The effect of three different root canal filling materials on postoperative pain in teeth with irreversible pulpitis: a randomized clinical trial

Abstract

Background

This randomized clinical trial aimed to compare postoperative pain (PP) and analgesic consumption following single-visit root canal treatment using two calcium silicate–based sealers (BioMTA + and Well-Root PT) and one epoxy resin–based sealer (Endoplus) in mature permanent mandibular molars diagnosed with asymptomatic irreversible pulpitis.

Methods

Fifty-four patients were randomly allocated into three groups (n = 18) according to the obturation material used: Endoplus, BioMTA+, or Well-Root PT. All treatments were performed in a single visit under standardized clinical conditions. Root canals were prepared using FKG Race Evo rotary files and irrigated with NaOCl and EDTA, followed by passive ultrasonic activation. Postoperative pain was assessed using a visual analog scale (VAS) at 6, 12, 24, 48, and 72 h and at 1 week postoperatively. Analgesic intake was recorded. Data were analyzed using repeated measures ANOVA and chi-square tests, with the significance level set at p < 0.05.

Result

All groups exhibited a statistically significant reduction in postoperative pain over time (p < 0.001 for Endoplus and BioMTA+; p = 0.004 for Well-Root MTA). However, intergroup comparisons revealed no statistically significant differences in pain scores at any evaluation time point (p > 0.05). The highest pain levels were observed within the first 24 h, followed by a rapid decline thereafter. None of the patients required analgesic intake during the postoperative period. Demographic variables were comparable among the groups.

Conclusion

Within the limitations of this randomized clinical trial, no statistically significant differences were detected among BioMTA+, Well-Root PT, and Endoplus regarding early postoperative pain following single-visit root canal treatment in mandibular molars with asymptomatic irreversible pulpitis. The type of root canal sealer did not significantly influence postoperative pain outcomes.

Trial registration

This study was registered at ClinicalTrials.gov (ID: NCT06795282, Record Dates: 22/12/2024).

Introduction

Postoperative pain (PP) following root canal treatment remains a persistent challenge for clinicians and represents an unpleasant experience for patients [1]. The incidence of post-endodontic pain has been reported in the literature to range from 3% to 58% [2, 3]. In contrast, the occurrence of severe pain has been noted in less than 12% of cases after treatment [4]. PP is considered a consequence of acute inflammation resulting from chemical, mechanical, or microbial injuries to the periapical tissues [5]. Inadequate cleaning and shaping or insufficient obturation of the root canals are among the factors predisposing patients to PP [3]. Specifically, the extrusion of sealer during root canal obturation can lead to cytotoxic effects, inflammation, necrosis, and pain within the periapical tissues [6]. Furthermore, the chemical composition of the filling materials is a critical factor influencing the degree of the tissue response [7].

One of the primary objectives for the success of root canal treatment is to entomb residual microorganisms following chemomechanical disinfection and to facilitate the healing of periapical tissues [8]. This is typically achieved using gutta-percha (GP) in combination with a root canal sealer. Since GP alone cannot provide a complete seal of the canal, sealers enhance the efficacy of the seal by filling voids and irregularities between the core filling material and the canal walls. An ideal root canal sealer is expected to be biocompatible, radiopaque and dimensionally stable without exhibiting shrinkage [1]. However, sealers may come into contact with periapical tissues through lateral canals, the apical foramen or diffusion thereby triggering an inflammatory response [5, 9]. For this reason, root canal sealers have been considered potentially associated with postoperative pain following treatment. Ruparel et al. suggested that root canal sealers may activate trigeminal nociceptors which in conjunction with the immune response, could elicit pain-related symptoms [9].

Epoxy resin-based sealers (ERBS), particularly materials such as AH Plus, have been established as the gold standard due to their superior physicochemical properties, minimal solubility, and dimensional stability [10–13]. AH Plus offers excellent flowability and an extended setting time which facilitates enhanced micromechanical interlocking with dentinal structures [11]. Nevertheless the disadvantages of ERBS include risks of mutagenicity, cytotoxicity and hydrophobicity [7, 14]. In their freshly mixed state these sealers may release cytotoxic monomers, potentially causing irritation or pain upon contact with periapical tissues [5, 15]. An in vitro study reported that the monomers released by AH Plus could prolong periapical inflammation by increasing oxidative stress [7].

In recent years, calcium silicate-based bioceramic sealers (CSBS) have gained popularity as alternatives to address these disadvantages. These sealers typically contain inorganic powders such as tricalcium and dicalcium silicates and exhibit hydrophilic properties [12, 16]. CSBS demonstrate antibacterial activity, the ability to stimulate biomineralization, and the potential to support apical healing [11, 15, 17]. They exert an antibacterial effect through the release of alkaline pH and promote hydroxyapatite formation upon contact with apical tissues [18]. These characteristics support the evidence that CSBS exhibit lower cytotoxicity and reduced inflammatory responses compared to ERBS [19].

The aim of this study is to compare the effects of two CSBS, BioMTA+ (Cerkamed, Stalowa Wola, Poland) and Well-Root PT (Vericom Co., Chuncheon, Korea), with those of a conventional ERBS, Endoplus (President Dental GmbH, Allershausen, Germany), in terms of postoperative pain (PP) and analgesic consumption following single-visit root canal treatment in mature permanent mandibular molars diagnosed with asymptomatic irreversible pulpitis. To the best of our knowledge, no study has directly compared the effects of these three specific root canal sealers on postoperative pain following single-visit treatment in mature permanent mandibular molars. Therefore, this study aims to address this gap in the existing literature.

The null hypothesis (H₀) of the study is that there is no significant difference in postoperative pain among single-visit root canal treatments performed using BioMTA+, Well-Root PT, and Endoplus.

Materials and methods

In accordance with CONSORT guidelines, the flow of participants through each stage of the randomized clinical trial is presented in the CONSORT flow diagram (Fig. 1).

Fig. 1.

CONSORT flow diagram of the study

Ethical approval and sample size calculation

This study was registered at ClinicalTrials.gov (ID: NCT06795282, Record Dates: 22/12/2024) and approved by the Erciyes University Clinical Research Ethics Committee (2025/185) and the National Pharmaceuticals and Medical Devices Authority (Protocol: 2025/210). Based on a prior study [2], a minimum of 15 patients per group was estimated using G*Power 3.1.9.7 software (University of Düsseldorf, Germany) with an alpha level of 0.05 and 90% power. To increase statistical power and account for potential patient dropouts, 18 patients were enrolled per group. Thus, a total of 54 patients were included in this study. All participants were first informed about the study design and clinical treatment procedures, including the risks, and then signed a written informed consent form.

Patient selection and eligibility criteria

Patients were selected from those referred to the Department of Endodontics, Faculty of Dentistry, Erciyes University, between March 2025 and December 2025. Patients diagnosed with asymptomatic irreversible pulpitis due to deep carious lesions in mandibular first or second molar teeth with healthy periapical tissues as detected by periapical radiography were included in the study. All inclusion and exclusion criteria are listed in Table 1.

Table 1.

Inclusion and exclusion criteria for study participants

Inclusion criteria	Exclusion criteria
• Patients aged between 18 and 60 years	• Patients with systemic conditions such as diabetes mellitus, immunosuppression, a history of pregnancy, or those who were medically compromised due to ongoing medication use
• Patients who had not used any analgesics or antibiotics within the previous 7 day	• Patients requiring antibiotic prophylaxis
• Asymptomatic teeth exhibiting a delayed positive response to thermal and electric pulp vitality tests	• Use of analgesics or antibiotics within 7 days prior to the initiation of treatment
• Presence of a large pulp exposure during caries removal	• Known allergy to materials used during root canal treatment or to analgesics and/or antibiotics
• Inflamed pulp tissue in which bleeding could not be controlled within 5 min	• Cases in which bleeding could be controlled within 5 min, allowing vital pulp therapy to be performed
• Patients diagnosed with asymptomatic irreversible pulpitis due to deep carious lesions in mandibular first or second molar teeth	• Teeth showing a negative response to pulp vitality tests (non-vital) and/or presenting with symptoms
• Patients with radiographically confirmed healthy periapical tissues on periapical radiographs	• Presence of an associated periapical lesion on radiographic examination
• Periodontally healthy, mature mandibular first or second molar teeth	• Teeth requiring post–core restoration or planned to be used as prosthetic abutments
	• Teeth with calcified root canals or exhibiting internal or external root resorption, Teeth with open apices
	• Cases with overfilling (radiographic extrusion of gutta-percha or sealer beyond the apex) or underfilling (> 2 mm short of the radiographic apex)

Randomization

A total of 54 patients were randomly allocated into three study groups. Randomization was performed using a computer-generated random number sequence obtained from www.randomizer.org, a freely accessible web-based tool commonly used for participant allocation in clinical research. Patients were assigned sequentially according to the generated randomization list. As a result of randomization, the study groups were comparable in terms of age and sex distribution.

All endodontic treatment procedures were performed in a single visit by an experienced endodontist following a standardized clinical protocol, thereby minimizing procedural variability. Blinding of the operator was not possible; therefore, the study was conducted with partial blinding.Observer blinding was ensured for postoperative outcome assessment, as pain evaluations were self-reported by the patients using standardized visual analog scale (VAS) forms without investigator involvement.

Treatment protocol

All procedures were performed using 5x magnification in a single visit by a specialist with a minimum of 5 years of clinical experience. Inferior alveolar nerve block anesthesia was administered using 2 mL (one carpule) of 4% articaine hydrochloride with 1:100,000 adrenaline. The tooth was then isolated with a rubber dam and carious tissue as well as existing restorations were removed under water cooling using high-speed diamond burs. The working length was determined using the Dentsply Propex Pixi Apex Locator (Dentsply Sirona, USA) and confirmed radiographically. Root canal shaping was performed using FKG Race Evo (FKG Dentaire, La Chaux-de-Fonds, Switzerland) rotary files, with the mesial canals prepared to size 30.04 and the distal canals to size 40.04. Following each instrument change, the canals were irrigated with 10 mL of 5% sodium hypochlorite (NaOCl) using a 30-gauge irrigation needle. During all irrigation procedures, the needle was positioned 2 mm short of the working length to prevent irrigation complications. For the final irrigation protocol, the canals were rinsed with 5% NaOCl for 5 min followed by 17% EDTA for 1 min. All the final irrigation solutions were agitated using passive ultrasonic activation with Ultra-X (flexible X Silvertip-25/0.02) (Eighteeth, Changzhou, China) cordless device operating at a high frequency of 45 kHz. This ultrasonic activation was performed for 60 s for 2 cycles at 2 mm short of the WL.

The canals were dried using sterile paper points, and the patients were randomly assigned to one of three groups.

Group 1 (Endoplus group)

In this group, after checking the master apical cone with a digital periapical radiograph, the root canals were filled with GP (SureEndo, Korea) and Endoplus using the traditional lateral compaction technique. Sealer was prepared with a 1:1 ratio and placed on canal orifices with intra-oral tips (Dentsply DeTrey, Konstanz, Germany). Applying the Master-Point Technique, the wall of the canal was wet gently by counterclockwise rotation of the point.

Group 2 (BioMTA+ group)

Powder was mixed with the liquid at a 3:1 ratio according to the manufacturer’s instructions. An MTA filling with 3–5 mm thickness was placed using a Map system (Produits Dentaires SA, Vevey, Switzerland) and packed using a plugger (Dentsply, Maillefer, Switzerland). Pluggers of appropriate diameters (Dentsply, Charlotte, USA) were selected and adjusted to be positioned 1 mm short of the working length. After radiographic confirmation of the quality and length of the MTA filling, if the apical region was inadequately filled, the Auger technique was applied by selecting a rotary file with a size of 30/0.04 taper (FKG Dentaire, La Chaux-de-Fonds, Switzerland), which was operated using an endomotor (Dentsply, Charlotte, USA) in reverse mode at 100 rpm.

Group 3 (Well-Root MTA group)

An MTA filling with 3–5 mm thickness was placed using a applicator and packed using a plugger (Dentsply, Maillefer, Switzerland). Pluggers of appropriate diameters (Dentsply, Charlotte, USA) were selected and adjusted to be positioned 1 mm short of the working length. After radiographic confirmation of the quality and length of the MTA filling, if the apical region was inadequately filled, the Auger technique was applied by selecting a rotary file with a size of 30/0.04 taper (FKG Dentaire, La Chaux-de-Fonds, Switzerland), which was operated using an endomotor (Dentsply, Charlotte, USA) in reverse mode at 100 rpm.

Following root canal obturation, the teeth were radiographically evaluated to confirm adequate filling. After the applied materials had set, they were covered with a flowable glass ionomer cement (Ruby Liner, England, United Kingdom) and the definitive restoration was completed using a composite resin (3 M ESPE, St. Paul, MN, USA) (Fig. 2).

Fig. 2.

Periapical radiographs in (A, D, and G) were initial diagnostic radiographs. Periapical radiographs in (B, E), and (I) were mastercone radiographs. C was a post-canal radiograph filled with Endoplus. F was a post-canal radiograph filled with BioMTA+. J was a post-canal radiograph filled with Well-Root MTA

Postoperative pain and analgesic assessment

Postoperative pain was evaluated using a questionnaire based on the Visual Analog Scale (VAS). Pain measurements were recorded at 6, 12, 24, 48, and 72 h, and 1 week post-treatment. Pain intensity was categorized into four levels (0: no pain; 1–3: mild pain; 4–6: moderate pain; 7–10: severe pain). Patients were prescribed ibuprofen 400 mg to be used only in cases of severe pain, and analgesic consumption was recorded on the postoperative pain form (0: no analgesic use; 1: analgesic use).

Statistical analysis

Statistical analyses were performed using SPSS software version 26 (SPSS Inc., Chicago, IL, USA). The normality of the data distribution was utilized the Shapiro–Wilk test. Since the VAS data met the assumptions of normal distribution, parametric analysis was considered appropriate. VAS scores were treated as continuous variables for statistical analysis.

Changes in postoperative pain over time (from 6 h to 7 days) were evaluated using repeated measures analysis of variance (ANOVA). Intergroup comparisons and time–group interactions were also analyzed using repeated measures ANOVA. In cases where statistically significant results were obtained, the LSD post hoc test was applied to identify the specific time points or groups from which the differences originated. For all analyses, the statistical significance level was set at p < 0.05.

Categorical variables (e.g., gender, analgesic intake) were compared using chi-square tests, with the level of significance set at p = 0.05. Parametric data are presented as mean and standard deviation, nonparametric data as median (25th/75th percentiles), and categorical data as frequencies and percentages (n, %).

Result

In Table 2, the gender distribution was comparable among the Endoplus, BioMTA+, and Well-root MTA groups, with male proportions of 42.1%, 26.3%, and 31.6% and female proportions of 28.6%, 37.1%, and 34.3%, respectively; no statistically significant difference was observed between the groups (p = 0.566). The mean ages were 31.11 ± 11.91 years in the Endoplus group, 25.33 ± 8.74 years in the BioMTA+ group, and 29.00 ± 7.50 years in the Well-root MTA group, with no statistically significant difference among groups (p = 0.196). These findings indicate that the study groups were comparable in terms of demographic characteristics.

Table 2.

Comparison of demographic and clinical characteristics by group

Variables	Endoplus	BioMTA+	Well-root MTA	p
Gender
Male	8(42,1)	5(26,3)	6(31,6)	0,566
Female	10(28,6)	13(37,1)	12(34,3)
Age	31,11 ± 11,91	25,33 ± 8,74	29 ± 7,5	0,196

*:p < 0,05

According to Table 3, the Endoplus group exhibited a rapid decrease in measurement values starting from the 6th hour, with the reductions observed between the 6th and 12th hours and between the 12th and 24th hours being statistically significant (p < 0.05). In contrast, because the values approached zero after the 24th hour, no further significant decrease was observed, and the measurements remained stable from this time point onward.

Table 3.

Comparison of measurement values ​​over time

Groups	6 h	12 h	24 h	48 h	3 day	4 day	5 day	6 day	7 day	F	p
Endoplus	2,50 ± 1,50a	1,11 ± 1,23b	0,39 ± 0,78c	0,00 ± 0,00c	0,06 ± 0,24c	0,00 ± 0,00c	0,00 ± 0,00c	0,00 ± 0,00c	0,00 ± 0,00c	32,482	0,000*
BioMTA+	2,22 ± 1,22a	1,39 ± 1,29b	0,67 ± 0,97c	0,22 ± 0,65cd	0,06 ± 0,24d	0,06 ± 0,24d	0,00 ± 0,00d	0,06 ± 0,24d	0,06 ± 0,24d	37,163	0,000*
Well-root MTA	1,83 ± 1,42a	0,94 ± 1,16b	0,67 ± 1,53b	0,39 ± 1,24c	0,28 ± 0,96c	0,28 ± 0,96c	0,06 ± 0,24c	0,06 ± 0,24c	0,00 ± 0,00c	11,572	0,004*
F	1,049	0,601	0,356	1,047	0,863	1,198	1,000	0,500	0,971
p	0,358	0,552	0,702	0,359	0,428	0,310	0,375	0,609	0,386

*:p < 0,05; a, b, c, d: There is no significant difference between groups containing the same letter

In the BioMTA+ group, a statistically significant reduction was observed from the 6th to the 12th hour and from the 12th to the 24th hour; additionally, a limited but statistically significant decrease in measurement values was detected during the transition from the 24th to the 48th hour (p < 0.05). From the third day onward, the measurement values in the BioMTA+ group remained at very low levels, with no further significant changes observed thereafter.

In the Well root MTA group, a marked decrease was observed between the 6th and 12th hours; however, the change between the 12th and 24th hours was not statistically significant (p > 0.05). Intergroup comparisons at identical time points revealed no statistically significant differences among the Endoplus, BioMTA+, and Well-root MTA groups (p > 0.05).

These findings indicate that the observed changes in measurement values were primarily time dependent, and that none of the tested materials demonstrated a clear superiority over the others at the corresponding time intervals.

Discussion

This randomized controlled trial evaluated PP levels following single-visit root canal treatment in mandibular molars diagnosed with asymptomatic irreversible pulpitis, comparing two CSBS (BioMTA + and Well-Root PT) with an ERBS (Endoplus). The results demonstrated no statistically significant difference in postoperative pain among the groups. This finding is consistent with several previous randomized clinical trials reporting comparable postoperative pain levels between AH Plus (epoxy resin–based) and various bioceramic sealers [2, 3, 5, 11, 20, 21].

It is well established that ERBS, such as AH Plus, release cytotoxic monomers during their setting reactions, which may induce inflammatory responses in the periapical tissues [1, 7, 15]. In contrast CSBS, including BioMTA + and Well-Root PT, exhibit anti-inflammatory and osteogenic effects owing to their bioactive properties [8, 12, 17]. Moreover, these CSBSs have been shown to demonstrate lower cytotoxicity than ERBSs under in vitro conditions [3, 19].

However, the similarity in postoperative pain levels observed in our clinical outcomes may indicate that these biological differences in the chemical composition of the sealers do not exert a dominant short-term effect on the overall severity of PP. The rapid decline in pain levels across all groups after the peak period within the first 6–24 h may be attributed to the dilution of chemical irritants by tissue fluids as the sealers undergo setting [11, 22]. These findings support the notion that PP is governed predominantly by the natural progression of the acute inflammatory response rather than by the type of sealer used [8]. Conversely, the more intense pain observed within the first 24 h after treatment may be associated with the induction of reactive oxygen species (ROS) formation following the extrusion of unpolymerized components of root canal filling materials into the periapical tissues during the setting process, which is consistent with previous studies [21, 23].

The study was meticulously designed to control for variables known to increase PP. The inclusion of only teeth diagnosed with asymptomatic irreversible pulpitis and without radiographic evidence of periapical lesions ensured a low baseline inflammatory burden. It is well documented that pre-existing periapical lesions significantly increase the incidence of PP [5, 7, 12]. Therefore, in cases with minimal initial inflammation, the lack of a pronounced effect of the sealer’s chemical differences on clinical pain outcomes can be considered an expected finding.

Furthermore, the exclusion of cases with sealer overfilling —a potential contributor to PP— minimized chemical irritation resulting from sealer extrusion and subsequent sealer–tissue contact. Sealer extrusion has been identified as a critical factor capable of increasing PP, particularly with ERBS such as AH Plus [10, 24] Under clinical conditions, the concentration of toxic substances may be reduced by dilution with tissue fluids [25]. Although certain bioceramic sealers (e.g., NeoSealer Flo) have been reported to produce lower PP levels than AH Plus despite exhibiting higher extrusion rates [7], the prevention of such pronounced extrusion in the present study may have attenuated the impact of potential biological differences among the sealers on PP outcomes.

Bioceramic materials such as MTA are biocompatible, dimensionally stable, capable of adapting to dentinal walls, and able to induce the formation of cementum-like tissue [1]. When MTA comes into contact with water, its calcium oxide content is converted into calcium hydroxide creating a high-pH microenvironment [26]. Well-Root PT is a next-generation CSBS with bioactive calcium silicate content and offers a shorter setting time compared with conventional MTA [27].

The results of clinical studies comparing CSBS and ERBS with respect to PP are conflicting [7, 10, 19, 21]. Several studies have reported no significant differences in the incidence or intensity of PA between AH Plus and various CSBS, including Endoseal MTA and EndoSequence BC Sealer [3, 5, 11, 20, 21]. For example, Atav Ates et al. compared the resin-based sealer AH Plus with the calcium silicate–based sealer iRoot SP and found no significant difference in PP outcomes [20]. In contrast, some meta-analyses have suggested that CSBS may be associated with a lower incidence of PP at 24 h postoperatively [28]. In addition, NeoSealer Flo (a CSBS) has been reported to be associated with lower PP at 24 h compared with AH Plus, despite exhibiting a higher extrusion rate [7]. These findings support the potential of bioceramic sealers to attenuate the early inflammatory response owing to their biocompatibility and bioactive properties [7].

Although both Well-Root PT and BioMTA + are classified as CSBS, they differ in formulation and setting time, with Well-Root PT setting in approximately 45 min and BioMTA + in about 2 h [27]. Theoretically sealers with shorter setting times might be expected to terminate chemical irritation more rapidly and thereby result in lower PP levels [3]. However, the absence of a significant difference between the groups indicates that the overall effects of these CSBS on early PP are comparable in clinical practice. This finding further supports the prevailing clinical perception that, compared with ERBS, CSBS do not confer a distinct advantage in terms of early postoperative comfort.

The fact that none of the patients required the use of analgesics indicates that all three sealers were similarly well tolerated by the patients. Prescribing ibuprofen (400 mg) only in cases of severe pain may have contributed to maintaining low analgesic consumption rates [29].

This study has several strengths. First, it was designed as a randomized clinical trial with standardized treatment protocols, which enhances the internal validity of the findings. Second, all procedures were performed by a single experienced operator, minimizing procedural variability. Third, the study focused on a homogeneous patient group with asymptomatic irreversible pulpitis, reducing confounding factors related to pre-existing inflammation.

A limitation of the present study is the use of different obturation protocols across groups. Specifically, lateral compaction was performed in the Endoplus group, whereas MTA-based placement techniques were used in the BioMTA + and Well-Root PT groups. This variation may have introduced a potential confounding factor, as both the sealer type and the obturation technique could independently affect postoperative pain outcomes. Future studies with standardized obturation techniques are needed to better isolate the effect of sealer type.

According to the findings of the present study, the null hypothesis, which proposed that there would be no difference in postoperative pain among the tested root canal sealers, was not rejected.

Conclusion

The obtained data indicate that BioMTA+, Well-Root PT, and Endoplus demonstrate comparable clinical performance in terms of early postoperative pain management.

Future studies should investigate the effects of these CSBS in more complex clinical scenarios, such as cases with pulp necrosis and periapical lesions, using longer follow-up periods. In addition, given the higher flowability of CSBS, the potential impact of even minimal sealer extrusion on long-term healing outcomes should be carefully evaluated.

Abbreviations

CSBS

Calcium silicate–based sealers

EDTA

Ethylenediaminetetraacetic acid

ERBS

Epoxy resin–based sealers

GP

Gutta-percha

MTA

Mineral trioxide aggregate

NaOCl

Sodium hypochlorite

PP

Postoperative pain

ROS

Reactive oxygen species

VAS

Visual analog scale

WL

Working length

Authors’ contributions

Author Contributions: Conceptualization: Ayşe Tuğba Eminsoy Avcı, Yakup Üstün **; Methodology: Ayşe Tuğba Eminsoy Avcı, Büşranur Yavuz **; Validation: Büşranur Yavuz **; Formal analysis: Batuhan Karakaya **; Data curation: Batuhan Karakaya **; Writing—original draft preparation: Ayşe Tuğba Eminsoy Avcı, Yakup Üstün **Writing—review and editing: Tuğrul Aslan, Ayşe Tuğba Eminsoy Avcı.

Funding

This research did not receive any specific grants from public, commercial, or not-for-profit funding agencies.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was registered at ClinicalTrials.gov (ID: NCT06795282, Record Dates: 22/12/2024) and approved by the Erciyes University Clinical Research Ethics Committee (2025/185) and the National Pharmaceuticals and Medical Devices Authority (Protocol: 2025/210). All participants were informed about the purpose of the study, and informed consent was obtained from all individual participants prior to their participation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.