• Users Online: 326
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 1  |  Issue : 4  |  Page : 218-224

Assessment of association of periodontal disease status with obesity and various other factors among a population of South India


1 Department of Periodontology and Prosthodontics, Sri Sukhmani Dental College and Hospital, Dera Bassi, Punjab, India
2 Department of Periodontology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
3 Department of Periodontology, Yenepoy Dental College, Mangalore, Karnataka, India
4 Department of Oral Pathology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
5 Department of Periodontology, P.M.N.M Dental College and Hospital, Bagalkot, Karnataka, India

Date of Submission10-Aug-2014
Date of Decision27-Oct-2014
Date of Acceptance27-Nov-2014
Date of Web Publication11-Dec-2014

Correspondence Address:
Siddhartha Varma
Department of Periodontology, School of Dental Sciences, KIMSDU, Karad 415 110, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9906.146800

Rights and Permissions
  Abstract 

Background: Growing prevalence of obesity has raised significant public health concern. Obesity has been implicated as a risk for several chronic health conditions. The association between obesity and periodontal disease (PD) has been shown in many studies. The purpose of this study is to examine the relation between obesity and PD among a population of north Karnataka. Materials and Methods: A total of 2,000 subjects aged 20 years and above was enrolled for the study. Periodontal status of the subjects was recorded using community periodontal index. Body mass index (BMI) and waist circumference were used as measures to assess obesity. Other variables like age, occupation, smoking status, tobacco chewing, diabetic status, educational status, previous visit to dentist, sedentary/nonsedentary lifestyle, daily exercise and physical activity, family history of obesity were also recorded. Results: A significant association between measures of body fat and PD was found among the study subjects. In younger age group the prevalence of PD was significantly higher in obesity type-I category (odds ratio [OR] = 12.72 and 95% confidence interval (CI) 6.54-24.75) and obesity type-II category (OR = 10.83 and 95% CI 2.63-44.65), in middle age group the prevalence of PD was significantly higher in obesity type-I category (OR = 11.19 and 95% CI 4.85-25.84) and obesity type-II category (OR = 3.45 and 95% CI 1.46-8.15) and in older age group the prevalence of PD was significantly higher in overweight at risk category (OR = 12.52 and 95% CI 2.85-54.94) and obesity type-I category (OR = 2.47 and 95% CI 0.79-7.74) as compared to normal range BMI category. Conclusion: The prevalence of PD is higher among obese subjects. Obesity could be a potential risk factor for PD in all age groups.

Keywords: Body mass index, epidemiological study, obesity, periodontal disease, prevalence, waist circumference


How to cite this article:
Bhola S, Varma S, Shirlal S, Jenifer HD, Gangavati R, Warad S. Assessment of association of periodontal disease status with obesity and various other factors among a population of South India . J Obes Metab Res 2014;1:218-24

How to cite this URL:
Bhola S, Varma S, Shirlal S, Jenifer HD, Gangavati R, Warad S. Assessment of association of periodontal disease status with obesity and various other factors among a population of South India . J Obes Metab Res [serial online] 2014 [cited 2021 May 15];1:218-24. Available from: https://www.jomrjournal.org/text.asp?2014/1/4/218/146800


  Introduction Top


Obesity is a chronic disease, prevalent globally among the affluent and sedentary subjects and affects the young and the old equally. The prevalence of obesity is increasing at alarming rates, approaching epidemic proportions globally. It has been recognized as a key risk factor for many chronic diseases, such as diabetes. [1] If present trends continue, obesity is likely to become a major health concern for Indian population. [2]

In 1997, the incidence of obesity in India was reported to be 7-9%, which is a significant number due to large population size of India. [3] For many years adipose tissue was considered as an inert organ that stored triglycerides. It is now clear that adipose tissue is a complex and metabolically active endocrine organ that secretes various bioactive molecules collectively known as adipokines. These molecules regulate various metabolic and inflammatory processes. Periodontal disease (PD) is one of the most common chronic inflammatory diseases. Obesity has been found to contribute significantly to PD severity on experimental animals. [4] Various studies on human subjects have shown obesity as assessed by body mass index (BMI) and waist circumference (WC) to be a significant risk factor PD. [5],[6] The purpose of this study was to assess the association between PD status and obesity among a population of South India and examining the impact of various confounding factors like age, gender, oral hygiene status, WC, BMI, smoking status, tobacco chewing status, lifestyle, diabetic status, educational status, previous dental visit, daily exercise and physical activity and family history of obesity on periodontal health.


  Materials and methods Top


Data source and sampling method

The research protocol was submitted to the Institutional review board and due ethical clearance was obtained. The study population consisted of the convenience sample of 2,000 subjects from the outpatient Department of Periodontics, P.M.N.M Dental College and Hospital, Bagalkot. Dentate persons of 20 years and above were included in the study. Physically and mentally challenged patients, and pregnant women were excluded from the study. The patients were stratified according to age in three different age groups, younger age (18-34 years), middle age (35-59 years) and older adults (60 years and above). [7]

Outcome variables

An informed consent was obtained from each single subject included in the study. All the subjects were examined by a single examiner. The observations and readings were recorded in a printed proforma. PD was estimated by recording full mouth pocket depth and attachment loss scores. PD was defined as the presence of one or more periodontal sites with both pocket depth ≥ 4 mm (community periodontal index scores 3 and 4) and loss of attachment ≥ 4 mm (loss of attachment scores 1, 2, 3 and 4).

Obesity

The status of obesity was recorded using BMI and WC measurement. The height and weight of the patient were recorded using calibrated measuring devices. BMI, used as indicator for overall adiposity, was computed from weight in kilograms divided by square of height in meters and was divided into following five categories: [8] Underweight (<18.5 kg/m 2 ), normal range (18.5-22.9 kg/m 2 ), overweight at risk (23.0-24.9 kg/m 2 ), obesity class I (25.0-29.9 kg/m 2 ), obesity class II (≥≥30 kg/m 2 ).

The WC was measured (in centimeters) at midpoint between lower border of ribs and upper border of pelvis and was divided into two categories using the cut-off points 90 cm for Indian men (as opposed to 102 cm globally) and 80 cm for Indian women (as opposed to 88 cm at the international level). [11] All the above measurements were recorded in centimeters using a measuring tape. It was taken into consideration that the tape measure be snug, but did not cause compression of the skin.

Covariates

Demographic variables and PD risk factors, which could act as co-variants for the PD were recorded. The selected variables were age, oral hygiene status, smoking status, tobacco chewing status, diabetic status, educational status, and previous visit to dentist, sedentary/nonsedentary lifestyle, daily exercise and physical activity, family history of obesity. A complete intraoral examination was performed. Assessment of oral hygiene status was done using oral hygiene index-simplified and was recorded in three categories: Good, fair or poor. The smoking status was recorded as current smokers, former smokers and never smokers. [5] Tobacco chewing status was recorded as presence or absence of usage of any form of nonsmoke oral tobacco products. Diabetic status was recorded as presence or absence of history of known diabetes (as told by physician). [5] Those reporting to have common symptoms of diabetes were referred to the physician for the confirmation of their diabetic status. Educational status was recorded as educated or uneducated based on whether the individual has undergone basic primary education or not. Previous visit to the dentist was recorded as whether the patient has visited a dentist before or not. Lifestyle of the patient was recorded as sedentary/nonsedentary based on the patient's occupation. The habit of daily exercise and physical activity was recorded as present or absent based on presence or absence of the habit of moderate to severe physical activity. [7] Subjects reporting ≥5 episodes of moderate physical activity or ≥ ≥3 episodes of vigorous physical was recorded as meeting the recommended levels of physical activity. A family history of obesity was recorded as present/absent based on questioning the presence of obesity in one or both the parents.

Data analysis

The data so collected were entered in excel format and were subjected to statistical analysis as follows:

  • Impact of factors (like age, gender, oral hygiene status, WC, BMI, smoking status, tobacco chewing status, lifestyle, diabetic status, educational status, previous dental visit, daily exercise and physical activity and family history of obesity) was assessed by Multivariate Logistic Regression Analysis
  • The relation between each factor and PD was assessed using the Chi-square test
  • Odds ratio was calculated to assess risk of occurrence of PD with different independent factors.



  Results Top


[Table 1] shows characters of study population and their PD status. Out of 2,000 subjects, 77% (n = 1540) had PD. The association between PD and age was statistically significant (p = 0.0347), showing an increase of prevalence of PD with age. The prevalence of PD was significantly higher (p = 0.0178) among males compared to females.

The prevalence of PD was higher in present smokers, and past smokers compared to nonsmokers and in tobacco chewers compared to nonchewers. The prevalence of periodontitis was found higher among individuals with sedentary lifestyle compared to individuals with nonsedentary lifestyle. These results were statistically significant (p = 0.000) [Table 1].
Table 1: Characteristics of the study population by PD status (n=2000)


Click here to view


Out of 2,000 subjects, 190 were reported as diabetics and the prevalence of PD was higher among known diabetics compared to nondiabetics. The relationship between history of diabetes and PD was statistically significant (p = 0.0013). The prevalence of PD was higher among uneducated compared to that of educated subjects. The prevalence of PD was more among subjects who never visited a dentist before compared to those who visited a dentist. Majority of subjects (n = 1644) had no habit of daily exercise and physical activity in their lifestyle. Subjects with no exercise and physical activity had a higher prevalence of PD as compared to subjects with habit of exercise and physical activity, but the difference was not statistically significant (p = 0.0922). In the study population 392 subjects presented with a family history of obesity and the prevalence of PD was more among them compared to subjects without family history of obesity and the difference was statistically significant (p = 0.000).

Comparison of prevalence of PD according to age groups and BMI is shown in [Figure 1] and [Figure 2] shows the comparison of prevalence of PD according to WC and BMI.
Figure 1. Comparison of prevalence of periodontal disease according to age groups and body mass index

Click here to view
Figure 2. Comparison of prevalence of periodontal disease according to waist circumference and body mass index

Click here to view


To assess the association of PD with various other confounding factors that were recorded, odds ratio and 95% confidence interval were recorded as shown in [Figure 3], [Figure 4], [Figure 5] and [Table 2]. Factors like older age, poor oral hygiene, WC above cut-off range, BMI in the range of obesity type-I and obesity type-II, smoking and tobacco chewing habits, sedentary lifestyle, history of diabetes, poor educational status, no previous dental visits, no habit of exercise and physical activity, and family history of obesity were significantly associated with PD. [Table 3] shows Impact of factors (like age, gender, oral hygiene status, WC, BMI, smoking status, tobacco chewing status, lifestyle, diabetic status, educational status, previous dental visit, daily exercise and physical activity and family history of obesity) on PD as assessed by logistic regression analysis.
Figure 3. Distribution of study subjects according to age groups and gender

Click here to view
Figure 4. Comparison of prevalence of periodontal disease according to oral hygiene status

Click here to view
Figure 5. Comparison of prevalence of periodontal disease according to smoking status

Click here to view
Table 2: OR and 95% CI of various independent factors and PD in study subjects


Click here to view
Table 3: Multivariate logistic analysis of PD with number of independent characteristics


Click here to view



  Discussion Top


In the present study, the prevalence of PD was found to be higher among obese subjects as compared to normal weight subjects, which is in agreement with the previous studies. [5],[6],[10] Variety of potential mechanisms could explain the association between obesity and periodontitis. Overweight people generally have unhealthy diet pattern. They include higher sugar and fat content in their diet, and lesser micronutrients. These dietary patterns can increase the risk of periodontal destruction. [8],[9] Changes in host immunity and/or increased stress levels, which are often associated with gain of excess fat early in life, may also play a role. Plausible biological mechanism relating obesity to PD is not well established. However, it is evident that the adipose tissue actively produces high levels of cytokines and hormones, collectively called adipokines. [5],[10] Adipokines like leptin, adiponectin, and resistin play a key role in the inflammatory process. Also, pro-inflammatory cytokines like interleukin-1, interleukin-6, tumor necrosis factor-α produced by adipose tissue result in a pro-inflammatory systemic state, which can also effect periodontium. Altered metabolism in obese subjects increases blood glucose and lipid levels. This can result in altered immune cell function. [10]

In our study, obesity was significantly associated with the prevalence of PD. This association was seen in all the three age groups. But this finding is not in agreement with the study conducted by Al-Zaharni et al.[7] WC above cut-off was associated significantly with the higher prevalence of PD compared to below cut-off group. This finding is consistent with the study conducted by Al-Zahrani et al. (NHANES III data). [7]

In the present study, the prevalence of PD was significantly higher in individuals who do not have a habit of exercise and physical activity and in individuals with sedentary lifestyle. This is in agreement with the study conducted by Al-Zahrani et al. [11] There are several pathways by which exercise and physical activity may influence periodontal health. Diabetes is known to be a risk factor for periodontitis, and it is well accepted that physical activity may reduce the incidence of type-II diabetes by enhancing the sensitivity to insulin. [11] Another possible mechanism is similar to the one for colon cancer: it has been suggested that physical activity protects against colon cancer by reducing the prostaglandin (PGE2) synthesis. Thus, physical activity may reduce PGE2 synthesis in the gingival tissue and subsequently protect against periodontal destruction. [7] Finally, two recent analyses of NHANES III data found an inverse association between physical activity and levels of inflammatory markers such as C-reactive proteins in plasma. Thus, physical activity may protect against periodontitis by reducing inflammation, which is important in the pathogenesis of periodontitis. [11]

Prevalence of PD was significantly higher in older age group. This finding could be a result of long-term cumulative effect of prolonged exposure to etiological factors leading to periodontal destruction in elderly rather than an age specific condition. [11] The strong association observed between the age and bone loss may be explained by the reported effects of age in reducing the down-regulation of osteoblasts and response to mitogens and stimulators of bone formation and repair. [12] The effect of age per se as a risk factor for PD is not very clear. [11] In the present study, the prevalence of PD was lower in females as compared to males but the value was not statistically significant. This finding is consistent with previously reported gender differences. It has been shown that males usually exhibit evidence of poorer oral hygiene than females, in terms of both calculus and soft plaque deposits, [11] although this may be explained by greater utilization of dental care by woman. [12]

The prevalence of PD was significantly higher in poor oral hygiene group compared to good oral hygiene group. This finding is consistent with previously reported differences with oral hygiene. [5],[11],[12],[13]

The correlation between smoking and PD has been well documented. The prevalence of PD was significantly higher in past smokers, and present smokers compared to nonsmokers. This finding is in agreement with previous studies, suggesting that the present effect of smoking on periodontal health cannot be reversed, and its detrimental effects may diminish after smoking cessation. [13],[14] Cigarette smoking, nicotine, and its by-products have a vasoconstrictive effect not only on peripheral circulation, but also on coronary, placental, and gingival blood vessels. In addition, smoking may reduce the functional activity of leukocytes and macrophages in saliva and crevicular fluid, as well as decreasing chemotaxis and phagocytosis of blood and tissue polymorphonuclear leukocytes (PMNs); thereby depressing the phagocyte mediated protected response to periodontal pathogens. Tobacco smoking also reduces the short-term oxidation reduction potential in the dental plaque. Reduced oxygen levels are associated with a decrease in PMNs mobility and an increase in proportion of anaerobic bacteria in dental plaque. Cytotoxic substances, such as nicotine and cotinine (major metabolites) present in tobacco are detected in saliva, crevicular fluid, serum and urine, and periodontally diseased tooth root surfaces of smokers. Fibroblast attachment to root the surface in vitro is also altered by the presence of nicotine. Smoking may also have a negative effect on the cellular turnover and repair of periodontium. [14]

The prevalence of PD was significantly higher in tobacco chewers compared to nontobacco chewers. This finding is at par with the study done by Mehta F.S, wherein he concluded that betel nut chewing was one of the detrimental factors in causing PD. [15] The reason being that, the teeth of the betel leaf chewers are covered with tartar, a deposit that has been definitely associated with PD. Some of the important causes of tartar formation are stagnation of saliva and presence of calcium salts. The chewing action causes a profuse flow of saliva, which the chewer does not swallow but keeps in his mouth for considerable time resulting in more tartar formation and destruction might be caused by the local destructive effects of chemicals released from tobacco products. [15]

In the present study, the prevalence of PD was significantly higher in individuals with reported diabetes compared to nondiabetic individuals. This finding is in agreement with the study done by Grossi et al. in 1994. [15] The increased prevalence of periodontitis in diabetics could be attributed to altered subgingival microbial flora with increased numbers of Capnocytophaga, anaerobic vibrios, and Actinomyces species. [16] Other studies have reported scarce Capnocytophaga and abundant  Actinobacillus actinomycetemcomitans Scientific Name Search itans and black pigmented bacteriods as well as Prevotella intermedia, Porphyromonas gingivalis, and Campylobacter rectus. [17] Increased susceptibility of diabetic patients to infection could be attributed to PMN deficiencies resulting in impaired chemotaxis, defective phagocytosis, and an impaired adherence. [18] Also increased collagenase activity and decreased collagen synthesis is found in individuals with poorly controlled diabetes. [19],[20] Advanced glycated end products (AGEs) play a central role in classical complication of diabetes mellitus and may also play a significant role in the progression of PD as well. Poor glycemic control, with the associated increase in AGEs render periodontal tissue more susceptible to destruction. [21]

The prevalence of PD in this study was significantly higher in uneducated individuals compared to educated individuals. This is in agreement with previous studies, [5],[11],[13],[14] who reported increased prevalence of periodontitis with lesser education. This could be explained based on poorer oral hygiene and lesser dental awareness among uneducated or lesser educated individuals.

Study also showed that the PD was significantly higher in individuals who had never visited a dentist before compared to individuals who visited a dentist previously. This result is in agreement with other studies, [5],[11] which could be attributed to enhanced patient motivation, professional cleaning as well as control of other etiological factors associated with the PD.

There is a multifaceted relationship among body weight, oral health, and globesity epidemic. The frequency with which most patients visit their dentists, supports that oral health care provider can serve to screen and identify patients with obesity. Early detection of nonnormal weight may help to engage patients in intentional weight loss strategies and referral to the physician. Although the relationship between obesity and periodontitis needs further investigation, periodontist can counsel obese persons regarding the possible oral complications of obesity, to diminish morbidity for these individuals. Weight screening should be an integral part of periodontal risk assessment on a regular basis. This will reduce the patient's risk of developing chronic diseases including periodontitis.


  Conclusion Top


The results of this cross-sectional study indicate an association between obesity and PD. The study has several strengths: A large sample size and availability of information on many potential confounding factors. However, there are certain limitations to the present study. As the anthropometric data and periodontal status were recorded simultaneously, a temporal between obesity and PD cannot be established. This problem can be overcome by conducting a prospective cohort study to assess whether obese individuals are more likely to develop periodontitis over time. As the present study is an observational study, it cannot establish a cause effect relation. The observed association might have been the result of some unidentified underlying factors. Further interventional studies can be conducted in obese individuals to observe a beneficial effect of weight loss program on PD.

 
  References Top

1.
Ramachandran A. Diabetes and obesity - The Indian angle. Indian J Med Res 2004;120:437-9.  Back to cited text no. 1
    
2.
Amin Hel-S. Relationship between overall and abdominal obesity and periodontal disease among young adults. East Mediterr Health J 2010;16:429-33.  Back to cited text no. 2
[PUBMED]    
3.
Chowbey PK. Obesity and India: Myth or reality. J Ethicon Endo Surg 2003. Available from: http://www.openmed.nic.in/2931/01/Chowbey_585.pdf. [Last cited on 2009 Jan 13].  Back to cited text no. 3
    
4.
Verzeletti GN, Gaio EJ, Linhares DS, Rösing CK. The effect of obesity on alveolar bone loss in Wistar rats. J Appl Oral Sci. 2012;20:218-21.  Back to cited text no. 4
    
5.
Ritchie CS. Obesity and periodontal disease. Periodontol 2000 2007;44:154-63.  Back to cited text no. 5
    
6.
Perlstein MI, Bissada NF. Influence of obesity and hypertension on the severity of periodontitis in rats. Oral Surg Oral Med Oral Pathol 1977;43:707-19.  Back to cited text no. 6
[PUBMED]    
7.
Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity and periodontal disease in young, middle-aged, and older adults. J Periodontol 2003;74:610-5.  Back to cited text no. 7
    
8.
Wood N, Johnson RB, Streckfus CF. Comparison of body composition and periodontal disease using nutritional assessment techniques: Third National Health and Nutrition Examination Survey (NHANES III). J Clin Periodontol 2003;30:321-7.  Back to cited text no. 8
    
9.
Government.in (internet). New Delhi: India reworks obesity guidelines, BMI lowered. Available from: http://www.igovernment.in/site. [Uploaded 2008 Nov; Last cited on 2012 Feb 10].  Back to cited text no. 9
    
10.
Anuurad E, Shiwaku K, Nogi A, Kitajima K, Enkhmaa B, Shimono K, et al. The new BMI criteria for asians by the regional office for the western pacific region of WHO are suitable for screening of overweight to prevent metabolic syndrome in elder Japanese workers. J Occup Health 2003;45:335-43.  Back to cited text no. 10
    
11.
Al-Zahrani MS, Borawski EA, Bissada NF. Periodontitis and three health-enhancing behaviors: Maintaining normal weight, engaging in recommended level of exercise, and consuming a high-quality diet. J Periodontol 2005;76:1362-6.  Back to cited text no. 11
    
12.
Soben P. Essentials of Preventive and Community Dentistry. 4 th ed. New Delhi: Arya (Medi) Publishing House; 2009. p. 318-21.  Back to cited text no. 12
    
13.
Ekuni D, Yamamoto T, Koyama R, Tsuneishi M, Naito K, Tobe K. Relationship between body mass index and periodontitis in young Japanese adults. J Periodontal Res 2008;43:417-21.  Back to cited text no. 13
    
14.
Norderyd O, Hugoson A. Risk of severe periodontal disease in a Swedish adult population. A cross-sectional study. J Clin Periodontol 1998;25:1022-8.  Back to cited text no. 14
    
15.
Grossi SG, Genco RJ, Machtei EE, Ho AW, Koch G, Dunford R, et al. Assessment of risk for periodontal disease. II. Risk indicators for alveolar bone loss. J Periodontol 1995;66:23-9.  Back to cited text no. 15
    
16.
Torrungruang K, Tamsailom S, Rojanasomsith K, Sutdhibhisal S, Nisapakultorn K, Vanichjakvong O, et al. Risk indicators of periodontal disease in older Thai adults. J Periodontol 2005;76:558-65.  Back to cited text no. 16
    
17.
Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE, et al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994;65:260-7.  Back to cited text no. 17
    
18.
Mehta FS, Sanjana MK, Barretto MA. Relation of betel leaf chewing to periodontal disease. J Am Dent Assoc 1955;50:531-6.  Back to cited text no. 18
[PUBMED]    
19.
Mashimo PA, Yamamoto Y, Slots J, Park BH, Genco RJ. The periodontal microflora of juvenile diabetics. Culture, immunofluorescence, and serum antibody studies. J Periodontol 1983;54:420-30.  Back to cited text no. 19
[PUBMED]    
20.
Sastrowijoto SH, Hillemans P, van Steenbergen TJ, Abraham-Inpijn L, de Graaff J. Periodontal condition and microbiology of healthy and diseased periodontal pockets in type 1 diabetes mellitus patients. J Clin Periodontol 1989;16:316-22.  Back to cited text no. 20
    
21.
Tan JS, Anderson JL, Watanakunakorn C, Phair JP. Neutrophil dysfunction in diabetes mellitus. J Lab Clin Med 1975;85:26-33.  Back to cited text no. 21
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed2376    
    Printed81    
    Emailed0    
    PDF Downloaded71    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]