Influence of a new method of sterilization on the morphology and physical properties of extracted human teeth

Influência de um novo método de esterilização na morfologia e propriedades físicas de dentes humanos extraídos

Abstract

Introduction

Sterilization methods adopted in Human Teeth Bank can promote structural changes in enamel and dentin. Thus, the ideal method should combine the antimicrobial efficacy and preservation of the substrate biomechanical properties.

Aim

Evaluated the morphology and physical properties of enamel and dentin of extracted human teeth, after being submitted to different sterilization methods.

Method

Sixteen extracted third molars were sectioned in the following tooth regions: mesio-distal, vestibular-lingual and at the cement enamel junction. Forty specimens were selected according to values of microhardness and roughness initials, and distributed in four experimental groups (n = 10/group): Group 1 = Autoclave 121 °C (30 minutes); Group 2 = 2.5% Sodium hypochlorite (07 days); Group 3 = 5.25% Sodium hypochlorite (07 days); Group 4= 30% Acetic Acid (7 days). After sterilization, the microhardness, roughness and morphology of enamel and dentin were evaluated. Data were analyzed by paired t-test, Wilcoxon, Kruskal-Wallis and Analysis of Variance. A significance level of 5% was adopted.

Result

All sterilization methods altered the microhardness and roughness of the dentine (p <0.05). Regarding to enamel, the microhardness was affected only by Autoclave and 2.5% Sodium hypochlorite treatment (p <0.05). A large aperture of the enamel pores and dentinal tubules was verified in the micrographs.

Conclusion

The sterilization methods adopted altered the morphology and/or physical properties of enamel and dentine.

Descriptors:
Dental enamel; hardness; sterilization; dentin

Resumo

Introdução

Métodos de esterilização adotados em Banco de Dentes Humanos podem promover mudanças estruturais no esmalte e na dentina. Assim, o método ideal deve combinar a eficácia antimicrobiana e a preservação das propriedades biomecânicas do substrato.

Objetivo

Avaliar a morfologia e propriedades físicas do esmalte e dentina dos dentes humanos extraídos, após serem submetidos a diferentes métodos de esterilização.

Método

Dezesseis terceiros molares extraídos foram seccionados nas seguintes regiões dentárias: mesio-distal, vestibulo-lingual e na junção amelocementária. Quarenta espécimes foram selecionados de acordo com valores de microdureza e rugosidade iniciais, e distribuídos em quatro grupos experimentais (n = 10 / grupo): Grupo 1 = Autoclave 121 °C (30 minutos); Grupo 2 = 2,5% de hipoclorito de sódio (07 dias); Grupo 3 = 5,25% Hipoclorito de sódio (07 dias); Grupo 4 = ácido acético a 30% (7 dias). Após a esterilização, foi avaliada a microdureza, rugosidade e morfologia do esmalte e dentina. Os dados foram analisados ​​pelo teste t pareado, Wilcoxon, Kruskal-Wallis e Análise de Variância. Um nível de significância de 5% foi adotado.

Resultado

Todos os métodos de esterilização alteraram a microdureza e a rugosidade da dentina (p <0,05). Em relação ao esmalte, a microdureza foi afetada apenas pela Autoclave e pelo tratamento com 2,5% de hipoclorito de sódio (p <0,05). Foi verificada nas micrografias, uma grande abertura dos poros do esmalte e dos túbulos dentinários.

Conclusão

os métodos de esterilização adotados alteraram a morfologia e / ou propriedades físicas do esmalte e da dentina.

Descritores:
Esmalte dentário; dureza; esterilização; dentina

INTRODUCTION

Human Teeth Bank (HTB) is a nonprofit institution that stores, maintains and donates extracted human teeth, respecting ethical, legal and biosafety standards ¹ . Teeth manipulation can provide a risk of contamination for dentists, academics and researchers due to the presence of blood pathogens from pulp and periodontal tissues ² .

Previous studies highlight some methods of human teeth disinfection, such as immersion in formalina, sodium hypochlorite, glutaraldehyde or autoclave ³ . Related to teeth sterilization, other studies point out ethylene oxide, and gamma radiation use ⁴ . However, their efficacy can be altered and depends on the time of exposure, temperature, pressure, number of microorganisms and type of organic material that surrounds the teeth ⁵ .

Sterilization methods adopted in HTB can promote structural changes in enamel and dentin ⁵ . Thus, the ideal method should combine the antimicrobial efficacy and preservation of the substrate biomechanical properties, such as surface microhardness, coloration, mineral composition, microleakage, bond strength and dentin permeability ⁶ . Therefore, the choice of method should be careful in order to provide less variability in the studies and greater reliability of the results.

The Center for Disease Control and Prevention ⁷ considers that extracted teeth used for scientific and didactic purposes should be autoclaved or disinfected with sodium hypochlorite or other germicidal solutions. However, these methods modify or remove the enamel protein matrix ⁸ . Considering these criteria, the most recommended method would be gamma radiation ⁴ , despite of its complex and expensive process ⁹ .

Additionally, since an ideal method for tooth sterilization has not been well established, acetic acid solution has been investigated as an available, simple, low toxicity and cheaper antimicrobial agent ¹⁰ . However, there are few studies evaluating the effects of this substance on the enamel and dentin properties.

Therefore, this in vitro study evaluated the morphology and physical properties of enamel and dentin, after being submitted to sterilization methods. The hypothesis tested was that sterilization methods would not influence the morphology and physical properties of extracted human teeth.

MATERIAL AND METHOD

This in vitro study was approved by the Research Ethics Committee of the Federal University of Piauí (UFPI) – nº 1.872.436, in accordance with the World Medical Association Declaration of Helsinki.

Specimens Preparation

Sixteen third molars, newly extracted from patients aged 18-25 years, were selected. Teeth were acquired from the UFPI’s HTB, and stored in distilled water at 4 °C. After cleaning, the absence of defects in the enamel development, carious lesions and pre-existing fractures were verified.

The coronary portion was sectioned mesio-distal, vestibular-lingual/palatine, and at cement enamel junction (CEJ). A double-face diamond steel disc (KG Sorensen, Barueri, SP, Brazil) was used and 64 specimens containing enamel and dentin were obtained. The inner surface was polished with silicon carbide sandpaper (#400, #600 and #1200) (Buehler, Lake Bluff, Illinois, USA). After each sandpaper changing, the blocks were placed on ultrasound (Branson 1210 – Odontobrás, Ribeirão Preto, SP) containing deionized water for 5 minutes. This procedure was performed to prevent interference of sandpaper grains in the dental surface smoothness. Ultra-polishing was performed with SUPRA felt disc (Arotec S/A Ind. e Com., Cotia, SP) and aqueous diamond suspension (Arotec S/A Ind. e Com., Cotia, SP) with 1μm abrasive particles.

Microhardness and Surface Roughness Analyses

After finishing and polishing the blocks, values ​​of initial microhardness (KHN₁) of enamel and dentin were determined. It was used a Knoop hardness tester (Future-Tech FM hardness tester, FM-ARS 900 software) at 50 g static load for enamel and 5 g for dentin, both for 5 seconds. Enamel indentations were performed at 150 μm below the surface, 150 μm above the dentin and between these two distances. To perform microhardness in dentin, the specimens were left at room temperature for 30 minutes in order to minimize the interference of dehydration during measurement. Indentations were done 150 μm after dentin beginning, 150 μm above its terminus and between these two distances. KHN ₁ in enamel and dentin were obtained from the average of the three indentations in each dental tissue.

Roughness analysis (Ra) was determined using a Surfcorder SE 1700® rugosimeter (Kosaka Laboratory Ltd, Kosaka, Japan) with cut-off adjusted to 2.5 mm. After three readings in each specimen, the mean and initial total roughness (Ra₁) was established.

General averages were calculated for microhardness and surface roughness against the individual values. Therefore, specimens that presented values ​​outside the range (± 20% of the overall mean) were excluded of the study. The selected specimens were randomized and distributed into the treatment groups (n = 10/group): G1 = Autoclave 121 °C (30 min); G2 = 2.5% Sodium hypochlorite (07 days); G3 = 5.25% Sodium hypochlorite (07 days); G4 = 30% Acetic acid (7 days). After the sterilization process, new tests of microhardness (KHN₂) and roughness (Ra₂) were performed.

Scanning Electron Microscopy Analysis (SEM)

A morphological analysis was performed on enamel and dentin treated with different methods of sterilization (n = 4), and without treatment (n = 1). The specimens were washed with distilled water, gradually dehydrated with ethanol in the following concentrations: 25% (20 min), 50% (20 min), 75% (20 min), 95% (30 min), 98.93% (60 min), 100% (60 min). Then, specimens were fixed with hexamethyldisilazane (10 min). After 24 hours at room temperature, the specimens were metallized with gold (Bal-Tec SDC 050 Sputtercoater, Balzers, Liechtenstein), and visualized at 7,500x of magnification (JSM 5600LV, Jeol, Tokyo, Japan).

Statistical Analysis

Data were analyzed using the statistical program SPSS (Statistical Package for Social Sciences) version 20.0, specific for Windows. The assumptions of equality of variances and normal distribution of errors were checked by Kolmogorov-Smirnov test. Paired t-test was used to compare normal data from the same group, otherwise the Wilcoxon test was adopted. For analyses among groups with normal values, it was used Analysis of Variance (ANOVA) followed by post hoc Tukey test. Kruskal-Wallis test was used for the others. The significance level was set at 5%.

RESULT

KHN₁ and KHN₂ analyses showed that the Autoclave and 2.5% Sodium hypochlorite methods significantly decreased enamel microhardness (p <0.05). Regarding dentin, all treatments significantly altered its surface (p <0.05). Additionally, it was not possible to calculate the microhardness values ​​of the specimens treated with acetic acid, due to the high demineralization caused in enamel and dentin ( Table 1 ). Related to the Ra₁ and Ra₂ means, a significant difference (p <0.05) was observed in all treated groups ( Table 2 ).

Table 1
Mean microhardness of enamel and dentin, along with the standard deviations, before and after treatment

Dental tissues	Experimental groups	KHN1± σ	KHN2± σ	p
Enamel	G1	292.28 ± 19.58	269.22 ± 20.84	0.005 **
	G2	292.57 ± 13.23	266.74 ± 16.83	0.005 **
	G3	289.74 ± 19.96	266.55 ± 18.00	0.985 *
	G4	-	-	-
Dentin	G1	48.61 ± 3.43	45.42 ± 3.36	0.009 *
	G2	47.65 ± 4.45	19.42 ± 2.03	0.000 *
	G3	46.12 ± 4.67	20.5 ± 2.32	0.000 *
	G4	-	-	-

• p<0.05 is statistically significant;
• ^*
  Value of p (paired t-test);
• ^**
  p-value (Wilcoxon’s test);
• σ = standard deviation; KHN₁ = superficial Knoop microhardness before treatment; KHN₂ = superficial Knoop microhardness after treatment; G1 = Autoclave; G2 = 2.5% Sodium hypochlorite; G3 = 5% Sodium Hypochlorite; G4 = 30% Acetic Acid.

Table 2
Means of total roughness of the specimen, accompanied by standard deviations, before and after treatment

Groups	Ra1± σ	Ra2± σ	p
G1	0.095 ± 0.125	0.143 ± 0.035	0.000
G2	0.097 ± 0.12	0.174 ± 0.059	0.002
G3	0.095 ± 0.14	0.167 ± 0.042	0.000
G4	0.095 ± 0.13	0.463 ± 0.121	0.000

• p<0.05 is statistically significant for the paired t-test; σ = standard deviation; Ra₁ = total roughness of the specimen before treatment; Ra₂ = total roughness of the specimen after treatment; G1 = Autoclave; G2 = 2.5% Sodium hypochlorite; G3 = 5% Sodium Hypochlorite; G4 = 30% Acetic Acid.

After enamel SEM analysis, it was observed that the morphology of the untreated specimen ( Figure 1 a) was characterized by a homogeneous, dense and smooth surface. Micrographs of the Autoclave and Sodium hypochlorite treated groups showed a porous surface ( Figures 1 c, e, g). In addition, it was noted that the surface exposed to acetic acid ( Figure 1 i) showed distinct morphological characteristics from the other treatments, presenting a porous, irregular, and with high roughness surface.

Figure 1
Scanning Electron Microscopy of enamel and human dentin submitted to different methods of sterilization and control group. (a) Untreated dental enamel (Control); (b) Untreated dental dentin (Control); (c) Enamel treated with autoclave; (d) Dentin treated with autoclave; (e) Enamel treated with Sodium Hypochlorite 2.5%; (f) Dentin treated with 2.5% Sodium Hypochlorite; (g) Enamel treated with 5% Sodium Hypochlorite; (h) Dentin treated with 5% Sodium Hypochlorite; (i) Enamel treated with 30% Acetic Acid; (j) Dentin treated with 30% Acetic Acid. Increase of 7.500 X.

In dentin specimens, the untreated surface presented opened dentinal tubules associated to peritubular dentin ( Figure 1 b). Based on these characteristics, the micrographs of the surfaces treated with Autoclave and Sodium hypochlorite ( Figures 1 d, f, h) showed increase in the dentinal tubules opening. Also, it was observed collagen fibers alteration as the hypochlorite concentration increased. In addition, acetic acid treatment caused greater increase of the dentinal tubules and removal of collagen fibers ( Figure 1 j).

Therefore, it was observed that all the sterilization methods used in this study increased the porosity and widened the aperture of the dentinal tubules, demonstrating greater dissolution in the peritubular dentin region, and increasing the permeability of this tissue.

DISCUSSION

The sterilization methods adopted in this experiment altered the physical and morphological properties of the enamel and dentin, thus the null hypothesis of this study was rejected.

For Humel et al. ¹¹ , sterilization methods should eliminate all pathogens present in extracted human teeth to avoid the risk of contamination. The sterilization methods used in this research demonstrated efficacy in previous studies ^2,12 . Besides microbiological factor, the maintenance of the morphology and structural integrity of the enamel and dentin should be considered when sterilization methods are chosen ¹³ . However, there is no consensus in the literature about the ideal method that preserves physical and structural properties of dental tissues ¹⁴ .

In order to observe higher alterations in the substrate, roughness and microhardness data were obtained from the specimens, since these values ​​determine mineral loss or gain ¹⁵ . To reduce possible bias, both analyzes were performed in the same specimen and in standardized moments. The results of this study indicated that Autoclave and 2.5% Sodium hypochlorite decreased KHN of enamel, while all treatments affected KHN in dentin. The effect caused by Autoclave was observed in previous studies ^13,16 . Parsell et al. ¹⁷ explain this effect by the presence of under pressure heat, which is able to break ionic bonds between collagen and hydroxyapatite, leading to denaturation of the organic matrix. However, there is still no agreement among the authors about the effect of this method on dental substrate ^14,18 . Moreover, Patil, Uppin ¹⁹ showed that microhardness values changed similarly when 2.5% and 5% hypochlorite concentrations were used.

Another study pointed out that this solution was able to weaken the dental substrate, besides changing the microhardness according to its concentration and time of action ²⁰ . Regarding Sodium hypochlorite concentration and its effect on the substrate, it was observed that only 2.5% Sodium hypochlorite caused KHN change. This fact might be explained by the natural instability of this solution, and interference of time, light, exposure to air and high temperatures, changing the solution of the solution ²¹ .

Previous studies also have used acetic acid for disinfection of extracted human teeth, due to discussions about the toxicity of chlorine and other disinfectants ^22,23 . This substance is not commonly used in dentistry, but is considered an alternative disinfectant for teeth, acrylic resins and toothbrushes ^10,24 . In addition, the inclusion of this substance in this study was due to its availability, low cost and low toxicity ²³ .

In the evaluation of the roughness, all the methods used were able to alter teeth properties, as previously showed in the literature ²⁵ . Compared to other methods, acetic acid produced the most significant increase due to its acidic character and demineralizing effect on the substrate.

SEM analysis showed that all sterilization methods increased enamel pores and dentinal tubules, indicating a greater permeability of these tissues. However, these results were different from those found by Pashley et al. ¹⁸ , besides did not observe changes in the permeability and adhesive strength of dentin.

Therefore, it is suggested that all sterilization methods evaluated in this study provided changes in the physical and morphological properties of enamel and dentin. Furthermore, it is recommended that extracted human teeth used in research should be stored in purified water until selection of the sterilization method. Thus, the researcher must choose the method that best fits its research objectives, in order to achieve reliable results and eliminate study bias.

CONCLUSION

Despite the limitations of this in vitro study, our findings suggest that sterilization methods can alter the morphology and/or physical properties of enamel and dentin.

REFERENCES

• ¹
  Motta-Murguia L, Saruwatari-Zavala G. Mexican regulation of biobanks. J Law Med Ethics. 2016 Mar;44(1):58-67. http://dx.doi.org/10.1177/1073110516644199. PMid:27256124.
  » http://dx.doi.org/10.1177/1073110516644199
• ²
  Dominici JT, Eleazer PD, Clark SJ, Staat RH, Scheetz JP. Disinfection/sterilization of extracted teeth for dental student use. J Dent Educ. 2001 Nov;65(11):1278-80. PMid:11765875.
• ³
  White JM, Goodis HE, Marshall SJ, Marshall GW. Sterilisation of teeth by gamma radiation. J Dent Res. 1994 Sep;73(9):1560-7. http://dx.doi.org/10.1177/00220345940730091201. PMid:7929992.
  » http://dx.doi.org/10.1177/00220345940730091201
• ⁴
  Tate WH, White RR. Disinfection of human teeth for education purposes. J Dent Educ. 1991 Sep;55(9):583-5. PMid:1910059.
• ⁵
  Silva MF, Mandarino F, Sassi JF, Menezes M, Centola ALB, Nonaka T. Influência do tipo de armazenamento e do método de desinfecção de dentes extraídos sobre a adesão à estrutura dental. Rev Odontol Univ Cidade de São Paulo. 2006 Maio-Ago;18(2):175-80.
• ⁶
  Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings: 2003. MMWR Recomm Rep. 2003 Dec;52(RR-17):1-61. PMid:14685139.
• ⁷
  Brauer DS, Saeki K, Hilton JF, Marshall SJ, Marshall SJ. Effect of sterilization by gamma radiation on nano mechanical properities of teeth. Dent Mater. 2008 Aug;24(8):1137-40. http://dx.doi.org/10.1016/j.dental.2008.02.016. PMid:18436298.
  » http://dx.doi.org/10.1016/j.dental.2008.02.016
• ⁸
  Nassif AC, Tieri F, Ana PA, Botta SB, Imparato JC. Estruturação de um banco de dentes humanos. Pesqui Odontol Bras. 2003 Maio;17(Suppl 1):70-4. http://dx.doi.org/10.1590/S1517-74912003000500012. PMid:12937749.
  » http://dx.doi.org/10.1590/S1517-74912003000500012
• ⁹
  Barbosa SV, Safavi KE, Spångberg SW. Influence of sodium hypochlorite on the permeability and structure of cervical human dentine. Int Endod J. 1994 Nov;27(6):309-12. http://dx.doi.org/10.1111/j.1365-2591.1994.tb00274.x. PMid:7751064.
  » http://dx.doi.org/10.1111/j.1365-2591.1994.tb00274.x
• ¹⁰
  Salvia AC, Matilde FS, Rosa FC, Kimpara ET, Jorge AO, Balducci I, et al. Disinfection protocols to prevent cross-contamination between dental offices and prosthetic laboratories. J Infect Public Health. 2013 Oct;6(5):377-82. http://dx.doi.org/10.1016/j.jiph.2013.04.011. PMid:23999338.
  » http://dx.doi.org/10.1016/j.jiph.2013.04.011
• ¹¹
  Humel MMC, Oliveira MT, Cavalli V, Giannini M. Effect of storage and disinfection methods of extracted bovine teeth on bond strength to dentin. Braz J Oral Sci. 2007 Jul-Sep;6(22):1402-6.
• ¹²
  Gogineni S, Ganipineni K, Babburi S, Venigalla A, Pinnisetti S, Kotti AB, et al. evaluation of vinegar as a disinfectant for extracted human teeth - an in vitro study. J Clin Diagn Res. 2016 Jul;10(7):ZC50-2. http://dx.doi.org/10.7860/JCDR/2016/19025.8167. PMid:27630953.
  » http://dx.doi.org/10.7860/JCDR/2016/19025.8167
• ¹³
  Amaecha BT, Higham SM, Edgar WM. Effect of sterilisation methods on the structural integrity of artificial enamel caries for intra-oral cariogenicity tests. J Dent. 1999 May;27(4):313-6. http://dx.doi.org/10.1016/S0300-5712(98)00064-5. PMid:10193110.
  » http://dx.doi.org/10.1016/S0300-5712(98)00064-5
• ¹⁴
  Salem-Milani A, Zand V, Asghari-Jafarabadi M, Zakeri-Milani P, Banifatemeh A. The effect of protocol for disinfection of extracted teeth recommended by the Center for Disease Control (CDC) on microhardness of enamel and dentin. J Clin Exp Dent. 2015 Dec;7(5):e552-6. http://dx.doi.org/10.4317/jced.52280. PMid:26644828.
  » http://dx.doi.org/10.4317/jced.52280
• ¹⁵
  Pashley D, Okabe A, Parham P. The relationship between dentin microhardness and tubule density. Endod Dent Traumatol. 1985 Oct;1(5):176-9. http://dx.doi.org/10.1111/j.1600-9657.1985.tb00653.x. PMid:3865764.
  » http://dx.doi.org/10.1111/j.1600-9657.1985.tb00653.x
• ¹⁶
  Viana PS, Machado AL, Giampaolo ET, Pavarina AC, Vergani CE. Disinfection of bovine enamel by microwave irradiation: effect on the surface microhardness and demineralization/remineralization processes. Caries Res. 2010;44(4):349-57. http://dx.doi.org/10.1159/000318528. PMid:20616552.
  » http://dx.doi.org/10.1159/000318528
• ¹⁷
  Parsell DE, Stewart BM, Barker JR, Nick TG, Karns L, Johnson RB. The effect of steam sterilization on the physical properties and perceived cutting characteristics of extracted teeth. J Dent Educ. 1998 Mar;62(3):260-3. PMid:9566190.
• ¹⁸
  Pashley EL, Tao L, Pashley DH. Sterilization of human teeth: its effect on permeability and bond strength. Am J Dent. 1993 Aug;6(4):189-91. PMid:7803006.
• ¹⁹
  Patil CR, Uppin V. Effect of endodontic irrigating solutions on the microhardness and roughness of root canal dentin: an in vitro study. Indian J Dent Res. 2011 Jan-Feb;22(1):22-7. http://dx.doi.org/10.4103/0970-9290.79969. PMid:21525672.
  » http://dx.doi.org/10.4103/0970-9290.79969
• ²⁰
  Slutzky-Goldberg I, Maree M, Liberman R, Heling I. Effect of sodium hypochlorite on dentin microhardness. J Endod. 2004 Dec;30(12):880-2. http://dx.doi.org/10.1097/01.DON.0000128748.05148.1E. PMid:15564869.
  » http://dx.doi.org/10.1097/01.DON.0000128748.05148.1E
• ²¹
  Pişkin B, Türkün M. Stability of various sodium hypochlorite solutions. J Endod. 1995 May;21(5):253-5. http://dx.doi.org/10.1016/S0099-2399(06)80991-X. PMid:7673825.
  » http://dx.doi.org/10.1016/S0099-2399(06)80991-X
• ²²
  Nascimento MS, Silva N, Catanozi MP, Silva KC. Effects of different disinfection treatments on the natural l microbiota of lettuce. J Food Prot. 2003 Sep;66(9):1697-700. http://dx.doi.org/10.4315/0362-028X-66.9.1697. PMid:14503728.
  » http://dx.doi.org/10.4315/0362-028X-66.9.1697
• ²³
  Makino SI, Cheun HI, Tabuchi H, Shirahata T. Antibacterial activity of chaff vinegar and its practical application. J Vet Med Sci. 2000 Aug;62(8):893-5. http://dx.doi.org/10.1292/jvms.62.893. PMid:10993188.
  » http://dx.doi.org/10.1292/jvms.62.893
• ²⁴
  Smitha D, Kasetty S, Kallianpur S, Gupta S, Amith HV, Tijare M. Vinegar as a disinfectant of extracted human teeth for dental educational use. J Oral Maxillofac Pathol. 2014 Jan;18(1):14-8. http://dx.doi.org/10.4103/0973-029X.131883. PMid:24959031.
  » http://dx.doi.org/10.4103/0973-029X.131883
• ²⁵
  Eldeniz AU, Erdemir A, Belli S. Effect of EDTA and citric acid solutions on the microhardness and the roughness of human root canal dentin. J Endod. 2005 Feb;31(2):107-10. http://dx.doi.org/10.1097/01.don.0000136212.53475.ad. PMid:15671820.
  » http://dx.doi.org/10.1097/01.don.0000136212.53475.ad

Publication Dates

• Publication in this collection
  07 May 2018
• Date of issue
  Mar-Apr 2018

History

• Received
  15 Feb 2018
• Accepted
  11 Apr 2018