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The Xerostomia Inventory: A multi-item approach to measuring dry mouth

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Community Dental Health (1999) 16, 12-17 O BASCD 1999
Received 28 January, 1998; accepted8 April, 1998

The XerostomiaInventorv:
a multi-item approachto measuringdry mouth
W. Murray Thomsonr,JaneM. Chalmers2,A. John Spencer2and SheilaM. Williams3
lDepartment of Oral Health, The University of Otago, Dunedin, New Zealand 'zAIHW Dental Statistics and Research (Jnit,
University of Adelaide, South Australia 3Departmentof Preventive and Social Medicine, University of Otago, Dunedin, New Zealancl

Objective To develop a valid multi-item method of measuring the symptoms of xerostomia which includes the wide range of
xerostomia symptoms in a single quantitative measure. Design A combination of qualitative and quantitative approaches. Setting
A cohort study in South Australia. Participants Older people aged 65 years or more who were taking part in the South Australian
Dental Longitudinal Study. Measures Xerostomia symptoms were evaluated using a multi-item inventory format and, for
comparison pulposes, a standard single dry-mouth question. Resting whole-salivary flow rate was estimated using the 'spit'
method. Resulls Xerostomia and flow-rate data were available for 636 individuals. Factor analysis revealed the presence of a
discrete xerostomia dimension, representedby l1 items whose responseswere summated to give a single Xerostomia Inventory
(XI) scale score. This had a very low correlation with resting flow rate but a much stronger, positive correlation with the standard
dry-mouth question responses.Conclusinns The XI shows adequatecontent and concurrent validity, and appearsto be a promising
advance on previous approachesto xerostomia symptomatology although further testing is required.

Key words: dry mouth, measuremen| sialometry, xerostomia

Introduction among older adults, the prevalence of both xerostomia

Xerostomia is the subjective feeling of dry mouth.
Estimates of its prevalence in older populations range
from 10 to 38 per cent (Osterberget al., 1992; Thomson
et a1.,1993;Locker, 1995).Salivary gland hypofunction
(SGH) is a measurablereduction in salivary output;
estimatesof SGH prevalenceamong older adults are more
difficult to compare because different approaches and
definitions have been used.Johnsonet al. (1984) reported
that 44 per cent of an institutionalised older population
had a stimulated parotid flow rate of 0.2 mVmin or less.
Osterberg et al. (1984) reported that 32 per cent of a
representativesample of Swedes aged 70 or more had a
resting whole-salivary flow rate below 0.1 mVmin, while
Fure and Zickert (1990) reported a prevalence rate of22
per cent for the same flow rate among a representative
sampleof 55-, 65- and 75-year-oldSwedes.It is apparent
from the prevalence estimates for xerostomia and SGH
that substantial numbers of older people are affected.
Evidence suggests that older people's salivary
systemsare susceptibleto exogenousfactors that may act
to reduce their secretory capacity, such as medications
(Atkinson et al., 1989',Johnsonet al., op. cit.; Loesche
et al., 1995',Narhi er al., 1992; Osterberg et al., 19841'
Persson et al., l99l; Thomson et al., op. cit.), some
chronic inflammatory conditions (Sreebny and Valdini,
1989), and radiation such as that received during radio-
therapy for cancer of the head or neck (Dreizen et al.,
1977). Becatse these exogenous factors are common
and SGH is higher among older people (Baum 1989),
and hasbeen shownto increaseover time (Locker, 1995).
The measurement of xerostomia is problematic. In
contrast to SGH, which can be objectively evaluatedby
using sialometry(Navazesh,1993),xerostomiais comprised
of a setof symptoms,and thereforecan be assessed only by
directly questioningindividuals (Fox et a1.,1987). Despite
the many studies that have investigated xerostomia, no
insffumenthas been developedwhich clearly and distinctly
represents the condition so that its measurement can be
undertakento allow comparisonsacrossgroups.
In some reports, the method of assessingxerostomia
has not been specified, except for reference to
patient-reported changes in symptoms (Greenspan and
Daniels, 1987; Fox et al., 1986').In other reports, a
single-item questionnaire(Neverlien, 1994)has been used
(Fox er al., 1987; Gilbert et al., 19931,Johnson et al.,
op. cit.; Locker, 1993, 19951,Narhi, 1994; Osterberg er
al ., 1992;'Thomson et al., op. cit;). There is no way of
determining exactly what is being measured with such
approaches.The researchermay assumethat a single item
representsa range of severity of xerostomia symptoms,
but in reality it may be measuring a completely different
dimension because interpretation of the single question
may differ amongrespondents.Moreover, such single-item
approachesto objectively measuringxerostomiahave been
limited to dry mouth only, without exploring the wider
constellation of symptoms which appear to form the
xerostomia experience.

Correspondenceto: W. Murray Thomson, Department of Oral Health, The University of Otago, PO Box 647, Dunedin, New Zealand
 In a notableexception,Narhi, er al., (op. cit.) took a
broader approachand employed a seriesof items ranging
from the experience of a continuously dry mouth, to
difficulty in speaking and in swallowing. Less
frequently-explored symptoms such as oral burning or
itching sensationswere also investigated,and were found
to be more prevalent in individuals with dry mouth, more
of whom also repofied taste impairment and difficulties
in eating dry foods. This more inclusive approach was a
useful development, but each item was still analysed in
isolation rather than being aggregatedinto an inventory.
A more integrated approach would provide a continuous
score which would allow more precise measurementof
the severity of symptoms, and reduce the potential for
misclassificationwhich occurswith categoricalapproaches
to defining the condition.
Valid expressionof the total concept of an experience
such as xerostomia requires a derived measure which is
a combination of many different, fundamental and
directly observed measures (Kaplan et al., 1976). In
measuring xerostomia, it is assumed to be a complex
phenomenon which can be represented by a latent
variable for which direct measurement is not possible,
and which must therefore be estimatedby making obser-
vations of a set of relevant indicator variables. Clinical
depressionoffers a ready analogy: to label an individual
'clinically
as being depressed' means that he or she
exhibits a set of symptoms which commonly occur in
conjunction with one another; however, no single
indicator exists for clinical depression (Bartholomew,
1996). Out of these considerations (and the plethora of
different items which have been used to date) arose the
notion that this approach may be useful for measuring
xerostomia.
The purpose of this paper is to describe the
development and preliminary testing of the Xerostomia
Inventory, a multi-item instrument for measuring
xerostomia symptoms which enablesan estimate of their
severity to be made on a continuous scale.
Method
The development of the XI involved a combination of
qualitative and quantitative techniques. A literature
search revealed a number of items which had been
developed and used by other workers using single-item
inventory approaches(Table 1), and this enableda frame-
work to be developed for semi-structuredinterviews
which were undertaken with a convenience sample of
four diagnosed long-term sufferers of xerostomia who
were patients in the high caries clinic at the Adelaide
Dental Hospital. It is not known how representativethose
individuals were of xerostomia sufferers in general, but
they appearedto be typical ofpatients seenin that clinic.
Responseswere recordedin longhand, and content analy-
sis was used to identify dominant themes which were
then either developed into new XI items - using the
interviewees' own words where possible - or used to
confirm and/or modify those which had been obtained
from the literature. This process resulted in 19 separate
items, and ensured: (1) that those which were used
reflected many manifestations of the xerostomia
experience; (2) that their most appropriate wording was
determined; and, (3) that they were grounded in the

Table L, Previousapproaches
to investigatingxerostomia

Items used specified in report Workers

Does your mouth feel distinctly dry? Osterberg et al., 1984
Do you sip liquids to aid in swallowing dry foods? Fox et al.,198'7
Does your mouth feel dry when eating a meal? Fox et a1.,1987
Do you have difficulties swallowing any foods? Fox et a1.,1987
Does the amount of saliva in your mouth seem to be too little, too much, or you don't notice it? Fox et a1.,1987
Do you feel dryness in the mouth at any time? Fure & Zickert;1990
Do you have mouth dryness? Osterberg et al., 1992
Is your mouth sometimes dry? Gilbelt e/ al., 1993
How often does your mouth feel dry? Thomson et al., 1993
During the last four weeks, have you had any of the following....dryness of mouth? Locker, 1993
Does your mouth feel dry? Narhi er al.,1992
Does your mouth usually feel dry? Nederfors et al., 1997
Exact wording of items used not specffied in report but indication given of approach which was used

Difficulty in eating dry foods Narhi 1994

Difficulty in speaking Narhi 1994
Difficulty in swallowing Narhi 1994
Taste impairment Narhi 1994
Dry lips Narhi 1994
Burning sensation in oral mucosa Narhi 1994
Burning sensation in tongue Narhi 1994
Itching sensation in oral mucosa Narhi 1994
Itching sensation in tongue Narhi 1994
Mouth breathing Narhi 1994
Dry throat Narhi 1994
Dry nose Narhi 1994
Dry skin Narhi 1994
Drv eves Narhi 1994

t-l
experiencesof xerostomia sufferers. The 19 items were
then assembledinto inventory fotmat for testing in the
five-year data collection phase of the South Australian
Dental Longitudinal Study (SADLS). Responseoptions
were presented in a large font for ease of reading by
older adults, with each response item having the same
'Hardly
five options: 'Never', ever',
'Frequently',or'Always'.
The SADLS sampling strategyand data collection has
been describedpreviously (Slade and Spencer, 1994),
but a brief description follows. For the baseline study in
1991, a stratified random sample of non-institutionalised
persons aged 60+ years was selected from the compul-
sory State Electoral Database of non-institutionalised
Australian citizens (aged 18 or more). The sampling
method defined 24 strata, 18 in the Adelaide Statistical
Division, and 6 within the Mt Gambier City and District
Council. The former comprised three age groups
(60-64, 65*14 and 75+ years), two genders and three
locality groups (which were basedon their distance from
a public or school dental clinic), while the latter was
comprised of the same three age groups and two
genders. A different selection probability was used for
each stratum in order to draw a simple random sample
of participants. Dentate people (those who had one or
more natural teeth) were over-sampled by excluding a
percentageof edentulouspeople which ranged from 100
per cent in Mt Gambier to 50 per cent among the
Adelaide residents aged 60-64 years. The baseline and
two-year data collections took place in l99l and 1993
respectively. At five years (1996), the participants were
again examined and interviewed, with computer-assisted
telephone interviews being used to collect household and
personal information just prior to the clinical examina-
tion. During the telephone interview stage of the study,
responsesto a standardsingle xerostomiaquestion ("How
often does your mouth feel dry?" Responseoptions:
' N e v e r ' , ' O c c a s i o n a l l y ' , ' F r e q u e n t l y ' , ' A l w a y s 'w
collected. The Xerostomia Inventory was sent as a postal
questionnaire to all parlicipants who had agreed to a
clinical examination, and they were instructed to either
bring the completed questionnairesto the clinical
examination or return them by post. There was no
systematic follow-up of non-responders to the postal
questionnaire, and so information on the reasons for
refusal was not obtained.
Resting whole saliva was collected at the clinical
examination appointment using the
(Navazesh and Christensen, 1982). Each participant had
been instructed to refrain from food, beverages and
smoking for the 60 minutes prior to collection. Some
five minutes before saliva collection, participants were
instructed to rinse the mouth out with plain water and
then to sit quietly while administrative procedures were
completed. Immediately prior to saliva collection, each
was asked to clear the mouth by swallowing, and then to
actively spit saliva into a pre-weighed plastic collection
tube over the next four minutes. At the end of that time,
a beeper sounded and the participant was asked to spit
any remaining saliva into the tube, which was then sealed
and placed in a cool-storagebin. The collection time was
recorded. The tubes were weished later at the Adelaide
14
Dental Hospital. Resting saliva flow (in ml/min) was
computedas the weight of saliva collected(assuming1g =
lnrl) divided by the collection time in minutes.
Data were entered into an SPSS data file and
analysed using SPSS. Univariate statistics were
computed. No prior hypotheses about the factor struc-
'Occasionally',
ture of the data were available, so exploratory factor
analysis was undertaken using Maximum Likelihood
methods. Cronbach's o was computed to confirm the
internal consistencyof responsesto the xerostomia items
prior to the collapsing of their responsesinto a single
continuous factor scale. Bivariate analysesused analysis
of variance.
Results
Of the 939 people (56.9 per cent of baseline) who
remainedin the study at five years,483 (51.4 per cent)
were male and 456 (48.6 per cent) female. In compari-
son with the baseline characteristicsof those who were
lost to follow-up, the individuals who remained were
younger, had fewer missing teeth, fewer chronic medical
conditions, and were more likely to be regular users of
dental services. The ages of the remaining study
members ranged from 65 to 100, with a mean age of 75
years (SD, 7 years). Xerostomia questionnaireswere
mailed to the 708 (75.4 per cent) who had a dental
examination appointment. The questionnaires were
completed and returned by 649 (91.7 per cent) of those
individuals, of whom 201 (31.0 per cent) were from Mt
Gambier and 448 (69.0 per cent) were Adelaide resi-
dents. Where there were difficulties in getting
co-operation from participants, priority was given to the
dental examination rather than the saliva collection;
consequently, saliva samples were collected from 676
(95.5 per cent) of those examined. Both xerostomia
inventory questionnaireand salivary flow-rate data were
) ere available for 636 individuals (89.8 per cent), and 662
(93.5 per cent) supplied saliva samplesand answeredthe
standard question.
Responsesto individual items are shown in Table 2.
The factor analysis revealed three eigen values greater
than 1 (5.06, 1.85 and 1.26 respectively),and solutions
with 1, 2 and 3 factors were considered. Inspection of
the loadings after varimax rotation - as well as
examination of the scree test - suggested that two
factors provided the best solution. The factor loadings
'spit' which show how each item correlated with the underly-
method
ing latent variable are shown in Table 3. Two scales
were constructedby summing the responsesto the items
which loaded on each factor. The correlations between
the unweighted factor scales and those constructed with
optimal weighting were 0.93 for the first scale and 0-95
for the second,indicating that the unweighted summated
scales representedthe underlying factors well. Coeffi-
cient o was 0.84 for the first scale, and 0.80 for the
second scale. The means for each scale are shown in
Table 4. The Factor 1 scale was designated the Xeros-
tomia Inventory (XI) score, while the Factor 2 scale was
named the Burning Mouth Syndrome (BMS) score. The
correlation between the two scales was positive and
significant (r = 0.40; P<0.01).
Table 2. Resoonsesto individual items (N=649)

Never Hardly Occasionally Fairly Very Missing

et)er often often
q
I sip liquids to aid in swallowing food 437 96 83 22 2
My mouth feels dry when eating a meal 450 116 63 12 5 3
I get up at night to drink 306 115 152 A' -)L 2
I have difficulty in eating dry foods 404 119 86 LJ 12 5
I suck sweets or cough lollies to relieve dry mouth 404 103 106 4,4 10 2
I have difficulties swallowing certain foods 435 118 6'7 18 11 0
I have a burning sensationin my gums 5't4 39 28 2 2 4
I h a v ea b u m i n g s e n s a t i o inn m y t o n g u e 584 28 l5 12 o 4
My gums itch 592 35 14 3 2 3
My tongue itches s83 37 t9 5 I 4
The skin of my face feels dry JJ+ 90 150 A7
29 3
My eyes feel dry 339 89 149 20 10
My lips feel dry . A"' 150 186 49 18 4
The inside of my nose feels dry 328 106 154 38 l6 7

Table 3. Outcome of the factor analvsis'

Factor l Factor 2
Xerostomia Burning mouth Syndrome (BMS)

I sip liquids to aid in swallowing food (SIPLIQ) 0.69

My mouth feels dry when eating a meal (MOUTHDRY) 0.'74
I get up at nighr to drink (NITDRINK) 0.45
My mouth feels dry (DRYMOUTH) 0.54
I have difficulty in eating dry foods (DRYFOOD) 0.14
I suck sweets or cough lollies to relieve dry mouth (SUCK) 0.46
I have difficulties swallowing certain foods (DIFFSWAL) 0.69
The skin of my face feels dry (DRYSKIN) 0.39
My eyes feel dry (EYESDRY) 0.42
My lips feel dry (LIPSDRY) 0.42
The inside of my nose feels dry NOSEDRY) 0.42
I have a buming sensation in my gums (BURNGUMS) 0.61
I have a burning sensation in my tongue (BURNTONG) 0.72
My gums itch (GUMITCH) 0.65
My tongue itches (TONGITCH) 0.'7'7
Eigenvalue 5.06 1.85
'Order of items in questionnaire: SIPLIQ, MOUTHDRY, LIPSDRY, DIFFSWAL, DRYMOUTH, NITDRINK, GUMITCH,
BURNGUMS, TONGITCH, BURNTONG. EYESDRY, DRYFOOD, NOSEDRY, SUCK, DRYSKIN

Table 4. Responsesto the standard question and comparison with mean factor scale scores

How ojlen does your mouth feel dry? Number (7o)' Mean XI score (SD)h Mean BMS scale score (SD)'
Never 196 3r.4 16.9'7 5.54 4.37 1 . 5l
Occasionally 299 47.8 19.49 3.43 4.51 1.27
Frequently 108 r7.3 24.54 7.47 4.85 2.20
Always 22 3.5 3r.29 9.'t1 6.67 3.10
'7.03
625 100.0 19.95 4.60 1.67
" Number of participants who responded to the standard question and who also returned XI questionnaires
b Oneway ANOVA (Scheffe; P<0.0001): the scores for all four groups differ
' Oneway ANOVA (Scheffe; P<0.0001): the score for the Always group differs from the other three

Responsesto the standard question How ofien does
your mouth feel dry? from participants who returned XI
questionnairesare presentedin Table 4, alotg with mean
XI and BMS scale scores for each level of the standard
question. The correlation between responses to the
standardquestion and XI scoreswas 0.42 (P<0.01). There
was no difference between males and females in their
responsesto the standardquestion, but XI scoresdiffered
significantly between males (19.34; SD, 6.85) and
females(20.61: SD, 7.19; ANOVA P<0.05). The corre-
lation between BMS scores and the standard question
was 0.16 (P<0.01),but there were no significant gender
differences in BMS scores.Across the sample,XI scores
were only very weakly (and positively) conelated with
age (r = 0.03, P>0.05), and BMS scoreswere also only
weakly correlated with age (r = 0.005; P>0.05).

l5
 Resting whole salivary flow rates ranged from 0.00
mVmin to 1.84 ml/min, with a mean flow rate of 0.21 ml/
min (SD, 0.22). The median flow rate was 0.21 ml/min.
The difference between the mean flow rates of males
(0.29 ml/min; SD, 0.24) and females (0.25 mVmin, SD,
0.25) almost reached statistical significance (ANOVA;
P=0.06). Of the individual items, only "My mouth feels
dry" showed a significant correlation with resting whole
salivary flow rate (Spearman'sP=-0.09, P<0.05); corre-
lation coefficients for the others ranged from -0.08 to
0.07, but none was statistically significant. The conela-
tion between XI scores and resting whole salivary flow
rates was low and not significant (r=-0.05). The correla-
tion between responsesto the standardquestion and rest-
ing whole salivaryflow rateswas also low, but it reached
statistical significance(Spearman's P=-O.10; P=0.01).
Thus, both the standardquestion and the XI scale scores
were negatively correlated with the resting salivary flow
rate. The correlation between BMS scores and salivary
flow rate was positive but not significant (r=0.009;
P>0.05).
Discussion
The purpose behind the development of the Xerostomia
Inventory was to enable an estimate of xerostomia to be
made (on an ordinal scale) for each individual so that it
could be included as a continuous covariate in the
modelling of coronal and root surface caries incidence
among elderly participants in the South Australia
Dental Longitudinal Study. Measuring xerostomia
symptoms on a continuous scale in this way is intended
to reduce the risk of misclassification error which can
'xerostomic'
occur when individuals are labelled as on
the basis of an arbitrary cut-off point, as with previous
attemptsto measurethe condition. Those earlier attempts
to measureobjectively the symptoms of xerostomia have
been relatively crude, and have not employed an analyti-
cal approach which, first, confirmed that a discrete
xerostomia dimension did exist and was actually being
measured,and second, acknowledged (and satisfactorily
included) the wider constellation of symptoms which
appear to comprise the condition. It appears therefore
that the XI may offer considerable advantagesover
previous approachesto xerostomia symptomatology.
The two discrete dimensions revealed by the factor
analysis were intuitively appropriate.The 11 items upon
which Factor I loaded did indeed appear to represent a
xerostomia dimension which included both experiential
and behavioural aspectsof sufferers' experiencesof the
condition. For example, it is considered that the
MOUTHDRY (my mouth feels dry when eating a meal),
DRYFOOD (I have dfficulty in eating dry foods) and
DIFFSWAL (I have dfficulties swallowing certainfoods)
statementsrelate directly to the individual's awareness
of xerostomia, while the SIPLIQ Q sip liquids to aid in
swallowing /ood), NITDRINK (1 get up at night to
drink) and SUCK (l suck sweets or cough lollies
to relieve dry mouth) statementsreflect the consequences
of xerostomia symptoms. The inclusion of both
aspects strengthens the case for the XI being a valid
representation of xerostomia symptoms.
Factor 2 indicated the oresence of what has been
16
describedas Burning Mouth Syndrome(Savage,1996),
with the four significant items pertaining to sensations
of burning or itching of the gums and tongue. It is
worthy of note that the mean scores on that scale were
higher for individuals who answered "Always" to the
standardquestion, confirming previous observationsof
the associationof severe xerostomia and burning mouth
(Grushka, 1987). The scale for Factor 2 may therefore
offer useful insights into the occurrenceand associations
of a condition which may be closely related to xerosto-
mia, and warrants furlher investigation which is beyond
the scope of this paper. Those items would not be
included in future use of the Xerostomia Inventory
unless the researchwas to specifically examine Burning
Mouth Syndrome as well.
Validity
Validity is a key issue in consideringthe merits of an
instrument which purports to measure subjective symp-
toms, and relates to whether it is really measuring what
the researcherintends to measure. There are several
types of validity which can be considered. Content
validity is held to be acceptable when the instrument
adequately samples the domain which it is supposedto
measure. This depends, in part, on demonstrating that
all relevant dimensions have been used in defining the
domain, and that the domain was appropriately and
adequatelysampled (Kaplan et al., op. cit). Valid
content requires that it must positively and exhaustively
define the dimensions of the construct which it is to
measure. The combined empirical-theoretical approach
taken to deriving the items for the pretest version -
together with the factor structure which was revealed -
suggeststhat it did indeed representa distinct, authentic
xerostomia dimension.
Concurrent Validity pertains to the inventory's
performance against an existing standard; such a
criterion-related approachrequires that it show a similar
gradient in scores to an alternative method of measure-
ment which is assumedto be valid. One of the problems
in xerostomia researchis the wide range of items which
studieshave used to ask individuals about their experi-
ence of the condition (Table 1). The choice" of the
particular question used in the current study was not a
reflection of any perceived lack of utility of the other
questions which have been used; rather, it reflected the
researchers' familiarity with the use of that particular
item in investigating xerostomia. Perhaps,in retrospect,
one or two more should have been used to gain a more
complete picture of the XI's performance against exist-
ing standards.Comparison of the increasing XI scores
with the increasing severity categories of the standard
single-item inventory in Table 4 suggests that this
aspect of validity was also satisfactory, particularly in
view of the difference in scores across al1 four response
groups for the standard question.
Construct validity pertains to the extent to which the
instrument appears to conform to theoretically-derived
predictions about it; in other words, construct validation
involves assembling empirical evidence to support the
inference that the XI has meaning. The Xerostomia
Inventory's ability to assign higher scoresto individuals
who complain of frequent dry mouth suggests that it
does indeed show this, but the degree of overlap (as
represented by the standard deviations in Table 4) among
'gold
XI score distributions and standard' categories
indicates that further examination of this characteristic in
other populations would be advisable before making a
definitive statement on the construct validity of the XI.
Some aspects of validity were not examined in the
pretest phase. Convergent validity is apparent where
several dissimilar methods of measurement of the concept
correlate well with the test being investigated; in the case
of the Xerostomia Inventory, this could not be examined,
as only one alternative method was used to assess
xerostomia. However, a sufficient number of altematives
exist for this to be undertaken in subsequent studies.
Discriminant validity is apparent when the test does
not correlate well with measures of other concepts; in
other words, it is able to distinguish the xerostomia
experience from other symptom sets. This was only
superficially examined in the current study: although the
two factor scales were moderately correlated, their
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different relationship to the standard question (Table 4)
suggeststhat they would be adequatein discriminating
xerostomia sufferers from BMS sufferers.
Future researchefforts in the development and testing
of the Xerostomia Inventory will need to examine its
convergent and discriminant validity - as well as its
temporal stability - before it can be held up as a truly
viable alternative method of measuring xerostomia. The
relationship between Xerostomia Inventory scores and
existing psychometricscalesalso needsto be clarified,
particularly in view of a recent report of a higher
prevalenceof depressivesymptoms in individuals with
xerostomia (Bergdahl et al., 1997).
Acknowledgements:The study members are thanked for
their participation and senseof humour. Dr Mohammad
Ketabi is thanked for his assistancewith collecting and
weighing saliva samples. Dr Sarah Lawrence and
Dr Rhonda Lacey are thanked for their assistancewith
testins.
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