Qualitative somatosensory evaluation of recipient and donor sites of subepithelial connective tissue grafts

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This study aimed to qualitatively evaluate the somatosensory profile of recipient and palatal donor sites of SCTG. Materials and Methods Sensory tests were applied at SCTG recipient and donor sites at baseline, after 3 and 6 months. A single calibrated examiner applied Douleur Neuropathique 4 questionnaire (DN4), qualitative sensory test (QualST), discriminating the areas as hypersensitive, hyposensitive or normosensitive, and two-point acuity test. Descriptive statistics, non-parametric Kruskal Wallis test for QualST evaluation and ANOVA for Two-point test (p < 0.05) were used. Results QualST revealed that recipient areas presented no significant differences in tactile, pressure and thermal tests. Brush test revealed hyposensitivity after 3 months (p = 0.03). In donor areas, only thermal evaluation showed a significant difference (p = 0.01), being hypersensitive after 3 months and hyposensitive after 6 months. At baseline, all evaluations in recipient and donor areas were normosensitive. According to DN4, no patient reported pain in recipient and donor sites. Non-painful sensory perception was reported as numbness in recipient (3.14% of patients) and donor (18.4%) areas. No significant differences were found for two-point acuity test values. Conclusions The extent to which these alterations in sensations affected oral functions showed no impairment. Clinical Relevance : Although some punctual somatosensory changes occurred, they did not disable important oral functions, thus reinforcing the positive results obtained with periodontal plastic surgeries. Periodontics gingival graft connective tissue graft qualitative sensory testing somatosensory function Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Introduction Root coverage procedures represent one of the most extensively investigated techniques within periodontal plastic surgeries [ 1 ]. This is attributed not only to the high prevalence of GR, leading to aesthetic discomfort and dental sensitivity but also to the inherent complexity of these techniques. Numerous studies [ 2 – 6 ] have assessed root coverage procedures using clinical parameters that can be precisely measured by examiners. However, patient-centered outcomes [ 2 ] and potential sensory changes need to be further explored [ 7 ]. Studies investigating the treatment of gingival recessions (GR) using SCTG plus coronal advanced flap (CAF)[ 8 ] often lack insights into how patients perceive and evaluate these improvements, including changes in painful or painless sensations in both the donor and recipient areas. For example, recipient areas that remain hyposensitive after surgical procedures may, supposedly, endure more substantial loads from traumatic brushing without the patient's awareness. In cases of hypersensitivity, the patient may experience pain during brushing, leading to biofilm accumulation. Patient-related outcome measures (PROMs) following these procedures have typically focused on immediate postoperative outcomes, such as pain and swelling, or dental sensitivity and aesthetic aspects [ 4 , 6 ]. Roccuzzo et al. (2002) [ 9 ] recommended that any evaluation of “success” should also include the patient’s own opinion concerning factors such as postoperative esthetics, possible discomfort, and sensitivity. However, there is a limited literature addressing the assessment of soft tissue sensory function after gingival graft procedures. A study involving the sensory evaluation of 15 recipient areas treated with SCTG for root coverage [ 10 ] utilized two types of stimulation tests (surface and deep sensations). After 12 months, the results demonstrated that in 50% (7 out of 15) of the surgical sites, patients experienced difficulties in identifying and recognizing stimuli applied to the gingiva in those areas. Considering grafts donor sites, a study [ 7 ] evaluated sensibility and discomfort (n = 36) in the first and eighth weeks after surgery, using pressure and friction movements. Sensibility assessments conducted before surgery did not reveal any disorders in any of the participants. Complete sensibility was regained in all patients after 8 weeks, with all patients reporting no loss of sensation. Harris et al (2005) [ 11 ] observed in a larger sample (n = 500), temporary paresthesia in SCTG donor area in 2 patients (0.4%) and paresthesia that continued beyond final postoperative appointment (3 months) in one patient (0.2%). A pilot study conducted by Buff et al. (2009) [ 12 ], included 14 participants and utilized neurosensory tests (2-point, soft-touch, pin-tactile and thermal discrimination) only in donor sites. Twelve patients had never noticed any dysfunction. However, two patients reported a persistent numbness or a rough palatal surface after 20 and 51 months postoperatively. Authors related that some sensory changes could occur after graft harvesting from the palate. A preliminary observational case-control study conducted by our research group[ 13 ] aimed to provide a qualitative assessment of the somatosensory profile in both the recipient and palatal donor sites following root coverage procedures utilizing SCTG. Patients (n = 18) were evaluated at 6 months postoperatively (G6) and a complementary group not submitted to SCTG (control) was selected to validate the measurements protocols. In the G6 group, the qualitative test showed significant differences in pressure hyposensitivity in recipient sites and thermal and tactile hyposensitivity in donor sites (p = 0.04). There were no significant differences in sensory acuity by the Two-point test. Comparisons in control group did not present changes, and normal sensitivity was reported. The DN4 questionnaire revealed normal sensitivity in grafted and palatal donor sites. The current prospective investigation assessed the somatosensory characteristics of both SCTG recipient and donor sites in a more extensive sample using established tests commonly employed in sensory research [ 12 , 14 – 17 ]. Hence, it is crucial to determine whether possible somatosensory alterations occur in graft recipient and donor sites. Gaining insights into potential complications and aftereffects following these treatments will provide additional knowledge regarding the postoperative outcomes of SCTG, facilitating appropriate patient counseling. Materials and methods The study was approved (CAAE: 18008919.5.0000.5417) by the Institutional Ethical Review Board of Bauru School of Dentistry – University of São Paulo (FOB-USP) according to Helsinki Declaration and registered in ReBEC (Brazilian Registry of Clinical Trials (#RBR-7zz3b6p). This prospective observational study was conducted at the clinical facility of the Discipline of Periodontology at the Bauru School of Dentistry, University of São Paulo. All patients who wished to participate in the research signed a written informed consent form. The sample consisted of systemically healthy individuals aged 18 to 70 years, following the inclusion criteria: normal and healthy palatal area, multiple GR (RT1), including canines and/or premolars. Exclusion criteria included patients with prostheses with palatal coverage, palatal areas previously submitted to graft removal, teeth mobility, smokers, pregnant and lactating women, history of periodontal disease or recurrent abscess formation, previously root coverage surgical procedures, use of medications [anticonvulsants, antihypertensives, contraceptives, or immunosuppressants] or drugs that influence wound healing, and a low level of oral hygiene (plaque index and bleeding index > 20%). All selected patients underwent basic periodontal procedures (scaling, root planing, and oral hygiene instructions). GR were treated with SCTG and CAF under magnification (3.5X). In the recipient areas (Fig. 1 ), oblique incisions (from the cemento-enamel junction to the gingival margin of the adjacent tooth) and intrasulcular incisions were performed designing surgical and anatomical papillae for the subsequent coronal displacement of the flap [ 8 ] (Fig. 2 ). The incisions were made with a number 15C scalpel blade and the interdental papilla region was deepithelialized. Partial flap thickness was made laterally to the GR and full thickness up to mucogingival junction. Apically, a partial flap was performed, eliminating muscular tensions, and allowing mobility to accommodate the flap coronally to the cemento-enamel junction [ 18 ]. Root surfaces were scaled with periodontal curettes. The SCTG was harvested from the palatal posterior area (de-epithelized gingival graft technique) (Fig. 3 ), with standardized grafts of mesio-distal extension of two teeth (canine/premolar or 2 premolars) and a height of 7 mm. The graft thickness was also standardized at 1.5 mm. Epithelial removal was performed with light reflector and magnification [ 19 ]. The SCTG was positioned and sutured at the level of the cemento enamel junction (Fig. 4 ) and flap was coronally advanced (Fig. 5 ), using non-resorbable monofilament sutures (6 − 0). Simple sutures were made in the palatal region and removed after 7 days. Sutures in the recipient area were removed 15 days post-surgical procedure. The participants were administered 200 mg of Nimesulide (2 times per day) on the first and second days and 100 mg of Nimesulide (2 times per day) on the third and fourth days. In case of pain, they could use 750 mg Paracetamol tablets every 6 hours. Chlorhexidine digluconate mouth rinses were prescribed for 15 days (2 times per day). After suture removal, patients were instructed to carefully maintain oral hygiene and were followed up after 30 days, 2, 3, and 6 months (Figs. 6–9). Somatosensory Profile Qualitative sensory evaluations (QualST) were conducted in grafted areas compared to adjacent non-grafted areas and in donor areas compared to adjacent areas without intervention at three time points (baseline and after 3 and 6 months). Assessments of adjacent non-intervened areas are essential for intrapersonal comparison of somatosensory characteristics, validating the methodology employed. The protocol was performed using a metal spatula (previously immersed in a container of ice-cold water), bristles of a toothbrush, a flexible cotton swab, and a wooden stick (Fig. 10–13). These instruments assessed dynamic tactile, cold thermal, and painful sensations [ 15 , 16 ]. Participants were asked to report hypo (hyposensitive: -1), hyper (hypersensitive: +1), or normosensitivity (normosensitive: 0) when comparing the surgical areas (donor and recipient sites) to adjacent non-intervened areas. The DN4 questionnaire was administered at 3 and 6 months postoperatively to assess items related to painful or non-painful sensations, using descriptive terms such as burning, painful cold sensation, electric shock, prickling, and tingling. For non-painful sensations, descriptors such as burning, electric shock, tingling, numbness, and itching were also employed [ 20 ]. Furthermore, in the case of a positive response to painful or non-painful sensations, the frequency and duration were reported, as well as whether induced by brushing or chewing. The questionnaire also included a visual analog scale regarding the impact of these painful or non-painful sensations on the ability to perform oral functions (chewing, speaking, brushing, etc.). This instrument was translated and validated in Portuguese [ 21 ]. For the Two-point Acuity Test (Touch-test), a dry-pointed caliper was used, with its tips spaced (using a caliper) at standardized intervals of 1 mm to 15 mm. When the participant distinguished the sensation of touch from two points, this measurement was recorded. The test was conducted horizontally and vertically in both recipient and donor areas, as well as in adjacent non-intervened areas at baseline, 3 and 6 months. The examiner's calibration was performed by calculating the intraclass correlation coefficient, resulting in a value of 0.84. Calibration involved the assessment of 10 individuals, applying the QualST and Two-point tests, and one week later, the tests were repeated. Due to the novel nature of the study, a convenience sample was utilized, totaling 31 patients. Statistical analyses compared the parameters between donor and recipient areas with their respective adjacent non-intervened areas and assessed potential differences in sensory parameters at different time points (baseline, 3 and 6 months postoperatively). Descriptive statistics were employed, the non-parametric Kruskal Wallis test was used to evaluate QualST, and ANOVA was applied to analyze the Two-point test (p < 0.05). Results A total of 82 patients were examined, of which 43 did not meet the eligibility criteria (systemic diseases, medication use, use of prostheses with palatal coverage, RT 2 GR). Thirty-nine patients were included and treated, but 8 did not attend the follow-ups (at 3 and 6 months) due to reasons such as relocation to another city or personal reasons (flu-like symptoms, family illness, new employment, COVID-19). The final sample consisted of 31 patients, comprising 20 women and 11 men, with a mean age of 34.4 ± 5 years. The QualST of grafted and homologous areas did not demonstrate significant differences in the cotton swab test (tactile), toothpick pressure (pressure), and thermal with a cold spatula (thermal) based on the non-parametric Kruskal-Wallis test (Table 1 ). Some results that showed differences between grafted and homologous areas were mostly values < 0, indicating the possibility of hyposensitivity, except for the tactile test, which had a value of = 0 (normosensitive) in all groups (Table 1 ). The test using the brush showed significant hyposensitivity after 3 months (p = 0.03) compared to the other groups (Table 1 ). Table 1 Comparison of qualitative sensorial evaluations considering baseline, 3 and 6 months postoperativelly for recipiente and donor sites (p < 0,05). Baseline 3M 6M p Recipient sites -TACTILE Mean 0 0 0 0,08 25% 0 0 0 75% 0 0 0 -BRUSH Mean 0 0 0 0,03 25% 0 -1 0 75% 0 0 0 -PRESSURE Mean 0 -0,5 0 0,12 25% 0 -1 -1 75% 0 0 0 -THERMAL Mean 0 0 0 0,07 25% 0 -1 -1 75% 0 0 0 Donor sites - TACTILE Mean 0 0 0 0,06 25% 0 0 -0,75 75% 0 1 0 - BRUSH Mean 0 0 0 0,88 25% 0 0 0 75% 0 1 0 - PRESSURE Mean 0 0 0 0,47 25% 0 0 0 75% 0 1 0 - THERMAL Mean 0 0 0 0,01 25% 0 0 -1 75% 0 0,25 0 In the donor areas, only thermal evaluation showed a significant difference between baseline and after 3 and 6 months (p = 0.01), being hypersensitive after 3 months and hyposensitive after 6 months. The tactile test demonstrated a tendency towards hypersensitivity (> 0) after 3 months and hyposensitivity after 6 months. The pressure and brush tests also showed a tendency towards hypersensitivity in the 3-month group but normosensitivity after 6 months. At baseline, all evaluations in both grafted and donor areas were normosensitive (Table 1 ). This result reinforced the validity of the methodology without alterations in the somatosensory profile. The descriptive analysis of the DN4 test showed that patients reported no pain in grafted and donor areas, and the majority also did not report non-painful sensations in these areas. However, when non-painful sensations were present, it was numbness in the grafted area (3.14% of patients) and donor area (18.4%). Another sensation found in the grafted and palatal areas was an electric shock sensation in 1.3% of participants. The duration of these sensations was described as indefinite, and the frequency was primarily related to brushing and eating. The degree to which this alteration in sensation impaired oral functions such as chewing, speaking, or tooth brushing showed that over 92% of participants rated this intensity as 0, indicating no impairment in oral functions. The parametric ANOVA test was used to compare the Two-point sensory acuity test between time points and in the grafted and donor areas (Table 2 ). No significant differences in sensory acuity (p > 0.05) were found in both vertical and horizontal directions between the different assessment periods in grafted and donor areas. Table 2 Vertical and horizontal two-point test for recipient and donor areas at baseline, 3 and 6 months postoperatively. GROUPS Vertical 2 point (RECIPIENT) Horizontal 2 point (RECIPIENT) Vertical 2 point (DONOR) Horizontal 2 point (DONOR) 0 3,94 ± 3,95 3,57 ± 3,20 3,15 ± 1,83 3,75 ± 2,61 G3 4,67 ± 5,31 4,50 ± 4,69 4,34 ± 5,37 4,12 ± 4,77 G6 4,20 ± 4,41 4,58 ± 4,34 4,25 ± 4,74 4,40 ± 4,50 Discussion The present investigation revealed that recipient and donor sites of SCTG could demonstrate sensorial alterations without compromising oral functions. These results reinforce the positive outcomes achieved from the surgical procedures for root coverage. In this prospective evaluation, only brush test revealed hyposensitivity after 3 months in recipient sites. In the donor areas, hypersensitivity (thermal test) was observed at 3 months, and hyposensitivity (thermal test) was observed at 6 months. In a preliminary observational case-control study [ 13 ], a trend towards hyposensitivity was also observed after 6 months in both the recipient (pressure test) and donor areas (thermal and tactile tests). The results were similar for DN4 questionnaire and the two-point acuity test. However, in the present investigation, non-painful sensory perception (numbness) was reported, in recipient and donor areas. Previous studies used different methodologies for sensorial assessment. Only one evaluated recipient site [ 10 ] and three investigated donor areas [ 7 , 11 , 12 ], demonstrating a tendency towards hyposensitivity in both sites. Aimetti et al. (2010) [ 10 ] evaluated alterations in recipient sites of SCTG that were divided into two groups: parestehesias, loss of epicritical sensation and anesthesias, loss of both epicritical and protopatical sensations. After 12 months, 50% of the patients reported difficulties in recognizing and responding to stimuli applied to the gingiva in those specific areas. In five sites, patients developed complete anesthesia and in one site only paresthesia. Del Pizzo et al. (2002) [ 7 ] assessed the sensitivity and discomfort of graft donor sites at 1, 2, 3, 4, 6, and 8 weeks following surgery. Authors compared three techniques for harvesting SCTG (free gingival graft, trap door and single incision). After 2 weeks, single incision group showed a faster recovery in terms of sensibility, although this result was not statistically significant compared to other groups (25% for the single incision, 8% for the trap door and 0% for free gingival graft). Loss of sensation was observed in all periods of evaluation with complete recovery after 8 weeks, with no differences among groups. Nonetheless, the complete restoration of sensibility, although expedited in the single incision group when compared to the other two groups, required a minimum of 8 weeks for most of the patients. The more rapid recovery in the single incision group could be due to the unique incision of the epithelial layer, which involves a minor number of sensory receptors. Although it occurred in a small percentage of the sample, Harris et al (2005) [ 11 ] described temporary and persistent donor-site paresthesia as moderate and severe complications of SCTG harvesting. Comparably to our studies [ 13 ], Buff et al (2009) [ 12 ] qualitatively evaluated SCTG donor sites, but with parallel incision technique. Although the methodology was similar, authors used discrimination between points for all sensations only in donor sites, while our study categorized sensations as normal, hyposensitive, or hypersensitive in relation to the non-operated sites (recipient and donor). In this pilot study, authors used neurosensory tests at the palate performed postoperatively including minimal 2-point discrimination, soft-touch, pin-tactile and thermal discrimination. They demonstrated that 86% of the patients never noted any dysfunction in the oral or palatal region at any time following graft harvesting. Two patients reported a persistent numbness or a rough palatal surface. Authors confirmed that some sensory changes can occur after graft harvesting from the palate. Patients may experience temporary sensory dysfunction following palatal harvesting, as free nerve endings might be severed intraoperatively [ 7 ]. In our study the technique used for graft harvesting was de-epithelized graft. Palatal soft tissue healing by secondary intention is characterized by a larger tissue deficit that requires a longer healing time and is susceptible to a greater risk of infection or scarring [ 22 , 23 ]. Altered tissue perfusion can be detected with temporary paresthesia following free gingival graft harvesting [ 22 ].This may justify the results observed in this study, which showed hypersensitivity at the 3-month evaluation and subsequently hyposensitivity. Periodontal plastic surgeries with soft tissue grafts are procedures orientated to root coverage. Unfortunately, there is no entire comprehension of the physiological mechanisms leading to the epithelial-connective wound healing. Aimetti et al. (2010) [ 10 ] demonstrated that sensorial alterations occur in recipient sites also after complete root coverage and clinical success of the surgery. This success anyway should ensure not only the esthetic integration between the tissues but also the physiological activity of the graft in terms of sensitivity and immunity, because the skin and the mucosae constitute the first natural specific borders against pathogens [ 10 ]. Considering the protective role of gingival tissue, Graziani et al (2014) [ 1 ] evaluated in split-mouth case-control study, clinical and biomolecular parameters to assess the level of inflammation of periodontal sites after treatment with SCTG (test) and healthy non-treated gingivae (control). Authors observed that sites treated with SCTG developed a lower degree of plaque-induced inflammation compared to healthy gingivae, showing the importance of the procedure for periodontal homeostasis. Even after decades of these publications, studies on sensory profile following periodontal surgical procedures remain limited. The scarcity of research on this subject, along with variations in methodologies and test periods, impede an accurate comparative analysis. Therefore, it is necessary to conduct studies in this field to gain a better understanding of the consequences of this surgical procedure for the patient. Conclusion This study concluded that some minor somatosensory alterations may occur, but without impairment of important oral functions, reinforcing the positive outcomes, absence of major complications, and sequelae from root coverage procedures with SCTG. Declarations Acknowledgment: Authors would like to thank the support of the São Paulo Research Foundation (Fapesp- process# 2021/12909-0). Author Contribution : EBN- performed clinical examinations and treatments; TSJ- performed clinical examinations and treatments; LRB- made substantial contributions to conception of the study and contributed to the study design and development; ACPS- performed data analysis and interpretation; CAD- contributed to the study design and development; MSRZ- made substantial contributions to conception of the study; contributed to the study design and development; prepared the manuscript. Ethics Approval and Consent to Participate: The study was approved (CAAE: 18008919.5.0000.5417) by the Institutional Ethical Review Board of Bauru School of Dentistry – University of São Paulo (FOB-USP) according to Helsinki Declaration All patients signed a written informed consent form. Funding: The undergraduate student EBN has been awarded a scientific initiation scholarship from FAPESP - São Paulo Research Foundation (process# 2021/12909-0). 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Cite Share Download PDF Status: Published Journal Publication published 27 Sep, 2024 Read the published version in Clinical Oral Investigations → Version 1 posted Editorial decision: Revision requested 11 Aug, 2024 Reviews received at journal 10 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviews received at journal 29 Feb, 2024 Reviewers agreed at journal 17 Feb, 2024 Reviewers invited by journal 15 Feb, 2024 Submission checks completed at journal 12 Feb, 2024 Editor assigned by journal 12 Feb, 2024 First submitted to journal 01 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3917849","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":272470860,"identity":"84005d97-15f6-47f1-a1c0-db695aa87a32","order_by":0,"name":"Esther Belotti do Nascimento","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Esther","middleName":"Belotti do","lastName":"Nascimento","suffix":""},{"id":272470861,"identity":"04695950-44ad-4ddd-92f9-b3233668448d","order_by":1,"name":"Talyta Sasaki Jurkevicz","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Talyta","middleName":"Sasaki","lastName":"Jurkevicz","suffix":""},{"id":272470862,"identity":"f0b647e3-afab-4e07-8691-17b7b7ed3e75","order_by":2,"name":"Leonardo Rigoldi Bonjardim","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Leonardo","middleName":"Rigoldi","lastName":"Bonjardim","suffix":""},{"id":272470863,"identity":"e5a428fd-586d-46cf-9ce8-2d7febcfa8f5","order_by":3,"name":"Adriana Campos Passanesi Sant`Ana","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Adriana","middleName":"Campos Passanesi","lastName":"Sant`Ana","suffix":""},{"id":272470864,"identity":"ca6275e5-29ff-481f-bcf8-22de53fbcaa1","order_by":4,"name":"Carla Andreotti Damante","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Carla","middleName":"Andreotti","lastName":"Damante","suffix":""},{"id":272470865,"identity":"1187bee7-ca14-433d-ba29-7b490d7c2c73","order_by":5,"name":"Mariana Schutzer Ragghianti Zangrando","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYJCCA0Asx97AA+EZEKvFmOcAKVpAILGHaC267WcfHvi5wy69h733ADPPnzsM5tIH8GsxO5NucLD3THJuD8+5BGbetmcMln0JBLQcSGM4wNvGnLtfIseAmbfhMIPBGQIOMzv/jOHg37b6dB6QFp4/xGi5kcZwmLftcAJECxtRWp4xHJZtO24I8svBuW3PeCx7CDosjfnj27ZqeR723oMP3vy5I2fOQ0ALCjgARCRpgOkaBaNgFIyCUYAGACcVRJUH2F6wAAAAAElFTkSuQmCC","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Mariana","middleName":"Schutzer Ragghianti","lastName":"Zangrando","suffix":""}],"badges":[],"createdAt":"2024-02-01 15:03:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3917849/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3917849/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00784-024-05933-7","type":"published","date":"2024-09-27T15:58:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51140752,"identity":"d9a1a214-2aed-4d31-995d-54fdbdfa7d9f","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":806460,"visible":true,"origin":"","legend":"\u003cp\u003eGingival recessions on recipient area.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/08cdc60d154c383e9e96277e.jpg"},{"id":51140751,"identity":"ac6521eb-24db-482e-a906-509b702637f6","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1831347,"visible":true,"origin":"","legend":"\u003cp\u003eOblique incisions and intrasulcular incisions for the subsequent coronal displacement of the flap.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/d749d5de54d3b2ab25371d6c.jpg"},{"id":51140755,"identity":"d3df4b4b-39a3-4212-9d39-8ceb0b1eb259","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2330194,"visible":true,"origin":"","legend":"\u003cp\u003eSCTG harvested from the palatal posterior area (de-epithelized gingival graft technique).\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/e00122a98d6056c2e9b95965.jpg"},{"id":51141565,"identity":"44a342c5-5e06-4ba1-bb0a-27a99a535b85","added_by":"auto","created_at":"2024-02-14 20:22:41","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1891629,"visible":true,"origin":"","legend":"\u003cp\u003eSCTG positioned and sutured at the level of the cemento enamel junction.\u003c/p\u003e","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/0603595e6b6f6d4d71896338.jpg"},{"id":51141147,"identity":"b82f006a-a47b-41ec-a7cf-d862be544b26","added_by":"auto","created_at":"2024-02-14 20:14:41","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2182483,"visible":true,"origin":"","legend":"\u003cp\u003eCoronally advanced flap stabilized with non-resorbable monofilament sutures.\u003c/p\u003e","description":"","filename":"Fig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/09b1c4134056bd0fc4b57bdf.jpg"},{"id":51140757,"identity":"0a1764c3-ffe3-4c1b-b91e-7efc44afc48e","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":998607,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical postoperative recipient areas after 30 days, 2, 3, and 6 months, respectively.\u003c/p\u003e","description":"","filename":"Fig6.30days.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/eedc879919796204d1714a57.jpg"},{"id":51140759,"identity":"df0ad6fd-1750-445c-b998-2263c512c712","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1253925,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical postoperative recipient areas after 30 days, 2, 3, and 6 moths, respectively.\u003c/p\u003e","description":"","filename":"Fig7.2mo.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/b982efdb68f46efc020ae270.jpg"},{"id":51140761,"identity":"e032cb21-8f12-45d5-b114-f43c8d413be2","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":1029424,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical postoperative recipient areas after 30 days, 2, 3, and 6 months, respectively.\u003c/p\u003e","description":"","filename":"Fig8.3mo.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/e6dde97e7970531100db6d05.jpg"},{"id":51140764,"identity":"09fa3c4f-bad1-41c1-ba78-883b5fc8f86a","added_by":"auto","created_at":"2024-02-14 20:06:42","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":918473,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical postoperative recipient areas after 30 days, 2, 3, and 6 months, respectively.\u003c/p\u003e","description":"","filename":"Fig9.6mo.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/b2a65d82046c1b7d7d228800.jpg"},{"id":51140758,"identity":"f068e32f-1fa9-43a0-a325-7ff8f8d925f4","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":2153008,"visible":true,"origin":"","legend":"\u003cp\u003eQualitative sensory evaluation using a metal spatula, bristles of a toothbrush, a flexible cotton swab, and a wooden stick.\u003c/p\u003e","description":"","filename":"Fig10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/3bd52470973b0408b7bfad83.jpg"},{"id":51140763,"identity":"8fa3e6fd-4963-406b-9519-d05f2da864c3","added_by":"auto","created_at":"2024-02-14 20:06:42","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":2602981,"visible":true,"origin":"","legend":"\u003cp\u003eQualitative sensory evaluation using a metal spatula, bristles of a toothbrush, a flexible cotton swab, and a wooden stick.\u003c/p\u003e","description":"","filename":"Fig11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/94cbb260ad5478557394ffe6.jpg"},{"id":51140760,"identity":"48b145ea-5379-48b5-96de-7b1292c1dd67","added_by":"auto","created_at":"2024-02-14 20:06:41","extension":"jpg","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":1915798,"visible":true,"origin":"","legend":"\u003cp\u003eQualitative sensory evaluation using a metal spatula, bristles of a toothbrush, a flexible cotton swab, and a wooden stick.\u003c/p\u003e","description":"","filename":"Fig12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/470b7434c908f35411ded477.jpg"},{"id":51141149,"identity":"800ba0e9-3f03-4836-820f-eb7cedfc0273","added_by":"auto","created_at":"2024-02-14 20:14:41","extension":"jpg","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":2213860,"visible":true,"origin":"","legend":"\u003cp\u003eQualitative sensory evaluation using a metal spatula, bristles of a toothbrush, a flexible cotton swab, and a wooden stick.\u003c/p\u003e","description":"","filename":"Fig13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/78c16e4a5f8c7c3b8abbeefe.jpg"},{"id":65627593,"identity":"dd2ce0d2-f3d5-47df-99e5-ac6e2b63221f","added_by":"auto","created_at":"2024-09-30 16:16:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":22690346,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3917849/v1/8abc2a60-f386-4950-a12e-ab75ac24cd42.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Qualitative somatosensory evaluation of recipient and donor sites of subepithelial connective tissue grafts","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRoot coverage procedures represent one of the most extensively investigated techniques within periodontal plastic surgeries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This is attributed not only to the high prevalence of GR, leading to aesthetic discomfort and dental sensitivity but also to the inherent complexity of these techniques. Numerous studies [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] have assessed root coverage procedures using clinical parameters that can be precisely measured by examiners. However, patient-centered outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and potential sensory changes need to be further explored [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies investigating the treatment of gingival recessions (GR) using SCTG plus coronal advanced flap (CAF)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] often lack insights into how patients perceive and evaluate these improvements, including changes in painful or painless sensations in both the donor and recipient areas. For example, recipient areas that remain hyposensitive after surgical procedures may, supposedly, endure more substantial loads from traumatic brushing without the patient's awareness. In cases of hypersensitivity, the patient may experience pain during brushing, leading to biofilm accumulation.\u003c/p\u003e \u003cp\u003ePatient-related outcome measures (PROMs) following these procedures have typically focused on immediate postoperative outcomes, such as pain and swelling, or dental sensitivity and aesthetic aspects [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Roccuzzo et al. (2002) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] recommended that any evaluation of \u0026ldquo;success\u0026rdquo; should also include the patient\u0026rsquo;s own opinion concerning factors such as postoperative esthetics, possible discomfort, and sensitivity. However, there is a limited literature addressing the assessment of soft tissue sensory function after gingival graft procedures.\u003c/p\u003e \u003cp\u003eA study involving the sensory evaluation of 15 recipient areas treated with SCTG for root coverage [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] utilized two types of stimulation tests (surface and deep sensations). After 12 months, the results demonstrated that in 50% (7 out of 15) of the surgical sites, patients experienced difficulties in identifying and recognizing stimuli applied to the gingiva in those areas.\u003c/p\u003e \u003cp\u003eConsidering grafts donor sites, a study [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] evaluated sensibility and discomfort (n\u0026thinsp;=\u0026thinsp;36) in the first and eighth weeks after surgery, using pressure and friction movements. Sensibility assessments conducted before surgery did not reveal any disorders in any of the participants. Complete sensibility was regained in all patients after 8 weeks, with all patients reporting no loss of sensation. Harris et al (2005) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] observed in a larger sample (n\u0026thinsp;=\u0026thinsp;500), temporary paresthesia in SCTG donor area in 2 patients (0.4%) and paresthesia that continued beyond final postoperative appointment (3 months) in one patient (0.2%). A pilot study conducted by Buff et al. (2009) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], included 14 participants and utilized neurosensory tests (2-point, soft-touch, pin-tactile and thermal discrimination) only in donor sites. Twelve patients had never noticed any dysfunction. However, two patients reported a persistent numbness or a rough palatal surface after 20 and 51 months postoperatively. Authors related that some sensory changes could occur after graft harvesting from the palate.\u003c/p\u003e \u003cp\u003eA preliminary observational case-control study conducted by our research group[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] aimed to provide a qualitative assessment of the somatosensory profile in both the recipient and palatal donor sites following root coverage procedures utilizing SCTG. Patients (n\u0026thinsp;=\u0026thinsp;18) were evaluated at 6 months postoperatively (G6) and a complementary group not submitted to SCTG (control) was selected to validate the measurements protocols. In the G6 group, the qualitative test showed significant differences in pressure hyposensitivity in recipient sites and thermal and tactile hyposensitivity in donor sites (p\u0026thinsp;=\u0026thinsp;0.04). There were no significant differences in sensory acuity by the Two-point test. Comparisons in control group did not present changes, and normal sensitivity was reported. The DN4 questionnaire revealed normal sensitivity in grafted and palatal donor sites.\u003c/p\u003e \u003cp\u003eThe current prospective investigation assessed the somatosensory characteristics of both SCTG recipient and donor sites in a more extensive sample using established tests commonly employed in sensory research [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHence, it is crucial to determine whether possible somatosensory alterations occur in graft recipient and donor sites. Gaining insights into potential complications and aftereffects following these treatments will provide additional knowledge regarding the postoperative outcomes of SCTG, facilitating appropriate patient counseling.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThe study was approved (CAAE: 18008919.5.0000.5417) by the Institutional Ethical Review Board of Bauru School of Dentistry \u0026ndash; University of S\u0026atilde;o Paulo (FOB-USP) according to Helsinki Declaration and registered in ReBEC (Brazilian Registry of Clinical Trials (#RBR-7zz3b6p). This prospective observational study was conducted at the clinical facility of the Discipline of Periodontology at the Bauru School of Dentistry, University of S\u0026atilde;o Paulo. All patients who wished to participate in the research signed a written informed consent form. The sample consisted of systemically healthy individuals aged 18 to 70 years, following the inclusion criteria: normal and healthy palatal area, multiple GR (RT1), including canines and/or premolars. Exclusion criteria included patients with prostheses with palatal coverage, palatal areas previously submitted to graft removal, teeth mobility, smokers, pregnant and lactating women, history of periodontal disease or recurrent abscess formation, previously root coverage surgical procedures, use of medications [anticonvulsants, antihypertensives, contraceptives, or immunosuppressants] or drugs that influence wound healing, and a low level of oral hygiene (plaque index and bleeding index\u0026thinsp;\u0026gt;\u0026thinsp;20%).\u003c/p\u003e\n\u003cp\u003eAll selected patients underwent basic periodontal procedures (scaling, root planing, and oral hygiene instructions). GR were treated with SCTG and CAF under magnification (3.5X). In the recipient areas (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), oblique incisions (from the cemento-enamel junction to the gingival margin of the adjacent tooth) and intrasulcular incisions were performed designing surgical and anatomical papillae for the subsequent coronal displacement of the flap [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e] (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The incisions were made with a number 15C scalpel blade and the interdental papilla region was deepithelialized. Partial flap thickness was made laterally to the GR and full thickness up to mucogingival junction. Apically, a partial flap was performed, eliminating muscular tensions, and allowing mobility to accommodate the flap coronally to the cemento-enamel junction [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Root surfaces were scaled with periodontal curettes. The SCTG was harvested from the palatal posterior area (de-epithelized gingival graft technique) (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), with standardized grafts of mesio-distal extension of two teeth (canine/premolar or 2 premolars) and a height of 7 mm. The graft thickness was also standardized at 1.5 mm. Epithelial removal was performed with light reflector and magnification [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. The SCTG was positioned and sutured at the level of the cemento enamel junction (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) and flap was coronally advanced (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e), using non-resorbable monofilament sutures (6\u0026thinsp;\u0026minus;\u0026thinsp;0). Simple sutures were made in the palatal region and removed after 7 days. Sutures in the recipient area were removed 15 days post-surgical procedure.\u003c/p\u003e\n\u003cp\u003eThe participants were administered 200 mg of Nimesulide (2 times per day) on the first and second days and 100 mg of Nimesulide (2 times per day) on the third and fourth days. In case of pain, they could use 750 mg Paracetamol tablets every 6 hours. Chlorhexidine digluconate mouth rinses were prescribed for 15 days (2 times per day). After suture removal, patients were instructed to carefully maintain oral hygiene and were followed up after 30 days, 2, 3, and 6 months (Figs. 6\u0026ndash;9).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eSomatosensory Profile\u003c/h2\u003e\n \u003cp\u003eQualitative sensory evaluations (QualST) were conducted in grafted areas compared to adjacent non-grafted areas and in donor areas compared to adjacent areas without intervention at three time points (baseline and after 3 and 6 months). Assessments of adjacent non-intervened areas are essential for intrapersonal comparison of somatosensory characteristics, validating the methodology employed. The protocol was performed using a metal spatula (previously immersed in a container of ice-cold water), bristles of a toothbrush, a flexible cotton swab, and a wooden stick (Fig.\u0026nbsp;10\u0026ndash;13). These instruments assessed dynamic tactile, cold thermal, and painful sensations [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Participants were asked to report hypo (hyposensitive: -1), hyper (hypersensitive: +1), or normosensitivity (normosensitive: 0) when comparing the surgical areas (donor and recipient sites) to adjacent non-intervened areas.\u003c/p\u003e\n \u003cp\u003eThe DN4 questionnaire was administered at 3 and 6 months postoperatively to assess items related to painful or non-painful sensations, using descriptive terms such as burning, painful cold sensation, electric shock, prickling, and tingling. For non-painful sensations, descriptors such as burning, electric shock, tingling, numbness, and itching were also employed [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, in the case of a positive response to painful or non-painful sensations, the frequency and duration were reported, as well as whether induced by brushing or chewing. The questionnaire also included a visual analog scale regarding the impact of these painful or non-painful sensations on the ability to perform oral functions (chewing, speaking, brushing, etc.). This instrument was translated and validated in Portuguese [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eFor the Two-point Acuity Test (Touch-test), a dry-pointed caliper was used, with its tips spaced (using a caliper) at standardized intervals of 1 mm to 15 mm. When the participant distinguished the sensation of touch from two points, this measurement was recorded. The test was conducted horizontally and vertically in both recipient and donor areas, as well as in adjacent non-intervened areas at baseline, 3 and 6 months.\u003c/p\u003e\n \u003cp\u003eThe examiner\u0026apos;s calibration was performed by calculating the intraclass correlation coefficient, resulting in a value of 0.84. Calibration involved the assessment of 10 individuals, applying the QualST and Two-point tests, and one week later, the tests were repeated. Due to the novel nature of the study, a convenience sample was utilized, totaling 31 patients. Statistical analyses compared the parameters between donor and recipient areas with their respective adjacent non-intervened areas and assessed potential differences in sensory parameters at different time points (baseline, 3 and 6 months postoperatively). Descriptive statistics were employed, the non-parametric Kruskal Wallis test was used to evaluate QualST, and ANOVA was applied to analyze the Two-point test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 82 patients were examined, of which 43 did not meet the eligibility criteria (systemic diseases, medication use, use of prostheses with palatal coverage, RT 2 GR). Thirty-nine patients were included and treated, but 8 did not attend the follow-ups (at 3 and 6 months) due to reasons such as relocation to another city or personal reasons (flu-like symptoms, family illness, new employment, COVID-19). The final sample consisted of 31 patients, comprising 20 women and 11 men, with a mean age of 34.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5 years.\u003c/p\u003e \u003cp\u003eThe QualST of grafted and homologous areas did not demonstrate significant differences in the cotton swab test (tactile), toothpick pressure (pressure), and thermal with a cold spatula (thermal) based on the non-parametric Kruskal-Wallis test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Some results that showed differences between grafted and homologous areas were mostly values\u0026thinsp;\u0026lt;\u0026thinsp;0, indicating the possibility of hyposensitivity, except for the tactile test, which had a value of =\u0026thinsp;0 (normosensitive) in all groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The test using the brush showed significant hyposensitivity after 3 months (p\u0026thinsp;=\u0026thinsp;0.03) compared to the other groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of qualitative sensorial evaluations considering baseline, 3 and 6 months postoperativelly for recipiente and donor sites (p\u0026thinsp;\u003cem\u003e\u0026lt;\u0026thinsp;0,05).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3M\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6M\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecipient sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e-TACTILE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e-BRUSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0,03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e-PRESSURE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-0,5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e-THERMAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDonor sites\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e- TACTILE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-0,75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e- BRUSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e- PRESSURE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e75%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e- THERMAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0,01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the donor areas, only thermal evaluation showed a significant difference between baseline and after 3 and 6 months (p\u0026thinsp;=\u0026thinsp;0.01), being hypersensitive after 3 months and hyposensitive after 6 months. The tactile test demonstrated a tendency towards hypersensitivity (\u0026gt;\u0026thinsp;0) after 3 months and hyposensitivity after 6 months. The pressure and brush tests also showed a tendency towards hypersensitivity in the 3-month group but normosensitivity after 6 months.\u003c/p\u003e \u003cp\u003eAt baseline, all evaluations in both grafted and donor areas were normosensitive (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This result reinforced the validity of the methodology without alterations in the somatosensory profile.\u003c/p\u003e \u003cp\u003eThe descriptive analysis of the DN4 test showed that patients reported no pain in grafted and donor areas, and the majority also did not report non-painful sensations in these areas. However, when non-painful sensations were present, it was numbness in the grafted area (3.14% of patients) and donor area (18.4%). Another sensation found in the grafted and palatal areas was an electric shock sensation in 1.3% of participants. The duration of these sensations was described as indefinite, and the frequency was primarily related to brushing and eating. The degree to which this alteration in sensation impaired oral functions such as chewing, speaking, or tooth brushing showed that over 92% of participants rated this intensity as 0, indicating no impairment in oral functions.\u003c/p\u003e \u003cp\u003eThe parametric ANOVA test was used to compare the Two-point sensory acuity test between time points and in the grafted and donor areas (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No significant differences in sensory acuity (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) were found in both vertical and horizontal directions between the different assessment periods in grafted and donor areas.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVertical and horizontal two-point test for recipient and donor areas at baseline, 3 and 6 months postoperatively.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGROUPS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVertical 2 point (RECIPIENT)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHorizontal 2 point (RECIPIENT)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVertical 2 point (DONOR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHorizontal 2 point (DONOR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3,94\u0026thinsp;\u0026plusmn;\u0026thinsp;3,95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3,57\u0026thinsp;\u0026plusmn;\u0026thinsp;3,20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3,15\u0026thinsp;\u0026plusmn;\u0026thinsp;1,83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e3,75\u0026thinsp;\u0026plusmn;\u0026thinsp;2,61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eG3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4,67\u0026thinsp;\u0026plusmn;\u0026thinsp;5,31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4,50\u0026thinsp;\u0026plusmn;\u0026thinsp;4,69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4,34\u0026thinsp;\u0026plusmn;\u0026thinsp;5,37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e4,12\u0026thinsp;\u0026plusmn;\u0026thinsp;4,77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eG6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4,20\u0026thinsp;\u0026plusmn;\u0026thinsp;4,41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4,58\u0026thinsp;\u0026plusmn;\u0026thinsp;4,34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4,25\u0026thinsp;\u0026plusmn;\u0026thinsp;4,74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e4,40\u0026thinsp;\u0026plusmn;\u0026thinsp;4,50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present investigation revealed that recipient and donor sites of SCTG could demonstrate sensorial alterations without compromising oral functions. These results reinforce the positive outcomes achieved from the surgical procedures for root coverage. In this prospective evaluation, only brush test revealed hyposensitivity after 3 months in recipient sites. In the donor areas, hypersensitivity (thermal test) was observed at 3 months, and hyposensitivity (thermal test) was observed at 6 months. In a preliminary observational case-control study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], a trend towards hyposensitivity was also observed after 6 months in both the recipient (pressure test) and donor areas (thermal and tactile tests). The results were similar for DN4 questionnaire and the two-point acuity test. However, in the present investigation, non-painful sensory perception (numbness) was reported, in recipient and donor areas.\u003c/p\u003e \u003cp\u003ePrevious studies used different methodologies for sensorial assessment. Only one evaluated recipient site [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and three investigated donor areas [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], demonstrating a tendency towards hyposensitivity in both sites. Aimetti et al. (2010) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] evaluated alterations in recipient sites of SCTG that were divided into two groups: parestehesias, loss of epicritical sensation and anesthesias, loss of both epicritical and protopatical sensations. After 12 months, 50% of the patients reported difficulties in recognizing and responding to stimuli applied to the gingiva in those specific areas. In five sites, patients developed complete anesthesia and in one site only paresthesia. Del Pizzo et al. (2002) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] assessed the sensitivity and discomfort of graft donor sites at 1, 2, 3, 4, 6, and 8 weeks following surgery. Authors compared three techniques for harvesting SCTG (free gingival graft, trap door and single incision). After 2 weeks, single incision group showed a faster recovery in terms of sensibility, although this result was not statistically significant compared to other groups (25% for the single incision, 8% for the trap door and 0% for free gingival graft). Loss of sensation was observed in all periods of evaluation with complete recovery after 8 weeks, with no differences among groups. Nonetheless, the complete restoration of sensibility, although expedited in the single incision group when compared to the other two groups, required a minimum of 8 weeks for most of the patients. The more rapid recovery in the single incision group could be due to the unique incision of the epithelial layer, which involves a minor number of sensory receptors. Although it occurred in a small percentage of the sample, Harris et al (2005) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] described temporary and persistent donor-site paresthesia as moderate and severe complications of SCTG harvesting. Comparably to our studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], Buff et al (2009) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] qualitatively evaluated SCTG donor sites, but with parallel incision technique. Although the methodology was similar, authors used discrimination between points for all sensations only in donor sites, while our study categorized sensations as normal, hyposensitive, or hypersensitive in relation to the non-operated sites (recipient and donor). In this pilot study, authors used neurosensory tests at the palate performed postoperatively including minimal 2-point discrimination, soft-touch, pin-tactile and thermal discrimination. They demonstrated that 86% of the patients never noted any dysfunction in the oral or palatal region at any time following graft harvesting. Two patients reported a persistent numbness or a rough palatal surface. Authors confirmed that some sensory changes can occur after graft harvesting from the palate. Patients may experience temporary sensory dysfunction following palatal harvesting, as free nerve endings might be severed intraoperatively [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study the technique used for graft harvesting was de-epithelized graft. Palatal soft tissue healing by secondary intention is characterized by a larger tissue deficit that requires a longer healing time and is susceptible to a greater risk of infection or scarring [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Altered tissue perfusion can be detected with temporary paresthesia following free gingival graft harvesting [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].This may justify the results observed in this study, which showed hypersensitivity at the 3-month evaluation and subsequently hyposensitivity.\u003c/p\u003e \u003cp\u003ePeriodontal plastic surgeries with soft tissue grafts are procedures orientated to root coverage. Unfortunately, there is no entire comprehension of the physiological mechanisms leading to the epithelial-connective wound healing. Aimetti et al. (2010) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] demonstrated that sensorial alterations occur in recipient sites also after complete root coverage and clinical success of the surgery. This success anyway should ensure not only the esthetic integration between the tissues but also the physiological activity of the graft in terms of sensitivity and immunity, because the skin and the mucosae constitute the first natural specific borders against pathogens [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Considering the protective role of gingival tissue, Graziani et al (2014) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] evaluated in split-mouth case-control study, clinical and biomolecular parameters to assess the level of inflammation of periodontal sites after treatment with SCTG (test) and healthy non-treated gingivae (control). Authors observed that sites treated with SCTG developed a lower degree of plaque-induced inflammation compared to healthy gingivae, showing the importance of the procedure for periodontal homeostasis.\u003c/p\u003e \u003cp\u003eEven after decades of these publications, studies on sensory profile following periodontal surgical procedures remain limited. The scarcity of research on this subject, along with variations in methodologies and test periods, impede an accurate comparative analysis. Therefore, it is necessary to conduct studies in this field to gain a better understanding of the consequences of this surgical procedure for the patient.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study concluded that some minor somatosensory alterations may occur, but without impairment of important oral functions, reinforcing the positive outcomes, absence of major complications, and sequelae from root coverage procedures with SCTG.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u0026nbsp;\u003c/strong\u003eAuthors would like to thank the support of the S\u0026atilde;o Paulo Research Foundation (Fapesp- process# 2021/12909-0).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eEBN- performed clinical examinations and treatments;\u003c/p\u003e\n\u003cp\u003eTSJ- performed clinical examinations and treatments;\u003c/p\u003e\n\u003cp\u003eLRB- made substantial contributions to conception of the study and contributed to the study design and development;\u003c/p\u003e\n\u003cp\u003eACPS- performed data analysis and interpretation;\u003c/p\u003e\n\u003cp\u003eCAD- contributed to the study design and development;\u003c/p\u003e\n\u003cp\u003eMSRZ- made substantial contributions to conception of the study; contributed to the study design and development; prepared the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved (CAAE: 18008919.5.0000.5417) by the Institutional Ethical Review Board of Bauru School of Dentistry \u0026ndash; University of S\u0026atilde;o Paulo (FOB-USP) according to Helsinki Declaration All patients signed a written informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe undergraduate student EBN\u0026nbsp;has been awarded a scientific initiation scholarship from FAPESP - S\u0026atilde;o Paulo Research Foundation (process# 2021/12909-0).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflict of interest. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGraziani A, Cirillo N, Pallotti S, Cricenti L, Romano F, Aimetti M (2014) Unexpected resilience to experimental gingivitis of subepithelial connective tissue grafts in gingival recession defects: a clinical-molecular evaluation. J Periodontal Res 49: 527\u0026ndash;535. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jre.12133\u003c/span\u003e\u003cspan address=\"10.1111/jre.12133\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonetti MS, Jepsen S (2014) Clinical efficacy of periodontal plastic surgery procedures: Consensus Report of Group 2 of the 10th European Workshop on Periodontology. J Clin Periodontol 41 (Suppl. 15): S36\u0026ndash;S43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpe.12219\u003c/span\u003e\u003cspan address=\"10.1111/jcpe.12219\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCairo F, Pagliaro U, Buti J, et al (2016) Root coverage procedures improve patient aesthetics. 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Wound Repair Regen 27: 59\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/wrr.12685\u003c/span\u003e\u003cspan address=\"10.1111/wrr.12685\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Periodontics, gingival graft, connective tissue graft, qualitative sensory testing, somatosensory function","lastPublishedDoi":"10.21203/rs.3.rs-3917849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3917849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe subepithelial connective tissue graft (SCTG) plus coronal advanced flap is commonly evaluated by clinical parameters, but potential sensory changes (patients\u0026rsquo; perception of painful or painless sensations) need to be further explored. This study aimed to qualitatively evaluate the somatosensory profile of recipient and palatal donor sites of SCTG.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eSensory tests were applied at SCTG recipient and donor sites at baseline, after 3 and 6 months. A single calibrated examiner applied Douleur Neuropathique 4 questionnaire (DN4), qualitative sensory test (QualST), discriminating the areas as hypersensitive, hyposensitive or normosensitive, and two-point acuity test. Descriptive statistics, non-parametric Kruskal Wallis test for QualST evaluation and ANOVA for Two-point test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were used.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eQualST revealed that recipient areas presented no significant differences in tactile, pressure and thermal tests. Brush test revealed hyposensitivity after 3 months (p\u0026thinsp;=\u0026thinsp;0.03). In donor areas, only thermal evaluation showed a significant difference (p\u0026thinsp;=\u0026thinsp;0.01), being hypersensitive after 3 months and hyposensitive after 6 months. At baseline, all evaluations in recipient and donor areas were normosensitive. According to DN4, no patient reported pain in recipient and donor sites. Non-painful sensory perception was reported as numbness in recipient (3.14% of patients) and donor (18.4%) areas. No significant differences were found for two-point acuity test values.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e The extent to which these alterations in sensations affected oral functions showed no impairment. \u003cb\u003eClinical Relevance\u003c/b\u003e: Although some punctual somatosensory changes occurred, they did not disable important oral functions, thus reinforcing the positive results obtained with periodontal plastic surgeries.\u003c/p\u003e","manuscriptTitle":"Qualitative somatosensory evaluation of recipient and donor sites of subepithelial connective tissue grafts","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-14 20:06:36","doi":"10.21203/rs.3.rs-3917849/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-11T10:02:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-10T11:54:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59644562657407735487937768042312948657","date":"2024-08-07T15:40:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-29T13:06:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"07592ee5-5a13-4364-b2dd-21d16b549d8c","date":"2024-02-17T19:35:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-15T11:46:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-12T16:14:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-12T16:14:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2024-02-01T14:52:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"85e9b4b8-0db3-4fd5-930b-a45e754817fd","owner":[],"postedDate":"February 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:08:09+00:00","versionOfRecord":{"articleIdentity":"rs-3917849","link":"https://doi.org/10.1007/s00784-024-05933-7","journal":{"identity":"clinical-oral-investigations","isVorOnly":false,"title":"Clinical Oral Investigations"},"publishedOn":"2024-09-27 15:58:17","publishedOnDateReadable":"September 27th, 2024"},"versionCreatedAt":"2024-02-14 20:06:36","video":"","vorDoi":"10.1007/s00784-024-05933-7","vorDoiUrl":"https://doi.org/10.1007/s00784-024-05933-7","workflowStages":[]},"version":"v1","identity":"rs-3917849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3917849","identity":"rs-3917849","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}