Novel Modifications in Endodontic Bioceramics to Improve their Properties: A Narrative Review

Enteghad, Maryam; Zerafat, Mahdi; Hadian, Saleh; Ghahramani, Yasamin

doi:10.30476/dentjods.2025.104239.2513

Novel Modifications in Endodontic Bioceramics to Improve their Properties: A Narrative Review

Document Type : Literature Review

Authors

Maryam Enteghad ¹

Mahdi Zerafat ¹

Saleh Hadian ¹

Yasamin Ghahramani ²

¹ Postgraduate Student Dept. of Endodontics, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran.

² Dept. of Endodontics, School of Dentistry, Oral and Dental Disease Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

https://doi.org/10.30476/dentjods.2025.104239.2513

Abstract

Bioceramics (BCs) have gained significant popularity in various dental applications, including regenerative procedures, apexification, and root-end filling obturation, due to their remarkable characteristics, such as biocompatibility, sealing ability, and bioactivity. Despite their versatile applications, these materials possess few drawbacks, including extended setting time, discoloration, granular consistency, and complex handling. It is imperative to consider reformulating these materials in order to improve their properties and meet their special needs. Additionally, further research is needed to ensure their safety for clinical use. In recent decades, modifications in mineral trioxide aggregate (MTA) composition and properties have been a topic of research interest. This study aims to review recent advancements in modifying the chemical, mechanical, and biological properties of this versatile material and introduce some new commercial products to help practitioners select their required material wisely and assist researchers in planning future investigations.

Highlights

Yasamin Ghahramani (Google Scholar)

Keywords

Bioceramic

Biocompatibility

Discoloration

Mineral Trioxide Aggregate

Regeneration

Zafar MJ, Zhu D, Zhang Z. 3D Printing of Bioceramics for Bone Tissue Engineering. Materials. 2019; 12: 3361.
Salah M, Tayebi L, Moharamzadeh K, Naini FB. Three- dimensional bio-printing and bone tissue engineering: technical innovations and potential applications in maxillofacial reconstructive surgery. Maxillofac Plast Reconstr Surg. 2020; 42: 18.
Baino F, Vitale-Brovarone C. Bioceramics in ophthalmology. Acta Biomater. 2014; 10: 3372-3397.
Jafari N, Habashi MS, Hashemi A, Shirazi R, Tanideh N, Tamadon A. Application of bioactive glasses in various dental fields. Biomater Res. 2022; 26: 31.
Shenoy A, Shenoy N. Dental ceramics: An update. J Conserv Dent. 2010; 13: 195-203.
Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. The use of bioceramics in endodontics: literature review. Clujul Med. 2016; 89: 470-473.
Rahaman MN, Day DE, Bal BS, Fu Q, Jung SB, Bonewald LF, et al. Bioactive glass in tissue engineering. Acta Biomater. 2011; 7: 2355-2373.
Wilson CJ, Clegg RE, Leavesley DI, Pearcy MJ. Mediation of biomaterial-cell interactions by adsorbed proteins: a review. Tissue Eng. 2005; 11: 1-18.
Mangat P, Azhar S, Singh G, Masarat F, Yano N, Sah S. Bioceramics in Endodontics: A Review. Int J Oral Care Res. 2021; 9: 59-62.
Thamaraiselvi TV, Rajeswari S. Biological evaluation of bioceramic materials: A review. Trends Biomater Artif Organs. 2004; 18: 9.
Boch P, Baumard JF. Ceramic Compounds: Ceramic Materials. Ceramic Materials: Processes, Properties, and Applications. 1th ed. USA: ISTE; 2007. p. 1-28.
Raghavendra SS, Jadhav GR, Gathani KM, Kotadia P. Bioceramics in endodontics: A review. J Istanb Univ Fac Dent. 2017; 51(3 Suppl 1): S128-S137.
Tomer A, Kumari D, Rastogi D, Cecilia LL, Singh D, Tyagi A. Bioceramics in Endodontics: A Review. Int J Appl Dent Sci. 2020; 6: 588-594.
Danesh G, Dammaschke T, Gerth HU, Zandbiglari T, Schäfer E. A comparative study of selected properties of ProRoot mineral trioxide aggregate and two Portland cements. Int Endod J. 2006; 39: 213-219.
Islam I, Chng HK, Yap AU. Comparison of the physical and mechanical properties of MTA and Portland cement. J Endod. 2006; 32: 193-197.
De-Deus G, Audi C, Murad C, Fidel S, Fidel R. Similar expression of through-and-through fluid movement along orthograde apical plugs of MTA Bio and white Portland cement. Int Endod J. 2008; 41: 1047-1053.
Shahi S, Yavari HR, Rahimi S, Eskandarinezhad M, Shakouei S, Unchi M. Comparison of the sealing ability of mineral trioxide aggregate and Portland cement used as root-end filling materials. J Oral Sci. 2011; 53: 517-522.
Dammaschke T, Gerth HU, Züchner H, Schäfer E. Chemical and physical surface and bulk material characterization of white Pro- Root MTA and two Portland cements. Dent Mater. 2005; 21: 731- 738.
Komabayashi T, Spångberg LS. Comparative analysis of the particle size and shape of commercially available mineral trioxide aggregates and Portland cement: a study with a flow particle image analyzer. J Endod. 2008; 34: 94-98.
Húngaro*Duarte MA, de*Oliveira*El*Kadre GD, Vivan RR, Guerreiro*Tanomaru JM, Tanomaru*Filho M, de*Moraes IG. Radiopacity of Portland cement associated with different radiopacifying agents. J Endod. 2009; 35: 737-740.
Camilleri J. Introduction to Mineral Trioxide Aggregate. In: Camilleri J, editor. Mineral Trioxide Aggregate in Dentistry, From Preparation to Application. 1th ed. Heidelberg New York Dordrecht London: Springer; 2014. p. 1-18.
Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt*Ford TR. Biocompatibility of two commercial forms of mineral trioxide aggregate. Int Endod J. 2004; 37: 699-704.
Lotfi M, Vosoughhosseini S, Saghiri MA, Rahimi S, Zand V, Reyhani MF, et al. Effect of synthetic tissue fluid on microleakage of Grey and White Mineral Trioxide aggregate as root-end filling materials: An in vitro study. Sultan Qaboos Univ Med J. 2012; 12: 323-329.
Al-Hezaimi K, Al-Shalan TA, Naghshbandi J, Oglesby S, Simon JH, Rotstein I. Antibacterial effect of two mineral trioxide aggregate (MTA) preparations against Enterococcus faecalis and Streptococcus sanguis in vitro. J Endod. 2006; 32: 1053-1056.
Bidar M, Moradi S, Jafarzadeh H, Bidad S. Comparative SEM study of the marginal adaptation of white and grey MTA and Port- land cement. Aust Endod J. 2007; 33: 2-6.
Parirokh M, Asgary S, Eghbal MJ, Stowe S, Eslami B, Eskandarizade A, et al. A comparative study of white and grey mineral trioxide aggregate as pulp capping agents in dog's teeth. Dent Traumatol. 2005; 21: 150-154.
Asgary S, Parirokh M, Eghbal MJ, Stowe S, Brink F. A qualitative X-ray analysis of white and grey mineral trioxide aggregate using compositional imaging. J Mater Sci Mater Med. 2006; 17: 187-191.
Nekoofar MH, Oloomi K, Sheykhrezae MS, Tabor R, Stone DF, Dummer PM. An evaluation of the effect of blood and human serum on the surface microhardness and surface microstructure of mineral trioxide aggregate. Int Endod J. 2010; 43: 849-858.
Cardoso-Silva C, Barbería E, Maroto M, García-Godoy F. Clinical study of Mineral Trioxide Aggregate in primary molars. Comparison between Grey and White MTA-a long term follow-up (84 months). J Dent. 2011; 39: 187-193.
Subramanyam D, Vasantharajan M. Effect of Oral Tissue Fluids on Compressive Strength of MTA and Biodentine: An In vitro Study. J Clin Diagn Res. 2017; 11: Zc94-Zc96.
Camilleri J. Modification of mineral trioxide aggregate. Physical and mechanical properties. Int Endod J. 2008; 41: 843-849.
Torabinejad DM. Calcium Silicate–Based Cements. In: Torabinejad DM, editor. Mineral Trioxide Aggregate, Properties and Clinical Applications. 1th ed. USA: Wiley; 2014. p. 315-316.
Camilleri J. The physical properties of accelerated Portland cement for endodontic use. Int Endod J. 2008; 41: 151-157.
Camilleri J, Montesin FE, Curtis RV, Ford TR. Characterization of Portland cement for use as a dental restorative material. Dent Mater. 2006; 22: 569-675.
Lee BN, Hwang YC, Jang JH, Chang HS, Hwang IN, Yang SY, et al. Improvement of the properties of mineral trioxide aggregate by mixing with hydration accelerators. J Endod. 2011; 37: 1433-1436.
Parirokh M, Asgary S, Eghbal MJ, Kakoei S, Samiee M. A comparative study of using a combination of calcium chloride and mineral trioxide aggregate as the pulp-capping agent on dogs' teeth. J Endod. 2011; 37: 786-788.
Camilleri J. Mineral Trioxide Aggregate in Dentistry from Preparation to Application. Camilleri J, editor. 1th ed. Heidelberg New York Dordrecht London: Springer; 2014. p. 206.
Kharouf N, Zghal J, Addiego F, Gabelout M, Jmal H, Haikel Y, et al. Tannic acid speeds up the setting of mineral trioxide aggregate cements and improves its surface and bulk properties. J Colloid Interface Sci. 2021; 589: 318-326.
Camilleri J, Formosa L, Damidot D. The setting characteristics of MTA Plus in different environmental conditions. Int Endod J. 2013; 46: 831-840.
Yousefi K, Manesh HD, Khalifeh AR, Gholami A. Fabrication and characterization of a nanofast cement for dental restorations. Biomed Res Int. 2021; 2021: 7343147.
Moazzami F, Sahebi S, Shirzadi S, Azadeh N. Comparative in vitro assessment of tooth color change under the influence of nano fast cement and MTA. J Dent. 2021; 22: 48-52.
Moazami F, Gholami A, Mehrabi V, Ghahramani Y. Evaluation of the antibacterial and antifungal effects of ProRoot MTA and Nano-fast cement: An in vitro study. J Contemp Dent Pract. 2020; 21: 760-764.
Akbari M, Zebarjad SM, Nategh B, Rouhani A. Effect of nano silica on setting time and physical properties of mineral trioxide aggregate. J Endod. 2013; 39: 1448-1451.
Bernardi A, Bortoluzzi EA, Felippe WT, Felippe MCS, Wan WS, Teixeira CS. Effects of the addition of nanoparticulate calcium carbonate on setting time, dimensional change, compressive strength, solubility and pH of MTA. Int Endo J. 2017; 50: 97-105.
Formosa LM, Mallia B, Camilleri J. A quantitative method for determining the antiwashout characteristics of cement-based dental materials including mineral trioxide aggregate. Int Endod J. 2013; 46: 179-186.
Parthasarathy H, Modak A, Yarmunja*Mahabala K, Natarajan S, Baliga S, Thomas M, et al. Comparative evaluation of sealing ability and adaptation of gel form of MTA to dentinal walls: an in vitro study. BDJ Open. 2024; 10: 86.
Prasad A, Pushpa S, Arunagiri D, Sawhny A, Misra A, Sujatha R. A comparative evaluation of the effect of various additives on selected physical properties of white mineral trioxide aggregate. J Conserv Dent. 2015; 18: 237-241.
Bernardi A, Bortoluzzi EA, Felippe WT, Felippe MC, Wan WS, Teixeira CS. Effects of the addition of nanoparticulate calcium carbonate on setting time, dimensional change, compressive strength, solubility and pH of MTA. Int Endod J. 2017; 50: 97-105.
Eskandarinezhad M, Ghodrati M, Pournaghi*Azar F, Jafari F, Samadi*Pakchin P, Abdollahi AA, et al. Effect of Incorporating Hydroxyapatite and Zinc Oxide Nanoparticles on the Compressive Strength of White Mineral Trioxide Aggregate. J Dent. 2020; 21: 300-306.
Samiei M, Aghazadeh M, Lotfi M, Shakoei S, Aghazadeh Z, Vahid*Pakdel SM. Antimicrobial Efficacy of Mineral Trioxide Aggregate with and without Silver Nanoparticles. Iran Endod J. 2013; 8: 166-170.
Kucukyildiz EN, Dayi B, Altin S, Yigit O. In vitro comparison of physical, chemical, and mechanical properties of graphene nano- platelet added Angelus mineral trioxide aggregate to pure Angelus mineral trioxide aggregate and calcium hydroxide. Microsc Res Tech. 2021; 84: 929-942.
Juenger MCG, Snellings R, Bernal SA. Supplementary cementitious materials: New sources, characterization, and performance insights. Cement and Concrete Research (JCCR). 2019; 122: 257-273.
Choi Y, Park SJ, Lee SH, Hwang YC, Yu MK, Min KS. Biological effects and washout resistance of a newly developed fast- setting pozzolan cement. J Endod. 2013; 39: 467-472.
Kogan P, He J, Glickman GN, Watanabe I. The effects of various additives on setting properties of MTA. J Endod. 2006; 32: 569- 572.
Mathew AI, Lee SC, Rossi-Fedele G, Bogen G, Nagendrababu V, Ha WN. Comparative evaluation of mineral trioxide aggregate obturation using four different techniques- a laboratory study. Materials (Basel). 2021; 14: 435.
Zerafat M, Enteghad M, Baghaei S, Asadi A, Ghahramani Y. Maxillary Second Molar with Five Root Canals and a Root-Like Enamel Pearl: A Rare Case Report. Iranian Endo J. 2025; 20: e6.
Ghoddusi J. Material modifications and related materials. Mineral Trioxide Aggregate in Dentistry: From Preparation to Application. 1th ed. USA: Springer; 2014. p. 131-149.
Alotaibi J, Saji S, Swain MV. FTIR characterization of the setting reaction of biodentine™. Dent Mater. 2018; 34: 1645-1651.
Akman M, Akbulut MB, Güneşer MB, Eldeniz AÜ. Effect of intracanal medicaments on the push-out bond strength of Bio-dentine in comparison with Bioaggregate apical plugs. J Adhes Sci Technol. 2016; 30: 459-467.
Yazdani A. Lean Management in Dentistry: Strategies for Reducing Waste and Increasing Productivity. J Oral Dental Health Nexus. 2024; 1: 53-60.
Debelian G, Trope M. The use of premixed bioceramic materials in endodontics. G Ital Endod. 2016; 30: 70-80.
Chavarria-Bolaños D, Komabayashi T, Vega-Baudrit J, Ulate E, Pereira-Reyes R, Montero-Aguilar M. Examining the Physicochemical Composition of Three Bioceramic Putties for Endodontic Use. Eur Endod J. 2024; 9: 210-217.
Persson C, Engqvist H. Premixed calcium silicate cement for endodontic applications. Biomatter. 2011; 1: 76-80.
Lozano-Guillén A, López-García S, Rodríguez-Lozano FJ, Sanz JL, Lozano A, Llena C, et al. Comparative cytocompatibility of the new calcium silicate-based cement NeoPutty versus NeoMTA Plus and MTA on human dental pulp cells: an in vitro study. Clin Oral Invest. 2022; 26: 7219-7228.
Prentice LH, Tyas MJ, Burrow MF. The effect of particle size distribution on an experimental glass-ionomer cement. Dent Mater. 2005; 21: 505-510.
Cintra LTA, Benetti F, de*Azevedo*Queiroz ÍO, de*Araújo*Lopes JM, Penha*de*Oliveira SH, Sivieri*Araújo G, et al. Cytotoxicity, Biocompatibility, and Biomineralization of the New High- plasticity MTA Material. J Endod. 2017; 43: 774-778.
Palczewska-Komsa M, Kaczor-Wiankowska K, Nowicka A. New Bioactive Calcium Silicate Cement Mineral Trioxide Aggregate Repair High Plasticity (MTA HP): A Systematic Review. Materials. 2021; 14: 4573.
Martins MD, Coelho FH, Moreira MS, Marques MM, Pilar EFS, Palo RM, et al. Cytotoxicity, biocompatibility and osteoinductive profile of an MTA-hydrogel-based cement: An in vitro and animal study. Int Endod J. 2023; 56: 955-967.
Bueno CRE, Vasques AMV, Cury MTS, Sivieri-Araújo G, Jacin-to RC, Gomes-Filho JE, et al. Biocompatibility and biomineralization assessment of mineral trioxide aggregate flow. Clin Oral In- vest. 2019; 23: 169-177.
Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some root end filling materials. J Endod. 1995; 21: 403-406.
Hernandez EP, Botero TM, Mantellini MG, McDonald NJ, Nör JE. Effect of ProRoot MTA mixed with chlorhexidine on apoptosis and cell cycle of fibroblasts and macrophages in vitro. Int Endod J. 2005; 38: 137-143.
Jacinto RC, Linhares-Farina G, Sposito OdS, Zanchi CH, Cenci MS. Influence of 2% chlorhexidine on pH, calcium release and setting time of a resinous MTA-based root-end filling material. Braz Oral Res. 2015; 29: S1806-83242015000100237.
Jafarnia B, Jiang J, He J, Wang YH, Safavi KE, Zhu Q. Evaluation of cytotoxicity of MTA employing various additives. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: 739- 744.
Saatchi M, Hosseini HS, Farhad AR, Narimany T. The effect of various concentrations of iodine potassium iodide on the antimicrobial properties of mineral trioxide aggregate--a pilot study. Dent Traumatol. 2012; 28: 474-477.
Shin JH, Ryu JJ, Lee SH. Antimicrobial activity and biocompatibility of the mixture of mineral trioxide aggregate and nitric oxide-releasing compound. J Dent Sci. 2021; 16: 29-36.
Ghahramani Y, Yaghoobi F, Motamedi R, Jamshidzadeh A, Abbaszadegan A. Effect of endodontic irrigants and medicaments mixed with silver nanoparticles against biofilm formation of enterococcus faecalis. Iranian Endo J. 2018; 13: 559.
Almeida LHS, Moraes RR, Morgental RD, Cava SS, Rosa WLO, Rodrigues P, et al. Synthesis of silver-containing calcium aluminate particles and their effects on a MTA-based endodontic sealer. Dent Mater J. 2018; 34: e214-e23.
Cheraghiyan M. Nanotechnology in Dentistry: Potential Applications and Future Perspectives. J Oral Dent Health Nexus. 2025; 2: 1-3.
Bohns FR, Leitune VCB, Garcia IM, Genari B, Dornelles NB, Guterres SS, et al. Incorporation of amoxicillin-loaded microspheres in mineral trioxide aggregate cement: an in vitro study. Restor Dent Endod. 2020; 45: e50.
Ravindran V, Jeevanandan G, Veeraraghavan VP, ElSherbiny M, Bohairi AL, Mardini YMR, et al. Comparative evaluation of physical and antimicrobial properties of metronidazole incorporated formulation of mineral trioxide aggregate-an invitro study. J Int Dent Med Res. 2024; 17: 127-135.
Camilleri J, Gandolfi MG. Evaluation of the radiopacity of calcium silicate cements containing different radiopacifiers. Int Endod J. 2010; 43: 21-30.
Cutajar A, Mallia B, Abela S, Camilleri J. Replacement of radiopacifier in mineral trioxide aggregate; characterization and determination of physical properties. Dent Mater. 2011; 27: 879-891.
De-Deus G, de*Souza MC, Sergio*Fidel RA, Fidel SR, de*Campos RC, Luna AS. Negligible expression of arsenic in some commercially available brands of Portland cement and mineral trioxide aggregate. J Endod. 2009; 35: 887-890.
Vivan RR, Zapata RO, Zeferino MA, Bramante CM, Bernardineli N, Garcia RB, et al. Evaluation of the physical and chemical properties of two commercial and three experimental root-end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: 250-256.
Gomes-Filho JE, de*Faria MD, Bernabé PF, Nery MJ, Otoboni-Filho JA, Dezan-Júnior E, et al. Mineral trioxide aggregate but not light-cure mineral trioxide aggregate stimulated mineralization. J Endod. 2008; 34: 62-65.
Tanomaru-Filho M, Morales V, da*Silva GF, Bosso R, Reis JM, Duarte MA, et al. Compressive Strength and Setting Time of MTA and Portland Cement Associated with Different Radiopacifying Agents. ISRN Dent. 2012; 2012: 898051.
Pelepenko LE, Marciano MA, Shelton RM, Camilleri J. Leaching and cytotoxicity of bismuth oxide in ProRoot MTA: A laboratory investigation. Int Endod J. 2024; 57: 1293-1314.
Asadi MR, Rezaei M, Ghahramani Y. Recent advances in bioactive materials for diagnosis and treatment of oral cancer advances in applied nano biotechnology. Adv Appl NanoBio Tech. 2023; 4: 21-35.
Peng TY, Chen MS, Chen YY, Chen YJ, Chen CY, Fang A, et al. Impact of Zr-Doped Bi2O3 Radiopacifier by Spray Pyrolysis on Mineral Trioxide Aggregate. Materials (Basel). 2021; 14: 453.
Hoseini MS, Naeeni SK. Aesthetic Considerations in Prosthodontics: A Literature Review. J Oral Dent Health Nexus. 2025; 2: 27-39.
De*Oliveira NG, de*Souza*Araújo PR, da*Silveira MT, Sobral APV, de*Vasconcelos*Carvalho M. Comparison of the biocompatibility of calcium silicate-based materials to mineral trioxide aggregate: Systematic review. Eur J Dent. 2018; 12: 317-326.
Ghahramani Y, Tabibi SS, Khan MMR, Asadi A, Mohammadi E, Khaksar E, et al. Recent advances in bioactive materials: Future perspectives and opportunities in oral cancer biosensing. Talanta. 2025; 286: 127494.
Tabari M, Seyed*Majidi M, Hamzeh M, Ghoreishi S. Biocompatibility of mineral trioxide aggregate mixed with different accelerators: an animal study. J Dent. 2020; 21: 48-55.
Kulan P, Karabiyik O, Kose GT, Kargul B. Biocompatibility of accelerated mineral trioxide aggregate on stem cells derived from human dental pulp. J Endod. 2016; 42: 276-279.
Lim M, Song M, Hong CU, Cho YB. The biocompatibility and mineralization potential of mineral trioxide aggregate containing calcium fluoride: an in vitro study. J Dent Sci. 2021; 16: 1080-1086.
Dianat O, Mahdian A, Sanagoo N, Mozayeni MA, Eskandarion S. Setting Time and Surface Microhardness of Mineral Trioxide Aggregate and 1% and 5% Fluoride-Doped Mineral Trioxide Aggregate Mixed with Water and Gel-like Polymer. Iran Endod J. 2019; 14: 265-270.
Han JW, Lee BN, Kim SM, Koh JT, Min KS, Hwang YC. Odontogenic Potential of Parathyroid Hormone–related Protein (107- 111) Alone or in Combination with Mineral Trioxide Aggregate in Human Dental Pulp Cells. J Endod. 2017; 43: 2054-2060.
Gupta R, Prasad AB, Raisingani D, Srivastava H, Mital P, Moryani V. Evaluation of calcium ion release from apical plugs formed by Biodentine and MTA with and without incorporation of triple antibiotic powder and modified triple antibiotic powder (cefaclor) using atomic absorption spectrophotometry: An in vitro study. J Conserv Dent Endod. 2023; 26: 519-524.
Almeshari A, Elsafadi M, Almadhari R, Mahmood A, Alsubait S, Aksel H. The additive effect of iloprost on the biological properties of Mineral trioxide aggregate on mesenchymal stem cells. J Dent Sci. 2022; 17: 225-232.
Sobhnamayan F, Sahebi S, Moazami F, Malekzadeh P, Hasani S. Combination of metformin and double antibiotic paste for the regeneration of non-vital immature teeth: a preliminary randomized clinical study. BMC Oral Health. 2023; 23: 847.
Alenizy M, Alhussein A, Almutairi N, Ba-Armah I, Ma T, Wang S, et al. Novel Fast-Setting and Mechanically-Strong Calcium Phosphate Pulp-Capping Cement with Metformin Release to Enhance Dental Pulp Stem Cells. Bioengineering. 2025; 12: 13.
Etezadkeyhan P. Recent Advances in Regenerative Endodontics: Clinical Applications and Challenges. J Oral Dent Health Nexus. 2024; 1: 29-42.