The burden of Diabetes, Its Oral Complications and Their Prevention and Management
DOI:
https://doi.org/10.3889/oamjms.2018.294Keywords:
Diabetes, Oral complications, PreventionAbstract
BACKGROUND: Diabetes mellitus (DM), chronic disease, is a public health problem that affects 8.5% adult population worldwide. The number of adults with DM has risen sharply from 108 million in 1980 to 422 million in 2014. In 2012, 1.5 million individuals died because of DM and an additional 2.2 million deaths occurred because of high blood glucose level resulting in cardiovascular and other systemic diseases. DM brings huge economic loss to patients, their families, and healthcare systems. Globally, the cost of DM was US$1•31 trillion in 2015.
AIM: This review article utilised the prevalence data of diabetes mellitus from the World Health Organization and International Diabetes Federation to provide a comprehensive picture of the disease in different parts of the world.
METHODS: Electronic databases such as Google Scholar, Medline via PubMed, Scopus, and Web of Science were used to search the literature. The library resources of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia were used to retrieve studies on the topics of the present review.
RESULTS: Systemic complications of DM include heart attack, kidney disease, limb loss, blindness, and peripheral nerve damage. More than 90% of diabetic patients were found to have oral manifestations. It is known that DM severely damages oral tissues causing periodontal disease, tooth loss, xerostomia, caries, burning mouth disorder, taste and salivary gland dysfunction, delayed wound healing, lichen planus, geographic tongue, and candidiasis. The evidence is mounting about a strong bidirectional relationship between DM and periodontal disease. Unfortunately, many diabetic patients are unaware of the association between DM and oral health, and only a small percentage of them visit the dentist for routine dental check-ups. Changes in lifestyles (control of blood glucose levels and self-care practices), regular dental check-ups with emphasis on periodontal assessment, and reinforcement of oral health instructions can effectively prevent oral complications of DM. Scaling and root planning are effective in improving glycemic control among diabetic patients.
CONCLUSION: Dental professionals should be part of the multidisciplinary team that helps individuals with diabetes.Downloads
Metrics
Plum Analytics Artifact Widget Block
References
American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes care. 2011; 34(Supplement 1):S11-S61. https://doi.org/10.2337/dc11-S011 PMid:21193625 PMCid:PMC3006050
World Health Organization. Global report on diabetes: World Health Organization, 2016.
Centers for Disease Control and Prevention. National diabetes statistics report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, 2017.
Kim DL, Kim SD, Kim SK, Park S, Song KH. Is an oral glucose tolerance test still valid for diagnosing diabetes mellitus? Diabetes & metabolism journal. 2016; 40(2):118-28. https://doi.org/10.4093/dmj.2016.40.2.118 PMid:26616592 PMCid:PMC4853219
Indurkar MS, Maurya AS, Indurkar S. Oral Manifestations of Diabetes. Clinical Diabetes 2016; 34:54-57. https://doi.org/10.2337/diaclin.34.1.54 PMid:26807010 PMCid:PMC4714722
Mariam TG, Alemayehu A, Tesfaye E, Mequannt W, Temesgen K, Yetwale F, Limenih MA. Prevalence of Diabetic Foot Ulcer and Associated Factors among Adult Diabetic Patients Who Attend the Diabetic Follow-Up Clinic at the University of Gondar Referral Hospital, North West Ethiopia, 2016: Institutional-Based Cross-Sectional Study. Journal of diabetes research. 2017; 2017.
Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, Lin JK, Farzadfar F, Khang YH, Stevens GA, Rao M. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2• 7 million participants. The Lancet. 2011; 378(9785):31-40. https://doi.org/10.1016/S0140-6736(11)60679-X
Moradi-Lakeh M, Forouzanfar MH, El Bcheraoui C, Daoud F, Afshin A, Hanson SW, Vos T, Naghavi M, Murray CJ, Mokdad AH. High fasting plasma glucose, diabetes, and its risk factors in the eastern mediterranean region, 1990–2013: findings From the Global Burden of Disease Study 2013. Diabetes care. 2016;dc161075.
Capozzi JD, Lepkowsky ER, Callari MM, Jordan ET, Koenig JA, Sirounian GH. The prevalence of diabetes mellitus and routine hemoglobin A1c screening in elective total joint arthroplasty patients. The Journal of arthroplasty. 2017; 32(1):304-8. https://doi.org/10.1016/j.arth.2016.06.025 PMid:27452137
World Health Organization. Diabetes country profiles, 2016. Available from: http://www.who.int/diabetes/country-profiles/en/
International Diabetes Federation. The country report, the IDF Atlas, 7th Edition, 2015.
Akhtar SN, Dhillon P. Prevalence of diagnosed diabetes and associated risk factors: Evidence from the large-scale surveys in India. Journal of Social Health and Diabetes. 2017; 5(1):28. https://doi.org/10.4103/2321-0656.194001
Pandit S, Gonsalves MN, Karkera B, Jasphin S. Diabetes: Risk Factor for Oral Cancer?-A Review. International Journal of Advanced Health Sciences. 2015; 1:25-28.
General S. The health consequences of smoking—50 years of progress: a report of the surgeon general. In: US Department of Health and Human Services, 2014.
Hernandez-Romieu AC, Garg S, Rosenberg ES, Thompson-Paul AM, Skarbinski J. Is diabetes prevalence higher among HIV-infected individuals compared with the general population? Evidence from MMP and NHANES 2009–2010. BMJ Open Diabetes Research and Care. 2017; 5(1):e000304. https://doi.org/10.1136/bmjdrc-2016-000304 PMid:28191320 PMCid:PMC5293823
Naito R, Miyauchi K. Coronary Artery Disease and Type 2 Diabetes Mellitus. Int Heart J. 2017; 58:475-80. https://doi.org/10.1536/ihj.17-191 PMid:28717115
American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes care. 2013; 36:1033-1046. https://doi.org/10.2337/dc12-2625 PMid:23468086 PMCid:PMC3609540
Bommer C, Heesemann E, Sagalova V, Manne-Goehler J, Atun R, B?rnighausen T, Vollmer S. The global economic burden of diabetes in adults aged 20–79 years: a cost-of-illness study. The lancet Diabetes & endocrinology. 2017; 5(6):423-30. https://doi.org/10.1016/S2213-8587(17)30097-9
Neidell M, Lamster IB, Shearer B. Cost?effectiveness of diabetes screening initiated through a dental visit. Community dentistry and oral epidemiology. 2017; 45(3):275-80. https://doi.org/10.1111/cdoe.12286 PMid:28145564
Mauri-Obradors E, Jan?-Salas E, del Mar Sabater-Recolons M, Vinas M, L?pez-L?pez J. Effect of nonsurgical periodontal treatment on glycosylated hemoglobin in diabetic patients: a systematic review. Odontology. 2015; 103:301-13. https://doi.org/10.1007/s10266-014-0165-2 PMid:25062756
Llamb?s F, Arias-Herrera S, Caffesse R. Relationship between diabetes and periodontal infection. World journal of diabetes. 2015; 6(7):927. https://doi.org/10.4239/wjd.v6.i7.927 PMid:26185600 PMCid:PMC4499526
Artese HPC, Foz AM, de Sousa Rabelo M, et al. Periodontal therapy and systemic inflammation in type 2 diabetes mellitus: a meta-analysis. PLoS One. 2015; 10:e0128344. https://doi.org/10.1371/journal.pone.0128344 PMid:26010492 PMCid:PMC4444100
Bajaj S, Prasad S, Gupta A, Singh VB. Oral manifestations in type-2 diabetes and related complications. Indian J Endocrinol Metab. 2012; 16:777-9. https://doi.org/10.4103/2230-8210.100673 PMid:23087863 PMCid:PMC3475903
Kaur G, Mohindra K, Singla S. Autoimmunity—Basics and link with periodontal disease. Autoimmunity reviews. 2017; 16(1):64-71. https://doi.org/10.1016/j.autrev.2016.09.013 PMid:27664383
Kawasaki E. Type 1 Diabetes and Autoimmunity. Clin Pediatr Endocrinol. 2014; 23(4):99–105. https://doi.org/10.1297/cpe.23.99 PMid:25374439 PMCid:PMC4219937
Koutouzis T, Haber D, Shaddox L, Aukhil I, Wallet SM. Autoreactivity of serum immunoglobulin to periodontal tissue components: a pilot study. Journal of periodontology. 2009; 80(4):625-33. https://doi.org/10.1902/jop.2009.080422 PMid:19335083 PMCid:PMC3594842
Kudiyirickal MG, Pappachan JM. Diabetes mellitus and oral health. Endocrine. 2015; 49(1):27-34. https://doi.org/10.1007/s12020-014-0496-3 PMid:25487035
Li Q, Hao S, Fang J, Xie J, Kong XH, Yang JX. Effect of non-surgical periodontal treatment on glycemic control of patients with diabetes: a meta-analysis of randomized controlled trials. Trials. 2015; 16(1):291. https://doi.org/10.1186/s13063-015-0810-2 PMid:26137892 PMCid:PMC4490675
Simpson TC, Weldon JC, Worthington HV, Needleman I, Wild SH, Moles DR, Stevenson B, Furness S, Iheozor-Ejiofor Z. Treatment of periodontal disease for glycaemic control in people with diabetes mellitus. Cochrane Database Syst Rev. 2015; 11(11). https://doi.org/10.1002/14651858.CD004714.pub3
D'Aiuto F, Gable D, Syed Z, Allen Y, Wanyonyi KL, White S, Gallagher JE. Evidence summary: The relationship between oral diseases and diabetes. British dental journal. 2017; 222(12):944. https://doi.org/10.1038/sj.bdj.2017.544 PMid:28642531
Balan P, Gogineni SB, Kumari S, Shetty V, Rangare AL, Castelino RL. Candida carriage rate and growth characteristics of saliva in diabetes mellitus patients: a case-control study. Journal of dental research, dental clinics, dental prospects. 2015; 9(4):274. https://doi.org/10.15171/joddd.2015.048 PMid:26889366 PMCid:PMC4753038
Rautemaa R, Ramage G. Oral candidosis–clinical challenges of a biofilm disease. Critical reviews in microbiology. 2011; 37(4):328-36. https://doi.org/10.3109/1040841X.2011.585606 PMid:21777047
Kumar S, Padmashree S, Jayalekshmi R. Correlation of salivary glucose, blood glucose and oral candidal carriage in the saliva of type 2 diabetics: A case-control study. Contemporary clinical dentistry. 2014; 5(3):312. https://doi.org/10.4103/0976-237X.137925 PMid:25191065 PMCid:PMC4147805
Izuora KE, Ezeanolue EE, Neubauer MF, Gewelber CL, Allenback GL, Umpierrez GE. Dental loss among ambulatory patients with diabetes. Journal of clinical & translational endocrinology. 2016; 4:28-31. https://doi.org/10.1016/j.jcte.2016.02.003 PMid:27088077 PMCid:PMC4827258
Kapp JM, Boren SA, Yun S, LeMaster J. Peer Reviewed: Diabetes and Tooth Loss in a National Sample of Dentate Adults Reporting Annual Dental Visits. Preventing chronic disease. 2007; 4(3). PMid:17572963 PMCid:PMC1955413
Macek MD, Taylor GW, Tomar SL. Dental care visits among dentate adults with diabetes, United States, 2003. Journal of public health dentistry. 2008; 68(2):102-10. https://doi.org/10.1111/j.1752-7325.2007.00064.x PMid:18221318
Martinez?Canut P. Predictors of tooth loss due to periodontal disease in patients following long?term periodontal maintenance. Journal of clinical periodontology. 2015; 42(12):1115-25. https://doi.org/10.1111/jcpe.12475 PMid:26498672 PMCid:PMC4737315
Lessa LS, Pires PD, Ceretta RA, Becker IR, Ceretta LB, Tuon L, Sim?es PW, S?nego FG. Meta-analysis of prevalence of xerostomia in diabetes mellitus. International Archives of Medicine. 2015; 8.
L?pez-Pintor RM, Casa?as E, Gonz?lez-Serrano J, Serrano J, Ram?rez L, de Arriba L, Hern?ndez G. Xerostomia, hyposalivation, and salivary flow in diabetes patients. Journal of diabetes research. 2016; 2016.
Lima DL, Carneiro SD, de Sousa Barbosa FT, de Lima Saintrain MV, Moizan JA, Doucet J. Salivary flow and xerostomia in older patients with type 2 diabetes mellitus. PloS one. 2017; 12(8):e0180891. https://doi.org/10.1371/journal.pone.0180891 PMid:28767676 PMCid:PMC5540406
Shrimali L, Astekar M, Sowmya GV. Correlation of oral manifestations in controlled and uncontrolled diabetes mellitus. International Journal of Oral and Maxillofacial Pathology. 2011; 2(4):24-7.
Kamaraj DR, Bhushan KS, Laxman VK, Mathew J. Detection of odoriferous subgingival and tongue microbiota in diabetic and nondiabetic patients with oral malodor using polymerase chain reaction. Indian Journal of Dental Research. 2011; 22(2):260. https://doi.org/10.4103/0970-9290.84301 PMid:21891897
Gurvits GE, Tan A. Burning mouth syndrome. World J Gastroenterol: WJG. 2013; 19:665. https://doi.org/10.3748/wjg.v19.i5.665 PMid:23429751 PMCid:PMC3574592
Grushka M, Su N. Burning mouth syndrome. Orofacial Disorders: Springer, 2017:223-32. https://doi.org/10.1007/978-3-319-51508-3_20
Gandara BK, Morton TH. Non-periodontal oral manifestations of diabetes: a framework for medical care providers. Diabetes Spectrum. 2011; 24(4):199-205. https://doi.org/10.2337/diaspect.24.4.199
Coculescu EC, Tovaru S, Coculescu BI. Epidemiological and etiological aspects of burning mouth syndrome. J Med Life. 2014; 7:305-9. PMid:25408745 PMCid:PMC4206710
Seethalakshmi C, Reddy RJ, Asifa N, Prabhu S. Correlation of salivary pH, incidence of dental caries and periodontal status in diabetes mellitus patients: A cross-sectional study. Journal of clinical and diagnostic research: JCDR. 2016; 10(3):ZC12. https://doi.org/10.7860/JCDR/2016/16310.7351
Kara SC, Nair GK, Gogineni SB. Sialometry, sialochemistry and oral manifestations in type 2 diabetes mellitus patients—a clinical and biochemical study. International Journal of Diabetes in Developing Countries. 2015; 35(4):573-7. https://doi.org/10.1007/s13410-015-0347-7
Al-Maskari AY, Al-Maskari MY, Al-Sudairy S. Oral manifestations and complications of diabetes mellitus: a review. Sultan Qaboos Univ Med J. 2011; 11:179. PMid:21969888 PMCid:PMC3121021
Aitken-Saavedra J, Rojas-Alcayaga G, Maturana-Ramirez A, et al. Salivary gland dysfunction markers in type 2 diabetes mellitus patients. J Clin Exp Dent. 2015; 7:e501-5. https://doi.org/10.4317/jced.52329 PMid:26535097 PMCid:PMC4628805
Singh I, Singh P, Singh A, Singh T, Kour R. Diabetes an inducing factor for dental caries: A case control analysis in Jammu. J Int Soc Prev Community Dent. 2016; 6:125. https://doi.org/10.4103/2231-0762.178748 PMid:27114951 PMCid:PMC4820571
Selwitz RH, Ismail AI, Pitts NB. Dental caries. The Lancet. 2007; 369(9555):51-9. https://doi.org/10.1016/S0140-6736(07)60031-2
Yonekura S, Usui M, Murano S. Association between numbers of decayed teeth and HbA1c in Japanese patients with type 2 diabetes mellitus. Upsala journal of medical sciences. 2017; 122(2):108-13. https://doi.org/10.1080/03009734.2017.1285838 PMid:28276781 PMCid:PMC5441370
Lundstrom IM. Incidence of diabetes mellitus in patients with oral lichen planus. Int J Oral Surg. 1983; 12:147-52. https://doi.org/10.1016/S0300-9785(83)80060-X
Petrou-Amerikanou C, Markopoulos AK, Belazi M, Karamitsos D, Papanayotou P. Prevalence of oral lichen planus in diabetes mellitus according to the type of diabetes. Oral Dis. 1998; 4:37-40. https://doi.org/10.1111/j.1601-0825.1998.tb00253.x PMid:9655043
Mozaffari HR, Sharifi R, Sadeghi M. Prevalence of Oral Lichen Planus in Diabetes Mellitus: a Meta-Analysis Study. Acta Inform Med. 2016; 24:390-93. https://doi.org/10.5455/aim.2016.24.390-393 PMid:28077900 PMCid:PMC5203753
Saini R, Al-Maweri SA, Saini D, Ismail NM, Ismail AR. Oral mucosal lesions in non oral habit diabetic patients and association of diabetes mellitus with oral precancerous lesions. Diabetes research and clinical practice. 2010; 89(3):320-6. https://doi.org/10.1016/j.diabres.2010.04.016 PMid:20488573
Rezaei F, Safarzadeh M, Mozafari H, Tavakoli P. Prevalence of Geographic tongue and Related Predisposing Factors in 7-18 Year-Old Students in Kermanshah, Iran 2014. Global journal of health science. 2015; 7(5):91. https://doi.org/10.5539/gjhs.v7n5p91 PMid:26156909 PMCid:PMC4803890
Zhang S, Wang S, Wei H, Li D, Song Y. Post-extraction socket changes in diabetic patients-a retrospective study. Int J Clin Exp Med. 2016; 9:14077-86.
Huang S, Dang H, Huynh W, Sambrook PJ, Goss AN. The healing of dental extraction sockets in patients with Type 2 diabetes on oral hypoglycaemics: a prospective cohort. Australian dental journal. 2013; 58(1):89-93. https://doi.org/10.1111/adj.12029 PMid:23441797
Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest. 2007; 117:1219-22. https://doi.org/10.1172/JCI32169 PMid:17476353 PMCid:PMC1857239
Gibran NS, Jang YC, Isik FF, et al. Diminished neuropeptide levels contribute to the impaired cutaneous healing response associated with diabetes mellitus. J Surg Res. 2002; 108:122-8. https://doi.org/10.1006/jsre.2002.6525 PMid:12443724
National institute of Diabetes and Digestive and Kidney Diseases. Diabetes, Gum Disease, & Other Dental Problems, 2017. Available from: https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems
Bahammam MA. Periodontal health and diabetes awareness among Saudi diabetes patients. Patient preference and adherence. 2015; 9:225. https://doi.org/10.2147/PPA.S79543 PMid:25673974 PMCid:PMC4321649
Gupta S, Sood S, Jain A, Garg V, Gupta J. Evaluation of oral health knowledge, attitude, and practices among diabetics in a Northern Union Territory of India. Indian Journal of Dental Sciences. 2017; 9(3):148. https://doi.org/10.4103/IJDS.IJDS_35_17
Herman WH, Taylor GW, Jacobson JJ, Burke R, Brown MB. Screening for prediabetes and type 2 diabetes in dental offices. Journal of public health dentistry. 2015; 75(3):175-82. https://doi.org/10.1111/jphd.12082 PMid:25662777 PMCid:PMC5053230
Ranjan R, Rajan S. Oral health manifestations in diabetic patients–a review. International Journal of Community Health and Medical Research. 2016; 2:58-62.
Mazzini Torres F, Ubilla Mazzini W, Moreira Campuzano T. Predisposing factors affecting oral health in diabetes mellitus patients. Revista Odontol?gica Mexicana. 2017; 21(2):103-8.
Kamath DG, Nayak SU, Pai KK, Shenoy R. Knowledge and awareness of oral health among diabetic patients—a cross-sectional study from Mangalore City. International Journal of Diabetes in Developing Countries. 2015; 35(2):71-5. https://doi.org/10.1007/s13410-015-0334-z
Bossart M, Calley KH, Gurenlian JR, Mason B, Ferguson RE, Peterson T. A pilot study of an HbA1c chairside screening protocol for diabetes in patients with chronic periodontitis: the dental hygienist's role. International journal of dental hygiene. 2016; 14(2):98-107. https://doi.org/10.1111/idh.12140 PMid:25809551
Wagh MR, Ravalia D. Perioperative management of diabetic patient. Journal of Advanced Medical and Dental Sciences Research. 2015; 3:79.
Foryciarz K, Obr?bski M, Kokoszka A. Results of the second Diabetes Attitudes, Wishes and Needs (DAWN2) study: Overview of the most important results from the Polish perspective. Clinical Diabetology. 2016; 5(6):185-94. https://doi.org/10.5603/DK.2016.0032
Saruta Saengtipbovorn DD, Taneepanichskul S. Lifestyle Change Plus Dental Care (LCDC) program improves knowledge, attitude, and practice (KAP) toward oral health and diabetes mellitus among the elderly with type 2 diabetes. J Med Assoc Thai. 2015; 98(3):279-90. PMid:25920299
Saengtipbovorn S, Taneepanichskul S. Effectiveness of lifestyle change plus dental care (LCDC) program on improving glycemic and periodontal status in the elderly with type 2 diabetes. BMC oral health. 2014; 14(1):72. https://doi.org/10.1186/1472-6831-14-72 PMid:24934646 PMCid:PMC4069273
Stevens JW, Khunti K, Harvey R, Johnson M, Preston L, Woods HB, Davies M, Goyder E. Preventing the progression to type 2 diabetes mellitus in adults at high risk: a systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions. Diabetes research and clinical practice. 2015; 107(3):320-31. https://doi.org/10.1016/j.diabres.2015.01.027 PMid:25638454
Javed F, Thafeed AlGhamdi AS, Mikami T, Mehmood A, Ahmed HB, Samaranayake LP, Tenenbaum HC. Effect of glycemic control on self?perceived oral health, periodontal parameters, and alveolar bone loss among patients with prediabetes. Journal of periodontology. 2014; 85(2):234-41. https://doi.org/10.1902/jop.2013.130008 PMid:23659422
Tummuru YR, Bellana VP, Koppula SK, et al. Salivary changes in medically compromised patients: A clinical and biochemical study. Journal of Indian Academy of Oral Medicine and Radiology. 2017; 29:12. https://doi.org/10.4103/jiaomr.JIAOMR_233_14
D'Aiuto F, Gable D, Syed Z, Allen Y, Wanyonyi KL, White S, Gallagher JE. Evidence summary: The relationship between oral diseases and diabetes. British dental journal. 2017; 222(12):944. https://doi.org/10.1038/sj.bdj.2017.544 PMid:28642531
Kapellas K, Mejia G, Bartold PM, Skilton MR, Maple?Brown LJ, Slade GD, O'dea K, Brown A, Celermajer DS, Jamieson LM. Periodontal therapy and glycaemic control among individuals with type 2 diabetes: reflections from the PerioCardio study. International journal of dental hygiene. 2017; 15(4):e42-51. https://doi.org/10.1111/idh.12234 PMid:27245786
Herlich A, Bosack RC. 45 When should you say no? Anesthesia complications in the dental office. 2015:315.
Al Amri MD, Kellesarian SV, Al?Kheraif AA, Malmstrom H, Javed F, Romanos GE. Effect of oral hygiene maintenance on HbA1c levels and peri?implant parameters around immediately?loaded dental implants placed in type?2 diabetic patients: 2 years follow?up. Clinical oral implants research. 2016; 27(11):1439-43. https://doi.org/10.1111/clr.12758 PMid:26756309
Aguilar?Salvatierra A, Calvo?Guirado JL, Gonz?lez?Jaranay M, Moreu G, Delgado?Ruiz RA, G?mez?Moreno G. Peri?implant evaluation of immediately loaded implants placed in esthetic zone in patients with diabetes mellitus type 2: a two?year study. Clinical oral implants research. 2016; 27(2):156-61. https://doi.org/10.1111/clr.12552 PMid:25623884
Ghiraldini B, Conte A, Casarin RC, Casati MZ, Pimentel SP, Cirano FR, Ribeiro FV. Influence of glycemic control on peri?implant bone healing: 12?month outcomes of local release of bone?related factors and implant stabilization in type 2 diabetics. Clinical implant dentistry and related research. 2016; 18(4):801-9. https://doi.org/10.1111/cid.12339 PMid:25825337
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2018 Muhammad Ashraf Nazir, Lamiah AlGhamdi, Mariam AlKadi, Noura AlBeajan, Latifah AlRashoudi, Mai AlHussan (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
http://creativecommons.org/licenses/by-nc/4.0