Research Article
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Impact of laparoscopic sleeve gastrectomy on periodontal status in obese patients

Year 2024, , 205 - 212, 01.04.2024
https://doi.org/10.31362/patd.1376207

Abstract

Purpose: This study aimed to determine the effects of laparoscopic sleeve gastrectomy surgery on clinical periodontal parameters at 6 months in the postoperative period.
Materials and methods: Fifty-four obese patients with periodontitis between 18 and 70 years of age were evaluated for obesity-related parameters and periodontal status before and 6 months after bariatric surgery. Correlations of the changes in periodontal parameters and the total weight loss and body mass index (BMI) loss at 6 months after bariatric surgery were determined with Spearman correlation analysis. P<0.05 was considered as the statistical significance value.
Results: Significant improvements were achieved at 6-month follow-up compared to baseline in BMI values and several systemic health-related serum biomarkers such as C-reactive protein, high-density lipoprotein, low-density lipoprotein, and albumin levels. Periodontal parameters; plaque index (p=0.000), gingival index (p=0.004), and bleeding on probing (p=0.007) were decreased significantly at 6 months after surgery. However, no significant changes in probing depth and clinical attachment level values were observed. The changes in plaque index values were positively correlated with the percent of total weight loss (r=0.301, p=0.027). Also, there was a positive significant correlation between the changes in the percent of bleeding on probing levels and the percent of total weight loss and the percent excess BMI loss (r=0.637, p=0.000 and r=0.370, p=0.006 respectively).
Conclusion: Laparoscopic sleeve gastrectomy surgery resulted in a reduction in periodontal inflammation in parallel with the decrease in BMI levels and obesity-related biochemical markers during the 6-month follow-up period.

Ethical Statement

Ethics committee approval: Permission was obtained from Pamukkale University Non-Interventional Clinical Research Ethics Committee dated 2018 and numbered 19 for the study

References

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  • 2. Who. Obesity and overweight. Available at: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed October 16, 2023
  • 3. Kim CM, Lee S, Hwang W, et al. Obesity and periodontitis: a systematic review and updated meta-analysis. Front Endocrinol (Lausanne) 2022;13:999455. https://doi.org/10.3389/fendo.2022.999455
  • 4. Kopelman PG. Obesity as a medical problem. Nature 2000;404:635-643. https://doi.org/10.1038/35007508
  • 5. Kwon T, Lamster IB, Levin L. Current concepts in the management of periodontitis. Int Dent J 2021;71:462-476. https://doi.org/10.1111/idj.12630
  • 6. Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: case definitions and diagnostic considerations. J Clin Periodontol 2018;45:171-189. https://doi.org/10.1111/jcpe.12947
  • 7. Jepsen S, Suvan J, Deschner J. The association of periodontal diseases with metabolic syndrome and obesity. Periodontol 2000 2020;83:125-153. https://doi.org/10.1111/prd.12326
  • 8. Ganesan SM, Vazana S, Stuhr S. Waistline to the gumline: relationship between obesity and periodontal disease-biological and management considerations. Periodontol 2000 2021;87:299-314. https://doi.org/10.1111/prd.12390
  • 9. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004;14:1157-1164. https://doi.org/10.1381/0960892042387057
  • 10. Popescu AL, Ionita Radu F, Jinga M, Gavrila AI, Savulescu FA, Fierbinteanu Braticevici C. Laparoscopic sleeve gastrectomy and gastroesophageal reflux. Rom J Intern Med 2018;56:227-232. https://doi.org/10.2478/rjim-2018-0019
  • 11. Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15:1024-1029. https://doi.org/10.1381/0960892054621125
  • 12. Marsicano JA, Sales Peres A, Ceneviva R, de C Sales Peres SH. Evaluation of oral health status and salivary flow rate in obese patients after bariatric surgery. Eur J Dent 2012;6:191-197.
  • 13. de Moura Grec PG, Yamashita JM, Marsicano JA, et al. Impact of bariatric surgery on oral health conditions: 6-months cohort study. Int Dent J 2014;64:144-149. https://doi.org/10.1111/idj.12090
  • 14. de Carvalho Sales HC, de Carvolho Sales Peres M, Ceneviva R, Bernabe E. Weight loss after bariatric surgery and periodontal changes: a 12-month prospective study. Surg Obes Relat Dis 2017;13:637-642. https://doi.org/10.1016/j.soard.2016.08.007
  • 15. Jaiswal GR, Jain VK, Dhodapkar SV, et al. Impact of bariatric surgery and diet modification on periodontal status: a six month cohort study. J Clin Diagn Res 2015;9:43-45. https://doi.org/10.7860/JCDR/2015/14663.6489
  • 16. Weinberg G, Bilder L, Horwitz J, et al. Oral health status of patients before and after bariatric surgery. Dentistry Oral Health Care 2018;1:1-8.
  • 17. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Periodontol 2018;89:159-172. https://doi.org/10.1002/JPER.18-0006
  • 18. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American association of clinical endocrinologists/American college of endocrinology, the obesity society, American society for metabolic & bariatric surgery, obesity medicine association, and American society of anesthesiologists - executive summary. Endocr Pract 2019;25:1346-1359. https://doi.org/10.4158/GL-2019-0406
  • 19. WHO. The World Health Organization warns of the rising threat of heart disease and stroke as overweight and obesity rapidly increase. Available at: https://www.cmaj.ca/content/cmaj/suppl/2020/07/27/192.31.E875.DC2/191707-guide-1-at.pdf. Accessed October 16, 2023
  • 20. Deitel M, Greenstein RJ. Recommendations for reporting weight loss. Obes Surg 2003;13:159-160. https://doi.org/10.1381/096089203764467117
  • 21. Silness J, Loe H. Periodontal disease in pregnancy. II. correlation between oral hygiene and periodontal condition. acta odontol scand 1964;22:121-135. https://doi.org/10.3109/00016356408993968
  • 22. Loe H, Silness J. Periodontal disease in pregnancy. I. prevalence and severity. Acta Odontol Scand 1963;21:533-551. https://doi.org/10.3109/00016356309011240 23. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-235. 24. Linden GJ, Lyons A, Scannapieco FA. Periodontal systemic associations: review of the evidence. J Clin Periodontol 2013;40:8-19. https://doi.org/10.1111/jcpe.12064
  • 25. Zhao P, Xu A, Leung WK. Obesity, bone loss, and periodontitis: the interlink. Biomolecules 2022;12:865. https://doi.org/10.3390/biom12070865
  • 26. Hayes K, Eid G. Laparoscopic sleeve gastrectomy: surgical technique and perioperative care. Surg Clin North Am 2016;96:763-771. https://doi.org/10.1016/j.suc.2016.03.015
  • 27. Ridker PM, Morrow DA. C-reactive protein, inflammation, and coronary risk. Cardiol Clin 2003;21:315-325. https://doi.org/10.1016/s0733-8651(03)00079-1
  • 28. Chen JY, Chou CH, Tsai WC, et al. Effects of increased systemic inflammation and central obesity on arterial stiffness in patients with nonalcoholic fatty liver disease. J Am Soc Hypertens 2012;6:253-260. https://doi.org/10.1016/j.jash.2012.04.003
  • 29. Paraskevas S, Huizinga JD, Loos BG. A systematic review and meta-analyses on C-reactive protein in relation to periodontitis. J Clin Periodontol 2008;35:277-290. https://doi.org/10.1111/j.1600-051X.2007.01173.x
  • 30. Lee JB, Yi HY, Bae KH. The association between periodontitis and dyslipidemia based on the Fourth Korea National Health and Nutrition Examination Survey. J Clin Periodontol 2013;40:437-442. https://doi.org/10.1111/jcpe.12095
  • 31. Awartani F, Atassi F. Evaluation of periodontal status in subjects with hyperlipidemia. J Contemp Dent Pract 2010;11:33-40.
  • 32. Schenkein HA, Papapanou PN, Genco R, Sanz M. Mechanisms underlying the association between periodontitis and atherosclerotic disease. Periodontol 2000 2020;83:90-106. https://doi.org/10.1111/prd.12304
  • 33. Gomes Filho IS, Freitas TOB, da Cruz SS, et al. Periodontitis in individuals with few remaining teeth and a high gingival bleeding index increases the probability of dyslipidemia. J Periodontol 2023. https://doi.org/10.1002/JPER.23-0091
  • 34. Arboleda S, Pianeta R, Vargas M, Lafaurie GI, Aldana Parra F, Chaux CF. Impact of bariatric surgery on periodontal status in an obese cohort at one year of follow-up. Med Int (Lond) 2021;1:4. https://doi.org/10.3892/mi.2021.4
  • 35. Kojima M, Kangawa K. Ghrelin: structure and function. Physiol Rev 2005;85:495-522. https://doi.org/10.1152/physrev.00012.2004
  • 36. Goitein D, Lederfein D, Tzioni R, Berkenstadt H, Venturero M, Rubin M. Mapping of ghrelin gene expression and cell distribution in the stomach of morbidly obese patients --a possible guide for efficient sleeve gastrectomy construction. Obes Surg 2012;22:617-622. https://doi.org/10.1007/s11695-011-0585-9
  • 37. Wang Y, Liu J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes Surg 2009;19:357-362. https://doi.org/10.1007/s11695-008-9688-3
  • 38. Peterli R, Steinert RE, Woelnerhanssen B, et al. Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a randomized, prospective trial. Obes Surg 2012;22:740-748. https://doi.org/10.1007/s11695-012-0622-3
  • 39. Mafra D, Farage NE, Lobo JC, et al. Relationship between total ghrelin and inflammation in hemodialysis patients. Peptides 2011;32:358-361. https://doi.org/10.1016/j.peptides.2010.11.023
  • 40. Yilmaz G, Kirzioglu FY, Doguc DK, Kocak H, Orhan H. Ghrelin levels in chronic periodontitis patients. Odontology 2014;102:59-67. https://doi.org/10.1007/s10266-012-0100-3
  • 41. Mohamed HG, Idris SB, Mustafa M, et al. Impact of chronic periodontitis on levels of glucoregulatory biomarkers in gingival crevicular fluid of adults with and without Type 2 Diabetes. PLoS One 2015;10:e0127660. https://doi.org/10.1371/journal.pone.0127660
  • 42. Miller GD, Nicklas BJ, Fernandez A. Serial changes in inflammatory biomarkers after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2011;7:618-624. https://doi.org/10.1016/j.soard.2011.03.006
  • 43. Illan Gomez F, Gonzalvez Ortega M, Orea Soler I, et al. Obesity and inflammation: change in adiponectin, C-reactive protein, tumour necrosis factor-alpha and interleukin-6 after bariatric surgery. Obes Surg 2012;22:950-955. https://doi.org/10.1007/s11695-012-0643-y

Obez hastalarda yapılan laparoskopik tüp mide ameliyatının periodontal duruma etkisi

Year 2024, , 205 - 212, 01.04.2024
https://doi.org/10.31362/patd.1376207

Abstract

Amaç: Bu çalışmada, laparoskopik tüp mide ameliyatının operasyon sonrası 6. ayda klinik periodontal parametreler üzerindeki etkilerinin belirlenmesi amaçlandı.
Gereç ve yöntem: Yaşları 18 ile 70 arasında değişen, periodontitisli 54 obez hasta, obezite ile ilişkili parametreler ve bariatrik cerrahi öncesi ve sonrasındaki periodontal durumları açısından değerlendirildi. Obezite cerrahisi sonrası 6. ayda periodontal parametrelerdeki değişiklikler ile toplam kilo kaybı ve vücut kitle indeksi (VKİ) kaybı arasındaki korelasyonlar Spearman korelasyon analizi ile belirlendi. P<0,05 istatistiksel anlamlılık değeri olarak kabul edildi.
Bulgular: 6 aylık takipte VKİ değerlerinde ve C-reaktif protein, yüksek yoğunluklu lipoprotein, düşük yoğunluklu lipoprotein ve albümin seviyeleri gibi sistemik sağlıkla ilgili çeşitli serum biyobelirteçlerinde başlangıca kıyasla önemli iyileşmeler elde edildi. Plak indeksi (p=0,000), gingival indeks (p=0,004) ve sondlamada kanama (p=0,007) gibi periodontal paramatreler ameliyattan 6 ay sonra anlamlı derecede azaldı. Ancak sondlama derinliği ve klinik ataçman seviyesi değerlerinde anlamlı bir değişiklik gözlenmedi. Plak indeksi değerlerindeki değişiklikler toplam kilo kaybı yüzdesi ile pozitif korelasyon gösterdi (r=0,301, p=0,027). Ayrıca sondlamada kanama yüzdesindeki değişiklikler ile toplam kilo kaybı yüzdesi ve aşırı VKİ kaybı yüzdesi arasında pozitif anlamlı bir korelasyon tespit edildi (sırasıyla r=0,637, p=0,000 ve r=0,370, p=0,006).
Sonuç: Laparoskopik tüp mide ameliyatı, 6 aylık takip döneminde VKİ seviyelerinde ve obezite ile ilişkili biyokimyasal belirteçlerde azalmaya paralel olarak periodontal inflamasyonda da azalma sağlamıştır.

References

  • 1. Blüher M. Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol 2019;15:288-298. https://doi.org/10.1038/s41574-019-0176-8
  • 2. Who. Obesity and overweight. Available at: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed October 16, 2023
  • 3. Kim CM, Lee S, Hwang W, et al. Obesity and periodontitis: a systematic review and updated meta-analysis. Front Endocrinol (Lausanne) 2022;13:999455. https://doi.org/10.3389/fendo.2022.999455
  • 4. Kopelman PG. Obesity as a medical problem. Nature 2000;404:635-643. https://doi.org/10.1038/35007508
  • 5. Kwon T, Lamster IB, Levin L. Current concepts in the management of periodontitis. Int Dent J 2021;71:462-476. https://doi.org/10.1111/idj.12630
  • 6. Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: case definitions and diagnostic considerations. J Clin Periodontol 2018;45:171-189. https://doi.org/10.1111/jcpe.12947
  • 7. Jepsen S, Suvan J, Deschner J. The association of periodontal diseases with metabolic syndrome and obesity. Periodontol 2000 2020;83:125-153. https://doi.org/10.1111/prd.12326
  • 8. Ganesan SM, Vazana S, Stuhr S. Waistline to the gumline: relationship between obesity and periodontal disease-biological and management considerations. Periodontol 2000 2021;87:299-314. https://doi.org/10.1111/prd.12390
  • 9. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004;14:1157-1164. https://doi.org/10.1381/0960892042387057
  • 10. Popescu AL, Ionita Radu F, Jinga M, Gavrila AI, Savulescu FA, Fierbinteanu Braticevici C. Laparoscopic sleeve gastrectomy and gastroesophageal reflux. Rom J Intern Med 2018;56:227-232. https://doi.org/10.2478/rjim-2018-0019
  • 11. Langer FB, Reza Hoda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15:1024-1029. https://doi.org/10.1381/0960892054621125
  • 12. Marsicano JA, Sales Peres A, Ceneviva R, de C Sales Peres SH. Evaluation of oral health status and salivary flow rate in obese patients after bariatric surgery. Eur J Dent 2012;6:191-197.
  • 13. de Moura Grec PG, Yamashita JM, Marsicano JA, et al. Impact of bariatric surgery on oral health conditions: 6-months cohort study. Int Dent J 2014;64:144-149. https://doi.org/10.1111/idj.12090
  • 14. de Carvalho Sales HC, de Carvolho Sales Peres M, Ceneviva R, Bernabe E. Weight loss after bariatric surgery and periodontal changes: a 12-month prospective study. Surg Obes Relat Dis 2017;13:637-642. https://doi.org/10.1016/j.soard.2016.08.007
  • 15. Jaiswal GR, Jain VK, Dhodapkar SV, et al. Impact of bariatric surgery and diet modification on periodontal status: a six month cohort study. J Clin Diagn Res 2015;9:43-45. https://doi.org/10.7860/JCDR/2015/14663.6489
  • 16. Weinberg G, Bilder L, Horwitz J, et al. Oral health status of patients before and after bariatric surgery. Dentistry Oral Health Care 2018;1:1-8.
  • 17. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Periodontol 2018;89:159-172. https://doi.org/10.1002/JPER.18-0006
  • 18. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American association of clinical endocrinologists/American college of endocrinology, the obesity society, American society for metabolic & bariatric surgery, obesity medicine association, and American society of anesthesiologists - executive summary. Endocr Pract 2019;25:1346-1359. https://doi.org/10.4158/GL-2019-0406
  • 19. WHO. The World Health Organization warns of the rising threat of heart disease and stroke as overweight and obesity rapidly increase. Available at: https://www.cmaj.ca/content/cmaj/suppl/2020/07/27/192.31.E875.DC2/191707-guide-1-at.pdf. Accessed October 16, 2023
  • 20. Deitel M, Greenstein RJ. Recommendations for reporting weight loss. Obes Surg 2003;13:159-160. https://doi.org/10.1381/096089203764467117
  • 21. Silness J, Loe H. Periodontal disease in pregnancy. II. correlation between oral hygiene and periodontal condition. acta odontol scand 1964;22:121-135. https://doi.org/10.3109/00016356408993968
  • 22. Loe H, Silness J. Periodontal disease in pregnancy. I. prevalence and severity. Acta Odontol Scand 1963;21:533-551. https://doi.org/10.3109/00016356309011240 23. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-235. 24. Linden GJ, Lyons A, Scannapieco FA. Periodontal systemic associations: review of the evidence. J Clin Periodontol 2013;40:8-19. https://doi.org/10.1111/jcpe.12064
  • 25. Zhao P, Xu A, Leung WK. Obesity, bone loss, and periodontitis: the interlink. Biomolecules 2022;12:865. https://doi.org/10.3390/biom12070865
  • 26. Hayes K, Eid G. Laparoscopic sleeve gastrectomy: surgical technique and perioperative care. Surg Clin North Am 2016;96:763-771. https://doi.org/10.1016/j.suc.2016.03.015
  • 27. Ridker PM, Morrow DA. C-reactive protein, inflammation, and coronary risk. Cardiol Clin 2003;21:315-325. https://doi.org/10.1016/s0733-8651(03)00079-1
  • 28. Chen JY, Chou CH, Tsai WC, et al. Effects of increased systemic inflammation and central obesity on arterial stiffness in patients with nonalcoholic fatty liver disease. J Am Soc Hypertens 2012;6:253-260. https://doi.org/10.1016/j.jash.2012.04.003
  • 29. Paraskevas S, Huizinga JD, Loos BG. A systematic review and meta-analyses on C-reactive protein in relation to periodontitis. J Clin Periodontol 2008;35:277-290. https://doi.org/10.1111/j.1600-051X.2007.01173.x
  • 30. Lee JB, Yi HY, Bae KH. The association between periodontitis and dyslipidemia based on the Fourth Korea National Health and Nutrition Examination Survey. J Clin Periodontol 2013;40:437-442. https://doi.org/10.1111/jcpe.12095
  • 31. Awartani F, Atassi F. Evaluation of periodontal status in subjects with hyperlipidemia. J Contemp Dent Pract 2010;11:33-40.
  • 32. Schenkein HA, Papapanou PN, Genco R, Sanz M. Mechanisms underlying the association between periodontitis and atherosclerotic disease. Periodontol 2000 2020;83:90-106. https://doi.org/10.1111/prd.12304
  • 33. Gomes Filho IS, Freitas TOB, da Cruz SS, et al. Periodontitis in individuals with few remaining teeth and a high gingival bleeding index increases the probability of dyslipidemia. J Periodontol 2023. https://doi.org/10.1002/JPER.23-0091
  • 34. Arboleda S, Pianeta R, Vargas M, Lafaurie GI, Aldana Parra F, Chaux CF. Impact of bariatric surgery on periodontal status in an obese cohort at one year of follow-up. Med Int (Lond) 2021;1:4. https://doi.org/10.3892/mi.2021.4
  • 35. Kojima M, Kangawa K. Ghrelin: structure and function. Physiol Rev 2005;85:495-522. https://doi.org/10.1152/physrev.00012.2004
  • 36. Goitein D, Lederfein D, Tzioni R, Berkenstadt H, Venturero M, Rubin M. Mapping of ghrelin gene expression and cell distribution in the stomach of morbidly obese patients --a possible guide for efficient sleeve gastrectomy construction. Obes Surg 2012;22:617-622. https://doi.org/10.1007/s11695-011-0585-9
  • 37. Wang Y, Liu J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes Surg 2009;19:357-362. https://doi.org/10.1007/s11695-008-9688-3
  • 38. Peterli R, Steinert RE, Woelnerhanssen B, et al. Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a randomized, prospective trial. Obes Surg 2012;22:740-748. https://doi.org/10.1007/s11695-012-0622-3
  • 39. Mafra D, Farage NE, Lobo JC, et al. Relationship between total ghrelin and inflammation in hemodialysis patients. Peptides 2011;32:358-361. https://doi.org/10.1016/j.peptides.2010.11.023
  • 40. Yilmaz G, Kirzioglu FY, Doguc DK, Kocak H, Orhan H. Ghrelin levels in chronic periodontitis patients. Odontology 2014;102:59-67. https://doi.org/10.1007/s10266-012-0100-3
  • 41. Mohamed HG, Idris SB, Mustafa M, et al. Impact of chronic periodontitis on levels of glucoregulatory biomarkers in gingival crevicular fluid of adults with and without Type 2 Diabetes. PLoS One 2015;10:e0127660. https://doi.org/10.1371/journal.pone.0127660
  • 42. Miller GD, Nicklas BJ, Fernandez A. Serial changes in inflammatory biomarkers after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2011;7:618-624. https://doi.org/10.1016/j.soard.2011.03.006
  • 43. Illan Gomez F, Gonzalvez Ortega M, Orea Soler I, et al. Obesity and inflammation: change in adiponectin, C-reactive protein, tumour necrosis factor-alpha and interleukin-6 after bariatric surgery. Obes Surg 2012;22:950-955. https://doi.org/10.1007/s11695-012-0643-y
There are 41 citations in total.

Details

Primary Language English
Subjects Surgery (Other)
Journal Section Research Article
Authors

Aysan Lektemür Alpan 0000-0002-5939-4783

Gizem Torumtay Cin 0000-0002-5362-4146

Muhammed Raşid Aykota 0000-0003-1862-6186

Early Pub Date December 11, 2023
Publication Date April 1, 2024
Submission Date October 15, 2023
Acceptance Date November 28, 2023
Published in Issue Year 2024

Cite

AMA Lektemür Alpan A, Torumtay Cin G, Aykota MR. Impact of laparoscopic sleeve gastrectomy on periodontal status in obese patients. Pam Tıp Derg. April 2024;17(2):205-212. doi:10.31362/patd.1376207
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