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胡 当, 张 锋, 李 蕙, 许 小, 文 萍, 郑 峥, 姚 吉. [Polycystic ovary syndrome is positively correlated with periodontitis: a prospective study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2024; 44:36-44. [PMID: 38293974 PMCID: PMC10878896 DOI: 10.12122/j.issn.1673-4254.2024.01.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE To explore the correlation between polycystic ovary syndrome (PCOS) and periodontitis in light of cytokines levels, sex hormone levels and metabolism-related indicators and their changes during progression of the two diseases. METHODS Twenty healthy subjects and 40 patients diagnosed with PCOS underwent full-mouth periodontal examinations to obtain full-mouth plaque score (FMPS), gingival bleeding index of probing (BOP), probing depth (PD), and clinical attachment level (CAL). The participants were divided into Group A without periodontitis or PCOS (n=15), Group B with PCOS but without periodontitis (n=28), Group C with periodontitis but without PCOS (n=5), and Group D with both diseases (n=12). Serum levels of luteinizing hormone/follicle stimulating hormone (LH/FSH), testosterone, prolactin, progesterone and estradiol, and the levels of interleukin 6 (IL-6), IL-17A, tumor necrosis factor α and matrix metalloproteinase 8 (MMP-8) in both serum and saliva samples were measured at the time of enrolment and at 3 and 6 months after enrolment and compared among the 4 groups. RESULTS Serum MMP-8 level was significantly higher in Group B than in Group A (P<0.05). Salivary MMP-8 level was significantly higher in Group D than in Group B (P<0.05). Salivary MMP-8, LH, and LH/FSH levels and serum and salivary IL-6 and progesterone levels all tended to increase in the 6 months after enrollment (OR>1, P<0.05). During the follow-up period, serum IL-6 levels differed significantly between the non-PCOS groups (A and C) and PCOS groups (B and D)(P<0.05); serum IL-6 and salivary MMP-8 levels differed significantly between the non-periodontitis groups (A and B) and periodontitis groups (C and D)(P<0.05). Spearman correlation analysis indicated positive correlations of LH and LH/FSH with PD (P<0.05); testosterone and LH/FSH were positively correlated with serum MMP-8 levels (P<0.05), and PD, BOP and FMPS were positively correlated with salivary MMP-8 levels (P<0.01). CONCLUSION There is a correlation between PCOS and periodontitis, and their progression is accompanied by changes in serum and salivary levels of pro-inflammatory cytokines and serum sex hormones.
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Affiliation(s)
- 当立 胡
- 南方医科大学第一临床医学院,深圳市妇幼保健院,广东 广州 516006Shenzhen Maternity and Child Healthcare Hospital, First School of Clinical Medicine, Southern Medical University, Guangzhou 516006, China
- 深圳市妇幼保健院妇科,广东 深圳 518028Department of Gynecology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
| | - 锋 张
- 深圳市妇幼保健院口腔防治中心,广东 深圳 518028Department of Stomatology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
| | - 蕙君 李
- 深圳市妇幼保健院口腔防治中心,广东 深圳 518028Department of Stomatology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
| | - 小艺 许
- 深圳市妇幼保健院科教科,广东 深圳 518028Department of Science and Education, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
| | - 萍 文
- 深圳市妇幼保健院科教科,广东 深圳 518028Department of Science and Education, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
| | - 峥 郑
- 深圳市妇幼保健院妇科,广东 深圳 518028Department of Gynecology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
| | - 吉龙 姚
- 南方医科大学第一临床医学院,深圳市妇幼保健院,广东 广州 516006Shenzhen Maternity and Child Healthcare Hospital, First School of Clinical Medicine, Southern Medical University, Guangzhou 516006, China
- 深圳市妇幼保健院妇科,广东 深圳 518028Department of Gynecology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen 518028, China
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Jaglan S, Tewari S, Singhal SR, Sharma RK. Impact of Polycystic Ovary Syndrome on Periodontal Status of Women of Adolescent and Adult Age Groups: A Cross-Sectional Study. Med Princ Pract 2024; 33:148-156. [PMID: 38211576 PMCID: PMC11095622 DOI: 10.1159/000536223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is identified as the most common endocrine disorder in reproductive-aged women, and symptoms of PCOS appear during the early pubertal age. There is a gap in knowledge in recognizing the status of gingival inflammation/periodontal destruction and high-sensitivity C-reactive protein levels (hsCRP) in adolescents versus adults with PCOS. This study aimed to observe the impact of PCOS on periodontal status and systemic inflammation in adolescents and compared them with adults with PCOS. METHODS A total of 100 newly diagnosed female subjects with PCOS were enrolled into two groups: adolescents (11-19 years, n = 50) and adult females (20-40 years, n = 50). Periodontal parameters, anthropometric parameters, PCOS phenotype, hirsutism score, and serum hsCRP levels were recorded. RESULTS High levels of mean hsCRP, gingival index, and bleeding on probing % were observed in adolescent and adult PCOS groups, though nonsignificant between the groups (p > 0.05). Significantly more sites with probing pocket depth 3-4 mm, higher mean clinical attachment level (CAL) and sites with CAL 1-2 mm, and high frequency of patients (n = 11) with periodontitis (stage 1) were observed in adults with PCOS compared to adolescents (p ≤ 0.05). Similar and predominant prevalence of PCOS phenotype A (66%) and moderate hirsutism (46% adolescents vs. 58% adults) were observed in both groups. CONCLUSION Similar levels of hsCRP and periodontal inflammation were found in adolescents and adults with PCOS. More periodontal tissue destruction was observed in adults with PCOS as compared to adolescents with PCOS.
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Affiliation(s)
- Swati Jaglan
- Department of Periodontics, Post Graduate Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, India
| | - Shikha Tewari
- Department of Periodontics, Post Graduate Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, India
| | - Savita Rani Singhal
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, India
| | - Rajinder Kumar Sharma
- Department of Periodontics, Post Graduate Institute of Dental Sciences, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, India
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Hu D, Wang J, Cheng T, Li H, Zhang F, Zhao D, Xu X, Yu R, Wen P, Cheng Y, Xu J, Jin L, Yao J. Comparative analysis of serum and saliva samples using Raman spectroscopy: a high-throughput investigation in patients with polycystic ovary syndrome and periodontitis. BMC Womens Health 2023; 23:522. [PMID: 37794378 PMCID: PMC10552415 DOI: 10.1186/s12905-023-02663-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) and periodontitis significantly affect women's oral and systemic health worldwide, and yet increase the risk of cardiovascular-metabolic diseases like diabetes and coronary heart disease. Regarding the PCOS-periodontitis connection, whether sex hormones, metabolic and inflammatory mediators could account for the underlying linking mechanism needs to be further investigated. This case-control study evaluated the hormonal, metabolic and inflammatory profiles in PCOS and non-PCOS subjects with various periodontal conditions, via assessing serum and saliva samples by Raman spectroscopy. METHODS A total of 66 females with PCOS and 22 systemically healthy female volunteers were recruited in a single hospital. Full-mouth periodontal examination was undertaken for identifying the subjects with periodontal health, gingivitis or periodontitis. The datasets of sex hormones and metabolic indicators were retrieved from the hospital information system. Both serum and saliva samples were collected for detecting inflammatory mediators and Raman spectroscopic assessment. The subjects were categorized into four groups according to their conditions of PCOS and periodontitis for Raman spectroscopic analysis. Partial least squares discriminant analysis was performed to examine the inter-group differences in Raman spectra. RESULTS PCOS patients exhibited greater mean probing depth (P < 0.05) and higher serum levels of triglycerides (P < 0.05) and matrix metalloproteinase-8 (P < 0.05) than those in non-PCOS participants. Both probing depth and triglyceride level were positively correlated with PCOS (P < 0.05). There was a significant difference in mean Raman spectra of saliva samples among the four groups with different conditions of PCOS and periodontitis (P < 0.05), while no significant inter-group difference existed in serum samples. CONCLUSIONS The present study shows that periodontal condition may affect the biomolecular profiles of Raman spectra in serum and saliva of PCOS patients. It underscores the importance of the collaborative teamwork of dentists and gynecologists for enhancing women's oral health, general wellbeing and quality of life.
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Affiliation(s)
- Dangli Hu
- Department of Obstetrics & Gynecology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, 518028, China
| | - Jianmei Wang
- Single-Cell Center, CAS Key Laboratory of Biofuels, Shandong Key Laboratory of Energy Genetics and Shandong Energy Institute, Qingdao Institute of Bioenergy and Bioprocess Technology, Chinese Academy of Sciences, Qingdao, 266101, China
- University of Chinese Academy of Sciences, Beijing, 101408, China
| | - Tianfan Cheng
- Division of Periodontology & Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
| | - Huijun Li
- Department of Stomatology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Feng Zhang
- Department of Stomatology, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Dan Zhao
- Division of Periodontology & Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
- Department of Implant Dentistry, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050, China
| | - Xiaoyi Xu
- Department of Science & Education, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Rong Yu
- Department of Science & Education, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Ping Wen
- Department of Science & Education, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028, China
| | - Yunfei Cheng
- Single-Cell Center, CAS Key Laboratory of Biofuels, Shandong Key Laboratory of Energy Genetics and Shandong Energy Institute, Qingdao Institute of Bioenergy and Bioprocess Technology, Chinese Academy of Sciences, Qingdao, 266101, China
- University of Chinese Academy of Sciences, Beijing, 101408, China
| | - Jian Xu
- Single-Cell Center, CAS Key Laboratory of Biofuels, Shandong Key Laboratory of Energy Genetics and Shandong Energy Institute, Qingdao Institute of Bioenergy and Bioprocess Technology, Chinese Academy of Sciences, Qingdao, 266101, China
- University of Chinese Academy of Sciences, Beijing, 101408, China
| | - Lijian Jin
- Division of Periodontology & Implant Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.
| | - Jilong Yao
- Department of Obstetrics & Gynecology, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, 518028, China.
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Maboudi A, Nasiri Amiri F, Shafizade S, Qujeq D, Mohammadpour RA, Moaddabi A, Amiri M, Yosefnia-Pasha S, Odhaib SA. Evaluation of the Salivary Matrix Metalloproteinase-9 in Women With Polycystic Ovaries Syndrome and Gingival Inflammation: A Case-Control Study. Cureus 2023; 15:e34458. [PMID: 36874743 PMCID: PMC9980837 DOI: 10.7759/cureus.34458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
Background Polycystic ovary syndrome (PCOS) is an endocrine disease of women of reproductive age that impacts their oral and systemic well-being. This study aimed to compare the gingival inflammation indices and matrix metalloproteinase-9 (MMP-9) of non-obese women with PCOS. Materials and methods This is a case-control study in which 78 women were referred to the Babol Clinic Hospital in Northern Iran between 2018 and 2019. They were divided into three groups: 26 women with PCOS and gingivitis, 26 women with PCOS with no gingivitis, and 26 women with no PCOS and no gingivitis as a control group. After recording the anthropometric and demographic variables, fasting saliva samples were taken from all participants before any periodontal intervention. These samples were transferred to Babol Molecular Cell Research Center under highly guaranteed cold-chain conditions to measure the serum levels of MMP-9. Periodontal status was evaluated for Gingival Index (GI), Plaque Index (PI), and Bleeding on Probing (BOP). Analysis of variance was used to compare the mean results for these indices. The significance level was considered when p ≤ 0.05. Results All the gingival indices were significantly higher for women with PCOS with gingivitis compared to the results for women from the other two groups. Similarly, women with PCOS showed high salivary MMP-9 levels but were within the normal reference ranges. Conclusion The gingival indices (GI, PI, and BOP) and salivary MMP-9 are higher in women with PCOS, regardless of the gingival status.
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Affiliation(s)
- Avideh Maboudi
- Department of Periodontology, Dental Research Center, Mazandaran University of Medical Sciences, Sari, IRN
| | - Fatemeh Nasiri Amiri
- Department of Obstetrics and Gynecology, Infertility and Health Reproductive Research Center, Babol University of Medical Sciences, Babol, IRN
| | - Sara Shafizade
- Department of Dentistry, Mazandaran University of Medical Sciences, Sari, IRN
| | - Durdi Qujeq
- Department of Clinical Biochemistry, Babol University of Medical Sciences, Babol, IRN
| | - Reza-Ali Mohammadpour
- Department of Statistic and Epidemiology, Mazandaran University of Medical Sciences, Sari, IRN
| | - Amirhosain Moaddabi
- Department of Oral and Maxillofacial Surgery, Mazandaran University of Medical Sciences, Sari, IRN
| | - Mania Amiri
- Department of Obstetrics and Gynecology, Obstetricians, Infertility and Health Reproductive Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, IRN
| | | | - Samih A Odhaib
- Department of Adult Endocrinology, Thi Qar Specialized Diabetes, Endocrine and Metabolism Center (TDEMC) Thi Qar Health Directorate, Thi Qar, IRQ
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Mizgier M, Watrowski R, Opydo-Szymaczek J, Jodłowska-Siewert E, Lombardi G, Kędzia W, Jarząbek-Bielecka G. Association of Macronutrients Composition, Physical Activity and Serum Androgen Concentration in Young Women with Polycystic Ovary Syndrome. Nutrients 2021; 14:73. [PMID: 35010948 PMCID: PMC8746804 DOI: 10.3390/nu14010073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 02/08/2023] Open
Abstract
The roles of dietary macronutrients and physical activity (PA) in patients with PCOS have not been sufficiently reported, especially in adolescent girls. To address this knowledge gap, we evaluated the associations between serum concentrations of total testosterone (tT), free testosterone (fT), androstenedione (A), dehydroepiandrosterone-sulfate (DHEA-S), sex hormone-binding globulin (SHBG) and dietary macronutrients intake as well as different types and levels of PA. The study population consisted of 96 girls of Caucasian ancestry, aged 14-18 years: 61 participants with polycystic ovary syndrome (PCOS) and 35 healthy controls. Serum tT, fT, A, DHEA-S, and SHBG were determined in fasting blood. Macronutrient intake and PA levels were assessed by using the three-day food record method and the Beliefs and Eating Habits Questionnaire (KomPAN), respectively. We found several positive correlations between dietary macronutrients such as total fat, saturated fatty acids (SFA), monounsaturated (MUFA) and polyunsaturated fatty acids (PUFA), and hormonal parameters across the entire cohort and in healthy girls. A positive correlation between SHBG and total protein consumption as well as an inverse correlation between SHBG and carbohydrate intake could be determined. No correlation between androgens and macronutrients was found in the PCOS group. In contrast, we observed an inverse correlation between androgen concentrations (except of DHEA-S) and "work/school" and/or "leisure time" PA only in PCOS patients. Moreover, the hormone levels differed according to PA intensity. In conclusion, the impact of diet and PA was strikingly different in adolescents with and without PCOS. These findings indicate that disturbed hormonal homeostasis in PCOS, at least in the youngest patients, likely "overtrump" dietary influences, and otherwise, PA offers a therapeutic potential that requires further evaluation of the long-term effects in randomized studies. (ClinicalTrial.gov Identifier: NCT04738409.).
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Affiliation(s)
- Małgorzata Mizgier
- Dietetic Department, Faculty of Physical Culture, Poznan University of Physical Education, 66-400 Gorzów Wielkopolski, Poland
| | - Rafał Watrowski
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Justyna Opydo-Szymaczek
- Department of Pediatric Dentistry, Poznan University of Medical Sciences, 60-812 Poznan, Poland;
| | - Elżbieta Jodłowska-Siewert
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-806 Poznan, Poland;
| | - Giovanni Lombardi
- Laboratory of Experimental Biochemistry and Molecular Biology, IRCCS Istituto Ortopedico Galeazzi, 20161 Milano, Italy;
- Department of Athletics, Strength and Conditioning, Poznań University of Physical Education, 61-871 Poznań, Poland
| | - Witold Kędzia
- Department of Perinatology and Gynecology, Division of Developmental Gynecology and Sexology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (W.K.); (G.J.-B.)
| | - Grażyna Jarząbek-Bielecka
- Department of Perinatology and Gynecology, Division of Developmental Gynecology and Sexology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (W.K.); (G.J.-B.)
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Mizgier M, Jarząbek-Bielecka G, Formanowicz D, Jodłowska-Siewert E, Mruczyk K, Cisek-Woźniak A, Kędzia W, Opydo-Szymaczek J. Dietary and Physical Activity Habits in Adolescent Girls with Polycystic Ovary Syndrome (PCOS)-HAstudy. J Clin Med 2021; 10:3469. [PMID: 34441766 PMCID: PMC8396824 DOI: 10.3390/jcm10163469] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 12/25/2022] Open
Abstract
The role of inappropriate lifestyle in the etiology of polycystic ovary syndrome (PCOS) and its metabolic and reproductive complications has attracted much attention in recent years; however, most studies involve adult patients. Thus, the study aimed to compare dietary patterns, physical activity, metabolic, anthropometric and inflammatory markers of 14-18-year-old girls with and without PCOS (n = 61 and n = 35, respectively) as well as to assess correlations between concentrations of metabolic and inflammatory markers and macronutrient intake and to identify the independent predictors of PCOS, related to diet and physical activity (PA). Compared to the control group, PCOS girls consumed significantly more total fat (p = 0.0005), including both saturated (SFA) (p = 0.03), monounsaturated (MUFA) (p = 0.0003) and polyunsaturated fatty acids (PUFA) (p = 0.01). A significantly higher percentage of PCOS patients consumed high and medium glycemic index (GI) foods (p = 0.03) and represented a low level of PA, both during school and in leisure time (41.67 vs. 6.06%; p = 0.0001 and 32.79 vs. 5.71%; p = 0.003, respectively). The PCOS group had also significantly higher waist circumference (WC), C-reactive protein (CRP) (p = 0.01), LDL cholesterol (p = 0.01), fasting insulin (p = 0.002) and HOMA-IR (p = 0.006) levels. There was an inverse correlation between fiber intake and fasting insulin, (p = 0.0002, r = -0.37), HOMA-IR (p = 0.0004, r = -0.35), WC (p = 0.029; r = -0.222) and a positive relationship between high and medium GI diet and insulin concentration (p = 0.003; r = 0.3). An increase of 10 g/day in total fat intake per day increases the probability of PCOS by 1.4 times. If the SFA or MUFA intakes increase by 10 g, the probability of PCOS increase 1.7-fold and 2.5-fold, respectively. The consumption of foods with a medium GI raises the probability of PCOS by more than 3 times, after adjusting for age. The odds ratio decreased for the moderate and high PA at school/work and in leisure time. Further research in girls with PCOS is needed to test whether low GI and dietary fatty acid reduction combined with increased PA is effective in the nonpharmacological treatment and prevention of PCOS complications. ClinicalTrial.gov Identifier: NCT04738409.
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Affiliation(s)
- Małgorzata Mizgier
- Department of Dietetics, Faculty of Physical Culture in Gorzów Wlkp., Poznan University of Physical Education, Estkowskiego 13, 66-400 Gorzów Wielkopolski, Poland; (K.M.); (A.C.-W.)
| | - Grażyna Jarząbek-Bielecka
- Department of Perinatology and Gynecology, Division of Developmental Gynecology and Sexology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (G.J.-B.); (W.K.)
| | - Dorota Formanowicz
- Chair and Department of Medical Chemistry and Laboratory Medicine, Poznan University of Medical Sciences, 60-806 Poznan, Poland;
| | - Elżbieta Jodłowska-Siewert
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-806 Poznan, Poland;
| | - Kinga Mruczyk
- Department of Dietetics, Faculty of Physical Culture in Gorzów Wlkp., Poznan University of Physical Education, Estkowskiego 13, 66-400 Gorzów Wielkopolski, Poland; (K.M.); (A.C.-W.)
| | - Angelika Cisek-Woźniak
- Department of Dietetics, Faculty of Physical Culture in Gorzów Wlkp., Poznan University of Physical Education, Estkowskiego 13, 66-400 Gorzów Wielkopolski, Poland; (K.M.); (A.C.-W.)
| | - Witold Kędzia
- Department of Perinatology and Gynecology, Division of Developmental Gynecology and Sexology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (G.J.-B.); (W.K.)
| | - Justyna Opydo-Szymaczek
- Department of Pediatric Dentistry, Chair of Pediatric Dentistry, Poznan University of Medical Sciences, 60-812 Poznan, Poland;
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