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ORIGINAL ARTICLE
Year : 2021  |  Volume : 39  |  Issue : 1  |  Page : 47-52
 

Comparison of staining potential of silver diamine fluoride versus silver diamine fluoride and potassium iodide under tooth-colored restorations: An in vitro study


Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Hyderabad, Telangana, India

Date of Submission22-Dec-2020
Date of Decision02-Apr-2021
Date of Acceptance11-Apr-2021
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. J Sharada
Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Room No. 305, 2nd Floor, Afzalgunj, Hyderabad - 500 012, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisppd.jisppd_533_20

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   Abstract 


Background: Silver diamine fluoride (SDF) is one of the effectual cariostatic agents widely used in minimal intervention dentistry. However, the major drawback of SDF is dark staining after its application. Aim: In the present study, the staining of 38% SDF alone and 38% SDF and potassium iodide (KI) was compared after restoration with glass-ionomer cement (GIC) and resin composite using ImageJ software. Methods and Material: Forty extracted carious primary teeth were sorted into four groups. In Group I and II, SDF was applied and restored with GIC and composite restorations, respectively. In Group III and IV, SDF application was followed by KI and restored with GIC and composite restorations, respectively. Images were captured after initial applications on day 1 and day 14 after restoration. The captured images were imported to ImageJ software and mean gray values were calculated. Statistical Analysis: The mean gray values obtained were subjected to statistical analysis using paired t-test and independent sample t-test. There was statistically significant if P < 0.05. Results: Following the application of SDF and RIVA STAR, the baseline mean gray values showed no statistical significance. On day 1, the mean gray values were highest in Group IV (208.30) and lowest in Group I (178.51). Similarly, on day 14, the highest mean gray values were observed in Group IV (208.45) and lowest in Group I (147.6) which were statistically significant. Conclusions: The restorations after SDF application attained dark stain eventually, whereas with the application of SDF followed by KI (RIVA STAR), the restorations showed the least staining.


Keywords: Dental caries, potassium iodide, silver diamine fluoride, tooth staining


How to cite this article:
Vennela E, Sharada J, Hasanuddin S, Suhasini K, Hemachandrika I, Singh P T. Comparison of staining potential of silver diamine fluoride versus silver diamine fluoride and potassium iodide under tooth-colored restorations: An in vitro study. J Indian Soc Pedod Prev Dent 2021;39:47-52

How to cite this URL:
Vennela E, Sharada J, Hasanuddin S, Suhasini K, Hemachandrika I, Singh P T. Comparison of staining potential of silver diamine fluoride versus silver diamine fluoride and potassium iodide under tooth-colored restorations: An in vitro study. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Jun 21];39:47-52. Available from: https://www.jisppd.com/text.asp?2021/39/1/47/314371





   Introduction Top


Early childhood caries (ECC) is an unacceptable burden for children their families and also for society. The timely and appropriate prevention and management of ECC is important to reduce this burden and improve the quality of life of children globally. For arresting dentinal caries in children, adolescents, and those with special health care needs, a less invasive procedure is the use of silver diamine fluoride (SDF) which combines the antibacterial effects of silver and the remineralizing effects of fluoride. Thus, SDF becomes one of the effective tools available to address caries.

SDF has invoked interest in pediatric dentistry around the globe, after its approval by the Food and Drug Administration as a desensitizing agent in August 2014, and its off-label use for arresting caries is now permissible and appropriate for patients.[1] It is theorized that SDF reacts with hydroxyapatite in an alkaline environment to form calcium fluoride and silver phosphate as major reaction products. A side effect of SDF is the discoloration of demineralized or cavitated surfaces. Patients and parents should be explained beforehand regarding the black staining of the lesions associated with the application of SDF. Ideally, prior to the use of SDF, parents should be shown before and after images of teeth treated with SDF. However, the most-cited barrier for the clinical use of SDF was perceived as nonacceptance of parent/caregiver of color change associated with caries arrest.[1]

The current pandemic COVID-19 caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) poses a unique risk of transmission of virus through the mucous membranes of the oronasal cavity, eyes, and the pulmonary apparatus. SARS-CoV-2 can be released when an infected person coughs, talks, and sneezes. Droplets containing the virus can infect others if they do not follow the safe distance. Moriyama et al. have stated that low humidity and temperatures increase the viability of SARS-CoV-2 in the droplets, and since the receptor of this virus, angiotensin-converting enzyme II appears in a small number of type II alveolar cells and SARS-CoV-2 defects ciliary clearance and defense innate immunity for greater access to deep lung tissue.[2],[3] This unique challenge of virus transmission through aerosol-generating procedures can be mitigated by the use of non-invasive restorative techniques such as SDF. Knight et al.[4] introduced a novel approach to overcome the staining problem of SDF by applying a saturated solution of potassium iodide (KI) immediately after SDF application. Hence, the present study was envisioned to evaluate and compare the staining potential of 38% SDF (FAgamin, SRL, Argentina) and a combination of 38% SDF and KI (RIVASTAR, SDI, Bay waters, Australia) on carious teeth, immediately and after a period of 2 weeks following restorations with self- cure glass- ionomer cement (GIC) and a light- cured resin composite using ImageJ, an open source Java image processing program developed by Wayne Rasband and inspired by NIH Image, Bethesda, MD, United States of America.


   Materials and Methods Top


Ethical clearances for the study were obtained from Institutional Ethical Committee. Forty extracted deciduous carious teeth with scores 5 and 6 (according to ICDAS criteria)[5] were collected and stored in phosphate buffer saline (PBS) solution.[4] Study samples were equally divided into four groups (n = 10).

  • Group I: SDF and GIC restoration
  • Group II: SDF and composite restoration
  • Group III: SDF and KI (RIVA STAR) and GIC restoration
  • Group IV: SDF and KI (RIVA STAR) and composite restoration.


In Group I and II, SDF was applied on carious lesions for 1 min as per the manufacturer's instructions and images were captured immediately with a 48-megapixel Sony IMX586 sensor, with an f/1.7 aperture, 1.6-μ pixels, optical image stabilization, electronic image stabilization, and phase detection autofocus camera and baseline gray values were recorded.

This was followed by restoring the teeth with GIC and with composite. In Group III and IV, SDF was applied for 1 min and KI was applied immediately as per the manufacturer's instructions until the precipitate was removed and washed thoroughly with water. Subsequently, images of the treated lesions were captured and baseline gray values were recorded. In all the 4 groups, images were captured with the same camera immediately after application of SDF and RIVASTAR in the respective groups, after restorations were finished with GIC and Composite and after 2 weeks. During the 2-week period, the teeth were stored in a dry environment at room temperature.

The captured images were imported individually to the ImageJ software,[6] in which individual lesions of each tooth were selected and mean gray values were calculated. As per the software, the following mean gray values represent the extent of staining, 0 = black, 127 = gray, and 255 = white. This scoring criterion suggests that the higher the mean gray value, the lower is the staining. The obtained mean gray values from the software were recorded and subjected to statistical analysis.


   Results Top


The mean gray value obtained immediately after application of SDF alone and the combination of SDF and KI in all the groups was in the range of 126.46 to 141.96 with a mean difference of 15.50. Thus, the selected teeth have shown similar mean gray values for both SDF and RIVA STAR, before bonding of restorations [Table 1]. The mean gray value (baseline value) obtained after SDF application alone on prepared dentin was 126.46, after GIC restorations at day 1 was 178.51, and after day 14 was 147.60 with a standard deviation (SD) difference of 0.58 (P = 0.026), which was statistically significant [Figure 1]. The mean gray value after SDF and composite restoration at day 1 was 194.33 and at day 14 was 159.31, with an SD difference of 2.99 (P = 0.000) which was statistically significant by paired t-test [Table 2] and [Figure 2].
Table 1: Comparison of mean gray values of silver diamine fluoride applied immediately to dentin and RIVA star applied immediately to dentin by paired t-test (P<0.05)

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Table 2: Comparison of mean gray values of Group I (silver diamine fluoride + glass-ionomer cement) and Group II (silver diamine fluoride + composite) at day 1 and at day 14 by paired t-test (P<0.05)

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Figure 1: Shows images of Group I (Silver diamine fluoride and glass-ionomer cement restoration) and the variation in the staining of restorations from day 1 to day 14. (a) Shows carious lesion immediately after application of silver diamine fluoride. (b) Shows image of glass-ionomer cement restoration on day 1. (c) Shows image of glass-ionomer cement restoration on day 14

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Figure 2: Shows images of Group II (silver diamine fluoride and composite restoration) and the variation in the staining of restorations from day 1 to day 14. (a) Shows carious lesion immediately after application of silver diamine fluoride. (b) Shows image of composite restoration on day 1. (c) Shows image of composite restoration on day 14

Click here to view


The mean gray value (baseline value) obtained after application of the combination of SDF and KI on prepared dentin was 141.96, after GIC restoration at day 1 was 200.38, and day 14 was 193.51, with an SD difference of 7.45, which was statistically non-significant (P = 0.0524) as per paired t-test [Figure 3]. The mean gray value after SDF and KI (RIVASTAR) and composite restoration at day 1 was 208.30 and day 14 was 208.45, with SD difference of 2.42, which was statistically non-significant (P = 0.981) as per paired t-test (P = 0.981) [Table 3] and [Figure 4].
Table 3: Comparison of mean gray values of Group III (silver diamine fluoride and potassium iodide + glass-ionomer cement) and Group IV (silver diamine fluoride and potassium iodide + composite) at day 1 and at day 14 by paired t-test (P<0.05)

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Figure 3: Shows images of Group I (silver diamine fluoride + potassium iodide and glass-ionomer cement restoration) and the variation in the staining of restorations from day 1 to day 14. (a) Shows carious lesion immediately after application of silver diamine fluoride + potassium iodide. (b) Shows image of glass-ionomer cement restoration on day 1. (c) Shows image of glass-ionomer cement restoration on day 14

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Figure 4: Shows images of Group II (silver diamine fluoride + potassium iodide and composite restoration) and the variation in the staining of restorations from day 1 to day 14. (a) Shows carious lesion immediately after application of silver diamine fluoride + potassium iodide. (b) Shows image of composite restoration on day 1. (c) Shows image of composite restoration on day 14

Click here to view


When comparing the study materials, after restoring with GIC, statistically significant differences were reported with both SDF and RIVA STAR on both day 1 and day 14 with SD difference values of 10.59 (P = 0.040) and 3.72 (P = 0.001) [Table 4], whereas when restored with composite, a statistrically significant difference was found with SDF and RIVA STAR on only day 14 with an SD difference value 1.92 (P = 0.000) which was statistically significant [Table 5]. While comparing the day 14 results of all 4 groups, the difference of mean gray values between Group I and Group II and similarly Group III and Group IV are nonsignificant with P = 0.273 NS and 0.116 NS, respectively [Table 6] and [Graph 1].
Table 4: Comparison of mean gray values of Group I (silver diamine fluoride + glass-ionomer cement) and Group III (silver diamine fluoride and potassium iodide + glass-ionomer cement) at day 1 and at days 14 by independent sample t-test

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Table 5: Comparison of mean gray values of Group II (silver diamine fluoride + composite) and Group IV (silver diamine fluoride and potassium iodide + composite) at day 1 and at days 14 by independent sample t-test

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Table 6: Intergroup comparison of Group I, II, III, and IV at days 14 by independent sample t-test

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Among all the forty extracted deciduous carious teeth (ICDAS Scores 5 and 6) [Figure 5], the mean gray values calculated were highest on day 14 (208.45) in Group IV (RIVA STAR with resin composite restoration).
Figure 5: Shows formation of white layer on the restoration after storing in phosphate buffer saline solution

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   Discussion Top


There is a paradigm shift in the concept of restorative treatment protocols in pediatric dentistry with the ever-evolving definition of dental caries. During the recent pandemic of COVID-19, the focus of all dental specialties is now shifted to adapting nonaerosol-generating procedures. These include the use of remineralizing agents, chemomechanical methods of caries removal, interim therapeutic restorations, use of Hall technique for primary crown placements, and use of SDF. In dentistry, reports of use of silver nitrate were well-documented for caries inhibition and silver nitrate was firmly thought to be a remedy for “hypersensitivity of dentin, erosion and pyorrhoea, as a sterilizing agent and caries inhibitor in deciduous as well as in permanent teeth.”[7],[8],[9] Howe's solution (ammonical silver nitrate) was reported to disinfect carious lesions and used as a sterilizing and disclosing agent for bacterial invasion of dentin to avoid direct pulp exposures, to detect incipient lesions, and to disclose leftover carious dentin.[10]

SDF is a caries-controlling reagent and is widely adopted in the USA off label, like fluoride varnish for caries prevention. However, it is being used for arresting caries in primary teeth. SDF is available in various concentrations, namely 12%, 30%, and 38%. However, 38% of SDF is found to be highly effective in arresting carious lesions and promoting remineralization.[11] Hence, in the present study 38%, SDF was used in all the study groups.

The formation of metallic silver from silver compounds results in dark staining of carious tissue. SDF forms a black precipitate on the surface of carious dentine because of the reaction of unreacted silver ions on the partially denatured collagen. The excess unreacted silver ions remain precipitated as silver sulphide (Ag2S) causing the staining. After the SDF application initially, no color change was observed but within 2– weeks, the carious tooth becomes dark brown to black. Light exposure increases the brown–black appearance of the carious lesion.[12] Staining on posterior teeth is acceptable to parents than staining on anterior teeth. Although parents may perceive the staining from SDF in anterior teeth as being un-esthetic, most of the parents are open to compromise aesthetics in favor of using a less invasive approach, especially when the child's cooperation becomes a barrier for traditional treatment. Clinicians should provide an informed consent form to parents which includes photographs of the staining, especially while treating the anterior teeth.[13] In a survey conducted by pediatric dentistry program directors, most of them agreed that SDF could be used to arrest caries in primary (87%) and permanent (66%) teeth in patients who were at high risk of experiencing caries. However, they expressed concerns regarding staining of teeth and the expected poor parental acceptance of esthetics after treatment. In fact, they viewed that the most frequently reported perceived barrier to the use of SDF was the concern of parental acceptance (91.8%).[14]

While the preliminary studies of SDF demonstrated an anti-caries effect, they also recognized that silver fluoride can blacken the caries lesions but not the sound tooth surfaces. Hence, newer in vitro studies use SDF followed by KI application, which produces a white silver iodide reaction product, thereby subsequently minimizes the staining of the restoration.[3]

In an in vivo trial for adults, Li et al.[15] concluded that application of KI did not minimize the black stain on root caries, especially in the long term. In contrast, Zhao et al.[16] stated that KI treatment can reduce discoloration of demineralized dentine caused by SDF. In the present study, the comparison of Group I (SDF with GIC) and Group III (RIVASTAR with GIC) after day 14, the mean grey values were 147.6 and 193.5 respectively (P= 0.001) suggesting that Group III showed significantly less staining when compared to Group I (with reference to per Image J scoring criteria, any grey values above 127 towards 255 suggests lightening or whitening of the stain). As per ImageJ scoring criteria, any gray values above 127 toward 255 suggest lightening or whitening of the gray stain. Similarly, in Group II (SDF with composite) and Group IV (RIVA STAR with composite), mean gray values of 159.31 and 208.45, respectively, showed the high statistical significance of (P = 0.000). The highest mean gray value (208.45) observed in Group IV (RIVA STAR with composite) suggested the least staining among all the groups. Furthermore, the present study suggested that in both SDF and RIVA STAR groups, the margins of composite restorations have shown lesser staining than GIC restorations at day 1 as well as at day 14 [Table 4] and [Table 5].

The mean gray values obtained in the present study were in accordance with the study done by Patel et al.[6] which was based on time-lapse photography and ImageJ software. However, in the present study, still photography of dried samples was used. Another study used spectrophotometry and simulated moist oral conditions to calculate the gray values and concluded that SDF and KI treatment inhibited the development of secondary caries around GIC restorations, but it was not as effective as SDF treatment alone. Although SDF and KI treatment caused a perceptible staining at the restoration margin, the intensity of the stain was less than that with SDF treatment alone.[17]

The limitation of the present study was using the dry specimens throughout the study period. To simulate the clinical environment, initially, staining was explored by immersing the teeth into PBS solution containing disodium hydrogen phosphate and sodium chloride. However, SDF was found to react with sodium or potassium chloride of PBS to form a white precipitate, probably silver chloride, which masked the underlying staining. This finding was similar to a study by Patel et al.,[6] in which the teeth were initially immersed in artificial saliva, which had resulted in a white precipitate of silver chloride [Figure 6]. Hence, in the present study, dried specimens were used to evaluate the staining potential of SDF and RIVA STAR at 14 days after restoration with GIC and composite. Staining potential is best evaluated in dry and desiccated conditions, as moist salivary conditions tend to reduce the degree of staining.
Figure 6: Shows forty extracted carious (ICDAS 5 and 6) deciduous teeth divide into four groups

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Although it is proved that the application of SDF/KI had no adverse effects on the bonding of conventional GICs to dentine, there are certain reservations with resin composite restorations.[18] In the present study, the staining of composite restorations was less with both SDF and SDF and KI, Lutgen et al. investigated the effect of SDF on the micro shear bond strength of commonly used adhesive systems and demonstrated that SDF had a negative effect on bonding, the severity of which strongly correlated with the application protocol used. Rinsing after SDF application led to improved bond strength compared to nonrinsing groups when following multistep adhesive protocols and removal of the superficial layer of SDF-treated dentin recovered bond strength values similar to the control group.[19] Hence, lesser staining of composite restorations with SDF and KI does not offer much of an advantage if the microshear bond strength of adhesives is compromised. However, an attempt was made in the present in vitro study to evaluate the staining of restoration margins after the use of SDF and SDF and KI.

Treating dental caries in a very young is a challenging task which sometimes might end up using sedation to prevent caries progression. Due to the long-term neurocognitive impairment caused by general anesthesia in the immature brain of young children, using GA at a tender age should be avoided.[20] Thus, the use of SDF and SDF+KI under esthetic restorations can be advocated as the best noninvasive restorative options in young children, adolescents, and those with limited access to advanced dental procedures.


   Conclusions Top


RIVA STAR has an overall less staining potential when compared to SDF alone under tooth-colored restorations after 14 days of dry storage. While using GIC in both Groups I and III, less staining of restoration margins was observed with RIVA STAR toward the end of the study period, which was statistically significant. (P = 0.001). Similarly, while using composites in both Groups II and IV, lesser staining of restoration margins was observed with RIVA STAR toward the end of the study period, which was statistically significant (P = 0.000), whereas comparing both GIC and resin composite materials on SDF-treated dentin, less stained margins were evident around the composite restorations among all the groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
American Academy of Pediatric Dentistry. Policy on the use of silver diamine fluoride for pediatric dental patients. The Reference Manual of Pediatric Dentistry. Chicago, III: American Academy of Pediatric Dentistry; 2020:66-9.  Back to cited text no. 1
    
2.
Moriyama M, Hugentobler WJ, Iwasaki A. Seasonality of respiratory viral infections. Annu Rev Virol 2020;7:83-101.  Back to cited text no. 2
    
3.
Zhao Y, Zhao Z, Wang Y, Zhou Y, Ma Y, Zuo W. Single-cell RNA expression profiling of ACE2, the receptor of SARS-CoV-2. Am J Respir Crit Care Med. 2020;202:756-9.  Back to cited text no. 3
    
4.
Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS, Gully NJ. An in vitro model to measure the effect of a silver fluoride and potassium iodide treatment on the permeability of demineralized dentine to Streptococcus mutans. Aust Dent J 2005;50:242-5.  Back to cited text no. 4
    
5.
Ismail AI. Rationale and Evidence for the International Caries Detection and Assessment System. ICDAS Coordination Committee; 2005; p. 1–67.  Back to cited text no. 5
    
6.
Patel J, Anthonappa RP, King NM. Evaluation of the staining potential of silver diamine fluoride: In vitro. Int J Paediatr Dent 2018; 28: 514–22.  Back to cited text no. 6
    
7.
Higginbottom J. On the use of the nitrate of silver in the cure of erysipelas. Prov Med Surg J 1847;11:458-60.  Back to cited text no. 7
    
8.
Stebbins EA. What value has argenti nitras as a therapeutic agent in dentistry? Int Dent J 1891;12:661-70.  Back to cited text no. 8
    
9.
Seltzer S, Werther L. Conservative silver nitrate treatment of borderline cases of deep dental caries. J Am Dent Assoc 1941;28:1586-91.  Back to cited text no. 9
    
10.
Howe PR. A method of sterilizing and at the same time impregnating with a metal affected dentinal tissue. Dent Cosmos 1917;59:891-904.  Back to cited text no. 10
    
11.
Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017;39:135-45.  Back to cited text no. 11
    
12.
Burgess JO, Vaghela PM. Silver diamine fluoride: A successful anticarious solution with limits. Adv Dent Res 2018;29:131-4.  Back to cited text no. 12
    
13.
Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc 2017;148:510-8.e4.  Back to cited text no. 13
    
14.
Nelson T, Scott JM, Crystal YO, Berg JH, Milgrom P. Silver diamine fluoride in pediatric dentistry training programs: Survey of graduate program directors. Pediatr Dent 2016;38:212-7.  Back to cited text no. 14
    
15.
Li R, Lo EC, Liu BY, Wong MC, Chu CH. Randomized clinical trial on arresting dental root caries through silver diammine fluoride applications in community-dwelling elders. J Dent 2016;51:15-20.  Back to cited text no. 15
    
16.
Zhao IS, Chu S, Yu OY, Mei ML, Chu CH, Lo EC. Effect of silver diamine fluoride and potassium iodide on shear bond strength of glass ionomer cements to caries-affected dentine. Int Dent J 2019;69:341-7.  Back to cited text no. 16
    
17.
Zhao IS, Mei ML, Burrow MF, Lo EC, Chu CH. Effect of Silver diamine fluoride and potassium iodide treatment on secondary caries prevention and tooth discolouration in cervical glass ionomer cement restoration. Int J Mol Sci 2017;18:340.  Back to cited text no. 17
    
18.
Knight GM, McIntyre JM, Mulyani. The effect of silver fluoride and potassium iodide on the bond strength of auto cure glass ionomer cement to dentine. Aust Dent J 2006;51:42-5.  Back to cited text no. 18
    
19.
Lutgen P, Chan D, Sadr A. Effects of silver diammine fluoride on bond strength of adhesives to sound dentin. Dent Mater J 2018;37:1003-9.  Back to cited text no. 19
    
20.
Backeljauw B, Holland SK, Altaye M, Loepke AW. Cognition and brain structure following early childhood surgery with anesthesia. Pediatrics 2015;136:e1-12.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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