Original article

Candida albicans adhesion on reinforced polymethylmethacrylate

denture resin: effect of fibre architecture and exposure to saliva

Buket Akalın-Evren1, Yasemin Kulak-Özkan1, Mutlu Özcan2 and Tanju Kadir3

1
Department of Prosthodontics, Faculty of Dentistry, University of Marmara, Istanbul, Turkey; 2Center for Dental and Oral Medicine, Clinic
for Fixed and Removable Prosthodontics and Dental Materials Science, Dental Materials Unit, University of Zurich, Zurich, Switzerland;
3
Department of Microbiology, Faculty of Dentistry, University of Marmara, Istanbul, Turkey

Gerodontology 2012; doi: 10.1111/ger.12024

Candida albicans adhesion on reinforced polymethylmethacrylate denture resin: effect of fibre
architecture and exposure to saliva
Background and objectives: Fiber-reinforced composites (FRC) are used to reinforce the prosthetic
and restorative appliances. This may result in the exposure of the FRCs which may affect the adherence
of microorganisms. This study evaluated the adhesion of Candida albicans to a denture base resin
(N = 48), reinforced with E-glass FRCs with different architectures [unidirectional (n = 16) and woven
(n = 16)], when exposed to either saliva or distilled water.
Materials and methods: Specimens without FRC reinforcement served as control (n = 16). After fiber
surfaces were exposed, half of the specimens (n = 8/per group) were treated with saliva, the other half
was stored in distilled water prior to C. albicans adhesion. The adhered microorganisms were counted
under an optical microscope and the data were analyzed.
Results: When exposed to distilled water or saliva, specimens with unidirectional (5403.4 cells/cm2 and
5013.4 cells/cm2, respectively) (p = 0.202), woven fibers (4053.5 cells/cm2 and 3726.6 cells/cm2, respec-
tively) (p = 0.283) and specimens without fibers (2250 cells/cm2 and 2006.8 cells/cm2, respectively)
(p = 0.423) showed C. albicans adhesion, being not significant. In general, all the specimens exposed to
saliva showed 3582.2 cells/cm2 C. albicans adhesion, while specimens exposed to distilled water showed
3902 cells/cm2 C. albicans adhesion, yet being not significant (p = 0.436). Regarding fiber type, C. albicans
adhesion was significantly affected by the exposed FRC architecture with more favorable results for
woven fibers (p < 0.001).
Conclusion: Polymethylmethacrylate without FRCs collected less C. albicans. The presence of saliva
seems to reduce the adhesion.

Keywords: Acrylic resin, Candida, Saliva

Accepted 10 October 2012

of FRC materials became a routine application in

Introduction
Since its introduction in 1937, polymethylmethac-
rylate (PMMA) has been the most commonly
used denture base material because of its easy
handling and low cost1. Despite their popularity,
the mechanical strength of denture resins is not
sufficient2. The longevity of the removable den-
tures is highly affected either due to fractures3,4
or microbial colonisation5,6.
One approach to reinforce such materials is
the incorporation of the fibre-reinforced compos-
ites (FRC) during processing dentures7,8. The use
frameworks of anterior or posterior direct and
indirect fixed-dental-prosthesis (FDP)9,10, posts11,
periodontal splints12 and removable dentures13.
All the commonly used FRC types in clinical
dentistry are carbon, aramid, ultra-high-molecu-
lar weight polyethylene and R-, S- or E-glass14–
18
. Among these FRC types, glass fibres are gen-
erally preferred for reinforcement of dentures
because of their superior biological properties
and the possibility of their silanization and
impregnation with resin monomers19. Preim-
pregnation of glass fibres particularly increases

© 2012 The Gerodontology Society and John Wiley & Sons A/S 1
2 B. Akalın-Evren et al.

wettability and adhesion of the relatively high-
viscose denture base resins20,21.
Candida albicans is the most common virulent
opportunistic fungal pathogen in the oral cavity,
and therefore, in the case of removable dentures,
it is considered as the primary microbial factor
playing a role in denture stomatitis22–25. The inci-
dence of denture stomatitis has been shown to
range between 27 and 65% in clinical stud-
ies22,23,25. The ability of C. albicans adhesion to
polymeric surfaces is usually as a consequence
of London, van der Waals and electrostatic
forces26,27. In fact, these forces are only important
in the initial adherence phase of the yeasts. The
presence of saliva, serum and other microorgan-
isms as well as differences in surface topography
of the polymers may further contribute to their
adhesion that surely makes the adherence process
more complicated28–30.
In clinical applications, FRC materials are placed
at the tensile side of the dentures or FDPs, and
they are covered with either particulate filler
composites or denture base polymers. During
placement of such reconstructions in the mouth,
usually adjustments are needed that may result in
the exposure of the FRCs to oral mucosa, saliva
and microorganisms27,31,32. Adhesion of C. albicans
and other yeasts on denture base polymers has
been widely studied in dentistry30,33,34. Reinforce-
ment of denture bases with FRCs having semi-
interpenetrating polymer matrix (IPN) has been
studied in vitro and clinically proven to perform
well from the mechanical aspect13,30. However,
information on the microbiological perspective to
FRC reinforced denture resins is scarce27,31,32.
Fibre-reinforced composite materials are avail-
able in different architectures namely, unidirec-
tional, woven (bidirectional), prepegs or fibre mat.
When total reinforcement is needed for the remov-
able dentures, the entire denture base is reinforced
Table 1 Materials tested in the study.
with woven FRCs but for partial reinforcement,
only the weakest part of the PMMA is reinforced
using unidirectional FRCs35,36. Hence, both types
of materials are indicated. It can be hypothesised
that due to larger surface area covering the PMMA,
woven FRCs in the form of a net would lead to
more microbial adhesion when compared with
unidirectional ones. The objectives of this in vitro
study therefore, were (i) to investigate the adhe-
sion of C. albicans to a heat-polymerised denture
base resin, reinforced with E-glass FRCs having dif-
ferent architectures and (ii) to study the effect of
contamination with either distilled water or saliva
on the adherence levels.
Materials and methods
Specimen preparation
The brand names, abbreviations, types, chemical
compositions, batch numbers and manufacturers
of the materials used for the experiments are
listed in Table 1. A heat-polymerised denture base
resin (Paladent 20, Heraeus Kulzer GmbH&Co.,
Hanau, Germany) was reinforced using either
unidirectional (everStick C&B, StickTech Ltd,
Turku, Finland) or woven (everStick Net, Stick-
Tech Ltd, Turku, Finland) E-glass FRCs.
Pink modelling wax (N = 48, n = 16 per group),
(10 9 10 9 1 mm) (Dental Wax, Cavex Set Up
Modelling Regular, Cavex, Harleem, the Nether-
lands) was placed in dental plaster (Moldano, He-
raeus Kulzer GmbH&Co., Hanau, Germany) in a
two-part mould using a standard dental flask. The
moulds were prepared in such a manner that both
parts of the moulds were filled with vacuum mixed
hard dental plaster under vibration (Bego GmbH &
Co., Bremen, Germany). After the boil out process,
the wax was eliminated under running hot water,
and plaster surfaces were sealed with two coats of

Brand name and

Abbreviations Type Chemical composition Batch number Manufacturer

Paladent 20 Heat-polymerised Powder: Polymethylmethaxrylate A1333B-2 Heraeus Kulzer

(PMMA) polymethylmethacrylate Liquid: Methylmethacrylate, 012121 GmbH&Co.,
dimethacrylate Hanau, Germany
everStick Unidirectional PMMA, bis-GMA impregnated, 2031119-EK-027 StickTech Ltd.
C&B (U) E-glass fibre silanised E-glass fibres Turku, Finland
everStick Bidirectional PMMA, bis-GMA impregnated, 2031119-EK-027 StickTech Ltd.
Net (W) (woven) silanised bidirectional weave Turku, Finland
E-glass fibre E-glass fibre

PMMA, Polymethylmethacrylate; bis-GMA, Bisphenol A diglycidylmethacrylate; TEGDMA, Triethyleneglycol

dimethacrylate.

© 2012 The Gerodontology Society and John Wiley & Sons A/S

isolation medium (Isolant CMS, Dentsply, Surrey,
UK) using a clean brush each time.
Specimen preparation with FRCs
The unidirectional E-glass FRC was cut with ster-
ile straight scissors into 10 mm length through
the silicon mould where they were stored. They
were then placed into the spaces in the flask with
special metal hand instruments only. FRC was
flared to cover the 100 mm² space. As this FRC
was readily impregnated, no additional adhesive
was applied.
The woven E-glass FRCs were obtained in
square sheets (100 mm²) and placed in the same
manner as described above. The denture resin
was placed in the flasks and heat-polymerised
according to the manufacturer’s instructions.
After deflasking, the specimens were finished
with a rotary instrument (Kavo, Kavo Dental
GmbH&Co. KG, Biberach, Germany) using a fine
grit cross-cut tungsten carbide bur (Komet, Paris,
France; Batch no. H79EFL), and the plaster side
of all the specimens, where the FRCs were placed,
were roughened using 800- and 2400-grit silicon
carbide abrasive papers (3M ESPE, St Paul, MN,
USA) in sequence under water cooling until the
fibre-rich regions were exposed. As all of the
fibres (both unidirectional and woven) were
placed on the plaster side of the specimens, they
were easily exposed after a few abrasions and
could be seen clearly with naked eye. Before
treating with saliva, surface roughness should be
measured to make sure that all specimen surfaces
had similar roughness. This is one of the limita-
tions of our study. All test specimens were stored
in distilled water for 24 h at 37°C. They were
then rinsed in 70% ethanol for 5 min in sterile
glass beakers and placed in phosphate-buffered
saline (PBS) solution (pH 7.3) (Delta Medical and
Chemical Materials Trading, Aurora, IL, USA)
prior to treating with saliva. The specimens were
randomly divided into two groups. While half of
each group was kept in distilled water, the other
half was treated with saliva.
Collection of saliva
Unstimulated mixed saliva was collected from five
healthy individuals (aged between 30 and 40, and
having 28–32 teeth) using a collection cup. The
donors had not taken any medication, and they had
no active periodontal disease or active caries. The
collected saliva was purified in centrifuge (Function
Line, Labofuge 400R, Heraeus Instruments, Hanau,
© 2012 The Gerodontology Society and John Wiley & Sons A/S
Candida albicans adherence on fiber-reinforced PMMA 3
Germany) at 2400 g for 15 min and kept at
20°C
prior to the experiment. Specimens were pretreated
with the saliva solution at room temperature for
10 min to obtain a pellicle on the surface.
Preparation of the Candida albicans
Candida albicans strain was obtained (Istanbul Uni-
versity, Faculty of Medicine, Department of
Microbiology) and incubated on Sabouraud dex-
trose agar slope at 37°C for 48 h. The culture was
centrifuged (Function Line, Labofuge 400R) at
1750 g for 10 min, and the resultant cell pellet
was washed twice with PBS solution. Finally, a
yeast suspension of approximately 106 C. albicans
per ml was prepared37,38.
Contamination procedure
Specimens (n = 8) from each group were placed
into sterile experiment cups that were filled with
30 ml C. albicans suspension and incubated at 37°
C for 1 h. They were then washed with PBS solu-
tion to remove the non-adherent cells. Following
the washing procedure, the specimens were placed
in methanol for the fixation of the adherent cells
and dyed with sterile methylene blue for the
microscopical evaluations. The dyed specimens
were washed again with PBS, allowed to dry in air
for 30 min. They were then kept is sterile experi-
ment cups until microscopical evaluation37,38.
Microscopical evaluation
C. albicans contaminated specimens were examined
under an optical microscope (Olympus CH2,
Olympus Optical Co., Ltd., Tokyo, Japan) at a
magnification of 9100. Number of cells was
counted at 30 microscopical areas (1 microscope
area = 0.25 mm²)38 by one researcher. For each
specimen in total an area of 7.5 mm² (30 9
0.25 mm²) was examined. The total number of
cells (C) on each specimen (10 mm 9
10 mm = 100 mm² = 1 cm2) was calculated by
the following formula:
100mm2  number of cells in 7:5mm2
C¼
7:5mm2
Statistical analysis
The statistical analysis was performed with the
SPSS software package (version 11.5; SPSS,
Chicago, IL, USA). Mean ranks obtained from
adherence assay were evaluated with two-way
4 B. Akalın-Evren et al.

ANOVA. As significant differences were found When exposed to distilled water or saliva, speci-
between or within groups, Least Significant Dif- mens with unidirectional (5403.4 cells/cm2 and
ference (LSD) post hoc tests were used to deter- 5013.4 cells/cm2, respectively) (p = 0.202), woven
mine the differences. Furthermore, one-way fibres (4053.5 and 3726.6 cells/cm2, respectively)
ANOVA was used to distinguish the differences (p = 0.283) and specimens without fibres (2250
between distilled water and saliva-treated groups. and 2006.8 cells/cm2, respectively) (p = 0.423)
In all comparisons, statistical significance was showed C. albicans adhesion, being not significant.
declared if the p-value was <0.05. In general, all the specimens exposed to saliva
showed 3582.2 cells/cm2 C. albicans adhesion,
while specimens exposed to distilled water
Results showed 3902 cells/cm2 C. albicans adhesion, yet
Fibre-reinforced composite architecture showed a being not significant (p = 0.436).
significant (p < 0.001) influence on C. albicans Optical microscope images showed rougher sur-
adhesion on the specimens (ANOVA, LSD) but the faces with unidirectional FRC than with woven
contamination media did not (p = 0.072) (Table 2). ones. C. albicans adhesion was often in clusters
All of the specimens showed C. albicans adhesion at spread on the surface (Fig. 1a–c).
varying levels. Mean ranks of C. albicans adherence
(number of adhered cells/cm2) per group are pre-
sented in Table 3.
Discussion
Unidirectional FRC reinforced specimens showed Adhesion and colonisation of microorganisms is
significantly more C. albicans adhesion (5208.37 the primary step in the development of common
cells/cm2) than those with woven FRC (3890.06 oral infectious diseases such as denture stomatitis.
cells/cm2) (p < 0.001). Therefore, C. albicans, being the most common
virulent opportunistic fungal pathogen in the oral
cavity, that is often associated with denture sto-
Table 2 Results of analysis of variance for the experi-
matitis5,22, was chosen as a model organism for
mental conditions.
this study.
Although a great plethora of FRC materials are
Source DF SS MS F value p-value*
available, they all present some limitations com-
Fibre type 2 76415417 38207708 105546 0.0000 pared with E- or S- and R-glass ones with which
Storage 1 1229120 1229120 3395 0.072 good adhesion to matrix polymers could be
medium achieved8. One of the major problems in using
Interaction 2 43351 21675 0060 0.942 FRCs for fabricating dentures is the poor impreg-
Residual 42 15204049 362001 nation of fibres with the dough of the denture
Total 48 765112305 base polymer19. Poorly impregnated regions
*p < 0.05. increase the water absorption, thereby reducing
the mechanical properties of the fibre-reinforced
structure19,21. Another problem is with the impro-
Table 3 Mean ranks of Candida albicans adherence per dispersion of FRCs through the dough that
(number of adhered cells/cm2) on the specimens. leads to latent discoloration due to penetration of
oral fluids and microorganisms into the voids15.
Contamination medium The use of preimpregnated FRCs with adhesive
resins could overcome this problem, while at the
Experimental Distilled Water Saliva same time, higher flexural strength and higher
groups (n = 8/per group) (n = 8/per group)
fibre volume could be achieved20. For these rea-
PMMA 2250 (417.5) 2006.8 (427.2) sons, a preimpregnated E-glass FRC was studied.
(n = 16) When the effect of FRC architecture (unidirec-
PMMA-U 5403.4 (803.3) 5013.4 (637.2) tional versus bidirectional/woven) is evaluated
(n = 16)* on the adherence of C. albicans, specimens with
PMMA-W 4053.5 (676.9) 3726.6 (553) unidirectional fibres showed significantly more
(n = 16)* C. albicans adhesion than with woven ones.
Total 3902 (632.6) 3582.2 (539.1)
Although there were studies comparing the trans-
(n = 48)
verse and fatigue strength of unidirectional and
*The indicated groups show significant differences woven fibres16,18, there is no study on the colonisa-
between the concerned groups (p > 0.001). tion of yeasts on fibres with different architectures.

© 2012 The Gerodontology Society and John Wiley & Sons A/S

(a)
Figure 1 (a-c) Optical microscope images (9100 original magnification) of Candida albicans adherence on (a) PMMA
only, (b) PMMA with unidirectional Fibre-reinforced composites (FRC) exposure. Note the rough surface and the
C. albicans adherence in clusters spread on the surface and the larger diameters of unidirectional FRC compared with
woven FRC, (c) PMMA with woven FRC exposure. Note the narrower diameters of woven FRC when compared
with unidirectional one.
Unidirectional and woven FRC materials used in
this study have the same composition with differ-
ent configurations. Apart from architecture, unidi-
rectional single FRC materials are in larger
diameters (12 lm) than the woven ones (5 lm)18.
Therefore, the higher adherence of C. albicans to
unidirectional fibres in comparison with woven
fibres could be attributed to the mechanical reten-
tion due to the increased surface area and thereby
roughness of the fibre yarns tested. Thus, the
hypothesis was rejected. Microscopic examinations
also supported this finding.
Material surface properties, such as surface
roughness34, surface free energy31 and hydropho-
bicity39 of the surface have been also shown to
influence adhesion of microorganisms. Surface
roughness directly influences microorganisms ini-
tial adherence to surfaces, biofilm development
and Candida species colonisation. Materials with
the roughest surface usually exhibit higher yeast
counts34,37,40. Quirynen et al.41 postulated a
threshold roughness value (0.2 lm) below which
no effect on the adhesion should be expected.
Smooth and highly polished surfaces are important
not only for patient comfort but also for denture
longevity, good aesthetical results and low plaque
retention. On the other hand, high-energy surfaces
are reported to collect more plaque than low
energy ones29,32. Dental restorative materials are
described as high-energy materials when their sur-
face energy is more than 50 mN/m. The term ‘low
energy materials’ is used to describe substances that
are softer and that have low melting points and
weak intermolecular forces (i.e. waxes and poly-
mers). Materials such as PMMA have a surface
energy value of 41 mN/m. Surfaces with high-sur-
face-free energy are postulated to attract more
microorganisms than surfaces with low surface free
energy29,31. In a study conducted by Minagi et al.33,
the adherence of C. albicans and C. tropicalis to 21
© 2012 The Gerodontology Society and John Wiley & Sons A/S
Candida albicans adherence on fiber-reinforced PMMA 5
(b) (c)
different acrylic resin materials concluded that with
the increase in the surface free energy, the micro-
organism adherence increased. On the other hand,
less C. albicans adherence was observed on the
hydrophobic materials.
Waltimo et al.27 studied the adherence of yeast
cells to the surface of an auto-polymerised denture
base polymer reinforced with unidirectional E-glass
FRCs. They found that the mean number of adher-
ent yeast cells on the surface of the polymer matrix
was significantly higher than that on the surface of
glass fibres. The number of adherent yeast cells
found at the interface between the fibres and poly-
mer matrix was found to be high. The authors con-
cluded that if fibres are exposed only during
polishing, the FRC material appears not to increase
the adherence but areas with permanently exposed
fibres may provide mechanical retention for yeast
cells at the interface of the components. From this
conclusion, it was not clear whether the FRCs were
completely exposed. In this study, the whole FRC
surface was exposed. Although a heat-polymerised
PMMA was used and not parotid saliva only, as in
the study of Waltimo et al.27, all specimens exclu-
sively showed C. albicans adhesion after contamina-
tion with this microorganism. Moreover, FRC
reinforced specimens showed more C. albicans
adhesion than PMMA alone. The number of
C. albicans at the fibre-PMMA interface in this
study was higher than it was reported by Waltimo
et al.27 even though the saliva incubation time was
the same.
The presence of saliva, serum and other micro-
organisms on the surface may also affect the
C. albicans adhesion process27,28. Different opin-
ions exist in the dental literature on the effect of
saliva on C. albicans adhesion: several investigators
reported that a saliva coating reduces the adherence
of C. albicans in acrylic resin based materials, oth-
ers showed increased adherence rates with saliva
6 B. Akalın-Evren et al.
coating and some research groups found no effect
of a saliva coating40,42–47. Consequently, apart
from surface properties of the materials tested,
this aspect was also considered in this study. An
acquired salivary pellicle is always present on the
denture surfaces in vivo. This was tried to be simu-
lated by exposing the specimens to saliva for 1 h.
In the present study, although not statistically sig-
nificant, less C. albicans adhesion was observed on
the specimens with saliva coating than with dis-
tilled water. These findings are not in agreement
with several authors, stating that pellicle coating
generally results in reduced numbers of adhering
bacteria where similar number of specimens were
used30. However, denture-wearing subjects suffer-
ing from xerostomia or those who are on medica-
tion and eventually have less salivary flow may
be more prone to C. albicans accumulation. There-
fore, ideal saliva coating cannot be assured in
every individual.
In an in vitro study, Tanner et al.31 studied the
adherence of S. mutans on E-glass FRC reinforced
resin composite, denture base polymer and four
other restorative materials with and without expo-
sure to saliva. In that study again, only parotid
saliva was used and glass surfaces were the control
substrates. Their results showed that saliva coating
resulted in decreased adherence of S. mutans on all
materials except glass. In the acquired pellicle,
high-molecular weight glycoproteins (agglutinins)
were thought to be the primary promoters of
S. mutans adhesion to glass surface. In the presence
of this protein, S. mutans showed more adherence
to hard surfaces such as glass. In other studies, it
has been reported that submandibular and sublin-
gual saliva support the C. albicans adhesion due to
the musin content, while parotid and mixed saliva
reduce the adhesion related to high-molecular
weight proteins42,43. Although saliva from differ-
ent origins (submandibular, sublingual and paro-
tid) was used in some studies investigating the
effect of saliva on C. albicans adherence on acrylic
surfaces, the most preferred type of saliva was
unstimulated mixed saliva47–55. So, in the present
study, unstimulated mixed saliva was used for a
better clinical approximation where all salivary
glands function simultaneously. In studies where
unstimulated mixed saliva was used, Samarana-
yake et al.48, Waters et al.50, Maza et al.50, McCour-
tie et al.53 and Bosch et al.54 observed reduced
adherence of C. albicans, Nikawa et al.55 reported
increased adherence rates and Nikawa et al.49 and
Jin et al.52 observed no effect. In the present study,
the specimens exposed to saliva showed less
C. albicans adhesion, yet being not significant. A
possible explanation for this contradictory effect
has been proposed by Elguezabal et al.47 when
studying the adhesion of C. albicans to polym-
ethylmethacrylate, as mixed saliva decreased or
enhanced the adhesion of C. albicans to polymeth-
ylmethacrylate depending on the morphological
phase of C. albicans. Thus, it is possible that mixed
saliva plays a dual role on the adhesion of C. albi-
cans to plastic materials used to make dental pros-
thesis, decreasing adhesion of germ tubes and
enhancing the adhesion of yeast cells.
There are some limitations of this study. As sur-
face roughness directly influences microorganisms
initial adherence to surfaces, biofilm formation
and Candida species colonisation, surface rough-
ness of the specimens should be measured to make
sure that all surfaces had similar roughness prior
to the contamination procedure. This could be one
of the reasons why we had these specific outcomes
regarding adherence of Candida albicans to polym-
ethylmethacrylate. Furthermore, individual effect
of saliva from different origins and the effect of
denture cleaning regimens should be involved in
the study. Nevertheless, the results of this study
indicate that increased C. albicans adhesion could
be expected mainly dominated by the fibre rough-
ness when PMMA is reinforced with FRC. There-
fore, from the clinical point of view, care should
be exercised in order not to expose the FRC mate-
rials during fitting procedures of dentures, and if
the fibres are exposed, the prosthetic devices
should be replaced. As the initial adhesion of Can-
dida species is influenced by surface roughness
and surface free energy, these characteristics
should also be evaluated in in vivo-like conditions.
Conclusions
From this study, the following could be con-
cluded:
1. All specimens showed C. albicans adhesion
but PMMA without FRC exposure collected
significantly less C. albicans.
2. C. albicans adhesion was significantly affected
by the exposed FRC architecture with more
favourable results for woven fibres than those
with unidirectional ones.
Acknowledgements
This investigation was supported by Scientific
Research Project Committee of Marmara Univer-
sity, Project No: SAG-094/081004.
© 2012 The Gerodontology Society and John Wiley & Sons A/S

Conflict of Interest
The authors declare that they have no conflict of
interest.
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Corresponding to:
Dr Buket Akalın-Evren, Faculty of Dentistry,
Department of Prosthodontics, University of Mar-
mara, Güzelbahçe Büyükçiftlik Sok. No:6, 80200
Nisantası, Istanbul, Turkey.
Tel: +90 0 212 2319120
Fax: +90 0 212 2465247
E-mail: buketakalin@hotmail.com
© 2012 The Gerodontology Society and John Wiley & Sons A/S