Effect of a demineralization model on the microhardness, surface roughness and topography of giomers: An in vitro study.

The purpose of this study is to compare the effect of a demineralization model on the microhardness, surface roughness, and topography of giomers.Seventy-two discs of six different dental materials in three different presentations (pit and fissure sealant (PFS), flowable and restorative materials) were divided into six groups (n = 12 p/g). Three experimental groups (giomers) consisted of BeautiSealant, Beautifil Flow Plus, and Beautifil II, and three control groups (resin-based materials) were formed using ClinproTM, FiltekTM Z350 XT Flow, and Filtek™ Bulk Fill materials. Vickers microhardness, surface roughness, and topographic analysis with atomic force microscopy were measured at the beginning (0) after four (1) and 7 days (2) of immersion in a demineralizing model. Statistical analysis was performed using One-way and Repeated Measures ANOVA and Pearson's correlation coefficient (p ≤ .05). The microhardness values showed significant variations, except for the G_RM group. All the groups presented significant increases in roughness through the experiment stages, except for RB_PFS in the Ra parameter. The topographic analysis showed variations in the micromorphology, especially in the experimental group at the end of the demineralization model. Finally, there was no correlation between microhardness and surface roughness. The demineralization model decreased the microhardness, with the lowest reductions in the giomers groups. The effect of the demineralizing model on the surface roughness and topography showed an increase in specific patterns for the experimental and control groups. Therefore, their clinical use is recommended. RESEARCH HIGHLIGHTS: The demineralization model decreased the microhardness property of the evaluated materials, with better performance for the giomer groups. The effect of the demineralizing model on surface roughness showed an increase with specific patterns for the experimental and control groups. Although the materials presented changes in their microhardness, roughness, and topography, their clinical use is recommended.

Effect of different industrialized acid beverages on the surface roughness of flowable composite resins: in vitro study.

Flowable composite resins are materials available for restorations in pediatric dentistry. However, these materials are subject to dangerous effects in the oral environment caused by acids that deteriorate and increase their roughness. Therefore it is important to evaluate the effect of different industrialized acid beverages on the roughness of flowable composite resins. An in vitro experimental study, was done using a convenience sample of 132 discs of 5 mm diameter by 2 mm depth of four flowable materials (FF (Filtek™ Z350 XT Flowable), TNF (Tetric® N-Flow), PF (PermaFlo®) and GF (Grandio® Flow)) exposed to three beverages (CC (Coca-Cola), AJ (apple juice), and FM (fermented milk)) and incubated at 37 ºC for 0, 15 and 30 days. The roughness (average roughness (Ra) and maximum height of profile (Rz) parameters) was measured at different intervals of time with a profilometer. For the data analysis, one-way analysis of variance (one-way ANOVA) and repeated measures analysis of variance (Repeated measures ANOVA) tests were applied (p < 0.05). In the roughness test before immersion, no differences were observed within the groups, with maximum roughness values for Filtek™ Z350 XT Flowable and minimum for PermaFlo®. However, at 15 and 30 days of immersion, the groups showed significant differences depending on the immersion drink, except Grandio® Flow in apple juice and fermented milk. The flowable materials studied presented specific behaviors according to the immersion period and drink used. The Filtek™ Z350 XT Flowable showed a similar increase in surface roughness independently of the drink used. Grandio® Flow was the most stable material against surface roughness changes after beverage immersion.

Effect of some industrialized acidic beverages on the roughness of pit and fissure sealants: an in vitro study.

This study evaluated in vitro the roughness of the pit and fissure sealants (PFS) after immersion in some industrialized acidic beverages. 120 discs (5 mm diameter and 2 mm thick) of 4 commercial brands (3M, Ivoclar, Ultradent, and VOCO) were immersed in 1.5 mL of 3 different industrialized acid beverages (soft drink, apple juice, and fermented milk) and incubated at 37 ºC for 15 and 30 days. Surface roughness (Ra and Rz) was measured at the beginning (0), 15 (1), and 30 days (2) after immersion, using a profilometer, under the standard ISO 4287-1997. Data were analyzed with one-way analysis of variance (One-way ANOVA) and repeated measures analysis of variance (Repeated measures ANOVA) test (p < 0.05). Ultradent and VOCO had the higher baseline surface roughness values, while 3M presented the lower baseline values (p > 0.05). After 15 and 30 days of immersion, the 3M group still showed the minimum values of surface roughness (p < 0.05). In addition, the maximum roughness values were seen in group UC (Ultradent/Coca-Cola) (p < 0.05). The surface roughness of the PFS increased according to the period of immersion in some industrialized acidic beverages. This increase was specific to each commercial brand. Therefore, the 3M PFS presented the best performance before and after immersion in the beverages.

Effect of Surface Roughness of Deciduous and Permanent Tooth Enamel on Bacterial Adhesion.

The adhesion of some bacteria has been attributed to critical levels of roughness in hard tissues, which increases the risk of developing caries. The objective of this work was to assess the effect of deciduous and permanent tooth enamel surface roughness on bacterial adhesion. One hundred and eight samples of deciduous and permanent enamel were divided into two groups (n = 54). G1_DE deciduous enamel and G2_PE permanent enamel. The surface roughness was measured by profilometry and atomic force microscopy (AFM). Subsequently, the evaluation of bacterial adherence was carried out in triplicate by means of the XTT cell viability test. Additionally, bacterial adhesion was observed using scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The average values of the micrometric roughness in both groups were similar; however, in the nanometric scale they presented significant differences. Additionally, the G1_DE group showed the highest amount of adhered S. mutans and S. sanguinis compared to the G2_EP group. Although the roughness of deciduous and permanent enamel showed contrasting results according to the evaluation technique (area and scale of analysis), bacterial adhesion was greater in deciduous enamel; hence, enamel roughness may not be a determining factor in the bacterial adhesion phenomenon.

Bond Strength of Adhesive Systems to Calcium Silicate-Based Materials: A Systematic Review and Meta-Analysis of In Vitro Studies.

Since the adhesion of resin composites to calcium silicate-based cement is considered challenging. Therefore, the best adhesion strategy should be indicated. This review aimed to assess the effect of different adhesive systems on the bond strength of resin composite to calcium silicate-based cement through a systematic review and meta-analysis. The subsequent PICOS framework used was: population, calcium silicate-based cement; intervention, use of self-etch adhesive systems; control, use of total-etch adhesive systems; outcome, bond strength; study design, in vitro studies. The literature search was conducted independently by two reviewers up to 18 February 2021. Electronic databases (PubMed, ISI Web of Science, SciELO, Scopus, and Embase) were searched for applicable articles. In vitro manuscripts studying the effect of adhesive systems on the bond strength of calcium silicate-based cement were considered. The meta-analyses were performed using Review Manager Software version 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Bond strength comparisons were made considering the type of calcium silicate-based cement (Mineral Trioxide Aggregate (MTA), Biodentine™, or TheraCal LC®). A p-value < 0.05 was considered statistically significant. A total of 7321 studies were retrieved in databases searched. After full-text evaluation, 37 eligible papers were assessed for qualitative analysis, leaving a total of 22 papers for the quantitative analysis. According to the meta-analysis, the bond strength values of resin composite materials to MTA and TheraCal LC® cement were favored when a total-etch adhesive system was used (p ≤ 0.02). On the other hand, the meta-analysis of the bond strength of resin-based materials to Biodentine™ calcium silicate-based cement was similar between both approaches (p = 0.12). The in vitro evidence suggests that the bond strength of resin-based materials to both MTA and TheraCal LC® cement was preferred by using the total-etch adhesive strategy. However, when bonding to Biodentine™, the use of self-etch or total-etch strategies displayed promising results. Given the lack of evidence related to the chemical interaction of self-etch adhesive materials with the bioceramics, if self-etch adhesives are used for bonding resin-based restorations to calcium silicate-based cement, a pretreatment with phosphoric acid could be recommended.

Morphological and porosity changes in primary enamel surface after an in vitro demineralization model.

In vitro models are very useful in dentistry, especially to evaluate preventive methods against dental caries. Although they have been used for more than 30 years, specific demineralization models have not been established for primary enamel, which is more prone to demineralization than permanent enamel. This study evaluates porosity changes in primary enamel surface after a demineralization model through a scientifically validated analytical tool. Nine healthy human anterior primary teeth extracted for therapeutic reasons were included in this study, previous informed consent. The samples were randomly assigned to three groups n = 3: G1_2D, G2_4D, and G3_7D. Scanning electron microscopy (SEM) images at ×200 and ×1000 were taken during two stages: before demineralization (BD) and after demineralization (AD). Morphological characterization was observed at ×1000, while porosity (pore count and perimeter) was analyzed by the ImageJ program, using ×200 SEM images previously converted. Several statistical analyses were used to determine differences (p ≤ .05). Morphological characterization AD revealed new pits and cracks on the enamel surface in G1_2D and G2_4D groups. Localized eroded enamel areas were observed in G3_7D. Pore count of enamel surface BD ranged from 64.26 ± 37.62 to 97.93 ± 34.25 and AD ranged from 150.06 ± 64.86 to 256 ± 58.14. AD, G_4D exhibited a decrease in pore perimeter contrary to G_2D and G_7D. Significant differences were observed. Finally, morphological changes were more evident as days of demineralization increased; 7 days of immersion could be employed as an enamel erosive model. The pore count increased after the demineralization model, BD pores perimeter was heterogeneous, and AD varied according to the immersion period. Morphological changes were more evident as days of demineralization increased. Seven days of immersion could be employed as an enamel erosive model. The initial porosity seems to be a determining factor for the final porousness. The pore perimeter of the primary enamel varied according to the immersion period on the demineralization model.

Effect of Er:YAG laser irradiation on deciduous enamel roughness and bacterial adhesion: An in vitro study.

Laser irradiation has been proposed as a preventive method against dental caries since it is capable to inhibit enamel demineralization by reducing carbonate and modifying organic matter, yet it can produce significant morphological changes. The purpose of this study was to evaluate the influence of Er:YAG laser irradiation on superficial roughness of deciduous dental enamel and bacterial adhesion. Fifty-four samples of deciduous enamel were divided into three groups (n = 18 each). G1_control (nonirradiated); G2_100 (7.5 J/cm2 ) and G3_100 (12.7 J/cm2 ) were irradiated with Er:YAG laser at 7.5 and 12.7 J/cm2 , respectively, under water irrigation. Surface roughness was measured before and after irradiation using a profilometer. Afterwards, six samples per group were used to measure bacterial growth by XTT cell viability assay. Adhered bacteria were observed using confocal laser scanning microscopy (CLSM) and a scanning electron microscopy (SEM). Paired t-, one-way analysis of variance (ANOVA), Kruskal-Wallis and pairwise Mann-Whitney U tests were performed to analyze statistical differences (p < .05). Before treatment, samples showed homogenous surface roughness, and after Er:YAG laser irradiation, the surfaces showed a significant increase in roughness values (p < .05). G3_100 (12.7 J/cm2 ) showed the highest amount of Streptococcus mutans adhered (p < .05). The increase in the roughness of the tooth enamel surfaces was proportional to the energy density used; the increase in surface roughness caused by laser irradiation did not augment the adhesion of Streptococcus sanguinis; only the use of the energy density of 12.7 J/cm2 favored significantly the adhesion of S. mutans.

Effect of Er:YAG and Fluoride Varnishes for Preventing Primary Enamel Demineralisation.

PURPOSE: To measure the demineralisation changes on human deciduous enamel produced by pH cycling after preventive treatment with Er:YAG laser irradiation, fluoride varnish application and a combination of the two. MATERIALS AND METHODS: Sixty extracted human anterior primary teeth were assigned to six groups (n = 10). Group C: untreated; group L: Er:YAG laser; group TCP-NaF: Clinpro White (5% sodium fluoride and modified tricalcium phosphate); group CPP-ACP-NaF: MI varnish (5% sodium fluoride with casein phosphopeptide-amorphous and calcium phosphate); group L+TCP-NaF: Er:YAG + 5% sodium fluoride + modified tricalcium phosphate; group L+ CPP-ACP-NaF: Er:YAG + 5% sodium fluoride with casein phosphopeptide-amorphous and calcium phosphate. The samples were subjected to a 10-day pH-cycling regimen to create caries-like lesions, with 8 h in demineralising solution and 16 h in remineralising solution at 37°C. Enamel demineralisation was evaluated by laser fluorescence (DIAGNOdent) before and after pH cycling. The Mann-Whitney U-test and Wilcoxon tests were performed with statistical significance set at p ≤ 0.05. RESULTS: The Wilcoxon test revealed statistically significant differences at baseline and after pH cycling in groups C (p = 0.02), L (p = 0.034) and L+TCP-NaF (p = 0.025) and the lowest percentage of healthy tooth substance compared to the other groups. CONCLUSIONS: The results suggest that the treatment protocols employed in groups TCP-NaF, CPP-ACP-NaF, and L+ CPP-ACP-NaF had similar effects in terms of preventing demineralisation, as reflected in a higher percentage of healthy dental structure maintained. Hence, these treatments are recommended for clinical use as an effective preventive measure.

Adhesion of Streptococcus mutans and Streptococcus sanguinis on Er:YAG Laser-Irradiated Dental Enamel: Effect of Surface Roughness.

Objective: To determine surface roughness caused by Er:YAG laser irradiation and its effect on the increase in bacterial adhesion. Background: Er:YAG laser was proposed as a strategic device to reduce caries by its ability to generate chemical and structural changes in tooth enamel; in turn, it produces undesirable effects on the tooth surface that could increase its roughness and allow a greater accumulation of microorganisms. Methods: Eighty-four samples of human enamel were divided into seven groups (n = 12): G1_control (no laser irradiation); G2_100/H2O, G3_200/H2O, and G4_300/H2O were irradiated with Er:YAG laser (12.7, 25.5, and 38.2 J/cm2, respectively) under water irrigation. In addition, G5_100, G6_200, and G7_300 were irradiated with the energy densities described above and no water irrigation. Surface roughness measurements were recorded before and after treatment using a profilometer. Afterward, three samples per group were incubated in a microorganism suspension for the tetrazolium salt (XTT) assay. Biofilm morphology was observed using scanning electron microscopy and confocal laser scanning microscope. One-way analysis of variance and t-tests were performed for statistical analysis (p < 0.05). Results: There were no statistically significant differences in roughness values in the G5_100 group before and after treatment, but there were statistically significant differences observed in the other groups evaluated (p < 0.05). No significant differences in adhesion of both strains were detected in irradiated groups compared with G1_control. Conclusions: The increase in roughness on dental enamel surfaces was proportional to the irradiation conditions. However, the increase in surface roughness caused by Er:YAG laser irradiation did not affect Streptococcus mutans and S. sanguinis adhesion.

Changes in deciduous and permanent dentinal tubules diameter after several conditioning protocols: In vitro study.

Innovators conditioning protocols are emerged in permanent dentin, however for deciduous dentin the information is limited; the aim of this study was to evaluate in vitro diameter of deciduous and permanent dentinal tubules after several conditioning protocols. Eighty dentin samples were distributed in sixteen groups (n = 5 p/g) and dentin surface was conditioned as follow: G1D/G1P acid etching; G2D/G2P, self-etch adhesive; G3D/G3P, G4D/G4P, Er: YAG laser irradiation at 200 mJ-25.5 J/cm2 and 300 mJ-38.2 J/cm2 , at 10 Hz under water spray respectively; G5D/G5P, G6D/G6P, G7D/G7P, and G8D/G8P were irradiated under the same energy densities followed phosphoric acid or self-etch adhesive conditioning. The sample dentin of deciduous and permanent teeth was analyzed with scanning electron microscopy and tubule diameter was evaluated by Image Tools Scandium program. Data were subjected to one-way analysis ANOVA to compare among groups with a level of significance at p ≤ .05. For deciduous dentin, diameters were from 1.52 ± 0.32 µm in G3D to 3.88 ± 0.37 µm in G1D; narrowest and widest diameter, respectively (p < .000). While permanent dentin tubules exhibited diameters from 1.16 ± 0.16/1.19 ± 0.12 µm in G7P/G8P to 2.76 ± 0.28 µm in G6P; narrowest and widest diameter, respectively (p < .000). All dentin conditioning protocols produced more open dentin tubules (diameter size) in deciduous dentin than permanent, specific conditioning protocols are required for each tissue (deciduous or permanent dentin), since same protocol produced stronger effects on primary dentin, which is important for dental clinical success in children and adolescents.

Morphological and chemical changes in human deciduous dentin after phosphoric acid, self-etching adhesive and Er: YAG laser conditioning.

The morphological and chemical changes in deciduous dentin produced by different conditioning protocols were evaluated in this in vitro study. Eighty primary dentin samples were divided into eight groups (n = 10): G1, acid etching; G2, self-etching adhesive; G3, G4, Er: YAG laser irradiation at 25.5 and 38.2 J cm-2 , respectively; 10 Hz and spray irrigation. Groups 5, 6, 7, and 8 were irradiated at previous densities, and then phosphoric acid or self-etching adhesive conditioning was applied. Scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDS) were used to evaluate chemical and morphological changes. Paired t-test and One-way ANOVA were used for statistical analysis (p ≤ 0.05). All samples showed different morphology with specific characteristics according to the conditioning protocol. Changing element concentration values are expressed in atomic percent (at %). After conditioning, there were statistically significant differences (p ≤ 0.05) for p at% and Ca/P in all groups; highlighting the following additional findings by group: G1, G7, and G8 showed changes in all elements studied, G2 presented a decrease in C at% and increased Ca at%, G3 and G4 exhibited at% changes in C, trace elements and Ca. Furthermore, G5 showed at% changes in O and trace elements; while G6 changes were observed on C at%, O at% and trace elements at%. Dentin morphology and chemical composition varied in accordance with the conditioning protocol, with characteristics specific for each one that could have clinical implications for the retention and bond strength performance of adhesive materials.

Chemical and morphological changes in human dentin after Er:YAGlaser irradiation: EDS and SEM analysis.

Sixty samples of human dentin were divided into six groups (n = 10) and were irradiated with Er:YAG laser at 100 mJ-19.9 J/cm(2), 150 mJ-29.8 J/cm(2), 100 mJ-35.3 J/cm(2), 150 mJ-53.0 J/cm(2), 200 mJ-70.7 J/cm(2), and 250 mJ-88.5 J/cm(2), respectively, at 7 Hz under a water spray. The atomic percentages of carbon, oxygen, magnesium, calcium, and phosphorus and the Ca-to-P molar ratio on the dentin were determined by energy dispersive X-ray spectroscopy. The morphological changes were observed using scanning electron microscopy. A paired t-test was used in statistical analysis before and after irradiation, and a one-way ANOVA was performed (P ≤ 0.05). The atomic percent of C tended to decrease in all of the groups after irradiation with statistically significant differences, O and Mg increased with significant differences in all of the groups, and the Ca-to-P molar ratio increased in groups IV, V, and VI, with statistically significant differences between groups II and VI. All the irradiated samples showed morphological changes. Major changes in the chemical composition of dentin were observed in trace elements. A significant increase in the Ca-to-P ratio was observed in the higher energy density groups. Morphological changes included loss of smear layer with exposed dentinal tubules. The changes produced by the different energy densities employed could have clinical implications, additional studies are required to clarify them.

Chemical changes associated with increased acid resistance of Er:YAG laser irradiated enamel.

BACKGROUND: An increase in the acid resistance of dental enamel, as well as morphological and structural changes produced by Er:YAG laser irradiation, has been reported. PURPOSE: To evaluate the chemical changes associated with acid resistance of enamel treated with Er:YAG laser. Methods. Forty-eight enamel samples were divided into 4 groups (n = 12). Group I (control); Groups II, III, and IV were irradiated with Er:YAG at 100 mJ (12.7 J/cm(2)), 200 mJ (25.5 J/cm(2)), and 300 mJ (38.2 J/cm(2)), respectively. RESULTS: There were significant differences in composition of irradiated groups (with the exception of chlorine) and in the amount of calcium released. CONCLUSIONS: Chemical changes associated with an increase in acid resistance of enamel treated with Er:YAG laser showed a clear postirradiation pattern characterized by a decrease in C at.% and an increase in O, P, and Ca at.% and no changes in Cl at.%. An increased Ca/P ratio after Er:YAG laser irradiation was associated with the use of higher laser energy densities. Chemical changes produced by acid dissolution showed a similar trend among experimental groups. Stable or increased Ca/P ratio after acid dissolution was observed in the irradiated groups, with reduction of Ca released into the acid solution.

Morphological and structural changes on human dental enamel after Er:YAG laser irradiation: AFM, SEM, and EDS evaluation.

OBJECTIVE: The purpose of this study was to evaluate, using atomic force microscopy (AFM), scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDS), the morphological and structural changes of the enamel after irradiation with the Er:YAG laser. BACKGROUND DATA: A previous study showed that subablative Er:YAG laser irradiation produced undesirable morphological changes on the enamel surface, such as craters and cracks; however, the enamel acid resistance was not increased. METHODS: Fifty-two samples of human enamel were divided into four groups (n = 13): Group I was the control (no laser irradiation), whereas Groups II, III, and IV were irradiated with the Er:YAG 100 mJ (12.7 J/cm(2)), 100 mJ (7.5 J/cm(2)), and 150 mJ (11 J/cm(2)), respectively, at 10 Hz with water spray. The morphological changes were observed by AFM and SEM. The weight percentages (wt%) of calcium (Ca), phosphorus (P), oxygen (O) and chlorine (Cl) were determined in the resultant craters and their periphery using EDS. Kruskal-Wallis and Mann-Whitney U tests were performed (p ≤ 0.05) to distinguish significant differences among the groups. RESULTS: The AFM images showed cracks with depths between 250 nm and 750 nm for Groups II and IV, respectively, and the widths of these cracks were 5.37 µm and 2.58 µm. The interior of the cracks showed a rough surface. The SEM micrographs revealed morphological changes. Significant differences were detected in Ca, P, and Cl in the crater and its periphery. CONCLUSIONS: AFM observations showed triangular-shaped cracks, whereas craters and cracks were evident by SEM in all irradiated samples. It was not possible to establish a characteristic chemical pattern in the craters.

Influence of four systems for dental bleaching on the bond strength of orthodontic brackets.

OBJECTIVE: To compare the influence of four systems for dental bleaching on the shear bond strength (SBS) of orthodontic brackets. MATERIALS AND METHODS: One-hundred and fifty freshly extracted bovine teeth were randomly divided into five groups. In group I the teeth were untreated (control). In the remaining groups the teeth were bleached, as follows: group II: 38% hydrogen peroxide; group III: 10% carbamide peroxide; group IV: resin-based coating material (RBCM), Beauty Coat; and group V: RBCM, White Coat. In all groups the enamel was conditioned with a self-etching primer and brackets were bonded with composite resin. Samples were stored (37°C, 24 hours), tested, and statistically analyzed, with significance predetermined at P ≤ .05. The adhesive remnant index (ARI) was also evaluated and analyzed. RESULTS: The SBS of group V (22.49 ± 5.34 MPa) was significantly higher than that of all other groups (I: 17.1 ± 5.11 MPa; II: 14.72 ± 5.42 MPa; III: 12.04 ± 5.29 MPa; and IV: 18.23 ± 5.58 MPa). In contrast, the SBS of group III was significantly lower than that of all groups (except group II). Significant differences in the ARI scores were present between groups. CONCLUSIONS: The use of RBCM for dental bleaching before bonding orthodontic brackets did not reduce the SBS. In contrast, hydrogen and carbamide peroxides negatively affected the SBS. The SBS yielded after bleaching with carbamide peroxide was significantly lower.

Acid resistance and structural changes of human dental enamel treated with Er:YAG laser.

OBJECTIVE: The purpose of this study was to evaluate the acid resistance and structural changes in the enamel surface of permanent teeth after subablative Er:YAG laser irradiation in vitro. BACKGROUND DATA: Er:YAG irradiation laser is expected to enhance acid resistance and to produce morphological changes on the enamel surface. METHODS: One hundred twenty samples of human enamel were divided into four groups (n = 30): Group I was the control (no laser irradiation), and Groups II, III, and IV were irradiated with Er:YAG laser at 100 mJ (12.7 J/cm(2)), 100 mJ (7.5 J/cm(2)), and 150 mJ (11 J/cm(2)), respectively, at 10 Hz and with water spray. The samples were placed in an acid solution, and the released calcium was quantified by atomic absorption spectrometry. The weight percentages of calcium, phosphorus, oxygen, and chlorine on the enamel surface were determined by energy dispersive X-ray spectroscopy. The morphological changes were observed by scanning electron microscopy. One-way ANOVA and Kruskal-Wallis tests were performed (p