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199]

Review Article

Effect of triple antibiotic paste and calcium

hydroxide on the rate of healing of periapical lesions:
A systematic review
N Kiran Kumar, Biji Brigit, B S Annapoorna, Savitha B Naik, Seema Merwade, Rashmi K
Department of Conservative Dentistry and Endodontics, Government Dental College, Bengaluru, Karnataka, India

ABSTRACT
Aim: The rate of healing of periapical lesion after the antibacterial dressing with triple antibiotic paste and calcium hydroxide
was assessed.
Materials and Methods: Case reports which used triple antibiotic paste and calcium hydroxide as the intracanal dressing was
searched in PubMed, Google Scholar and Cochrane Oral Health’s Trials Register up to August 2020, without language and
period restriction. Two authors independently reviewed all identified titles and abstracts for eligibility. Tables were generated to
summarize the included studies.
Results: Sixteen (n = 16) articles met the eligibility criteria. Nonsurgical endodontic treatment was carried out in eleven cases
with triple antibiotic paste and in nineteen cases calcium hydroxide was used. Results of the study after analyzing the case
reports indicate that both triple antibiotic paste and calcium hydroxide are equally effective as intracanal medicament. In cases
where calcium hydroxide failed to eliminate symptoms, triple antibiotic paste was found to be effective.
Conclusion: As far as the effect on the healing of the periapical lesions is concerned, all the studies showed a high success
rate. Available scientific data indicates nonsurgical treatment can be adopted as a routine measure to conservatively treat large
periapical lesions of endodontic origin.
Keywords: Calcium hydroxide; disinfection; lesion sterilization and tissue repair; periapical lesion; triple antibiotic paste

INTRODUCTION this method alone cannot render the root canal microbial
free, particularly when there is a large periapical lesion.
Periapical lesions develop as an inflammatory response to Complexities in the root canal system and the lodging
the invasion of the root canal system by microorganisms of microbes into deep layers of root canal dentin pose a
and their by‑products.[1] The rationale of endodontic challenge in disinfection and persistence of these microbes
therapy is to eliminate the microbes and disinfect the root can lead to the recurrence of periapical complications.[4] In
canal system.[2] The reduction in microbial load is essential addition, the polymicrobial nature of endodontic infections
before obturation not only to get rid of symptoms but also makes total disinfection of the canal space difficult.[1]
to lessen the occurrence of refractory periapical pathosis.[3]
Microbial eradication during an endodontic procedure is Currently, periapical lesions are managed either with
achieved using chemomechanical debridement. However, a surgical or nonsurgical approach.[5] When the lesion
size was huge, resorting to a surgical approach was the
Address for correspondence: dictum in the management of periapical lesions. However,
Dr. N Kiran Kumar, advancements in scientific knowledge of the genesis,
Government Dental College, Victoria Hospital Campus, Near City
Market, Bengaluru ‑ 560 002, Karnataka, India. pathologic nature, and clinical behavior of endodontic
E‑mail: kiransenate@gmail.com
Date of submission : 20.12.2020 This is an open access journal, and articles are distributed under the terms
Review completed : 01.06.2021 of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Date of acceptance : 04.06.2021 License, which allows others to remix, tweak, and build upon the work
Published : 13.01.2022 non‑commercially, as long as appropriate credit is given and the new
Access this article online creations are licensed under the identical terms.
Quick Response Code: For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Website:
www.jcd.org.in
How to cite this article: Kumar NK, Brigit B, Annapoorna BS,
Naik SB, Merwade S, Rashmi K. Effect of triple antibiotic paste
DOI: and calcium hydroxide on the rate of healing of periapical lesions:
10.4103/jcd.jcd_637_20
A systematic review. J Conserv Dent 2021;24:307-13.

© 2022 Journal of Conservative Dentistry | Published by Wolters Kluwer - Medknow 307

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Kumar, et al.: Triple antibiotic paste and calcium hydroxide on periapical healing
periapical lesions, the potential of the pulpo‑periapical
lesion to heal without intervention has favored nonsurgical
approach.[6] Moreover, surgical methods have many
drawbacks such as long healing time, lack of resolution of
pain, fistula, and swelling. Hence, it should be considered
as an option only when nonsurgical endodontic treatment
fails to induce resolution of the lesion. In the case of large
periapical lesions, nonsurgical endodontic therapy with the
use of an antimicrobial intracanal medicament should be
the primary line of management.
Different techniques can be used in the nonsurgical
management of periapical pathologies, most commonly
employed being lesion sterilization and repair therapy. This
includes the employment of various intracanal medicaments
such as calcium hydroxide and triple antibiotic paste.[7]
Calcium hydroxide has gained popularity as an intracanal
medicament since its introduction to dentistry by
Hermann in 1920. Healing is observed in clinical situations
with this medicament which is due to its antimicrobial
property, induction of hard‑tissue formation, and ability
to promote periodontal repair.[8] The major limitation
of calcium hydroxide is its ineffectiveness against some
microorganisms like Enterococcus faecalis and Candida
albicans which are commonly associated with persistent
endodontic infections.[9]
To overcome the limitations of calcium hydroxide many
other medicaments were advocated. Antibiotic therapy has
become an inseparable part of antimicrobial treatments
and various antibiotics are used to cure active and acute
infections. The use of antibiotics as intracanal medicament
has proven beneficial in treating endodontic infections.
The triple antibiotic paste is a blend of Ciprofloxacin,
Metronidazole, and Minocycline.[10] When used in a
concentration of 1:1:1 (33% each) as intracanal medicament,
it has given promising results in eliminating E. faecalis in
the root apex to a depth of about 400 µ.[11]
Hence, we aimed to review the influence of calcium
hydroxide and triple antibiotic paste on the rate of healing
of periapical lesions, by studying the currently available
literature on the intracanal use of these medicaments.
Objectives
To assess the effects of triple antibiotic paste and calcium
hydroxide on the healing of periapical lesions associated
with infected mature permanent teeth.
MATERIALS AND METHODS
This systematic review was carried out following the
Preferred Reporting Items for Systematic Reviews and
Meta‑Analyses guidelines.
308 Journal of Conservative Dentistry | Volume 24 | Issue 4 | July-August 2021
Registration
Registered at the international prospective register of
systematic reviews (PROSPERO‑CRD42020192568).
Research hypothesis
Our focused question was based on the Participants,
Interventions, Comparison, and Outcomes principle
“Does the rate of healing of periapical lesions remain
the same with calcium hydroxide and triple antibiotic
paste?”
Population: Mature permanent teeth with periapical lesion
Intervention: Triple antibiotic paste
Comparator: Calcium hydroxide
Outcome: Healing of periapical lesion.
Criteria for considering studies for this review:
Inclusion criteria
Type of study
Randomized controlled trials, in‑vivo studies.
Type of participants
Mature permanent teeth with periapical lesion.
Type of intervention
Nonsurgical management, triple antibiotic paste, double
antibiotic paste, calcium hydroxide.
Type of outcome
Rate of healing of periapical lesion with minimum 1‑year
follow‑up.
Exclusion criteria
All the reviews, animal studies, in–vitro studies, periapical
lesion with associated external/internal resorption and
teeth with the associated periodontal lesion, teeth treated
with MTA and Biodentine.
Search methods for the identification of studies:
The search strategy aimed at identifying all published
randomized controlled trials and in‑vivo studies/case reports
dealing with the subject of this review. Detailed search
strategies were utilized for each database to identify the
relevant studies. The subject search used a combination of
mesh words using the Boolean method.
Database searched
PubMed, Google Scholar, Cochrane Oral Health’s Trials
Register.
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Kumar, et al.: Triple antibiotic paste and calcium hydroxide on periapical healing
Search terms
The following search string summarizes the initial search
done in PubMed: ([“Periapical pathology” OR “Periapical
diseases” OR “Periapical lesion” OR “Chronic periapical
lesion” OR “Apical lesions”] AND [“calcium hydroxide” OR
“triple antibiotic paste” OR “Antibiotic paste” OR “Lesion
sterilization and tissue repair” OR “Intracanal dressing”]
AND [Periapical healing” OR “Periapical radiolucency”
OR “Periapical radiopacity” OR “Periapical repair” OR
“Periapical bony healing” OR “Tissue repair”]).
Data collection and analysis
Review authors, independently and not blinded, assessed
the titles, keywords, abstracts and/or methods sections
of studies identified by the search strategy. The search
included controlled clinical trials and case reports. We
obtained relevant articles identified by reference searching
as well as full‑text articles selected by the review authors.
We read in full, the articles on which review authors
disagreed and made the decision to include or exclude on
discussion based on eligibility criteria.
Data extraction
Review authors extracted relevant data from the included
studies independently and in duplicate. We recorded
the following types of data: study design, risk of bias,
studied outcome measures, year of publication, duration
of follow‑up, sample size, number and characteristics
of participants in each group, and reported results. We
assessed the comparability of participant characteristics
at baseline, how researchers dealt with confounding,
eligibility criteria, and the methodology used in measuring
outcomes. We discussed the results until we reached
agreement. In cases of uncertainty, we contacted study
authors for clarification. In case of uncertainty persist, we
did not use the data.
RESULTS
Literature search
In database search 5908 reports were identified. After title
and abstract screening, the study culminated in 40 case
reports that fulfilled both the inclusion and exclusion
criteria and which were conducted in the last 10 years.
After full‑text reading, case reports including apexification,
retreatments, cases with <1 year follow‑up, cases treated
with MTA, Biodentine, or medicaments other than triple
antibiotic paste and calcium hydroxide were excluded to
avoid possible bias in the study. Sixteen articles which met
eligibility were included for final reviewing [Figure 1].
These identified studies investigated the healing of periapical
lesion after nonsurgical root canal treatment using triple
antibiotic paste and calcium hydroxide including success
rates, follow‑up duration, and updated studies in nonsurgical
Journal of Conservative Dentistry | Volume 24 | Issue 4 | July-August 2021
root canal treatment. In all of the studies, the procedures
were performed on systemically healthy persons.
Study characteristics
Characteristics of studies finalized after abstract and
full‑text screening are summarized in Table 1. In the
sixteen studies selected, nineteen patients were treated
with calcium hydroxide (63.33%) and eleven patients with
triple antibiotic paste (36.66%). Studies also varied in their
follow‑up duration. In two studies, Caliskan et  al.[12] and
Matos  et  al.,[13] follow up was from 2 to 20 years and
2–5  years, respectively. Al-Kandari et al.,[13] Vijayshankar
et al.[15] recalled cases up to 2 years, cases were also
recalled at 14 months,[15] 15 months,[16] 18 months,[17] and
in the remaining studies, there was only 1‑year recall. As
far as the effect on the healing of the periapical lesions
is concerned, all the studies showed a highly significant
success rate. Complete healing of periapical lesion after
nonsurgical treatment was achieved.
DISCUSSION
Case reports and case series are unconstrained study
designs known for increased risk of bias but have profoundly
influenced the medical literature and continue to advance
our knowledge. Even though the evidence derived from
these case reports has less certainty, inferences from these
reports can be beneficial in clinical decision‑making.
The study was intended to systematically review the
available information on the rate of healing of periradicular
lesions treated nonsurgically with calcium hydroxide and
triple antibiotic paste as antibacterial dressing in mature
permanent teeth. The information given will aid the clinician
in treatment planning when managing similar case scenarios.
To the authors’ knowledge, this is the first systematic review
focusing on the effect of triple antibiotic paste and calcium
hydroxide on the rate of healing of the periapical lesion.
This presents a comprehensive compilation of evidence
taken from 16 articles. The selected articles comprised
of case reports/case series of patients seeking treatment
for teeth with large periapical lesions. Only those cases
involving mature permanent teeth which were managed
with nonsurgical endodontic treatment using either calcium
hydroxide or triple antibiotic paste were considered. The
healing time for periapical lesion when treated nonsurgically
ranged from 18 to 24 months. Periapical lesions take at least
6–12 months to show any dimensional changes on periapical
radiograph following the completion of endodontic therapy.
[5]
 Hence, a follow‑up period of minimum of 12 months was
added in the inclusion criteria for selecting the articles.
Case reports selected for final review consisted of 19 teeth
treated with calcium hydroxide as antibacterial dressing
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Kumar, et al.: Triple antibiotic paste and calcium hydroxide on periapical healing

Table 1: Summary of studies

Authors Study Intervention Lesion size Duration of follow‑up Main results Conclusion
design
Çalışkan[12] Clinical Calcium 7-18 mm 2-10 years Complete healing in Study demonstrated that nonsurgical
review hydroxide 73.8% root canal treatment using calcium
Incomplete healing hydroxide in teeth with cyst‑like
9.5% large periapical lesions can be an
alternative treatment to surgical
therapy
Matos Case Calcium ‑ Case 1: Case 1: At 2 years Apical endodontic surgery is not
et al. (2014)[13] report hydroxide 2 years+5 years showed complete always recommended for cases of
follow‑up healing large periapical lesions compromising
Case 2: 1 year Case 2: At 1 year showed several teeth
follow‑up decreased radiolucency Proper means of disinfection by
calcium hydroxide paste contributes
to clinical success
Al-Kandari Case Calcium ‑ 2 years follow‑up Complete healing at The largeness of the lesion does not
et al. (1994)[14] report hydroxide 2 years command its surgical removal and
that even cyst‑like lesions resolve
following conservative therapy
Vijayshankar Case Case 1: Calcium Case 1: Case 1: 3 years Case 1 : Marked Calcium hydroxide and TAP used
et al.[15] report hydroxide 2 cm×2 cm follow‑up reduction in size at for a prolonged period afford an
Case 2: TAP Case 2: Case 2: 2 years 3 years environment favorable to periapical
2 cm×2 cm follow‑up Case 2: Resolution of bone regeneration
lesion at 2 years
Soares et al.[16] Case Calcium 32 mm×25 mm 14 months follow‑up Significant reduction in Extensive periapical lesion can be
report hydroxide lesion size at 14 months healed by nonsurgical treatment
follow up involving biomechanical preparation,
lesion decompression by intracanal
aspiration and long term renewal of
aqueous calcium hydroxide paste
Taneja Case Calcium 13 mm×17 mm 15 months follow‑up 15 months: Complete Root canal treatment with TAP as an
et al. (2012)[17] report hydroxide bony healing antibacterial dressing was successful
followed by TAP in healing the large periradicular
lesion when conventional calcium
hydroxide fails to eliminate the
symptoms
Mutluay Case Calcium ‑ 6 and 18 months At 18 months: Healing The success at 18 months of clinical
et al. (2017)[18] report hydroxide for follow‑up of periapical lesion and radiographic follow up confirms
2 days followed that periapical inflammatory lesions
by TAP should be treated first by conservative
means and application of TAP is an
effective treatment method
Majumdar Case Calcium >4 mm 10 months follow‑up At 10 months: Nonsurgical endodontic treatment
et al. (2017)[19] report hydroxide Progressive healing was found to be successful in healing
large periapical lesions
Taneja Case Calcium Case 1: 10 mm Case 1: 16 months Case 1: At 16 months, When conventional medicament
et al. (2010)[20] report hydroxide Case 2: 14 mm follow‑up complete bony healing calcium hydroxide failed to eradicate
for 3 weeks Case 3: Case 2: 10 months Case 2: At 10 months, symptoms, TAP showed progressive
followed by TAP 13 mm×17 mm follow‑up progressive healing resolution of large periradicular
Case 3: 1 year Case 3: Progressive lesions
healing
Mandhotra Case Case 1 and Case 1: Case 1: 1 year Complete healing at Periapical lesions can be successfully
et al.[21] report 2: Calcium 16 mm×10 mm Case 2: 6 months and 1 year treated with the nonsurgical
hydroxide with Case 2: 1 year follow‑up endodontic approach with long term
iodoform paste 6 mm×9 mm Case 3: 1 year calcium hydroxide therapy
Case 3: RC call follow‑up
Karunakaran Case Calcium ‑ Case 1, 2, and 3: 3 Case 1, 2, 3 at 1 year A nonsurgical approach should be
et al. (2017)[22] report hydroxide months, 6 months follow‑up showed accepted as a routine method in
and 1 year follow up significant healing periapical lesions as conservative
orthograde endodontic therapy
demonstrates a favorable outcome
Saatchi Case Calcium ‑ Recalled at 1, 3, 6, At 1‑year progressive Nonsurgical root canal treatment
et al. (2007)[23] report hydroxide 12 months healing with calcium hydroxide is successful
in promoting the healing of a large
periapical lesion

Contd...

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Kumar, et al.: Triple antibiotic paste and calcium hydroxide on periapical healing

Table 1: Contd...
Authors Study Intervention Lesion size Duration of follow‑up Main results Conclusion
design
Bonny et al.[24] Case Calcium ‑ 1‑year follow‑up Considerable resolution Conventional endodontic treatment
report hydroxide for 1 of radiolucency at 1 year with calcium hydroxide was not
month followed enough for treating large cyst‑like
by TAP lesions. TAP was successful at healing
large periapical lesion
Tomar Case TAP Case 1: 1‑year follow‑up Case 1: At 6 months, Simple aspiration technique and LSTR
et al. (2015)[25] report 15 mm×15 mm complete healing of the technique together was successful in
Case 2: lesion healing large cyst‑like periradicular
25 mm×25 mm Case 2: At 1 year showed lesion
complete healing
Pandey Case TAP Case 1: 10 mm Case 1: 12 months Case 1: At 16 months, Case report demonstrates the
et al. (2018)[26] report Case 2: and 16 months complete healing resolution of the periradicular lesion
13 mm×17 mm follow‑up Case 2: At 1 year showed using nonsurgical endodontic
Case 2: 1 year progressing healing treatment that uses TAP
follow‑up
Kusgoz et al.[27] Case Calcium ‑ 30 months follow‑up 1 year complete healing A TAP can be an effective substitute
report hydroxide material to calcium hydroxide in teeth
followed by TAP with large periradicular lesion where
calcium hydroxide fails
TAP: Triple antibiotic paste, LSTR: Lesion sterilization and tissue repair

and 11 teeth treated with triple antibiotic paste. Among
those treated with calcium hydroxide, fourteen cases
showed signs of healing. Complete healing was observed
in twelve cases and two cases showed progressive healing.
Four cases[16,18,23,26] treated with calcium hydroxide failed to
eliminate symptoms and one case[20] showed incomplete
healing at 1 year follow up.
Failure to eliminate symptoms in four cases can be attributed
to the polymicrobial nature of root canal infections. Calcium
hydroxide antibacterial activity is mainly due to the release
of hydroxyl ions. Hosoya et al. analyzing the pH and the
concentration of calcium ions within the periapical area
concluded that a minimum of 2 weeks are necessary for
calcium hydroxide bactericidal activity. However, some
bacteria like E. faecalis are resistant to pH variations and are
capable of forming biofilm. This makes calcium hydroxide an
ineffective medicament in such situations.[28] Another possible
reason is the buffering capacity of dentin which brings down
the alkalinity of calcium hydroxide rendering it less effective.[29]
These cases were further treated with triple antibiotic paste.
One case which showed incomplete healing at 1 year
follow‑up, had received 5 months of antibacterial dressing
with calcium hydroxide. Despite it there was delay in
healing. The authors suggest that the intentional pushing
of calcium hydroxide beyond the apex might have been
the cause for delayed healing.[30] De Moor and De Witte
advocated that extrusion of calcium hydroxide beyond the
apical limit prolongs healing.[31] Yoshishige et al. reported
that such extrusion can lead to apical tissue damage,
affecting the healing rate.
The duration of antibacterial dressing with calcium
hydroxide in the majority of the studied case reports was
2–3  weeks. This period of treatment was sufficient to
promote healing in most of cases.
Rapid healing within 14 months was observed with
antibacterial dressing with calcium hydroxide for 3 weeks
in a case reported by Hariprakash et  al. However, on the
contrary, in the cases reported by Vijayshankar et  al.
healing did not occur at 3‑year follow‑up with 3 weeks
of calcium hydroxide treatment. The huge size of the
lesion (2 cm × 2 cm) might have been the cause.
Caliskan et al. and Karunakaran et al. observed healing in
periapical lesion sized (7–18 mm) at 12–14 months with a
calcium hydroxide dressing given for a duration of 3 months
which was changed every 3 weeks. Prabhat et al. showed
faster healing within 1 year in 2 cases in which the dressing
was extended for 6 months to 1 year. Healing was observed
in the shorter period in these cases despite the periapical
lesions being large (16 mm × 10 mm, 6 mm × 9 mm).
The extended duration of intracanal dressing might have
contributed to faster healing. Hence, it can be suggested
that as the lesion size increases, extended duration of
treatment might be required for faster resolution of
periapical lesions.
Among the eleven cases treated with triple antibiotic paste,
all cases showed signs of healing. Complete healing was
observed in seven cases and progressive healing in four
cases. Four of these cases received triple antibiotic paste
after calcium hydroxide failed to eliminate the symptoms.
Complete resolution of the lesion could be achieved in
cases with triple antibiotic paste dressing for 3 months.
Triple antibiotic paste being a mixture of 3 antibiotics
can address polymicrobial infections better than calcium

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Kumar, et al.: Triple antibiotic paste and calcium hydroxide on periapical healing
5908 Records were identified
through database searching
Identification
of PubMed, Google Scholar and
Cochrane using the keywords.
Duplicates removed = 30
(N = 5878)
Screening
5714 Records excluded after
title screening
164 articles were obtained after
title screening
Eligibility
40 articles assessed
for full text eligibility
Included
24 studies did not meet
the inclusion and
exclusion criteria
after full text screening
Figure 1: Flow chart
hydroxide. In lesions resistant to calcium hydroxide therapy
triple antibiotic paste is a viable alternative.
The average duration of treatment with triple antibiotic
paste was 3 months with the antibacterial dressing
changed every 3 weeks. Healing occurred within a period
of 1–2  years. Increase in bone density was observed in
18 months with triple antibiotic paste medicament given
for 3 months in cases reported by Abidin et al.
Soares at al. reported quick healing in a large lesion of size
32 mm × 25 mm treated with calcium hydroxide for up
to 1 year with medicament changed quarterly. The repair
occurred in 12 months. They had done aspiration of the
lesion before antibacterial dressing. This additional step
would have hastened up the repair process.
Such surprisingly faster rates of healing in 6 months and
1‑year follow‑up despite large lesion sizes (15 mm × 15 mm
and 25 mm × 25 mm) was reported by Deepak et al. with
the aspiration of lesion before antibacterial dressing with
triple antibiotic paste for 4 weeks and 8 weeks respectively.
From the case reports studied it can be stated that the
cardinal factors affecting the healing of periradicular
lesions are the size and type of lesions and the type and
duration of antibacterial dressing.
True cysts are self‑sustaining and are independent of the
presence or absence of irritants in the root canal system.
Such lesions may not respond to antibacterial dressing
312 Journal of Conservative Dentistry | Volume 24 | Issue 4 | July-August 2021
Further records identified
through other sources
(n=0)
124 articles rejected after
abstract screening
Final studies included
in the review
N=16
necessitating a surgical intervention for successful
management. Pocket or bay cyst tend to heal faster with the
cleaning of the canal system and antibacterial dressing.[32]
As the size of the lesion increases, the extension of the
duration of antibacterial dressing might become necessary
for the proper repair process. Bacterial flora in root canal
infections are complex with the number ranging from 102
to 108 colony‑forming units and a symbiotic relationship
is established between bacterial species which adds up
the virulence of the existing organisms.[33] Complete
disinfection of the lesion is mandatory to enable repair of
damaged tissues as stated by the Cariology Department of
the University of Niigata. To achieve this longer duration
of treatment may be necessary depending on the size of
the lesion.
Calcium hydroxide could successfully disinfect and enable
repair in most of the cases. However, some cases with
resistant root canal infections might respond better to
a combination drug therapy like triple antibiotic paste.
Aspiration done before antibacterial dressing in very large
lesions is recommended as it gives an impectus to the
repair rate leading to rapid healing.
The outcomes presented suggest that it is possible to treat
the mature permanent teeth with the periapical lesion
in a nonsurgical method using triple antibiotic paste and
calcium hydroxide. Both medicaments showed satisfactory
results when used as antibacterial dressing. However, the
rate of healing with triple antibiotic paste was found to be
faster compared to that of calcium hydroxide.
CONCLUSION
Nonsurgical root canal treatment using calcium hydroxide
and triple antibiotic paste in teeth with large periapical
lesions can be a better alternative to surgical therapy.
Healing rates were found to be faster with triple antibiotic
paste. Furthermore, aspiration of the lesion done before
this conservative orthograde therapy with antibacterial
dressing demonstrated favorable outcomes and accelerated
healing. Hence, this approach can be adopted as a routine
measure to conservatively treat large periapical lesions of
endodontic origin.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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