|Year : 2021 | Volume
| Issue : 1 | Page : 1-9
Clinical and microbiological evaluation of calcium silicate versus calcium hydroxide in two-step indirect pulp treatment: A randomized clinical trial
Ehsan Hossam El-Din Bayoumy1, Mohsen Hussien Abi Elhassan2, Ahmed Abdel Fattah Al-Zohairy2, Basma Ahmed Al-Awady3
1 Department of Conservative Dentistry, Faculty of Oral and Dental Medicine, Ahram Canadian University, 6th of October City, Egypt
2 Department of Conservative Dentistry, Faculty of Dentistry, Cairo University, Cairo, Egypt
3 Department of Microbiology and Immunology, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Submission||01-Feb-2020|
|Date of Decision||29-Jun-2020|
|Date of Acceptance||01-Aug-2020|
|Date of Web Publication||28-Jan-2021|
Dr. Ehsan Hossam El-Din Bayoumy
154 c Opera City , El Sheikh Zayed, 6 October City, Giza 41516.
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the clinical and microbiological performances of calcium silicate in comparison to calcium hydroxide in patients with deep carious lesions using two-step indirect pulp capping in 12 months follow-up. Materials and Methods: Fifty teeth with deep carious lesions received randomly either TheraCal (resin-modified calcium silicate pulp capping material) or Dycal (calcium hydroxide pulp capping material), application of both materials was done in accordance with the manufacturers’ instructions after the excavation of caries on the cavity walls and taking the caries sample from the central carious lesion for microbiological study then the cavities were sealed with conventional glass ionomer cement as a temporary restoration. After 6 months, pain assessment was performed, the cavities were reopened, temporary restorations and pulp capping material were removed, and another dentin sample was taken for microbiological study. In the same visit, caries was excavated to firm dentin and permanent resin composite restorations were applied. Then the patients were recalled after 6 months for pain assessment by a blinded assessor by the use of the visual analog scale system. Results: Pain score results showed a statistically significant difference between the two groups at 6 months and 12 months. Regarding bacterial reduction, there was a statistically significant difference between the two groups in all viable microorganisms except for lactobacilli and mutant streptococci. Conclusions: Resin-modified calcium silicate and calcium hydroxide can both be considered as effective pulp capping materials through relieving pain and possessing antibacterial properties.
Keywords: Calcium Hydroxide, Calcium Silicate, Indirect Pulp Treatment
|How to cite this article:|
Bayoumy EH, Abi Elhassan MH, Al-Zohairy AA, Al-Awady BA. Clinical and microbiological evaluation of calcium silicate versus calcium hydroxide in two-step indirect pulp treatment: A randomized clinical trial. J Int Oral Health 2021;13:1-9
|How to cite this URL:|
Bayoumy EH, Abi Elhassan MH, Al-Zohairy AA, Al-Awady BA. Clinical and microbiological evaluation of calcium silicate versus calcium hydroxide in two-step indirect pulp treatment: A randomized clinical trial. J Int Oral Health [serial online] 2021 [cited 2021 May 14];13:1-9. Available from: https://www.jioh.org/text.asp?2021/13/1/1/308367
| Introduction|| |
Preserving the pulp vitality is the main concern during the treatment of deep carious lesions. The stepwise caries excavation technique is one of the techniques that had been advocated to avoid pulp exposures. In this method, removal of the caries at the peripheries was done completely, whereas remnant caries above the pulp was untouched and preserved within the tooth, following a couple of months cavities were re-entered. It was reported that this method will help in remineralizing the carious dentine and reduces the number of viable organisms is significantly.,
Various pulp capping materials with bacteriostatic, bactericidal, or remineralizing properties were used. Calcium hydroxide (CaOH2) is considered a gold standard material in pulp capping usage. A drawback of the traditional calcium hydroxide is the high solubility that leads to the formation of tunnel defects due to the dissolution of the CaOH2 underneath the restoration covering it, affecting the seal against bacterial invasion., Irritation, dystrophic calcification, and potential degenerative changes are induced inside the pulp due to these occurrences.,,,
Calcium silicate is a contemporary capping material that induces dentin bridge formation, and it is available in two forms either chemically or light cured. The light-cured form offers an easier and controlled application. TheraCal is considered one of the latest light-cured resin-modified calcium silicate-filled material used in direct and indirect pulp capping which has good sealing capabilities and able to alkalinize the surrounding fluid primarily to approximately pH 10–11 (3 h–3 days), followed by a pH 8–8.5 (7–28 days). Photo-polymerized resin addition is used to control the setting time. TheraCal doubts the validity of this material, especially in the indirectly exposed pulp. Therefore, this study was conducted to evaluate the clinical and antibacterial effect of this material in comparison to calcium hydroxide in deep carious lesions.
| Materials and Methods|| |
This randomized controlled clinical study was conducted in the Faculty of Dentistry, Cairo University, Egypt. The protocol of this study was registered in www.clinicaltrials.gov/ database, with unique identification number NCT03032978. All procedures performed in this study, involving human participants, were in accordance with the ethical standards of the Research Ethics Committee of Faculty of Dentistry, Cairo University (CREC; Ref. 17/02/03).
Sample size calculation
According to the study of Sultana et al., the effectiveness rate (resolution of pain) among conventional methods (CaOH2) is 76% on 1-year follow-up. If the expected number of patients showing postoperative pain is 20% less in the TheraCal group on 1-year follow-up, then we have to evaluate 20 patients in each group as a mean of rejection to the null hypothesis that the success rates for experimental and control subjects are equal with probability (power) 0.8. The type I error probability associated with this test of this null hypothesis is 0.05. An uncorrected chi-square statistic was used to evaluate the null hypothesis. This number was increased to 25 in each group to compensate for probable losses during follow-up. The sample was calculated using the PS program.
The pulp capping materials are as follows:
- Calcium hydroxide “Dycal” (Comparator)
- Resin-modified calcium silicate “TheraCal” (Intervention).
- Temporary restorative material: conventional glass ionomer restorative material [GC Fuji IX].
- Adhesive system (3M ESPE) including single bond universal adhesive and scotch bond universal etchant. 34% phosphoric acid
- Resin composite material “Filtek™ Z250 universal restorative” (3M ESPE) [Table 1].
|Table 1: Material’s specification, composition, manufacturer, and lot number|
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Patients recruitment and caries risk assessment
Patients were recruited from the outpatient clinic of the conservative dentistry department in the Faculty of Dentistry, Cairo University. Selection and examination of all patients were done according to the inclusion and exclusion criteria. Eligible patients were recruited. The patients who agreed to participate in this study signed an informed consent. Caries risk assessment was done using the Cariogram. Only patients with good oral hygiene and a high percentage to avoid the development of new cavities during the follow-up period of the study were enrolled. The inclusion and exclusion criteria of teeth were given in [Table 2].
Allocation, sequence generation, and blinding
Randomization was assigned for participants by generating numbers from 1:50 using Random Integer Set Generator, Randomness and Integrity Service Ltd (http://www.random.org/). The patients and assessors were blinded to the material assignment while the operator was not due to a difference in restorative material presentation.
Grouping of samples
A total of 50 teeth of patients who fulfilled the inclusion criteria were selected. Teeth were divided into two groups, 25 teeth in each according to the lining material tested: control group (Dycal) and intervention group (TheraCal). The study took place over a period of 12 months (T). Postoperative pain was tested in this period at the baseline (T0), after 6 months (T6), and after 12 months (T12). Bacterial count was tested at the baseline (T0) and after 6 months (T6).
Preoperative clinical assessment
Cold pulp testing was carried out for confirmation of pulp vitality using a refrigerant spray (Endo Frost, Roeko, Coltène/Whaledent, Germany). Percussion test, palpation, and clinical examination for the signs of inflammation (pain, abscess, sinus tract, and mobility) were noted. Periapical radiographs using digital radiograph was taken at baseline (T0) and assessment was done to eliminate all indications of widening of periodontal ligament or periapical lesions.
Pain assessment was done using a visual analog scale (VAS) system. With reference to this method, VAS of 10cm in length line, horizontally plotted using points labeled 0–10 to describe the pain, no pain (0), mild pain (1–3), moderate pain (4–6), and severe pain (7–10). During data collection, sheet pain was recorded as no pain (0), mild pain (1), moderate pain (2), and severe pain (3).
Quadrant isolation using a rubber dam was performed for all the teeth involved in this study (Sanctuary, Dental Dam, Perak, Malaysia).
Access through the cavitated enamel and outline form were obtained with a sterile high-speed bur (#245 bur; Meisinger GmbH, Germany) or pear-shaped diamond point (809RG, size #012; Meisinger GmbH, Germany) using a high-speed handpiece (PanaAir®, NSK, Japan) with profuse water spray.
A sample of soft infected carious dentin was taken from the center of the carious lesion by a sterilized excavator. The samples were cultivated within 2 h for microbiological study to lactobacilli, Streptococcus mutans, and total viable microorganism.
Samples were placed in a tube shaker for 30s to disperse aggregates of bacteria and decimal dilutions were then prepared in sterile saline (0.9% NaCl). Then 0.1 ml aliquots from every dilution were spread on the following solid media: brain heart infusion agar for total viable microorganism count, Rogosa agar (Lactobacillus MRS agar; HiMedia) for Lactobacillus spp. count, and Mitis Salivarius agar (MSA; HiMedia) supplemented with 20% sucrose, 0.2 units/ml bacitracin (MSB), and 1% potassium tellurite for Streptococcus mutans count; all samples were incubated for 48 h.
After incubation, microbial counts were performed visually. The quantity of the colonies was determined and expressed as colony-forming units (CFUs). The CFUs were estimated by multiplying the number of colonies by the reciprocal of dilution at which the colony count was estimated, and the reciprocal of the volume utilized for inoculation, expressed as a fraction of 1 ml: Count = No. of colonies × reciprocal of dilution × 0.01 ml.
Caries removal procedure
Following the guidelines published by the International Caries Consensus Collaboration, total caries removal to hard dentine strategy was used for the peripheral walls of the cavity with the use of a sharp sterile spoon double-ended excavator (No. 51–52, Dentsply® Maillefer, Switzerland). Selective caries removal to soft dentine strategy was followed using the hardness criteria [Table 3].
The dentino-enamel junction, cavo-surface margins, and gingival seats (for proximal lesions) were inspected carefully and ensured to be clean, with at least 1.5–2 mm rim of peripheral sound tooth structure to provide a rigid marginal adhesion with the restoration. In the pulpal floor/axial wall, soft dentine was not removed to prevent pulpal exposure.
TheraCal LC was applied directly to the prepared cavity in 1 mm incremental layers. Each increment was light-cured for 20s. Then the cavity was temporarily sealed with chemically cured glass ionomer (Fuji IX GP FAST). After 3 min, the restoration was contoured and finished by a high-speed handpiece and water coolant using a yellow-coded diamond flame (No. 833C FG, size #014 and #016; Meisinger GmbH, Germany) and fine tapered diamond with a round end (805C FG, #012; Meisinger GmbH, Germany). Participants were re-scheduled for the next visit after 3 months (T3) to check the integrity of the intermediate restoration to avoid any leakage that may affect the study results and another visit after 6 months (T6) for reentry of the cavity.
Calcium hydroxide (Dycal) was applied on the cavity dentin with a material thickness of approximately 0.8–1 mm using a calcium hydroxide applicator. Dycal was left to completely set within 2 min. After a complete setting, any excess material was removed using a sharp spoon excavator or a bur. Then, the cavity was temporarily sealed with conventional glass ionomer (Fuji IX GP FAST) same as in case of intervention.
Reentry and stepwise excavation
Patients who showed symptoms of irreversible pulpitis, pulp necrosis, or periapical pathosis were recorded as failure and were not allocated into one of the study arms. After excluding failures and dropouts (n = 9), 41 teeth were allocated into one of the two study groups: Dycal group (n = 21) and TheraCal group (n = 20).
VAS scores were recorded prior to the start of the process. After local anesthetic was administered, isolation was achieved using rubber dam as previously mentioned. The glass ionomer restoration (GIC) and capping material were totally removed using the same tools used in the first visit. And another dentine sample was taken for microbiological study as previously mentioned. The reproducibility of CFU per milligram of dentine was evaluated by comparison of the total microorganism count before and after the application of pulp capping materials.
Stepwise excavation for hardened dentine layer and residual carious lesion was assessed for hardness and removal of the residual carious tissue was performed using a sharp excavator. The excavation endpoint was the detection of firm dentine at the pulpal floor/axial wall using a sharp dental explorer.
When a pulp exposure occurred during the excavation process, the exposure and surrounding area were rinsed with water to remove debris. A cotton pellet moistened with 5.25% sodium hypochlorite was placed over the exposure for 1–2 min to control hemorrhage and to disinfect the area. The cotton pellet was removed and hemostasis was established. Calcium hydroxide (Dycal; Dentsply, Germany) was applied as mentioned before. This was followed by restoring the cavity using highly viscous glass ionomer restorative material by the same protocol mentioned earlier. The procedure was explained to the patient and was rescheduled for a follow-up visit after 6 months.
Bonding protocol and resin composite application
Selective etching of enamel was performed using 35% phosphoric acid gel. A single layer of universal adhesive (Single Bond Universal) was added and cured following the manufacturer’s instructions. Filtek™ Z250 Universal Restorative (3M ESPE) composite was applied and then curing was done for 40s using an LED light-curing unit. Occlusion was checked and polishing has been performed by one-step polishing tips and/or cups (Dimanto, VOCO GmbH, Germany) operated at low-speed contra-angle handpiece (NAC-EC, NSK, Japan) with water coolant and minimal pressure.
Patients were recalled for follow-up after 6 months (T12; a total of 12 months from the first visit T0). Pain assessment was done in accordance with the VAS system.
Data collection methods
Baseline data collection
Medical and dental history was taken. Examination charts were filled.
Outcome data collection
- Primary outcome: VAS was evaluated by the first assessor at baseline, after 6 months and 12 months.
- Secondary outcome: bacterial count before and after indirect pulp treatment by microbiological analysis was done by the second assessor at baseline, after 6 months.
The mean and standard deviation values were calculated for each group in each test. Viable counts of antibacterial activity were transformed to their log10 values. Data were explored for normality using Kolmogorov–Smirnov and Shapiro–Wilk tests. Pain data showed nonparametric distribution while antibacterial activity showed parametric distribution. For nonparametric data, Mann–Whitney test was used to compare between two groups in nonrelated samples. Friedman test was used to compare between more than two groups in related samples. Wilcoxon test was used to compare between two groups in related samples. For parametric data, Independent sample t-test was used to compare between two groups in nonrelated samples. A paired sample t-test was used to compare between two groups in related samples. The significance level was set at P ≤ 0.05. Statistical analysis was performed with IBM® SPSS® Statistics Version 20 for Windows.
| Results|| |
Effect of capping material on postoperative pain score
VAS concerning the postoperative pain score was presented in the form of mean and standard deviation in [Figure 1]A and [B], revealed that both groups showed a statistically significant difference between T0, T6, and T12 groups where P < 0.001. Comparison between both groups showed a statistically significant difference between the two groups at 6 months (T6) and at 12 months (T12) where P = 0.025 and P = 0.038, respectively.
|Figure 1: Bar chart representing pain score (A) for different groups and (B) at different time periods. T0 = immediate, T6 = after 6 months, T12 = after 12 months|
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Effect of capping material on postoperative pain frequency
Statistical analysis for VAS concerning the postoperative pain frequency was presented in [Figure 1]. It revealed that both groups had a statistically significant difference between T0, T6, and T12 groups.
Comparison of postoperative pain frequency between both groups at different time intervals [Figure 2] showed that: at T6 and T12, there was a statistically significant difference between the two groups.
|Figure 2: Bar chart representing postoperative pain frequency for different groups. T0 = immediate, T6 = after 6 months, T12 = after 12 months|
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The antibacterial effect of capping material on total viable microorganisms [Figure 3]A and [B] revealed that there was a statistically significant difference between T0 and T6 groups where P < 0.001 in both TheraCal and Dycal groups. Regarding bacterial reduction that was presented in [Figure 4], there was a statistically significant difference between TheraCal and Dycal groups where P = 0.005.
|Figure 3: Bar chart representing (A) total antibacterial activity within each group and (B) bacterial count in both groups. T0 = immediate, T6 = after 6 months|
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|Figure 4: Bar chart representing a total bacterial reduction in different groups|
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The anti-bacterial effect of capping material on Lactobacilli (LB) was presented in the form of mean and standard deviation in [Figure 5]A and B revealed that there was a statistically significant difference between (T0) and (T6) groups where (P < 0.001) in both Theracal and Dycal groups. Regarding bacterial reduction that was presented in [Figure 6] there was no statistically significant difference between (Theracal) and (Dycal) groups where (P = 0.803).
|Figure 5: Bar chart representing (A) antibacterial activity (LB) within each group (B) LB count in both groups. T0 = immediate, T6 = after 6 months, LB = Lactobacillus|
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|Figure 6: Bar chart representing bacterial reduction (LB) in different groups. LB = Lactobacillus|
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The anti-bacterial effect of capping material on Streptococci mutans (SM) was presented in the form of mean and standard deviation in [Figure 7]A and B revealed that there was a statistically significant difference between (T0) and (T6) groups where (P < 0.001) in both Theracal and Dycal groups. Regarding bacterial reduction that was presented in [Figure 8] there was no statistically significant difference between (Theracal) and (Dycal) groups where (P = 0.488).
|Figure 7: Bar chart representing (A) antibacterial activity (SM) count in both groups and (B) SM within each group. T0 = immediate, T6 = after 6 months, SM = Streptococcus mutans|
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|Figure 8: Bar chart representing SM bacterial reduction in different groups. SM = Streptococcus mutans|
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| Discussion|| |
Indirect pulp capping, where the cavity preparation is in close proximity to the pulp but with no visible exposure, one and two-stage protocols were chosen. In the two-stage or stepwise caries removal methods, the whole carious dentin was detached from the walls and dentino-enamel junction of the cavity preparation. A layer of deep carious dentin, typically discolored though firm, could be left on the prepared floor, in case if its removal might cause a pulp exposure. Usually, a liner such as calcium hydroxide is then placed and covered by a temporary restoration such as glass ionomer which has vital importance in this technique to attain a well-sealed temporary restoration that lasts several months isolating all caries and bacteria left behind from the oral environment.
According to a systematic review conducted by Hoefler et al., there were fewer pulpal complications over a 3-year period when permanent teeth with deep dentin caries were treated with partial caries removal instead of stepwise excavation which increases the possibility of pulp exposure compared to single appointment partial caries removal that was stated by Ritter et al. and Orhan et al., Additionally, stepwise excavations accompanied with increased costs, more probability of patient distress and probability that the patient fails to finish the last step of treatment due to inadequate finances or hardly accessing care. Partial caries removal resulted in greater success of maintaining pulp vitality compared with stepwise excavation and nonselective removal. Secondary results, such as microbiological evaluation, restoration quality, and dentin deposition, showed similar results among treatments.
TheraCal LC is a light-cured resin-modified calcium silicate formulated to be used as a liner for both direct and indirect pulp capping procedures. The mechanism for the mineralization effect of TheraCal is still unclear. TheraCal is a resin-modified and calcium silicate filled material. It contains polymerizable methacrylate monomers, Portland cement, polyethylene glycol dimethacrylate, and barium zirconate. In addition, it has been shown to release significantly more calcium than MTA and Dycal. Once the resin components of resin-modified calcium silicate are light-polymerized, the MTA is essentially trapped in the polymer matrix so the presence of the resin matrix enhances both the setting method and ion leaching abilities and characteristics of the MTA in resin-modified calcium silicate. Water is essential during the hydraulic setting reactions and ion emitting property of MTA within resin-modified calcium silicate. So, “visibly moist” dentin as a water source is needed to assist in the initial setting reaction of the MTA.
Resin-modified calcium silicate has demonstrated the ability to form apatite when immersed in a model of phosphate-containing body fluid and has also been shown to induce odontoblastic differentiation and mineralization., Two in vivo studies have shown that resin-modified calcium silicate has the potential to induce reparative dentin (and dentin bridge formation) when used in the direct and indirect pulp capping procedures., Regarding the antibacterial activity of resin-modified calcium silicate, an in vitro study showed that MTA-based products as resin-modified calcium silicate show a distinct antibacterial activity varying from calcium hydroxide-based materials which showed increased antibacterial activity. MTA’s highly alkaline pH of 12.5 affords antimicrobial activity even in an aerobic situation.
In the current study regarding the assessment of pain at 12 months following the completion of the treatment showed that there was no pain in 17 of 21 (81%) of calcium hydroxide and 21 of 21 (100%) of resin-modified calcium silicate treated teeth, with a statistically significant difference between the two groups, indicating that resin-modified calcium silicate was more effective in reducing pain than that of calcium hydroxide as indirect pulp capping agent. The reason for mild pain occurred following treatment with either calcium hydroxide or resin-modified calcium silicate group was not clearly understood from the present study. It might be possible that the pulp in these teeth was already inflamed before treatment and initial postoperative pain was likely to be a sign of exacerbation of this inflammation.
Although patients were selected without any sign of pulp inflammation, the disadvantage of the pain assessment is that it is subjective and depends on the pain threshold of every patient. These results may be due to the properties of hydrophilic resin when formulated creates a stable and durable liner. In addition, the alkaline pH and calcium availability maintain its biocompatibility and antibacterial qualities.
According to the results obtained from the current study regarding the antibacterial activity of indirect pulp capping materials after 6 months, a significant reduction of aciduric bacteria (S. mutans and Lactobacillus) was observed in both groups after indirect pulp capping. This finding suggested that there was an absence of carious activity, and the restored environment was less acidic as compared to the carious tissue environment. These findings are in agreement with the studies done by Lula et al. and Singhal et al., The reduction in microbial count could be due to restriction of exogenous nutrient supply by isolating the caries process from the oral cavity or due to the cavity capping with calcium hydroxide or calcium silicate which has bactericidal and bacteriostatic properties and drastically reduce the presence of cariogenic bacteria.
Regarding the comparison between the two capping materials, it showed no significant difference between the two groups. Thus, it does not seem that the results found in this study were influenced by the pulp capping material, but the sealing property itself. This finding was supported with a randomized clinical trial conducted by Corralo and Maltz and systematic review/meta-analysis conducted by Schwendicke et al. who concluded that there is insufficient evidence to recommend cavity lining or the use of any specific liner based on their antibacterial properties. Also, our results are in agreement with that of Gurcan and Seymen who clinically evaluated resin-modified calcium silicate in indirect capping techniques and found no significant difference compared with calcium hydroxide or glass ionomer cements in a 2-year follow-up period.
An in vitro study stated that resin-modified calcium silicate displayed higher calcium releasing ability and lower solubility than calcium hydroxide and the capability of resin-modified calcium silicate to be cured to a depth of 1.7 mm may avoid the risk of untimely dissolution so these properties offer major advantages in pulp capping treatments.,
These results support the idea that the success of indirect pulp capping is unrelated to the capping material. The most important factors are the application of the indirect pulp treatment carefully, avoiding bacterial contamination, and sealing teeth with hermetic restoration. More clinical studies with longer follow-up periods are required for understanding the clinical efficiency of these materials.
Resin-modified calcium silicate and calcium hydroxide presented clinically effective pulp capping materials through relieving pain and possessing antibacterial properties.
The major limitation of the study was the patient’s commitment to the treatment process, which is a problem of the clinical trials. To the best of my knowledge, clinical trials with a large sample size will be beneficial.
First, grace and foremost thanks to Allah for blessing this work. My grateful thanks and deepest appreciations to Prof Dr. Mohsen Hussein Abi Elhassan, Prof Dr. Ahmed Abd El-Fattah Al-Zohairy, and Dr. Basma Ahmed Al Awady for their meticulous supervision. Special thanks to all the staff members of Conservative Dentistry Department, Faculty of Oral and Dental Medicine, Cairo University and Ahram Canadian University for their support.
Financial support and sponsorship
This study was self-funded by the authors.
Conflict of interest
There are no conflicts of interest.
Data collection was done by Ehsan Hossam and Ahmed El Zohairy, data acquisition and analysis were done by Ehsan Hossam and Basma El Awaddy, data interpretation by Mohsen Abi Elhasssan, and finally the manuscript was written by Ehsan Hossam.
Ethical policy and institutional review board statement
This randomized controlled clinical study was held in the Faculty of Dentistry, Cairo University, Egypt. The protocol of the current study was registered in www.clinicaltrials.gov/ database, with unique identification number NCT03032978. All procedures performed in this study, involving human participants, were in accordance with the ethical standards of the Research Ethics Committee of Faculty of Dentistry, Cairo University (CREC; Ref. 17/02/03).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
Data are available upon reasonable request.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]