Received: 22 October 2021 | Accepted: 20 June 2022

DOI: 10.1111/eve.13698

ORIGINAL ARTICLE

Blinded comparison of mirror and endoscopic oral examination

in the horse: Sensitivity, specificity and observer agreement

Naomi E. Chiero1 | Jeffrey D. Reiswig2 | Cleet E. Griffin3 | Kathryn J. Panigrahi1 |

Alison K. Gardner1

Summary
1
Department of Veterinary Clinical
Sciences, College of Veterinary Medicine,
The Ohio State University, Columbus, Background: Dental disease is commonly encountered in equine veterinary practice.
Ohio, USA Due to the horse's deep oral cavity, direct visual examination alone is not adequate for
2
Department of Veterinary Biosciences,
a complete oral evaluation. Typically, a long-­handled dental mirror is used as a visual aid.
College of Veterinary Medicine, The Ohio
State University, Columbus, Ohio, USA Oral endoscopy is another option to improve visual examination of the mouth. Although
3
Department of Large Animal Clinical recent literature suggests endoscopy is superior to mirror examination, these modalities
Sciences, Texas A&M University, College
Station, Texas, USA
have not been compared in a blinded study.
Objective: The objective of the study was to compare the sensitivity and specificity of
Correspondence
Naomi E. Chiero
identifying dental pathologies between oral mirror and rigid endoscopic examination, as
Email: [email protected] well as evaluating the inter-­and intra-­observer variability of each modality.

Funding information
Study design: Prospective randomised trial.
The study was supported by The Ohio Methods: Twenty-­one horses underwent oral examination using a mirror and an endo-
State University College of Veterinary
Medicine Intramural Grant No. 2018–­01.
scope with video recording of both techniques. An additional six horses received both
premortem and post-­mortem examinations. Two blinded observers evaluated the video
recordings and identified the presence of dental pathology to determine inter-­observer
and intraobserver agreement. Live examinations were compared with the six post-­
mortem examinations to determine sensitivity and specificity.
Results: Endoscopy sensitivity was far superior to mirror for all pathologies (83% vs.
39%), while specificity was high for both (71% vs. 87%, respectively) when compared to
the gold-­standard post-­mortem examination. Inter-­observer agreement for the presence
of pathology using endoscopy was substantial and higher than mirror examination. Intra-­
observer agreement was moderate to substantial.
Main limitations: The study was limited by the small number of horses and post-­mortem
examinations, although sample size was increased by assessing the pathology of each
tooth.
Conclusions: Moderate to substantial agreement was found using both endoscopy and
mirror examination. Sensitivity was improved with endoscopy. Oral endoscopy may be
beneficial for use in monitoring dental disease over time, as many minor pathologies do
not require immediate intervention. Endoscopic and mirror videos may also prove valu-
able in veterinary education.

KEYWORDS
horse, dentistry, endoscopy, mirror, oral examination

Equine Vet Educ. 2023;35:e227–e233. wileyonlinelibrary.com/journal/eve © 2022 EVJ Ltd. | e 227

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e228 CHIERO et al.

I NTRO D U C TI O N
Clinical relevance
Dental disease is one of the most common pathologies seen in
• Equine oral examination requires the use of a visual aid;
equine veterinary practice, with prevalence ranging from 64% to
mirror or rigid endoscope are commonly used. Recordings
93.8% (McGowan et al., 2010a, 2010b). Geriatric horses have higher
of a mirror or endoscopic examination are not only uti-
rates of dental disease with pathology in 100% of horses 30 years
lised to document pathology, but also aid communication
of age or older (Ireland et al., 2012). Similarly, Chinkangsadarn
with clients, students and other veterinarians.
et al. (2015) reported a higher prevalence of more severe dental
• Endoscopic examination sensitivity far exceeds the mirror,
disease in geriatric horses, including diastemata, mobile teeth and
while both have a high specificity. A mirror is an excellent
missing teeth. In horses, yearly dental examination is recommended
screening tool and affordable for field setting use.
to identify pathologies early and initiate treatment. Without regular
• Oral endoscopes are becoming widely available and af-
examination, dental pathologies often remain undetected until they
fordable; they can be used in a field setting but require
cause obvious clinical signs such as facial swelling, nasal discharge,
more equipment set-­up. Endoscopy is recommended at
facial fistula and weight loss. These clinical signs often correlate to
the specialty level.
advanced dental diseases that require invasive treatment.
Dental examination requires diagnostic aids for accurate diagnosis
(Easley & Tremaine, 2010), as direct visualisation is limited due to the
small mouth opening, long oral cavity and a large and active tongue. prior to oral examination. Midazolam (0.005–­0.02 mg/kg bwt IV) was
Visual aids consist of a bright light and an angled mirror, while tactile added as necessary to limit tongue mobility (Müller et al., 2017). Oral
aids include a dental explorer and a periodontal probe. Oral endos- examination was performed in standing stocks and facilitated using
copy is another available visual aid. To date, only one study has directly a dental halter, full-­mouth oral speculum (Capps Manufacturing)
compared the use of rigid oral endoscopy to a dental mirror. In a study and speculum light (MiCH bvba). Horses' mouths were rinsed using
by Goff endoscopy was recorded and viewed blindly, whereas chart- 0.12% chlorhexidine solution to eliminate feed material prior to
ing with a mirror was performed by the live examiner (Goff, 2006). examination.
It is unknown whether oral endoscopy or mirror examination is su- Mirror examination consisted of an equine dental mirror with
perior for diagnosing dental pathologies. This study aims to compare a two-­inch diameter head and 30° angle. Video recording was
the visual findings of these two modalities and determine the sensitiv- performed using a head-­mounted HD camera with a 16-­mm lens
ity and specificity of each diagnostic procedure. Our hypothesis is that (EduCam, Futudent, Novocam Medical Innovations Oy). A second-
oral endoscopy will have a higher sensitivity and specificity compared ary light, in addition to the speculum light, was mounted on top of
with a dental mirror. Video-­recorded examinations will allow blinded the camera for oral illumination and to guide the examiner on cam-
review and evaluation of intra-observer and inter-­observer reliability. era angle. In addition, an assistant viewing a live-­stream video on a
laptop computer adjusted the camera as needed to keep the teeth
centred on the screen and in focus (Figure 1).
M ATE R I A L S A N D M E TH O DS For endoscopic examination, a 44-­cm rigid endoscope with 70°
degree viewing angle (Karl Storz SE & Co. KG) and HD USB camera
Twenty-­seven horses were included in the study. Twenty-­one horses (M-­C AM-­HD USB camera with Olympus lens, Pferdefit-­Dental) with
were selected at random from a university-­owned teaching herd. An a fixed-­focus adapter and light source was used. A speculum light
additional six horses received both premortem and then post-­mortem was used to limit variability between examinations. Live feed of the
examination. These horses were being euthanised for a separate ter- examination was viewed on a laptop during examination by an assis-
minal study; none were donated for reasons related to dental dis- tant for quality control.
ease. All horses underwent sequential recorded oral examinations A coin toss determined which examination technique would be
using a rigid endoscope and a dental mirror in randomised order. In performed first. One examiner (NC) performed all examinations. All
total, 14 geldings and 13 mares were examined. Animals ranged in examinations started with the 100 arcade (upper right quadrant).
age from 4 to 29 years of age; body condition scores (BCS) ranged The occlusal surface of the 106 was recorded first and examination
from 3.5/9 to 8/9 using the Henneke scale (Henneke et al., 1983) and then moved distally towards the 111 at a constant, steady pace. The
included breeds representative of the region (Table 1). examination then rotated to the palatal aspect of the 111 and moved
rostral back to the 106; this repeated from 106 to 111 on the buc-
cal side. Each arcade was examined in this manner in order of 100,
Oral examination 200, 300, 400 (upper right, upper left, lower left and lower right
quadrants); the tongue was retracted by an assistant for the lower
Sedation consisted of a combination of detomidine (0.01–­0.03 mg/ arcades. The second examination technique proceeded immediately
kg bwt IV) and butorphanol (0.01–­0.02 mg/kg bwt IV) administered after the first.
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MIRROR AND ENDOSCOPIC ORAL EXAMINATION e229

TA B L E 1 Horse data

Horse # Age BCS Sex Breed

1 29 3.5 F STBD
2 12 8 MC WB
3 7 7 MC WB
4 10 6 Mc WB
5 11 5 MC QH
6 4 3.5 F TB
7 14 5 F WB
8 17 5 F QH
9 17 4 F QH
10 11 5 F STBD
11 10 6 F QH
12 11 7 MC TB
13 13 4 F TB
14 14 5 F WB
15 13 6 F APH
16 10 6 MC QH
17 13 5 MC TB
18 15 5 MC WB F I G U R E 1 Mirror examination using a dental mirror and
speculum light. Examiner wearing a head-­mounted video camera
19 16 4 MC WB
with a secondary light mounted on top of the camera to guide the
20 17 6 MC WB examiner on camera angle
Donor 1 14 3 F QH
Donor 2 12 NR MC QH
Donor 3 6 6 MC TB were administered xylazine (0.3–­1 .0 mg/kg bwt IV) prior to eu-
Donor 4 15 6 F STBD thanasia and then euthanised with pentobarbital (100–­4 00 mg/
Donor 5 7 2 MC TB kg bwt IV). Cadaver skulls were collected within 24 h of eutha-
Donor 6 16 NR F APH nasia and stored at 20°C until examination. The frozen skulls

Donor 7 12 4 MC QH
where thawed, sectioned in a sagittal plane and examined. Dental
charting was performed on the sagittally sectioned skulls by a
Note: Horse signalment and body condition score.
board-­certified equine dentist (JR) with the aid of a headlamp,
Abbreviations: APH, American Paint; BCS, body condition scores; F,
female; MC, male castrated; NR, not recorded; QH, Quarter Horse;
dental mirror, periodontal probe and dental explorer. As live ex-
STBD, Standardbred; WB, Warmblood. amination is inherently limited by the restrictive oral anatomy,
horse compliance and movement, these findings served as the
gold standard.
Videography and editing

Mirror examinations were recorded (Futudent Recording Software, Data analysis

Futudent, Novocam Medical Innovations Oy) and edited using
Apple iMovie software by one of the authors (AKG) for time and Video recordings of each arcade were assigned a randomly gener-
consistency. Endoscopic examinations were recorded via Fiegert ated three-­digit number, for a total of 108 endoscope videos and
MedicalEDA software (Fiegert MedicalEDA version 2.1, Fiegert 108 mirror examination videos. The videos were evaluated by two
Endotech), and as file formatting did not permit editing, videos were board-­certified equine dentists (CG and JR), who notated abnor-
submitted for expert review as is. malities on a dental chart using standard pathology terms from
the American Veterinary Dental College (AVDC) (Table 2). Twenty-­
seven randomly chosen videos of each examination type were
Cadaver examination evaluated again to assess intraobserver agreement. Abnormalities
were grouped into those considered MAJOR pathology (requiring
This study included six horses that underwent the same pre-­ intervention) and MINOR pathology (requiring only monitoring). If a
mortem mirror and endoscopic examinations as the other study tooth could not be clearly visualised, the reviewer marked it with an
subjects. After pre-­m ortem oral examinations, these six horses ‘X’ and it was counted as a MAJOR pathology.
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e230 CHIERO et al.

TA B L E 2 Dental pathology classification

Minor pathology Major pathology

Infundibular Caries—­grade 1 Infundibular Caries—­grade 3

Infundibular Caries—­grade 2 Infundibular Caries—­grade 4
Uncomplicated crown fracture Complicated crown fracture
Class 1 malocclusion Pulp horn defect
Stage 1 periodontal disease (gingivitis only) Open diastema
Valve diastema
Gingival recession
Mobile tooth
Tooth not present

Note: MAJOR (requiring intervention) and MINOR (requiring monitoring).

TA B L E 3 Examination sensitivity and specificity TA B L E 4 Inter-­observer agreement

Minor Inter-­observer
All (%) Major (%) (%) kappa agreement All Major Minor

Mirror vs. Cadaver Endoscope 0.64 0.76 0.54

Sensitivity 39 29 23 Substantial Substantial Moderate
Specificity 87 91 97 Mirror 0.46 0.64 0.39
Endoscope vs. Cadaver Moderate Substantial Fair
Sensitivity 83 79 85
Specificity 71 81 89 Live Horse Examinations: Endoscopic inter-­observer agreement
was substantial for ALL and MAJOR pathologies (kappa 0.64 and
0.76, respectively), moderate for MINOR (kappa 0.54) and outper-
Sensitivity and specificity for ALL pathologies, MAJOR pathol- formed mirror inter-­observer agreement in every category (ALL
ogies and MINOR pathologies were calculated for pre-­mortem ex- kappa 0.46; MAJOR kappa 0.64; MINOR kappa 0.39). Intra-­observer
aminations against their post-­mortem gold-­standard examinations in agreement (Table 4) comparing endoscopy to mirror had moderate
the subset of six horses. Cohen's kappa reliability of agreement was agreement for both observers (kappa 0.48–­0.51). Intra-­observer
calculated to measure inter-­observer agreement between the two mirror agreement comparing repeated reviews of examinations
board-­certified equine dentists, as well as intra-observer agreement (Table 5) was substantial for both observers (0.656–­0.795). Intra-­
of mirror versus endoscope examination in all horses. Repeated observer endoscope agreement was moderate to substantial for
intra-observer agreement using Cohen's kappa was also calculated both observers (0.52–­0.66).
in the 27 videos re-­reviewed by the experts. Agreement was consid- Overall, 39% of teeth on mirror examination and 58% on rigid
ered nearly perfect if kappa >0.82, substantial if kappa was between endoscopy had pathologies identified. All horses had some pathol-
0.61 and 0.80, moderate if between 0.41 and 0.6, fair if between 0.21 ogy identified on endoscopic examination, whereas one horse had
and 0.4 and poor if <0.2. All statistical analysis was performed using no pathology identified during mirror examination.
a commercially available software program (GraphPad Software).

DISCUSSION
R E S U LT S
Numerous live examination studies (McGowan et al., 2010a, 2010b;
Cadaver Examinations—­Sensitivity and Specifity: Endoscopic exami- Salem et al., 2017) and abattoir studies (Chinkangsadarn et al., 2015;
nation sensitivity was far superior to mirror examination in regard Vemming et al., 2015) have documented a high prevalence of den-
to ALL, MAJOR and MINOR pathologies (Table 3). Endoscope sen- tal disease in horses. Although awareness of dental disease has
sitivity ranged from 79 to 85% compared with mirror sensitivity of increased in recent decades, significant dental pathologies are still
23%–­39%. Specificity for identifying pathology was high using both under-­diagnosed. Performing an equine oral examination is clinically
the mirror and endoscope relative to gold-­standard cadaver exami- challenging. Direct visualisation is limited due to the small mouth
nation. Mirror examination specificity ranged from 87% to 97% and opening, long oral cavity and a large and active tongue. However,
slightly outperformed endoscopic examination specificity which the need for routine oral examination is critical due to the paucity of
ranged from 71% to 89%. clinical signs in early stages of disease. Adequate oral examination
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MIRROR AND ENDOSCOPIC ORAL EXAMINATION e231

TA B L E 5 Intraobserver agreement
of disease, and staging disease was not the goal of this study. A
Intra-­observer kappa Observer dental explorer is used in a similar manner. For these reasons, the
agreement Observer A B authors felt video recordings appropriately limited the scope of ex-
Endoscope vs. Mirror 0.48 0.51 amination but allowed blinded review which would not be possible
examination (same Moderate Moderate by live examination experts. It also allowed randomised viewing of
observer)
the individual arcades, which would not be possible if charting were
Mirror: first viewing vs. second 0.80 0.66 performed live with one examination modality proceeding the other
viewing Substantial Substantial in one sedated session.
Endoscope: first viewing vs. 0.52 0.66 In this study, mirror examination had a low sensitivity (23%–­
second viewing Moderate Substantial 39%) and high specificity (87%–­97%), resulting in a high rate of un-
diagnosed dental pathologies. In contrast, the endoscope had a high
sensitivity (79%–­85%) and high specificity (71%–­89%) when com-
equipment includes a full-­mouth dental speculum, bright light pared to the gold-­standard post-­mortem examination. This would
source, chemical restraint, dental explorer, periodontal probe and reflect the authors' experience in clinical practice and is similar to
an imaging aide such as a dental mirror or oral endoscope. A dental Simhoffer's observations in his oral endoscopic examination study
mirror is affordable, easy to use, widely available and increases ex- (Simhofer et al., 2008).
amination ability. Oral endoscopy is becoming widely used, though Mirror examination is practical due to low cost and ease of use.
mostly in a specialty setting due to cost and user proficiency. The Endoscopy allows for magnification that permits subtle findings to
benefits of visual aids are demonstrated in Figure 2. Without a visual be more readily identified or possibly over-­identified (false positives);
aid (Figure 2), a fractured tooth could be missed. Mirror examination this may explain why the mirror examination had a higher specificity
allows an occlusal view of each tooth (Figure 2), and oral endoscopy than endoscopy. Photograph and video documentation are easier
amplifies examination details (Figure 2). In the last decade, several with endoscopy. However, even simple endoscope systems require
papers have been published on the use of the rigid oral endoscope more time and space for set-­up and cannot be used in a horse that
and its enhancement of oral examination (Dotzel & Baratt, 2017; is chewing or moving. With a compliant horse, most of our exam-
Galloway & Easley, 2013; Ramzan, 2009). Our study results high- inations with either modality took between 1 and 2 min per arcade.
light the strengths and weakness of both a mirror and endoscopic Inter-­observer and intra-observer variability have been cal-
examination. culated for other imaging modalities with varying results. Inter-­
This study is aimed to compare visual aids which are used in prac- observer agreement for a glandular gastric ulcer study done by
tice to identify structures that warrant further investigation. Thus, Tallon and Hewetson (2020) using flexible endoscopy resulted in
we purposefully did not include the use of tactile aids such as digi- poor inter-­observer agreement. In contrast, Perkins et al. (2009)
tal palpation, periodontal probes and a dental explorer. Periodontal examined resting endoscopic grading of recurrent laryngeal neu-
probing is not performed around each tooth in the equid for rou- ropathy, where inter-­observer agreement was substantial and
tine examination as is common in brachydont species. Periodontal concordance within observers was nearly perfect. Our study's
probing of visually identified pathology further stages the extent methodology is comparable to a study by Beccati et al. (2013)

(a) (b) (c)

F I G U R E 2 Oral examination images taken from the same horse on the same day. (a) Image using an iPhone 6 (Apple) with speculum and
bright light source; a step tooth on the lower arcade is visible. (b) Image was taken with iPhone 6 (Apple), same as above, and zoomed in
with visual aid of a dental mirror demonstrating a fractured tooth in the middle of the arcade. (c) Image taken with a rigid oral endoscope;
magnification allows further evaluation
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e232 CHIERO et al.

comparing radiography and ultrasonography to the gold-­s tandard (Caramello et al., 2020; Dixon et al., 2005; Langeneckert et al., 2015;
arthroscopic findings and then comparing variability between Rice et al., 2018). Early recognition of dental pathology and many
each using the k statistic. These authors concluded that ultra- treatment techniques employed for dental cases require the use of
sound was superior for diagnosing lesions due to its increased sen- the visual aids highlighted in this paper. In addition, the use of video
sitivity over radiology, at some expense to specificity. Likewise, recording for veterinary instruction and client discussion is a valu-
rigid endoscopy in our study had a much higher sensitivity, while able tool in explaining pathologies. Videography and digital imaging
mirror examination was slightly better than the endoscopic exam- of the oral cavity have become more valuable as web-­based learning
ination regarding specificity. Agreement across both mirror and has rapidly expanded. Though not the main aim of this study, these
endoscopic examination was rated as moderate to substantial, in- data provide the initial validation for the use of both modalities for
dicating repeatability of findings in our study regardless of meth- teaching. Videos from this study have already been integrated into
odology. This may be important if the practitioner determines the authors' veterinary curriculum and in veterinary continuing edu-
monitoring is indicated rather than immediate intervention. cation courses. In addition to allowing visualisation of body cavities,
Recorded pathologies were limited to dental caries, periodontal endoscopy also allows for precise and repeatable examinations, as
disease, endodontic disease and displaced teeth. Soft tissue lesions demonstrated by the moderate to substantial agreement of inter-­
(buccal or lingual lacerations), sharp enamel points and dental over- observer and intra-­observer examinations. This allows serial moni-
growths were purposefully not evaluated as most of these are visible toring of disease over time and improves communication between
without the aid of a mirror or endoscope. colleagues during case referral.
A diastema, or an abnormal space between two teeth, was the
most frequent MAJOR pathology. Diastemata accounted for 27%–­
57% of the total pathologies depending on reviewer and examination Limitations
technique. The incidence of diastemata in our study is similar to a
previous survey of abattoir specimens (Chinkangsadarn et al., 2015). This study was limited by the number of both pre-­mortem and post-­
Mirror examination significantly underdiagnosed diastemata more mortem examinations, although sample size was increased by as-
than any other pathology, which highlights various challenges in- sessing the pathology of each tooth. We were also limited by the
volved with achieving good interproximal visualisation of the cheek two dimensionality of comparing recorded examinations. Live physi-
teeth in equids, even by experienced examiners. Diastemata were cal examination of the patient allows sensory and spatial feedback
at least three times more likely to occur between mandibular teeth that improves examination that cannot be replicated with video re-
compared with maxillary teeth. cordings. However, recordings allow blinded review by multiple peo-
Minor pathologies were considered abnormalities that require ple and randomisation of samples. Finally, visual examination alone
monitoring. In our study, infundibular caries was the most common by either method still only examines a fraction of the equine tooth.
pathology found on endoscopic examination and made up 40%–­ Most of the major pathologies identified would require radiographic
55% of the overall pathologies. Infundibular caries occur due to a or computed tomography to definitively diagnose disease severity
combination of developmental infundibular cemental hypoplasia and determine appropriate treatment.
and occlusal exposure with subsequent carious decay. Depending
on the extent of pathology and the age of the tooth, infundibular
caries can be considered normal (Windley et al., 2009). Infundibular CO N C LU S I O N
caries warrant monitoring as they can progress to significant dental
disease leading to tooth fracture and apical disease. There was a sig- Both examination techniques resulted in a high specificity (71%–­
nificant difference in observers between teeth counted as normal 97%), but endoscopic examination far surpassed mirror examination
and those identified with stage 1 infundibular caries. This could ex- in sensitivity (79%–­85% vs. 23%–­39% respectively).
plain the lower specificity of endoscopy (89%) compared with mirror
examination (97%) for MINOR pathologies. As the examiner who AU T H O R C O N T R I B U T I O N S
performed the gold-­standard cadaver examinations, JDR, identified All authors contributed to the preparation of the manuscript and
this pathology at a much lower rate compared to CEG. Like other im- final approval of the manuscript. N. Chiero, K. Panigrahi, J. Reiswig
aging modalities, not every abnormality seen is clinically significant. and C. Griffin contributed to study execution. N. Chiero, J. Reiswig,
The remaining minor pathologies included uncomplicated crown C. Griffin and A. Gardner contributed to study design, data analysis
fractures (not involving a pulp horn), Class 1 malocclusion and stage and interpretation.
1 periodontal disease (gingivitis only) and had an incidence of 1%–­
15% of all pathologies. C O N FL I C T O F I N T E R E S T
Historically, dental procedures such as tooth extraction were not No competing interests have been declared.
pursued until obvious clinical signs had developed. Equine dentistry
has seen a great decrease in complication rates due to improved E T H I C S S TAT E M E N T
oral extraction techniques and less invasive surgical extractions The Institutional Animal Care and Use Committee (IACUC).
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MIRROR AND ENDOSCOPIC ORAL EXAMINATION e233

ORCID McGowan, T., Pinchbeck, G., Phillips, C., Perkins, N., Hodgson, D. &
Naomi E. Chiero https://orcid.org/0000-0002-3499-7668 McGowan, C. (2010b) A survey of aged horses in Queensland,
Australia. Part 2: clinical signs and owners' perceptions of health
Cleet E. Griffin https://orcid.org/0000-0002-3128-9201
and welfare. Australian Veterinary Journal, 88, 465–­471. https://doi.
Alison K. Gardner https://orcid.org/0000-0001-9440-6033 org/10.1111/j.1751-­0 813.2010.00638.x
Müller, T.M., Hopster, K., Bienert-­Zeit, A., Rohn, K. & Kästner, S.B.R.
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