Assessment of the anatomical relationship of the roots of maxillary molars and the floor of maxillary sinus using cone-beam computed tomography (CBCT) in the Saudi sub-population

Abstract

Background

This study aimed to assess the relationship between the roots of the maxillary molars and the maxillary sinus floor in a Saudi subpopulation using cone-beam computed tomography (CBCT).

Methods

The study was conducted at the Dental University Hospital of King Saud University in Riyadh, Saudi Arabia. A sample of 220 Saudi patients who attended the Dental University Hospital between January 2009 and January 2024 and had CBCT images was included. The vertical relationship between the maxillary sinus floor and the root apices of the maxillary molars was assessed using the classification of Kwak et al. Vertical distances were recorded on both sides for each maxillary molar root.

Results

A total of 880 maxillary molars and 2640 individual roots were analyzed. The linear mixed-effects model showed a significant effect for tooth root on root-to-sinus distance (p < 0.001). Age group demonstrated a significant overall effect in the model; however, no pairwise comparisons between age groups remained statistically significant after Bonferroni correction. No significant effect of gender was observed. The roots of the maxillary second molars are closer to the maxillary sinus. Type 2 was the most frequently observed relationship among maxillary molars in both genders.

Conclusions

The shortest root-to-sinus distance was observed among the roots of the maxillary second molars. These findings highlight the value of CBCT imaging in preoperative clinical assessment for identifying high-risk cases, thereby modifying treatment planning and reducing the likelihood of sinus-related complications.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12903-026-09112-w.

Background

The maxillary sinus is a vital anatomical region within the maxillary bone, consisting of a paired, pyramid-shaped, air-filled cavity that is bordered by various critical structures, with its roof supporting the orbital base and its floor formed by the alveolar and palatine processes of the maxilla [1]. The sinus is lined by a delicate membrane, the Schneiderian membrane, which is attached to the periosteum. The membrane’s thickness measures approximately 1 mm; therefore, it is undetectable on the radiograph unless it thickens to 2 to 3 mm in response to an allergic reaction or infection, appearing on the radiograph as a white or grayish soft tissue line along the sinus floor [2]. The volume of the maxillary sinus averages 6 mL at birth and progressively enlarges with downward extension into the alveolar process until the eruption of permanent molars, at which point it reaches approximately 15 mL in volume, and the sinus floor is situated approximately 5 mm below the floor of the nasal cavity during adolescence [3].

The floor of the sinus plays a crucial role in clinical practice because it is close to the root tips of the maxillary posterior teeth, particularly the molars, which are closer than the premolars [4]. Recognizing this anatomical association reduces the risk of complications during diagnosis and therapy. Numerous side effects can develop in the maxillary sinuses related to malpractice or lack of knowledge of this association, including the spread of odontogenic infection to the sinus cavity, entry of endodontic materials beyond the root apex during root canal treatment, or oral surgical procedures such as apicoectomy, tooth extraction, or implant placement. Such complications can potentially result in the development of sinusitis, root displacement into the sinus, perforation of the sinus floor, or oroantral fistula [5, 6].

Three-dimensional radiography studies have indicated that craniofacial dimensions, such as the shape and proportions of the maxillary sinus, vary with age and between races and ethnicities. Considering its clinical significance, the relationship between the maxillary posterior teeth and the maxillary sinus floor has been extensively studied. CBCT analysis revealed that the second molar was closest to the maxillary sinus floor, followed by the first molar, second premolar, and first premolar, with the mesiobuccal roots of the second molars being the nearest roots, with a mean distance of 1.97 mm [7, 8]. A study of this association in a Turkish population found that roughly 34% of the palatal roots of the maxillary first molars passed through the sinus floor, while approximately 40% of the mesiobuccal and distobuccal roots of the maxillary first molars were placed at a level below the sinus floor. Furthermore, approximately 36% of the mesiobuccal roots of the second molars are in contact with the sinus floor [9]. Another study, which included a Saudi subpopulation from the Al-Qassim region, found that the mean distance from the sinus floor ranged from 0.68 ± 0.39 mm for the distobuccal root of the maxillary second molar to 3.93 ± 1.26 mm for the palatal root of the maxillary first molar [10]. Research involving the Korean population, utilizing hemi-sectioned skull specimens of the maxillae, demonstrated that the mean distances from the root tips of the first molars to the sinus floor varied from approximately 0.4 mm to 4.6 mm, whereas for the second molars, the distances ranged from approximately 0.5 mm to 4.6 mm [11]. Another study in East Asia revealed that the mean distance from the sinus floor ranged from 0.3 mm to 3.9 mm for the first molar root tips and from 0.3 mm to 4.6 mm for the second molar root tips [12]. In addition, data obtained from a Romanian population showed that the mean distance from the sinus floor was 0.50 mm for the first molar and 0.34 mm for the second molar root tips [13].

Referring to the published data on the correlation between the posterior maxillary teeth and the maxillary sinus floor, this study has used CBCT to comprehensively investigate the relationship between each maxillary molar root and the maxillary sinus floor in a Saudi subpopulation from the Riyadh region using a larger sample size. Thus, this study aimed to assess the relationship between the roots of the maxillary molars and the maxillary sinus using cone beam computed tomography (CBCT) by measuring the distances between the roots of the maxillary molars and the sinus floor.

Methods

This study was conducted in accordance with the ethical principles of the World Medical Association Declaration of Helsinki, and the study protocol was approved by the Institutional Review Board (E-24-9093) of the College of Medicine, King Saud University, Riyadh, Saudi Arabia. The requirement for informed consent was waived.

This study was conducted at the Dental University Hospital of King Saud University in Riyadh, Saudi Arabia. A sample of 220 Saudi patients (with 880 upper molars) who attended the dental university hospital between January 2009 and January 2024 were medically fit, had CBCT images, were both male and female, were aged ≥ 21 years (to ensure full development of maxillary sinuses), and had fully erupted permanent right and left first and second molars with fully formed apexes were included. Patients who were non-Saudi, had pathologically or developmentally damaged maxillary sinus floors, had undergone previous surgery on the maxillary sinus, had periapical or periradicular lesions on the molar teeth, had craniofacial trauma, had neoplasm or deformity, had root or bone resorption or destruction over the molar teeth, had undergone root canal treatment, or had supernumerary teeth in the molar area were excluded.

CBCT images were obtained using a CBCT scanner (PLANMECA ProMax 3D Max (C149-11B), Helsinki, Finland) with the following parameters: anode voltage, 90 kV; anode current was 9–11 mA, and scan time was 9–12 s. The voxel size was 0.2 mm, and the field of view varied from small to medium, ranging from 10 × 9 to 10 × 13 cm. The images were examined using the Romexis imaging software. Image manipulation was performed by changing the contrast, brightness level, and magnification to enhance visibility. Before measurements were obtained, image orientation was adjusted on the axial section according to the tooth position. Assessment was performed for each root on the coronal section. A data collection sheet was used, which included demographic variables (gender and age), type of tooth (first molar and second molar), side of the tooth (right and left), patient’s file number, and date of evaluation. CBCT images were randomly collected.

After calibration between the observer and a radiology consultant from the oral and maxillofacial radiology unit, the images were reviewed by an endodontic consultant who reviewed 20 CBCT images. Intra- and inter-examiner reliability were assessed using Cohen’s kappa and intraclass correlation coefficient (ICC).

To assess the vertical relationship between the maxillary sinus floor and the root apices of the maxillary molars, the classification of Kwak et al. [11]. was used as follows:

• Type I: The inferior wall of the maxillary sinus floor is located above the root apex of the buccal and palatal roots (Figure 1A).

• Type II: The inferior wall of the maxillary sinus is located below the level connecting the buccal and palatal root apices without apical protrusion over the maxillary sinus (Figure 1B).

• Type III: An apical protrusion of the buccal root apex is observed over the inferior wall of the maxillary sinus (Figure 1C).

• Type IV: An apical protrusion of the palatal root apex is observed over the inferior wall of the maxillary sinus (Figure 1D).

• Type V: Apical protrusions of the buccal and palatal root apices are observed over the inferior wall of the maxillary sinus (Figure 1E).

Fig. 1.

A Type I: The inferior wall of the maxillary sinus floor is located above the root apex of the buccal and palatal roots. B Type II: The inferior wall of the maxillary sinus is located below the level connecting the buccal and palatal root apices without an apical protrusion over the maxillary sinus. C Type III: An apical protrusion of the buccal root apex is observed over the inferior wall of the maxillary sinus. D Type IV: An apical protrusion of the palatal root apex is observed over the inferior wall of the maxillary sinus. E Type V: Apical protrusions of the buccal and palatal root apices are observed over the inferior wall of the maxillary sinus

Vertical relationship types were observed in cross-sectional images and recorded on both sides (right and left). The distance from the maxillary sinus floor to the root apices of the maxillary molars was measured for each root.

Statistical analysis

A descriptive analysis of the data was presented. The intraclass correlation coefficient (ICC) and Cohen’s kappa were used to assess intra- and inter-examiner reliability. A linear mixed-effects regression model was used to analyze root-to-maxillary sinus distances. Tooth root, age group, and gender were included as fixed effects, while patient identifier was included as a random effect to account for clustering of multiple teeth and roots within the same individual. This approach accounted for the non-independence of repeated observations within patients. Post hoc pairwise comparisons were performed using Bonferroni correction. Fisher’s Exact test was applied to assess the association between gender and Kwak classification. Statistical analysis was carried out using the R programming language (version 4.3.1).

Results

A total of 880 maxillary molars and 2,640 individual roots were analyzed from 220 CBCT images. Females accounted for 56.4% and males for 43.6% of the sample population. The distribution across age groups was as follows: 21–29 years (41.8%), 30–39 years (33.2%), 40–49 years (14.5%), 50–59 years (8.2%), and 60 + years (2.3%).

Cohen’s kappa test indicated almost perfect agreement between the two evaluators (κ = 0.86) as well as within the same evaluator (κ = 0.86) for the Kwak classification readings. The intraclass correlation coefficient demonstrated excellent agreement both between the two evaluators (ICC = 0.9) and within the same evaluator (ICC = 0.91) for the measurements of the distance from the maxillary sinus floor to the root apices of the maxillary molars.

Root-to-maxillary sinus distance measurements revealed considerable anatomical variations across different roots. The smallest mean distance was observed in the palatal root of the maxillary second molar (#27) (0.21 ± 1.49 mm), followed by the mesiobuccal root of the same tooth (#27) (0.25 ± 1.58 mm) (Table 1). Negative mean distance values indicate apical protrusion of the buccal root apex (Kwak type III), the palatal root apex (Kwak type IV), or both buccal and palatal root apices (Kwak type V) over the inferior wall of the maxillary sinus.

Table 1.

Mean root-maxillary sinus distances (in mm) for first and second molars

		Right Side				Left Side
	N	Mean ± S.D.	Min.	Max.	N	Mean ± S.D.	Min.	Max.
First Molar		#16				#26
MBR	220	1.31 ± 2.66	-4.12	12.80	220	0.97 ± 2.45	-3.50	12.15
DBR	220	1.17 ± 2.53	-2.13	14.37	220	0.89 ± 2.27	-3.40	13.63
PR	220	0.85 ± 2.42	-3.02	10.43	220	0.56 ± 2.23	-6.00	11.00
Second Molar		#17				#27
MBR	220	0.51 ± 2.04	-6.00	12.84	220	0.25 ± 1.58	-6.80	10.91
DBR	220	0.50 ± 1.88	-6.00	12.33	220	0.30 ± 1.67	-5.04	12.23
PR	220	0.68 ± 2.20	-3.03	10.67	220	0.21 ± 1.49	-4.39	8.09

Values represent unadjusted (raw) CBCT measurements expressed as mean ± standard deviation

MBR Mesiobuccal root, DBR Distobuccal root, PR Palatal root

The linear mixed-effects model demonstrated a significant effect of tooth root on root-to-sinus distance (p < 0.001) and a significant overall effect of age group. Gender was not a significant predictor (p = 0.113) (Table 2).

Table 2.

The linear mixed-effects model summary on the root-to-maxillary sinus distances

Effect	Estimate range (mm)	Standard Error	t value	p-value
Intercept	0.537	0.246	2.179	0.030
Tooth Root	-0.964 to 0.138	0.068–0.105	-9.176 to 2.034	< 0.001–0.054*
Age Group	0.648–1.844	0.297–0.858	2.150–2.462	0.0146–0.0327*
Gender (M)	0.412	0.259	1.591	0.113

M Male

* Significance level ≤ 0.05

Post-hoc comparisons indicated that the roots of the maxillary second molars were closer to the maxillary sinus than those of the maxillary first molars. The palatal roots of the maxillary first molars (#16, #26) were generally closer to the maxillary sinus, with most differences being statistically significant, and the mesiobuccal roots of the maxillary second molars, particularly on the left side (#27), were generally closer to the maxillary sinus (Table 3). Although the age group showed a significant overall effect in the model, no post-hoc pairwise comparisons between age groups remained statistically significant after Bonferroni correction (Table 4).

Table 3.

Post-hoc pairwise comparisons for tooth-root for selected significant comparisons

Comparison	Root 1 Mean ± SD	Root 2 Mean ± SD	Estimate	Standard Error	t-ratio	p-value
#16DBR vs. #16PR	1.17 ± 2.53	0.85 ± 2.42	0.3283	0.0678	4.841	< 0.0001 ****
#16DBR vs. #17DR	1.17 ± 2.53	0.50 ± 1.88	0.6747	0.1050	6.420	< 0.0001 ****
#16DBR vs. #17MBR	1.17 ± 2.53	0.51 ± 2.04	0.6613	0.1050	6.292	< 0.0001 ****
#16DBR vs. #17PR	1.17 ± 2.53	0.68 ± 2.20	0.4971	0.1050	4.730	0.0002 ***
#16DBR vs. #26PR	1.17 ± 2.53	0.56 ± 2.23	0.6134	0.1050	5.837	< 0.0001 ****
#16DBR vs. #27DBR	1.17 ± 2.53	0.30 ± 1.67	0.8830	0.1050	8.401	< 0.0001 ****
#16DBR vs. #27MBR	1.17 ± 2.53	0.25 ± 1.58	0.9327	0.1050	8.875	< 0.0001 ****
#16DBR vs. #27PR	1.17 ± 2.53	0.21 ± 1.49	0.9643	0.1050	9.176	< 0.0001 ****
#16MBR vs. #16PR	1.31 ± 2.66	0.85 ± 2.42	0.4662	0.0678	6.875	< 0.0001 ****
#16MBR vs. #17PR	1.31 ± 2.66	0.68 ± 2.20	0.6350	0.1050	6.043	< 0.0001 ****
#16MBR vs. #26PR	1.31 ± 2.66	0.56 ± 2.23	0.7513	0.1050	7.149	< 0.0001 ****
#16MBR vs. #27PR	1.31 ± 2.66	0.21 ± 1.49	1.1022	0.1050	10.488	< 0.0001 ****
#17DBR vs. #26DBR	0.50 ± 1.88	0.89 ± 2.27	-0.3902	0.1050	-3.713	0.0141 *
#17DBR vs. #26MBR	0.50 ± 1.88	0.97 ± 2.45	-0.4722	0.1050	-4.493	0.0005 ***
#17PR vs. #27DBR	0.68 ± 2.20	0.30 ± 1.67	0.3858	0.1050	3.671	0.0166 *
#17PR vs. #27MBR	0.68 ± 2.20	0.25 ± 1.58	0.4355	0.1050	4.144	0.0024 **
#17PR vs. #27PR	0.68 ± 2.20	0.21 ± 1.49	0.4672	0.1050	4.445	0.0006 ***
#26DBR vs. #26PR	0.89 ± 2.27	0.56 ± 2.23	0.3289	0.0678	4.850	< 0.0001 ****
#26DBR vs. #27DBR	0.89 ± 2.27	0.30 ± 1.67	0.5985	0.1050	5.694	< 0.0001 ****
#26DBR vs. #27MBR	0.89 ± 2.27	0.25 ± 1.58	0.6482	0.1050	6.168	< 0.0001 ****
#26DBR vs. #27PR	0.89 ± 2.27	0.21 ± 1.49	0.6798	0.1050	6.469	< 0.0001 ****

MBR Mesiobuccal root, DBR Distobuccal root, PR Palatal root

Significance levels: *p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001

Table 4.

Post-hoc pairwise comparisons for age groups

Comparison	Estimate (mm)	Standard Error	t-ratio	p-value
21–29 vs. 30–39	-0.6482	0.297	-2.179	0.3044
21–29 vs. 40–49	-0.7172	0.384	-1.866	0.6339
21–29 vs. 50–59	-1.1850	0.481	-2.462	0.1460
21–29 vs. 60+	-1.8445	0.858	-2.150	0.3269
30–39 vs. 40–49	-0.0691	0.397	-0.174	1.0000
30–39 vs. 50–59	-0.5368	0.495	-1.084	1.0000
30–39 vs. 60+	-1.1963	0.863	-1.386	1.0000
40–49 vs. 50–59	-0.4677	0.551	-0.848	1.0000
40–49 vs. 60+	-1.1272	0.898	-1.256	1.0000
50–59 vs. 60+	-0.6595	0.945	-0.698	1.0000

Significance level ≤ 0.05

An additional multivariate comparison of right and left sides revealed no significant difference in root-to-sinus distances (p = 0.10), suggesting bilateral symmetry in the root–sinus relationship Fig. 2.

Fig. 2.

Presenting violin plots of root-to-sinus distances by tooth and root type

The distribution of Kwak classification types according to gender for each maxillary molar is presented in Table 5. Type 2 was the most frequently observed relationship in all maxillary molar teeth across both genders. However, Fisher’s exact analysis revealed no statistically significant gender differences in the distribution of Kwak classification types for any tooth (#16: p = 0.449; #17: p = 0.287; #26: p = 0.354; #27: p = 0.265).

Table 5.

Vertical relationship of maxillary molars to maxillary sinus by tooth and gender

Tooth number	Gender	Type 1 (%)	Type 2 (%)	Type 3 (%)	Type 4 (%)	Type 5 (%)	Total N	p-value
#16	Female	38 (30.6%)	71 (57.3%)	1 (0.8%)	7 (5.6%)	7 (5.6%)	124	0.449
#16	Male	32 (33.3%)	48 (50.0%)	0 (0.0%)	11 (11.5%)	5 (5.2%)	96
#17	Female	20 (16.1%)	93 (75.0%)	4 (3.2%)	2 (1.6%)	5 (4.0%)	124	0.287
#17	Male	21 (21.9%)	63 (65.6%)	1 (1.0%)	4 (4.2%)	7 (7.3%)	96
#26	Female	31 (25.0%)	81 (65.3%)	1 (0.8%)	7 (5.6%)	4 (3.2%)	124	0.354
#26	Male	24 (25.0%)	56 (58.3%)	0 (0.0%)	12 (12.5%)	4 (4.2%)	96
#27	Female	12 (9.7%)	102 (82.3%)	2 (1.6%)	3 (2.4%)	5 (4.0%)	124	0.265
#27	Male	14 (14.6%)	68 (70.8%)	1 (1.0%)	5 (5.2%)	8 (8.3%)	96
Total		192 (21.8%)	582 (66.1%)	10 (1.1%)	51 (5.8%)	45 (5.1%)	880

Significance level ≤ 0.05

Discussion

This study aimed to assess the anatomical relationship between the maxillary molar roots and the maxillary sinus floor in a Saudi subpopulation using cone-beam computed tomography (CBCT). The three-dimensional nature of CBCT enables a detailed assessment of osseous anatomy, including accurate visualization of root morphology, surrounding alveolar bone, and spatial proximity of posterior maxillary teeth to the sinus floor, offering diagnostic advantages over conventional two-dimensional imaging techniques [14–16].

Accurate knowledge of the root–sinus relationship is clinically essential, particularly in the context of odontogenic maxillary sinusitis. In cases where the apices of the maxillary molars are close to or in contact with the sinus floor, or sometimes their protrusion, may lead to the extension of pulpal or periapical infections into the sinus cavity, complicating diagnosis and management [17]. In addition, this anatomical proximity has direct implications for treatment planning in procedures such as nonsurgical endodontic therapy, particularly during working length determination, apical enlargement, and obturation, apical surgery, tooth extraction, and implant placement. This proximity may increase the risk of sinus membrane irritation, extrusion of irrigants or filling materials, and post-operative maxillary sinusitis [5]. Similarly, in apical surgery, awareness of apical proximity to the sinus is critical to minimize the risk of sinus perforation and to guide flap design and surgical approach [11]. This anatomical relationship is also relevant during tooth extraction, as the likelihood of oroantral communication complication may increase with teeth close to, in contact with, or protruding to the sinus floor. Consequently, CBCT imaging should be considered a valuable diagnostic adjunct when close root–sinus proximity is suspected, allowing careful evaluation of both the vertical distance and spatial orientation, particularly when surgical intervention, complex endodontic treatment, or implant planning is anticipated [18].

The findings of the present study demonstrated that the roots of the maxillary second molars exhibited the shortest distance from the maxillary sinus floor. Among the first molars, the palatal root had the shortest distance to the maxillary sinus, and among the second molars, the palatal and mesiobuccal roots had the shortest distances. This observation is consistent with those of previous CBCT-based studies conducted across different populations [4, 7–9, 18–20]. However, other studies have demonstrated that the distobuccal root of the maxillary second molar is the closest to the sinus floor [10, 11, 21]. Comparable proximity patterns have been reported in Turkish, East Asian, Korean, Indian, and Romanian populations, although the reported mean distances and prevalence of sinus contact vary considerably [12, 13, 22–24]. These discrepancies likely reflect differences in craniofacial anatomy, sinus pneumatization patterns, population characteristics, methodological approaches, and sample size. Anatomically, the close association observed in the posterior maxilla may be explained by the tendency of the maxillary sinus to pneumatize inferiorly and posteriorly, particularly in the region of the second molars [3].

Multivariate analysis showed no significant overall difference between the right and left sides in the mean root-sinus distance. Previous studies by Tian et al. [12], Kilic et al. [21], and Ragab et al. [25] reported bilateral symmetry in the root-sinus distance. Similarly, in the present study, gender did not significantly influence the root-sinus distance, which is inconsistent with previous studies [20, 26–28]. In contrast, some studies have shown that male patients have root apices of the maxillary posterior teeth closer to the floor of the maxillary sinus than those of female patients because of a larger maxillary sinus [29–31].

In the present study, although the age groups showed significance in the linear mixed-effects model, no post-hoc pairwise comparisons reached statistical significance. This result can be attributed to the uneven age distribution, particularly the small ≥ 60 group. Gu et al. observed a reduced incidence of root apices contacting or protruding into the sinus with increasing age [26]. This pattern may be attributed to the physiological changes associated with aging, including alterations in sinus pneumatization and continuous alveolar bone remodeling. Over time, increased bone deposition and potential thickening of the sinus floor may lead to greater separation between the root apices and sinus cavity. Conversely, other studies have reported greater proximity between the root and the sinus in younger individuals [12, 20, 32]. Moreover, von Arx et al. reported that age has no significant effect on the mean distance between the premolar roots and the maxillary sinus floor in the Swiss population [33]. Such conflicting results may be related to differences in age stratification, imaging protocols, population characteristics, classification systems, and ethnic variations in craniofacial development.

Gender had no significant effect on the vertical relationship between the maxillary molar roots and the sinus floor. Both male and female patients predominantly exhibited a Type II relationship, characterized by the sinus floor extending below the level of the buccal and palatal root apices while remaining separated from them by a thin bony layer without apical penetration into the sinus cavity. These results are similar to those reported in a previous study in Saudi Arabia [10]. In contrast, type I vertical relationship has been reported in several studies in different populations [4, 7, 11, 21]. These differences could be attributed to the different population characteristics and ethnic variations.

This study had certain limitations. Its retrospective design and reliance on existing CBCT scans may have introduced potential selection bias, as imaging was obtained for diagnostic or treatment-related purposes rather than standardized research protocol. In addition, the study population was limited to a Saudi subpopulation from a single institution; therefore, the results cannot be generalized. Moreover, variations in the field of view across scans may have affected image standardization and may have influenced spatial resolution and measurement accuracy. Finally, the analysis focused primarily on the vertical root–sinus relationships; future studies incorporating three-dimensional volumetric assessments may provide more comprehensive anatomical insights.

Conclusions

Within the limitations of this study, the relationship between the maxillary molar roots and the maxillary sinus floor varied according to the tooth type. The shortest root-to-sinus distance was observed in the roots of the maxillary second molars. A larger sample size is needed to evaluate the effect of age. These findings highlight the value of CBCT imaging in clinical preoperative assessment and treatment planning for minimizing sinus-related complications.

Authors' contributions

Conceptualization, A.A. and N.A.; methodology, A.A., N.A., L.A., S.A., S.A., S.A., and S.J.; validation, A.A. and N.A.; formal analysis, F.F., N.A., and A.A.; investigation, A.A., N.A., L.A., S.A., S.A., S.A., and S.J.; resources, L.A., S.A., S.A., S.A., and S.J.; data curation, A.A. and N.A.; writing—original draft preparation, A.A., S.B., S.A.; writing—review and editing, A.A., S.B., S.A., N.A., and F.F.; project administration, A.A. All authors reviewed the manuscript.

Funding

The authors declare that they have no funding support.

Data availability

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

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles of the World Medical Association Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (E-24-9093) of the College of Medicine, King Saud University, Riyadh, Saudi Arabia, and the requirement for informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.