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��ࡱ�>��	OR����LMN�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�	��T�bjbj����	4�ΐΐ?�%�������pp������������8�����*B��q"���n �!,,!AAAAAAA$2E��GXCA��D!n n D!D!CA������A*8*8*8*D!�����A8*D!A8*8*�c<�G>�����@� �����'l=	A�A<*B3=,Hh)�,H0G>G>�,H��>(D!D!8*D!D!D!D!D!CACA8*D!D!D!*BD!D!D!D!��������������������������������������������������������������������,HD!D!D!D!D!D!D!D!D!p	y:	The prevalence, pattern of dental erosion and associated risk factors in 6-12 year old children in Ile � Ife, Nigeria.

Oziegbe EO, Kolawole KA, Oshomoji V, Onyejaka N, Agbaje H, Oyedele TA, Chukwumah NM, Folayan MO.
Elizabeth O Oziegbe1, 2, 3*, Kikelomo A Kolawole1,2,3�, Olusegun V Oshomoji1,2�, �, Nneka Onyejaka1,2�, Hakeem O Agbaje 1,2 *, 3Titus A Oyedele1,2�, Morenike O Folayan1, 2�, 
Oral Habit Study Group, Ile-Ife, Nigeria.
Department of Child Dental Health, Obafemi Awolowo University Teaching Hospitals� Complex, Ile-Ife, Nigeria
Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria.

�These authors contributed equally to this work

*Corresponding author

Elizabeth O Oziegbe
Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria.
elioziegbe@yahoo.com





Abstract
Background: Dental erosion is the most common form of tooth wear in children and has been identified as an important cause of tooth loss in both children and adolescents.
Objectives: To determine the prevalence, pattern and identify associated risk factors for dental erosion in the mixed dentition of children resident in Ile �Ife, Nigeria.
Methods: A cross sectional study that involved 495 children aged 6 -12 year old recruited through a household survey using stratified random sampling technique. A structured questionnaire was used to obtain information on the socio-demographic status of each child and associated risk factors (vomiting, chewing of food after meal, regurgitation, use of acidic drugs, frequent consumption of carbonated beverages and exposure to battery acid) for dental erosion. The index of O�Sullivan was used to determine the distribution, severity and area of tooth affected by erosion.
Results: The prevalence of dental erosion was 1.8%. More females than males (1.2% vs 0.6%; �2= 0.91; p=0.34), children in the age group 6-9 years (�2= 0.43; p=0.51), and children from the low socioeconomic class (�2= 4.06; p=0.13) had dental erosion, though the observed differences were not statistically significant.. Most (0.06%) of the affected teeth were primary teeth.  Also, 67% of the teeth had the occlusal or incisal surface affected. The odds of having dental erosion for children who frequently consumed aspirin/ vitamin C was 1.72 (95%CI: 0.32 -17. 11) 
Conclusion: The prevalence of dental erosion in the study population was low, primary teeth was worse affected in the mixed dentition, and the occlusal and incisal surfaces were most often affected. No significant risk factor for dental erosion was identified in the study population.

Introduction
Dental erosion is the surface loss of dental hard tissue by a chemical process without bacteria involvement.1 It is the most common form of tooth wear in children2 and is often complicated by other forms of tooth wear.3 It is a notable clinical challenge in paediatric dentistry and has been identified as an important cause of tooth loss in both children and adolescents.4 
The prevalence of dental erosion is on the increase 5 with prevalence varying by age and population group. Prevalence range between 10% and 80%.6 In the United Kingdom,, the prevalence of erosion with dentine involvement on the palatal surfaces of primary teeth in 2 and 5 year-olds was 8% and 24% respectively.7 In the permanent dentition, the prevalence of erosion on the palatal surfaces was 8% in 7-year-olds and increased to 31% in 14-year-olds.7 In China, 5.7% of children aged 3-5 years-olds had erosion of the maxillary incisors.8 While 27% of 12-13-year-old Chinese children had signs of dental erosion.9 In Libya, the prevalence was as high as 40.8% in 12-year-olds.10 The prevalence of erosion increases as age increases due to longer exposure of the teeth to the erosive acidic environment.
The cause of dental erosion is acid, the source of which may be extrinsic or intrinsic. Extrinsic factors such as diet, in particular citric fruit juices, carbonated beverages and soft drinks, play a significant role in the cause of dental erosion.11 -14 Intrinsic factors like gastro-oesophageal reflux disease (GERD) and other medical conditions that results in efflux in gastric acid into the mouth are responsible for some dental erosion.15, 16
Multiple predisposing factors for dental erosion in children have been identified. Some studies4, 9 reported fewer lesions in children whose mother had higher level of education, others reported no relationship between erosion and social class.17 Continuous access to acidic drinks at home and/or school, and financial capacity to consistently purchase and consume acidic drinks are some factors that cause distinction in the social class prevalence of erosion in children.8
The primary dentition is more susceptible to erosion because the hard tissues are thinner and less mineralized. This makes the enamel more liable to acid dissolution than its permanent counterpart.2 Dental erosion may progress into the dentine and pulp, resulting in tooth sensitivity and death of the pulp tissue. It could also lead to occlusal derangement and altered aesthetics.18 
Most studies on dental erosion in children have been from developed countries with dearth of information from Africa. There is also very little known about the prevalence and possible cause of tooth erosion in children in Africa. Prior studies on the subject had been limited to adult population.19,20  This study tried to address some of the identified gaps. It specifically tried to determine the prevalence and pattern of dental erosion in children aged 6-12 years resident in a sub-urban area of Nigeria. It also identified associated risk factors for dental erosion in the primary and permanent dentition in children with mixed dentition. 

Methods
Study design: This was a secondary analysis of a data collected through a household survey primarily focused on assessing the association between oral habits and dental caries. The study recruited 992 study participants. Part of the study had been reported in previous publications.21 
Study population: It recruited children from Ife Central Local Government Area (LGA) of Osun State, Nigeria. Recruitments were done at the National Population Enumeration sites in the LGA. The Enumeration sites were the same used for the 2007 National Adolescent Reproductive Health Survey. Most of the participants in the sites chosen were familiar with such surveys. According to the 2006 National Population Census, the population of children resident in the LGA was about 14,000. The diet of the population mainly consists of carbohydrate. However recently, there has been a change from the traditional fibrous diet to consumption of refined diet and sugary/carbonated drinks. 22 
The primary study recruited children age 6 months to 12 years whose parents gave written consent to participate in the study. Children who were 8 to 12 years also gave assent for study participation. Children also had to be living with biological parents or legal guardians to be able to participate in the study. Also, only children who were present in the home at the time of study conduct were recruited for the study. 
Sample size: The sample size was determined by the statistical formula proposed by Araoye 23. The estimated proportion of children with dental erosion was 20%, using the prevalence from a study on the same age group 6 years to 12 years.24 The calculated minimum sample size needed with 10% attrition rate was 203 children. However the data of 495 children age 6 years to 12 years was retrieved from the primary data.

Sampling procedure: The sampling procedure was a multi-stage cluster sampling that involved three-levels aimed at selecting qualified children with known probability. The first stage involved random selection of enumeration areas within the LGA. The second stage involved the selection of households for the study. Every third house on street in the enumeration area were selected for the study. The third stage involved the selection of actual respondents for interview and clinical examination.  In each household, only one qualified child was selected to participate in the study. Alternative sexes and age range identified for study recruitment were selected to participate in each eligible household. Recruitment continued in the enumeration sites until the study sample per data collector was reached.
Study procedure: Data was collected using an interviewer-administered structured questionnaire. Experienced field workers who had participated in past national surveys were recruited for the study. The field workers were trained centrally on the study protocol prior to data collection.
Information retrieved from the data for this study included the socio-demographic status (age, sex and socioeconomic class) of each child. The socioeconomic class of each child was determined using the father�s occupation and the mother�s level of education. An adapted version of the index developed by Olusanya et al.25 was used. For this study, data was collected on educational level and profession of parents of respondents. The mother�s level of education was classified as �no formal education, Quranic and primary school education� and scored as 2; secondary school education scored as 1; and tertiary education scored as 0. The father�s occupation was also categorised into three:  Those who were civil servants or skilled professional with tertiary level of education were scored 1; those who were civil servants or skilled professional with secondary level of education were scored 2; and unskilled, unemployed individuals, students, and civil servants or skilled professional with primary and or Quranic level of education were scored 3. The social class was obtained through the addition of the score of the mother�s level of education with that of the father�s occupation. Each child was therefore allocated into social class I- V where class I referred to upper class, class II referred to upper middle class, class III referred to middle class, class IV referred to lower middle class and class V referred to lower class. When a child had lost a parent, the socio- economic status was scored using the figure obtained for the living parent.
Information was also obtained on frequency of intake of acidic drink (carbonated drinks and fruit juices) per week, general health status (frequency of vomiting, regurgitation of food or fluid), frequency of intake of drugs such as antacids, aspirin and vitamin C supplements, and exposure to acids from car batteries were also retrieved. Information on exposure to acids from car batteries was collected in the field based on a prior report from the study site.19 Details of the questionnaire were based on the brief protocol for diagnosis of dental erosion proposed by Gupta et al.26. 
The face validity of the instrument was conducted through a review of the questionnaire by seven other dentists. The dentists reviewed the questions to ensure there were no ambiguity in the questions and the possibility of multiple or different interpretation of the questions. The questions were also reviewed during the training of the eight field workers to rule out ambiguity in the wordings of the questions. The questionnaire was field tested by each of the right field workers and the questions were once again reviewed for any form of ambiguity.
Intra-oral examination: Trained dentists carried out intra oral examination on each child who met the study inclusion criteria. The child was examined under natural light using sterilized dental mirrors and probes, and food debris was removed from tooth surface using sterilized cotton wool. All the teeth present in the mouth were examined for dental erosion. The index of O�Sullivan 15 was adapted to record the distribution, severity, and area of affected teeth. Children with erosion on the labial or buccal only were coded as �A�; those with erosion on the lingual or palatal only coded �B�; those with erosion on the occlusal or incisal only coded �C�; those with erosion on the labial and incisal/occlusal coded �D� and erosion on multiple tooth surfaces coded �F�. Each tooth in the mouth was examined and coded for presence or absence of tooth erosion.
The severity of the erosion was graded codes 0-9 based on extent of loss of enamel. The worst score for an individual tooth was recorded. Teeth with normal enamel were coded �0�; teeth with matt appearance of the enamel surface with no loss of contour were code �1�; teeth with loss of enamel only signified by loss of surface contour was code �2�; teeth with loss of enamel with exposure of dentine and the enamel-dentin junction was visible on visual inspection was coded �3�; teeth with loss of enamel and dentine beyond enamel dentine junction was code �4�; teeth with loss of enamel and dentine with exposure of the pulp was coded �5�. Code 9 was ascribed to teeth that the field examiner was unable to assess due to presence of tooth crown or large restoration. Surface affected by erosion were also coded � �� when less than half of surface is affected and �+� when more than half of surface is affected.
Calibration of field workers:  Eight data collectors were recruited as field workers and trained on the data collection procedure and details of the study collection tool. The field workers were taken through the questionnaire on the first day of the training. They were also taught the techniques of asking questions and the how to obtain consent.  
Eight qualified dentists were also trained and calibrated for this study. The diagnostic criteria for dental erosion were thoroughly discussed by the examiners. A range of dental erosion levels based on the diagnosis via photographic images was reviewed in the calibration exercise. The examiners examined 15 children for dental erosion in a pilot study. These children were not included in the main study. To assess the reproducibility of the diagnostic criteria, the examiners re-examined the same group of children after a week. Intra- and inter-examiner agreement was evaluated using Cohen�s kappa. The intra-examiner scores ranged from xx to xx while the inter-examiner scores ranged from xx to xx. 
During the data collection process, four teams were constituted. Each team consisted of two data collectors and two dentists. All data collected each day was submitted to a study coordinator. The study coordinator went over each data collection tool to ensure adequate completion of the questionnaire. All queries were addressed within 24 hours.  
Ethics approval: Ethical approval for the study was obtained from the research and ethics committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Approval to carry out the study was also obtained from the Ife Central LGA prior to commencement of the study. Informed consent was obtained from the parent of each child.  Assent was obtained from all children aged 8 years to 12 years old after obtaining consent from parents. 
Data analysis:  For ease of analysis the age of study participants were dichotomised: (i) 5-9 years (ii) 10-12 years. Also the socioeconomic status was regrouped into three: (i) High (those who were from the upper and upper middle classes) (ii) middle (those from the middle) and low (those from the lower middle and lower classes) class. This categorisation of socio-economic status had been previously described by Olusanya et al25.   
Descriptive analysis was done to describe the sex, socioeconomic status, prevalence and pattern of dental erosion. Pearson�s or Fisher�s exact Chi �square test was used to determine the association between dental erosion, sex and socioeconomic status where appropriate. Relative risk of the risk factors for presence of dental erosion was calculated. Statistical analysis was performed using SPSS software (version 16.0). Statistical significance was defined as p<0.05.
Results
Table 1 shows the socio-demographic profile of the 495 children aged 6 to 12 years who met the inclusion criteria for this study. There were 242 (48.9%) males and 253 (51.1%) females with a mean age of 8.53 + (1.89) years. Forty one percent of the children were from middle socioeconomic class, 36.4% were from low socioeconomic class while 22.3% were from high socioeconomic class. There was no statistically significant difference in the proportion of children recruited from the different socio-economic classes (p = 0.25).
Table II shows the distribution of children with dental erosion. Of the 495 children, 9 (1.8%) had dental erosion. There were six (1.2%) females and three males (0.6%). This was not statistically significant in the proportion of males and females who had dental erosion (�2 = 0.91; p = 0.34). More children in the age group 6 -9 years old (1.0%) had dental erosion though the age group difference was not statistical significant (�2 = 0.43; p =0.51). Most of the children with dental erosion were from low socioeconomic class with no significant difference observed in the proportion of children who had dental erosion by socioeconomic status (�2 = 4.06; p= 0.13). 
Most of the teeth (0.06%) affected were in the primary dentition. The mandibular teeth were more affected (0.07%) than the maxillary teeth. The mandibular second primary molar was mostly (0.03%) affected followed by the mandibular first primary molar (0.01%). Table III. 
The affected tooth surface was majorly (83.3%) the occlusal/incisal surfaces (code �C�). Loss of enamel with exposure of dentine and visible enamel �dentine junction (code �3�) was observed in 58.3% of the affected teeth while about sixty seven percent of the affected teeth had more than half of the surfaces (code �+�) affected by dental erosion. Table IV.
Table V shows the predictive factors for dental erosion for the study population. Children who consumed aspirin/vitamin C frequently were almost twice likely to have dental erosion when compared with children who were not consuming aspirin/vitamin C frequently (OR: 1.72; 95%CI: 0.32 � 17.11). Children who did not regurgitate their food were less likely to have dental erosion than children who regurgitated their food (OR: 0.34; 95%CI:0.04 -15.98). 

Discussion
The study showed the prevalence of dental erosion among the population as 1.8%. There was no significant difference in the prevalence of dental erosion with respect to age, sex and socioeconomic status. Most of the affected teeth were primary dentition with more mandibular teeth affected than maxillary teeth. Majority of the teeth had the occlusal or incisal surface affected with the lesion extending to the enamel dentine junction and affecting more than half of the tooth surface. The prevalence of dental erosion in this study is low compared to the 19.9% reported for 6 to 12 years children in Brazil 24 and 40.8% reported for 12-year-olds in Libya.10 Other studies had reported prevalence of dental erosion in children ranging between 30% and 65% for children in the United States and the United Kingdom 27,28. The prevalence reported for this population was still low despite the challenges with the Tooth Wear Index: the index can overestimate dental erosion due to lack of specificity, as a result other forms of tooth wear are measured. 29 The low prevalence reported may be due to low exposure to risk factors for dental erosion since the children reside in a sub-urban region with less access to acidic drinks30; a major risk factor for dental erosion31. 
We observed no significant difference in the prevalence of dental erosion by gender, socioeconomic class and age. This is unlike the observation by Wang et al.9 who observed higher prevalence of dental erosion in females, and the observation by Mangueira et al.24 and Truin et al.32 who observed higher prevalence of dental erosion in males. There are a few other studies that did not observe significant gender differences in the prevalence of dental erosion like our study.2,29 Similarly, some studies have reported difference in prevalence of dental erosion by socioeconomic status4,8,9,33 while Al-Malik et al.17 reported no relationship between socioeconomic class and dental erosion.
Prior studies had also observed that the occlusal or incisal surfaces of the teeth were most frequently affected by dental erosion9,34 though studies in children in Brazil identified the palatal surface as the most affected surface. 23,35 This observed differences in sites of dental erosion implies that risk factors for dental erosion vary between populations. Understanding risk factors for dental erosion for each population would help communities develop specific interventions that can address community needs.  Paradoxically, the factor that could otherwise cause increased risk of dental erosion on the occlusal or incisal surfaces of the teeth � drinking of acidic beverages - had no likelihood of causing dental erosion in the study population. The risk factor - frequent consumption of aspirin/ vitamin had almost twice increased risk for dental erosion in the study population. We are aware that we do need to interpret our study result with caution since the number of children with dental erosion was very small and the confidence intervals were very wide. Despite this limitation, the data helps us to identify risk factors for dental erosion we need to explore further in the study population as we try and understand how to prevent any increase in prevalence of the lesion in the study environment. 
The result also suggests that children who have dental erosion may be exposed to the risk factor for a long time or may have high intensity exposure30 as we see that a large number of the children with the lesion had loss of contours of the enamel, dentine exposure and more than half of the tooth surface affected. This is more severe than the lesions observed in children in China. Unfortunately, poor utilisation of dental services by children in the study population for preventive oral health care 36 will lead to delayed diagnosis and late interventions to prevent complications. This implies that prevention programmes for dental erosion in the study population requires a community-based approach for it to be effective.

One other limitation with the study is the low number of children with dental erosion, which makes it difficult to conduct subgroup analysis. While the study was adequately powered with sufficient sample for the data analysis, the low proportion of study participants with dental erosion increases the likelihood for type I error 37. Despite the limitation of this study, we have been able to provide data on the prevalence and pattern of dental erosion in the study population. The use of a household survey for study participants� recruitment makes the sample more representative of the children in the study environment thus making the study findings generalizable to the study population. 
In conclusion, the prevalence of dental erosion in the study population was low with more lesions observed in the primary dentition, on the occlusal/incisal surfaces and in the mandible. The severe presentation of erosion in the few study participants may indicate poor oral health care seeking habits for the management of the lesion. It may also indicate that the few children with dental erosion are intensely exposed to risk factors. It is important to increase public awareness about the lesion despite its low prevalence in the study population in view of the high risk for tooth loss on late diagnosis. 

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Table I: Gender distribution of the children by socioeconomic class
GenderHigh SES
N (%)Middle SES
N (%)Low SES
N (%)Total
N (%)Male58 (11.7)104 (21.1)79 (16.0)241 (48.8)Female52 (10.5)100 (20.2)101 (20.4)253 (51.2)Total110 (22.3)204 (41.3)180 (36.4)494 (100.0)* Socioeconomic status of one child was not recorded. �2 = 2.81,  df = 2, p = 0.25






Table II: Distribution of dental erosion by gender 
VariablesDental erosion absent
N (%)Dental erosion present
N (%)Total

N (%)�2(df)P valueGenderMale239 (48.3)3 (0.6)242 (48.9)
     0.91
0.34Female247 (49.9)6 (1.2)253 (51.1)Total486 (98.2)9 (1.8)495 (100. 0)Age group (years) 6  - 9
        322 (65.1)        5  (1.0)      325 (65.7)

    0.43

0.5110 � 12
        164  (33.1)        4   (0.8)       170 (34.3)Total
        486 (98.2)       9 (1.8)     495(100.0)Socioeconomic ClassHigh
107 (21.6)  3 (0.6)110 (22.3)


   4.06


0.13Middle
203 (41.0)  1 (0.2)204 (41.3)Low 
176 (35.6)  5  (1.0)180 (36.4)Total
486 (98.2) 9 (1.8)495(100.0)












Table III: Distribution of teeth affected dental erosion by pattern and severity
Tooth typePattern and severity of dental erosionNo of affected teeth (%)Total number of primary teeth (N= 4,667)  74-C3 - occlusal or incisal surface affected by erosion with less than half of surface is affected with loss of enamel and exposure of dentine    1 (0.02)
 +C3 - occlusal or incisal surface affected by erosion with more than half of surface is affected with loss of enamel and exposure of dentine   1 (0.02)  75-C1   - occlusal or incisal surface affected by erosion with less than half of surface affected and  matt appearance of the enamel surface  
 1 (0.02)+C3 - occlusal or incisal surface affected by erosion were more than half of surface is affected with loss of enamel and exposure of dentine   2 (0.04)  83
-A2 - labial or buccal surface with loss of enamel and loss of surface contour affecting less than half of tooth surface 2 (0.04)  84
+C3 - occlusal or incisal surface affected by erosion with more than half of surface is affected with loss of enamel and exposure of dentine 1 (0.02)  85
+C3 - occlusal or incisal surface affected by erosion with more than half of surface is affected with loss of enamel and exposure of dentine 2 (0.04)Total number of permanent teeth (N= 7,903)  26
+C4  - occlusal or incisal surface loss of enamel and dentine beyond enamel dentine junction affecting  more than half of the tooth surface 1(0.02)  46
+C1 -  occlusal or incisal surface affected with more than half of surface affected and  matt appearance of the enamel surface1(0.02)





Table IV: Percentage of affected children by site, severity and area of tooth surface affected by dental erosion
Variables  No of affected teeth
              (N=12) Percentage (%)Site of erosionA - labial or buccal surface216.7B - lingual or palatal surface00C - occlusal or incisal surface1083.3D - labial and incisal/occlusal00F - multiple tooth surfaces00Total12100Severity
0 � Normal teeth1 - matt appearance of the enamel surface with no loss of contour216.72 - loss of enamel with loss of surface contour216.73 - loss of enamel with exposure of dentine758.34 - loss of enamel and dentine beyond enamel dentine junction18.35 - loss of enamel and dentine with exposure of the pulp00.09 - teeth that the field examiner was unable to assess due to presence of tooth crown or large restoration00.0Total12100Area affected�-� - Surface affected by erosion were less than half of surface is affected.433.3�+� - lmvwx�����������������			����³�����w�w�ocZcZcKo@h*@h �OJQJh �CJH*OJQJ^JaJh �H*OJQJh�<nh �H*OJQJh �OJQJh76Wh��CJOJQJaJh76Wh{�CJOJQJaJh76Wh�CJOJQJaJh76Wh $CJOJQJaJh76Wh(-�CJOJQJaJh76Wh� 5�CJOJQJaJh(-�5�CJOJQJaJh76Wh�5�CJOJQJaJh76Wh(-�5�CJOJQJaJwx��	�	
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la�p�������yt)�Surface affected by erosion were more than half of surface is affected.866.7Total12100
Table V: Association between risk factors and presence of dental erosion
Risk factorsDental erosion absent
N= 486Dental erosion present
N=9Odds ratioCIP valueVomiting 
<once in a month
 Occasionally /never
5 (1.0%)
481 (99.0%)
0 (0.0%)
9 (100.0%)

         -

        -

1.00*Chewing of food after meal
Yes
No

  13 (2.7%)
473 (97.2%)

0 (0.0%)
9 (100.0%)

-

-

 1.00*Fluid regurgitation
Yes
No
    9 (1.9%)
477 (98.1%)
0 (0.0%)
9 (100.0%)
-
-
  1.00*Food regurgitation
Yes
No
  20 (4.1%)
466 (95.9%)
1 (28.0%)
8 (72.0%)
1
0.34
-
0.04 -15. 98
-
Regular use of antacids
Yes
No

  42 (8.6%)
444 (91.4%)

0 (0.0%)
9 (100.0%)

-

-

1.00*Frequent consumption of coke/fruit juice
> three times a week
<  three times a week


200 (41.2%)

286 (58.8%)


4 (44.4%)

5 (55.6%)


1

0.95


-

0.44-1.94


-

Frequent consumption of aspirin/ vitamin c 
Yes
No


160 (32.9%)
326 (67.1%)


2 (22.2%)
7(77.8%)


1
1.72


-
  0.32 � 17.11


-
0.72*Exposure to battery acids
Yes
No

   12 (2.5%)
 474 (97.5%)

0 (0.0%)
9 (100.0%)

      -

      -

1.00**Fischer�s exact
Odds ratio cannot be calculated for cases with �0"
Where the odds ratio was calculated there is no p - value 










PAGE  


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