International Journal of Current Research and Review
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IJCRR - 8(19), October, 2016

Pages: 21-24

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TREATMENT OF SPECIAL CHILDREN: AN ORTHODONTIC PERSPECTIVE

Author: Shyama Dash1, Uday N. Soni, Rahul S. Baldawa, N. G. Toshniwal, Shubhangi A. Mani

Category: Healthcare

Abstract:Orthodontic care may seem out of reach for many children with special needs due to physical and developmental disabilities. Orthodontists who lack education and experience to work with such patients with disabilities end up denying treatment of these patients, as a result, patients and parents become frustrated.Orthodontic treatment is an elective procedure for essentially all patients, including those with medical problems. Correction of disfiguring dental and facial problems contributes in an important way to an individual's self-esteem. The positive benefits of orthodontic treatment influence social integration and interaction, and can lead to significant improvement in overall well-being.

Keywords: Special children, Special needs, Orthodontics

Full Text:

INTRODUCTION

As a result of tremendous progress made in the fields of medicine and dentistry in the 20th century, a remarkable improvement in the survival rates, longevity and quality of life of children affected by congenital, developmental or pathologic conditions is continually occurring. Coupled with elevations in public awareness, changing social policies and opinion, and favorable legislation, higher standards of non-institutionalized medical and dental care are becoming routinely available to these individuals. In the present scenario, the practicing clinician in the community responsible for addressing the needs of these special patients has to be accessible to them, and competent and willing to provide them the required optimal level of care. Orthodontic treatment is an elective procedure for essentially all patients, including those with medical problems. Correction of disfiguring dental and facial problems contributes in an important way to an individual’s self-esteem. The positive benefits of orthodontic treatment influence social integration and interaction, and can lead to significant improvement in overall well-being (1, 2). However, there are important considerations while planning and rendering orthodontic care to children with special needs. The goal of this review is to discuss the indications and implications of orthodontic therapy for children in some of these special situations.

MENTAL RETARDATION

Mental retardation is defined as a significant decrease in the intellectual ability with consequent limited ability to adapt to the environment. The degree of retardation varies among individuals, ranging from mild to severe, and often occurs along with other systemic problems. Mental retardation is frequently associated with a greater occurrence of malocclusion.

Orthodontic Care

  • Orthodontic treatment can provide significant esthetic and functional benefits to affected individuals. The orthodontic treatment plan for a mentally challenged patient should be individualized and developed keeping the child’s strengths and weaknesses in sight.
  • Short appointments should be planned
  • The clinician should ensure that a good level of communication is established with the child, and that all explanations and instructions are simple and well understood by the patient.

DOWN’S SYNDROME

Down's syndrome (3-8), is a genetic disorder caused by trisomy of chromosome 21, which is an autosomal chromosome. This syndrome is associated with physical growth delays, typical facial features, and mild to moderate intellectual disability. In some conditions, such as Down syndrome, a generalized retardation of growth and development is often found.

Clinical Manifestation

  • Eruption of both deciduous and permanent teeth is frequently delayed, and there is also a delay in the exfoliation of the deciduous teeth.
  • Pseudoprognathism decreased lower facial height, small midface, perioral hypotonia, a large and protruded tongue, crossbite, anterior open bite, and crowding are common associated craniofacial features.
  • Additionally, children with Down syndrome have an increased susceptibility to rapid, destructive periodontal disease due to both local and systemic factors.
  • These children are also more prone to suffer from cardiac defects, leukemia’s and respiratory infections.
  • Children with Down syndrome are frequently the victims of a stereotype image that has come to be associated with their mental condition even though their mental retardation is usually of a mild or moderate nature, and these children often have a wide range of comprehensive and performance capabilities.

Orthodontic Care

  • The orthodontist should be careful to assess the potential of each child individually and structure treatment strategies accordingly.
  • The extent to which orthodontic appliance therapy can be successfully instituted varies with the cooperative abilities of the patient, but a good orthodontic treatment result is certainly achievable for many patients.
  • In the more severely mentally retarded patients, the initial placement of limited fixed appliances or bonded/cemented bite planes can be accomplished under general anesthesia. Surgical orthodontic treatment is an important consideration in this in group of patients.

CEREBRAL PALSY

Cerebral palsy (9-10) is a collection of disabling conditions due to permanent brain damage in the prenatal and perinatal period. One newborn in approximately 200 live births is afflicted with this condition.

Clinical Manifestations

  • Cerebral palsy is characterized by variable severities of muscle weakness, stiffness or paralysis, poor balance, irregular gait, and uncoordinated, involuntary movements.
  • Mental retardation, seizures, strabismus and speech problems may accompany the neurological problems.
  • A wide range of neuromuscular dysfunction is seen, which presents as spasticity, dyskinesia, ataxia or a mixture of these.
  • These children also may suffer from abnormalities of the cervical spine.

Oral Manifestations

  • They lack intraoral, perioral and masticatory muscle coordination and have limited control of the neck muscles, which contributes to the risk of head roll in the supine position.
  • Children with cerebral palsy often have severe attrition due to bruxism, and a higher frequency of periodontal disease and gingival hyperplasia that is related to both local factors and anticonvulsant therapy.
  • They frequently have a marked overjet, open bite, posterior cross bite, and are more susceptible to trauma to the anterior maxilla, thus implicating the need for orthodontic treatment.

Orthodontic Care

  • Depending on the severity of neuromuscular dysfunction, specific goal-oriented orthodontic treatment, often in conjunction with orthognathic surgery to correct the large overjet and open bite can be undertaken for them.
  • Care should be taken to stabilize the patient’s head and to avoid a completely supine position in the dental chair during treatment.
  • In general, for patients with a known history of seizures, orthodontic treatment can be carried out safely when the disease is under good medical control and there is no active seizure activity in the recent history of the disease.
  • Gingival surgery for reducing the hyperplasia may be required to facilitate orthodontic treatment.

Cystic Fibrosis

Cystic fibrosis(11-14) has an occurrence of one in 2,000 births, is the most common lethal genetic disorder in Caucasians. Children with cystic fibrosis have progressive obstructive lung disease and are at a high risk of infection. Antibiotic administration is the mainstay of therapy for the treatment of cystic fibrosis. New and potent antibiotics, more aggressive antibiotic treatment and multiple routes of administration have contributed to improved survival among cystic fibrosis patients.

Oral Manifestations

  • Oral implications associated with cystic fibrosis include enamel hypoplasia and tooth discoloration
  • Salivary gland dysfunction
  • Reduced levels of dental plaque, caries and oral disease.

These are also related to the effects of antibiotics in these patients. Cystic fibrosis patients are always at a high risk of developing lethal lung infection(15), and the mouth may act as a reservoir for potentially pathogenic respiratory bacteria. They have deficient salivary secretion, and are at a greater risk of decalcification around fixed orthodontic appliance attachments. When undertaking orthodontic treatment, precautions should be taken to avoid the possibility of the patient aspirating infective material. (16)

Orthodontic Care

  • For this reason, and also to avoid restricting their already diminished lung volume, these children should be treated in a more upright rather than fully reclined position.
  • However, since longevity in affected children varies widely among individual patients, an evaluation by the patient’s physician of the severity of the problem and life expectancy should be included while planning possible orthodontic treatment.

Juvenile Rheumatoid Arthritis (17)

It is an inflammatory condition of the joints, probably of autoimmune origin, in which the inflamed and hyperplastic synovial membrane encroaches on the articulating joint surfaces and leads to the destruction of the articular cartilage and underlying bone if left untreated.

It is the major arthritic problem in children and young adults, and is extremely variable in onset, severity and clinical course. The proliferative arthritis involving multiple joints may frequently affect the temporomandibular joint in children, either unilaterally or bilaterally. It may be self-limiting with satisfactory recovery in many cases, or may, in severely affected patients, progress to irreversible damage to the joint spaces, leading to significant functional disability.

Clinical Manifestations

  • The patient may have varying degrees of mandibular retrognathia(24,25) with a steep mandibular plane, anterior open bite(18), mandibular asymmetry in patients with unilateral involvement, and signs and symptoms of temporomandibular joint dysfunction.
  • These may include difficulty in wide mouth opening, pain on mandibular movements and joint sounds.
  • Erosion of the cortical outline in the TMJ is the most common radiographic finding, followed by flattening with or without erosion, and the complete loss of the condylar head in the very severely affected patients.
  • A multidisciplinary approach is usually required for the management of various componentsof juvenile rheumatoid arthritis.(19-21)
  • Medical treatment involves steroidal and non-steroidal anti-inflammatory agents, while gold salts, d penicillamine and cytotoxic drugs may be required for select patients. Temporomandibular therapy is aimed at reducing pain and dysfunction in the masticatory system, restoring and maintaining mandibular mobility to correct and prevent occlusion problems and deformities, and at stimulating mandibular growth.(22,23)
  • Therapeutic exercises against resistance and chewing training are beneficial to increase muscle strength andmandibular mobility. Occlusal splints or passive activators may be helpful to decrease the load on the TMJ and reduce masticatory muscle tension.

Orthodontic Care

  • Children with juvenile rheumatoid arthritis should have annual orthodontic examinations, which should include a functional evaluation of the masticatory system, and radiographic studies of the face and the temporomandibular joints.
  • Orthodontic treatment in patients with juvenile rheumatoid arthritis should be attempted only when the disease is under control. It must be remembered that stress on the joint during orthodontic treatment may result in further degeneration of the condyle.
  • Functional appliances with large mandibular propulsions, heavy intermaxillary elastics and orthognathic surgery involving large mandibular advancements can lead to increased joint stress.
  • Therefore, in the more severely retrognathic patients, surgical orthodontic treatment options involving maxillary surgery and genioplasty should be considered when possible.

Discussion

Children with special needs are refrained from having normal activities because of any physical or mental disability. They require special orthodontic attention due to increased prevalence and severity of malocclusion.In order to deal with such patients the most important quality an orthodontist must have is “communication skill”. Good soft skills can help convincing the parents as well as patients to undergo treatment. Before starting such cases it is always advisable to take advice from the patients’ physician. This will help us for being more cautious while framing the treatment plan. The orthodontist should be careful to assess the potential of each child individually and structure treatment strategies accordingly. The extent to which orthodontic appliance therapy can be successfully instituted varies with the cooperative abilities of the patient, but a good orthodontic treatment result is certainly achievable for many patients .most of these patients present with poor oral hygiene and they should be educated for the same.

Conclusion

These patients had these disabilities by chance not by choice, so we as clinicians must not differentiate them from our normal patients. Rather we should make efforts to help them to establish their self –esteem and giving them a better quality of life.

Conflict of interest: None

Source of funding: None

References:

  1. Uday N. Soni et al. “Patient’s expectations of orthodontic treatment at first visit”. Indian Journal of Orthodontics and Dentofacial Research, April–June 2016; 2(2):39-42.
  2. UN Soni et al. “Knowledge and awareness of malocclusion among rural population in India” Asian Pac. J. Health Sci., 2014; 1(4): 329-334
  3. Patterson, D (Jul 2009). "Molecular genetic analysis of Down syndrome." Human Genetics 126 (1): 195–214.
  4. Weijerman, ME; de Winter, JP (Dec 2010). "Clinical practice. The care of children with Down syndrome.". European journal of pediatrics 169 (12): 1445–52.
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  6. Townsend GC. Tooth size in children and young adults with trisomy 21 (Down syndrome). Arch Oral Biol. 1983; 28:159– 166.
  7. Peretz B et al. Modification of tooth size and shape in Down’s syndrome. J Anat. 1996; 188: 167–172.
  8. Peretz B et al, Modified cuspal relationship of mandibular molar teeth in children with Down’s syndrome. J Anat. 1998; 193:529–533.
  9. Oskoui, M et al, "An update on the prevalence of cerebral palsy: a systematic review and meta-analysis."Developmental medicine and child neurology (June 2013). 55 (6): 509–19.
  10. Nieuwenhuijsen et al.; Transition Research Group South West Netherlands "Experienced problems of young adults with cerebral palsy: targets for rehabilitation care". Archives of Physical Medicine and Rehabilitation (2009);90 (11): 1891–1897.
  11. Anderson DH: Cystic fibrosis of the pancreas and its relation to celiac disease clinical and pathological study. Am J Dis Child 56:344-99, 1938.
  12. Blacharsh C: Dental aspects of patients with cystic fibrosis: a preliminary clinical study. J Am Dent Assoc 95:106-110, 1977.
  13. Boat TF et al: Cystic fibrosis, in The Metabolic Basis of Inherited Disease, 6th ed. Scriver CR et al., eds. McGraw Hill: New York, 1989, pp 2649-80.
  14. Cystic fibrosis: a current review: The American Academy of Pediatric Dentistry April/May, 1990 - Volume 12, 71-78.
  15. Cheng PW et al: Increased sulfation of glycoconjugates by cultured nasal epithelial cells from patients with cystic fibrosis. J Clin Invest 84:68-72, 1989.
  16. DiSant’Agnese PA, Davis PB: Research in cystic fibrosis. N Engl J Med 295:481-85; 534-41; 597-602, 1976.
  17. David L. Turpin ;Juvenile rheumatoid arthritis: a 14-year posttreatment evaluation The Angle Orthodontist Sep 1989, Vol. 59, No. 3 pp. 233-238.
  18. Bertha Barriga et al : An Investigation of the Dental Occlusion in Children with Juvenile Rheumatoid Arthritis;The Angle Orthodontist Oct 1974, Vol. 44, No. 4  pp. 329-335
  19. Grokoest AW et al. Some aspects of juvenile rheumatoid arthritis. Bull Rheum Dis. 1957; 8: 147–148. 13.
  20. Schaller J, Wedgwood RJ. Juvenile rheumatoid arthritis: a review. Pediatrics. 1972; 50:940–953.
  21. Cassidy JT, Martel W. Juvenile rheumatoid arthritis: clinicoradiologic correlations. Arthritis Rheum. 1977; 20(2 suppl):207–211.
  22. Twilt M et al. Facioskeletal changes in children with juvenile idiopathic arthritis. Ann Rheum Dis. 2006; 65:823–825.
  23. Kjellberg H et al. Craniofacial structure in children with juvenile chronic arthritis (JCA) compared with healthy children with ideal or postnormal occlusion. Am J OrthodentofacialOrthop. 1995; 107:67–78.
  24. Stabrun AE et al. Reduced mandibular dimensions and asymmetry in juvenile rheumatoid arthritis. Pathogenetic factors. Arthritis Rheum. 1988; 31:602–611.
  25. Stabrun AE. Impaired mandibular growth and micrognathic development in children with juvenile rheumatoid arthritis. A longitudinal study of lateral cephalographs. Eur J Orthod. 1991; 13:423–434.

Announcements

Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

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SCOPUS indexing: 2014, 2019 to 2021


Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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Disclaimer: International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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