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PubMed1997

Evaluation of anionic collagen membranes in the treatment of class II furcation lesions: an histometric analysis in dogs.

This study aims to evaluate the effect of using anionic collagen membranes in guided tissue regeneration treatment of Class II furcation lesions in dogs. The defects were created in the buccal furcation of 16 mandibular premolars of four dogs. After 56 days without plaque control, the sites were scaled and divided into two groups according to the treatment applied: control sites, open flap debridement; and test sites, guided tissue regeneration treatment. The animals were killed after 3 months. Histological and histometrical analyses showed that the collagen membrane was better than open flap debridement in terms of newly formed cementum and epithelial migration prevention. It provided effective blockade of epithelial tissue and promoted regeneration of lost periodontal tissues, suggesting that the membrane warrants further study.

Animals↗
PubMed1997

A clinical evaluation of guided tissue regeneration with a bioabsorbable matrix membrane combined with an allograft bone graft. A series of case reports.

THE PURPOSE OF THIS STUDY was to evaluate the clinical effectiveness of a surgical technique in treating periodontal defects. The technique combined tetracycline treatment of a root planed root, grafting of the osseous defect with a demineralized freeze-dried bone allograft combined with tetracycline and the placement of a bioabsorbable matrix membrane, made of polylactic acid softened with citric acid ester. Thirty defects were treated in 27 patients. Statistically significant changes, as a result of the surgical procedure, were observed in marginal recession (mean: 0.5 mm), probing depth reductions (mean: 5.7 mm), and attachment level gain (mean: 5.2 mm). No statistically significant difference existed between the results in the furcation and non-furcation groups. The defects with probing depths > or = 10 mm had a greater mean probing depth reduction (7.4 mm) and mean attachment level improvement (7.2 mm) than the defects with < 10 mm probing depths (probing depth reduction 4.5 mm and attachment level gain 3.9 mm). The proposed surgical procedure seemed to be an effective method to treat periodontal defects.

Adult↗
PubMed1989

Relationship between the radiographic periodontal defect angle and healing after treatment.

This study radiographically evaluated the correlation between the changes in alveolar bone level occurring in bony defects after periodontal therapy and the corresponding pretreatment defect angles. The defect angle was defined by the bony defect surface and the root surface. The changes were determined from identically exposed and processed radiographs obtained just prior to surgery and 15 to 18 months later. The defect angle was clearly correlated to the radiographic changes in alveolar bone level. Most defects with an angle less than 45 degree showed a gain of bone while defects with the largest defect angles showed a loss. In addition, defects on root surfaces without furcations showed better healing than defects associated with furcations.

Alveolar Process↗
PubMed2001

The effect of membrane exposure on the outcome of regenerative procedures in humans: a meta-analysis.

BACKGROUND: The significance of early membrane exposure on the regenerative outcome in guided tissue regeneration (GTR) and guided bone regeneration (GBR) procedures is somewhat controversial. Several clinical trials have shown better response when the membranes remained submerged (S) compared to those that have become exposed (E) during healing. Other studies have failed to show any such difference. Small sample size and/or large standard deviation of the changes might account for these discrepancies. The purpose of this meta-analysis is to critically combine the existing data in order to provide meaningful information based on a large database. METHODS: Studies of GTR in Class II furcation and intrabony defects (IBD), together with GBR around dental implants, where the membrane became exposed during the postoperative period, were combined to form 3 separate databases. A meta-analysis was employed to compare the 2 subgroups (E versus S) in each of the databases. First, weighted mean changes and weighted standard errors were calculated for each subgroup. Next, an individual study P value was calculated (1-tailed Student t test); finally, a combined Fisher's P statistic (with 5% significance level) was calculated from the individual P values. RESULTS: Five studies with a total of 101 sites were included in the furcation database; 43 of these sites became exposed. Mean horizontal attachment level (AL) gain for the S sites (3.72 +/- 0.15 mm) was slightly greater than that of the E sites (3.06 +/- 0.15 mm; P = 0.030257). For the intrabony group, there were 309 sites in 5 studies: of these, 142 sites became exposed. Mean gain in vertical AL was 4.22 +/- 0.15 mm and 4.69 +/- 0.13 mm for the E and S group, respectively (P = 0.011415). The GBR group included 60 sites in 2 studies: new bone formation in the 24 S sites (3.01 +/- 0.38 mm) was 6-fold greater compared with the 36 E sites (0.56 +/- 0.45 mm). These differences were also statistically significant (P = 0.001875). CONCLUSIONS: Membrane exposure during healing had a major negative effect on GBR around dental implants but only a minimal effect on GTR around natural teeth.

Alveolar Bone Loss↗
PubMed2006

Evaluation of the oral health status of the people aged 65 years and over living in near rural district of Middle Anatolia, Turkey.

The aim of this study was to assess the oral health status of aged 65 years and over, and evaluate the level of edentulousness and study the factors that could have an influence on edentulism. The participants of this study were 215 patients; 94 males (47.3%) and 121 females (56.3%), aged 65 years and over. Each subject underwent a comprehensive dental and radiographic examination by one examiner. Periodontal attachment loss observed in the panoramic radiographs was divided into three diagnostic categories: infrabony defects, horizontal bone loss, and furcation lesions. The number of teeth with apical periodontitis lesions, the number of carious teeth, and restorations, type of dentures and wear duration, intrabony root remains, impacted teeth, smoking status, educational level and self-reported medical history of the participants were recorded. Extent of tooth loss was significantly higher in females than males and increased with increasing age (p<0.05). Tooth loss was significantly associated with educational levels; lower literacy level was found to be associated with a higher number of missing teeth (p<0.01). Also, as the educational levels of the participants increased, the number of infrabony defects, furcation lesions and number of carious teeth decreased (p<0.05). Low literacy level and female gender are found to be high-risk groups for tooth loss. Community-based oral disease prevention programs should be implemented to reduce the risk for tooth loss in this population.

Age Distribution↗
PubMed2005

Mandibular bone deficit with a histologic study in man.

The aim of this study was that to determine the clinical and histologic results of a new hydroxyapatite, with innovative properties compared with the other alloplastic materials used in the regenerative treatment of grade 3 bony defects of the mandibular furcations in the human. The hydroxyapatite used in our research is characterized by a scarce density and crystallinity, while from a microstructural point of view, the granules have nanometric dimensions (0.05-0.1 microm). The patient reported here by the authors had a grade 3 infrabony defect into a mandibular furcation. The surgical procedure used consists of the creation of a flap, roots planing, the conditioning of the roots with tetracycline HC, the accurate positioning of the granules of the hydroxyapatite in the furcation area, the crown replacing of the flap, and finally the suture of the same. Six months after the insertion of hydroxyapatite, the clinical effect was studied, comparing the variations found in probing the insertion of depth. At the end of the treatment, a block section of the molar was performed, with part of the surrounding soft tissues, whose histologic analysis underlined the moderate and initial formation of bony tissue, periodontal ligament, and radicular cement in the middle and lower portion of the furcation. In light of these results, the authors conclude that the use of this new hydroxyapatite is promising in the treatment of the mandibular furcations in the human, even if it will be necessary to continue to test its effectiveness through more studies.

Adult↗
PubMed1998

Regeneration of oxytalan fibres in different types of periodontal defects: a histological study in monkeys.

The aim of the present study was to investigate in monkeys the regrowth of oxytalan fibres in different types of acute and chronic periodontal defects following regenerative periodontal treatment. One-wall intrabony and mandibular furcation III-defects were produced surgically in 3 monkeys (Macaca fascicularis). After a 6-wk dental plaque accumulation period the defects were exposed using a full thickness flap procedure. The granulation tissue was removed and the root surfaces were scaled and planed. Additionally, fenestration-type defects were produced at the vestibular surfaces of the maxillary and mandibular canines by surgically removing the vestibular bone plates and the root cementum. Subsequently, the defects were treated with guided tissue regeneration (GTR), enamel matrix proteins (EMP), combination of EMP and GTR or with coronally repositioned flaps. The postoperative care included tooth cleaning once a week during the experiment. After 5 months the animals were sacrificed and and the block sections were embedded in paraffin. Eight microns histological sections were cut and stained with the oxone-aldehyde-fuchsin-Halmi method. The results revealed that in all specimens where a regenerated periodontal ligament could be observed newly formed oxytalan fibers were present. They had a mainly apico-occlusal orientation and were localized closer to the cementum than to the alveolar bone. The regenerated oxytalan fibers had a similar morphological appearance than those observed in the original periodontal ligament regardless of the treatment modality by which regeneration was accomplished. Their presence was related to that of newly formed cementum suggesting a strong relationship between these 2 tissues. The neoformation of oxytalan fibres can thus be observed in some types of periodontal defects where the cementum and the periodontal ligament have been regenerated.

Animals↗
PubMed1997

Evidence for healing of class II and III furcations after GTR therapy: digital subtraction and clinical measurements.

In 21 patients with advanced periodontitis, 39 teeth exhibiting class II (n = 21) and class III (n = 18) furcations were treated by the guided tissue regeneration technique using expanded polytetrafluoroethylene (ePTFE) membranes (n = 20) or bioabsorbable barriers (n = 19), respectively. Clinical parameters were assessed before and 6 months after surgery. Presurgically and 6 months postsurgically, 35 pairs of standardized bitewing radiographs were taken. Using subtraction radiography, gain of bone density within furcation areas was assessed. Eighteen radiographs showed sufficiently accurate geometry to be analyzed by subtraction. Within the defects suitable for subtraction, the average gain of vertical attachment assessed was 1.35 +/- 1.27 mm in the class II furcation group and 1.58 +/- 1.37 mm in the class III furcation group. The average horizontal attachment gain in the class II furcation group was 1.96 +/- 0.59 mm. No statistically significant differences were observed between results after GTR therapy using non-resorbable and bioabsorbable barriers. Radiographic bone gain as assessed by subtraction analysis correlated with vertical (r = 0.458, P < 0.025) and horizontal (r = 0.734, P < 0.005) attachment gain. A statistically significant number of more radiographs for maxillary molars were not suitable for subtraction analysis than mandibular molars (P < 0.05). Further, statistically more radiographs that were taken with potentially unstable support of the filmholder were not suitable for subtraction analysis than those with stable support (P < 0.05). There is a statistically significant correlation between clinical improvements and bony fill within furcation defects. Only 18 of 35 pairs of radiographs were suitable for subtraction analysis. Subtraction analysis of maxillary molars seems to be more difficult than assessment of radiographic bone changes in mandibular molars. Potentially stable support of the filmholder seems to be a condition to provide radiographs suitable for subtraction analysis.

Absorption↗
PubMed1998

Guided tissue regeneration update.

The ultimate goal of periodontal therapy is to restore periodontal tissues lost through disease or trauma. The most predictable way to accomplish this goal is by guided tissue regeneration (GTR). The principle of GTR is to give preference to certain cells to repopulate the wound area to form a new attachment apparatus. Clinically this is accomplished by placing a barrier over the defect thereby excluding gingival tissues from the wound during early healing. The first generation of GTR barriers were non-resorbable which implies that they have to be removed in a second surgical procedure. Resorbable barriers have recently been introduced, changing GTR into a single-step procedure. Periodontal defects that will predictably benefit from GTR therapy are intrabony, furcation class II and gingival recession defects. This paper reviews the scientific evidence of what can be achieved by GTR procedures for various periodontal defects as well as factors of importance to increase the predictability of a successful treatment outcome.

Absorption↗
PubMed2004

A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part II: secondary outcomes.

BACKGROUND: This multicenter, randomized trial compared enamel matrix derivative (EMD) with barrier membranes for the treatment of Class II mandibular furcations with regard to secondary outcomes. The influence of furcation morphology on the effectiveness of either treatment was also evaluated. METHODS: Forty-eight patients (age range 28 to 73 years; 22 females, 26 males) with buccal Class II furcation involvements in both contralateral lower first or second molars were included. After initial periodontal treatment, defects were randomized to either EMD or bioabsorbable guided tissue regeneration (GTR) barrier. Study design and the results for the primary parameter were previously described. Results of the following secondary outcome variables are reported here: changes of the hard tissue boundaries describing the anatomical situation of the furcation defect and changes in the following clinical parameters between baseline and 14 months: plaque, level of gingival margin, probing depth, bleeding on probing, attachment level, and bone sounding at five sites/tooth at the buccal side. Descriptive statistics were applied for changes in clinical parameters and measurements of hard tissue boundaries. The differences observed under treatment with EMD or membrane were analyzed by means of the Wilcoxon two-sample test. The difference between the effect of the EMD and membrane treatment was estimated by means of the Hodges-Lehmann estimator. RESULTS: Overall, similar healing results were observed for both treatments. However, there was slightly more recession in the mid-furcation site following membrane treatment (P = 0.04). Additionally, different treatment effects could be detected for the distances from the stent or cemento-enamel junction (CEJ) to the buccal bone crest, mid-distal root (Pstent = 0.01; PCEJ = 0.07) and for the distance from the stent or CEJ to the buccal bone crest, mid-mesial root (Pstent = 0.01; PCEJ = 0.01). There was no measurable bone resorption in EMD sites, whereas a slight resorption occurred with membrane treatment. Furcation morphology at the time of surgery was not associated with clinical outcome, irrespective of the treatment. CONCLUSION: With regard to secondary outcome parameters, enamel matrix derivative treatment led to a similar regenerative result as the membrane procedure.

Absorbable Implants↗
PubMed1999

Furcation involvement in posterior teeth.

This article presents two cases in which different treatments were used for mandibular molars with furcation lesions. In the first case, a conventional amputation treatment of the distal root was performed to save the mesial root as a terminal tooth, which was used as a partial denture abutment. The second case describes a relatively new technique in which a root perforation was filled with graft material (synthetic bioglass) and covered with a resorbable membrane to treat an iatrogenic furcation lesion adjacent to the mesial root. Twelve months after surgery, periapical radiographs of both treated cases showed increased bone density. Follow-up in both cases--30 months in the first case and 12 months in the second--showed no pathological recurrence or clinical dysfunction. Root amputation may provide an alternative to extraction in periodontally involved molars. Synthetic bone replacement materials combined with guided tissue regeneration may also help to correct osseous defects incurred by recent furcation perforations with associated bone loss.

Aged↗
PubMed2001

Collagen membranes: a review.

Collagen materials have been utilized in medicine and dentistry because of their proven biocompatability and capability of promoting wound healing. For guided tissue regeneration (GTR) procedures, collagen membranes have been shown to be comparable to non-absorbable membranes with regard to probing depth reduction, clinical attachment gain, and percent of bone fill. Although these membranes are absorbable, collagen membranes have been demonstrated to prevent epithelial down-growth along the root surfaces during the early phase of wound healing. The use of grafting material in combination with collagen membranes seems to improve clinical outcomes for furcation, but not intrabony, defects when compared to the use of membranes alone. Recently, collagen materials have also been applied in guided bone regeneration (GBR) and root coverage procedures with comparable success rates to non-absorbable expanded polytetrafluoroethylene (ePTFE) membranes and conventional subepithelial connective tissue grafts, respectively. Long-term clinical trials are still needed to further evaluate the benefits of collagen membranes in periodontal and peri-implant defects. This article will review the rationale for each indication and its related literature, both in vitro and in vivo studies. The properties that make collagen membranes attractive for use in regenerative therapy will be addressed. In addition, varieties of cross-linking techniques utilized to retard the degradation rate of collagen membranes will be discussed.

Absorbable Implants↗
PubMed1991

[Guided tissue regeneration for the treatment of different periodontal defects. A clinical study].

In 31 patients we implanted a teflon membrane (Gore-Tex) during flap operation for a duration of 6 weeks. The periodontal situation was assessed clinically and radiographically 1-1.5 years after surgery. The study comprised 18 upper and lower molars with furcation involvement and 15 single-rooted teeth with a 2-wall-, 3-wall- or combined bony defect. Clinical gain of attachment only occurred in furcation class II lesions (upper molars + 2.3 mm, lower molars + 2.5 mm), whereas the attachment level was unchanged in "through and through" furcation defects in the upper jaw and loss of attachment was observed at lower molars with class III furcations. In single-rooted teeth the gain of attachment varied between 0.5 and 8.5 mm, depending on the proportions of the defect and the number of the surrounding bony walls.

Adult↗
PubMed2003

Wound healing of degree III furcation involvements following guided tissue regeneration and/or Emdogain. A histologic study.

BACKGROUND: The use of enamel matrix proteins (EMD) has been recently introduced as a new treatment alternative for periodontal regeneration. However, no histological studies are available investigating the effect of EMD in the treatment of degree III furcation involvements. OBJECTIVES: The aim of this study was to evaluate the healing of mandibular degree III furcation involvements histologically following treatment with guided tissue regeneration (GTR), EMD and a combination of EMD and GTR. MATERIAL AND METHODS: Degree III furcation involvements were surgically created at the teeth 36, 37, 46, 47 in three monkeys (Macaca fascicularis). Spontaneous healing of the defects was prevented by placing impression material into the defects. After 6 weeks, full-thickness flaps were elevated at the buccal and lingual aspect of the experimental teeth. Following removal of all granulation tissue from the furcation defects, scaling/root planing and conditioning of the root surfaces with 24% EDTA gel, the defects were treated with one of the following treatment modalities: (i) EMD, (ii) GTR or (iii) a combination of EMD and GTR. The defects serving as control did not receive any treatment, except from complete coverage with coronally displaced flaps. After 5 months of healing, the animals were killed and perfused with 10% buffered formalin for fixation. The experimental teeth with surrounding tissues were dissected free, decalcified in EDTA, dehydrated and embedded in paraffin. 8 microm thick histological sections were cut and stained and subsequently examined under the light microscope. RESULTS: The histological analysis revealed that with GTR or combined EMD and GTR treatment, new attachment formation (new cementum with inserting collagen fibers) had occurred on almost the entire circumference of the furcation and new bone was almost filling the defect in the situations where the membrane was not exposed. The sites treated only with EMD exhibited new attachment and new bone formation to a varying extent, while the control sites presented only limited new attachment and bone formation. CONCLUSION: The results provided histological evidence suggesting that both GTR and EMD may result in true periodontal regeneration, and suggest that this type of healing might be favored by such treatments in comparison with flap surgery.

Animals↗
PubMed1996

Multi-center evaluation of bioabsorbable collagen membrane for guided tissue regeneration in human Class II furcations.

Clinical data related to GTR therapy for Class II furcations were analyzed from 7 treatment centers that evaluated one of two possible treatment pairs, either bioabsorbable collagen membrane (Type I bovine tendon collagen) (COLL) versus control surgical debridement (DEBR) or COLL versus expanded polytetrafluoroethylene (ePTFE). After initial preparation and re-evaluation, full thickness flaps were reflected, the defects debrided, and the roots planed. Furcations and associated bony defects in each patient were randomly assigned to one of the 2 treatments in each pair, and the flaps closed. Patients received quarterly periodontal maintenance until surgical re-entry at 6 to 12 (mean 11.1) months. Data from 59 pairs of Class II furcations were analyzed via paired t, Wilcoxon signed rank, and RM ANOVA tests. COLL showed better results than DEBR for vertical defect fill, percent defect resolution, and horizontal furcation fill. When COLL was compared to ePTFE in furcations across patients, no differences were found. Both COLL and ePTFE resulted in an improvement in clinical furcation Class about 50% of the time (compared to 7% frequency with DEBR). COLL use yielded 8 and ePTFE yielded 1 clinically-complete furcation closures. COLL barriers resulted in generally favorable clinical results in furcation defects, appeared to be better than DEBR alone, and were at least similar to and often better than ePTFE. COLL of the type used in this study appears to be a useful and beneficial material for regenerative therapy in Class II furcation type periodontal defects.

Adult↗
PubMed1997

Six-year clinical evaluation of HTR synthetic bone grafts in human grade II molar furcations.

A biocompatible microporous composite of PMMA (poly-methyl-methacrylate), PHEMA (poly-hydroxy-ethyl-methacrylate) and calcium hydroxide bone replacement graft material (Bioplant HTR Synthetic Bone) was evaluated in 16 maxillary molar and 10 mandibular molar Grade II furcations in 13 patients. Following initial preparation, full thickness flaps were raised to gain access to the furcations; mechanical hand and ultrasonic root and defect debridement and chemical tetracycline root preparation were performed; furcation and adjacent osseous defects in each patient were grafted with HTR Synthetic Bone; and the host flaps replaced or slightly coronally positioned. Weekly, then monthly deplaquing was performed until surgical re-entry at 6-12 months. Patients were then followed on approximate 3-month recalls for > or = 6 yr. Evaluation of the primary clinical outcome of furcation grade change showed that in the maxilla 5/16 furcations were clinically closed, 9/16 were Grade I, and 2/16 remained Grade II; while in the mandible 3/10 were clinically closed, 5/10 were Grade I, and 2/10 remained Grade II. Other significant clinical changes included decrease in mean horizontal furcation probing attachment level from 4.4 mm at surgery to 2.2 mm at re-entry to 2.0 mm at 6 yr, decrease in probing pocket depth from 5.4 mm at surgery to 3.0 mm at re-entry to 3.2 mm at 6 yr, and improvement in vertical clinical probing attachment level from 5.4 mm at surgery to 4.2 mm at re-entry to 4.1 mm at 6 yr (all p < 0.05 from surgery to re-entry and surgery to 6 yr, n.s. from re-entry to 6 yr via ANOVA). These favorable results with HTR polymer are similar to several reports with other graft materials and with GTR barriers, and suggest that HTR polymer may have a beneficial effect in the clinical management of Grade II molar furcations.

Adult↗
PubMed1994

Clinical evaluation of HTR polymer bone replacement grafts in human mandibular Class II molar furcations.

A biocompatible microporous composite of PMMA (poly-methyl-methacrylate), PHEMA (poly-hydroxyl-ethyl-methacrylate), and calcium hydroxide (HTR) or autogenous osseous coagulum (AOC) bone replacement grafts were evaluated in 15 pairs of mandibular molar Class II furcations in 9 patients. Following initial preparation, full thickness flaps were raised to gain access to the furcations; mechanical hand and ultrasonic root and defect debridement and chemical (tetracycline) root preparation were performed; paired furcations in each patient were randomly grafted with either HTR or AOC; and the host flaps replaced or slightly coronally positioned. Weekly, then monthly, deplaquing was performed until surgical re-entry at 6 to 12 months. Both treatments improved the clinical status of the treated furcations. Direct clinical measurements demonstrated essentially equivalent clinical results with both bone replacement graft materials related to most hard and soft tissue changes in the furcations. Differences in favor of HTR were found for horizontal residual furcation depth (2.4 mm vs. 3.9 mm), horizontal furcation fill (1.9 mm vs. 0.8 mm), and percent horizontal furcation fill (44.4% vs. 17.1%) (all P < or = 0.05 paired t test). These favorable results with HTR polymer are similar to several reports with other graft materials and with GTR barriers, and suggest that HTR polymer may be a useful therapeutic adjunct in the clinical management of grade II mandibular molar furcations.

Adult↗
PubMed2002

Assessment of periodontal conditions and systemic disease in older subjects. II. Focus on cardiovascular diseases.

BACKGROUND: Panoramic radiographs (PMX)s may provide information about systemic health conditions. AIMS: i). To study clinical periodontal conditions and collect self-reported health status in a cohort of 1084 older subjects; ii). to study signs of alveolar bone loss and carotid calcification from panoramic radiographs obtained from these subjects; and iii). to study associations between study parameters. MATERIAL AND METHODS: PMXs from 1064 adults aged 60-75 (mean age 67.6, SD +/- 4.7) were studied. Signs of alveolar bone loss, vertical defects, and molar furcation radiolucencies defined periodontal status. Medical health histories were obtained via self-reports. Signs of carotid calcification were identified from panoramic radiographs. RESULTS: The PMX allowed assessment of 53% of the films (Seattle 64.5% and Vancouver 48.4%). A self-reported history of a stroke was reported by 8.1% of men in Seattle and 2.9% of men in Vancouver (P < 0.01). Heart attacks were reported by 12% of men in Seattle and 7.2% in Vancouver (N.S.). PMX evidence of periodontitis was found in 48.5% of the subjects, with carotid calcification in 18.6%. The intraclass correlation score for PMX findings of carotid calcification and stroke was 0.24 (95% CI: 0.10-0.35, P < 0.001). The odds ratio for PMX carotid calcification and periodontitis was 2.1 (95% CI: 1.3-3.2, P < 0.001), and for PMX carotid calcification and stroke 4.2 (95% CI: 1.9-9.1, P < 0.001). The associations disappeared when smoking was accounted for. A history of a heart attack was associated with stroke, gender, age, and PMX scores of alveolar bone loss. CONCLUSIONS: PMXs may provide valuable information about both oral conditions and signs of carotid calcification, data that are consistent with self-reported health conditions. Alveolar bone loss as assessed from PMXs is associated with cardiovascular diseases.

Aged↗