Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62: 404–411

doi: 10.1111/adj.12516

Oral manifestations related to dengue fever: a systematic

review of the literature
MS Pedrosa,*†‡ MHP de Paiva,§ LGFL Oliveira,¶ SMS Pereira,** CHV da Silva,†† JGF
Pompeu‡‡
*Department of Dentistry, Faculdade Integral Diferencial – FACID | DeVry Brazil, Teresina, Brazil.
†Oral Pathology and Maxillofacial Surgery Group – LACPO, Faculdade Integral Diferencial – FACID | DeVry Brasil, Teresina, Brazil.
‡Centro Educacional Tr^es Irm~as – CETI, Barras, Piauı, Brazil.
§Department of Nursing, Faculdade Integral Diferencial – FACID | DeVry Brasil, Teresina, Brazil.
¶Luiz Gustavo Aesthetic Dentistry and Oral Implantology, Teresina, Brazil.
**Deparment of the Post-Graduate Program in Dentistry, CEUMA University, S~ao Luıs, Brazil.
††Department of Prosthetic Dentistry and Maxillofacial Surgery, Federal University of Pernambuco – UFPE, Recife, Brazil.
‡‡Department of Restorative Dentistry, Federal University of Piauı – UFPI, Teresina, Brazil.

ABSTRACT
The focus on oral manifestations of dengue fever (DF) is not common in the scientific literature and the patient affected
can present signs and symptoms that may not be noticed by dental professionals. This systematic review article was con-
ducted to identify and discuss the oral manifestations related to DF. The electronic databases PubMed, Latin American
and Caribbean Literature in Sciences (LILACS), Web of Science and Scopus were searched from November to December
2016 by two authors, simultaneously, using the search terms ‘dengue and oral manifestation’ combined. We included
complete original articles, clinical trials and clinical case reports published in Portuguese, Spanish and English. No limits
were applied to the year of publication. Review articles and those with no health outcomes were removed. A limited
number of studies aimed to investigate the oral manifestations of DF (N = 25). However, several manifestations were
identified in the oral cavity of patients diagnosed with DF such as acute gingival and palate bleeding, dryness of the
mouth, taste changes, and erythematous plaque and vesicles on the tongue and palate. Osteonecrosis of jaw associated
with DF was also reported. In conclusion, oral manifestations may represent a relevant contributory factor to identify
DF disease among patients undergoing dental procedures in general practise.
Keywords: Dengue, dentistry, oral manifestations, public health, review.
Abbreviations and acronyms: BM = bleeding manifestations; CC = confirmed cases of dengue; CI = confidence interval; COMD =
cutaneous oral manifestations of dengue; CST = clinical and serological tests; DF = dengue fever; DHF = dengue haemorrhagic fever;
DSS = dengue shock syndrome; GB = gingival bleeding; HM = haemorrhagic manifestations; MeSH = Medical Subject Heading; OC =
oral candidiasis; OM = oral manifestations; OMC = oral mucous membrane; OR = odds ratio.
(Accepted for publication 2 April 2017.)

transmitted.8 Annually, 100 million cases of classical

INTRODUCTION
Dengue fever (DF) is an acute infectious disease of
viral origin, in which the main vector is the female
Aedes aegypti mosquito.1–3 For more than 200 years,
the dengue virus as well as its vector have been widely
distributed in several tropical countries.4 As a global
disease,5 it affects over 100 countries including the
USA.6
Due to its evolution in the last 50 years and the
predominance in urban and semi-urban areas, DH has
become an important public health problem.7 It is
estimated that approximately 2.5 billion people
worldwide live in areas where the dengue virus can be
404
DH and 500 million cases of dengue haemorrhagic
fever (DHF) are reported globally, with an average
fatality rate of 5–20%.9
The viral infection shows a variety of clinical
presentations, so its accurate diagnosis is difficult and
depends, in most cases, on laboratory tests.10 Typical
symptoms may include high fever, headache, back
pain, muscle and joint pains (ankles, knees and shoul-
ders), metallic taste in the mouth, loss of appetite,
vomiting, diarrhoea, abdominal pain and rashes.4,11
The World Health Organization also mentions organ
dysfunction as an indicator of the severity of
dengue.12.
© 2017 Australian Dental Association

The patient diagnosed with DH may present signs
and symptoms of DH that may be overlooked by
health professionals.3 Thus, the present systematic lit-
erature review was conducted to identify the oral
manifestations related or associated with DH disease
as well as to discuss its clinical implications for gen-
eral practitioners.
METHODS
For the purpose of this study, we followed instruc-
tions provided by Moher et al.13 in ‘Preferred report-
ing items for systematic reviews and meta-analyses:
The PRISMA statement’. As instructed, we conducted
‘. . .a review of a clearly formulated question that uses
systematic and explicit methods to identify, select,
and critically appraise relevant research, and to collect
and analyze data from the studies that are included in
the review’.
Identification and selection of relevant research
An exploratory bibliographic search was conducted
from October to December 2016 using the electronic
databases PubMed, Latin American and Caribbean
Literature in Sciences (LILACS), Web of Science and
Scopus. Two authors performed the search employing
the Medical Subject Heading (MeSH) term ‘dengue’ in
combination with ‘oral manifestation’, ‘dentistry’, ‘cu-
taneous’, ‘tongue’, ‘gingival bleeding’, ‘osteonecrosis’
and ‘mouth’ (see Table 1). Inclusion criteria were
original research articles, clinical trials and clinical
Table 1. Search strategy for all databases
Keyword combinations
1 (‘dengue’ [MeSH Terms] OR ‘dengue’ [All Fields])
COMBINED with (‘oral manifestations’ [MeSH
Terms] OR (‘oral’ [All Fields] AND ‘manifestations’
[All Fields]) OR ‘oral manifestations’ [All Fields]
OR (‘oral’ [All Fields] AND ‘manifestation’ [All
Fields]) OR ‘oral manifestation’ [All Fields]); OR
cutaneous[All Fields]; OR (‘dentistry’ [MeSH
Terms] OR ‘dentistry’ [All Fields]); OR tongue[All
Fields]; OR ‘gingival bleeding’ [All Fields]; OR
(‘osteonecrosis’ [MeSH Terms] OR ‘osteonecrosis’
[All Fields]); OR (‘mouth’ [MeSH Terms] OR
‘mouth’ [All Fields])
2 (tw:(dengue)) COMBINED with (tw:(oral
manifestation)) OR (tw:(cutaneous)) OR
(tw:(dentistry)) OR (tw:(tongue)) OR (tw:(gingival
bleeding)) OR (tw:(osteonecrosis)) OR (tw:(mouth))
3 (TS=(dengue)) COMBINED with ‘oral
manifestation’ OR ‘cutaneous’ OR ‘dentistry’ OR
‘tongue’ OR ‘gingival bleeding’ OR ‘osteonecrosis’
OR ‘mouth’ AND Language: (English OR
Portuguese OR Spanish)
4 TITLE-ABS-KEY (dengue) COMBINED with ‘oral
manifestation’ OR ‘cutaneous’ OR ‘dentistry’ OR
‘tongue’ OR ‘gingival bleeding’ OR ‘osteonecrosis’
OR ‘mouth’
© 2017 Australian Dental Association
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Oral manifestations related to dengue fever
case reports published in Portuguese, Spanish and
English. No limits were applied to the year of
publication.
Studies identified were exported to Mendeley soft-
ware (London, UK) for Windows, and duplicates
were removed. Subsequently, titles and abstracts
were screened for relevance, considering the exclu-
sion criteria. Next, the remaining studies were
obtained in full text and were screened using the
same criteria, the eligible ones being included in this
review. We removed review studies, articles not
available in full text and publications that did not
address the oral manifestations of DH. Eligible stud-
ies also had their reference lists screened following
the specified criteria with the ones eligible assigned
to an additional category.
Data collection and analyses
All the selected articles addressed DH and its related
oral manifestations and included the following param-
eters: authorship, year of publication, country of pub-
lication, type of study, sample size (and age),
outcomes measured, relevant data and results, and
study considerations.
Based on the studies’ findings, we determined the
following themes for critical analysis of the results:
characteristics of the studies, oral manifestations
related to DH and implications for practise. Yet, con-
sidering our study design and its referred findings, we
present the section ‘Study limitations’.
RESULTS AND DISCUSSION
For this systematic review, the initial search yielded a
Database total of 750 titles found in the electronic search in the
databases PubMed, LILACS, Web of Science and Sco-
PubMed
pus. Seventy-five studies were excluded for duplication
and the remaining 675 papers were screened for rele-
vance to this study. Six hundred and thirty publica-
tions were excluded after reading their titles and
abstracts. Then, the 45 remaining documents were
obtained in full text and assessed for eligibility, in
consideration of oral manifestations of DH. After
reading the documents in full text, 23 studies were
included. Two additional studies that did not come
LILACS
up on the database search were also included, totaliz-
ing 25 studies eligible for this systematic review (see
Fig. 1 and Table 2). No studies from reference lists
Web of
Science were added for not being eligible.
Characteristics of the studies
Scopus
We identified 25 studies that addressed, in some
respect, the oral manifestations of DH. Out of the 25
documents selected, 40% (N = 10) were clinical case
405
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MS Pedrosa et al.

Table 2. Results of the literature search displayed in chronological order.

Author/year Study type Sample Variables/relevant data Results Conclusions or final
(country) considerations

Fagbami et al., Cross 426 patients. 182 Clinical, virological, 8% reported HM. A wide spectrum of
1995 (Fiji)24 sectional (43%) CC (55% and epidemiological Among the children clinical manifestations
males and 45% investigations were and adults was observed during
females) performed hospitalized for the epidemic, ranging
dengue, 43% had from mild, non-
HM, including descript febrile illness
epistaxis, GB, to severe
haematemesis, melena haemorrhagic disease
and haematuria and shock
Vasconcelos Cross A total of 1341 serum Frequency of clinical GB, showed statistically The most referred oral
et al., 1998 sectional samples, 589 (44%) manifestations (signs significant differences sign was GB (3%)
(Brazil)35 were positive and 752 and symptoms) and
(56%) negative prevalence of DF
Ahmed et al., Prospective 72 children with DF/ Clinical manifestations, The clinical diagnosis A high prevalence of
2001 cohort DHF (8.4 + 3.0 years morbidity and of DF was made in 26 HM was found
(Bangladesh)1 old) mortality from DF/ children (36.0%);
DHF fever in DHF in 36 (50.0%),
Bangladesh and DSS in 10
children (14.0%).
Sixty-two (86%)
patients had forms of
BM. GB in 10 patients
Dıaz-Quijano Prospective 891 patients Clinical findings Associations were Under the study
et al., 2005 cohort (DF, 420; DHF, 471) found between DHF conditions, there was
(Colombia)29 and GB (OR, 1.55; an association
95% CI, 1.11–2.18; between early clinical
P < 0.01) findings and DHF
Malavige et al., Prospective 104 children Patterns of clinical Oral candidiasis (OC) Oral candidiasis had
2006 (Sri cohort disease in a cohort of was seen in 19 not been previously
Lanka)32 children hospitalized children documented in
with dengue children suffering
from acute dengue in
Sri Lanka or
elsewhere
Ramırez-Zepeda Cross 241 cases (207 DF Clinical and The results showed the The presence of ascites,
et al., 2009 sectional and 34 DHF), epidemiological presence of gingival gingival bleeding,
(Mexico)34 (34.7  15.1 characteristics present bleeding (OR, 7.35; haematemesis,
years old) in dengue patients 95% CI, 2.11–25.61) thrombocytopenia and
persistent vomiting
were confirmed as
warning signs of an
imminent dengue
attack
Bhaskar et al., Descriptive 128 patients with DHF Clinical manifestations GB, 81 (63.00%) Oral manifestations are
2010 (India)27 (33  15 years old) and associated important for dengue
comorbidities diagnosis
Kumar et al., Retrospective 466 patients. Majority Clinical manifestations, HM included petechiae Community awareness,
2010 (India)31 cohort were males, 301 trends and outcomes 84 (67.2%), early diagnosis and
(64.6%) of all confirmed ecchymosis 29 (6.2%), management, and
dengue cases gum bleeding 24 vector control
(5.2%), haematuria 23 measures need to be
(4.9%), melena 22 strengthened.
(4.7%), haematemesis
15 (3%), and epistaxis
12 (2.6%)
Sarkar et al., Clinical Young man Dengue with an Patient diagnosed with DHF leading to lingual
2011 (India)14 case unusual site of dengue through CST bleeding and resulting
report bleeding (tongue) intra-lingual
leading to airway haematoma, causing
obstruction significant upper
airway obstruction.

(continued)

406 © 2017 Australian Dental Association

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Oral manifestations related to dengue fever

Table 2 continued
Author/year Study type Sample Variables/relevant data Results Conclusions or final
(country) considerations

Azfar et al., Cross 300 patients with The spectrum of Mucosae were involved A variety of cutaneous
2012 sectional dengue cutaneous changes in in 40.66% patients. features were observed
(Pakistan)7 (2–80 years) DF patients Oral mucosa was the in patients of dengue
most frequently viral infection
involved (43.58%).
The major finding was
erythema of the
buccal mucosa and
palate
Mahboob et al., Prospective 60 patients, 48 CC Prevalence and type of Common Different patients
2012 cohort (5–68 years old) dermatological dermatological showed oral
(Pakistan)25 manifestations presentations were mucocutaneous
OMC congestion manifestations related
(66.67%) to DF
Sheikh et al., Cross 109 patients (3– Various types of Oral mucosa showed Cutaneous findings are
2012 sectional 78 years old) cutaneous diffuse erythema in 16 commonly seen in
(Pakistan)26 manifestations in a (14%) patients, patients of DF. It may
patient of DF candidiasis occurred in help in the early
only two (1.9%) and diagnosis of DF, while
oral aphthae presented the laboratory tests
in two (1.9%) patients are still awaited
Ahmed et al., Descriptive 640 adult patients, General and oral Among 159 DHF Knowledge and
2013 281 CC manifestations patients, 108 (67.9%) understanding of these
(Pakistan)2 had bleeding from findings are useful for
gums and oral cavity the management of
patients in outbreaks
of DHF
Byatnal et al., Clinical 50 year old patient Spontaneous and Patient diagnosed with It is important to
2013 (India)15 case profuse tongue and dengue through CST recognize the OM of
report palate bleeding thrombocytopenia
because the oral cavity
is a frequent site of
haemorrhage and may
be the only
manifestation of the
disease
Dubey et al., Clinical 62 year old hitherto Prolonged post- Patient diagnosed with Because haemorrhage is
2013 (India)17 case male patient extraction bleeding in dengue through CST the hallmark of this
report a patient suffering disease, it is
from DF imperative that dental
practitioners are made
aware of the
implications of
performing even
minor dental surgery
in a patient suffering
from DF/DHF
Khan et al., Clinical 20 year old patient Acute gingival bleeding Patient diagnosed with It is important to take
2013 (India)19 case (>24 h) dengue through CST a correct medical
report history along with
proper diagnosis in
episodes of acute GB
Mithra et al., Clinical Middle-aged patient Gingival bleeding and Patient diagnosed with This case report
2013 (India)23 case vesicles on lips and dengue through CST highlights the
report palate importance of oral
lesions in DHF
Bansal et al., Clinical 40 year old patient Acute gingival bleeding Patient diagnosed with Dengue may be
2014 (India)18 case (>3 days). dengue through CST considered as a
report differential diagnosis
to GB
Brito, 2014 Retrospective 997 patients Clinical characteristics GB were observed in The description of an
(Cuba)28 cohort with DHF of hospitalized adult 3.4% of the patients epidemic is crucial
patients diagnosed from a clinical and
with DHF epidemiological point
of view

(continued)

© 2017 Australian Dental Association 407

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MS Pedrosa et al.

Table 2 continued
Author/year Study type Sample Variables/relevant data Results Conclusions or final
(country) considerations

Pontes et al., Clinical 18 year old patient Gingival bleeding and Patient diagnosed with Dengue viral infection
2014 (Brazil)16 case vesicles on lips dengue through CST presents a broad range
report of alterations and
dental professionals
must be aware of
these alterations
Indurkar and Clinical 46 year old patient Osteonecrosis of the Patient diagnosed with The blood supply to
Sethi, 2015 case jaw associated with dengue through CST the maxillary jaw
(India)20 report DF and chronic could be impaired due
periodontitis to the DF leading to
the osteonecrosis
Al-Namnam Clinical 30 year old patient Maxillary Patient diagnosed with The exact cause of the
et al., 2016 case osteonecrosis, dengue through CST bone necrosis is still
(Yemen)21 report periodontitis with root not conclusive, but
resorption associated could be marrow
with DHF suppression and
intraosseous
haemorrhage leading
to bone infarction and
periodontal infection
Bhardwaj et al., Clinical case 19 year old male Blisters in mouth, Patient diagnosed with Differential diagnosis
2016 (India)22 report patient soreness on the gums, dengue through CST for DF should be
alveolar mucosa on considered
soft palate, and
difficulty in
swallowing
Fern
andez et al., Retrospective 548 patients, 390 CC Clinical, haematological In multivariable logistic The ability to
2016 cohort and demographical regression analysis, differentiate between
(Honduras)30 outcomes GB was associated dengue and other
with increased risk of conditions is of prime
dengue importance to
clinicians in dengue
endemic areas
Pone et al., 2016 Retrospective 145 children Clinical and laboratory History of GB in Bleeding, severe
(Brazil)33 cohort (2–11 years) signs physical examination haemorrhage,
were frequent in hemoconcentration
severe dengue disease and thrombocytopenia
(P < 0.01) did not reach
adequate diagnostic
accuracy

BM = bleeding manifestations; CC = confirmed cases of dengue; CI = confidence interval; COMD = cutaneous oral manifestations of dengue;
CST = clinical and serological tests; DF = dengue fever; DHF = dengue haemorrhagic fever; DSS = dengue shock syndrome; GB = gingival
bleeding; HM = haemorrhagic manifestations; OC = oral candidiasis; OM = oral manifestations; OMC = oral mucous membrane; OR = odds
ratio.

reports, whereas 60% (N = 15) of the studies were
either cohort (N = 8), cross sectional (N = 5) or
descriptive (N = 2).
In a chronological analysis, we identified only
nine studies published in a 16-year time frame with
sporadic intervals over the years: 1995 (N = 1),
1998 (N = 1), 2001 (N = 1), 2005 (N = 1), 2006
(N = 1), 2009 (N = 1), 2010 (N = 2) and 2011
(N = 1). Three and five studies were identified for
2012 and 2013, respectively, and three 2014 articles
were encountered. In 2015 and 2016, the number
of publications on oral manifestations of dengue
was one and four, respectively. These findings show
an increasing interest in oral manifestations of den-
gue over the years, but also the lack of studies and
the need for more evidence-based research in the
field.
408
A few studies, basically clinical case reports, addressed,
in a specific way, oral manifestations associated with or
related to DH such as lingual haematoma,14 thrombo-
cytopaenic disorders,15,16 post-extraction bleeding,17
gingival bleeding,18,19 osteonecrosis of the jaw20 and
dentoalveolar bone.21 Blisters in different areas of the
mouth and difficulty in swallowing were also
reported.22,23.
Other research studies addressed haemorrhagic
manifestations,24 dermatological (cutaneous or muco-
cutaneous) manifestations7,25,26 and clinical, laborato-
rial and epidemiological characteristics of DH.1,2,27–35
Oral manifestations related to DH
The search revealed a small number of studies in the
literature reporting oral manifestations of DH disease
© 2017 Australian Dental Association

Studies identified through electronic
database searching n = 750
PubMed n = 208
LILACS n = 135
Web of Science n = 162
Scopus n = 245
Duplicates removed n = 75
Unique studies n = 675
Studies excluded on title/abstract
screening n = 630
Studies for full-text screening n = 45
Studies excluded on full-text screening
n = 22
Review articles n = 7
Not available in full-text n = 6
Letter to editor n = 2
Panel for conference n = 2
Eligible Studies included from the
electronic database search n = 23
Did not address oral manifestation n = 5
Additional studies from other sources
n=2
Total included studies n = 25
Fig. 1 Flow diagram for the review of papers (adapted from Moher
et al., 2009). [Colour figure can be viewed at wileyonlinelibrary.com]
(research studies and clinical cases). Sample sizes
found in most studies were acceptable. Table 2 pre-
sents the main findings of all of the 25 selected arti-
cles that addressed DH and its related or associated
oral manifestations and included the following param-
eters: authorship, year of publication, country of pub-
lication, type of study, sample size (and age),
outcomes measured, relevant data and results, and
study considerations.
Oral manifestations are infrequently observed in cases
of classic DH being more commonly associated with
DHF, in which gingival bleeding erythema, lip crusts, and
vesicles on the lips and palate are the prominent oral char-
acteristics in dengue virus infection.2,7,15,16,18,19,22,25,27
Oral candidiasis,26,32 osteonecrosis of the dentoalveolar
structure20,21 and post-extraction bleeding17 were also
reported.
We observed in the clinical case reports raised in
this systematic literature review14–23 that several
patients presented poor oral hygiene and presence of
dental biofilm and calculus. In light of these published
reports,14–23 in which the main signs were bleeding of
the tongue, palate and gingiva, as well as vesicles on
the lips and palate, and the research studies,1,2,7,24–35
that showed that the occurrence of oral manifesta-
tions varies greatly among hospitalized patients, we
hypothesized that associated systemic diseases and/or
previous poor oral health may be a contributory fac-
tor to the presentation of the bleeding conditions
observed. In other words, among others, the occur-
rence of associated comorbidities and/or the presence
of dental biofilm or calculus on the tooth surfaces
could have led, synergistically, to the oral manifesta-
tion of DH in some of the reported cases.
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Oral manifestations related to dengue fever
Yet, although oral manifestations regarding DH are
not commonly reported in the scientific literature,
dengue viral infection presents a broad range of alter-
ations and dental professionals must be aware of
this.16 This systematic literature review highlights the
importance of oral lesions or presentations of DH to
clinicians of all fields, especially in dengue endemic
areas. Thus, a detailed description of oral changes in
the context of dengue infections is lacking in the
scientific literature, requiring future research with
appropriate methodologies focusing on the oral mani-
festations of DH.
Implications for practise
Given the high complexity of the nature of dengue
and failures in control strategies, there is a need to
find ways to reduce the morbidity and mortality
attributed to this condition,27 because its adequate
identification allows the prompt institution of treat-
ment and prevention of more severe complications.15
Dengue monitoring is still a challenge due mainly to
the late diagnosis of the disease and its eventual evo-
lution into an epidemic.25
The identification of oral manifestations of dengue
is a relevant and contributory factor in establishing
the early diagnosis of this pathology, because the
oral cavity is considered the gateway and the place
of manifestation of a wide variety of systemic dis-
eases. In this sense, we highlight the role of dental
professionals, especially general practitioners, in iden-
tifying these problems and guiding the patient
regarding the search for medical care, aiming at the
definitive diagnosis, as well as the effective treatment
of the disease.
Because haemorrhage is the hallmark of this dis-
ease, it is imperative that dental practitioners are
made aware of the implications of performing dental
procedures in a patient suffering from DF/DHF. The
importance of taking a good pretreatment history can-
not be overemphasized.17 It is important to take a
correct medical history along with proper diagnosis in
episodes of acute gingival bleeding as the dentist is
the first person who can actually diagnose and refer
these patients for proper management.19
Moreover, if a patient comes for dental care and
presents signs or symptoms of the disease, their care
should be delayed, or it is especially important to
not perform more invasive procedures due to the
risk of haemorrhagic complications. In addition,
medicines have to be carefully prescribed given the
nature of the disease. Patients suspected of dengue
are not recommended to use non-essential drugs,
especially anti-inflammatories, antibiotics and other
drugs that show renal, hepatic or haematological
toxicity.
409

MS Pedrosa et al.
Study limitations
This study has some limitations given that the litera-
ture presented a small number of scientific publica-
tions regarding the oral manifestations of DH.
Because the majority of the studies did not specifically
address this topic, it would have been impossible to
develop a comprehensive systematic review of the lit-
erature with only the original research articles found.
For this reason, we decided to include clinical case
reports, which definitely made it possible to define the
most accurate picture of the scientific production on
the oral manifestations of DH.
CONCLUSIONS
Because early diagnosis plays a fundamental role in
the treatment of diseases, oral manifestations, haem-
orrhagic or mucocutaneous, may represent a relevant
factor to the clinical evaluation of the patient with
signs and symptoms suggestive of DH.
We highlight the role of dental professionals, espe-
cially general practitioners, in identifying the oral mani-
festations of DH and guiding the patient regarding the
search for medical care, aiming at the definitive diagno-
sis, as well as the effective treatment of the case.
DISCLOSURE
The authors report no conflict of interest related to
the present authors and this research did not receive
any specific grant from funding agencies in the public,
commercial or not-for-profit sectors.
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