Oral disorders such as dental caries and periodontal disease are worldwide public health problems. The “Global Burden of Oral Conditions in 1990–2010” report showed that oral conditions continue to be highly prevalent, affecting about 3.69 billion people. In this report, untreated dental caries in the permanent dentition was identified as the most common of all the evaluated disorders, having the highest worldwide disease load, affecting 35% of all age groups. Severe periodontitis was the sixth most prevalent condition (11% of world population) and untreated caries of the primary dentition was the tenth (9% of world population). Severe tooth loss was the 36th most prevalent condition, affecting 2% of the world’s population [
Oral and dental diseases can cause pain, suffering, functional deterioration, and diminished quality of life. The high cost of treatment constitutes a substantial burden to the national health system and for individual households. Families often opt to pay directly for dental care in an effort to maintain adequate oral health among household members. In developed countries, oral health treatment represents from 5 to 10% of health expenses. This treatment is unavailable or extremely limited in many developing countries, where affected teeth are often not treated or merely extracted, making them the main source of pain [
The experience of pain, considered a normal consequence of organ or system disorders, is a ubiquitous public health concern. Untreated dental caries generally leads to dental pain. Although dental pain can seriously affect peoples’ daily life, negatively affecting quality of life, few epidemiological studies on oral health include questions on dental pain. Orofacial pain, and especially dental pain, can cause sleep loss, diminished work effectiveness or academic performance, absence from school or work, weight loss, and avoidance of certain foods. Some researchers treat it as a predictor of dental health service use (usually curative or emergency) [
Health needs can be identified through either subjective self-reporting of symptoms, diseases, injuries, and disabilities or a normative method applied by trained health personnel in a health clinic [
Most orofacial pain is due to dental disorders, and acute pain is generally caused by oral conditions, particularly dental caries and periodontitis. However, pathological processes are not necessarily the sole or sufficient cause of this kind of pain. Pain perception can be modulated by cognitive factors such as knowledge, beliefs, and expectations, which in turn can be influenced by the social, economic, and cultural environment of affected individuals. Here we aimed to identify the factors associated with dental pain as an oral health indicator in schoolchildren, aged 6 to 12 years in the state of Hidalgo, Mexico.
This cross-sectional study was focused on schoolchildren attending primary schools in the city of Pachuca de Soto, Hidalgo. Previously published portions of the methodology explain the use of oral health assistants [
Data were collected through a questionnaire answered at home by the schoolchildren’s parent/guardian. The questionnaire was divided into sections that allowed the collection of sociodemographic, socioeconomic, food habits, oral health habits, oral appearance satisfaction, and oral health services use data. Questionnaires were distributed and recovered through the schools. The schoolchildren’s self-report of dental pain was the studied variable. This was measured using the question “
A total of eight independent sociodemographic variables were used: age of schoolchild in years (0 = 6-7 yrs.; 1 = 8–10 yrs.; 2 = 11-12 yrs.); sex of schoolchild (0 = female; 1 = male); head of household (0 = mother; 1 = father; 2 = other); mother’s and father’s ages in years (continuous format); mother’s and father’s education level (0 = primary; 1 = middle; 2 = high; 3 = Bachelor’s or higher); health insurance coverage (0 = uninsured, 1 = IMSS/ISSSTE, 2 = PEMEX, SEDENA, SEMAR, 3 = private, 4 = Seguro Popular); and automobile in household (0 = yes; 1 = no). Four schoolchild oral health variables were measured: brushing frequency (0 = at least once a day; 1 = less than once a day); toothpaste use (0 = at least once a day; 1 = less than once a day); dental floss use (0 = at least once a week; 1 = never, do not know); and mouthwash use (0 = at least once a week; 1 = never, do not know). Parent/guardian variables included brushing frequency (0 = at least once a day; 1 = less than once a day) and perception of schoolchild’s oral health condition (0 = bad/very bad; 1 = regular; 2 = good/very good).
Using a polychoric correlation as part of a principal components analysis, three different interrelated groups of variables were formed. The first group encompassed two variables indicating socioeconomic position, one referring to housing characteristics (e.g., wall, roof, and floor building materials, presence/absence of a kitchen, bathroom characteristics, and number of bedrooms) and the other to household appliances (e.g., refrigerator, stove, television, and telephone). A second group consisted of three variables addressing frequency of candy, fried foods, and fruit consumption. The third group was one variable on parent/guardian knowledge of schoolchild oral health. After generating the principal component for each of these six (continuous) variables, the socioeconomic condition indices were categorized into quartiles, while the food intake and oral health knowledge indices were categorized into tertiles. Depending on the variable, the first indicated the lowest level and the last the highest level.
After cleaning the database, we performed a descriptive analysis of the studied variables, estimating frequencies and percentages for each category of qualitative variable. The quantitative variables were analyzed by calculating the mean and standard deviation (SD). In the bivariate analysis, contingency tables were generated for the dental pain dependent variable with each independent variable and the Pearson
This methodology met study subject protection guidelines and relevant Helsinki ethical regulations. The study protocol was approved by the Ethics and Research Committee of the Autonomous University of the State of Hidalgo (Universidad Autónoma del Estado de Hidalgo [UAEH]) and the committees of the National Institute of Public Health (UAEH Institutional Ethical Review Committee code: UAEH-DI-ICSA-ODO-CF-016). Written consent was obtained from all the patients/guardians.
The 1,404 schoolchildren in the sample had a mean age of
Sociodemographic and socioeconomic data for schoolchildren aged 6 to 12 years in dental pain survey.
Variables |
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% |
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6-7 yrs. | 409 | 29.1 |
8–10 yrs. | 609 | 43.4 |
11-12 yrs. | 386 | 27.5 |
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Female | 701 | 49.9 |
Male | 703 | 50.1 |
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Mother | 241 | 17.2 |
Father | 1090 | 77.6 |
Other | 73 | 5.2 |
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Primary | 137 | 9.8 |
Middle | 517 | 36.8 |
High | 493 | 35.1 |
Bachelor’s or higher | 257 | 18.3 |
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Primary | 125 | 9.2 |
Middle | 365 | 26.8 |
High | 443 | 32.5 |
Bachelor’s or higher | 430 | 31.5 |
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Uninsured | 433 | 30.8 |
IMSS/ISSSTE | 727 | 51.8 |
PEMEX/SEDENA/SEMAR | 68 | 4.8 |
Private | 49 | 3.5 |
Seguro Popular | 127 | 9.1 |
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1st quartile | 351 | 25.0 |
2nd quartile | 352 | 25.1 |
3rd quartile | 351 | 25.0 |
4th quartile | 350 | 24.9 |
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1st quartile | 356 | 25.3 |
2nd quartile | 354 | 25.2 |
3rd quartile | 345 | 24.6 |
4th quartile | 349 | 24.9 |
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Yes | 893 | 63.6 |
No | 511 | 36.4 |
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1404 | 34.89 ± 6.06 |
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1363 | 37.72 ± 6.32 |
Risk indicator (diet, oral health habits, and behavior) distribution among schoolchildren aged 6 to 12 years in dental pain survey.
Variables |
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% |
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Candies | ||
Low | 470 | 33.5 |
Moderate | 466 | 33.2 |
High | 468 | 33.3 |
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Fried food | ||
Low | 471 | 33.5 |
Moderate | 467 | 33.3 |
High | 466 | 33.2 |
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Fruit | ||
Low | 469 | 33.4 |
Moderate | 473 | 33.7 |
High | 462 | 32.9 |
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Brushing frequency | ||
At least once a day | 1204 | 85.7 |
Less than once a day | 200 | 14.3 |
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Toothpaste use | ||
At least once a day | 1276 | 90.9 |
Less than once a day | 128 | 9.1 |
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Dental floss use | ||
At least once a week | 273 | 19.4 |
Never, do not know of it | 1131 | 80.6 |
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Mouthwash use | ||
At least once a week | 396 | 28.2 |
Never, do not know of it | 1008 | 71.8 |
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Brushing frequency | ||
At least once a day | 1255 | 89.4 |
Less than once a day | 149 | 10.6 |
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Knowledge of oral health | ||
Sufficient | 468 | 33.3 |
Regular | 468 | 33.3 |
Insufficient | 468 | 33.3 |
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Perception of child’s oral health | ||
Very bad/bad | 158 | 11.3 |
Regular | 635 | 45.2 |
Good/very good | 611 | 43.5 |
Of the half of the children who reported to have had dental pain, the largest proportion were male, affiliated with the Seguro Popular system, located in the lowest socioeconomic level in terms of housing characteristics, and lived in households without an automobile (Table
Bivariate analysis of sociodemographic and socioeconomic variables for schoolchildren aged 6 to 12 years in dental pain survey.
Variables | No pain |
Pain |
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6-7 yrs. | 210 (51.3) | 199 (48.7) | 0.601 |
8–10 yrs. | 296 (48.6) | 313 (51.4) | |
11-12 yrs. | 198 (51.3) | 188 (48.7) | |
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Female | 375 (53.5) | 326 (46.5) |
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Male | 329 (46.8) | 374 (53.2) | |
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Mother | 131 (54.4) | 110 (45.6) | 0.356 |
Father | 537 (49.3) | 553 (50.7) | |
Other | 36 (49.3) | 37 (50.7) | |
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Primary | 63 (46.0) | 74 (54.0) | 0.103 |
Middle | 242 (46.8) | 275 (53.2) | |
High | 260 (52.7) | 233 (47.3) | |
Bachelor’s or higher | 139 (54.1) | 118 (45.9) | |
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Primary | 56 (44.8) | 69 (55.2) | 0.190 |
Middle | 168 (46.0) | 197 (54.0) | |
High | 225 (50.8) | 218 (49.2) | |
Bachelor’s or higher | 226 (52.6) | 204 (47.4) | |
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Uninsured | 235 (54.3) | 198 (45.7) |
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IMSS/ISSSTE | 358 (49.2) | 369 (50.8) | |
PEMEX/SEDENA/SEMAR | 39 (57.4) | 29 (42.6) | |
Private | 25 (51.0) | 24 (49.0) | |
Seguro Popular | 47 (37.0) | 80 (63.0) | |
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1st quartile | 205 (58.4) | 146 (41.6) |
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2nd quartile | 170 (48.3) | 182 (51.7) | |
3rd quartile | 170 (48.4) | 181 (51.6) | |
4th quartile | 159 (45.4) | 191 (54.6) | |
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1st quartile | 150 (42.1) | 206 (57.9) |
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2nd quartile | 167 (47.2) | 187 (52.8) | |
3rd quartile | 179 (51.9) | 166 (48.1) | |
4th quartile | 208 (59.6) | 141 (40.4) | |
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Yes | 489 (54.8) | 404 (45.2) |
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No | 215 (42.1) | 296 (57.9) | |
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35.47 ± 6.15 | 34.30 ± 5.91 |
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37.97 ± 6.36 | 37.48 ± 6.28 |
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Of the schoolchildren with reported dental pain, a larger proportion had high fried food intake and low fruit intake (Table
Bivariate analysis of risk indicators (diet, oral health habits, and behavior) among schoolchildren aged 6 to 12 years in dental pain survey.
Factors | No pain |
Pain |
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Candies | |||
Low | 230 (48.9) | 240 (51.1) | 0.502 |
Moderate | 244 (52.4) | 222 (47.6) | |
High | 230 (49.2) | 238 (50.8) | |
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Fried food | |||
Low | 268 (56.9) | 203 (43.1) |
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Moderate | 230 (49.2) | 237 (50.8) | |
High | 206 (44.2) | 260 (55.8) | |
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Fruit | |||
Low | 207 (44.1) | 262 (55.9) |
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Moderate | 247 (52.2) | 226 (47.8) | |
High | 250 (54.1) | 212 (45.9) | |
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Brushing frequency | |||
At least once a day | 640 (53.2) | 564 (46.8) |
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Less than once a day | 64 (32.0) | 136 (68.0) | |
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Toothpaste use | |||
At least once a day | 662 (51.9) | 614 (48.1) |
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Less than once a day | 42 (32.8) | 86 (67.2) | |
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Dental floss use | |||
At least once a week | 121 (44.3) | 152 (55.7) |
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Never, do not know of it | 583 (51.5) | 548 (48.5) | |
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Mouthwash use | |||
At least once a week | 157 (39.7) | 239 (60.3) |
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Never, do not know of it | 547 (54.3) | 461 (45.7) | |
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Brushing frequency | |||
At least once a day | 656 (52.3) | 599 (47.7) |
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Less than once a day | 48 (32.2) | 101 (67.8) | |
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Knowledge of child’s oral health | |||
Sufficient | 285 (60.9) | 183 (39.1) |
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Regular | 218 (46.6) | 250 (53.4) | |
Insufficient | 201 (42.9) | 267 (57.1) | |
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Perception of child’s oral health | |||
Very bad/bad | 46 (29.1) | 112 (70.9) |
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Regular | 325 (51.2) | 310 (48.8) | |
Good/very good | 333 (54.5) | 278 (45.5) |
Our multivariate model results revealed that, for each year of increase in mother’s age, the possibility of dental pain in the schoolchild decreased (
Multivariate analysis of dental pain in schoolchildren aged 6 to 12 years in dental pain survey.
Variables | OR | CI 95% |
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0.98 | 0.96–0.99 |
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1st to 3rd quartile (−) | 1 |
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4th quartile (+) | 0.52 | 0.30–0.92 |
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Yes | 1 |
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No | 1.49 | 1.14–1.93 |
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Low | 1 |
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Moderate | 1.87 | 1.30–2.69 |
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High | 2.34 | 1.42–3.88 |
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Low | 1 |
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Moderate | 0.68 | 0.48–0.97 |
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High | 0.61 | 0.42–0.88 |
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At least once a day | 1 |
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Less than once a day | 2.31 | 1.51–3.53 |
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At least once a week | 1 |
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Never, do not know of it | 0.46 | 0.27–0.78 |
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Sufficient | 1 |
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Regular | 2.09 | 1.43–3.04 |
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Insufficient | 2.72 | 1.55–4.77 |
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Very bad/bad | 1 |
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Regular | 0.39 | 0.19–0.80 |
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Good/very good | 0.34 | 0.19–0.62 |
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Note: Model fitted to variables in table;
To our knowledge, our study is one of the first to address the prevalence of and factors associated with dental pain in Mexico. The frequently observed relationship between dental pain and dental caries in this age group makes it an important variable. Identifying dental pain in schoolchildren can be a good indicator of the need for curative or emergency treatment, an estimator of the proportion of people who may use oral health services in the future, and therefore a key datum in planning oral health service needs.
Half (49.9%) of the studied schoolchildren had experienced dental pain in the twelve months prior to the survey, and different variables were associated with its presence. This prevalence is higher than the 35.7% reported for schoolchildren from private and public schools in Brazil [
In a previous study on parent/guardian influence and responsibility for child health, parents acknowledged the benefits of brushing teeth with fluoride toothpaste. Even so, the parents of children that had experienced caries and dental pain believed that the causes were beyond their control, due to genetics, attributed to health problems intrinsic to childhood, or just random [
The positive impact of greater mother’s age on dental pain may be due to the information and experience older mothers have accumulated throughout their lives. This coincides with a study in the United Kingdom indicating that greater mother’s age favorably affects child cognitive, behavioral, and health condition [
Describing the association between an individual’s pain and their socioeconomic level (based here on the socioeconomic variables remaining in the final model: housing characteristics and automobile in household) can be quite complex since socioeconomic position is a multifactorial construct [
Fried food intake was associated with a greater possibility of dental pain in the studied schoolchildren. A possible explanation for this is the greater presence of dentobacterial plaque caused by intake of fried, high carbohydrate foods between regular meals. This in turn can directly affect teeth and gums exposed for long periods [
Brushing of teeth mechanically removes and disorganizes dental biofilm, limiting its ability to cause disease. It is the most cost effective dental care instruction, is widely recommended for maintaining oral health, and is a habit best inculcated at an early age [
Health literacy is the “ability to obtain, process and understand information” and the services needed to make adequate health decisions [
Parents are vital to child development because they are responsible for seeking timely treatment for any disorders that might occur in the child. Oral health is a component of overall good health since it can affect taste, mastication, speech, and facial expression [
The present study has three main limitations. The first is that, due to its cross-sectional design, the temporality between variables is not accurate (temporality ambiguity), potentially causing reversed directions, and representing a possible inherent bias. Information selection bias (i.e., memory) is the second limitation; dental pain was explored over a 12-month period prior to the survey, affecting memory accuracy, be it in the individual or in cooperation with the parent/guardian-child. The third limitation is that the study does not include all of the schoolchildren in the region, meaning it is not representative of the state’s overall school population. Future research should now address the source(s) of dental pain in schoolchildren.
Overall, dental pain prevalence in the sampled population was high: 1 in every 2 children had experienced dental pain in the 12 months prior to the survey. Among the diverse factors affecting this prevalence, socioeconomic condition (housing characteristics and presence of an automobile in the home) suggested the presence of inequalities in oral health status and access to dental care among the studied children. Future studies should now evaluate the response of oral health services to people with dental pain.
The authors declare that they have no conflicts of interest.
Mauricio Escoffié-Ramirez, Leticia Ávila-Burgos, Elena Saraí Baena-Santillan, and Carlo Eduardo Medina-Solís were involved in the design and development of the study, did the analysis of the data, and wrote the first draft of the manuscript. Fernando Aguilar-Ayala, Edith Lara-Carrillo, Mirna Minaya-Sánchez, Martha Mendoza-Rodríguez, and María de Lourdes Márquez-Corona were involved in the conception of the paper and analysis and interpretation of the results. All the authors were involved in the critical review and made intellectual contributions; they also accepted the final version.