ORIGINAL Rajab ARTICLE et al
Traumatic Dental Injuries Among 12-year-old Schoolchildren in Jordan: Prevalence, Risk Factors and Treatment Need Lamis D. Rajaba/Zaid H. Baqainb/Suha B. Abu Ghazalehc/Hawazen N. Sonbold/ Mahmoud A. M. Hamdane Purpose: To assess the prevalence and related factors of traumatic dental injuries (TDI) among 12-year-old Jordanian schoolchildren. Materials and Methods: For this cross-sectional study among schoolchildren, a sample of 2560 schoolchildren (1209 boys, 1351 girls) aged 12 years were randomly selected. The epidemiological classification adopted by the World Health Organization (WHO) and modified by Andreasen et al was used to record TDI on incisors. Results: Of the children examined, 5.5% showed TDI. The difference in prevalence between boys and girls was statistically significant (P < 0.01). Maxillary central incisors were the most affected and the most common type of crown injury was enamel/dentin fracture. The relationship between dental injuries and geographic location, area, and socioeconomic indicators was not statistically significant. Most of the TDI occurred at home, followed by school; the most frequent cause was falls. No statistically significant association was found between TDI and dental caries experience (P > 0.05). There was a tendency for boys (P < 0.01), children with an incisal overjet > 3 mm (P < 0.01) and incompetent lip closure (P < 0.001) to have experienced dental injuries. Treatment need due to dental injuries was very high. Conclusion: The prevalence of traumatic injuries to permanent incisors in 12-year-old Jordanian schoolchildren was relatively low. TDI was associated with gender, overjet and lip competence, but was not influenced by dental caries experience. There was a great unmet treatment need. Key words: children, epidemiology, Jordan, prevalence, risk factors, traumatic dental injuries, treatment need Oral Health Prev Dent 2013;11:105-112 doi: 10.3290/j.ohpd.a29362
T
raumatic dental injuries (TDI) in children and adolescents are a serious dental public health problem. They result in functional, aesthetic and psychological disturbances accompanied by great concern from the child, parents and dentists. A a
Professor, Department of Pediatric and Preventive Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan.
b
Professor, Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology, and Periodontology, Faculty of Dentistry, University of Jordan, Amman, Jordan.
c
Assisstant Professor, Department of Pediatric and Preventive Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan.
d
Associate Professor, Department of Pediatric and Preventive Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan.
e
Professor, Department of Pediatric and Preventive Dentistry, Faculty of Dentistry, University of Jordan, Amman, Jordan.
Correspondence: Prof. Lamis D. Rajab, P.O. Box 13595, 11942 Amman, Jordan. Tel: +962-6-535-5000 (ext. 23623), Fax: +962-6-5300844. Email:
[email protected]
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Submitted for publication: 19.12.11; accepted for publication: 16.05.12
wide range of prevalence in the levels of TDI has been reported from different countries (Marcenes et al, 1999; Al-Majed et al, 2001; Hamdan and Rajab, 2003; Artun et al, 2005; Malikaew et al, 2006; Traebert et al, 2006; Soriano et al, 2007; Glendor et al, 2008; Cavalcanti et al, 2009; David et al, 2009; Naidoo et al, 2009; Soriano et al, 2009; Bendo et al, 2010; Navabazam et al, 2010). In formulating strategies to prevent TDI, some of the studies addressed factors believed to be associated with TDI. Often-reported predisposing factors include increased overjet with protrusion and inadequate lip coverage (Marcenes et al, 1999; Hamdan and Rajab et al, 2003; Artun et al, 2005; Traebert et al, 2006; Cavalcanti et al, 2009). However, the role of socioeconomic indicators is controversial (Hamdan and Rajab et al, 2003; Malikaew et al, 2006; Soriano et al, 2007; Naidoo et al, 2009) and few studies have explored the associa-
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tion between TDI and dental caries experience (Locker, 2005; Fakhruddin et al, 2008; Artun and Al-Azemi, 2009; Bendo et al, 2010). There is a paucity of data on the prevalence of TDI from the Middle East. In Jordan, there have been few epidemiological studies on TDI among schoolchildren. Jamani and Fayyad (1991) reported a prevalence of 10.5% of traumatised incisors among schoolchildren aged 7–12. Hamdan and Rock (1995) investigated 10- to 12-year-old schoolchildren and found a prevalence of 19.1% and 15.5% in an urban and a rural area, respectively. Hamdan and Rajab (2003) found a prevalence of 13.8% of traumatised incisors in schoolchildren aged 12 years. The objectives of the present study were to: (1) determine the prevalence and types of injuries to permanent incisors among 12-year-old Jordanian schoolchildren living in rural and urban areas, and among schoolchildren of different social groups living in the middle geographic area (Amman), (2) evaluate the relative effect of overjet, lip-closure competence and dental caries experience as predisposing factors and (3) assess the treatment provided for the injured teeth and treatment need.
MATERIALS AND METHODS A cross-sectional survey was carried out on children of both sexes aged 12 years attending schools in urban and rural areas in Jordan. Three geographical/administrative areas were identified as focal points for the present survey in order to obtain a nationally representative sample of 12-year-olds: 1. the northern part: the Irbid area; 2. The middle part: Amman, the capital area; 3. the southern part: the Alkarak area. Children were chosen from a representative sample schools for boys and girls using stratified cluster sampling. The schools were selected to include urban and rural areas. Moreover, in the urban area of the capital Amman, three different areas were identified and children were chosen by socioeconomic criteria to balance the sample. Children were classified into socioeconomic groups according to standard of schools: high social class covered children from private schools; middle social class were children from state schools, while low social class included children from schools located in deprived areas and refugee camps. The local authority (Ministry of Education) provided the necessary information for the construction of a sample frame. In all, 45 schools were
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selected, 25 from urban and 20 from rural areas, where 2000 children from grade 6 (approximately 12 years) were intended for the survey to achieve the number required for the sample. The final study population comprised 2560 children of age 12 (girls: 52%; boys: 48%). All parents agreed on their children participating in the study and the response rate was 100%. The data were obtained in agreement with Jordanian ethics regulations. An explanatory letter was sent to parents explaining the aim, characteristics and importance of the study and asking for their participation; negative consent was adopted. The clinical examiners were calibrated prior to the study in order to control reliability. Clinical instructions and calibration took place at the Department of Pediatric and Preventive Dentistry located at the Jordan University Hospital. The pre-survey calibration was performed in two series of clinical examinations on 60 children (excluded from the main sample) at a 4-week interval to establish intra-examiner reproducibility. The recommended level of inter-examiner consistency in recording dental trauma was achieved. During the survey, double examinations of approximately 10% of the children were performed in order to assess intraand inter-examiner variability in the use of the diagnostic criteria. The Kappa values on intra- and interexaminer consistency in the diagnosis of trauma and dental caries were greater than 0.82, indicating excellent agreement. Dental examination was conducted using individually wrapped and sterilised sets of plain mouth mirrors, community periodontal index probes and gauze pads. The children were examined at their schools under natural light. Because radiographic examination was not carried out, root fractures were not recorded. Pulp vitality tests were not performed. The dental examination for TDI included only maxillary and mandibular permanent incisors. Injuries were classified as follows according to the epidemiological classification adopted by the World Health Organization (WHO) (1994) and modified by Andreasen et al (2007): no injury, treated dental injuries, enamel fracture only, enamel/dentin fracture; pulp injury; missing tooth due to trauma. Increased overjet was defined as protrusion in excess of 3 mm. Incisor overjet was measured with a ruler to the nearest half-mm as the distance parallel to the occlusal plane from the incisal edge of the most labial maxillary central incisor to the most labial mandibular central incisor, with the teeth in centric occlusion. The measurements were taken
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with the Frankfort plane parallel to the floor. Lip closure competence was evaluated with the lips in the resting position; closure was considered competent if the child had lips naturally closed without perceptible tension and incompetent if the lips were naturally apart with lip strain evident on closure. Children who were diagnosed with TDI answered an interview addressing the history of the injury. Data on dental caries were collected using the Decayed, Missing and Filled Teeth Index (DMFT) according to the standardised criteria of the WHO (1997). Demographic information (gender, location, social class) was recorded as part of the clinical examination. The data were processed and analysed by means of SPSS PC Version 17.0 (Chicago, IL, USA). Data analysis included descriptive and analytic statistics. The chi-square test was used to compare qualitative data, and logistic regression was used to identify potential predictors of traumatic dental in-
juries. First, a simple logistic regression was carried out for each variable studied. Next, all variables were forced into the model to adjust for possible confounding effects and to identify the independent contribution of each explanatory variable. Variables were included independently of the statistical significance if they were conceptually relevant. Statistical significance was set at 5%. The variables were tested for two-way interaction.
RESULTS As shown in Table 1, the overall prevalence of trauma in Jordan was 5.5% (142 children), with 7% of boys (85) and 4.2% of girls (57) being affected. The overall ratio between boys and girls was 1.6:1; a statistically significant difference was found, showing positive association between the male gender and the prevalence of TDI (P < 0.01).
Table 1 Prevalence of traumatic injuries to the permanent incisors in a sample of 2560 12-year-old schoolchildren by gender, area and socioeconomic status No injury N (%)
Injury N (%)
Total N (%)
Boys
1124 (93)
85 (7)
1209 (47.2)
Girls
1294 (96)
57 (4.2)
1351 (52.8)
Total
2418 (94.5)
142 (5.5)
2560 (100)
Urban
1566 (94.5)
92 (5.5)
1658 (64.8)
Rural
852 (94.5)
50 (5.5)
902 (35.2)
Total
2418 (94.5)
142 (5.5)
2560 (100)
Middle
1167 (94.3)
71 (5.7)
1238 (48.4)
North
685 (95.1)
35 (4.9)
720 (28.1)
South
566 (94)
36 (6)
602 (23.5)
Total
2418 (94.5)
142 (5.5)
2560 (100)
High
307 (95.3)
15 (4.7)
322 (34.3)
Middle
298 (94.9)
16 (5.1)
314 (33.5)
Low
238 (93.1)
20 (6.6)
302 (32.2)
Total
888 (94.5)
52 (5.5)
938 (100)
Gender *
Area
Geographic location
Socioeconomic status (urban Amman)
*P < 0.01
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Table 2 Distribution of children by gender, place of injury and cause of injury Gender, N (%)
Place of trauma
Male
Female
Total
Home
44 (51.8)
32 (56.1)
76 (53.5)
School
12 (14.1)
14 (24.6)
26 (18.3)
Street
18 (21.2)
8 (14)
26 (18.3)
Playground
11 (12.9)
3 (5.3)
14 (9.9)
Total
85 (100)
57 (100)
142 (100)
Fall
47 (55.3)
45 (78.9)
92 (64.8)
Playing sports
24 (28.2)
3 (5.3)
27 (19)
Collision
7(8.2)
4 (7)
11 (7.7)
Violence
7 (8.2)
3 (5.3)
10 (7)
Traffic accident
-
2 (3.5)
2 (1.4)
Total
85 (100)
57 (100)
142 (100)
Cause of injury*
*P < 0.01
Table 1 indicates that the prevalence of traumatised incisors was 5.5% in both urban and rural areas. TDI frequency in different socioeconomic groups (high, middle and low social class) of urban Amman children did not differ significantly (Table 1; P > 0.05). In all, 78.2% of the injured children (111) had only one tooth damaged, 20.4% (29) had two teeth damaged and only 1.4% (8) had three or more. The children had a total of 177 injured teeth, representing approximately 1.2 per accident. The maxillary central incisors were the most frequently affected teeth (91%), followed by the maxillary lateral incisors (4.5%), then the mandibular central incisors (4%) and the mandibular lateral incisors (0.6%). As shown in Table 2 most of the TDI occurred at home (53.5%), followed by school (18.3%), street (18.3%) and playgrounds (9.9%). Boys had more injuries in the street and in playgrounds than did girls, whereas girls sustained most injuries at home and school. There was no statistically significant association between gender and place of injury (P > 0.05). The most frequent cause of TDI was falls (64.8%), followed by playing sports (19%), collisions with people or inanimate objects (7.7%), violence (7%) and road accidents (1.4%). Falling was the main cause of injury in boys and girls; boys had more injuries owing to sports and violence than did girls. A
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highly statistically significant association between gender and cause of injury was found (P < 0.01) (Table 2). Most of the TDI due to falling occurred at home (63%) and at school (19.6%), while more than the one-third were due to playing sports in the street (37%). There was a highly statistically significant association between the cause and place of injury (P < 0.01) (Table 3). The most common type of injury was enamel/ dentin fracture (42.3%), followed by fracture of enamel only (37.3%). All types of TDI were more common in boys than in girls. A statistically significant association between gender and type of injury was not found (P > 0.05) (Table 4). As shown in Table 5, falling caused more than one-third of cases with fractured enamel (37%) and nearly half of those with fractured dentin (45.7%). A statistically significant association between cause and type of injury was not found (P > 0.05). Only 10 incisors (5.6%) out of 177 were treated. The type of treatment recorded was acid-etched, adhesively luted restorations or crowns. Among the 167 untreated injuries, only 62% needed treatment; 38% did not need treatment as they were minor, such as a small enamel fracture. Treatment needs included simple composite resin restoration (45%), root canal treatment (11%) and fixed or removable prosthetic replacement of missing teeth (6%).
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Home
School
Street
Playground
Total
Fall
58 (63)
18 (19.6)
12 (13)
4 (4.3)
92 (64.8)
Playing sporst
8 (29.6)
4 (14.8)
10 (37)
5 (18.5)
27 (19)
Collision
5 (45.5)
2 (18.2)
1 (9.1)
3 (27.3)
11 (7.7)
Violence
5 (50)
2 (20)
1 (3.8)
2 (20)
10 (7)
Traffic accident
0 (0)
0 (0)
2 (100)
0 (0)
2 (1.4)
Total
76 (53.5)
26 (18.3)
26 (18.3)
14 (9.9)
142 (100)
*P < 0.01
Table 4 Distribution of injured teeth by type of injury and distribution of children with injured teeth by type of injury and gender Number of injured teeth N (%) Type of injury
Gender, N (%) Male
Female
Total
Treated dental injuries
10 (5.6)
2 (2.4)
4 (7)
6 (4.2)
Enamel fracture only
64 (36.2)
27 (31.8)
26 (45.6)
53 (37.3)
Enamel/ dentin fracture
75 (42.4)
40 (47.1)
20 (35.1)
60 (42.3)
Pulp injury
18 (10.2)
11 (12.9)
4 (7)
15 (10.6)
Missing tooth due to trauma
10 (5.6)
5 (5.9)
3 (5.3)
8 (5.6)
Total
177 (100)
85 (100)
57 (100)
142 (100)
Table 5 Distribution of children with injured teeth by type and cause of injury Cause of trauma N (%) Type of injury
Fall
Playing sports
Road accident
Collision with people or inanimate object
Violence
Total
Treated dental injuries
4 (4.3)
1 (3.7)
0 (0)
1 (9.1)
0 (0)
6 (4.2)
Enamel fracture only
34 (37.0)
12 (44.4)
0 (0)
4 (36.4)
3 (30.0)
53 (37.3)
Enamel /dentin fracture
42 (45.7)
7 (25.9)
1 (50)
6 (54.5)
4 (40.0)
60 (42.3)
Pulp injury
8 (8.7)
6 (22.2)
1 (50)
0 (0)
0 (0)
15 (10.6)
Missing tooth due to trauma
4 (4.3)
1 (3.7)
0 (0)
0 (0)
3 (30)
8 (5.6)
Total
92 (100)
27 (100)
2 (100)
11 (100)
10 (100)
142 (100)
There was a tendency for children with an incisal overjet > 3 mm (P < 0.01) and incompetent lip closure (P < 0.001) to have experienced dental injuries and the differences were statistically significant.
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There was no significant association between caries experience and TDI (P > 0.05). The proportion of TDI was similar among children with dental caries experience (5.9%) compared with those who were caries free (5.3%). The mean DMFT of those
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showing evidence of TDI was 1.13 compared to 1.06 for those without evidence of injury. The results of simple logistic regression showed a highly statistically significant association between dental injuries and gender (P < 0.01), overjet > 3 mm (P < 0.01), and lip closure competence (P < 0.001). The results of multiple logistic regression confirmed the statistically significant associations observed in the simple logistic regression (Table 6). Adjusted results showed that boys were 1.656 times (95% CI = 1.170–2.346) more likely to have dental injuries than girls. Children having overjet > 3 mm were 1.843 times (95% CI = 1.255– 2.705) more likely to have dental injuries than those who had overjet ≤ 3 mm. Furthermore, children with competent lip closure were 0.477 times (95% CI = 0.315–0.723) less likely to have dental injuries than those without.
DISCUSSION This cross-sectional survey identified a prevalence of 5.5% of TDI to the permanent incisors of 12-yearold Jordanian children. This prevalence is lower than those reported previously in Jordan, 10.5% to 19.1%, (Jamani and Fayyad, 1991; Hamdan, et al, 1995; Hamdan and Rajab, 2003) and from other Middle Eastern countries, 11.7% to 27.5% (Marcenes et al, 1999; Artun et al, 2005; Livny et al, 2010; Navabazam et al, 2010), and finally from developing countries in Latin America, 10.5% to 17.3% (Traebert et al, 2006; Soriano et al, 2007; Bendo et al, 2010). However, the prevalence of TDI in the present study is close to 6% and 6.4%, reported in 12-year-old school children in South Africa (David et al, 2009) and southern India (Naidoo et al, 2009), respectively. The cross-sectional design of the present survey might have contributed to the overall low prevalence in TDI. This study was conducted in field circumstances without optimal conditions for diagnosis. Previous epidemiological studies of TDI that have included radiographs (Borssén and Holm, 1994), better clinical examination techniques (a mobile unit with good light) (Shulman and Peterson, 2004) and questionnaires for child/ parents (Fakhruddin et al, 2009) have presented higher prevalence of TDI. In addition, the relative lack of outdoor activities among this study sample might have, to some degree, lowered the prevalence of TDI compared to previous studies conducted in Jordan (Jamani and Fayyad, 1991; Hamdan, et al, 1995; Hamdan and Rajab, 2003). Most Jor-
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danian children now have access to home computers and use them for playing games, doing schoolwork, chatting and surfing the Web. This comes at the expense of outdoor physical activities predisposing to trauma. There was a significant difference in dental trauma between genders – boys had a higher prevalence than girls – which is in accordance with previous studies (Marcenes et al, 1999; Hamdan and Rajab, 2003; Malikaew et al, 2006; Soriano et al, 2007). After adjusting for the effect of different variables, boys had an almost 1.65-times higher probability of experiencing a TDI than did girls. The finding of a male:female ratio of 1.6 is close to that found in previous studies (Hamdan and Rock, 1995; Rajab, 2003). The difference by gender is explained by behaviour, as boys practice more dangerous activities and contact sports and participate more in fights than do girls (Marcenes et al, 1999; Rajab, 2003). The prevalence of TDI was similar in urban and rural areas; this compares well with previous reports in Jordan among 12-year-old schoolchildren (Hamdan and Rock, 1995; Hamdan and Rajab, 2003). In addition, there was no statistically significant difference among children in the three selected geographic areas. Several reports on dental injuries have included socioeconomic indicators, and the results were conflicting. For instance, in one study, TDI was more common among adolescents from low than middle and upper socioeconomic groups (Malikaew et al, 2006). However, other studies reported a higher prevalence among high socioeconomic groups (Naidoo et al, 2009) and yet others showed no association (Hamdan and Rajab, 2003; Oliveira et al, 2007; Bendo et al, 2010). In the present study, the association was not statistically significant, which is in line with the findings of a previous Jordanian study (Hamdan and Rajab, 2003). These conflicting results may be explained by the differences in in the socioeconomic classification used (Bendo et al, 2010). The maxillary central incisors were most commonly affected in the present study; this corroborates well with other authors (Hamdan and Rajab, 2003; Malikaew et al, 2006; David et al, 2009; Naidoo et al, 2009). Most TDI occurred at home, followed by the street for boys and school for girls, which is similar to that reported by several researchers (Rajab, 2003; Malikaew et al, 2006; Soriano et al, 2007). Falls were the most common reason for TDI in this study, as in previous studies (Malikaew et al, 2006;
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David et al, 2009; Naidoo et al, 2009). This was followed by sports in boys and collisions in girls; as expected boys had more TDI from interpersonal violence. Most of TDI due to falls occurred at home and school, while more than the one-third were due to playing sports in the street. This is of special importance for health policy makers seeking to establish prevention strategies to reduce traumatic orofacial injuries. This includes involving parents more closely to control the home environment. The role of the school environment as a determinant of TDI is well established; in schools with a supportive social and physical environment, TDI is less likely (Malikaew et al, 2003). In the past few years, Jordan has witnessed the launch of several campaigns aimed at creating safer school environments and streets by supporting and designing safe architectural models, repairing and restoring schools to make them safer and promoting safer playgrounds by adjusting schoolyards and spaces. These campaigns reflected public-private partnership. The most common type of injury sustained to permanent incisors was enamel/dentin fracture, which is in agreement with previous studies (Hamdan, and Rock, 1995; Rajab, 2003). Other authors (Traebert et al, 2006; Bendo et al, 2010) found enamel fracture to be the most frequent injury. Similar to epidemiological studies in other countries (Marcenes et al, 1999; Al-Majed et al, 2001; Traebert et al, 2006; Naidoo et al, 2009), the present study showed that the treatment need of TDI is not properly met. The prevalence of treated traumatised teeth was only 5.6%, lower than the 23.3%, 11% and 15.6% found in studies conducted in Brazil (Bendo et al, 2010), Malaysia (Nik-Hussein, 2001) and South Africa (Naidoo et al, 2009), respectively, but comparable to those observed in Syria (6.7%) (Marcenes et al, 1999) and Saudi Arabia (2.4%) (Al-Majed et al, 2001). Since the last survey carried out in Jordan (Hamdan and Rajab, 2003), it seems that treatment of traumatised teeth has not improved (3.1%). A few previous studies have reported the amount of untreated damage while taking into consideration the need for treatment (Marcenes et al, 1999; Marcenes and Murray, 2001; Oliveira et al, 2007). This study showed that not all untreated dental injuries required treatment as some injuries were minor; however, the assessment of treatment need used in this study confirmed that treatment of TDI was neglected, as 62% of incisors that sustained damage were judged as needing treatment but were untreated. In develop-
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ing countries, the majority of the population cannot afford private dental care, and public services are unable to offer complex treatment (Bendo et al, 2010). Another factor that may determine the low treatment rates in both developing and developed countries is the fact that TDI is not a disease and parents do not pay it much attention (Traebert et al, 2006). Regarding increased overjet with protrusion and inadequate lip coverage, the finding in the present study is in agreement with previous reports (Marcenes et al, 1999; Hamdan and Rajab, 2003; Traebert et al, 2006; Soriano et al, 2007; Cavalcanti et al, 2009). In some studies, the definition of protrusion begins at > 3–3.5 mm (Traebert et al, 2006) but in others at > 5.0 mm (Marcenes et al, 1999; Hamdan and Rajab, 2003; Soriano et al, 2007), which makes it difficult to compare studies. The present study considered 3 mm a normal overjet. The results of the present study support previous findings in that reduced incisor protection through lip incompetence increases the likelihood of trauma (Artun et al, 2005). Therefore, the treatment of increased overjet is a necessary preventive measure for avoiding TDI. A few recent studies (Locker, 2005; Fakhruddin et al, 2008; Bendo et al, 2010) have found a strong association between dental caries experience and the occurrence of TDI in the permanent anterior teeth; children with caries were found to have more experience with TDI than those who were caries free. This study failed to identify this association, corroborating results of a previous study which suggested that the association between untreated caries and behavior conducive to TDI is unclear (Artun and Al-Azemi, 2009). More research is needed in this area. In the light of the findings of the present study, there is a need for public interventions to reduce the risk for TDI among children and adolescents in Jordan. A safe environment at home, in schools and the community, including safer playgrounds, can help minimise the risks. Health education should aim at increasing the awareness of hazards in the home, school and street environment as well as reducing the participation in unsafe activities. Contact sports should be played under competent supervision on appropriate surfaces and with complete safety equipment in order to prevent TDI. Interceptive orthodontic treatment in this age group would be beneficial to reduce the risk of TDI in those children with excessive overjet.
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CONCLUSION The results of this study showed that the prevalence of TDI to permanent incisors in 12-year-old Jordanian schoolchildren was relatively low. The main places and activities related to the occurrence of TDI were home and school through falls and playing sports in the street. TDI was associated with gender, overjet and lip closure competence but was not influenced by dental caries experience. There was a great unmet treatment need.
ACKNOWLEDGMENTS The study was supported by the Higher Council for Science and Technology, research grant number 1-2-1-2081.
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