. Sex and gender differences in autism spectrum disorder: Summarizing evidence gaps and identifying emerging areas of priority. Mol. Autism. 2015;6:36–41. doi: 10.1186/s13229-015-0019-y.
    1. Happe F., Frith U. Annual research review: Looking back to look forward–changes in the concept of autism and implications for future research. J. Child. Psychol. Psychiatry. 2020;61:218–232. doi: 10.1111/jcpp.13176.
    1. Bernier R., Mao A., Yen J. Psychopathology, families, and culture: Autism. Child Adolesc. Psychiatr. Clin. N. Am. 2010;19:855–867. doi: 10.1016/j.chc.2010.07.005.
    1. Harrison A.J., Long K.A., Tommet D., Jones R.N. Examining the role of race, ethnicity, and gender on social and behavioral ratings within the Autism Diagnostic Observation Schedule. J. Autism Dev. Disord. 2017;47:2770–2782. doi: 10.1007/s10803-017-3176-3.
    1. Mandell D., Wiggins L., Carpenter L., Daniels J., DiGuiseppi C., Durkin M., Giarelli E., Morrier M.J., Nicholas J.S., Pinto-Martin J.A., et al. Racial/ethnic disparities in the identification of children with autism spectrum disorders. Am. J. Public Health. 2009;99:493–498. doi: 10.2105/AJPH.2007.131243.
    1. Liptak G.S., Benzoni L.B., Mruzek D.W., Nolan K.W., Thingvoll M.A., Wade C.M., Fryer G.E. Disparities in diagnosis and access to health services for children with autism: Data from the National Survey of Children’s Health. J. Dev. Behav. Pediatr. 2008;29:152–160. doi: 10.1097/DBP.0b013e318165c7a0.
    1. Lopez K., Reed J., Magaña S. Associations among family burden, optimism, services received and unmet need within families of children with ASD. Child. Youth. Serv. Rev. 2019;98:105–112. doi: 10.1016/j.childyouth.2018.12.027.
    1. Zuckerman K., Sinche B., Mejia A., Cobian M., Becker T., Nicolaidis C. Latino parents’ perspectives on barriers to autism diagnosis. Acad. Pediatr. 2014;14:301–308. doi: 10.1016/j.acap.2013.12.004.
    1. Murdoch J.D., State M.W. Recent developments in the genetics of autism spectrum disorders. Curr. Opin. Genet. Dev. 2013;23:301–315. doi: 10.1016/j.gde.2013.02.003.
    1. Yoo H. Genetics of autism spectrum disorder: Current status and possible clinical applications. Exp. Neurobiol. 2015;24:257–272. doi: 10.5607/en.2015.24.4.257.
    1. Centers for Disease Control and Prevention What is Autism Spectrum Disorder? [(accessed on 26 March 2020)]; Available online: .
    1. Li Y., Qiu S., Zhong W., Li Y., Liu Y., Cheng Y., Liu Y. Association between DCC polymorphisms and susceptibility to autism spectrum disorder. J. Autism Dev. Disord. 2020;50:3800–3809. doi: 10.1007/s10803-020-04417-3.
    1. Bai D., Yip B.H.K., Windham G.C., Sourander A., Francis R., Yoffe R., Glasson E., Mahjani B., Suominen A., Leonard H., et al. Association of genetic and environmental factors with Autism in a 5-country cohort. JAMA Psychiatry. 2019;76:1035–1043. doi: 10.1001/jamapsychiatry.2019.1411.
    1. Rylaarsdam L., Guemez-Gamboa A. Genetic causes and modifiers of autism spectrum disorder. Front. Cell Neurosci. 2019;13:385–400. doi: 10.3389/fncel.2019.00385.
    1. Lyall K., Croen L., Daniels J., Fallin M.D., Ladd-Acosta C., Lee B.K., Park B.Y., Snyder N.W., Schendel D., Volk H. The changing epidemiology of Autism Spectrum Disorders. Annu. Rev. Public Health. 2017;38:81–102. doi: 10.1146/annurev-publhealth-031816-044318.
    1. Modabbernia A., Velthorst E., Reichenberg A. Environmental risk factors for autism: An evidence-based review of systematic reviews and meta-analyses. Mol. Autism. 2017;8:1–16. doi: 10.1186/s13229-017-0121-4.
    1. Pew Research Center They’re Waiting Longer but U.S. Women Today More Likely to Have Children than a Decade Ago. [(accessed on 23 November 2018)]; Available online: .
    1. World Health Organization Preterm Birth. [(accessed on 23 November 2018)]; Available online: .
    1. Bettelheim B. The Empty Fortress: Infantile Autism and the Birth of the Self. Free Press; New York, NY, USA: 1967.
    1. Kanner L. Early infantile autism. J. Pediatr. 1944;25:211–217. doi: 10.1016/S0022-3476(44)80156-1.
    1. Hodge N. Reflections on diagnosing autism spectrum disorders. Disabil. Soc. 2005;20:345–349. doi: 10.1080/09687590500060810.
    1. Russell G., Norwich B. Dilemmas, diagnosis and de-stigmatization: Parental perspectives on the diagnosis of autism spectrum disorders. Clin. Child. Psychol. Psychiatry. 2012;17:229–245. doi: 10.1177/1359104510365203.
    1. Durkin M.S., Maenner M.J., Newschaffer C.J., Lee L.-C., Cunniff C.M., Daniels J.L., Kirby R.S., Leavitt L., Miller L., Zahorodny W., et al. Advanced parental age and the risk of autism spectrum disorder. Am. J. Epidemiol. 2008;168:1268–1276. doi: 10.1093/aje/kwn250.
    1. Lee B.K., McGrath J.J. Advancing parental age and autism: Multifactorial pathways. Trends Mol. Med. 2015;21:118–125. doi: 10.1016/j.molmed.2014.11.005.
    1. Roberts A.L., Lyall K., Hart J.E., Laden F., Just A.C., Bobb J.F., Koenen K.C., Ascherio A., Weisskopf M.G. Perinatal air pollutant exposures and autism spectrum disorder in the children of nurses’ health study II participants. Environ. Health Perspect. 2013;121:978–984. doi: 10.1289/ehp.1206187.
    1. Volk H.E., Lurmann F., Penfold B., Hertz-Picciotto I., McConnell R. Traffic-related air pollution, particulate matter, and autism. Arch. Gen. Psychiatry. 2013;70:71–77. doi: 10.1001/jamapsychiatry.2013.266.
    1. Dickerson A.S., Rahbar M.H., Bakian A.V., Harrington R.A., Pettygrove S., Kirby R.S., Durkin M.S., Han I., Moye L.A., Pearson D.A., et al. Autism spectrum disorder prevalence and associations with air concentrations of lead, mercury, and arsenic. Environ. Monit. Assess. 2016;188:407–423. doi: 10.1007/s10661-016-5405-1.
    1. U.S. Environmental Protection Agency National Air Quality: Status and Trends of Key Air Pollutant. [(accessed on 5 November 2019)]; Available online: .
    1. Srikantha P., Mohajeri M.H. The possible role of the microbiota-gut-brain axis in autism spectrum disorder. Int. J. Mol. Sci. 2019;20:2115. doi: 10.3390/ijms20092115.
    1. U.S. Department of Health and Human Services Healthy People 2020: Oral Health. [(accessed on 25 January 2017)]; Available online: .
    1. Stein L.I., Polido J.C., Lopez Najera S.O., Cermak S.A. Oral care experiences and challenges in children with autism spectrum disorders. Pediatr. Dent. 2012;34:387–391.
    1. Marshall J., Sheller B., Mancl L. Caries-risk assessment and caries status of children with autism. Pediatr. Dent. 2010;32:69–75.
    1. Marco E.J., Hinkley L.B., Hill S.S., Nagarajan S.S. Sensory processing in autism: A review of neurophysiologic findings. Pediatr. Res. 2011;69:48R–54R. doi: 10.1203/PDR.0b013e3182130c54.
    1. Stein L.I., Polido J.C., Cermak S.A. Oral care and sensory over-responsivity in children with autism spectrum disorders. Pediatr. Dent. 2013;35:230–235.
    1. Stein Duker L.I. Adapting Oral Care Protocols to Support Children with Sensory Sensitivities: Occupational Therapy and Dentistry. In: Nelson T., de Bord J.R., editors. Dental Care for Children with Special Needs: A Clinical Guide. Springer; Cham, Switzerland: 2019. pp. 77–98.
    1. American Academy of Pediatric Dentistry Behavior Guidance for the Pediatric Dental Patient. [(accessed on 23 November 2018)]; Available online:
    1. Casamassino P.S., Seale N.S., Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J. Dent. Educ. 2004;68:23–28. doi: 10.1002/j.0022-0337.2004.68.1.tb03730.x.
    1. Marshall J., Sheller B., Williams B., Mancl L., Cowan C. Cooperation predictors for dental patients with autism. Pediatr. Dent. 2007;29:369–376.
    1. McKinney C.M., Nelson T., Scott J.M., Heaton L.J., Vaughn M.G., Lewis C.W. Predictors of unmet dental need in children with autism spectrum disorder: Results from a national sample. Acad. Pediatr. 2014;14:624–631. doi: 10.1016/j.acap.2014.06.023.
    1. Alumran A., Almulhim L., Almohim B., Bakodah S., Aldossary H., Alakrawi Z. Preparedness and willingness of dental care providers to treat patients with special needs. Clin. Cosmet. Investig. Derm. 2018;10:624–631. doi: 10.2147/CCIDE.S178114.
    1. Dao L.P., Zwetchkenbaum S., Inglehart M.R. General dentists and special needs patients: Does dental education matter? J. Dent. Educ. 2005;69:1107–1115. doi: 10.1002/j.0022-0337.2005.69.10.tb04011.x.
    1. Inglehart M.R., Schneider B.K., Bauer P.A., Dharia M.M., McDonald N.J. Providing care for underserved patients: Endodontic residents’, faculty members’, and endodontists’ educational experiences and professional attitudes and behavior. J. Dent. Educ. 2014;78:735–744. doi: 10.1002/j.0022-0337.2014.78.5.tb05725.x.
    1. Isong I.A., Rao S.R., Holifield C., Iannuzzi D., Hanson E., Ware J., Nelson L.P. Addressing dental fear in children with autism spectrum disoredres: A randomized controlled pilot study using electronic screen media. Clin. Pediatr. 2014;53:230–237. doi: 10.1177/0009922813517169.
    1. Alamoudi N.M., Almushayt A.S., el Derwi D.A., Mirdad L.H., el-Ashiry E.A. Dentists’ perception of the care of patients with special health care needs in Jeddah, Saudi Arabia. J. Oral Hyg. Health. 2017;5:226–233. doi: 10.4172/2332-0702.1000226.
    1. Weil T.N., Inglehart M.R. Dentist education and dentist attitudes and behavior concerning patients with autism. J. Dent. Educ. 2010;74:1294–1307. doi: 10.1002/j.0022-0337.2010.74.12.tb05005.x.
    1. Jones D.M., Miller S.R. Effectiveness of an educational module on dental hygiene students’ attitudes towards persons with disabilities. J. Dent. Hyg. 2018;92:27–34.
    1. Weil T.N., Bagramian R.A., Inglehart M.R. Treating patients with autism spectrum disorder—SCDA members’ attitudes and behavior. Spec. Care Dent. 2011;31:8–17. doi: 10.1111/j.1754-4505.2010.00173.x.
    1. Formicola A.J., Bailit H.J., Weintraub J.A., Fried J.L., Polverini P.J. Advancing dental education in the 21st century: Phase 2 report on strategic analysis and recommendations. J. Dent. Educ. 2018;82:eS1–eS32. doi: 10.21815/JDE.018.109.
    1. American Academy of Pediatrics Engaging Patients and Families: What is a Medical Home? [(accessed on 4 November 2020)]; Available online: .
    1. Katkin J.P., Kressly S.J., Edwards A.R., Perrin J.M., Kraft C.A., Richerson J.E., Tieder J.S., Wall L. Guiding principles for team-based pediatric care. Pediatrics. 2017;140:e20171489. doi: 10.1542/peds.2017-1489.
    1. Lin C., Romley J.A., Carlin C. The relationship between the patient-centered medical homes, healthcare expenditures, and quality of care among children with special health care needs. Matern Child. Health J. 2018;22:1751–1760. doi: 10.1007/s10995-018-2572-4.
    1. Kuhaneck H.M., Chisholm E.C. Improving dental visits for individuals with autism spectrum disorders through an understanding of sensory processing. Spec. Care Dent. 2012;32:229–233. doi: 10.1111/j.1754-4505.2012.00283.x.
    1. Datt C., Travers M., Odell C. Improving the hospital experience for young people with autism. Arch. Dis. Child. 2017;102:A20.
    1. Chen H.-Y., Yang H., Chi H.-J., Chen H.-M. Physiological effects of deep touch pressure on anxiety alleviation: The weighted blanket approach. J. Med. Bio. Eng. 2012;33:463–470. doi: 10.5405/jmbe.1043.
    1. Hong E.Y., Cermak S.A., Stein Duker L.I. Occupational therapists’ distinct value in creating a sensory-friendly waiting room. Sis. Q. Pract. Connect. 2018;3:11–13.
    1. Autism Speaks Dental Guide. [(accessed on 26 March 2020)]; Available online: .
    1. Marion I.W., Nelson T.M., Sheller B., McKinney C.M., Scott J.M. Dental stories for children with autism. Spec. Care Dent. 2016;36:181–186. doi: 10.1111/scd.12167.
    1. Elmore J.L., Bruhn A.M., Bobzien J.L. Interventions for the reduction of dental anxiety and corresponding behavioral deficits in children with Autism Spectrum Disorders. J. Dent. Hyg. 2016;90:111–120.
    1. Mah J.W.T., Tsang P. Visual schedule system in dental care patients with Autism: A pilot study. Int. J. Clin. Pediatr. Dent. 2016;5:393–399. doi: 10.17796/1053-4628-40.5.393.
    1. Popple B., Wall C., Flink L., Powell K., Discepolo K., Keck D., Madamtzi M., Volkmar F., Shic F. Brief report: Remotely delivered video modeling for improving oral hygiene in children with ASD: A pilot study. J. Autism Dev. Disord. 2016;46:2791–2796. doi: 10.1007/s10803-016-2795-4.
    1. Narzisi A., Bondioli M., Pardossi F., Billeci L., Buzzi M.C., Buzzi M., Pinzino M., Senette C., Semucci V., Tonacci A., et al. “Mom let’s go to the dentist!” Preliminary feasibility of a tailored dental intervention for children with autism spectrum disorder in the Italian public health service. Brain Sci. 2020;10:444. doi: 10.3390/brainsci10070444.
    1. Grewal N., Sethi T., Grewal S. Widening horizons through alternative and augmentative communication systems for managing children with special care needs in a pediatric dental setup. Spec. Care Dent. 2015;35:114–119. doi: 10.1111/scd.12099.
    1. Cermak S.A., Stein Duker L.I., Williams M.E., Dawson M.E., Lane C.J., Polido J.C. Sensory adapted dental environments to enhance oral care for children with autism spectrum disorders: A randomized controlled pilot study. J. Autism Dev. Disord. 2015;45:2876–2888. doi: 10.1007/s10803-015-2450-5.
    1. American Occupational Therapy Association Occupational therapy practice framework: Domain and process. Am. J. Occup. 2014;68:S1–S48. doi: 10.5014/ajot.2014.682006.
    1. World Federation of Occupational Therapy Definition of Occupational Therapy. [(accessed on 26 March 2020)];2012 Available online: .
    1. Interactive Autism Network Ian research findings: Occupational therapy for autism. [(accessed on 2 November 2019)]; Available online: .
    1. American Occupational Therapy Association [AOTA] Occupational Therapy’s Role with Autism. [(accessed on 5 November 2019)]; Available online: .
    1. Stein Duker L.I., Florindez L.I., Como D.H., Tran C.F., Henwood B.F., Polido J.C., Cermak S.A. Strategies for success: A qualitative study of caregiver and dentist approaches to improving oral care for children with autism. Pediatr. Dent. 2019;41:4E–12E.
    1. Gray C. The New Social Story Book. 15th ed. Future Horizons; Arlington, TX, USA: 2015.
    1. Stein L., Lane C.J., Williams M.E., Dawson M.E., Polido J.C., Cermak S.A. Physiological and behavioral stress and anxiety in children with autism spectrum disorder during routine oral care. BioMed Res. Int. 2014;2014:1–10. doi: 10.1155/2014/694876.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever