Oral hygiene - aim and theoretical base. Methods and instruments

Report
Prof. d-r R.Kabaktchieva -2014

Soft, microbial dental plaque continually
forms on the tooth surfaces, is the primary
agent in the development of dental caries
and periodontal diseases.

If plaque biofilm is completely removed with
self-care procedures, dental caries and
periodontal diseases can be prevented.

Plaque deposits can be removed either
mechanically or chemically.
The
focus of this lectur is the
mechanical removal of plaque,
using toothbrushes and
toothbrushing techniques.
The History of the Toothbrush

Since ancient times, individuals have chewed twigs from
plants with high aromatic properties.

In Arabic countries individuals used a piece of the root of
the arak tree - the root fibers stood out like bristles; the
fibers contained antibacterial oils and tannins.

(618-907 A.D.) the Chinese invented a toothbrush with a
handle and bristles. They used hog bristles

In 1780 in England, William Addis manufactured "the first
modern toothbrush.“ This brush had a bone handle and
holes for placement of natural hog bristles.

In the early 1900s, celluloid began replacing the
bone handle.

Nylon bristles were introduced;

Nylon bristles did not have the hollow stem of
natural bristles; therefore, they did not allow
water absorption.

Other advantages of nylon bristles, were the
ability to form the bristles in various diameters
and shapes, and to round the bristle ends to be
gentler on gingival tissues.

In 1916, Dr. Alfred C. Fones, founder of dental
hygiene, wrote a textbook, Mouth Hygiene,
which specifically directed dental hygienists to
teach specific toothbrushing methods to
schoolchildren.

In 1919, the American Academy of
Periodontology developed guidelines for both
toothbrush design and brushing techniques.
Fones School of Dental Hygiene instructors and students during

In 1939, the first power toothbrush was
developed in Switzerland and was introduced
in the United States in the 1960.

In the 1980s, powered toothbrushes were
revitalized with the introduction of the
InterPlak.

Compared with manual toothbrushes,
powered toothbrushes have shown an
increased efficacy
(ability to produce a desired effect);
 Sonic-powered
toothbrushes have
been developed;
 They remove more plaque compared
with manual toothbrushes.
 Most
recently, battery-powered,
disposable toothbrushes have been
introduced.
 A toothbrush
is the primary instrument
used for oral hygiene care.
 There
are many different types of
toothbrushes.
 There
are manual and power
toothbrushes, with each having various
designs of the handle, head, and bristles.
 These
variations all have unique benefits.
Manual Toothbrush Designs

Manual toothbrushes vary in size,
shape, texture, and design
Fig. Lateral profiles of selected toothbrushes
Fig. Parts of a toothbrush.
 A manual
toothbrush consists of
a head with bristles and a handle.
 Тhe bristles are bunched together, and
form tufts.
 The head is divided into the toe, and
the heel.
 The shank occurs between the handle and
the head.

Toothbrushes are manufactured in different
sizes: large, medium, and small

Toothbrushes are differ in their hardness
or texture being classified as:
hard, medium, soft, or extra soft.

Extra soft and soft toothbrush bristles
are preferred, because hard bristles damage
teeth by causing abrasion of the tooth
surface.
Figure . Cross-sectional profile of toothbrushes:
Figure . Overhead
appearance of toothbrushes,
Toothbrush Profiles
 Viewed
from the side, toothbrushes
have four basic lateral profiles:
concave, convex, flat,
multileveled rippled or
scalloped.

The concave shape, with shorter bristles in
the middle of the head, may be most useful
for increased cleaning of facial tooth
surfaces.

Convex shapes, with longer bristles in the
middle of the head, appear more useful for
improved cleaning of lingual surfaces.

Toothbrushes with multilevel profiles were
consistently more effective ,especially when
interproximal efficacy was evaluated.
Nylon Versus Natural Bristles

The nylon bristle is superior to the natural
hog bristle:

Nylon bristles flex more than natural
bristles before breaking;


Nylon bristles do not split or abrade and are
easier to clean.

The shape and stiffness of nylon bristles can
be standardized.
Bristle Shape

Nylon bristles can be manufactured in various
dimensions.

A thinner diameter filament allows the bristle to
be softer and more resilient.

Angled filaments remove direct pressure
from the tooth and gingiva, and therefore
appear to be more flexible.

Еnd-rounded tips are recommended for the
safety of hard and soft oral tissues.
Fig. End rounding of toothbrush bristle.
Manual Toothbrushing Methods
The purposes of toothbrushing include:

(1) removal of plaque biofilm and disturbance of its
re-formation;

(2) removal of food, debris, and stain from the oral
cavity;

(3) stimulation of the gingival tissues;

(4) application of a dentifrice containing specific
ingredients to address caries, periodontal
disease, or sensitivity.
 The
several different
toothbrushing methods remove
plaque most efficiently,
 Any
method that is taught should
not damage hard or soft tissues,
or cause excessive tooth wear.
The most natural brushing methods:
 horizontal
 rotary
scrub technique;
motion such as the Fones technique;
 simple
up-and-down motion over the
maxillary and mandibular teeth,
( the Leonard technique.)
Тhese techniques can clean:
the facial,
 the lingual,
 the occlusal surfaces of the teeth;
 all are ineffective in cleaning
interproximal areas.
 the Bass technique is effective in
cleaning the sulcus.

Bass Method

The Bass method is acceptable for all
patients.

This method is effective at removing plaque at
the gingival margin and directly below it.
Fig. Bass technique.
The toothbrush bristles are angled apically at a 45-degree
angle to the long axis of the tooth.
The filaments are then gently placed subgingivally into the
sulcus.
With very light pressure, the brush is moved with very short
horizontal strokes, while keeping the bristles in the sulcus.
After several vibrations, the bristles are removed from the
sulcus, and the brush is repositioned on the next 2 or 3 teeth.
Technique
Bristle
Position
Bass
Brushing
Motion
At 45
Vibratory,
degrees,
horizontal
with tips in jiggle
sulcus
Effect
Claimed
Supragingiv
al
cleansing,
gingival
stimulation
Rolling Method






The rolling technique is most appropriate for
children.
The bristles are positioned apically along the long
axis of the tooth.
The edge of the brush head should be touching the
facial or lingual aspect of the tooth.
Then with light pressure the bristles are rolled
against the tooth from the apical position toward the
occlusal plane.
This motion is repeated several times; then the brush
is repositioned on the next teeth, with bristles
overlaping a portion of the teeth previously cleaned.
The heel or toe of the brush is used on the lingual
aspect of the anterior teeth
Technique
Bristle
Position
Rolling
Apically
against
attached
gingiva
Brushing
Motion
Effect
Claimed
Sweep in arc
toward
occlusal
surface
Supragingiva
l cleansing,
gingival
stimulation
Stillman Method

The Stillman method was originated to massage
and stimulate the gingiva while cleansing the
cervical areas.

The bristles are positioned apically along the long
axis of the tooth.

The edge of the brush head should be touching the
facial or lingual aspect of the tooth.

Then the brush is slightly rotated at a 45-degree
angle and vibrated over the crown .
Technique
Stillman
Brushing
Bristle Position
Motion
Effect Claimed
Against apical Vibratory,
Gingival
part of gingiva pulsing strokes stimulation
and cervical
part of tooth
Fig. Stillman toothbrushing technique seen
diagrammatically
Charters Method

The Charters technique is effective for cleaning
around devices used to correct improper contact
of opposing teeth (orthodontic appliances),
and plaque under abutment teeth of a fixed
bridge.
The bristles are placed at a 45-degree angle
toward the occlusal or incisal surface of the
tooth.
 The bristles should touch at the junction of the
free gingival margin and tooth.
 A circular vibratory motion is then activated.

Technique
Charters
Brushing
Bristle Position
Motion
Effect Claimed
Circular,
At 45 degrees
vibratory
to tooth
strokes
Gingival
stimulation,
interproximal
cleansing
Fig. Charters
toothbrushing technique.
Fones Method






The Fones method is a easy technique for young
children to learn.
The teeth are clenched, and the brush is placed
inside the cheeks.
The brush is moved in a circular motion over both
maxillary and manibular teeth.
In the anterior region, the teeth are placed in an
edge-to-edge position and the circular motion is
continued.
On the lingual aspect, an in-and-out stroke is used
against all surfaces.
This technique can be damaging if done too
vigorously
Technique
Bristle
Position
Brushing
Motion
Fones
Supragingival
Large circles
At 90 degrees
cleansing,
over teeth and
to tooth
gingival
gingiva
stimulation
Effect Claimed
Fig. Fones toothbrushing
technique:
Circulatory motion extending from
maxillary to mandibular teeth.
Leonard Method

Тhe toothbrush is placed at a 90-degree angle to
the long axis of the tooth.

The teeth are held in an edge-to-edge position.

Next, the toothbrush is moved in a vertical,
vigorous motion up and down the teeth.

The maxillary and mandibular teeth are brushed
separately .
Technique
Brushing
Bristle Position
Motion
Leonard
Supragingival
At 90 degrees
cleansing,
Vertical strokes
to tooth
gingival
stimulation
Effect Claimed
Fig. Leonard toothbrushing
technique
Horizontal Method

In the horizontal technique, the teeth are
placed edge to edge, while the brush
maintains a 90-degree angle to the long axis
of the tooth.

The brush is then moved in a horizontal
stroke.

This technique is known to cause excessive
toothbrush abrasion
Technique
Horizontal
Brushing
Bristle Position
Motion
At 90 degrees Horizontal
to tooth
strokes
Effect Claimed
Supragingival
cleansing,
gingival
stimulation
Fig. Horizontal
toothbrushing technique
Smith Method

The Smith method is a physiologic technique,
which follows the pattern that food follows when
it is in the mouth during mastication.

The bristles are positioned directly onto the
occlusal surface.

The brush is then moved back and forth with the
bristles reaching from the occlusal surface to the
gingiva.

Smith also recommends a few gentle horizontal
strokes to clean the sulcus areas near furcations
.
Technique
Smith
Brushing
Bristle Position
Motion
At occlusal
surface
Effect Claimed
Sweep toward Supragingival
gingiva
cleansing
Fig. Smith toothbrushing technique.
Scrub Toothbrushing Method

The scrub toothbrushing technique is a
combination of horizontal, vertical, and
circular strokes.

It also incorporates vibration movements in
certain areas.
Fig. Scrub toothbrushing technique.
Modified Brushing Methods

In attempts to enhance brushing of the entire facial
and lingual tooth surfaces, the original techniques
have been modified.

The modified brushing technique integrates a
rolling stroke after use of the vibratory motion.

The position of the brush is maintained after the
completion of the original method's stroke.

The bristles are then rolled coronally over the
gingiva and teeth.

During this rolling motion, care should be taken that
some of the filaments reach the interdental areas.
Technique
Modified (in
combination
with an above
method)
Bristle
Position
Brushing
Motion
Effect Claimed
Sweep toward Supragingival
occlusal
cleansing
surface
Powered Toothbrushes

Powered toothbrushes were first advertised
in 1886.

Broxadent was introduced in the 1960.
design of the power toothbrush
Fig. Selected power toothbrushes, from left to right:
Crest SpinBrush; Oral-B Sonic Complete; Sonicare
Elite.]
The power toothbrushes can
be categorized as:
-mechanical,
-sonic,
-ionic.

A mechanical brush uses the motion of the
bristles to remove the plaque and debris.

The sonic toothbrush emits sound waves in
addition to the movement of the filaments.

The ionic toothbrushes temporarily reverse
the negative ionic charge of a tooth to a
positive charge. A portion of the toothbrush,
that is positively charged, attracts the plaque
and food particles away from the tooth.

The main movements in the power
toothbrushes are oscillation,
reciprocation, and rotational.

The oscillation movement takes the bristles in
a consistent back-and-forth movement.

The reciprocation moves the bristles up and
down or back and forth.

The rotational movements are circular.
Rotating
Speed of a powered toothbrush

The typical brushes movements - from 3,800
to 7,600 per minute.

A pulsation-type head can produce
approximately 40,000 pulses per minute
POWERED TOOTHBRUSH METHODS
AND USES
Each
tooth and corresponding
gingival areas should be
brushed separately, always
with light, steady pressure.
Toothbrushing Time and Frequency

Dental providers advised patients to brush
their teeth after every meal.

If plaque is completely removed every other
day, no harmful effects will occur in the oral
cavity .

Very few individuals completely remove
plaque; therefore, frequent brushing is still
extremely important and recommended.
 Dentis
suggest 5 to 10 strokes in each
area or advocate the use of a timer.
 The
child should be encouraged to brush
for up to 2-3 minutes and to use a timing
device.
Clinical Assessments of Toothbrushing

Disclosing agents provide a means of evaluating
of cleaning the teeth.

Disclosing agents, ( disclosants), may be in
either a liquid or a tablet form.

They should be swished around in the mouth for
15 to 30 sec..

They allow the patient to see plaque in the
mouth before or after brushing.
Disclosing agents allow the patient to see
plaque in the mouth before or after brushing
Toothbrush Replacement
 The
average life of a manual
toothbrush is 2 to 3 months.
Tongue Brushing

The tongue is anatomically perfect for
harboring bacteria.

The fissuring or prominent papilla, should be
regularly cleaned.

Tongue cleaners,
are curved so they
can be placed over
the tongue without
touching the teeth.

These instruments
are swept over the
dorsum of the
tongue to remove
bacterial plaque
and debris.
In initiating effective toothbrushing, it is
necessary to:
 (1) select the appropriate toothbrush(es) for
the patient;
 (2) create individual goals for toothbrushing
and explain the need for good oral hygiene;
 (3) teach a technique or combination of
brushing methods necessary to meet
established goals;
 (4) assess and refine toothbrushing
techniques as a part of the total oral hygiene
program.
Simplified Oral Hygiene Index | OHI-S
- OHI-S (Simplified) (Greene and Vermillion, 1964)

The OHI-S, like the OHI, has two components:
- the Debris Index
- the Calculus Index.
Each of these indexes, is based on numerical
determinations representing the amount of debris
or calculus found on the preselected tooth
surfaces.
SELECTION OF TOOTH SURFACES

The six surfaces examined for the OHI-S are
selected from four posterior and two anterior
teeth.

In the posterior portion of the dentition, usually
the first molar (16, 26,36,46). but sometimes the
second (17) is examined.

In the anterior portion of the mouth, the labial
surfaces of the upper right (11) and the lower left
central incisors (31) are scored. In the absence
of either of this anterior teeth, the central incisor
(21 or 41 respectively) on the opposite side of
the midline is substitted.
The buccal surfaces of
the selected upper
molars and the lingual
surfaces of the selected
lower molars are
inspected.
Тhe labial surfaces of
the upper right (11) and
the lower left central
incisors (31) are scored.
Criteria for classifying debris
Scores
Criteria
0
No debris or stain present
1
Soft debris covering not more than one third of
the tooth surface,
2
Soft debris covering more than one third, but not
more than two thirds, of the exposed tooth
surface.
3
Soft debris covering more than two thirds of the
exposed tooth surface.
Criteria for classifying calculus
Scores
Criteria
0
No calculus present
1
Supragingival calculus covering not more than third
of the exposed tooth surface.
2
Supragingival calculus covering more than one third
but not more than two thirds of the exposed tooth
surface or the presence of individual flecks of
subgingival calculus around the cervical portion of
the tooth or both.
3
Supragingival calculus covering more than two third
of the exposed tooth surface or a continuos heavy
band of subgingival calculus around the cervical
portion of the tooth or both.
CALCULATION EXAMPLE:

After the scores for debris and calculus are
recorded, the Index values are calculated.
 For
each individual, the debris
scores are totaled and divided by the
number of surfaces scored.

The average individual score is known as the
Simplified Debris Index (DI-S).

The same methods are used to obtain the calculus
scores or the Simplified Calculus Index (CI-S).

The average individual debris and
calculus scores are combined to obtain the
Simplified Oral Hygiene Index.
The CI-S and DI-S values may range from
0 to 3;
 Тhe OHI-S values from 0 to 6.

The following example shows how to calculate
the index.
The scores for debris and calculus should be
tabulated separately and index for each
calculated independently, but in the same
manner.
Right molar
Anterior
Buccal Lingual Labial
Labial
Left molar
Total
Buccal Lingual Buccal Lingual
Upper
3
-
2
-
3
-
8
-
Lower
-
2
-
1
-
2
1
4
Debris Index = (The buccal-scores) + (The lingual-scores) / (Total number of
examined buccal and lingual surfaces).
Debris Index = (9+4) / 6 = 2.2
Calculus
Right molar
Anterior
Left molar
Total
Buccal Lingua Labial Labial Buccal Lingua Buccal Lingua
l
l
l
Upper
1
-
0
-
1
-
2
-
Lower
-
1
-
2
-
2
2
3
Calculus Index = (4+3) / 6= 1.2

The average individual or group debris
and calculus scores are combined to
obtain simplified Oral Hygiene Index, as
follows.
Oral Hygiene =
Index
Debris Index + Calculus
Index
2.2 + 1.2 = 3.4
Dentifrices, Mouthrinses, and
Chewing Gums
Dentifrices and mouthrinses are major products
for routinely administering effective cosmetic and
therapeutic agents in the mouth.
 Dentifrices are substances used to clean the
teeth.
 Mouthrinses are used to flush food debris from
the oral cavity, freshen breath, or if fluoridated, to
deposit fluoride on the teeth.
 Chewing gums are products with cosmetic
claims and the ability to deliver therapeutic
compounds.

Dentifrices are marketed:
- as toothpastes
- as gels,
- as toothpowders (to a lesser extent).

Some dentifrices are sold as:
- liquid gels,
- liquid pastes,
- stripes, ( breath strips).


All are sold as either therapeutic or cosmetic
products.
A
therapeutic dentifrice must
reduce some disease-related
process in the mouth - caries ,
gingivitis, plaque, or tooth sensitivity.
 The
purpose of a cosmetic
toothpaste is to clean and polish the
teeth.

Toothpastes contain several or all of the
ingredients: Abrasives, Water, Humectants,
Foaming agent (soap or detergent), Binding
agent, Flavoring agent, Sweetening agent,
Therapeutic agent, Coloring or preservative.

Gel dentifrices contain the same components
as toothpastes, except that gels have a higher
proportion of the thickening agents.

Both tooth gels and toothpastes are equally
effective in plaque removal and in delivering
active ingredients.
Abrasives
 The
degree of dentifrice
abrasiveness depends on the
hardness of the abrasive, size
and shape of the abrasive
particles.
The most common types of abrasives
used are:

Carbonates include calcium carbonate (chalk) and sodium
carbonate (baking soda).

Sodium monofluorophosphate - be used when the
combination of fluoride and calcium carbonate is desired.

Phosphate abrasives include calcium pyrophosphate and
dicalcium phosphate dihydrate.

Silicas, such as silicon oxides, mechanically cleanse the
tooth,

Aluminum oxides and perlites have also been introduced
into dentifrice formulas,
Humectants were added to maintain the
moisture and prevent hardening.
 Commonly used humectants are:
- sorbitol,
- mannitol,
- glycerol,
- propylene glycol.


Preservatives such as sodium benzoate are
added to prevent the growth of MO.
Detergents

The soaps disappeared from dentifrices, when
detergents appeared on the market.

Today, sodium lauryl sulfate (SLS) is the
most widely used detergent.

It has antibacterial properties, and a low
surface tension, which facilitates the flow of the
dentifrice over the teeth.

Sodium lauryl sulfate is active at a neutral pH,
has a flavor that is easy to mask, and is
compatible with the current dentifrice
ingredients.
Flavoring and Sweetening Agents

-
Synthetic flavors provide the desired taste:
Spearmint,
peppermint,
wintergreen,
cinnamon,
vanilla
They give toothpaste a pleasant taste, aroma,
and refreshing aftertaste.
Essential oils such as thymol, menthol,
may provide a "medicinal" taste to the
product. In addition, these oils may
impart antibacterial effects.
Sweetening Agents

Noncariogenic sweetening agents: saccharin,
cyclamate, sorbitol, and mannitol.

Sorbitol and mannitol are sweetening agents and
humectants.

Glycerin is a humectant and adds to the sweet
taste.

A new sweetener is xylitol – has an anticaries
capability by facilitating the remineralization of
incipient carious lesions.
Baking-Soda Dentifrices
 All
contain hydrated silica, which is
compatible with fluoride.
 Baking-soda
dentifrices actually
contain only a small amount of baking
soda, in addition to the standard
fluoride-compatible abrasives.
Therapeutic Dentifrices

The most commonly used therapeutic
agent added to dentifrices is fluoride,
which aids in the control of caries.

In 1960, the Council on Dental
Therapeutics of the American Dental
Association classified Crest toothpaste
with stannous fluoride as a caries
prophylactic dentifrice.

The original level of fluoride in dentifrices and
gels was restricted to 1,000 to 1,100 ppm
fluoride and a total of no more than 120 mg of
fluoride in the tube.

Most dentifrices today still contain 1,000 ppm.

Therapeutic toothpastes, dispensed on
prescription, could contain up to 260 mg or
4,950 ppm of fluoride in a tube.
The following fluorides are generally recognized
as effective and safe for sales:

0.22% sodium fluoride (NaF) at a level of 1,100 ppm,

0.76% sodium monofluorophosphate (MFP) at a level
of 1,000 ppm,

0.4% stannous fluoride (SnF2) at a level of 1,000
ppm.

Fluoride levels were increased to 1,500 ppm sodium
monofluorophosphate - “ Extra Strength Aim”.

A prescription dentifrice, Colgate PreviDent 5,000,
contains 5,000 ppm of fluoride.

The addition of calcium and phosphate ions
to a fluoride dentifrice may improve the
ability of enamel to resist caries initiation
and subsequent progression of a lesion.

Calcium phosphate encourages the
remineralization of enamel by rapidly
hydrolyzing to form apatite.
Stannous Salts
Stannous fluoride (SnF2), specifically the
stannous ion, has reported activity against
caries, plaque, and gingivitis.
 but his long-term stability in dentifrices and
mouthrinses has been questioned.


Superior efficacy has been shown for Crest
Pro-Health (Procter & Gamble) -this product
combines a stabilized stannous fluoride
(0.454%) and sodium hexametaphospate.
Triclosan

Triclosan is a broad-spectrum antibacterial
agent, marketed by its manufacturer, CibaGeigy, for use in oral products under the
trade name Irgacare.

Colgate Total developed by ColgatePalmolive, contains triclosan, a patented
copolymer, "Gantrez," and fluoride.

A triclosan dentifrice inhibits plaque regrowth
and provides anti-calculus activity, thereby
reducing gingival inflammation.
Mouthrinses



Freshening bad breath has been the traditional purpose of
mouthrinses.
However, mouthrinses can be cosmetic, therapeutic, or both.
Therapeutic mouthrinses
- Therapeutic benefits include a reduction in bacterial plaque,
gingivitis, and dental caries.
- Mouthrinses are often used daily by patients;
- It is important that patients understand proper usage of
mouthrinses to achieve successful outcomes.
When antimicrobial mouthrinses are used daily along with
brushing and flossing, they are most effective in reducing
plaque and gingivitis.
Therapeutic Mouthrinse Agents
Chlorhexidine
 is a cationic compound that binds to the
hydroxyapatite of tooth enamel, the pellicle,
plaque bacteria, the extracellular polysaccharide
of the plaque, and especially to the mucous
membrane.

The chlorhexidine adsorbed to the
hydroxyapatite is believed to inhibit bacterial
colonization and prevent pellicle formation.

The FDA has approved prescription plaquecontrol rinses containing 0.12% chlorhexidine.
Fluoride Rinses

Fluoride mouthrinses are effective in the
reduction of the incidence of dental caries.
They are intended for daily or weekly use,
depending on their categorization as:
- low-concentration/high-frequency or
- high-concentration/low-frequency rinses.
 Some low-concentration mouthrinses are
available over the counter.

The active agents in fluoride mouthrinse products
are NaF, acidulated phosphofluorides, or SnF.
 Concentration for daily use is 0.05% (250 ppm);


For weekly use the concentration of each agent is
0.2% (900 ppm), 0.44% (440 ppm), and 0.63%
(250 ppm), respectively.
The dose directions are 5 ml (1 teaspoon) of
product once daily
 The rinse is to be swished for 60 seconds and
then expectorated.


For stannous fluoride, the daily rinse
concentration is diluted with water to produce
a 0.1% concentration.

Stannous fluoride and acidulated
phosphofluoride mouthrinses are not
recommended for weekly usage.

It is found that the fluoride in
mouthrinses is retained in dental plaque
and saliva to help prevent dental caries.

Studies report a 30% to 40% average
reduction in the incidence of dental
caries for fluoride mouthrinse users.

Fluoride mouthrinses are highly indicated for
patients who have a history of moderate-torampant caries, who are undergoing
orthodontia.

Fluoride mouthrinses are not recommended for
children under 6 years of age or those who
have difficulty swishing and expectorating.
END

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