Abstract
Objective
To assess whether the estimation of clinical signs of hyposalivation is applicable in recognising long‐term care facility (LTCF) residents with poor oral health, and which individual characteristics are important in that respect.
Background
A common inconvenience among older adults, dry mouth, particularly hyposalivation, can cause many complications, such as greater susceptibility to root caries and oral infections, and it can lead to further deterioration of oral health. However, very little is known about the association of clinically assessed signs of hyposalivation with the oral health status of LTCF residents.
Methods
The study sample comprised 362 individuals (dentate n = 266, edentate n = 96) aged 65 or older. The examinations included a questionnaire and clinical oral examination. Participants were categorised into three groups based on clinically assessed oral dryness: normal salivation (n = 83, 22.9%), lower salivation (n = 182, 50.3%) and dry mouth (n = 97, 26.8%). The association between signs of dry mouth with aspects to oral health was evaluated and further tested with logistic regression analysis.
Results
The signs of oral dryness were observed among females, those with dementia, and those with longer stays in the current facility. Root caries (odds ratio, OR 1.3) and diagnosis of periodontitis (OR 4.1), together with several individual periodontal parameters, as well as having less than ten occluding pairs of natural teeth (OR 3.5) were associated with dry mouth. Edentate participants showed an increased likelihood of having dry mouth with advancing age, and lesions on the lips were associated with dry mouth with OR 3.0.
Conclusion
Clinical estimation of signs of oral dryness can be a useful adjunct in evaluating the oral health status of dentate LTCF residents. Poor oral health was a frequent finding, especially among dentate LTCF residents with signs of dry mouth.
Keywords: dry mouth, hyposalivation, long‐term care, older adults, saliva
1. INTRODUCTION
Populations are rapidly ageing globally, and with increases in many age‐related health problems. Dry mouth is a very typical inconvenience among older adults. 1 Oral health is associated with patients' general health, influencing such aspects as patients' nutrition, weight, social interactions and independency. 2 , 3 , 4 , 5 Saliva plays a vital part in oral health and homeostasis, and it defends against bacteria and fungi, moistens and protects oral mucous membranes, affects speech, swallowing, chewing and aids in digestion. 5 , 6 , 7 , 8 , 9
The term hyposalivation refers to the objectively measured dryness of the mouth; its diagnosis is based on collected fluids from salivary glands as well as total salivary flow, assessed by collected whole saliva. By contrast, xerostomia is a subjective sensation of oral dryness. 10 , 11 Hyposalivation can be caused by salivary gland hypofunction, autoimmune diseases (for instance Sjögren syndrome), medications, treatment side effects, radiotherapy, glandular trauma, tumours or malnutrition. 12 , 13
Medication is the most common risk factor for hyposalivation. Generally, the use of medicines increases with age, and it is estimated that 75 per cent of those 65 years or older are using at least one medication. 14 The most relevant xerogenic medications are anticholinergics, diuretics, cardiovascular drugs, tricyclic antidepressants and antispasmodics. 4 , 9 , 11 , 15 , 16 The prevalence of dry mouth has been approximated to be one in five in older adults. 17 , 18 Hyposalivation can also result from dehydration, such as that arising from diarrhoea or vomiting. In addition, dry mouth is common among diabetes mellitus patients. Moreover, psychological elements (including anxiety, stress and depression) can induce hyposalivation. 19 , 20
Collecting saliva from poorly functional/demented older adults can be challenging. Instead, hyposalivation can be assessed by evaluating the signs of oral dryness. 21 , 22 Mucosal wetness has been found to reflect the amount of residual saliva on oral mucosa and is a viable measure of oral dryness; low mucosal wetness can also be an early indication of hyposalivation. 21 The most common intraoral signs of oral dryness are the mirror sticking to buccal mucosa, furrowed or depapillated tongue, atrophic and glassy oral mucosa, food debris and the lack of saliva pool on the floor of the mouth. 22
Oral health is generally poor among frail, older adults living in long‐term care facilities (LTCF). Such residents are frequently in need of assistance to maintain acceptable oral hygiene. 23 , 24 , 25 , 26 Dry mouth can cause many problems, such as difficulties in eating, swallowing, talking, wearing dentures, oral infections (Candida), halitosis, taste abnormalities and dental caries. 19 , 27 These can also have more general effects, such as lack of appetite, risk of malnutrition, poorer social interactions and even depression. 28 , 29
There are few studies focusing on clinically assessed hyposalivation and its association with the clinical oral health status of LTCF residents. Accordingly, we investigated the association between the clinically observed signs of hyposalivation and the oral health of Finnish LTCF residents.
2. MATERIALS AND METHODS
The sample of the Finnish Oral Health Studies in Older Adults (FINORAL study) consisted of 550 older adults (aged 65 or older) living in LTCF in Helsinki, Finland. Individuals who required prophylactic antibiotics (n = 47), those having severe difficulties in participating or entirely declined (n = 35) from the examination and participants who had died (n = 75) before the study was conducted, were excluded. The number of examined LTCF residents was 393 individuals. Individuals with incomplete documentation of the clinically detectable signs of hyposalivation (n = 31) were excluded from the study, resulting in a final study sample of n = 362.
Each individual participated voluntarily, and they or their proxy signed an informed consent. The city of Helsinki and the Ethics Committee of the Hospital District of Helsinki and Uusimaa agreed with the study protocol (HUS/968/2017). This study follows the guidelines of the Declaration of Helsinki. The examinations included a questionnaire and clinical oral examination. The questionnaire concerning demographic and other background characteristics of the participants was completed by a nurse at each living facility. Residents were assessed using the questionnaire on their ability to eat (independently or with assistance), the length of the stay in current facility, the number of medications (≤5 or >5), dementia (yes or no), diabetes (yes or no), and the ability to uphold daily oral hygiene (by themselves or as assisted).
The clinical oral examinations were conducted between September 2017 and January 2019 by two specifically trained dentists. The inspection was executed with regular dental instruments and loupes (Merident Optergo Mo Ultralight Flip‐up) with a headlamp attached to it (Merident Optergo Delight LED). Residents were sitting on a chair or lying in bed during the inspection. It was not possible to take x‐rays in this study. 30
A person with at least one natural tooth or root remnant was considered being dentate. Extraoral examination included the visual inspection of skin and lips (healthy, chapped or cheilitis angularis). In addition, intraoral examination consisted of the evaluation of oral mucosa (healthy, lesions associated with denture use or not), removable denture, clinically assessed oral wetness (normal, reduced salivation, dry mouth), root remnants and number of teeth. Moreover, plaque accumulation and gingival inflammation were assessed using the plaque index (PI) ranging from 0 (no plaque) to 4 (plaque covered whole tooth) and gingival index (GI) ranging from 0 (no inflammation) to 3 (severe inflammation). 31 Both were evaluated by the highest value for each tooth and the mean value for the entire dentition was then calculated.
In addition, examinations consisted of the visual evaluation of caries lesions of the root surface and the tooth crown, pocket probing depth (PPD) measured as the deepest PPD for each tooth (<4 mm, 4–5 mm, ≥6 mm), bleeding on probing (BOP, yes or no for each tooth), teeth with increased mobility in static mode (beyond the physiologic range, yes or no). Furthermore, the study participants' clearness of speech (clear/somewhat clear or incapable to of speaking) was assessed. The clinical diagnosis of periodontitis was based on the finding of clinical attachment loss together with PPD ≥4 mm at least for two separate proximal sites together with a positive BOP.
Study participants were divided into 3 groups based on the (modified) Oral Dryness Score (CODS) by Osailan et al. 21 , 22 : Group 1, with normal salivation (n = 83), all surfaces of the oral cavity were moist, the mirror does not stick to oral mucosa; Group 2, with signs of lower salivation (oral mucosa has shiny appearance and appears to be strained, slimy or foam‐like saliva [n = 182]); and Group 3, with dry mouth (mirror sticks to mucosa or tongue, foam‐like saliva, the appearance of oral mucosa glassy, and fissured or depapillated tongue [n = 97]).
2.1. Statistical methods
Numbers and percentages (%) were used to summarise the categorical variables, whereas the continuous variables were presented as means and standard deviations (SD). The linearity across three groups with the clinically estimated signs of hyposalivation was evaluated using the Chi‐Square linear‐by‐linear association or with the Jonckheere‐Terpsta test for the linear trend. In addition, a logistic regression analysis with hyposalivation as a the dependent variable (adjusted with age, sex and number of teeth) was constructed. Statistical analyses were conducted with SPSS Statistics 27 (IBM Japan). Differences were considered significant at P < .05.
3. RESULTS
The sample's mean age was 83 (SD 8.4; min–max 65–101) years and 74% were female. Seventy‐three percent of participants (n = 266) were dentate and 27% (n = 96) edentate. Mean length of stay at the current facility was 46 (SD 36; min–max 1–240) months. Table 1 presents the oral dryness data by participant characteristics. Some 22.9% had clinically normal salivation, 50.3% had signs of low salivation, and 26.8% had dry mouth. Dry mouth was more common among female, those who had dementia, older participants and those who had longer stays in the current facility. The proportion of participants using more than five daily medications did not differ across the saliva groups.
TABLE 1.
Clinically estimated oral dryness data by participant characteristics.
| Category | ||||
|---|---|---|---|---|
| Normal salivation | Lower salivation | Dry mouth | All combined | |
| n (%) | ||||
| All | 83 (22.9) | 182 (50.3) | 97 (26.8) | 362 (100) |
| Dentate | 62 (23.2) | 135 (50.6) | 70 (26.2) | 267 (73.8) |
| Edentate | 21 (22.1) | 47 (49.5) | 27 (28.4) | 95 (26.2) |
| Age, years mean (SD) | ||||
| All | 80.9 (8.6) | 84.1 (8.2) | 83.8 (7.7) | 83.3 (8.3) |
| Dentate | 80.4 (9.3) | 84.1 (8.2) | 82.6 (8.0) | 83.8 (8.6) |
| Edentate | 82.4 (5.8) | 84.0 (8.2) | 87 (6.1) | 84.5 (7.3) |
| Sex, female n (%) | ||||
| All | 55 (66.3) | 132 (72.5) | 82 (84.5) | 269 (74.3) |
| Dentate | 41 (66.1) | 97 (71.9) | 60 (85.7) | 198 (74.2) |
| Edentate | 14 (66.7) | 35 (74.5) | 22 (81.5) | 71 (74.7) |
| Length of stay in current facility, months mean (SD) | ||||
| All | 41.5 (37.8) | 45.5 (35.2) | 48.3 (36.6) | 45.3 (36.1) |
| Dentate | 36.7 (36.6) | 46.4 (37.4) | 47.4 (34.8) | 44.4 (36.6) |
| Edentate | 56.0 (39.4) | 42.8 (27.8) | 50.6 (41.3) | 48.0 (34.8) |
| Diabetes n (%) | ||||
| All | 16 (20.8) | 27 (15.5) | 19 (20.2) | 62 (18.0) |
| Dentate | 14 (27.5) | 19 (37.3) | 18 (35.3) | 51 (19.8) |
| Edentate | 2 (18.2) | 8 (72.7) | 1 (9.1) | 11 (12.6) |
| Dementia n (%) | ||||
| All | 57 (74) | 137 (79.2) | 79 (86.8) | 273 (80.1) |
| Dentate | 41 (69.5) | 99 (78.0) | 58 (86.6) | 198 (78.3) |
| Edentate | 16 (88.9) | 38 (82.6) | 21 (87.5) | 75 (85.2) |
| Medications per day, >5 n (%) | ||||
| All | 57 (68.7) | 121 (66.5) | 65 (67) | 243 (67.1) |
| Dentate | 44 (71.0) | 90 (66.7) | 47 (67.1) | 181 (67.8) |
| Edentate | 13 (61.9) | 31 (66.0) | 18 (66.7) | 62 (65.3) |
Dry mouth was common both among dentate and edentate participants having lesions on the lips, and dentate having lesions on oral mucosa (Table 2). In addition, those with more dry mouth signs had more difficulty forming speech and keeping their mouth open during oral examination and needed more frequent assistance in their daily oral hygiene.
TABLE 2.
Clinically estimated oral dryness data by oral examination findings among dentate and edentate participants.
| Category | P‐value* | ||||
|---|---|---|---|---|---|
| n (%) | |||||
| Normal salivation | Lower salivation | Dry mouth | All combined | ||
| Lips, healthy | |||||
| Dentate | 46 (74.2) | 77 (57.9) | 31 (44.3) | 154 (58.1) | <.01 |
| Edentate | 15 (71.4) | 37 (78.7) | 13 (48.1) | 65 (68.4) | .058 |
| Oral mucosa, healthy | |||||
| Dentate | 53 (88.3) | 107 (81.1) | 51 (73.9) | 211 (80.8) | .042 |
| Edentate | 17 (85) | 37 (80.4) | 19 (73.1) | 73 (79.3) | .315 |
| Removable dentures, in use | |||||
| Dentate | 13 (21.7) | 30 (22.7) | 14 (24.6) | 57 (21.8) | .803 |
| Edentate | 15 (71.4) | 28 (60.9) | 17 (68) | 60 (65.2) | .851 |
| Food remains in oral cavity | |||||
| Dentate | 33 (55) | 74 (55.2) | 34 (51.5) | 141 (54.2) | .687 |
| Edentate | 6 (28.6) | 17 (37) | 11 (40.7) | 34 (36.2) | .396 |
| Daily oral hygiene, as assisted | |||||
| Dentate | 18 (30.0) | 47 (37) | 30 (44.1) | 95 (37.3) | .076 |
| Edentate | 9 (50) | 18 (43.9) | 15 (60) | 42 (50.0) | .445 |
| Ability to keep the mouth open, succeeds well | |||||
| Dentate | 49 (81.7) | 95 (71.4) | 47 (67.1) | 191 (72.6) | .069 |
| Edentate | 16 (76.2) | 33 (73.3) | 19 (70.4) | 68 (73.1) | .652 |
| Speech clarity, clear/somewhat clear | |||||
| Dentate | 42 (70) | 76 (57.1) | 37 (52.9) | 155 (58.9) | .052 |
| Edentate | 14 (66.7) | 31 (67.4) | 18 (66.7) | 63 (67.0) | .995 |
Pearson Chi‐Square, linear‐by‐linear association; Significant P‐values indicated with bold face.
Among the dentate participants (Table 3), root caries, as well as several findings of periodontal problems, together with clinically diagnosed periodontitis as well as having fewer than 10 occluding pairs of natural teeth were common among those who had signs of dry mouth.
TABLE 3.
Clinically estimated oral dryness data by dentate participants' (n = 266) dentition‐related findings.
| Category | P‐value** | ||||
|---|---|---|---|---|---|
| Normal salivation | Lower salivation | Dry mouth | All combined | ||
| n = 61 | n = 135 | n = 70 | |||
| Mean (SD) | |||||
| N of teeth* | 14.6 (8.6) | 12.6 (8.3) | 13.2 (8.5) | 13.2 (8.4) | .412 |
| N of root remnants | 1.2 (2.8) | 1.6 (2.9) | 2.1 (3.8) | 1.6 (3.1) | .142 |
| Teeth with open caries lesion of crown | 0.49 (1.0) | 0.50 (1.1) | 0.45 (0.9) | 0.48 (1.0) | .958 |
| Teeth with root surface caries | 0.82 (1.6) | 0.96 (1.8) | 2.01 (2.9) | 1.2 (2.1) | .001 |
| Teeth with PPD 4–5 mm | 2.16 (2.7) | 3.62 (5.0) | 4.59 (4.8) | 3.5 (4.5) | .008 |
| Teeth with PPD ≥6 mm | 0.67 (1.9) | 0.67 (1.8) | 0.75 (1.7) | 0.7 (1.8) | .475 |
| Teeth with mobility | 1.14 (3.0) | 1.36 (2.5) | 2.21 (3.1) | 1.5 (2.8) | .002 |
| BOP, % of teeth | 78.7 (34.1) | 83.2 (32.8) | 83.3 (29.9) | 82.1 (32.4) | .447 |
| PI | 2.22 (0.9) | 2.56 (0.98) | 2.57 (0.97) | 2.5 (1.0) | .039 |
| GI | 1.43 (0.7) | 1.69 (0.9) | 1.94 (0.9) | 1.7 (0.8) | .001 |
| n (%) | P‐value*** | ||||
|---|---|---|---|---|---|
| Gingival recession, generalised | 8 (14.8) | 28 (51.9) | 18 (33.3) | 54 (23.2) | .011 |
| Periodontitis, clinical diagnosis | 25 (44.6) | 54 (50.5) | 41 (78.8) | 120 (55.8) | <.001 |
| Occluding pairs, natural teeth, < 10 | 41 (67.2) | 109 (80.7) | 59 (86.8) | 209 (79.2) | .007 |
Note: Significant P‐values indicated with bold face.
Abbreviations: BOP, bleeding on probing, GI, gingival index; PI, plaque index.
*Root remnants not included **Joncheere‐Terpstra test for ordered alternatives; *** Pearson Chi‐Square test, linear‐by‐linear‐association.
The logistic regression model is shown in Table 4. For the dentate, lesions on the lips (odds ratio, OR 2.05), teeth with root caries (OR 1.25), PPD 4–5 mm (OR 1.10), greater tooth mobility (OR 1.12), and a higher GI value (OR 1.56) were associated with dry mouth. In addition, diagnosis of periodontitis and having <10 occluding pairs of natural teeth were associated with respective ORs 4.10 and 3.52 with dry mouth. Among the edentate, only lesions on the lips were associated with dry mouth.
TABLE 4.
Logistic regression model for clinically estimated dry mouth (adjusted for dentate by age, sex and the number of teeth, and for edentate by age and sex).
| OR | 95% CI | P‐value | |
|---|---|---|---|
| Lesions on lips | |||
| Dentate | 2.05 | 1.16–3.61 | .013 |
| Edentate | 3.00 | 1.15–7.78 | .025 |
| Dentate | |||
| Lesion on oral mucosa | 1.74 | 0.87–3.42 | .108 |
| Root caries | 1.25 | 1.10–1.43 | <.001 |
| PPD 4–5 mm | 1.10 | 1.10–1.18 | .016 |
| Plaque Index (PI) | 1.11 | 0.83–1.48 | .497 |
| Gingival Index (GI) | 1.56 | 1.10–2.20 | .012 |
| Mobile teeth | 1.12 | 1.01–1.23 | .025 |
| Gingival recession, generalised | 1.74 | 0.87–3.48 | .118 |
| Diagnosis of periodontitis | 4.10 | 1.93–8.72 | <.001 |
| <10 occluding pairs (natural teeth) | 3.52 | 1.26–9.88 | .017 |
Note: Significant P‐values indicated with bold face.
Abbreviations: GI, gingival index; PI, plaque index.
4. DISCUSSION
We investigated the occurrence and associations of signs of hyposalivation among Finnish LTCF residents. Among dentate participants, problems related to periodontal diseases, root caries and fewer occluding natural teeth were associated with clinically estimated signs of oral dryness. The signs of oral dryness were observed among females, those with dementia, and those with longer stays in the current facility. The older the edentate participant was, the more signs of dry mouth she/he had; a dry mouth was also associated with lesions on the lips.
The main strengths of the study were using comparably large sample of the most care‐dependent and frail senior citizens, and using a thorough oral examination. The main limitation was its cross‐sectional nature, which means that causal inferences cannot be made. In addition, we did not know the type of prescription/regular medications residents were taking.
It is challenging to measure saliva secretion in non‐cooperative patients. 27 There are no common practices for collecting saliva from individuals having cognitive and functional deficiencies and if salivation is much impaired. 7 For this reason, in this study, we used modified clinical oral dryness score (CODS) and formed groups based on the participants' clinically estimated signs of hyposalivation. 21 , 22 CODS has been found to be a valid way to determine the severity of dry mouth, and it is related to both salivary secretion and mucosal wetness. 11 , 32 CODS has also been found to be associated with unstimulated and stimulated salivary flow in a heterogenous group of hyposalivation patients. 11 , 32 To our awareness, our study is the foremost investigating the association between clinically assessed oral dryness and oral health‐related findings in LTCF residents.
Just one in four participants had clinically assessed dry mouth, and more than 70% had at least some clinical signs of low salivation. One systematic review estimated the prevalence of hyposalivation to be approximately 22% but noted high heterogeneity among studies, and the prevalence of dry mouth was higher with advancing age. 17 Another systematic review reported the prevalence of dry mouth among older adults to be approximately 33%. 18
Oral health is generally considered poor among LTCF residents, who are frail and depend on care. 31 , 33 , 34 Our findings suggest that dry mouth may be harmful to oral health, especially for dentate people. Root caries and periodontal complications have been shown to occur simultaneously among older adults, 35 , 36 , 37 which is in line with our findings. The association of periodontitis and periodontitis‐related findings with dry mouth was particularly noteworthy, but the study design precludes further interpretation.
Daily preventive oral care activities, especially meticulous oral hygiene, are important for the older population. 26 , 33 There is evidence that oral dryness should be clinically assessed regularly, and the alleviation of dry mouth symptoms should be incorporated into the oral hygiene routine. 22 , 32 , 38 Among our dentate participants, signs of dry mouth seemed to be more common among those who had a long residency in their current facility, which supports this view. Focusing on preventive measures and raising oral health awareness among nursing staff, as well as recognising the signs of dry mouth, could be employed to improve residents' overall oral health‐related quality of life (OHRQoL). 39 , 40
Our findings partly contradict those of an earlier study, where a higher PI was associated with dry mouth. 41 Among our study participants, regardless of the degree of signs of dry mouth, there was only a small difference in the amount of plaque. Because several oral disease findings were common in individuals with dry mouth, we hypothesise that the same amount of microbial plaque may be a greater disadvantage for these individuals due to their relative lack of salivary protection.
The number of teeth or use of removable dentures were at the same level in all dentate study groups. Nevertheless, having fewer than 10 occluding pairs of teeth associated with dry mouth, but even in this case we cannot infer causality. We can only speculate that earlier tooth loss may have been a consequence of dry mouth for an extended period and/or of poor‐oral‐health related habits, which have led to tooth loss. Hyposalivation has been found to be associated with poorer masticatory function, particularly among denture‐wearing people. 42 , 43 For instance, Ikebe et al. (2007) found that hyposalivation was strongly associated with impaired masticatory function in edentate participants. 44
Hyposalivation has previously been shown to be associated with the number of medications in use. 45 , 46 , 47 , 48 , 49 We did not find any such association with the number of medications (categorised as ≤5 or >5). Two‐thirds of participants, regardless of their clinical saliva status, took six or more daily medications. All participants were multimorbid and had poor functioning. The large burden of age‐ and disease‐related changes may have hindered the recognition of the influence of medications because the variation in the sample may have been insufficient. In addition, we had no information of the type of prescription/regular medications residents were taking.
Dementia is one of the most common medical conditions affecting a patient's functionality and usually leads to progressive decline in oral health. 38 Low salivary flow has been found to be more common among patients who have dementia than among healthy individuals. 44 Moreover, according to Gil‐Montoya et al. (2016), 70% of with diagnosed dementia have some signs of dry mouth. 39 In our sample, dentate participants with dementia had more signs of dry mouth.
5. CONCLUSIONS
Poor oral health was a frequent finding, especially among dentate LTCF residents with signs of dry mouth. Our findings suggest that clinical estimation of the signs of oral dryness could be used to recognise LTCF residents with poor oral health status. This could be carried out by trained nurses. Clinically estimated normal salivary function is a crucial part of oral health; therefore, focusing on prevention and alleviating the symptoms of dry mouth in LTCF residents is highly recommended. In conclusion, clinical estimation of signs of oral dryness would be an effortless and affordable way to distinguish LTCF residents with poor oral health.
AUTHOR CONTRIBUTIONS
Päivi Mäntylä, Riitta Saarela and Kaija Hiltunen contributed to the study concept and design. Lina Julkunen has collected the data. Otto Brandt and Päivi Mäntylä acquired the data. Päivi Mäntylä and Otto Brandt contributed to the analysis and interpretation of the data. Päivi Mäntylä, Riitta Saarela, Lina Julkunen, Kaija Hiltunen and Otto Brandt drafted the manuscript and critically revised it for important intellectual content.
FUNDING INFORMATION
This study was supported by the Finnish Dental Society Apollonia.
CONFLICT OF INTEREST STATEMENT
The authors report no conflict of interest.
ETHICAL INFORMATION
Each individual participated voluntarily, and they or their proxy signed an informed consent. The city of Helsinki and the Ethics Committee of the Hospital District of Helsinki and Uusimaa agreed with the study protocol (HUS/968/2017). This study follows the guidelines of the Declaration of Helsinki.
ACKNOWLEDGEMENTS
None.
Brandt O, Julkunen L, Saarela RK, Hiltunen K, Mäntylä P. Clinically estimated signs of hyposalivation in older adult residents of long‐term care. Gerodontology. 2025;42:186‐193. doi: 10.1111/ger.12776
DATA AVAILABILITY STATEMENT
Data is available on request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data is available on request from the corresponding author.