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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 1  |  Page : 80-86
Oral health status and knowledge among 10-15years old type 1 diabetes mellitus children and adolescents in Bengaluru


1 Public Health Dentistry, MR Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India
2 Public Health Dentistry, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India
3 Community Medicine, Vijayanagar Institute of Medical Science, Bellary, India

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Date of Web Publication20-Mar-2019
 

   Abstract 

Context: Type 1 diabetes mellitus (T1DM) is a chronic systemic metabolic disease. This disorder affects mainly children and adolescents. The main complications of diabetes mellitus affect the organs and tissues rich in capillary vessels such as kidney, retina, and nerves. These complications are secondary to the development of microangiopathy. Similar changes in small vessels can be found in the oral tissues. There is a significant increase in gingival inflammation and plaque seen in children with T1DM. Aims: The aim of this study is to assess the oral health status and knowledge among T1DM children and young adolescents aged 10–15 years in Bengaluru. Subjects and Methods: One hundred and seventy-five 10–15 year-old children with T1DM and 175 age, sex, and socioeconomic status matched nondiabetic controls were included in the study. Oral health status was assessed using community periodontal Index and decayed/decayed-missing/missing-filled/filled teeth index (DMFT/dmft). Oral health knowledge was assessed using 11 item questionnaire. Chi-square test and Student's t-test were used in the statistical analysis. Results: With regard to periodontal status, subjects with healthy periodontal tissue were less in diabetic than control group. Patients with bleeding and calculus were more in diabetic group than control group. The difference between diabetic group and control group was statistically significant (P = 0.001).The mean number of DMFT/dmft were less in diabetics (0.07 ± 0.006)/(0.26 ± 0.05) compared to control groups (0.1 ± 0.01)/(0.84 ± 0.2), respectively. Overall, oral health knowledge was more among diabetic patients (8.3 ± 1.7) compared to controls (7.5 ± 1.8). Conclusions: The results of the present study showed more gingival changes and higher oral health knowledge in diabetic group when compared to control group.

Keywords: India, oral health knowledge, oral health status, type 1 diabetes

How to cite this article:
Geetha S, Pramila M, Jain K, Suresh C M. Oral health status and knowledge among 10-15years old type 1 diabetes mellitus children and adolescents in Bengaluru. Indian J Dent Res 2019;30:80-6

How to cite this URL:
Geetha S, Pramila M, Jain K, Suresh C M. Oral health status and knowledge among 10-15years old type 1 diabetes mellitus children and adolescents in Bengaluru. Indian J Dent Res [serial online] 2019 [cited 2019 Oct 21];30:80-6. Available from: http://www.ijdr.in/text.asp?2019/30/1/80/254524

   Introduction Top


Insulin-dependent diabetes mellitus (IDDM) is a chronic systemic metabolic disease characterized using an absolute insulin deficient production by the pancreatic beta cells. This disorder affects mainly children and adolescents.[1] This form of diabetes is the most severe type. Peak incidence occurs during puberty, around 10–12 years of age in girls and 12–14 years of age in boys.[2]

The incidence of IDDM is reported to be increasing in many countries worldwide. Globally, there are 500,000 children of age 15 years suffering from type 1 diabetes. It is increasing at a rate of 3% each year.[3] In India, many hospital records and clinic data indicate that young diabetics (diabetes onset before 15 years) constitute 1%–5% of the total diabetic patients enrolled.[4] In Karnataka, it is 3.7/100,000 in boys and 4.0/100,000 in girls.[3]

The main complications of diabetes mellitus affect the organs and tissues rich in capillary vessels such as kidney, retina, and nerves. These complications are secondary to the development of microangiopathy. Similar changes in small vessels can be found in the oral tissues.[5]

A number of oral disorders have been associated with diabetes mellitus. The association of diabetes mellitus and periodontal diseases (such as gingivitis and periodontitis) has received the greatest attention.[6] Studies have reported that there is a significant increase in gingival inflammation and plaque is seen in children with type 1 diabetes.[7],[8],[9] The occurrence of dental caries in patients with diabetes mellitus showed no specific association between them. The relationship between dental caries and diabetes mellitus is complex.[10] Although these patients are oriented to follow a diet with restricted consumption of sucrose (the most cariogenic of sugars), the lack of knowledge of good oral health habits can lead to poor glycemic control and the onset of morbidities related to oral health.[1]

The systemic complications, poor oral health, and lack of knowledge among these patients can have an impact on overall health and wellbeing. However, awareness of these complications is deficient worldwide. Therefore, diabetic oral complications need to be recognized and included in the definitive care of diabetes to fight this chronic metabolic disease efficiently. In India, studies related to TIDM children and their knowledge towards oral health are inadequate. Hence, the present study was conducted to assess oral health status and knowledge among type 1 diabetic children aged 10–15 years in Bengaluru city.


   Subjects and Methods Top


An analytical case–control study was undertaken on the children diagnosed for type 1 diabetes mellitus (T1DM) belonging to the age group of 10–15 years visiting diabetes hospitals. Analyzing the data and prevalence rate of the previous study,[11] sample size was estimated at 157 with tolerance of α-error at 0.05 and power of the test at 80%. After considering 10% nonresponse rate, the final sample size was determined to be 175. An equal number of 175 age, sex, and socioeconomic status (SES) matched children who are nondiabetic were selected as controls. Among the major diabetes hospitals in Bengaluru, Bangalore Diabetes Hospital was selected randomly by lottery method for the purpose of the study. T1DM children of age 10–15 years attending Bangalore Diabetes Hospital were taken. Patients undergoing orthodontic treatment, revealing the history of any other systemic complications, who were physically disabled and not able to take care of their oral hygiene and patients on medications (other than diabetic drugs) which have an influence on oral health were excluded from the study. The pro forma used in this study had five sections.

  • Section one consisted of informed consent and sociodemographic information such as age, sex, and SES based on Kuppuswamy's Scale updated for 2012[12] consisting of education, occupation, and income of parents
  • Section two consisted of a medical history of type 1 diabetic patients such as duration, age at diagnosis, complications, drug history, and blood sugar level
  • Section three consisted of oral hygiene practices which included a method of cleaning; materials used; frequency of cleaning and visit dentist and tobacco use
  • Section four included a provision to record oral health knowledge


  • A self-designed questionnaire was used to assess the oral health knowledge of type 1 diabetic patients. Its respective psychometric properties (validity and reliability) were assessed as follows. Content validity was assessed using a panel of ten experts made up of staff members of all the departments of M. R. Ambedkar dental college and hospital, Bengaluru. The purpose was to depict those items with a high degree of agreement among experts Aiken's V was used to quantify the concordance between experts for each item and the values higher than 0.82 were always obtained. The questions were translated from English to local language (Kannada) for convenience and feasibility of the study and then translated back to English to ensure the meaning of the question remains the same

  • Section five included provision to record community periodontal index (CPI), Dentition status and treatment needs by applying WHO modified pro forma (1997).


Ethical clearance was obtained from the Ethical Review Board of the Institution and permission to examine the controls was obtained from the Headmaster/Mistress of the respective school.

Before the data collection and clinical examination, the purpose and the methodology of the study were explained to the patients and parents. Voluntarily written informed consent was then obtained from the parents along with the verbal assent from the participants. One of the authors underwent intensive training in the usage of CPI (this index included first three coding criteria to assess periodontal status) and dentition status and treatment needs. To ensure intra-examiner consistency, a randomly selected ten subjects were examined from the study group for CPI and dentition status and Treatment Needs and were re-examined. Using Kappa statistics, intra examiner reliability was 0.86 for CPI, and 0.83 for decayed-missing-filled teeth index (DMFT). All the scores imply a high degree of reproducibility.

Collection of data

A pro forma was used to record data. First, four sections in the pro forma were recorded by interview method and the fifth section was examined by a single calibrated examiner and data were recorded by an assistant. The assistant was trained in recording pro forma before the examination.

Clinical examination

The patients were made to sit comfortably on a chair and the oral cavity was examined under artificial illumination. The type III clinical examination that is inspection using mouth mirror and explorer with adequate illumination was followed throughout the study.

Statistical analysis

The analysis was carried out using a statistical package (SPSS version 18.0 statistical software), and appropriate statistical tests were employed.

  1. The response to each of the nine items was re-coded as correct or incorrect (including the “don't know” response). Participants were divided into two groups according to their number of correct responses: those above the median (five or more items answered correctly) and those at or below the median (four or fewer items answered correctly). Participants who scored above the median were signified as having adequate knowledge of oral health versus those participants who scored at or below the median who were signified as having inadequate knowledge of oral health. Placing the cutoff at the median is a commonly used method to set the cutoff score in health knowledge test[13]
  2. Categorical data were compared using Chi-square test
  3. Continuous data were compared using Student t-test.



   Results Top


The study comprised 350 subjects. Out of them, 175 were T1DM children, and 175 were healthy controls, who were matched for age, sex, and SES. Mean age of the diabetic group was 12.9 ± 1.7 years and control group was 12.7 ± 1.6 years. The sociodemographic details are projected in [Table 1].
Table 1: Distribution of the study subjects according to sociodemographic details

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Distribution of the study participants according to oral hygiene habits

In diabetic group, all subjects used toothbrush to clean their teeth. Among control group, 137 (99.9%) patients used toothbrush, and 2 (1.1%) used a finger for cleaning the teeth. In diabetic group, 169 (96.6%) of patients used toothpaste and 6 (3.4%) used toothpowder for cleaning their teeth. In control group, 162 (92.6%) used toothpaste, 13 (7.4%) used powder for cleaning their teeth. All oral hygiene habits are projected in [Table 2]. Regarding dental visit, 71 (40.6%) of patients in diabetic and 54 (30.9%) of patients in control group had visited the dentist. The difference between diabetic group and control group was statistically significant (P = 0.04) [Table 3].
Table 2: Distribution of the study subjects according to oral hygiene habits

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Table 3: Distribution of the study subjects according to dental visit

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Distribution of the study participants according to oral health knowledge

Overall oral health knowledge was more among the diabetic group (8.3 ± 1.7) compared to control group (7.5 ± 1.8) and showed the statistically significant difference between the two groups (P = 0.001) [Figure 1]a and [Figure 1]b.
Figure 1: (a) Distribution of the diabetic subjects according to oral health knowledge (b) distribution of the control subjects according to oral health knowledge

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Oral health status

Assessment of periodontal health status

Mean numbers of sextants with healthy gingiva (CPI score 0) were lower in diabetic group than in control group. Mean numbers of sextants affected by gingival bleeding (CPI score 1) and calculus (score 2) were slightly higher in diabetic group than in control group. The difference between diabetic group and control group was statistically significant (P = 0.001) [Figure 2].
Figure 2: Distribution of the study subjects according to mean number of sextants affected per person

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Assessment of dental caries

Distribution of study participants according to caries status

In diabetic group, out of 175 participants, 45 (25.7%) had a carious lesion, and 130 (74.3%) of subjects were caries free. In control group, out of 175 participants, 68 (38.9%) had a carious lesion, and 107 (61.1%) participants were caries free. The difference between diabetic group and control group was statistically significant (P = 0.008) [Table 4] and [Figure 3].
Table 4: Distribution of the study subjects according to decayed-missing-filled teeth index/decayed-missing-filled teeth index score

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Figure 3: Distribution of the study subjects according to caries status

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   Discussion Top


Diabetes mellitus is one of the major chronic health problems facing the world today, and its implication on oral health is very well recognized. Diabetes mellitus has been linked with an increased risk of caries, gingivitis and periodontal disease. The present study targeted at 10–15 years T1DM children and adolescents with this disorder affect mainly children and adolescents.[1] Peak incidence occurs during puberty, around 10–12 years of age in girls and 12–14 years of age in boys.[2] Hence, the present study focused mainly on 10–15 years T1DM children and adolescents.

In this study, more than 50% of participants used a soft and medium type of toothbrush and toothpaste in diabetic group and control group. The probable reason could be that in an urban area, people are more concerned about their oral hygiene. This result is comparable to a study done by Alves et al.[1] and Siudikiene et al.[11] where toothpaste was used by 100% of the diabetics and 98.2% of nondiabetics. Participants in control group brushed their teeth twice a day, while in the diabetic group, they brushed their teeth once a day. This is in line with the study done by Siudikiene et al.[11] In our study, less number of subjects in diabetic group and control group had visited dentist in previous 1 year. Participants in both the groups exposed to public oral health programs conducted in hospitals and schools in last 1 year. When compared to a study conducted by Moore et al.,[14] 69% in diabetics and 75% in controls had visited the dentist in 1 year and in a study by Siudikiene et al.,[11] where both groups were similar with regard to frequency of dental visits. Majority of the participants in both diabetic group and control group not visited the dentist as they were not aware and did not had dental pain followed by high cost and transportation problems.

Results of this study showed that participants in the diabetic group have adequate oral health knowledge compare to control group. These findings are in contrast with the studies conducted by Alves et al.[1] and Akyüz and Oktay[15] This may be attributed to the increase in oral health information received in this area from health professionals. Diabetic subjects were more knowledgeable on the causes of dental caries, signs of gum disease compared to control group. Less than 50% of the participants in the diabetic group believed that they are not more prone to oral diseases which can be because being a diabetic; their diet is almost sugar-free. Majority of diabetic subjects were aware that taking care of oral health is equally important as taking care of general health. This in contrary to the study conducted by Akyüz and Oktay[15] Even though, diabetic participants had higher oral health knowledge but a number of dental visit and oral hygiene practice was low. The reason could be that the diabetic subjects were not aware of their oral health problems and also they believed that since their diet is sugar-free, they were less prone to dental problems.

Periodontitis was often assessed using different criteria or indices. In the present study, CPI[16] was used to assess periodontal health status. The first three scoring criteria were used to assess periodontal health status as 10–15 years age was considered in the study therefore further scoring criteria was not applicable. In the present study, prevalence of healthy periodontal tissue was less in diabetic than control. Diabetic patients had significantly more gingival bleeding compared to the control group. This can be attributed to altered collagen metabolism and increased vascular permeability in gingival tissues in diabetics.[17],[18] The other reason is that imbalance of glucose metabolism associated with diabetes predisposed to gingival inflammation.[19] This finding is in accordance with the study done by Pinson et al.,[20] Pinducciu et al.,[21], Lalla et al.,[8] Leeper et al.,[22] and Busato et al.[23] but in contrast with the studies conducted by Novaes et al.[24] and Sbordone et al.[25] Calculus score was significantly higher in diabetics than controls. T1DM patients have increased a number of Gram-negative bacteria which lead to increased calculus formation than nondiabetics.[18] This is similar to the studies conducted by Galea et al.[26] and Sandholm et al.[27]

Dental caries, either compared to healthy controls or in relation to the diabetic status, is a much less investigated topic than the periodontal disease in patients with diabetes, and the results have been notably inconsistent, as is evident from the literature review. In this study, there was a significant difference in the scores of DMFT/dmft was found between both the group. DMFT/dmft score was less in diabetic group than the control group. It was suggested that the modern management of diabetes with blood glucose monitoring and flexibility in insulin treatment allows a less restricted diet and reduces the significance of the dietary factors as the indicator for differences in caries development.[28] Furthermore, there is a decrease in the presence of salivary lactobacilli, due to the diet prescribed in such patients.[29] This is in line with a study conducted by Bacić et al.[30] Whereas contrast results were found in the study conducted by Twetman et al.,[31] López et al.[32] and Moore et al.[14]

However, the study has few limitations as the use of only close-ended questions (i.e., yes/no/don't know) in the oral health knowledge test may allow participants to guess the correct answer. Larger samples and number of controls can be used to generalize the study on a larger population.


   Conclusion Top


Diabetic subjects had higher gingival bleeding & calculus compared to controls. There is a significant difference in the mean DMFT score between diabetic and non diabetic subjects. Mean numbers of healthy sextants was less among diabetic group than the control group. Over all Oral health knowledge was more in diabetic group than the control group.

Medical specialist should play a leading role in encouraging diabetic patients to visit their dentists regularly. Dental practitioners have an opportunity and the responsibility to educate diabetic patients about the oral complications of diabetes and to promote proper oral health behaviors that limit the risks of tooth loss and periodontal disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Alves C, Brandão M, Andion J, Menezes R. Oral health knowledge and habits in children with type 1 diabetes mellitus. Braz Dent J 2009;20:70-3.  Back to cited text no. 1
    
2.
Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontol 2000 2007;44:127-53.  Back to cited text no. 2
    
3.
Kumar P, Krishna P, Reddy SC, Gurappa M, Aravind SR, Munichoodappa C, et al. Incidence of type 1 diabetes mellitus and associated complications among children and young adults: Results from Karnataka Diabetes Registry 1995-2008. J Indian Med Assoc 2008;106:708-11.  Back to cited text no. 3
    
4.
Srikanta SS. Insulin “dependent” diabetes mellitus in India: Classical versus atypical. Int J Diabetes Dev Ctries 1993;l: 29-35.  Back to cited text no. 4
    
5.
Orbak R, Simsek S, Orbak Z, Kavrut F, Colak M. The influence of type-1 diabetes mellitus on dentition and oral health in children and adolescents. Yonsei Med J 2008;49:357-65.  Back to cited text no. 5
    
6.
Lamster IB, Lalla E, Borgnakke WS, Taylor GW. The relationship between oral health and diabetes mellitus. J Am Dent Assoc 2008;139 Suppl: 19S-24S.  Back to cited text no. 6
    
7.
Lalla E, Cheng B, Lal S, Tucker S, Greenberg E, Goland R, et al. Periodontal changes in children and adolescents with diabetes: A case-control study. Diabetes Care 2006;29:295-9.  Back to cited text no. 7
    
8.
Lalla E, Cheng B, Lal S, Kaplan S, Softness B, Greenberg E, et al. Diabetes-related parameters and periodontal conditions in children. J Periodontal Res 2007;42:345-9.  Back to cited text no. 8
    
9.
Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. JAMA 2002;287:2563-9.  Back to cited text no. 9
    
10.
Ship JA. Diabetes and oral health: An overview. J Am Dent Assoc 2003;134:4S-10S.  Back to cited text no. 10
    
11.
Siudikiene J, Maciulskiene V, Dobrovolskiene R, Nedzelskiene I. Oral hygiene in children with Type I diabetes mellitus. Stomatologija 2005;7:24-7.  Back to cited text no. 11
    
12.
Kumar N, Gupta N, Kishore J. Kuppuswamy's socioeconomic scale: Updating income ranges for the year 2012. Indian J Public Health 2012;56:103-4.  Back to cited text no. 12
  [Full text]  
13.
Yuen HK, Wolf BJ, Bandyopadhyay D, Magruder KM, Salinas CF, London SD, et al. Oral health knowledge and behavior among adults with diabetes. Diabetes Res Clin Pract 2009;86:239-46.  Back to cited text no. 13
    
14.
Moore PA, Orchid T, Guggenheimer J, Weyant RJ. Diabetes and oral health promotion. JADA 2000;131:1333-41.  Back to cited text no. 14
    
15.
Akyüz S, Oktay C. The relationship between periodontitis and tooth decay in juvenile diabetes mellitus cases and in healthy children. J Marmara Univ Dent Fac 1990;1:58-65.  Back to cited text no. 15
    
16.
WHO. Oral Health Surveys – Basic Methods. 4th ed. Geneva: WHO; 1997.  Back to cited text no. 16
    
17.
Caranza FA, Newman MG, Takei HH. Clinical Periodontology. 9th ed. Elsevier publisher, 2001. p. 204-29.  Back to cited text no. 17
    
18.
Lal S, Cheng B, Kaplan S, Softness B, Greenberg E, Goland RS, et al. Gingival bleeding in 6- to 13-year-old children with diabetes mellitus. Pediatr Dent 2007;29:426-30.  Back to cited text no. 18
    
19.
Karjalainen KM, Knuuttila ML, Käär ML. Relationship between caries and level of metabolic balance in children and adolescents with insulin-dependent diabetes mellitus. Caries Res 1997;31:13-8.  Back to cited text no. 19
    
20.
Pinson M, Hoffman WH, Garnick JJ, Litaker MS. Periodontal disease and type I diabetes mellitus in children and adolescents. J Clin Periodontol 1995;22:118-23.  Back to cited text no. 20
    
21.
Pinducciu G, Micheletti L, Piras V, Songini C, Serra C, Pompei R, et al. Periodontal disease, oral microbial flora and salivary antibacterial factors in diabetes mellitus type 1 patients. Eur J Epidemiol 1996;12:631-6.  Back to cited text no. 21
    
22.
Leeper SH, Kalkwarf KL, Strom EA. Oral status of “controlled” adolescent type I diabetics. J Oral Med 1985;40:127-33.  Back to cited text no. 22
    
23.
Busato IM, Ignácio SA, Brancher JA, Moysés ST, Azevedo-Alanis LR. Impact of clinical status and salivary conditions on xerostomia and oral health-related quality of life of adolescents with type 1 diabetes mellitus. Community Dent Oral Epidemiol 2012;40:62-9.  Back to cited text no. 23
    
24.
Novaes AB Jr., Silva MA, Batista EL Jr., dos Anjos BA, Novaes AB, Pereira AL, et al. Manifestations of insulin-dependent diabetes mellitus in the periodontium of young Brazilian patients. A 10-year follow-up study. J Periodontol 1997;68:328-34.  Back to cited text no. 24
    
25.
Sbordone L, Ramaglia L, Barone A, Ciaglia RN, Iacono VJ. Periodontal status and subgingival microbiota of insulin-dependent juvenile diabetics: A 3-year longitudinal study. J Periodontol 1998;69:120-8.  Back to cited text no. 25
    
26.
Galea H, Aganovic I, Aganovic M. The dental caries and periodontal disease experience of patients with early onset insulin dependent diabetes. Int Dent J 1986;36:219-24.  Back to cited text no. 26
    
27.
Sandholm L, Swanljung O, Rytömaa I, Kaprio EA, Mäenpää J. Periodontal status of finnish adolescents with insulin-dependent diabetes mellitus. J Clin Periodontol 1989;16:617-20.  Back to cited text no. 27
    
28.
Twetman S, Nederfors T, Stahl B, Aronson S. Two-year longitudinal observations of salivary status and dental caries in children with insulin-dependent diabetes mellitus. Pediatr Dent 1992;14:184-8.  Back to cited text no. 28
    
29.
Swanljung O, Meurman JH, Torkko H, Sandholm L, Kaprio E, Mäenpää J, et al. Caries and saliva in 12-18-year-old diabetics and controls. Scand J Dent Res 1992;100:310-3.  Back to cited text no. 29
    
30.
Bacić M, Plancak D, Granić M. CPITN assessment of periodontal disease in diabetic patients. J Periodontol 1988;59:816-22.  Back to cited text no. 30
    
31.
Twetman S, Johansson I, Birkhed D, Nederfors T. Caries incidence in young type 1 diabetes mellitus patients in relation to metabolic control and caries-associated risk factors. Caries Res 2002;36:31-5.  Back to cited text no. 31
    
32.
López ME, Colloca ME, Páez RG, Schallmach JN, Koss MA, Chervonagura A, et al. Salivary characteristics of diabetic children. Braz Dent J 2003;14:26-31.  Back to cited text no. 32
    

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Correspondence Address:
Dr. S Geetha
MR Ambedkar Dental College and Hospital, 1/36 Cline Road, Cooke Town, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_572_17

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