Shell Shocking Impacts from PTSD a Peer-Reviewed Publication Written by Brittany Getz, RDH, Rey Gabriel Carandang, RDH, Samantha Harpenau, RDH, Emily R

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Shell Shocking Impacts from PTSD A Peer-Reviewed Publication Written by Brittany Getz, RDH, Rey Gabriel Carandang, RDH, Samantha Harpenau, RDH, Emily R. Holt, RDH, MHA, CDA, EFDA © Talashow | Dreamstime.com Talashow ©

Abstract Educational Objectives Author Profiles Post-traumatic stress disorder (PTSD) is a mental health During this course the participant will: Brittany Getz is a 2017 dental hygiene graduate from the University of Southern Indiana. She is looking forward to providing quality care in Colorado upon completion of licensure condition that may develop after experiencing or witnessing a 1. Describe the inflammatory process requirements. shocking, scary, or dangerous event. Individuals with PTSD have that evolves from PTSD. Rey Gabriel Carandang is a 2014 graduate of the University of Evansville for Exercise and demonstrated increased levels of stress hormones that initiate 2. Identify harmful coping mechanisms Sports Sciences, and a 2017 graduate of the University of Southern Indiana, majoring in an inflammatory response. The inflammatory response releases used when PTSD is untreated. Dental Hygiene. He is looking forward to providing quality care upon completion of licensure chemicals that assist in the breakdown of the periodontium. 3. Identify oral damage seen in patients requirements. Individuals with PTSD are more likely to create their own coping with PTSD and bruxism. Samantha Harpenau is a recent graduate from the University of Southern Indiana majoring mechanisms that may include tobacco use, alcohol abuse, and 4. Implement methods to manage in dental hygiene. She plans to provide clinical care upon completion of licensure requirements. poor diet. The oral effects of these unhealthy habits include PTSD and stress. Emily R. Holt, RDH, MHA, CDA, EFDA is a Clinical Associate Professor of Dental Hygiene at loss of tooth structure, gingival inflammation, xerostomia, the University of Southern Indiana. She also provides clinical care in Indiana and is a consultant periodontal disease, and oral cancer. Bruxism may occur due member of the Commission on Dental Competency Assessments. to the untreated stress. Replacing unhealthy PTSD coping Author Disclosures mechanisms with alternative methods aimed at reducing stress The authors have no commercial ties with the sponsors or the providers of the may improve systemic and periodontal inflammation. unrestricted educational grant for this course. INSTANT EXAM CODE 15171 Go Green, Go Online to take your course

Publication date: July 2017 Supplement to PennWell Publications Expiration date: June 2020

This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 2 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 02-4527-15171 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 2 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $49.00 for 2 CE credits. (10/31/2019) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives system makes the body more susceptible to infections and in- At the conclusion of this educational activity participants will be creases the risk for systemic inflammation.4 Stress causes the body able to: to remain in alert state, which causes release of prostaglandins, 1. Describe the inflammatory process that evolves from PTSD. cytokines, and T-cells.4 Prostaglandins and cytokines chemical 2. Identify harmful coping mechanisms used when PTSD is inflammatory mediators known to damage periodontal tissues.4 untreated. Prostaglandins cause vasodilation, increased vascular permeabil- 3. Identify oral damage seen in patients with PTSD and brux- ity, increased pain, bronchoconstriction, and fever.4 Vasodilation ism. and increased vascular permeability allow other chemokines, like 4. Implement methods to manage PTSD and stress. cytokines, to enter the tissues. Cytokines include interleukin-1 (Il-1) and tumor necrosis factor-alpha (TNF-a). Il-1 and TNF-a Abstract produce fever, an increased the need for sleep, and decrease ap- Post-traumatic stress disorder (PTSD) is a mental health condi- petite.4 Fever denatures healthy cells and stimulates damage.4 A tion that may develop after experiencing or witnessing a shock- decrease in appetite may limit the amount of nutrition provided to ing, scary, or dangerous event. Individuals with PTSD have the periodontium. The inflammatory response has the potential demonstrated increased levels of stress hormones that initiate to initiate or exacerbate gingival inflammation. The purpose of an inflammatory response. The inflammatory response releases this course is to identify negative oral effects from PTSD, deter- chemicals that assist in the breakdown of the periodontium. In- mine if PTSD can exacerbate gingival inflammation, and identify dividuals with PTSD are more likely to create their own coping methods to reduce inflammation associated with PTSD. mechanisms that may include tobacco use, alcohol abuse, and poor diet. The oral effects of these unhealthy habits include loss Oral Damage from Coping Mechanisms and Bruxism of tooth structure, gingival inflammation, xerostomia, periodon- Individuals living with PTSD find methods to cope with their tal disease, and oral cancer. Bruxism may occur due to the un- emotional pain. Unfortunately, several of these coping mecha- treated stress. Replacing unhealthy PTSD coping mechanisms nisms are harmful to the body. Tobacco use, alcohol abuse, with alternative methods aimed at reducing stress may improve poor diet, and bruxism are common concerns within those with systemic and periodontal inflammation. PTSD.3 A study performed by Gavrieli et al. found that those with PTSD engage in smoking cigarettes more frequently, expe- Background rience more sleep disturbances, exercise less frequently, and de- Posttraumatic stress disorder (PTSD) is a mental health condition velop poor eating habits more often than those without PTSD.5 that develops after a life-threatening event. This includes, but is Poor psychological health places an individual at an increased not limited to natural disasters, military combat, motor vehicle risk for cardiometabolic disorders such as coronary heart disease, accidents, death of a loved one, abuse, and sexual assault.1 Only a hypertension, type II diabetes mellitus, and obesity.5 small portion of those who have experienced a traumatic event will Most PTSD victims use tobacco.6 Military deployment is develop PTSD. About 7-8% of the population will have PTSD at associated with smoking initiation particularly among those with some point in their lives.1 Approximately 10% of women develop prolonged deployments, multiple deployments, or combat expo- PTSD sometime in their lives compared to 4% of men.1 The preva- sure.6 Nicotine stimulates the release of dopamine within seconds lence of PTSD within those who have served in the military varies upon entering the body.7 Dopamine gives the body a feeling of according to when the individual was in active duty. For example, reward and relaxation.7 The act of smoking tobacco temporarily the prevalence of PTSD for Vietnam veterans is 30.9% of men and increases positive emotions and provides short-term relief from 8.1% of women while Operation Iraqi Freedom veterans have a stress and anxiety.7 Smoking tobacco has been found to play a 12.8% prevalence of PTSD.2 Before the term PTSD was coined, critical role in the onset, progression, and negative treatment military personnel who experienced psychological disturbance outcomes of periodontal disease.7 The initiation of periodontal from war-time situations were said to have shell-shock. disease in smokers is multifactorial. Nicotine constricts the blood Symptoms of PTSD are grouped into four categories. Two vessels, making it difficult for nutrients, oxygen, and inflamma- symptoms related to arousal and reactivity must be present to re- tory mediators to reach the periodontal tissues.7 Tissues deprived ceive a diagnosis.3 These include being easily startled, feeling tense, of oxygen and nutrients are more susceptible to inflammation difficulty sleeping, and angry outbursts.3 Physiological responses and destruction.7 Healing is compromised when blood flow is from arousal and reactivity symptoms mimic the fight or flight limited.7 Tobacco use may impair the function of the salivary response. Arousal and reactivity symptoms are constantly present glands leading to xerostomia.7 Xerostomia works synergistically in those with PTSD.3 These symptoms elicit the feeling of being with reduced blood flow to allow the initiation and progression of stressed and angry. If these symptoms are present, it is difficult to periodontal inflammation.7 Saliva is an antimicrobial agent.7 Bac- perform daily tasks, such as concentrating, sleeping, or eating.3 teria flourish in its absence, triggering inflammation to begin.7 Studies support that stress disrupts homeostasis of the body, Tobacco smokers have 50% more alveolar bone loss compared leading to alteration of the immune system.4 A lowered immune to non-smokers.7 There is also a positive correlation between the

2 www.DentalAcademyOfCE.com amount of cigarettes smoked per day and marginal bone loss.7 The where a positive correlation between oxidative stress and severe presence of calculus increases as the amount of cigarettes smoked periodontal disease was found.15 per day increases.7 Calculus is a periodontal irritant capable of A stressful lifestyle is a significant risk factor for bruxism.16 harboring organisms that cause gingival inflammation. Emotional stress is considered the main triggering factor of Individuals with untreated PTSD are likely to consume al- bruxism.16 Smoking and alcohol consumption are also causative cohol.8 Up to 75% of those who have survived abusive or violent factors of bruxism.16 The American Academy of Orofacial Pain trauma report having a drinking problem.8 This is unfortunate defines bruxism as a nocturnal parafunctional activity that in- in many ways. Frequent tissue contact with alcohol is known to cludes unconscious clenching, grinding, or bracing of the teeth.16 increase the risk for oral cancer.9 The American Cancer Society It is the third most common sleep disorder behind snoring and recommends no more than 2 drinks per day for men and 1 drink sleep talking.16 As mentioned before, sleep disturbances are one of a day for women to reduce the risk of developing oral cancer.9 the diagnostic symptoms classically found with PTSD. Bruxism Alcohol abuse is considered as having more than the daily lim- can also occur while awake when the brain subconsciously tries its listed above. Alcohol abuse can lead to alcohol use disorder to find the perfect functional occlusion. If the habit continues (AUD). To be diagnosed with AUD, individuals must have 2 for extended periods of time, it may lead to occlusal trauma and of the 11 criteria during the same 12-month period.10 Some of periodontal breakdown.16 Bruxism is not a direct causative factor these criteria include drinking more or longer than intended, fail- of periodontal disease, but can exacerbate periodontal destruc- ing to cut down on drinking when wanting to, craving alcohol, tion if periodontal tissues are already compromised.16 Symptoms drinking interferes with other life activities, drinking alcohol associated with bruxism include soreness in the joint, facial pain, replaces once enjoyable activities, drinking alcohol causes you hypersensitive teeth, attrition, and hearing loss.16 Severe attrition to get injured drinking alcohol even though it causes you to feel due to bruxism in a patient with PTSD can be seen in Figures depressed or anxious, developing tolerance to alcohol, exhibit- A, B, and C. This patient reported a high incidence of nocturnal ing withdrawal symptoms when alcohol wears off.10 AUD may bruxism associated with frequent episodes of nightmares. His make symptoms of PTSD worse by increasing irritability and bruxism is so severe that several teeth fractured off while sleep- depression.7 Alcoholics have 18-27% higher risk of acquiring ing. Headaches triggered by bruxism are a daily problem for this periodontal disease than non-drinkers.7 Alcohol can lower the patient. His headaches are managed with medication. host’s immune response by destroying neutrophil, macrophage, Figure A and T-cell functions.7 This may lead to uncontrolled growth of biofilm and gingival inflammation. Dietary choices of alcoholics are frequently high in refined carbohydrates and fats, providing scant nutrition for periodontal tissues.11 Dietary choices of those with PTSD are also frequently less than optimal. Those with PTSD consume more soda and fast food and less fruits compared to individuals without PTSD.5 A study performed by Farr et al. showed that the severity of PTSD is associated with an increase in obesity, body mass index, type II diabetes mellitus, and cardiometabolic diseases.12 These conditions have been linked to the incidence and exacerbation of chronic periodontitis. They are inflammatory conditions which can be initiated or exacerbated by consumption of pro-inflammatory foods. Some pro-inflammatory foods include sugar, refined carbohydrates, mono-sodium glutamate (MSG), gluten, casein, aspartame, saturated fat, trans fat, omega-6 fatty acids, alcohol, Figure B red meat, and processed meat.13 Soda and fast food qualify as pro- inflammatory foods. A poor diet may lead to higher cholesterol levels and a decrease in metabolism, which may increase additional stress to the heart. 5 Dursun et al. compared the periodontal status of obese and lean women and measured the oxidant status levels in gingival crevicular fluid and blood serum.14 The results of the study revealed that although the obese women were healthy overall, they showed indications of early signs of periodontal disease compared to the lean women.14 The increased levels of oxidative stress produced by obesity is to blame for this.14 This study can be supported by research performed by D’Aiuto et al.

www.DentalAcademyOfCE.com 3 Figure C may help the facial muscles relax.11 Oral appliances, such as an acrylic night guard, are also recommended for nocturnal bruxism. These oral appliances help displace the pressure that is applied on the teeth when the individual bruxes and prevents attrition.11 Nutritional counseling should be incorporated in care for the patient with PTSD. The aim is to improve the diet with more anti-inflammatory foods. Foods containing vitamins A, C, D, and E have been noted for their ability to reduce inflammation.17 Consuming fruits and vegetables may reduce the risk of cardiometabolic syndrome.18

Conclusion PTSD promotes harmful lifestyle habits, such as poor diet, tobacco use, and alcohol abuse. These poor lifestyle habits, Symptom Relief and Stress Management metabolic disorders, and parafunctional habits have a direct Symptoms of PTSD can be relieved through psychotherapy and negative effect on the periodontal tissues and cause gingival in- prescribed medications.3 Examples of psychotherapy include flammation. Uncontrolled chronic stress also increases gingival cognitive processing therapy, prolonged exposure therapy, inflammation. Managing PTSD with medications and psycho- and eye movement desensitization and reprocessing therapy.1 therapy and incorporating stress reduction techniques may Selective serotonin reuptake inhibitors (SSRIs) and serotonin- alleviate PTSD symptoms and have the potential to decrease norepinephrine reuptake inhibitors (SNRIs) are antidepres- or prevent gingival inflammation. Incorporating a healthier sant medications proven to be effective at relieving symptoms diet and cessation of tobacco and alcohol can lead to healthier of PTSD.1 Prazosin is an alpha-1 blocker that can be used to outcomes for those with PTSD. decrease nightmares related to the trauma.1 Positive stress management is key for individuals with PTSD. Exercise and References social interaction are examples of positive stress management 1. U.S. Department of Veterans Affairs. PTSD: National interventions. By managing stress, individuals with PTSD are Center for PTSD. http://www.ptsd.va.gov/public/ptsd- less likely to depend on the psychological effects from use of overview/basics/what-is-ptsd.asp. Updated October 4, tobacco and alcohol. Bruxism frequency may be reduced with 2016. Accessed April 21, 2017. stress management. Systemic inflammation can be reduced or 2. Gradus J. U.S. Department of Veteran Affairs. eliminated through stress management. Epidemiology of PTSD. https://www.ptsd.va.gov/ Discontinuation of tobacco products will halt periodontal professional/PTSD-overview/epidemiological-facts- damage from nicotine and tobacco. Cessation begins by setting ptsd.asp. Updated March 30, 2017. Accessed April 21, a quit date. Next, find a tobacco cessation product that suits the 2017. individual’s needs to provide a transition to a tobacco-free life- 3. National Institute of Mental Health. Post-Traumatic style. Oral tissues begin to heal after tobacco cessation because Stress Disorder. https://www.nimh.nih.gov/health/ proper circulation of blood and nutrients returns. Salivary flow topics/post-traumatic-stress-disorder-ptsd/index.shtml. returns to normal levels upon cessation of tobacco products.11 Updated February 2016. Accessed April 2017. Reducing alcohol intake may decrease systemic inflam- 4. DeLong L, Burkhart N. General and Oral Pathology for mation and strengthen the body’s immune system.11 This may the Dental Hygienist. 2nd ed. Wolters Kluwer Health; assist in the repair of the periodontal tissues. Alcohol cessa- 2012. tion is proven to reduce depression, which is a comorbidity of 5. Gavrieli A, Farr O, Davis C, Crowell J, Mantzoros C. PTSD.11 If treating a patient who abuses alcohol, it is prudent Early life adversity and/or posttraumatic stress disorder to implement routine oral cancer screenings to detect abnormal severity are associated with poor diet quality, including tissue changes. consumption of trans fatty acids, and fewer hours of A primary step to discontinue bruxism is to eliminate caus- resting or sleeping in a US middle-aged population: A ative factors, such as cessation of tobacco and alcohol in addition cross-sectional and prospective study. Metabolism. 2015; to reducing caffeine intake.16 Stress reduction techniques allow 1597-1610. the individual to manage stress in a positive manner, which may 6. de Silva V, Jayasekera N, and Hanwella R. Smoking reduce the frequency of bruxism. Symptoms from bruxism are Among Troops Deployed in Combat Areas and its managed by applying heat and massage to the affected tissues. Association with Combat Exposure Among Navy Applying a warm press and incorporating massage techniques Personnel in Sri Lanka. Substance Abuse Treatment,

4 www.DentalAcademyOfCE.com Prevention, and Policy. 2012; 7:27. Author Profiles 7. Chatzopoulos G. Smoking, Smokeless Tobacco, and Alcohol Consumption as Contributing Factors to Brittany Getz is a 2017 dental hygiene Periodontal Disease. Northwest Dentistry. 2016; 95(1): 37- graduate from the University of Southern 41. Indiana. She is looking forward to providing 8. U.S. Department of Veterans Affairs. PTSD and Problems quality care in Colorado upon completion of with Alcohol Use 2015. http://www.ptsd.va.gov/public/ licensure requirements. problems/ptsd-alcohol-use.asp. Updated August 13, 2015. Accessed September 26, 2016. 9. The American Cancer Society. Alcohol Use and Cancer. Rey Gabriel Carandang is a 2014 graduate https://www.cancer.org/cancer/cancer-causes/diet- of the University of Evansville for Exercise physical-activity/alcohol-use-and-cancer.html. Revised and Sports Sciences, and a 2017 graduate of April 7, 2017. Accessed June 16, 2017. the University of Southern Indiana, major- 10. The National Institute on Alcohol Abuse and Alcoholism. ing in Dental Hygiene. He is looking forward Alcohol Use Disorder. https://www.niaaa.nih.gov/ to providing quality care upon completion of alcohol-health/overview-alcohol-consumption/alcohol- licensure requirements. use-disorders. Accessed June 20, 2017. 11. Darby M, Walsh M. Dental Hygiene: Theory and Samantha Harpenau is a recent graduate Practice. 4th ed. Elsevier/Saunders; 2015. from the University of Southern Indiana 12. Farr O, Ko B, Joung K, et al. Posttraumatic Stress majoring in dental hygiene. She plans to Disorder, Alone or Additively with Early Life Adversity is provide clinical care upon completion of Associated with Obesity and Cardiometabolic Risk. Nutr licensure requirements. Metab Cardiovasc Dis. 2015; 25(5) 479-488. 13. Arthritis Foundation. Food Ingredients and Inflammation. http://www.arthritis.org/living-with-arthritis/arthritis- Emily R. Holt, RDH, MHA, CDA, diet/foods-to-avoid-limit/food-ingredients-and- EFDA is a Clinical Associate Professor inflammation-2.php. Accessed October 3, 2016. of Dental Hygiene at the University of 14. Dursun E, Akalin F, Genc T, Cinar N, Erel O, Yildiz B. Southern Indiana. She also provides clinical Oxidative Stress and Periodontal Disease in Obesity. care in Indiana and is a consultant member Medicine. 2016; 95(12): e3126. of the Commission on Dental Competency 15. D'Aiuto F, Nibali L, Parkar M, Patel K, Suvan J, Donos Assessments. N. Oxidative Stress, Systemic Inflammation, and Severe Periodontitis. J Dent Res. 2010; 89(11):1241-1246. Author Disclosures 16. Murali R, Rangarajan P, Mounissamy A. Bruxism: The authors have no commercial ties with the sponsors or the Conceptual Discussion and Review. Journal of Pharmacy providers of the unrestricted educational grant for this course. & Bioallied Sciences. 2015; 7: S265-S270. 17. Gehrig J, Willmann D. Foundations of Periodontics for the Dental Hygienist. 4th ed. Wolters Kluwer; 2016. 18. Esmaillzadeh A, Kimiagar M, Mehrabi Y, Azadbakht L, Hu F, Willett W. Fruit and vegetable intakes, C-reactive protein, and the metabolic syndrome. Am J Clin Nutr. 2006; 84:1489-1497. Notes

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Questions

1. Each of the following is an example a. It releases acetylcholine 14. Distribution of vital nutrients to of an arousal and reactivity symptom b. It forces the muscles to relax periodontal tissues can be restricted that accompanies PTSD EXCEPT c. It increases blood flow to the tissues to relieve in those with PTSD because of each one. Which one is the EXCEP- inflammation of the following EXCEPT one. d. It prevents occlusal trauma TION? Which one is the EXCEPTION? a. Feeling tense 8. Alcoholics have a ______higher risk a. Production of cytokines b. being easily startled of acquiring periodontal disease than b. Poor dietary habits c. nightmares non-drinkers. c. Smoking tobacco d. angry outbursts a. 9-15% d. Medications 2. The presence of calculus increases as b. 18-27% 15. Smoking tobacco releases the amount of ______increases. c. 26-31% ______, which stimulates a. smoking tobacco d. 34-48% positive feelings. b. alcohol ingestion 9. When an individual with PTSD a. dopamine c. bruxism positively manages stress, he/she is b. serotonin d. fat intake also more likely to: c. norepinephrine d. cortisol 3. Which of the following represents a. get angry easily. the current prevalence rate of PTSD b. feel upset. 16. Tobacco smokers have ____ more in the USA? c. quit smoking tobacco. alveolar bone loss than non-smokers. a. 1-4% d. grind teeth more often. a. 10% b. 7-8% 10. Each of the following are common b. 20% c. 15-20% c. 40% in the PTSD population EXCEPT d. 50% d. 35-39% one. Which one is the EXCEP- 4. Alcohol cessation is proven to TION? 17. Alcohol abuse may make symptoms reduce: a. Poor diet of PTSD worse by increasing: a. tobacco use. b. Cigarette smoking a. tobacco use. b. nightmares. c. Alcohol abuse b. irritability and depression. c. flashbacks. c. gingival inflammation. d. Gambling d. depression. d. avoidance patterns. 11. Coronary heart disease, hyperten- 5. Which of the following inflamma- 18. Each of the following is a symptom sion, type II diabetes mellitus, and of bruxism EXCEPT one. Which tory mediators found in periodontal obesity are directly linked to: disease is also present due to one is the EXCEPTION? a. poor psychological health. a. Soreness in the tongue prolonged stress? b. smoking. b. Facial pain a. Lipopolysaccharide c. alcohol abuse. c. Hypersensitive teeth b. Histamine d. bruxism. d. Attrition c. Cytokines 12. Stress, alcohol use, and cigarette d. Serotonin 19. Which of the following classes of smoking are causative factors for: medication is used to manage the 6. Each of the following is an anti- a. depression. inflammatory component found in symptoms of PTSD? b. poor sleeping habits. a. Narcotic food EXCEPT one. Which one is c. bruxism. b. Antidepressant the EXCEPTION? d. anxiety. c. Antianxiety a. Calcium 13. How common is alcohol abuse in d. Stimulant b. Vitamin A persons who have survived abusive or c. Vitamin C 20. Consuming fruits and vegetables d. Vitamin E violent trauma? may reduce the risk of: a. 25% a. depression. 7. What effect does massage have on b. 50% b. PTSD. the facial muscles when an individual c. 75% c. bruxism. bruxes? d. 100% d. cardiometabolic syndrome.

6 www.DentalAcademyOfCE.com INSTANT EXAM CODE 15171 ANSWER SHEET Shell Shocking Impacts from PTSD

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