Protocol on comparative evaluation of the effect of application of 38% silver diamine fluoride on sealing ability of Biodentine and MTA Angelus as a perforation repair material: a confocal laser microscopic study

Saee Wazurkar; Dr. Aditya Singh patel

doi:10.12688/f1000research.133856.1

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Study Protocol

Protocol on comparative evaluation of the effect of application of 38% silver diamine fluoride on sealing ability of Biodentine and MTA Angelus as a perforation repair material: a confocal laser microscopic study

[version 1; peer review: 1 approved]

Saee Wazurkar ¹, Dr. Aditya Singh patel¹

PUBLISHED 19 Sep 2023

Author details Author details

¹ Sharad Pawar Dental College, Department of Conservative Dentistry and Endodontics, Datta Meghe Institute of Medical Science, Wardha, Maharashtra, 442001, India

Saee Wazurkar
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Dr. Aditya Singh patel
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

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This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

Background: Perforation can occur while performing root canal treatment. Biodentine has been made utilizing MTA (mineral trioxide aggregate) as a base, and claims to improve its properties in aspects such as physical property, durability, and handling, as well as its many other applications in restorative dentistry. The chemical components of SDF (silver diamine fluoride) have been suggested to have the following benefits: fluoride aids in remineralization and prevention, silver salts induce dentin sclerosis/calcification, and exhibit germicidal actions. It works by occluding dentinal tubules thus helping in preventing microleakage. This study aims to focus on the use of SDF on Biodentine and MTA as perforation repair material using a confocal microscope.
Methods: Mandibular molars will be selected for the study. The study will be divided into 4 groups: Group 1: Biodentine without application of 38% SDF; Group 2: Biodentine with the application of 38% SDF; Group 3: MTA Angelus without application of 38% SDF; and Group 4: MTA Angelus along with the application of 38% SDF. An artificial perforation 2 mm in diameter will be made directly in the middle of the pulpal floor. 38% silver diamine fluoride (FAMAGAIN) will be applied on the walls of the perforation according to the manufacturer’s instructions for the experimental groups (Groups 2 and 4). In the four groups, Biodentine will be applied in groups 1 and 2 and MTA will be applied in 3 and 4 (perforation repair material).
To evaluate the sealing capacity of perforation material in this study, we will use the average values of coronal dye leakage at the perforation site and Escobar’s criteria, which are used to assess the infiltration proportions.
Conclusions: It is expected that application of 38% of silver diamine fluoride on MTA Angelus and Biodentine may show better sealing ability than MTA Angelus and Biodentine alone.

Keywords

* MTA, Biodentine, perforation, silver diamine fluoride, sealing ability, Confocal laser microscope.

Corresponding author: Saee Wazurkar

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Wazurkar S and patel DAS. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Wazurkar S and patel DAS. Protocol on comparative evaluation of the effect of application of 38% silver diamine fluoride on sealing ability of Biodentine and MTA Angelus as a perforation repair material: a confocal laser microscopic study [version 1; peer review: 1 approved]. F1000Research 2023, 12:1171 (https://doi.org/10.12688/f1000research.133856.1) First published: 19 Sep 2023, 12:1171 (https://doi.org/10.12688/f1000research.133856.1) Latest published: 19 Sep 2023, 12:1171 (https://doi.org/10.12688/f1000research.133856.1)

Introduction

Root canal therapy is a dental procedure that helps to alleviate pain caused by a tooth that is diseased or abscessed. The inflamed pulp is removed during the root canal procedure. Procedural errors are often seen during the treatment, which will have an overall impact on the outcome of the tooth. Furcal perforation is one of the most unpleasant and frequent accidents that can occur during endodontic treatment.¹ The term “perforations” refers to “mechanical or pathological communication between the root canal system and the tooth surface”.² Iatrogenic factors, such as root canal treatment, or pathologic factors, such as carious lesions or resorption, can both cause root perforations.³ These root perforations hamper treatment responses and might develop into a bacterial invasion and lead to further endodontic periodontal diseases if not addressed properly.⁴

MTA (mineral trioxide aggregate) was introduced by Mahmoud Torabinejad in 1993, and was developed to treat perforations. The use of MTA can result in a complete seal between the root canal and the outer surface of the tooth.⁵ Biodentine is a new calcium silicate-based bioactive cement created to solve several limitations of white MTA, which is difficult to work with and requires a long curing period.⁶

Root perforation is thought to be an infinite pit in which repair material frequently escapes along the periodontal area. Some of the most important criteria for furcal perforation repair materials are their capacity to seal the surrounding tissues, their nontoxicity, and their ability to regulate the flow of material.⁷

Since 1840, silver compounds have been administered in dentistry. Silver inhibits the growth of bacteria, and fluoride aids in remineralization and prevention.⁸ Numerous in vitro studies have confirmed silver diamine fluoride’s (SDF) clinical efficacy in reducing tooth tissue solubility concerning chemical acid challenges and further aiding in enamel remineralization. SDF can also increase the microhardness of dentin.⁹

Sometimes, perforation can occur due to large carious lesions, and attempts to remove caries can lead to bigger and wider perforation will lead to a poor prognosis of the teeth.² MTA and Biodentine tend to show limited antimicrobial properties and are not efficient when directly placed on dentine. One of the studies, conducted by Jasim et al., evaluated the microleakage of composite resin and self-cure glass ionomer (GI) restorations in primary molars when the restorations were applied on the same day of SDF treatment. After 14 days, they concluded that there was a substantial decrease in microleakage after the use of SDF before restoration.⁹ Henceforth, there is a need for an antimicrobial and caries-inhibiting agent that will provide an alternative to enhance the efficacy of MTA and Biodentine as a root repair material.

Rationale

Biodentine and MTA have been used as root repair materials because of their ability to seal, being nontoxic and compatible with the surrounding tissue, and their ability to promote the regeneration of surrounding tissue. SDF can be used in addition to Biodentine and MTA as it is a widely used antibacterial compound. It has shown effectiveness in both hardening tooth structure and killing bacteria. Studies have been done to evaluate the microleakage of composites and GIC (glass inomer cement) in the application of SDF, and they have reported decreased microleakage after the application of SDF.⁹ As such, there is a need for research to evaluate the application of SDF in addition to Biodentine and MTA as a perforation repair technique.

Objectives

To assess the outcome and sealing ability of the application of Biodentine as a perforation repair material with the application of 38% SDF using dye penetration by a confocal laser microscope.

To assess the outcome and sealing ability of the application of Biodentine perforation repair material without the application of 38% SDF using dye penetration by a confocal laser microscope.

To assess the outcome and sealing ability of the application of MTA Angelus as a perforation repair material with the application of 38% SDF using dye penetration by a confocal laser microscope.

To assess the outcome and sealing ability of the application of MTA Angelus as a perforation repair material without the application of 38% SDF using dye penetration by a confocal laser microscope.

To compare the above parameters with each other.

Protocol

Ethical considerations

Written informed consent was taken from patients who underwent extraction regarding the use of extracted teeth in this study.

Ethical approval was received from Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha (reference DMIHER (DU)/IEC/2023/581) on 06/02/2023.

Trial design

This will be an in-vitro study with samples divided into four groups:

Group 1: Biodentine without application of 38% SDF.

Group 2: Biodentine with the application of 38% SDF.

Group 3: MTA Angelus without application of 38% SDF.

Group 4: MTA Angelus along with the application of 38% SDF.

The materials used in this study will be Biodentine™ (Septodont, Saint-Maur-des Fosses, France); MTA Angelus^® White (Angelus Lodrina, Parana Brazil); 38% silver diamine fluoride (Fagamin); Rhodamine B fluorescent dye; and a confocal laser microscope.

Inclusion criteria

Freshly extracted permanent mandibular molars with intact tooth structure.

Exclusion criteria

Teeth with caries and teeth with a fractured root will be excluded.

Procedure

Mandibular permanent molars will be selected in this study. Calculus and soft tissue tags will be removed by ultrasonic scaling, and the teeth will be kept in 0.5% chloramine T for 7 days then in normal saline until the next step. After access cavity preparation of each molar, the crown will be sectioned up to the roof of the pulp chamber, and the apical one-third of the roots will be sectioned using straight fissure carbide bur.The root canal orifices in each selected tooth and the terminus of sectioned roots will be sealed using sticky wax. An artificial perforation of 2 mm in diameter will be made directly in the middle of the pulpal floor using a 2 mm width round bur in a high-speed handpiece with water coolant. The area will be then flushed with water and dried with compressed air. 38% silver diamine fluoride (FAMAGAIN) will be applied on the walls of the perforation according to the manufacturer’s instructions for the experimental group. Over which the perforation repair material, that is MTA and Biodentine, will be applied both in control and experimental groups.

The teeth will be randomly divided into four groups:

Group 1: Biodentine without application of 38% SDF.

Group 2: Biodentine with the application of 38% SDF.

Group 3: MTA Angelus without application of 38% SDF.

Group 4: MTA Angelus along with the application of 38% SDF.

After 24 hours, the teeth will be covered with two layers of clear, air-dry nail varnish leaving 1–2 mm around the perforation site exposed. Then, all teeth will be immersed in 100% humidity at 37°C for 24 hours, followed by immersion in 0.6% aqueous rhodamine B dye for 48 hours. Then each tooth will be sectioned longitudinally in a buccolingual direction and crossing the perforation site with a diamond disc (0.3mm thickness) and a water-cooled handpiece, and the maximum apical extent of dye leakage at the interfacial surface between tooth structure and repair material will be measured using a confocal microscope at 10× magnification. To evaluate the sealing capacity of perforation material in this study, we will use the average values of coronal dye leakage at the perforation site and Escobar’s criteria⁴ which are “used to assess the infiltration proportions”:

0 – infiltration loss (dye penetration 0–<1.5 mm).

1 – simple infiltration (dye penetration 1.5–3 mm).

2 – medium infiltration (dye penetration > 3 mm).

Sample size

The target sample size will be calculated using mean difference.

n 1 = n 2 = 2 \frac{{(Z_{α} + Z_{β})}^{2} σ^{2}}{{(δ)}^{2}}

Z_{α} = 1.96

α = Type I error at 5% at both sides two tailed

Z_{β} = 1.28 (1 - β) = Power at 90%

σ = std. dev

• Primary variable: microleakage in millimetres
• Microleakage of MTA in mm = 1.24 ± 0.13 (as per reference article)
• Microleakage of MTA in mm = 0.88 ± 0.02 (as per reference article)
• Clinically relevant difference = 0.36
• Pooled std.dev = 0.25 (estimated)
• As per reference articles.
• N1 = 2 *[(1.96+ 1.28)²(0.25)²] / (0.36)² = 10
• Total samples required = 40
• Study reference: Ref. 7.

Statistical methods

All the data will be analysed using SPSS version 27 software. Data for outcome variables will be tested for normality using the Kalmogorov-Smirnov test. The comparative analysis of the micro tensile bond strength will be evaluated on the measurement of Newton. ANOVA will be used to find the significant difference between the mean of the four groups. Tukey’s test will be used for comparative evaluation of measurement in between two groups pairwise. P-value ≤ 0.05 will be considered as significant at 5% level of significance and 95% confidence of interval.

Discussion

Perforation is an unfortunate mishap that happens while performing root canal treatment. The size of the perforation, level, and position of the perforation, time of healing, and presence of periodontal or pulpal disorders are all factors that influence the result of perforated teeth.¹⁰ MTA is one of the most commonly used materials for furcal repair because of its ability to seal and its biocompatibility, bioactivity, and low solubility. Biodentine uses MTA as a base, and it claims to improve its properties in several aspects such as physical properties, durability, and handling, as well as its many other applications in restorative dentistry, such as endodontic treatment and pulp capping.¹¹ In vitro testing is an important tool for the initial screening of dental material as it gives data for further clinical evaluation. Fluoride aids in remineralization and inhibition of caries while silver salts induce dentin sclerosis/calcification and have germicidal properties. It works by occluding dentinal tubules thus helping in preventing microleakage.¹² This study aims to focus on the use of SDF on Biodentine and MTA as perforation repair material using a confocal microscope.

Conclusion

It is expected that application of 38% of silver diamine fluoride on MTA Angelus and Biodentine may show better sealing ability than MTA Angelus and Biodentine alone.

Dissemination

The study may provide information about the new protocol which provides a better sealing ability to get the best outcome for the perforation repair by the clinician.

After obtaining the results of the data, we will publish them in a scientific journal.

Study status

The study began on 1^st August 2023, and is currently at the sample preparation stage.

Data availability

No data are associated with this article.

Acknowledgements

I would like to thank my institute, my Guide, HOD and my colleagues.

References

1. ElDeeb ME, ElDeeb M, Tabibi A, et al.: An evaluation of the use of amalgam, Cavit, and calcium hydroxide in the repair of furcation perforations. J. Endod. 1982 Oct; 8(10): 459–466. PubMed Abstract | Publisher Full Text
2. Mohammed S, Ashley M, Darcey J: Root perforations: Aetiology, management strategies and outcomes. The hole truth. BDJ. 2016 Feb 26; 220: 171–180. Publisher Full Text
3. Kakani A, Chandrasekhar V: Sealing ability of three different root repair materials for furcation perforation repair: An in vitro study.2020 Oct 22.
4. Escobar C, Michanowicz AE, Czonstkowsky M, et al.: A comparative study between injectable low-temperature (70 degrees C) gutta-percha and silver amalgam as a retroseal. Oral Surg. Oral Med. Oral Pathol. 1986 May 1; 61(5): 504–507. PubMed Abstract | Publisher Full Text
5. Adiga S, Ataide I, Fernandes M, et al.: Nonsurgical approach for strip perforation repair using mineral trioxide aggregate. J. Conserv. Dent. 2010 Apr; 13(2): 97–101. PubMed Abstract | Publisher Full Text | Free Full Text
6. Dammaschke T: A new bioactive cement for direct pulp capping.2(2).
7. Mohan D, Singh AK, Kuriakose F, et al.: Evaluation of Sealing Potential of Different Repair Materials in Furcation Perforations Using Dye Penetration: An In Vitro Study. J. Contemp. Dent. Pract. 2021 Jan 1; 22(1): 80–83. PubMed Abstract
8. Delbem ACB, Bergamaschi M, Sassaki KT, et al.: EFFECT OF FLUORIDATED VARNISH AND SILVER DIAMINE FLUORIDE SOLUTION ON ENAMEL DEMINERALIZATION: pH-CYCLING STUDY. J. Appl. Oral Sci. 2006 Apr; 14(2): 88–92. PubMed Abstract | Publisher Full Text | Free Full Text
9. Jasim MZ, Khalaf MS: Comparison of Microleakage of Composite and Glass Ionomer Restorations in Primary Molars Pretreated with Silver Diamine Fluoride at Two Time Intervals: An in vitro study. Dent. Hypotheses. 2022 Oct 1; 13(4): 145. Publisher Full Text
10. Comparative Evaluation of Sealing Ability of Three Materials Used in Furcal Perforation Repair (In Vitro).[cited 2023 Jan 24]. Reference Source
11. Farea M, Husein A, Pameijer CH: Furcation perforation: current approaches and future perspectives.
12. Mei ML, Lo ECM, Chu CH: Clinical Use of Silver Diamine Fluoride in Dental Treatment. Compend. Contin. Educ. Dent. Jamesburg NJ 1995. 2016 Feb; 37(2): 93–98. quiz100.

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Version 1

VERSION 1 PUBLISHED 19 Sep 2023

Author details Author details

¹ Sharad Pawar Dental College, Department of Conservative Dentistry and Endodontics, Datta Meghe Institute of Medical Science, Wardha, Maharashtra, 442001, India

Saee Wazurkar
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Dr. Aditya Singh patel
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 19 Sep 2023, 12:1171

https://doi.org/10.12688/f1000research.133856.1

Copyright

© 2023 Wazurkar S and patel DAS. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Wazurkar S and patel DAS. Protocol on comparative evaluation of the effect of application of 38% silver diamine fluoride on sealing ability of Biodentine and MTA Angelus as a perforation repair material: a confocal laser microscopic study [version 1; peer review: 1 approved]. F1000Research 2023, 12:1171 (https://doi.org/10.12688/f1000research.133856.1)

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PUBLISHED 19 Sep 2023

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Reviewer Report 25 Apr 2024

Srinidhi Surya Raghavendra, Conservative Dentistry & Endod, Dr D Y Patil Vidyapeeth University (Ringgold ID: 121766), Pune, Maharashtra, India

Approved

https://doi.org/10.5256/f1000research.146871.r267845

Abstract: has been written in a structured manner giving the background and the method. Key words have been mentioned.
Introduction: Etiology of perforations, MTA have been explained well. One point which can be added is an enumeration of the ... Continue reading

Abstract: has been written in a structured manner giving the background and the method. Key words have been mentioned.
Introduction: Etiology of perforations, MTA have been explained well. One point which can be added is an enumeration of the various materials used to seal perforations, apart from MTA and Biodentine. You have to write the formulation available for SDF.
Rationale: Have been mentioned
Objectives: clearly written
Protocol: Groups have been defined. You have to mention the country of origin of Famagain.
Statistical tests have been mentioned and the sample size determination has been explained.
Estimation of the seal of the materials to the tooth structure will be measured with the CLSM.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Endodontic microbiology, sealing ability of perforation repair materials, outcomes of endodontic treatment

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Version 1 19 Sep 23	read

Srinidhi Surya Raghavendra, Dr D Y Patil Vidyapeeth University (Ringgold ID: 121766), Pune, India

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Reviewer Report

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25 Apr 2024 | for Version 1

Srinidhi Surya Raghavendra, Conservative Dentistry & Endod, Dr D Y Patil Vidyapeeth University (Ringgold ID: 121766), Pune, Maharashtra, India

8 Views Cite this report Responses(0)

Approved

Abstract: has been written in a structured manner giving the background and the method. Key words have been mentioned.
Introduction: Etiology of perforations, MTA have been explained well. One point which can be added is an enumeration of the various materials used to seal perforations, apart from MTA and Biodentine. You have to write the formulation available for SDF.
Rationale: Have been mentioned
Objectives: clearly written
Protocol: Groups have been defined. You have to mention the country of origin of Famagain.
Statistical tests have been mentioned and the sample size determination has been explained.
Estimation of the seal of the materials to the tooth structure will be measured with the CLSM.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Endodontic microbiology, sealing ability of perforation repair materials, outcomes of endodontic treatment

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

[1] 1. ElDeeb ME, ElDeeb M, Tabibi A, et al.: An evaluation of the use of amalgam, Cavit, and calcium hydroxide in the repair of furcation perforations. J. Endod. 1982 Oct; 8(10): 459–466. PubMed Abstract | Publisher Full Text

[2] 2. Mohammed S, Ashley M, Darcey J: Root perforations: Aetiology, management strategies and outcomes. The hole truth. BDJ. 2016 Feb 26; 220: 171–180. Publisher Full Text

[3] 3. Kakani A, Chandrasekhar V: Sealing ability of three different root repair materials for furcation perforation repair: An in vitro study.2020 Oct 22.

[4] 4. Escobar C, Michanowicz AE, Czonstkowsky M, et al.: A comparative study between injectable low-temperature (70 degrees C) gutta-percha and silver amalgam as a retroseal. Oral Surg. Oral Med. Oral Pathol. 1986 May 1; 61(5): 504–507. PubMed Abstract | Publisher Full Text

[5] 5. Adiga S, Ataide I, Fernandes M, et al.: Nonsurgical approach for strip perforation repair using mineral trioxide aggregate. J. Conserv. Dent. 2010 Apr; 13(2): 97–101. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Dammaschke T: A new bioactive cement for direct pulp capping.2(2).

[7] 7. Mohan D, Singh AK, Kuriakose F, et al.: Evaluation of Sealing Potential of Different Repair Materials in Furcation Perforations Using Dye Penetration: An In Vitro Study. J. Contemp. Dent. Pract. 2021 Jan 1; 22(1): 80–83. PubMed Abstract

[8] 8. Delbem ACB, Bergamaschi M, Sassaki KT, et al.: EFFECT OF FLUORIDATED VARNISH AND SILVER DIAMINE FLUORIDE SOLUTION ON ENAMEL DEMINERALIZATION: pH-CYCLING STUDY. J. Appl. Oral Sci. 2006 Apr; 14(2): 88–92. PubMed Abstract | Publisher Full Text | Free Full Text

[9] 9. Jasim MZ, Khalaf MS: Comparison of Microleakage of Composite and Glass Ionomer Restorations in Primary Molars Pretreated with Silver Diamine Fluoride at Two Time Intervals: An in vitro study. Dent. Hypotheses. 2022 Oct 1; 13(4): 145. Publisher Full Text

[10] 10. Comparative Evaluation of Sealing Ability of Three Materials Used in Furcal Perforation Repair (In Vitro).[cited 2023 Jan 24]. Reference Source

[11] 11. Farea M, Husein A, Pameijer CH: Furcation perforation: current approaches and future perspectives.

[12] 12. Mei ML, Lo ECM, Chu CH: Clinical Use of Silver Diamine Fluoride in Dental Treatment. Compend. Contin. Educ. Dent. Jamesburg NJ 1995. 2016 Feb; 37(2): 93–98. quiz100.

Protocol on comparative evaluation of the effect of application of 38% silver diamine fluoride on sealing ability of Biodentine and MTA Angelus as a perforation repair material: a confocal laser microscopic study

Abstract

Keywords

Introduction

Rationale

Objectives

Protocol

Ethical considerations

Trial design

Inclusion criteria

Exclusion criteria

Procedure

Sample size

Statistical methods

Discussion

Conclusion

Dissemination

Study status

Data availability

Acknowledgements

References

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Open Peer Review

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