{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T17:11:31Z","timestamp":1790097091260,"version":"4.0.1"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"10","license":[{"start":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T00:00:00Z","timestamp":1758844800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T00:00:00Z","timestamp":1758844800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"University of Bern"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Clin Oral Invest"],"abstract":"<jats:title>Abstract<\/jats:title>\n          <jats:sec>\n            <jats:title>Objectives<\/jats:title>\n            <jats:p>This ex vivo study aimed to compare the accuracy in detection of interproximal natural carious lesions between intraoral (iBWR) and extraoral bitewing radiographs (eBWR) using a multi-observer design and a rigorous gold standard.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Materials and methods<\/jats:title>\n            <jats:p>Eighty extracted teeth (40 premolars, 40 molars) were arranged in anatomical sequence within a simulated jaw composed of PMMA and modified gypsum, with an emphasis on creating natural interproximal contacts. Approximately 50% of the teeth exhibited enamel caries, while the remaining 50% were caries-free. Image acquisition was performed using a custom-designed PMMA phantom. iBWR were obtained with a CMOS intraoral sensor (XIOS XG Supreme, Sirona Dental Systems, Bensheim, Germany), and eBWR with a digital panoramic device (Orthophos SL 3D, Dentsply Sirona, Bensheim, Germany).<\/jats:p>\n            <jats:p>Twenty-seven licensed dentists assessed caries presence and depth on 120 approximal surfaces (each surface assessed twice using both modalities) using a 5-point confidence scale and a 4-point lesion depth scale. Observers were blinded to the true caries status, which was determined through histological serial sectioning and brightfield microscopy. Diagnostic accuracy was evaluated via ROC analysis, with Youden\u2019s index used to calculate sensitivity, specificity, predictive values, and likelihood ratios. Statistical analyses were conducted at a significance level of \u03b1\u2009=\u20090.05.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Overall accuracy was higher for iBWR (Az<jats:sub>pooled<\/jats:sub> = 0.58) than for eBWR (Az<jats:sub>pooled<\/jats:sub> = 0.54). Both intra-rater (test-retest, eBWR <jats:inline-formula>\n                <jats:tex-math>$$\\:\\rho\\:$$<\/jats:tex-math>\n              <\/jats:inline-formula>\n              <jats:sub>spearman<\/jats:sub> = 0.44, iBWR <jats:inline-formula>\n                <jats:tex-math>$$\\:\\rho\\:$$<\/jats:tex-math>\n              <\/jats:inline-formula>\n              <jats:sub>spearman<\/jats:sub> = 0.48) as well as inter-rater reliability (mean ICC eBWR\u2009=\u20090.19, iBWR\u2009=\u20090.27) were low. For enamel caries detection, iBWR outperformed eBWR in terms of specificity and positive predictive values, while eBWR in the first reading round achieved significantly higher sensitivity.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions<\/jats:title>\n            <jats:p>Overall, our multi-observer ex vivo study using microscopy as ground truth revealed higher diagnostic accuracy for intraoral bitewing radiography as compared to its extraoral counterpart.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Clinical Relevance<\/jats:title>\n            <jats:p>Our results from a highly standardized study using a rigorous gold standard support the assumption that intraoral bitewing radiography still represents the radiographic state-of-the-art in interproximal caries detection. For minute enamel, diagnostic accuracy of both methods is just above random guessing.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1007\/s00784-025-06511-1","type":"journal-article","created":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T07:35:50Z","timestamp":1758872150000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Intraoral vs. extraoral bitewing radiography for approximal caries detection: A multi-observer ex vivo ROC study using thin-section microscopy as gold standard"],"prefix":"10.1007","volume":"29","author":[{"given":"Julia Caroline","family":"Quintus","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7880-0046","authenticated-orcid":false,"given":"Ralf Kurt Willy","family":"Schulze","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,9,26]]},"reference":[{"key":"6511_CR1","doi-asserted-by":"publisher","first-page":"2","DOI":"10.21037\/atm-21-2197","volume":"10","author":"P Grieco","year":"2022","unstructured":"Grieco P, Jivraj A, Silva JD, Kuwajima Y, Ishida Y, Ogawa K, Ohyama H, Ishikawa-Nagai S (2022) Importance of bitewing radiographs for the early detection of interproximal carious lesions and the impact on healthcare expenditure in Japan. Ann Transl Med 10:2. https:\/\/doi.org\/10.21037\/atm-21-2197","journal-title":"Ann Transl Med"},{"key":"6511_CR2","doi-asserted-by":"publisher","DOI":"10.1007\/s41894-020-00086-8","volume":"4","author":"F Schwendicke","year":"2020","unstructured":"Schwendicke F, G\u00f6stemeyer G (2020) Conventional bitewing radiography. clin. Dent Rev 4:22. https:\/\/doi.org\/10.1007\/s41894-020-00086-8","journal-title":"clin. Dent Rev"},{"key":"6511_CR3","volume-title":"Towards universal health coverage for oral health by 2030. regional summary of the Eastern mediterranean region","author":"Global oral health status report","year":"2023","unstructured":"Global oral health status report (2023) Towards universal health coverage for oral health by 2030. regional summary of the Eastern mediterranean region. World Health Organization, Geneva. https:\/\/iris.who.int\/bitstream\/handle\/10665\/375771\/9789240070806-eng.pdf?sequence=1 Licence: CC BY-NC-SA 3.0 IGO"},{"key":"6511_CR4","unstructured":"Fleming E, Afful J (2018) Prevalence of total and untreated dental caries among youth: United States, 2015\u20132016. NCHS Data Brief, no 307. Hyattsville, MD: National Center for Health Statistics https:\/\/www.cdc.gov\/nchs\/data\/databriefs\/db307.pdf"},{"key":"6511_CR5","doi-asserted-by":"publisher","DOI":"10.1259\/dmfr.20170450","volume":"48","author":"N Takahashi","year":"2019","unstructured":"Takahashi N, Lee C, Silva JDD, Ohyama H, Roppongi M, Kihara H, Hatakeyama W, Ishikawa-Nagai S, Izumisawa M (2019) A comparison of diagnosis of early stage interproximal caries with bitewing radiographs and periapical images using consensus reference. Dentomaxillofac Radiol 48:20170450. https:\/\/doi.org\/10.1259\/dmfr.20170450","journal-title":"Dentomaxillofac Radiol"},{"key":"6511_CR6","first-page":"270","volume-title":"Oral radiology, principles and interpretation","author":"A Wenzel","year":"2009","unstructured":"Wenzel A (2009) Dental caries. In: White SC, Pharoah MJ (eds) Oral radiology, principles and interpretation, 6th edn. Mosby, St Louis, MO, pp 270\u2013281","edition":"6"},{"key":"6511_CR7","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1259\/dmfr\/30526171","volume":"41","author":"K Kamburoglu","year":"2012","unstructured":"Kamburoglu K, Kolsuz E, Murat S, Y\u00fcksel S, Ozen T (2012) Proximal caries detection accuracy using intraoral bitewing radiography, extraoral bitewing radiography and panoramic radiography. Dentomaxillofac Radiol 41:450\u2013459. https:\/\/doi.org\/10.1259\/dmfr\/30526171","journal-title":"Dentomaxillofac Radiol"},{"key":"6511_CR8","doi-asserted-by":"publisher","DOI":"10.1259\/dmfr.20150159","volume":"45","author":"GL Terry","year":"2016","unstructured":"Terry GL, Noujeim M, Langlais RP, Moore WS, Prihoda TJ (2016) A clinical comparison of extraoral panoramic and intraoral radiographic modalities for detecting proximal caries and visualizing open posterior interproximal contacts. Dentomaxillofac Radiol 45:20150159. https:\/\/doi.org\/10.1259\/dmfr.20150159","journal-title":"Dentomaxillofac Radiol"},{"key":"6511_CR9","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1259\/dmfr.28.3.10740465","volume":"28","author":"A Wenzel","year":"1999","unstructured":"Wenzel A, Hintze H (1999) The choice of gold standard for evaluating tests for caries diagnosis. Dentomaxillofac Radiol 28:132\u2013136. https:\/\/doi.org\/10.1259\/dmfr.28.3.10740465","journal-title":"Dentomaxillofac Radiol"},{"key":"6511_CR10","doi-asserted-by":"publisher","first-page":"20150326","DOI":"10.1259\/dmfr.20150326","volume":"45","author":"WH Abu El-Ela","year":"2016","unstructured":"Abu El-Ela WH, Farid MM, Mostaf MS (2016) Intraoral versus extraoral bitewing radiography in detection of enamel proximal caries: an ex vivo study. Dentomaxillofac Radiol 45:20150326. https:\/\/doi.org\/10.1259\/dmfr.20150326","journal-title":"Dentomaxillofac Radiol"},{"key":"6511_CR11","doi-asserted-by":"publisher","first-page":"287","DOI":"10.1016\/0030-4220(74)90070-x","volume":"38","author":"M Goldman","year":"1974","unstructured":"Goldman M, Pearson AH, Darzenta N (1974) Reliability of radiographic interpretations. Oral Surg Oral Med Oral Pathol 38:287\u201393. https:\/\/doi.org\/10.1016\/0030-4220(74)90070-x","journal-title":"Oral Surg Oral Med Oral Pathol"},{"key":"6511_CR12","doi-asserted-by":"publisher","first-page":"330","DOI":"10.1016\/S0099-2399(88)80193-6","volume":"14","author":"I Kaffe","year":"1988","unstructured":"Kaffe I, Gratt BM (1988) Variations in the radiographic interpretation of the periapical dental region. J Endod 14:330\u2013335. https:\/\/doi.org\/10.1016\/S0099-2399(88)80193-6","journal-title":"J Endod"},{"key":"6511_CR13","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1055\/s-0034-1390974","volume":"7","author":"B Madsack","year":"2014","unstructured":"Madsack B, Walz M, Weisser G (2014) Abnahme und Konstanzpr\u00fcfung an Bildwiedergabesystemen \u2013 was \u00e4ndert Sich Mit der Neuen DIN V 6868\u2009\u2013\u2009157? Radiopraxis 7:195\u2013210. https:\/\/doi.org\/10.1055\/s-0034-1390974","journal-title":"Radiopraxis"},{"key":"6511_CR14","doi-asserted-by":"publisher","first-page":"504","DOI":"10.2341\/06-148","volume":"32","author":"MT Alkurt","year":"2007","unstructured":"Alkurt MT, Peker I, Bala O, Altunkaynak B (2007) In vitro comparison of four different dental X-ray films and direct digital radiography for proximal caries detection. Oper Dent 32:504\u2013509. https:\/\/doi.org\/10.2341\/06-148","journal-title":"Oper Dent"},{"key":"6511_CR15","first-page":"307","volume":"29","author":"JA Hanley","year":"1989","unstructured":"Hanley JA (1989) Receiver operating characteristic (ROC) methodology: the state of the art. Crit Rev Diagn Imaging 29:307\u2013335","journal-title":"Crit Rev Diagn Imaging"},{"key":"6511_CR16","doi-asserted-by":"publisher","first-page":"4447","DOI":"10.1016\/j.actbio.2010.06.022","volume":"6","author":"E Willbold","year":"2010","unstructured":"Willbold E, Witte F (2010) Histology and research at the hard tissue\u2013implant interface using technovit 9100 new embedding technique. Acta Biomater 6:4447\u20134455. https:\/\/doi.org\/10.1016\/j.actbio.2010.06.022","journal-title":"Acta Biomater"},{"key":"6511_CR17","doi-asserted-by":"publisher","first-page":"318","DOI":"10.1111\/j.1600-0714.1982.tb00172.x","volume":"11","author":"K Donath","year":"1982","unstructured":"Donath K, Breuner G (1982) A method for the study of undecalcified bones and teeth with attached soft tissues. The S\u00e4ge-schliff (sawing and grinding) technique. J Oral Pathol 11:318\u2013326. https:\/\/doi.org\/10.1111\/j.1600-0714.1982.tb00172.x","journal-title":"J Oral Pathol"},{"key":"6511_CR18","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1159\/000069016","volume":"37","author":"H Hintze","year":"2003","unstructured":"Hintze H, Wenzel A (2003) Diagnostic outcome of methods frequently used for caries validation. A comparison of clinical examination, radiography and histology following hemisectioning and serial tooth sectioning. Caries Res 37:115\u2013124. https:\/\/doi.org\/10.1159\/000069016","journal-title":"Caries Res"},{"key":"6511_CR19","doi-asserted-by":"crossref","unstructured":"Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86:420\u2013428. https:\/\/doi.org\/10.1037\/\/0033-2909.86.2.420","DOI":"10.1037\/\/0033-2909.86.2.420"},{"key":"6511_CR20","unstructured":"R Core Team (2024) _R: A Language and Environment for Statistical Computing_. R Foundation for Statistical Computing, Vienna, Austria. https:\/\/www.R-project.org\/"},{"key":"6511_CR21","volume-title":"RStudio: integrated development for R. RStudio","author":"RStudio Team","year":"2020","unstructured":"RStudio Team (2020) RStudio: integrated development for R. RStudio. PBC, Boston., MA. http:\/\/www.rstudio.com\/"},{"key":"6511_CR22","unstructured":"Robin X, Turck N, Hainard A, Tiberti N, Lisacek F, Sanchez J-C, M\u00fcller M, Siegert S, Doering M, Billings Z (2023) [accessed 1 November 2024]). pROC: display and analyze ROC curves [Internet]. https:\/\/cran.r-project.org\/web\/packages\/pROC\/pROC.pdf"},{"key":"6511_CR23","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","volume":"15","author":"TK Koo","year":"2016","unstructured":"Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15:155\u2013163. https:\/\/doi.org\/10.1016\/j.jcm.2016.02.012","journal-title":"J Chiropr Med"},{"issue":"4","key":"6511_CR24","first-page":"203","volume":"19","author":"A-M \u0160imundi\u0107","year":"2009","unstructured":"\u0160imundi\u0107 A-M (2009) Measures of diagnostic accuracy: basic definitions. Electron J Int Fed Clin Chem Lab Med 19(4):203\u2013211","journal-title":"Electron J Int Fed Clin Chem Lab Med"},{"key":"6511_CR25","unstructured":"Cohen J (1988) Statistical power analysis for the behavioral sciences. Lawrence Erlbaum Associates,"},{"key":"6511_CR26","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1159\/000016454","volume":"32","author":"H Hintze","year":"1998","unstructured":"Hintze H, Wenzel A, Danielsen B, Nyvad B (1998) Reliability of visual examination, fibre-optic transillumination, and bite-wing radiography, and reproducibility of direct visual examination following tooth separation for the identification of cavitated carious lesions in contacting approximal surfaces. Caries Res 32:204\u2013209. https:\/\/doi.org\/10.1159\/000016454","journal-title":"Caries Res"},{"key":"6511_CR27","first-page":"157","volume":"5","author":"V Machiulskiene","year":"2004","unstructured":"Machiulskiene V, Nyvad B, Baelum V (2004) Comparison of diagnostic yields of clinical and radiographic caries examinations in children of different age. Eur J Paediatr Dent 5:157\u2013162","journal-title":"Eur J Paediatr Dent"},{"key":"6511_CR28","doi-asserted-by":"publisher","first-page":"481","DOI":"10.1038\/s41415-021-3526-6","volume":"231","author":"H Devlin","year":"2021","unstructured":"Devlin H, Williams T, Graham J, Ashley M (2021) The ADEPT study: a comparative study of dentists\u2019 ability to detect enamel-only proximal caries in bitewing radiographs with and without the use of assistdent artificial intelligence software. Br Dent J 231:481\u2013485. https:\/\/doi.org\/10.1038\/s41415-021-3526-6","journal-title":"Br Dent J"},{"key":"6511_CR29","doi-asserted-by":"publisher","DOI":"10.1259\/dmfr.20210010","volume":"50","author":"A Wenzel","year":"2021","unstructured":"Wenzel A (2021) Radiographic modalities for diagnosis of caries in a historical perspective: from film to machine-intelligence supported systems. Dentomaxillofac Radiol 50:20210010. https:\/\/doi.org\/10.1259\/dmfr.20210010","journal-title":"Dentomaxillofac Radiol"},{"key":"6511_CR30","doi-asserted-by":"publisher","first-page":"444","DOI":"10.1016\/j.adaj.2021.02.015","volume":"152","author":"KB Johnson","year":"2021","unstructured":"Johnson KB, Mol A, Tyndall DA (2021) Extraoral bite-wing radiographs: a universally accepted paradox. J Am Dent Assoc 152:444\u2013447. https:\/\/doi.org\/10.1016\/j.adaj.2021.02.015","journal-title":"J Am Dent Assoc"},{"key":"6511_CR31","doi-asserted-by":"publisher","first-page":"e129","DOI":"10.1016\/j.oooo.2016.01.016","volume":"121","author":"K Hell\u00e9n-Halme","year":"2016","unstructured":"Hell\u00e9n-Halme K, Johansson C, Nilsson M (2016) Comparison of the performance of intraoral X-ray sensors using objective image quality assessment. Oral Surg Oral Med Oral Pathol Oral Radiol 121:e129\u2013137. https:\/\/doi.org\/10.1016\/j.oooo.2016.01.016","journal-title":"Oral Surg Oral Med Oral Pathol Oral Radiol"},{"issue":"1","key":"6511_CR32","doi-asserted-by":"publisher","DOI":"10.1186\/s12880-020-00472-5","volume":"20","author":"HG Yeom","year":"2020","unstructured":"Yeom HG, Kim JE, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC (2020) Correlation between Spatial resolution and ball distortion rate of panoramic radiography. BMC Med Imaging 68. https:\/\/doi.org\/10.1186\/s12880-020-00472-5","journal-title":"BMC Med Imaging"},{"key":"6511_CR33","doi-asserted-by":"publisher","first-page":"867","DOI":"10.2214\/ajr.182.4.1820867","volume":"182","author":"NA Obuchowski","year":"2004","unstructured":"Obuchowski NA (2004) How many observers are needed in clinical studies of medical imaging? AJR Am J Roentgenol 182:867\u2013869. https:\/\/doi.org\/10.2214\/ajr.182.4.1820867","journal-title":"AJR Am J Roentgenol"},{"key":"6511_CR34","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1016\/j.adaj.2017.08.032","volume":"149","author":"M Chan","year":"2018","unstructured":"Chan M, Dadul T, Langlais R, Russell D, Ahmad M (2018) Accuracy of extraoral bite-wing radiography in detecting proximal caries and crestal bone loss. J Am Dent Assoc 149:51\u201358. https:\/\/doi.org\/10.1016\/j.adaj.2017.08.032","journal-title":"J Am Dent Assoc"},{"key":"6511_CR35","doi-asserted-by":"publisher","DOI":"10.1259\/dmfr.20150281","volume":"45","author":"L Gaalaas","year":"2016","unstructured":"Gaalaas L, Tyndall D, Mol A, Everett ET, Bangdiwala A (2016) Ex vivo evaluation of new 2D and 3D dental radiographic technology for detecting caries. Dentomaxillofac Radiol 45:20150281. https:\/\/doi.org\/10.1259\/dmfr.20150281","journal-title":"Dentomaxillofac Radiol"},{"issue":"2","key":"6511_CR36","doi-asserted-by":"publisher","first-page":"182","DOI":"10.1016\/j.oooo.2023.09.002","volume":"137","author":"AK Dorsey","year":"2024","unstructured":"Dorsey AK, Mol A, Green P, Ludlow J, Johnson B (2024) Radiation doses in extraoral bitewing radiography compared with intraoral bitewing and panoramic radiography. Oral Surg Oral Med Oral Pathol Oral Radiol 137(2):182\u2013189. https:\/\/doi.org\/10.1016\/j.oooo.2023.09.002","journal-title":"Oral Surg Oral Med Oral Pathol Oral Radiol"}],"container-title":["Clinical Oral Investigations"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00784-025-06511-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00784-025-06511-1\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00784-025-06511-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T06:12:13Z","timestamp":1760595133000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00784-025-06511-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,26]]},"references-count":36,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["6511"],"URL":"https:\/\/doi.org\/10.1007\/s00784-025-06511-1","relation":{},"ISSN":["1436-3771"],"issn-type":[{"value":"1436-3771","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,26]]},"assertion":[{"value":"27 March 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 August 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 September 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"As phantom study, no ethical approval was required. The teeth for the phantom were taken from regular extractions under the consent of the patients for secondary scientific use.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}},{"value":"All patients in which the teeth had been extracted gave their general consent for secondary scientific use of material and data.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent"}},{"value":"Financial interests: RS (The University Medical Center of the Johannes Gutenberg-University of Mainz) received financial support by Dentsply Sirona for the project. Non-financial interests: RS is an unpaid member of different national (DIN) and international (IEC) standardization committees.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"477"}}