Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 4  |  Page : 277-282

Prevalence of gingivitis and associated factors in 619-year-old children in Rudraprayag District, Uttarakhand


1 Department of Dentistry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission17-May-2021
Date of Decision06-Jul-2021
Date of Acceptance08-Oct-2021
Date of Web Publication15-Dec-2021

Correspondence Address:
Nidhi Sharma
All India Institute of Medical Sciences, Veerbadr Marg, Rishikesh, Uttarakhand
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_80_21

Rights and Permissions
  Abstract 


Background: Gingivitis is the most prevalent oral disease among children with a strong influence of social gradients. To date, its studies in the Uttarakhand state are scarce and inconclusive. This study aimed to investigate the epidemiologic parameters of gingivitis and its association with sociodemographic and clinical risk factors in the 6–19-year-old children in Uttarakhand state. Materials and Methods: Cross-sectional data from 1400 children 6–19 years old from Rudraprayag district, Uttarakhand, were analyzed. Sociodemographic status and oral hygiene habits were assessed by questionnaires answered by parents and children. Oral health status and anthropometric examination of each participant were also conducted. Multivariable logistic regression modeling was used to evaluate relationships between gingivitis and risk factors. Results: The prevalence of gingivitis was 20.0% of which 5.4% of children had severe gingivitis affecting gums around more than 6 teeth. Older children (>12 years), children with good oral hygiene habits, and normally aligned teeth with Angle's Class 1 occlusion displayed better gingival conditions, whereas, poor Socioeconomic status had a negative effect on gingival health. Conclusions: As compared to other states of the country, the prevalence of gingivitis was lower in Uttarakhand. The children belonging to lower socioeconomic status and who do not brush daily were more frequently affected by gingivitis. Children with maligned teeth (crowding or spacing), and Angle's Class 2 and 3 occlusions had a high prevalence of gingivitis.

Keywords: Gingivitis, malocclusion, oral hygiene practices, sociodemographic factors


How to cite this article:
Sharma N, Saxena V, Naithani M. Prevalence of gingivitis and associated factors in 619-year-old children in Rudraprayag District, Uttarakhand. J Indian Assoc Public Health Dent 2021;19:277-82

How to cite this URL:
Sharma N, Saxena V, Naithani M. Prevalence of gingivitis and associated factors in 619-year-old children in Rudraprayag District, Uttarakhand. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Jan 22];19:277-82. Available from: https://www.jiaphd.org/text.asp?2021/19/4/277/332538




  Introduction Top


The condition of the oral cavity, directly and indirectly, influences the general health of an individual and, therefore, requires to be monitored. Epidemiological studies indicate that gingivitis is frequently observed in children and adolescents.[1],[2] Gingivitis is inflammation of the soft tissue (gums) around the teeth characterized by redness, edema, and bleeding on probing. It is reversible with no permanent damage and can be easily treated. But if left untreated, it may lead to a more complex and destructive entity known as chronic periodontitis. According to WHO, the disease of soft and hard tissues around a tooth was the 11th most prevalent disease globally in 2016.

Poor oral hygiene and the accumulation of bacterial plaque are important predisposing factors of gingivitis.[3] It is nondestructive in young individuals, but dental plaque accumulation in childhood can be associated with the development of periodontal disease in later life. Therefore, the key concern is good oral hygiene in childhood, especially the first few years of life, when proper health-promoting behaviors are formed like effective daily prophylactic-hygienic procedures to remove dental plaque. However, the presence of bacterial biofilm has been regarded as the vital primary factor for the onset of gingival diseases, it is not the only factor, and other factors, such as genetic, demographic, socioeconomic, behavioral, and clinical, may also influence disease development.[4],[5],[6],[7]

Epidemiological data on gingivitis in children help understand the natural course of the disease, analyzing its risk factors, and predicting its time trends.[8],[9] They are also important for developing and, later, evaluating community preventive programs.[10] However, while an overwhelming amount of such data is available for children in other parts of the country, little is known about oral hygiene practices and gingival health in Uttarakhand. Therefore, this study is conducted to analyze the pattern of gingivitis and to investigate its relationship with risk factors such as oral hygiene practices, socioeconomic status, and malocclusion in children of Rudraprayag district.


  Materials and Methods Top


Study setting and study population

Rudraprayag district lies in the northwest direction in Uttarakhand situated in the Himalayas. There are 688 villages and the total population of the district is around 242,285 of which around 40,000 (children 6–19 years of age) constituted the study population.

A cross-sectional study was conducted in the Rudraprayag district. The sample size was calculated taking prevalence 36.92% at 95% confidence level, alpha error at 0.05, and margin of error 10%.[11] The final sample size came out to be 1386 which was rounded off to 1400. Data collection was done for a period of 12 months from March 2019 to February 2020. The study was conducted after IEC approval.

The study used a multistage random sampling method. The district has three blocks, three Nyaya panchayats were selected from two smaller blocks and four Nyaya panchayat from one larger block. From each Nyaya panchayat, three villages were randomly selected using probability-proportional-to-size sampling. Thus, a total of 30 villages were selected and 1400 children belonging to age 6–19 years and who were residents of the district in their first 8 years of life were enrolled for the study.

To analyze the pattern of gingivitis, data were collected using a predesigned, pretested, semi-structured questionnaire by personal interview method. Sociodemographic status and food habits of participants were recorded through a questionnaire developed by the Dental Council of India which was utilized in the National Oral Health Survey and Fluoride Mapping in 2003–2004. Along with this, the clinical examination of children (oral and anthropometric) was done by a single examiner in the presence of parents/guardians and oral health status was assessed through the WHO Oral Health Assessment Questionnaire (2013). Consent was obtained from the parents/guardians of the children after explaining the procedure and importance of the study.

Gingival status assessment

Upon oral examination of children, gingival health status was recorded through Gingival Bleeding Index (Ainamo And Bay 1975). To evaluate the severity of gingivitis, it was further categorized as:

  1. No gingivitis: Absence of bleeding gums
  2. Moderate gingivitis: Bleeding present in gums around ≤6 teeth
  3. Severe gingivitis: Bleeding present in gums around >7 teeth socioeconomic status assessment.


The modified BG Prasad Scale was used to measure the socioeconomic status of families. It is based on per capita monthly income.[12]

Social class income/month

  1. 7008 and above
  2. 3504–7007
  3. 2102–3503
  4. 1051–2101
  5. 1050 and Below.


Anthropometric assessment

Anthropometry for obtaining the body weight and height of the children was performed according to international recommendations (WHO, 2006b), and a stadiometer and weighing machine (Krups, Duchess) were used to measure height and weight, respectively. Age- and sex-standardized specific z-scores were calculated for body mass index (BMI; kilograms per square meter) using the WHO Child Growth standards (2011) and classified as below:

  1. Thinness for age and sex, BMI for age, Z (BMIAZ) score <−2.0 standard deviation [SD]
  2. Overweight for age and sex, Z (BMIAZ) score >+1SD
  3. Normal for age and sex, Z (BMIAZ) score from <+1SD to >−2.0 SD.


Occlusal assessment

Occlusal status was assessed by analyzing molar relationship according to Angle's classification and categorized in Angle's Class 1, 2, and 3 occlusions. In addition, crowding and spacing were also recorded and classified as below:

  1. Normal occlusion: Properly aligned teeth (absence of crowding/spacing) with molars in Angle's Class 1 relationship
  2. Malocclusion: Misaligned teeth and Angle's Class 2 and 3 occlusion.


Statistical analysis

Data were analyzed by statistical software SPSS version 23, categorical data were expressed as frequency and percentage. Chi-square/Fisher exact test was used to find an association between gingivitis and its risk factors. Univariate logistic regression was used and those variables found statistically significant and clinically important (P < 0.10) were included in multiple logistic regression (P < 0.05 considered as statistically significant).


  Results Top


The sociodemographic characteristics of the study population are summarized in [Table 1].
Table 1: Sociodemographic characteristic of study population (n=1400)

Click here to view


Among the total participants, 52.3% (732) were girls and 47.7% (668) were boys. Most of the families belonged to lower socioeconomic status, BG Class 4, 44.1% (617) with parents having a maximum educational level to grade 10. Many participants about 16.1% (225) were unaware of common causes of dental problems and 19% (266) did not know how to prevent these problems.

About 60% (828) of children in the study population do not brush daily and 79.1% (1107) of children started brushing after the age of 4 years. However, almost all the children used toothbrushes and toothpaste for cleaning the oral cavity.

The overall prevalence of gingivitis was 20.0% (280) of which 5.4% (75) of children had severe gingivitis affecting gums around more than 6 teeth. Gingivitis was most frequently observed among children of 16–17 years of age, they attributed around 24.7% among the children having gingivitis.

Among the study population majority of children, 83.9% (1174) had Angle's Class 1 occlusion followed by Angle's Class 2, 9.4% (132), and only 1% (15) of children showed Angle's Class 3 occlusal relationship. Around 11.0% (153) of children had crowding, whereas 1.8% (25) of children showed spacing between the teeth.

[Table 2] shows that there were no significant differences in the prevalence of gingivitis among the boys and girls. Gingivitis was more frequent among children >12 years, 23.3% (186) as compared to the younger children (15.6%, 94). Children who brushed sometimes in a week were 1.5 times more affected by gingivitis than those who brushed daily (P = 0.009, odds ratio [OR] adjusted 1.47 [1.10–1.96]). The frequency of gingivitis was more among children of lower socioeconomic status as compared to children belonging to higher socioeconomic status (P = 0.010, OR adjusted 1.48 [1.10–2.00]). Children consuming rice as a main staple food had two times more chances of being affected by gingivitis than the children consuming wheat (P = 0.001, OR adjusted 1.85 [1.27–2.71]). Children with properly aligned teeth in Angle's Class 1 occlusion were 34% less affected by gingivitis than children with maligned teeth (crowded, spacing, etc.).
Table 2: Risk factors related to prevalence of gingivitis: Logistic regression

Click here to view


The study also signifies that, bad oral habits like digital sucking, and mouth breathing had no significant association with prevalence of gingivitis. Even the BMI of children was not associated with the prevalence of gingivitis.


  Discussion Top


This study is among the foremost efforts to analyze the oral behaviors and prevalence, and severity of gingivitis in children aged 6–19 in one of the districts of Uttarakhand state. Besides, the study also evaluated the association of gingivitis with sociodemographic and clinical risk factors such as other oral diseases and BMI.

The results of this study revealed that 20.0% of children aged 6–19 had moderate-to-severe gingivitis. This observed prevalence is less than what is recorded among children around the world. A recent survey in Lucknow, Uttar Pradesh, that included schoolchildren aged 8–16 years revealed that 71.11% of schoolchildren in the 8–10 years age group were affected by mild-to-moderate form of gingivitis.[13] A survey in Kaunas observed that around 59.6% of schoolchildren in the 6–8 years age group suffered from very mild gingivitis.[14] Another survey among older age group children of 11–15 years in Lithuania also showed that >50% of them had a problem of gum bleeding.[15] A study in Tehran showed that 87.7% of schoolchildren of 9–13 years of age suffered from gingivitis. This low prevalence of gingivitis in the district may be attributed high consumption of citrus fruits by children. Orange trees are very common in this part of Uttarakhand state and they were noticed in almost every house. Oranges are rich in Vitamin C which is considered protective against gingivitis.[16] Another citrus fruit, Alma, is also a common part of the diet among the study population as it is also locally available in abundance. Furthermore, hilly areas have limited availability of junk food and packed snacks which are known to be detrimental to oral health. Thus, the gingivitis protective dietary habits among the study participants may be accountable for the low prevalence of gingivitis.

Like most studies, the present study result revealed that the prevalence of teeth with gingival bleeding was related to age so that younger children had a superior oral hygiene status and periodontal health.[17],[18],[19],[20] [Figure 1] shows that there is a gradual rise in the prevalence of gingivitis from the age of 6 years (12.1%) to 32.9% at 19 years of age, which corresponds to pubertal age. This is in coherence with earlier studies highlighting that the prevalence and development of periodontal diseases increase with age. They are initiated at the early age when tooth eruption occurs and reaches its peak at puberty.[21] Several cross-sectional studies have demonstrated that hormonal changes occurring during puberty affect gingival health resulting in gingival inflammation without an accompanying increase in plaque levels.
Figure 1: Variation in prevalence of gingivitis with increase in age of participant

Click here to view


Toothbrushing is not common or regularly practiced in children in the Rudraprayag district. Only 40% of children among the study population brush daily. Brushing is the most effective way of dental plaque removal which is the main cause of gingivitis. Many studies have shown that following good oral hygiene practices reduces the occurrence of gingivitis in individuals.[22] A study in Karnataka concluded that regular toothbrushing helped to improve the gingival health and reduce the amount of plaque accumulation resulting in reduced gingival bleeding.

The present study finding that children with lower socioeconomic status had an increased risk of having gingivitis corroborates findings of Nganga and Valderhaug in Nairobi.[23] [Figure 2] shows that as the socioeconomic status declined, the prevalence and severity of gingivitis increased, the high proportion of children belonging to Class 4 (46.7%) and Class 5 (28.0%) were affected by severe gingivitis as compared to higher classes (8%–17.3%). Differences in socioeconomic status may impact gaining of the knowledge and skills on tooth cleaning; which is also supported by the study concluding that children from rural areas reported a higher percentage of inadequate oral hygiene than children from urban areas. Reisine et al.[24] also revealed that it is slightly difficult for children from the lower socioeconomic strata to obtain professional health care and to live in a healthy environment, resulting in the development of negative behaviors toward their oral health. On the other hand, children from high socioeconomic strata are more likely to use oral health services for preventive rather than curative care. Similar results were also reported in public schools when compared to private schools.[25]
Figure 2: Pattern of gingivitis within different socioeconomic classes

Click here to view


Malocclusion showed a significant association with gingivitis with its frequency more in Angle's Class 2 (23.6%) as compared to Class 1 (20.1%) and 3 (22.9%). A high prevalence of gingivitis was observed among children with crowded teeth as compared to children with aligned teeth, especially children with upper anterior crowding (33.3%) were most frequently affected by gingivitis which is in coherence with findings of prior studies that identified an association between crowding and gingivitis.[26],[27] Children having spacing in Angle's Class 2 (66.7%) showed the highest prevalence of gingivitis. The study also highlighted the fact that maxillary protrusion (50.0%) with increased overjet predisposed to gingivitis that has been identified in earlier studies too.[28],[29] Increased overjet is significantly associated with lip incompetence, hyperplastic gingivitis around the upper incisors, and gingivitis due to drying out of the oral mucosa in the absence of lip cover and the protective effect of saliva.

The study reported a nonsignificant relationship between digital sucking[30] and gingivitis that contrasts with the findings of Misbah[31] who reported that digit sucking is susceptible to increased severity of oral diseases. The maneuver of digit sucking possibly increases saliva flow and interrupts the harmful effects of plaque bacteria associated with gingivitis. It may also act as a self-cleaning mechanism through the constant movements of the lips against the anterior teeth during digit sucking. However, this supposition is not known to increase the protection of digit suckers from gingivitis when compared to nondigit suckers.

One of the strengths of this study is the large sample size with meticulous study participants' recruitment process. The children from various socioeconomic strata were included in the study. The household recruitment process reduced the possibility of bias sampling, which is possible with school-based studies. In addition, the high response rate from participants and one single examiner increased the internal validity. Another advantage of this research is that other aspects such as sociodemographic characteristics, food habits, and health service accessibility, which are part of the overall picture of the natural history of oral diseases in the epidemiological studies, were taken into consideration. Despite these factors, some limitations do exist, the cross-sectional study design restricts causal inferences, and further longitudinal studies are encouraged to verify the significant associations.


  Conclusions Top


The prevalence of gingivitis among children of Uttarakhand was lower than in other states of the country. The distribution of gingivitis showed social inequalities with increased frequency among children of lower socioeconomic status families. Children practicing good oral hygiene habits such as regular toothbrushing and children with properly aligned teeth in Angle's Class 1 occlusion had better gingival health. The study suggests that regular oral health education sessions via Aganwadi/ANM workers in villages motivating residents for adopting good oral hygiene practices and regular dentist checkup visits may help improve their gingival health status. Frequent dental visits may also intercept the developing malocclusion among growing children at an early stage preventing the risk of gingivitis. Furthermore, the results of the study can help design and implement wide-scale interventional health promotion programs in the district.

Financial support and sponsorship

This study was financially supported by Uttarakhand Council of Science and Technology, Dehradun.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pari A, Ilango P, Subbareddy V, Katamreddy V, Parthasarthy H. Gingival diseases in childhood – A review. J Clin Diagn Res 2014;8:E01-4.  Back to cited text no. 1
    
2.
Chrysanthakopoulos NA. Prevalence of gingivitis and associated factors in 13-16-year-old adolescents in Greece. Eur J Gen Dent 2016;5:58-64.  Back to cited text no. 2
  [Full text]  
3.
Leous P, Palianskaya L, Leous L. Oral hygiene and gingival inflammation in 6–8-year-olds from a junior school in Minsk who participated in a supervised oral hygiene programme. Oral Health Dent Manag 2009;7:27-30.  Back to cited text no. 3
    
4.
Kazemnejad A, Zayeri F, Rokn AR, Kharazifard MJ. Prevalence and risk indicators of periodontal disease among high-school students in Tehran. East Mediterr Health J 2008;14:119-25.  Back to cited text no. 4
    
5.
Broadbent JM, Thomson WM, Boyens JV, Poulton R. Dental plaque and oral health during the first 32 years of life. Am Dent Assoc 2011;142:415-26.  Back to cited text no. 5
    
6.
Peres MA, Peres KG, Cascaes AM, Correa MB, Demarco FF, Hallal PC, et al. Validity of partial protocols to assess the prevalence of periodontal outcomes and associated sociodemographic and behavior factors in adolescents and young adults. J Periodontol 2012;83:369-78.  Back to cited text no. 6
    
7.
CascaesAM, PeresKG, PeresMA, DemarcoFF, SantosI, MatijasevichA, et al. Validity of the oral hygiene standard for children aged five years reported by mothers. Rev Saude Publica 2011;45:668-75.  Back to cited text no. 7
    
8.
Albandar JM, Tinoco EM. Global epidemiology of periodontal diseases in children and young persons. Periodontol 2000 2002;29:153-76.  Back to cited text no. 8
    
9.
Clerehugh V, Tugnait A. Diagnosis and management of periodontal diseases in children and adolescents. Periodontol 2000 2001;26:146-68.  Back to cited text no. 9
    
10.
The Monitoring Process and its Importance for Achievement of the Global Goals for oral Health by the Year 2000. Available from: https://pubmed.ncbi.nlm.nih.gov/6574115/. [Last accessed on 2021 Mar 25].  Back to cited text no. 10
    
11.
Davidson J, Sharma MD, Kumar A. Assess the oral hygiene practices, occurrence of dental caries and gingivitis among school age children. Int J Trend Sci Res Dev 2020;4:78-84.  Back to cited text no. 11
    
12.
Pandey VK, Aggarwal P, Kakkar R. Modified BG prasad socio-economic classification, update-2019. Indian J Community Health 2019;31:123-5.  Back to cited text no. 12
    
13.
Singh DA. Prevalence of gingivitis and periodontitis among schools children in Lucknow region of Uttar Pradesh, India. IOSR J Dent Med Sci 2014;13:21-3.  Back to cited text no. 13
    
14.
Pauraite J, Milciuviene S, Sakalauskiene J. The prevalence of gingivitis among 4-16 year old schoolchildren in Kaunas. Stomatol Balt Dent Maxillofac J 2003;5:97-100.  Back to cited text no. 14
    
15.
Zaborskytė A, Bendoraitienė EA. Oral hygiene habits and complaints of gum bleeding among schoolchildren in Lithuania. Stomatologija 2003;5:31-6.  Back to cited text no. 15
    
16.
Tada A, Miura H. The relationship between Vitamin C and periodontal diseases: A systematic review. Int J Environ Res Public Health 2019;16:E2472.  Back to cited text no. 16
    
17.
Folayan MO, Kolawole KA, Oziegbe EO, Oyedele TA, Agbaje HO, Onjejaka NK, et al. Association between family structure and oral health of children with mixed dentition in suburban Nigeria. J Indian Soc Pedod Prev Dent 2017;35:134-42.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Gopinath VK, Rahman B, Awad MA. Assessment of gingival health among school children in Sharjah, United Arab Emirates. Eur J Dent 2015;9:36-40.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Chauhan D, Chauhan T, Sachdev V, Kirtaniya B. Study of oral hygiene status and prevalence of gingival diseases in 9 and 12-year-old school children of a northern hilly state, India. Int J Heal Allied Sci 2012;1:258.  Back to cited text no. 19
    
20.
Shaju J, Zade R, Das M. Prevalence of periodontitis in the Indian population: A literature review. Indian Soc Periodontol 2011;15:29.  Back to cited text no. 20
    
21.
Massler M, Schour I, Chopra B. Occurrence of gingivitis in suburban Chicago school children. J Periodontol 1950;21:146-64.  Back to cited text no. 21
    
22.
Hayasaki H, Saitoh I, Nakakura-Ohshima K, Hanasaki M, Nogami Y, Nakajima T, et al. Tooth brushing for oral prophylaxis. Jpn Dent Sci Rev 2014;50:69-77.  Back to cited text no. 22
    
23.
Ng'ang'a PM, Valderhaug J. Oral hygiene practices and periodontal health in primary school children in Nairobi, Kenya. Acta Odontol Scand 1991;49:303-9.  Back to cited text no. 23
    
24.
Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998;26 Suppl 1:32-44.  Back to cited text no. 24
    
25.
Sukhabogi J, Shekar C, Hameed I, Ramana I, Sandhu G. Oral health status among 12 and 15-year-old children from government and private schools in Hyderabad, Andhra Pradesh, India. Ann Med Health Sci Res 2014;4:272.  Back to cited text no. 25
    
26.
Buckley LA. The relationships between malocclusion, gingival inflammation, plaque and calculus. J Periodontol 1981;52:35-40.  Back to cited text no. 26
    
27.
Chiapinotto FA, Vargas-Ferreira F, Demarco FF, Corrêa FO, Masotti AS. Risk factors for gingivitis in a group of Brazilian schoolchildren. J Public Health Dent 2013;73:9-17.  Back to cited text no. 27
    
28.
Kukletova M, Izakovicova Holla L, Musilova K, Broukal Z, Kukla L. Relationship between gingivitis severity, caries experience and orthodontic anomalies in 13-15 year-old adolescents in Brno, Czech Republic. Community Dent Health 2012;29:179-83.  Back to cited text no. 28
    
29.
Helm S, Petersen PE. Causal relation between malocclusion and periodontal health. Acta Odontol Scand 1989;47:223-8.  Back to cited text no. 29
    
30.
Agbaje HO, Kolawole KA, Folayan MO, Onyejaka NK, Oziegbe EO, Oyedele TA, et al. Digit sucking, age, sex, and socioeconomic status as determinants of oral hygiene status and gingival health of children in Suburban Nigeria. J Periodontol 2016;87:1047-56.  Back to cited text no. 30
    
31.
Misbah MM. Oral habits in relation to dental caries and gingival health among children attending the dental hospital. J Od Baghdad Coll Dent 2005;17:109-12.  Back to cited text no. 31
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed236    
    Printed2    
    Emailed0    
    PDF Downloaded39    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]