Medline Search: National Library of Medicine
Relationship of periodontal disease to low birth weight pregancy

  
 

TITLE:

Potential pathogenic mechanisms of periodontitis associated pregnancy complications.
AUTHOR: Offenbacher S; Jared HL; O'Reilly PG; Wells SR; Salvi GE; Lawrence HP; Socransky SS; Beck JD
AUTHOR AFFILIATION: University of North Carolina at Chapel Hill, School of Dentistry, Department of Periodontology, USA. Steve_Offenbacher@dentistry.une.edu
SOURCE: Ann Periodontol 1998 Jul;3(1):233-50
CITATION IDS: PMID: 9722707 UI: 98389931
ABSTRACT: During normal pregnancy, maternal hormones and locally acting cytokines play a key role in regulating the onset of labor, cervical ripening, uterine contraction, and delivery. Maternal infections during pregnancy have been demonstrated to perturb this normal cytokine and hormone- regulated gestation, sometimes resulting in preterm labor, preterm premature rupture of membranes, and preterm low birth weight (PLBW), i.e., <2,500 g and < 37 weeks of gestation. Our research focus has been to determine whether periodontal infections can provide sufficient challenge to the mother to trigger PLBW. New experiments from 48 case- control subjects have measured gingival crevicular fluid (GCF) levels of PGE(2) and IL-1-beta to determine whether mediator levels were related to current pregnancy outcome. In addition, the levels of 4 periodontal pathogens were measured by using microbe-specific DNA probes. Results indicate that GCF-PGE(2) levels are significantly higher in PLBW mothers, as compared with normal birth weight (NBW) controls (131.4 +/- 21.8 vs. 62.6 +/- 10.3 [mean +/- SE ng/mL], respectively, at P="0.02)." Furthermore, within primiparous PLBW mothers, there was a significant inverse association between birth weight (as well as gestational age) and GCF-PGE(2) levels at P="0.023." These data suggest a dose-response relationship for increasing GCF- PGE(2) as a marker of current periodontal disease activity and decreasing birth weight. Microbial data indicate that 4 organisms associated with mature plaque and progressing periodontitis-- bacteroides forsythus, Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, and Treponema denticola--were detected at higher levels in PLBW mothers, as compared to NBW controls. These data suggest that biochemical measures of maternal periodontal status and oral microbial burden are associated with current PLBW.
MAIN MESH HEADINGS: Gram-Negative Bacterial Infections/*metabolism
*Infant, Low Birth Weight
Inflammation Mediators/*metabolism
Labor, Premature/*microbiology
Periodontitis/*microbiology
*Pregnancy Complications, Infectious
ADDITIONAL MESH HEADINGS: Actinobacillus actinomycetemcomitans/isolation & purification
Amniotic Fluid/chemistry
Animal
Bacteroides/isolation & purification
Case-Control Studies
Dental Plaque/microbiology
Dinoprostone/analysis
Dinoprostone/metabolism
Female
Gingival Crevicular Fluid/chemistry
Hamsters
Human
Inflammation Mediators/analysis
Interleukin-1/metabolism
Logistic Models
Multivariate Analysis
Odds Ratio
Periodontitis/metabolism
Porphyromonas gingivalis/isolation & purification
Pregnancy
Pregnancy Complications, Infectious/metabolism
Pregnancy Complications, Infectious/microbiology
Support, U.S. Gov't, P.H.S.
Treponema/isolation & purification
PUBLICATION TYPES: JOURNAL ARTICLE
REGISTRY NUMBERS: 0 (Inflammation Mediators)
0 (Interleukin-1)
363-24-6 (Dinoprostone)
LANGUAGE: Eng
GRANT/CONTRACT ID: DE12453/DE/NIDR
HD26652/HD/NICHD
TITLE:

Preterm birth: associations with genital and possibly oral microflora.
AUTHOR: Hill GB
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA. gbh@acpub.duke.edu
SOURCE: Ann Periodontol 1998 Jul;3(1):222-32
CITATION IDS: PMID: 9722706 UI: 98389930
ABSTRACT: Opportunistic pathogenic microbes are indigenous to the female lower genital tract and etiologic in many types of pelvic infections and, apparently, a portion of preterm birth (PTB) cases. Bacterial vaginosis (BV) is a clinical syndrome based on an altered genital microflora in which Gardnerella vaginalis; anaerobic species primarily among Prevotella, Porphyromonas, Bacteroides, Peptostreptococcus, and Mobiluncus; Mycoplasma hominis; and Ureaplasma urealyticum become predominant in vaginal secretions. This BV complex of microbes, compared to a normal vaginal microflora dominated by facultative lactobacilli, is associated with significantly increased risks for preterm labor, preterm premature rupture of membranes, PTB, and other perinatal infectious complications. Pathogenetic mechanisms include an ascending route of infection and/or inflammatory process due to microbial products and maternal and/or fetal response(s) with production of prostaglandins and cytokines. In the presence of periodontal disease, oral opportunistic pathogens and/or their inflammatory products also may have a role in prematurity via a hematogenous route. Fusobacterium nucleatum, a common oral species, is the most frequently isolated species from amniotic fluid cultures among women with preterm labor and intact membranes. Also, the species and subspecies of fusobacteria identified from amniotic fluid most closely match those reported from healthy and diseased subgingival sites, namely F. nucleatum subspecies vincentii and F. nucleatum subspecies nucleatum, compared to strains identified from the lower genital tract. Although these fusobacteria also could be acquired through cunnilingus from a partner, new data associating maternal periodontal disease with preterm low birth weight taken with the isolation of F. nucleatum, Capnocytophaga, and other oral species from amniotic fluid support further study of a possible additional route, oral-hematogenous, to PTB.
MAIN MESH HEADINGS: Fusobacterium Infections/*microbiology
Labor, Premature/*microbiology
Mouth/*microbiology
Pregnancy Complications, Infectious/*microbiology
Vaginosis, Bacterial/*microbiology
ADDITIONAL MESH HEADINGS: Amniotic Fluid/microbiology
Female
Fusobacterium nucleatum/isolation & purification
Human
Infant, Newborn
Pregnancy
PUBLICATION TYPES: JOURNAL ARTICLE
REVIEW
REVIEW, TUTORIAL
LANGUAGE: Eng
TITLE:

The East London Study of Maternal Chronic Periodontal Disease and Preterm Low Birth Weight Infants: study design and prevalence data.
AUTHOR: Davenport ES; Williams CE; Sterne JA; Sivapathasundram V; Fearne JM; Curtis MA
AUTHOR AFFILIATION: Department of Paediatric Dentistry, St. Bartholomew's and Royal London School of Medicine and Dentistry, Queen Mary and Westfield College, University of London, UK.
SOURCE: Ann Periodontol 1998 Jul;3(1):213-21
CITATION IDS: PMID: 9722705 UI: 98389929
ABSTRACT: The influence of subject-based and environmental factors on the balance between the subgingival microbial challenge and the host response in periodontal diseases illustrates the intimate link between oral and systemic health. From this stems the hypothesis that the persistent Gram-negative challenge and associated inflammatory sequelae in periodontal disease may have consequences extending beyond the periodontal tissues themselves. This paper addresses the design of a case-control study to examine the relationship between preterm low birth weight (PLBW) and maternal periodontal disease. We present preliminary data on the prevalence of these 2 conditions in a group of mothers at the Royal Hospitals Trust, London, U.K. Cases are defined as mothers delivering an infant weighing less than 2,500g before 37 weeks gestation and controls as mothers delivering an infant of more than 2,500g after 38 weeks. We estimated that a study involving 800 mothers (1:3 case:control) should have sufficient power to detect an association with a minimum odds ration of 3 at the 5% significance level. Demographic details of 177 subjects demonstrated that they were representative of the local population, and the prevalence of PLBW was within the expected range. However, the extent and severity of periodontal disease were higher than predicted and may have reflected elevations in gingival inflammation associated with pregnancy. The final outcome of the study should help determine the need for further interventionist studies to demonstrate a causal relationship between periodontal disease and PLBW, as well as provide information on the prevalence of periodontal diseases in this study population.
MAIN MESH HEADINGS: Dental Research/*methods
*Infant, Low Birth Weight
Labor, Premature/*microbiology
Periodontal Diseases/*epidemiology
Periodontal Diseases/*microbiology
*Pregnancy Complications
ADDITIONAL MESH HEADINGS: Adolescence
Adult
Case-Control Studies
Female
Gram-Negative Anaerobic Bacteria/isolation & purification
Human
Infant, Newborn
Infant, Premature
London/epidemiology
Male
Odds Ratio
Periodontal Index
Pregnancy
Pregnancy Complications/microbiology
Prevalence
Questionnaires
Research Design
Risk Factors
Support, Non-U.S. Gov't
PUBLICATION TYPES: JOURNAL ARTICLE
LANGUAGE: Eng
TITLE:

Poor periodontal health of the pregnant woman as a risk factor for low birth weight.
AUTHOR: Dasanayake AP
AUTHOR AFFILIATION: Department of Oral Biology, School of Dentistry, University of Alabama at Birmingham. USA. Ananda@epi.soph.uab.edu
SOURCE: Ann Periodontol 1998 Jul;3(1):206-12
CITATION IDS: PMID: 9722704 UI: 98389928
ABSTRACT: In both developed and developing countries, low birth weight (LBW) has a tremendous impact on both the health care system and the individual families affected. This warrants the continuous search for risk factors for LBW that are amenable to prevention. Can poor oral health of the pregnant woman be one such factor? In a 1:1 matched case-control study (N = 55 pairs), we evaluated the hypothesis that poor oral health of the pregnant woman is a risk factor for LBW. The effect of periodontal and dental caries status of the woman at the time of delivery on the birth weight of the infant was evaluated by using conditional logistic regression analyses, while controlling for known risk factors for LBW. Mothers of LBW infants were shorter, less educated, married to men of lower occupational class, had less healthy areas of gingiva and more areas with bleeding and calculus, and gained less weight during the pregnancy. Conditional logistic regression analyses indicated that mothers with more healthy areas of gingiva (OR = 0.3, 95% CI = 0.12 - 0.72) and those who were taller (OR = 0.86, 95% CI = 0.75 - 0.98) had a lower risk of giving birth to an LBW infant. Risk of LBW was higher in mothers who had no or late prenatal care (OR = 3.9, 95% CI = 1.24 - 12.2). We conclude that poor periodontal health of the mother is a potential independent risk factor for LBW.
MAIN MESH HEADINGS: *Infant, Low Birth Weight
*Periodontal Diseases
*Pregnancy Complications
ADDITIONAL MESH HEADINGS: Case-Control Studies
Demography
Dental Caries/epidemiology
DMF Index
Female
Human
Infant, Newborn
Logistic Models
Male
Odds Ratio
Periodontal Diseases/epidemiology
Periodontal Index
Pregnancy
Pregnancy Complications/epidemiology
Risk Factors
Support, Non-U.S. Gov't
Thailand/epidemiology
PUBLICATION TYPES: JOURNAL ARTICLE
LANGUAGE: Eng
 

Medline Search: National Library of Medicine
Relationship of periodontal disease to systemic illness
TITLE:

Periodontitis: a risk factor for coronary heart disease?
AUTHOR: Beck JD; Offenbacher S; Williams R; Gibbs P; Garcia R
AUTHOR AFFILIATION: Department of Dental Ecology, School of Dentistry, University of North Carolina, Chapel Hill, USA.
SOURCE: Ann Periodontol 1998 Jul;3(1):127-41
CITATION IDS: PMID: 9722697 UI: 98389921
ABSTRACT: This paper evaluates the current information on the relationship between oral disease (specifically periodontitis) and atherosclerosis/coronary heart disease (CHD) to determine whether the information is sufficient to conclude that periodontitis is a risk factor for atherosclerosis/CHD. As background for this evaluation, the term "risk factor" is defined, and the 3 criteria used to establish exposures as risk factors are reviewed. In addition, epidemiologic criteria for defining an exposure as causal are presented. The available evidence then is evaluated according to the criteria for causality, which are extensions of the criteria for establishing a risk factor. This review is done in the context of the relationship between atherosclerosis/CHD and inflammation. A number of findings are briefly reviewed that link inflammation and atherosclerosis/CHD, such as: 1) prior flu-like symptoms were more common in cases of myocardial infarction than in concurrently sampled controls; 2) high levels of cytomegalovirus antibody titers were associated with elevated carotid intimal-medial wall thickness 18 years later; 3) prior infection with cytomegalovirus was a strong independent risk factor for restenosis after coronary atherectomy; 4) dental infections were more common in cases of cerebral infarction compared to community controls matched on age and sex; and 5) the gingival index was significantly correlated with fibrinogen and white cell counts in periodontal patients and controls, adjusted for age, smoking, and socioeconomic status. Three case-control studies and 5 longitudinal studies investigating the relationship between dental conditions and atherosclerosis/CHD are reviewed in terms of strength of associations, consistency of associations, specificity. of associations, time sequence between exposure and outcome, and degree of exposure and outcome. Related to the last criterion, new findings are presented which indicate that the extent of the periodontal infection, a measure reflecting microbial burden, also is related to onset of new CHD events. Our previously published model describing the potential biological mechanisms underlying the associations found is reviewed. This model places the associations into a context of an intrinsic or acquired hyperinflammatory monocyte trait that results in a more intense inflammatory response to lipopolysaccharide (LPS) challenges, such as periodontal infections. This hyperinflammatory response may promote atheroma formation and thromboembolic events. finally, new findings from ongoing animal studies are presented, indicating that high fat diets in atherosclerotic-susceptible mice induce greater inflammatory responses to Porphyromonas gingivalis challenges. We conclude that the available evidence does allow an interpretation of periodontitis being a risk factor for atherosclerosis/CHD. This conclusion, however. is made with some qualifications. While the associations found across a wide variety of subjects are remarkably consistent, for the most part they are represented by incidence odds ratios around 2.0. While this level of association would result in oral conditions contributing to a large number of CHD cases, it is possible that associations of this magnitude are due to bias in the study designs. In addition, some studies report that periodontitis is associated with all-cause mortality and low birth weight infants. These multiple associations detract from the credibility of periodontitis as a risk factor, as specificity of association is more often related to causality. However, all-cause mortality may largely be driven by mortality from cardiovascular events: and some exposures, such as smoking. are indeed risk factors for multiple conditions. On the other hand, current findings regarding the associations between oral conditions and atherosclerosis/CHD imply that the criteria for causality may be met in the not-too-distant future.
MAIN MESH HEADINGS: Coronary Disease/*epidemiology
Coronary Disease/*etiology
Focal Infection, Dental/*complications
Periodontitis/*complications
ADDITIONAL MESH HEADINGS: Animal
Atherosclerosis/epidemiology
Atherosclerosis/etiology
Cohort Studies
Focal Infection, Dental/physiopathology
Human
Inflammation/physiopathology
Monocytes/metabolism
Odds Ratio
Phenotype
Reproducibility of Results
Risk Factors
Sensitivity and Specificity
PUBLICATION TYPES: JOURNAL ARTICLE
REVIEW
REVIEW, TUTORIAL
LANGUAGE: Eng

  
  

Medline Search: National Library of Medicine
Relationship of periodontal disease to systemic illness

  

TITLE:

Position paper of The American Academy of Periodontology: periodontal disease as a potential risk factor for systemic diseases.
AUTHOR: Scannapieco FA
SOURCE: J Periodontol 1998 Jul;69(7):841-50
CITATION IDS: PMID: 9706864 UI: 98370361
ABSTRACT: This paper on periodontal disease as a potential risk factor for systemic diseases was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to provide information regarding the role of periodontal disease in systemic diseases, including bacteremia, infective endocarditis, cardiovascular disease and atherosclerosis, prosthetic device infection, diabetes mellitus, respiratory diseases, and adverse pregnancy outcomes.
MAIN MESH HEADINGS: Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Atherosclerosis/etiology
Bacteremia/etiology
Cardiovascular Diseases/etiology
Diabetes Mellitus/etiology
Endocarditis, Bacterial/etiology
Female
Focal Infection, Dental/complications
Human
Infant, Low Birth Weight
Infant, Newborn
Mental Disorders/etiology
Pregnancy
Pregnancy Complications
Pregnancy Outcome
Prosthesis-Related Infections/etiology
Respiratory Tract Infections/etiology
Sepsis Syndrome/etiology
Social Desirability
PUBLICATION TYPES: JOURNAL ARTICLE
REVIEW
REVIEW, TUTORIAL
LANGUAGE: Eng
 
TITLE:

Heart attacks, strokes, diabetes and periodontal diseases: the relationship between periodontal health and systemic diseases.
AUTHOR: Dennison DK
AUTHOR AFFILIATION: Department of Stomatology, University of Texas-Houston Dental Branch, USA.
SOURCE: J Gt Houst Dent Soc 1998 Mar;69(8):22-3
CITATION IDS: PMID: 9667177 UI: 98331807
MAIN MESH HEADINGS: Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Biofilms
Cardiovascular Diseases/etiology
Diabetes Mellitus/etiology
Female
Human
Infant, Low Birth Weight/physiology
Infant, Newborn
Insulin Resistance
Periodontal Diseases/microbiology
Pregnancy
PUBLICATION TYPES: JOURNAL ARTICLE
LANGUAGE: Eng
TITLE:

Diabetes and periodontal diseases.
SOURCE: J Periodontol 1996 Feb;67(2):166-76
CITATION IDS: PMID: 8667138 UI: 96231203
ABSTRACT: This position paper on diabetes mellitus was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to: 1) update members of the dental profession on the diagnosis and medical management of patients with diabetes mellitus; 2) summarize current knowledge on the relation between diabetes mellitus and periodontal diseases; 3) provide an overview of factors in diabetic patients relevant to understanding the pathogenesis of periodontal diseases in these subjects; 4) outline special considerations associated with treatment of periodontal diseases in diabetic patients; and 5) discuss possible approaches to the management of diabetic emergencies in the dental office. Reliance on this position paper in patient management will not guarantee a successful outcome. Periodontal diseases often involve numerous and complex causes and symptoms. Ultimately, decisions regarding the diagnosis and treatment of disease in an individual patient must be made by the treating practitioner in light of the specific facts presented by that patient.
MAIN MESH HEADINGS: Diabetes Mellitus/*complications
Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Dental Care for Chronically Ill
Diabetes Mellitus/diagnosis
Diabetes Mellitus/drug therapy
Diabetes Mellitus, Insulin-Dependent/complications
Diabetes Mellitus, Non-Insulin-Dependent/complications
Emergencies
Human
Periodontal Diseases/diagnosis
Periodontal Diseases/therapy
PUBLICATION TYPES: JOURNAL ARTICLE
REVIEW
REVIEW, TUTORIAL
LANGUAGE: Eng
TITLE:

Periodontal and cardiovascular diseases [letter; comment]
AUTHOR: Chow JP
SOURCE: J Am Dent Assoc 1998 Apr;129(4):410
CITATION IDS: PMID: 9573691 UI: 98234775
COMMENT: Comment on: J Am Dent Assoc 1998 Jan;129(1):8, 12-4, 16
MAIN MESH HEADINGS: Cardiovascular Diseases/*complications
Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Human
PUBLICATION TYPES: COMMENT
LETTER
LANGUAGE: Eng
TITLE:

Systemic effects of periodontal disease. Toxic factors in periodontal disease.
AUTHOR: Hilming F
SOURCE: Int Dent J 1966 Jun;16(2):287-95
CITATION IDS: PMID: 5220559 UI: 66153295
MAIN MESH HEADINGS: Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Adult
Arthritis/etiology
Case Report
Endotoxins
Female
Fever/etiology
Headache/etiology
Human
PUBLICATION TYPES: JOURNAL ARTICLE
LANGUAGE: Eng
TITLE:

Periodontal diseases' contributions to cardiovascular disease: an overview of potential mechanisms.
AUTHOR: Kinane DF
AUTHOR AFFILIATION: Periodontal Department, Glasgow Dental School, Scotland.
SOURCE: Ann Periodontol 1998 Jul;3(1):142-50
CITATION IDS: PMID: 9722698 UI: 98389922
ABSTRACT: Periodontitis and atherosclerosis have complex etiologies, genetic and gender predispositions, and potentially share many risk factors-the most significant of which may be smoking status. These diseases also have many pathogenic mechanisms in common. It is becoming increasingly clear that infections and chronic inflammatory conditions such as periodontitis may influence the atherosclerotic process. The severity and chronicity of periodontal disease provides a rich source of subgingival microbial and host response products and effects over a long time period. The objective of this review is to consider the mechanisms whereby diseases such as periodontitis, which is chronic and Inflammatory In nature and initiated by microbial plaque, can predispose to atherosclerosis. In common with periodontal disease. the pathogenesis of atherosclerosis is not completely understood and both diseases are currently under Intensive investigation. Two main processes in particular are worthy of consideration and may provide the link between these 2 diseases, namely the lipopolysaccharide-related responses and the hyperresponsive monocyte phenomenon. Insufficient experimental evidence exists, however, to further support these hypotheses at present and clearly more research is needed on both of these processes and the interrelationships between both diseases.
MAIN MESH HEADINGS: Cardiovascular Diseases/*etiology
Focal Infection, Dental/*complications
Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Atherosclerosis/etiology
Focal Infection, Dental/physiopathology
Gram-Negative Bacteria/metabolism
Gram-Negative Bacterial Infections/complications
Human
Leukocytes/physiology
Lipopolysaccharides/immunology
Lipopolysaccharides/metabolism
Monocytes/physiology
Periodontal Diseases/metabolism
Periodontal Diseases/microbiology
Smoking/adverse effects
PUBLICATION TYPES: JOURNAL ARTICLE
REVIEW
REVIEW, TUTORIAL
REGISTRY NUMBERS: 0 (Lipopolysaccharides)
LANGUAGE: Eng
TITLE:

Periodontal disease as a risk factor for heart disease.
AUTHOR: Loesche WJ
AUTHOR AFFILIATION: School of Medicine, University of Michigan, Ann Arbor.
SOURCE: Compendium 1994 Aug;15(8):976, 978-82, 985-6 passim; quiz 992
CITATION IDS: PMID: 7741856 UI: 95079486
ABSTRACT: Many individuals with cardiovascular disease appear from epidemiologic studies to have either periodontal disease or to be edentulous. A Finnish group has provided evidence that after conventional risk factors for stroke and heart attacks have been accounted for, there still remains a significant relationship between dental disease and cardiovascular disease. A preliminary analysis of our own investigation of the interrelationship of medical and dental health shows that individuals with a high dental morbidity (ie, edentulous or with many missing teeth) have a high prevalence of coronary heart disease and stroke. A model based on how smoking can predispose to periodontal disease is used to explain how periodontal disease could be a potential risk factor for heart disease.
MAIN MESH HEADINGS: Cardiovascular Diseases/*etiology
Periodontal Diseases/*complications
ADDITIONAL MESH HEADINGS: Bacteremia/complications
Bacteria, Anaerobic/isolation & purification
Cardiovascular Diseases/epidemiology
Cardiovascular Diseases/microbiology
Human
Immunity, Natural
Mouth, Edentulous/complications
Mouth, Edentulous/epidemiology
Oral Hygiene
Periodontal Diseases/epidemiology
Periodontal Diseases/immunology
Prevalence
Risk Factors
Smoking/adverse effects
Stress, Psychological/complications
Support, U.S. Gov't, P.H.S.
PUBLICATION TYPES: JOURNAL ARTICLE
REVIEW
REVIEW, TUTORIAL
LANGUAGE: Eng
GRANT/CONTRACT ID: DE-09142/DE/NIDR
IP30-AG-008808/AG/NIA
TITLE:

Periodontal diseases and human health: new directions in periodontal medicine.
AUTHOR: Stamm JW
AUTHOR AFFILIATION: School of Dentistry, University of North Carolina at Chapel Hill, USA.
SOURCE: Ann Periodontol 1998 Jul;3(1):1-2
CITATION IDS: PMID: 9722684 UI: 98389908
MAIN MESH HEADINGS: *Dental Research
*Periodontal Diseases
ADDITIONAL MESH HEADINGS: Human
Periodontal Diseases/complications
Periodontal Diseases/etiology
PUBLICATION TYPES: JOURNAL ARTICLE
LANGUAGE: Eng