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Pediatric Dentistry IPediatric Dentistry I
(Dent 361)(Dent 361)
Risk Assessment,Risk Assessment,
Caries Prediction &Caries Prediction &Treatment PlanningTreatment Planning
Dr FEDA ZAWAIDEHDr FEDA ZAWAIDEHBDS (Jordan) ,BDS (Jordan) , GradDipClinDentGradDipClinDent,, DClinDentDClinDent ((MelbMelb), JDB,), JDB,
FRACDS, FRACDS (FRACDS, FRACDS (PaedPaed))
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INTRODUCTIONINTRODUCTION
Management of dental caries was basedManagement of dental caries was based
mainly on the identification of cariousmainly on the identification of carious
lesions followed by surgical intervention tolesions followed by surgical intervention to
remove and restore the infected toothremove and restore the infected toothstructure. Nowadays, caries managementstructure. Nowadays, caries management
includes various management options thatincludes various management options that
involve providing treatment, monitoring, ofinvolve providing treatment, monitoring, ofdemineralizeddemineralized, non, non--cavitatedcavitated tooth surfaces,tooth surfaces,
prevention, surgical intervention of primaryprevention, surgical intervention of primary
lesions and repair or replacement oflesions and repair or replacement of
defective and failed restorations.defective and failed restorations.
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Clinical Decision Making forClinical Decision Making for
Caries Management in ChildrenCaries Management in Children
(Tinanoff D, 2002)
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Natural History of CariesNatural History of Caries
ProgressionProgression Age of the child:Age of the child:The earlier that a child becomes colonizedThe earlier that a child becomes colonized
with thewith the cariogeniccariogenic bacterial group,bacterial group, mutansmutans streptococci, thestreptococci, the
greater is the childs caries risk.greater is the childs caries risk.
Those teeth that are first exposed to aThose teeth that are first exposed to a cariogeniccariogenicenvironment generally will be the first to show signs ofenvironment generally will be the first to show signs of
disease.disease.
Caries progression is dependent on the site of the lesionCaries progression is dependent on the site of the lesion
and level of risk and disease activity, as well as age.and level of risk and disease activity, as well as age.
Caries activity can be assessed by observing the speed ofCaries activity can be assessed by observing the speed of
progression of existing lesions or the incidence of newprogression of existing lesions or the incidence of new
lesions.lesions.
((TinanoffTinanoff D, 2002)D, 2002)
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Caries ProgressionCaries Progression
Results indicate
that 72-81% of
lesions remain inenamel after 1
year.
Progression in low
risk groups took
3.5 yrs and in high
risk group 1.5years.
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Caries ProgressionCaries Progression
Proximal lesion progression
in permanent teeth was
slower than that in primaryteeth.
Lesions may remain in
enamel for up to 3 years.
Evidence shows lesions
limited into enamel may
not require immediatesurgical intervention.
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CARIESCARIES RISK ASSESSMENTRISK ASSESSMENT
All children should have an assessment ofAll children should have an assessment of
disease risk before the final treatmentdisease risk before the final treatment
plan is determinedplan is determined
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Clinical decision making in theClinical decision making in themanagement of caries in children andmanagement of caries in children and
adolescents requires an understanding ofadolescents requires an understanding of
caries risk and risk indicators. Generallycaries risk and risk indicators. Generally
speaking,speaking, RiskRiskis defined as the probabilityis defined as the probabilityof incidence of an event within a certainof incidence of an event within a certain
period of time.period of time. Caries riskCaries riskis the probabilityis the probability
that a lesion will develop or that an existingthat a lesion will develop or that an existinglesion will progress during a specified periodlesion will progress during a specified period
((AnusaviceAnusavice K, 2003).K, 2003).
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Determination of caries risk isDetermination of caries risk is
important for:important for: Assessment of the individual factors of existingAssessment of the individual factors of existing
carious lesions and of the caries risk situation.carious lesions and of the caries risk situation.
Repeated determination of the caries risk allows anRepeated determination of the caries risk allows an
evaluation of the success of, or the need for,evaluation of the success of, or the need for,modification of preventive measures.modification of preventive measures.
Indications of an increased caries risk in specificIndications of an increased caries risk in specific
children in community preventive programs willchildren in community preventive programs willallow selection of an individual preventive programallow selection of an individual preventive program
in order to minimize the development of cariousin order to minimize the development of carious
lesions.lesions.
(Reich et al, 1999)(Reich et al, 1999)
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Goal of Risk AssessmentGoal of Risk Assessment
The ultimate goal of caries risk assessmentThe ultimate goal of caries risk assessment
in dentistry is to deliver preventive andin dentistry is to deliver preventive and
restorative care specific to an individualrestorative care specific to an individual
patient's need and to identify caries activepatient's need and to identify caries active
individuals and convert them to cariesindividuals and convert them to caries
inactive status and reduce their caries risk.inactive status and reduce their caries risk.
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Risk FactorRisk Factor
AArisk factorrisk factor is defined as an environmentalis defined as an environmental
behavioral or biological factor confirmed bybehavioral or biological factor confirmed by
temporal sequence, usually in longitudinaltemporal sequence, usually in longitudinal
studies, which, if present, directly increasesstudies, which, if present, directly increasesthe probability of a disease occurring. Ifthe probability of a disease occurring. If
absent or removed, it reduces theabsent or removed, it reduces the
probability. Risk factors are part of theprobability. Risk factors are part of the
causal chain or they expose the host to thecausal chain or they expose the host to the
causal chain. Once the disease occurs,causal chain. Once the disease occurs,
removal of the risk factor may not result inremoval of the risk factor may not result in
cure.cure. (Anderson M, 2002)(Anderson M, 2002)
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Diagrammatic view of caries risk factors in
children; The 3 primary factors and their
subcategories of risk. (Anderson M, 2002)
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AAPDAAPD
Caries Assessment Tool (CAT)Caries Assessment Tool (CAT)
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CARIES RISKCARIES RISK
LOWCARIES RISKLOWCARIES RISK
Caries free nowCaries free now
Access to water fluoridationAccess to water fluoridation Favorable history: appropriate diet, dentallyFavorable history: appropriate diet, dentally
healthy sibs, good oral hygiene, motivatedhealthy sibs, good oral hygiene, motivated
parentsparentsMODERATE CARIES RISKMODERATE CARIES RISK
One or two new lesions per yearOne or two new lesions per year
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CARIES RISKCARIES RISK
HIGHCARIES RISKHIGHCARIES RISK
Three or more new lesions per yearThree or more new lesions per year
Commencing orthodontic treatmentCommencing orthodontic treatment Chronic illness or hospitalizationChronic illness or hospitalization
Medically compromised childrenMedically compromised children
Social risk factorsSocial risk factors
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Prediction BasedOn Past CariesPrediction BasedOn Past Caries
ExperienceExperience The most powerful single predictor of future caries increment since it isThe most powerful single predictor of future caries increment since it is
a summary of the cumulative effect of all risk factors.a summary of the cumulative effect of all risk factors.
The significance of this factor as a single reliable predictor wasThe significance of this factor as a single reliable predictor was
confirmed in a study conducted byconfirmed in a study conducted by SaemundssonSaemundsson et al (1997) on 9690et al (1997) on 9690
children aged 5children aged 5--15 years of age who were ranked as low, medium and15 years of age who were ranked as low, medium andhigh risk by dentists or school dental therapists based on unrestoredhigh risk by dentists or school dental therapists based on unrestored
lesions on primary and permanent teeth and proximal caries scores.lesions on primary and permanent teeth and proximal caries scores.
On the other hand, in adults, existing DMFOn the other hand, in adults, existing DMF-- values are less sensitive forvalues are less sensitive for
predicting future coronal caries but have a close correlation with thepredicting future coronal caries but have a close correlation with the
development of root caries.development of root caries. The use of caries experience in the primary dentition for theThe use of caries experience in the primary dentition for the
assessment of future caries in permanent teeth has also been advised inassessment of future caries in permanent teeth has also been advised in
the literature based on the fact that the value ofthe literature based on the fact that the value of dmftdmft recorded at 6 yearsrecorded at 6 years
of age was a strong predictor of caries occurrence between the age 7of age was a strong predictor of caries occurrence between the age 7
and 13 years.and 13 years.
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TREATMENT PLANNINGTREATMENT PLANNING
SEQUENCE FOR CHILDRENSEQUENCE FOR CHILDREN
Emergency care, relief of painEmergency care, relief of pain
Preventive carePreventive care
Surgical treatmentSurgical treatment Restorative treatmentRestorative treatment
Orthodontic treatmentOrthodontic treatment
Extensive restorative, further surgicalExtensive restorative, further surgicalmanagementmanagement
Recall and reviewRecall and review
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STEPS IN DIAGNOSIS &STEPS IN DIAGNOSIS &
TREATMENT PLANNINGTREATMENT PLANNING
Collect general observations:Collect general observations:
Child/parent interactions, behaviorChild/parent interactions, behavior
Address reason for presenting FIRSTAddress reason for presenting FIRST Start with history:Start with history:
Medical, dental, family, socialMedical, dental, family, social
Record past dental careRecord past dental care
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STEPS IN DIAGNOSIS &STEPS IN DIAGNOSIS &
TREATMENT PLANNINGTREATMENT PLANNING
Finalize diagnosis and treatment plsnFinalize diagnosis and treatment plsn
Present case to patient/parentsPresent case to patient/parents
Outline recommended treatment planOutline recommended treatment plan Involve parents in planningInvolve parents in planning
Secure parental consentSecure parental consent
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TREATMENT PLAN SHOULDTREATMENT PLAN SHOULD
INCLUDE THESE FEATURESINCLUDE THESE FEATURES
Treat existing problemsTreat existing problems
Prevent progression of existing problemsPrevent progression of existing problems
Prevent anticipated future problemsPrevent anticipated future problems Plan periodic exams, preventive care andPlan periodic exams, preventive care and
treatmenttreatment
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TREATMENT PLANNINGTREATMENT PLANNING
CONCEPTSCONCEPTS
Consider behavior (eg. DesensitizingConsider behavior (eg. Desensitizing
app/procedure, modeling)app/procedure, modeling)
Involve parent in treatment choices, butInvolve parent in treatment choices, butdont be dictated to!dont be dictated to!
Incorporate preventionIncorporate prevention
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TREATMENT PLANNINGTREATMENT PLANNING
CONCEPTSCONCEPTS
Plan efficient use of LAPlan efficient use of LA
(QUADRANT THERAPY)(QUADRANT THERAPY)
Treat comprehensively with definitiveTreat comprehensively with definitivetreatment, not patchworktreatment, not patchwork
Consider full coverage if using GAConsider full coverage if using GA
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TREATMENT PLANNINGTREATMENT PLANNING
CONCEPTSCONCEPTS
Establish a follow up/review/recall planEstablish a follow up/review/recall plan
based on established criteria (eg. AAPD)based on established criteria (eg. AAPD)
Make referrals in writing and expect aMake referrals in writing and expect awritten report backwritten report back
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QUADRANT THERAPYQUADRANT THERAPY
First visit: Examination, Diagnosis and treatmentFirst visit: Examination, Diagnosis and treatment
planning, Prophylaxis, OHI, dietary adviceplanning, Prophylaxis, OHI, dietary advice
Second visit: Quadrant 1Second visit: Quadrant 1
Third visit: Quadrant 2Third visit: Quadrant 2
Fourth visit: Quadrant 3Fourth visit: Quadrant 3
Fifth visit: Quadrant 4, Fluoride applicationFifth visit: Quadrant 4, Fluoride application
Review and recallReview and recallSPACE MANAGEMENT IF EXTRACTIONISSPACE MANAGEMENT IF EXTRACTIONIS
DONEDONE
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CASE PRESENTATION ANDCASE PRESENTATION AND
TREATMENT PLANNINGTREATMENT PLANNING
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Biographic DataBiographic Data
InitialsInitials
DOBDOB
Initial examInitial exam Age at examAge at exam
ParentsParents
Marital statusMarital status SiblingsSiblings
ResidenceResidence
NHNH
13/11/199913/11/1999
23/05/200323/05/2003 3 years3 years
AO, AHAO, AH
MarriedMarried No siblingsNo siblings
MelbourneMelbourne
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Medical HistoryMedical History
CVSCVS
EndocrineEndocrine
GITGIT BleedingBleeding
UGSUGS
RespiratoryRespiratory
CNSCNS AllergiesAllergies
Past surgeryPast surgery
Immunization up to dateImmunization up to date
NORMALNORMAL
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Developmental HistoryDevelopmental History
BirthBirth
SpeechSpeech
LocomotionLocomotion
WeightWeight
HeightHeight
Full term, NormalFull term, Normal
deliverydelivery
NormalNormal NormalNormal
100.8 cm, (50100.8 cm, (50thth))
15 kg, (5015 kg, (50thth))
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Social HistorySocial History
Recently moved from EritreaRecently moved from Eritrea
NonNon--English speaking familyEnglish speaking family
Single childSingle child
Goes to KinderGoes to Kinder
Good social developmentGood social development
BottleBottle--feeding at nightfeeding at night
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Dental HistoryDental History
Past dental historyPast dental history
First dental visitFirst dental visit
ReferralReferral
Referred from North YarraReferred from North Yarra
community health services forcommunity health services for
management of dental cariesmanagement of dental caries
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Chief ComplaintChief Complaint
Spontaneous pain in upper anteriorSpontaneous pain in upper anterior
teethteeth
Pain disturbing sleepPain disturbing sleep Pain interfering with eatingPain interfering with eating
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Preventive HistoryPreventive History
Use of systemic FUse of systemic F
Water FluoridationWater Fluoridation
Use of topical FUse of topical F
Fluoridated toothpasteFluoridated toothpaste
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Head & Neck ExamHead & Neck Exam
Facial symmetryFacial symmetry
EyesEyes
Skin colourSkin colour
NailsNails
HairHair
TMJTMJ
Lymph nodesLymph nodes
SymmetricalSymmetrical
BrownBrown
Dark complexionDark complexion
NormalNormal
NormalNormal
NormalNormal
NormalNormal
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IntraIntra--oral Examoral Exam
SOFT TISSUESSOFT TISSUES
GingivaGingiva
Alveolar mucosaAlveolar mucosa PalatePalate
Buccal mucosaBuccal mucosa
TongueTongue Sublingual areaSublingual area
Soft palateSoft palate
OropharynxOropharynx
NORMALNORMAL
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IntraIntra--oral Examoral Exam--ContCont
PeriodontalPeriodontal
tissuestissues
Oral hygieneOral hygiene
NormalNormal
FairFair
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IntraIntra--oral Examoral Exam--ContCont
HARD TISSUESHARD TISSUES
Primary dentition stagePrimary dentition stage
Extensive dental cariesExtensive dental caries
Hypoplastic upper and lower centralHypoplastic upper and lower central
incisorsincisors
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Occlusal AnalysisOcclusal Analysis
SOFT TISSUESSOFT TISSUES
Facial profileFacial profile
Lip lineLip line
Lip sealLip seal
HabitsHabits
TRANSVERSETRANSVERSE
RELATIONSHIPRELATIONSHIP
Slightly convexSlightly convex
Normal lip lineNormal lip line
Incompetent lipsIncompetent lips
EvertedEverted lipslips
NoneNone
NormalNormal
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Occlusal Analysis ContOcclusal Analysis Cont
AA--P RELATIONP RELATION
Primary IsPrimary Is
Primary MsPrimary Ms OverjetOverjet
VERTICAL RELATIONVERTICAL RELATION
Facial typeFacial type OverbiteOverbite
SPACINGSPACING
Class IClass I
Flush terminalFlush terminal
2mm2mm
MesiofacialMesiofacial3mm3mm
Primate spacesPrimate spaces
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Teeth PresentTeeth Present
E D C B A A B C D EE D C B A A B C D E
E D C B A A B C D EE D C B A A B C D E
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DiagnosisDiagnosis
EARLY CHILDHOODEARLY CHILDHOOD
CARIESCARIES
Behaviour Frankle (Behaviour Frankle ( -- ))
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Treatment planTreatment plan
PREVENTIVE PHASEPREVENTIVE PHASE
Oral hygiene instructionsOral hygiene instructions
Dietary counsellingDietary counselling
Dental prophylaxisDental prophylaxis
Topical fluoride applicationTopical fluoride application Antimicrobial therapy (CHX)Antimicrobial therapy (CHX)
RESTORATIVE PHASERESTORATIVE PHASE
Under GAUnder GA
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TREATMENT PLANTREATMENT PLAN
Oral hygiene instructions, Dietary advice,Oral hygiene instructions, Dietary advice,Prophylaxis, Fluoride applicationProphylaxis, Fluoride application
Quadrant 1: Exo 51,52buccal, 54 MOD, 55Quadrant 1: Exo 51,52buccal, 54 MOD, 55
occlusalocclusalReview OH and diet changesReview OH and diet changes
Quadrant 2: Exo 61, 64 MOD, 65 occlusalQuadrant 2: Exo 61, 64 MOD, 65 occlusal
Quadrant 3: 74 MOD, 75 occlusalQuadrant 3: 74 MOD, 75 occlusal Quadrant 4: 84 DO, 85 occlusalQuadrant 4: 84 DO, 85 occlusal
Review 3/12 for Fluoride application, OHIReview 3/12 for Fluoride application, OHI
and monitoringand monitoring
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Treatment PerformedTreatment Performed
Oral hygiene instructionsOral hygiene instructions
( Brushing and Flossing)( Brushing and Flossing)
Diet analysisDiet analysis
Parent education regarding feedingParent education regarding feeding
habitshabits
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Dental TreatmentDental Treatment
PrePre--operative Rt & Lt BWoperative Rt & Lt BW
ProphylaxisProphylaxis
52 Buccal52 Buccal-- GICGIC
54 MOD54 MOD-- FormocresolFormocresol
pulpotomy, IRM, SSC,pulpotomy, IRM, SSC,
Ketac cementKetac cement 55 Occlusal55 Occlusal-- vitrebond liner,vitrebond liner,
GIC base, AmalgamGIC base, Amalgam
restorationrestoration
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Dental TreatmentDental Treatment
84 DO84 DO-- vitrebond liner,vitrebond liner,
GIC, SSC, Ketac cementGIC, SSC, Ketac cement 85 Occlusal85 Occlusal-- vitrebond liner,vitrebond liner,
GIC, SSC, Ketac cementGIC, SSC, Ketac cement
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Dental TreatmentDental Treatment
64 MOD64 MOD--vitrebond liner,vitrebond liner,
GIC, SSC, Ketac cementGIC, SSC, Ketac cement 65 Occlusal65 Occlusal-- vitrebondvitrebond
liner, Amalgamliner, Amalgam
restorationrestoration
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Dental TreatmentDental Treatment
74 MOD74 MOD-- vitrebond liner,vitrebond liner,
GIC, SSC, Ketac cementGIC, SSC, Ketac cement 75 Occlusal75 Occlusal-- FormocresolFormocresol
pulpotomy, IRM, SSC,pulpotomy, IRM, SSC,
Ketac cementKetac cement
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Dental TreatmentDental Treatment
Extraction of 51, 61Extraction of 51, 61
Duraphat applicationDuraphat application
PostPost--operative Rt & Lt BW.operative Rt & Lt BW.
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Post GA ReviewPost GA Review
Good oral hygieneGood oral hygiene
Diet modifiedDiet modified
Improved feeding and sleepingImproved feeding and sleeping Overall improvement in the quality of lifeOverall improvement in the quality of life
Prescribed CHX GelPrescribed CHX Gel
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PrognosisPrognosis
Very good prognosisVery good prognosis
Excellent patient and parentsExcellent patient and parents
compliancecompliance
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Long Term TreatmentLong Term Treatment
Review 3/12Review 3/12
BW,BW,
OH and Diet monitoring,OH and Diet monitoring, Topical Fluoride applicationTopical Fluoride application
Monitor growth changesMonitor growth changes
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TREATMENT PLANNINGTREATMENT PLANNING
EXCERCISESEXCERCISES
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