|
|
Year : 2008 | Volume
: 19
| Issue : 4 | Page : 326-330 |
|
Incremental lines in root cementum of human teeth: An approach to their role in age estimation using polarizing microscopy |
|
Pooja Aggarwal, Susmita Saxena, Puja Bansal
Department of Oral Pathology and Microbiology, Subharti Dental College, Meerut, UP, India
Click here for correspondence address and email
Date of Submission | 23-Jan-2008 |
Date of Decision | 19-May-2008 |
Date of Acceptance | 22-May-2008 |
|
|
 |
|
Abstract | | |
Age estimation is an important factor in the identification of an individual in forensic science. The hard tissues of the human dentition are able to resist decay and degradation long after other tissues are lost. This resistance has made teeth useful indicators for age calculation. Recent research indicates that tooth cementum annulations (TCA) may be used more reliably than any other morphological or histological traits of the adult skeleton for age estimation. The purpose of this study was to examine the correlation between age and the number of incremental lines in human dental cementum and to ascertain the best method of studying cementum with respect to different forms of microscopy. Thirty nonrestorable teeth were extracted from 20 people, and longitudinal ground section of each tooth was prepared. Photomicrographs of the area at the junction of apical and middle third of the root under light and polarized microscope were taken. The cementum was composed of multiple light and dark bands that were counted on the photomicrograph with the help of image analysis software and added to the average eruption time of individual tooth. The predicted age of the individual was thus obtained. Results showed a significant correlation between the predicted age and actual chronological age of the individual. These data indicate that quantitation of cementum annuli is a moderately reliable means for age estimation in humans and polarizing microscopy is a better means of visualizing incremental lines of cementum compared to light microscopy. Keywords: Age estimation, cementum, incremental lines
How to cite this article: Aggarwal P, Saxena S, Bansal P. Incremental lines in root cementum of human teeth: An approach to their role in age estimation using polarizing microscopy. Indian J Dent Res 2008;19:326-30 |
How to cite this URL: Aggarwal P, Saxena S, Bansal P. Incremental lines in root cementum of human teeth: An approach to their role in age estimation using polarizing microscopy. Indian J Dent Res [serial online] 2008 [cited 2023 Mar 23];19:326-30. Available from: https://www.ijdr.in/text.asp?2008/19/4/326/44536 |
Age determination plays an important role in forensic medicine, not only in identification of bodies but also in connection with crimes. When the subjects have undergone changes so extensive that external characteristics yield no information, the teeth are often the only means of identification. [1]
The hard tissues of the human dentition are able to resist decay and degradation long after other tissues are lost. This resistance has made teeth useful indicators for assessing variation in diet, expression of metabolic diseases, and calculation of age at the time of death. [2]
Gradual structural changes in teeth throughout the life are the basis for age estimation. The enamel, dentin, and cementum that comprise teeth have been used to estimate the chronologic age of unidentified individuals. Because of its position, cementum has not been used to the extent of enamel and dentin. However, the counting of cemental annulations may offer a more accurate method for age estimation in human beings. [3]
Zander and Hürzeler [4] stated that cementum is potentially a better age-estimating tissue due to its unique location in the alveolar process. It has been hypothesized that these incremental lines in the tooth cementum can be used as a more reliable age marker than any other morphological or histological traits in the human skeleton. This hypothesis is based on the biological factors of the tooth cementum annulations (TCA) formation known so far.
The purpose of this study was to examine the correlation between age and the number of incremental lines in human dental cementum and to ascertain the best method of studying cementum with respect to different forms of microscopy.
Materials and Methods | |  |
This study was carried out in the Department of Oral Pathology and Microbiology, Subharti Dental College, Meerut.
The study sample consisted of 30 teeth. They included seven maxillary canines, six mandibular canines, four mandibular central incisors, two maxillary lateral incisors, six mandibular premolars, and five mandibular molars.
The age of the individuals (when the tooth was extracted) ranged from 13-69 years. Teeth were extracted because of periodontal disease, caries, orthodontic, and prosthetic reasons. Teeth with periapical pathologies were not included in the study. The presence of periodontal disease, however, was not the criteria for exclusion because we were interested to see the possible impact of periodontal pathologies on TCA.
Among the 30 teeth in the sample, 19 originated from multiple extractions in seven individuals. These multiple extractions provided the basis for establishing intraindividual correlations in TCA.
Longitudinal ground section of each tooth was prepared and examined under light microscope and polarized microscope [Figure 1] and [Figure 2].
The measurements and counting were made without the age being known by two observers, to check for interobserver variation.
In each section, the area at the junction of apical and middle third of root [Figure 3] and the area where the lines were easiest to count, disregarding whether the cementum was cellular or acellular, were selected for counting. These areas were photographed and images were transmitted from the microscope to a computer monitor, and counting was done with the help of image analysis software [Figure 4].
First, the width of the cementum from the dentin-cemental junction to the surface of the cementum was measured in an area where the lines seemed to run approximately parallel. Then the measurement was made of the width occupied by the two adjacent incremental lines [Figure 5], which were most easily recognizable, and the number of incremental lines in the total cementum width was calculated.
Number of incremental lines (n) = X/ Y
Where, X is the total width of cementum (from DEJ to cementum surface) and Y the width of cementum between the two incremental lines.
By adding average age of eruption in years for each tooth as presented in Gray's Anatomy [5] in the counted number of incremental lines, the chronological age of the individual was obtained.
E = n + t
Where,Estimated age = number of incremental lines (n) + eruption age of tooth (t)
Results | |  |
Calculated and the actual chronological ages of individuals are shown in [Table 1], which represents the data of 30 specimens for ages between13-69 years. This indicates a fairly strong positive correlation between the two variables of estimated age and actual age.
Discussion | |  |
Cementum is the calcified tissue that surrounds the root portion of dentin and forms the attachment site for the periodontal fibers that links the tooth to the alveolar bone. In cementum formation, hypermineralized layers of extracellular matrix alternate with less-mineralized layers. The first layer of acellular cementum is produced before the tooth erupts, and further layers are added during and after eruption. [6]
A biological explanation for these alternating layers was given by Lieberman [7] and Schroder. [8] They suggested that the dark lines are stop phases of mineralization during continual growth of the fibroblasts, leading to a change in mineral crystal orientation. This pattern is visible under the microscope as a series of alternating light and dark lines or bands. The dark lines have been referred to as incremental lines and the cementum between each two lines as incremental bands.
In our study, we found that these lines were more clearly visible under polarized microscope than light microscope [Table 2]. Under light microscope, cemental annulations could not be found in each examined tooth and their visibility differed across specimens.
Along the axis of the tooth root there are two zones of different cementum types: the acellular cementum that grows close to the cervical part of the root, and the cellular cementum that mainly covers the apical part of the root. In the present study, we focused on the acellular cementum, predominantly seen in the middle third of the root. [5]
It was shown that each pair of lines corresponds to one year of life and constitutes a biological record that can be used to estimate the age of the individual. [7],[9]
Variations in cementogenesis that change the appearance of lines may be induced by different factors, including biomechanical forces, nutrition, hormonal cycle, or ecological conditions such as temperature, ultraviolet light, humidity, altitude, or pollution. [6]
The appearance of cementum lines, observed in more than 50 different mammalian species all over the world, has been said to reflect the natural metabolic rhythm of seasonal changes. Seasonal rhythms in cementum annulations, as observed in the alternating dark and light bands, can be explained by the metabolism of the parathyroid hormone, which in connection with vitamin D regulates the resorption of calcium. [6]
Thus, both hormones and vitamins may interact to produce a circannual rhythm by a complex mechanism of environmental and physiochemical synchronizers. Many questions remain regarding the mechanisms of TCA and its influencing factors, particularly concerning the interpretation of seasonal increments. [7],[10],[11]
The first use of cementum in human age estimation began with measurements of width of the total cementum layer, rather than the number of incremental lines. [12]
Stott et al., [10] in 1982 first used TCA, as an age estimation method in humans. Further technical improvements [13] led to the suggestion that the TCA is superior to other tooth-based methods of age estimation in the adult skeleton.
Initially, the TCA method was applied to freshly extracted teeth, but Grosskopf [14] showed that the method was also applicable to historical skeletons and cremations. This was confirmed by others and extended to forensic cases. These findings add further support to the idea that the number of incremental lines is a stable property, even under circumstances where other characteristics of the lines (e.g., width and degree of mineralization) have been altered by environmental or physiological perturbations. It was on the basis of these kinds of results that the TCA method was recently recommended as a reliable technique for age estimation in adults using skeletal materials. [6]
However, some problems remain regarding the full application of the TCA method. For example, the small samples used in previous studies limited the establishment of statistical parameters needed for practical paleodemographic and forensic applications and the question of whether dental disease, particularly periodontal disease, has an impact on TCA. [6]
One of the more contentious discussion associated with TCA is related to the effect of periodontal disease. As the cementum annulations are interrelated with the Sharpey fibers, it is plausible that with increasing periodontal decline, the Sharpey fibers may lose their functional significance and decay owing to the reducing alveolar bone. An arrest of the cementum annulation process might occur. In our sample, however, we did not observe any correlation between the deviation of TCA age from true age and degree of periodontal decline. From our study, we conclude that the accuracy of the TCA age estimation is independent of periodontal disease, a finding that supports the results of Grosskopf et al., [14] rather than those of Kragerer and Grup. [9]
To analyze reliability by tooth type, we had to split our sample into small subgroups. However, as no sex differences in TCA estimation error were observed, different tooth types were not analyzed separately based on the sex of the individual. The results of our study do not suggest the selection of a specific tooth type as a favorable tooth type for age estimation by cementum annulations. All teeth in our sample from the maxilla as well as from the mandible provided results of comparable reliability.
The sectioning method to be used has also not been a topic of agreement. Many authors prefer the sections to be longitudinal, whereas others prefer cross sections. Both methods seem to have advantages and limitations. Although the longitudinal sections allow viewing the whole root surface such as advocated by Klevezal and Kleinenberg, [15] others such as Stott et al., [11] prefer a cross section that allows a series of observations. The study of cemental incremental lines in longitudinal sections as in the present study gave the opportunity to count the lines in both the cellular and acellular cementum on the same tooth.
Annulation counts in younger age group (<55 years) appear to be very close to the actual age. Whereas, annulation for individuals above 55 years of age showed an increased tendency to be unrepresentative.
Inaccurate age estimation was obtained in three samples, all of which had actual age more than 60 years. The lower correlation in older persons in the Lipsinic et al., [16] study and the present study may be due to a decreased apposition of cementum in individuals over 60 years. Solheim [17] showed that cementum apposition diminishes by one-thirds after the age of 60 years.
Conclusion | |  |
Our results suggest that there is no significant influence of sex, age, periodontal disease, or tooth type on the estimation quality of the TCA method. This suggests that the accuracy and repeatability of the method is not dependent on tooth type or location, and this method can be applied to general populations regardless of systemic or periodontal health.
For a successful application in historical populations, the influence of living conditions that severely affect the calcium metabolism in the human body still has to be tested, including severe malnutrition or specific diseases. So, further studies are needed to show whether the same accuracy can be achieved in a historical known age collection exposed to different environmental conditions than in a modern population.
Finally, we can conclude from the current study that the application of TCA age estimation improves individual age estimation and it may serve as a valuable aid for forensic identification.
References | |  |
1. | Stein TJ, Corcoran JF, Arbor A, Mich. Pararadicular cementum deposition as a criterion for age estimation in human beings. Oral Surg Oral Med Oral Pathol 1994;77:266-70. |
2. | Stein TJ. Anatomy of root apex and histological changes with age. Oral Surg Oral Med Oral Pathol 1990;69:266-70. |
3. | Tencate A. The estimation of age of skeletal remains from color of roots of teeth. J Can Dent Assoc 1977;2:83-6. |
4. | Zander HA, Hürzeler B. Continuous cementum apposition. J Dent Res 1958;37:1035-44. |
5. | Gray's anatomy. In: Warwick R, Williams PL, editors. 35 th ed. W B Saunders Co; 1973. p. 1184-5. |
6. | Backofen UW, Gampe J, Vaupel JW. Tooth cementum annulation for age estimation: Results from a large known-age validation study. Am J Phys Anthropol 2004;123:119-29. |
7. | Lieberman DE. The biological basis for seasonal increments in dental cementum and their applications to archaeological research. J Archaeol Sci 1994;21:525-39. |
8. | Schrφder HE. Orale strukturbildung: Etwicklungsge-schichte, struktur und function normaler hartgewebe und weichgewebe der mundhφhle und des kiefergelenkes. Berlin: Thieme - Verlag; 2000. |
9. | Kagerer P, Grupe G. Age at deathdiagnosis and determination of life history parameters by incremental lines in human dental cementum as an identification aid. Forensic Sci Int 2001;118:75-82. |
10. | Stott GG, Sis RF, Levy BM. Cementum annulation as an age criterion in forensic dentistry. J Dent Res 1982;61:814-7. |
11. | Cipriano A. Cold stress in captive great apes recorded in incremental lines of dental cementum. Folia Primatol (basel) 2001;73:21-31. |
12. | Gustafson G. Age determinations on teeth. J Am Dent Assoc 1950;41:45-54. |
13. | Naylor JW, Miller WG, Stokes GN, Stott GG. Cemental annulation enhancement: A technique for age determination in man. Am J Phys Anthropol 1985;68:197-200. |
14. | Grosskopf B. Incremental lines in prehistoric cremated teeth. Z Morpho Anthro 1989;77:309-11. |
15. | Klevezal GA, Kleinenberg SE. Age determination of mammals from annual layers in teeth and bones. Springfield, Virginia: US Department of Commerce; 1967. |
16. | Lipsinic FE. Paunovich E, Houston GD, Robison SF. Corrlation of age and incremental lines in the cementum of human teeth. J Forensic Sci 1986;31:982-9. |
17. | Solheim T. Dental cementum apposition as an indicator of age. Scand J Dent Res 1990;98:510-9. |

Correspondence Address: Pooja Aggarwal Department of Oral Pathology and Microbiology, Subharti Dental College, Meerut, UP India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.44536

[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2] |
|
This article has been cited by | 1 |
DENTAL AGE ESTIMATION BY CEMENTUM INCREMENTAL LINES COUNTING: A SYSTEMATIC REVIEW AND META-ANALYSIS |
|
| Paulo Henrique Viana PINTO, Letícia Carneiro FARES, Ricardo Henrique Alves da SILVA | | Forensic Science International. 2022; : 111492 | | [Pubmed] | [DOI] | | 2 |
A morphometric assessment of developing permanent dentition for age and sex estimation in a select South African sample |
|
| S. Ishwarkumar, P. Pillay, M. Chetty, KS Satyapal | | Forensic Science International: Reports. 2022; 6: 100294 | | [Pubmed] | [DOI] | | 3 |
Reliability of dentin translucency and incremental cemental lines in age estimation using light and stereomicroscopes: A comparative study |
|
| Sanjeevareddygari Shylaja, Srinivas Munisekhar Manay, Kiran Kumar Ganji, Sharath Kumar Reddy Eppalapalli, Venkata Ramanand Oruganti, Rakhi Issrani | | Journal of Forensic Sciences. 2022; | | [Pubmed] | [DOI] | | 4 |
The Effects of Experimental Whole-Body Burning on Histological Age-at-Death Estimation from Human Cortical Bone and Dental Cementum |
|
| Sophia R. Mavroudas, Lauren A. Meckel, Timothy P. Gocha, Justin Z. Goldstein, Shelby L. Garza | | Biology. 2022; 11(11): 1569 | | [Pubmed] | [DOI] | | 5 |
Dental cementum examination with SEM/EDX for unravelling details along the lifeline to assist identification of a female individual |
|
| Mimoza Ristova, Dijana Josheva, Zuzana Brozek-Mucha | | Forensic Science International. 2021; : 111103 | | [Pubmed] | [DOI] | | 6 |
Age estimation with cemental incremental lines in normal and periodontally diseased teeth using phase contrast microscope: an original research |
|
| Ameena Sultana, Heena Zainab, Pramod Jahagirdar, Deepa Hugar, Shaimaa | | Egyptian Journal of Forensic Sciences. 2021; 11(1) | | [Pubmed] | [DOI] | | 7 |
Do upper third molars provide more accurate age estimation in the adult based on the pulp-to-tooth ratio than lower third molars? A cone-beam CT study |
|
| Salah A. Al-Omoush, Abeer Alhadidi, Awni Al-Kayed, Hamza Saoud, Firas Alsoleihat | | The Saudi Dental Journal. 2021; 33(7): 702 | | [Pubmed] | [DOI] | | 8 |
Stressful times for women - Reply to Edinborough et al. (2021) |
|
| Kristina Penezic, Marko Porcic, Petra Kathrin Urban, Ursula Wittwer-Backofen, Sofija Stefanovic | | Journal of Archaeological Science. 2021; 134: 105464 | | [Pubmed] | [DOI] | | 9 |
IMPLICATION OF PERIO IN FORENSIC ODONTOLOGY |
|
| Mahesh G. Chavda, Neeta V. Bhavsar, Mahendra Kumar Singh | | GLOBAL JOURNAL FOR RESEARCH ANALYSIS. 2020; : 116 | | [Pubmed] | [DOI] | | 10 |
Examination of tooth shade in relation to age and gender |
|
| Nenad Stošic, Jelena Popovic, Jovanka Gašic, Aleksandar Mitic, Marija Nikolic, Radomir Barac, Stefan Dacic | | Glasnik Antropoloskog drustva Srbije. 2019; (54): 41 | | [Pubmed] | [DOI] | | 11 |
Nondestructive adult age at death estimation: Visualizing cementum annulations in a known age historical human assemblage using synchrotron X-ray microtomography |
|
| Adeline Le Cabec,Nancy K. Tang,Valentin Ruano Rubio,Simon Hillson | | American Journal of Physical Anthropology. 2019; 168(1): 25 | | [Pubmed] | [DOI] | | 12 |
Age at death estimation by cementochronology: Too precise to be true or too precise to be accurate? |
|
| Benoit Bertrand,Eugenia Cunha,Anne Bécart,Didier Gosset,Valery Hédouin | | American Journal of Physical Anthropology. 2019; 169(3): 464 | | [Pubmed] | [DOI] | | 13 |
Age at death estimation by cementochronology: Too precise to be true or too precise to be accurate? |
|
| Benoit Bertrand,Eugenia Cunha,Anne Bécart,Didier Gosset,Valery Hédouin | | American Journal of Physical Anthropology. 2019; 169(3): 464 | | [Pubmed] | [DOI] | | 14 |
Testing and comparing the accuracy of two dental age estimation methods on saudi children: Measurements of open apices in teeth and the London Atlas of Tooth Development |
|
| Dara M. Alsudairi,Sakher J. AlQahtani | | Forensic Science International. 2019; 295: 226.e1 | | [Pubmed] | [DOI] | | 15 |
Testing and comparing the accuracy of two dental age estimation methods on saudi children: Measurements of open apices in teeth and the London Atlas of Tooth Development |
|
| Dara M. Alsudairi,Sakher J. AlQahtani | | Forensic Science International. 2019; 295: 226.e1 | | [Pubmed] | [DOI] | | 16 |
Cementochronology: A solution to assess mortality profiles from individual age-at-death estimates |
|
| Laëtitia Lanteri,Bruno Bizot,Bérengère Saliba-Serre,Jean Gaudart,Michel Signoli,Aurore Schmitt | | Journal of Archaeological Science: Reports. 2018; 20: 576 | | [Pubmed] | [DOI] | | 17 |
Spectrophotometric dental colour measurement to assess age in living adults |
|
| Stella Martin-de-las-Heras,Mar Del-Rey,Ana Molina,Leticia Rubio | | Australian Journal of Forensic Sciences. 2018; 50(1): 82 | | [Pubmed] | [DOI] | | 18 |
Spectrophotometric dental colour measurement to assess age in living adults |
|
| Stella Martin-de-las-Heras,Mar Del-Rey,Ana Molina,Leticia Rubio | | Australian Journal of Forensic Sciences. 2018; 50(1): 82 | | [Pubmed] | [DOI] | | 19 |
Differences between biological and chronological age-at-death in human skeletal remains: A change of perspective |
|
| Lourdes R. Couoh | | American Journal of Physical Anthropology. 2017; 163(4): 671 | | [Pubmed] | [DOI] | | 20 |
Differences between biological and chronological age-at-death in human skeletal remains: A change of perspective |
|
| Lourdes R. Couoh | | American Journal of Physical Anthropology. 2017; 163(4): 671 | | [Pubmed] | [DOI] | | 21 |
Inferring chronological age from DNA methylation patterns of human teeth |
|
| Cristina Giuliani,Elisabetta Cilli,Maria Giulia Bacalini,Chiara Pirazzini,Marco Sazzini,Giorgio Gruppioni,Claudio Franceschi,Paolo Garagnani,Donata Luiselli | | American Journal of Physical Anthropology. 2016; 159(4): 585 | | [Pubmed] | [DOI] | | 22 |
Inferring chronological age from DNA methylation patterns of human teeth |
|
| Cristina Giuliani,Elisabetta Cilli,Maria Giulia Bacalini,Chiara Pirazzini,Marco Sazzini,Giorgio Gruppioni,Claudio Franceschi,Paolo Garagnani,Donata Luiselli | | American Journal of Physical Anthropology. 2016; 159(4): 585 | | [Pubmed] | [DOI] | | 23 |
Relationship Between Mitochondrial DNA Mutations and Aging. Estimation of Age-at-death |
|
| Sara C. Zapico,Douglas H. Ubelaker | | The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2016; 71(4): 445 | | [Pubmed] | [DOI] | | 24 |
Relationship Between Mitochondrial DNA Mutations and Aging. Estimation of Age-at-death |
|
| Sara C. Zapico,Douglas H. Ubelaker | | The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2016; 71(4): 445 | | [Pubmed] | [DOI] | | 25 |
Dental age assessment of Western Saudi children and adolescents |
|
| Amin M. Alshihri,Estie Kruger,Marc Tennant | | The Saudi Dental Journal. 2015; 27(3): 131 | | [Pubmed] | [DOI] | | 26 |
Dental age assessment of Western Saudi children and adolescents |
|
| Amin M. Alshihri,Estie Kruger,Marc Tennant | | The Saudi Dental Journal. 2015; 27(3): 131 | | [Pubmed] | [DOI] | | 27 |
Age estimation in adult human sound and periodontally affected teeth using tooth cementum annulations |
|
| W.Y. Alghonamy,O.M. Gaballah,D.A. Labah | | Tanta Dental Journal. 2015; 12(4): 277 | | [Pubmed] | [DOI] | | 28 |
Age estimation in adult human sound and periodontally affected teeth using tooth cementum annulations |
|
| W.Y. Alghonamy,O.M. Gaballah,D.A. Labah | | Tanta Dental Journal. 2015; 12(4): 277 | | [Pubmed] | [DOI] | | 29 |
Age estimation among North Indians by cementum annulation count: A light microscopic study |
|
| Jasbir Arora,Daisy Sahni,Indu Talwar,Vidya Rattan | | Journal of the Anatomical Society of India. 2014; | | [Pubmed] | [DOI] | | 30 |
Cementum annulations, age estimation, and demographic dynamics in Mid-Holocene foragers of North India |
|
| Robbins Schug, G. and Brandt, E.T. and Lukacs, J.R. | | HOMO- Journal of Comparative Human Biology. 2012; 63(2): 94-109 | | [Pubmed] | | 31 |
Forensic odontology |
|
| Shamim, T. | | Journal of the College of Physicians and Surgeons Pakistan. 2012; 22(4): 240-245 | | [Pubmed] | | 32 |
Cementum annulations, age estimation, and demographic dynamics in Mid-Holocene foragers of North India |
|
| G. Robbins Schug,E.T. Brandt,J.R. Lukacs | | HOMO - Journal of Comparative Human Biology. 2012; 63(2): 94 | | [Pubmed] | [DOI] | | 33 |
Age estimation from dental cementum incremental lines and periodontal disease |
|
| Dias, P.E.M. and Beaini, T.L. and Melani, R.F.H. | | Journal of Forensic Odonto-Stomatology. 2010; 28(1): 13-21 | | [Pubmed] | | 34 |
Structural analysis of the indicators of dental age in hard dental tissues submitted to high temperatures [Análisis Estructural De Los Indicadores De Edad Dental En Los Tejidos Duros Del Diente Que Han Experimentado La Acción De Altas Temperaturas] |
|
| Paz, J.L.F. and Ortega, A.I. and Barrios, F.A. and Espina-Fereira, A.I. | | Acta Microscopica. 2010; 19(3): 291-304 | | [Pubmed] | |
|
|
 |
 |
|
|
|
|
|
|
Article Access Statistics | | Viewed | 23616 | | Printed | 663 | | Emailed | 10 | | PDF Downloaded | 1430 | | Comments | [Add] | | Cited by others | 34 | |
|

|