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ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 201-205

Assessment of oral health status of children living in orphanages of Hassan City, India


Department of Dentistry, Hassan Institute of Medical Sciences, Hassan, Karnataka, India

Date of Submission07-Dec-2018
Date of Acceptance07-Aug-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Dr. K L Girish Babu
Professor and Head, Department of Dentistry, Hassan Institute of Medical Sciences, Hassan - 573 201, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_222_18

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  Abstract 


Introduction: The children residing in orphanages suffer from poor oral health. Early identification of oral diseases is at most necessary in these high-risk group children so that the prevention and controlling of the diseases can be done at the earliest. Aim: This study aims to assess the oral health status of children residing in orphanages of Hassan city, India. Materials and Methods: In this descriptive cross-sectional study, children without parents, aged 6–14 years were selected from government-run orphanages. Children willing to participate were included. Each child was examined by a single investigator. Each child was examined on an upright chair in an adequate natural light using. The data obtained were subjected to statistical analysis using Student's t-test and SPSS software 19.0. P < 0.05 was considered as statistically significant. Results: The mean oral hygiene score among males was 1.32 ± 0.69 and among females was 0.89 ± 0.80 ( P = 0.006). On comparison of mean gingival index score between males and females, it was not statistically significant ( P = 0.160). The prevalence of dental caries in primary and permanent dentition was 26.21% and 23.07%, respectively. The prevalence of fractured tooth was found to be 8.57%. Conclusions: The oral hygiene status and gingival health status of the orphan children were good. The prevalence of dental caries and dental trauma was low among them.

Keywords: Dental caries, gingival health, oral hygiene, orphans, trauma


How to cite this article:
Kavayashree G, Girish Babu K L. Assessment of oral health status of children living in orphanages of Hassan City, India. J Indian Assoc Public Health Dent 2019;17:201-5

How to cite this URL:
Kavayashree G, Girish Babu K L. Assessment of oral health status of children living in orphanages of Hassan City, India. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Oct 23];17:201-5. Available from: http://www.jiaphd.org/text.asp?2019/17/3/201/266761




  Introduction Top


Many children are living in orphanages due to parental neglect, absence, substance abuse, and abandonment. These children are at risk for developing abnormal psychosocial development.[1] These children find themselves at higher risk of discrimination, inadequate care, and exploitation due to the absence of parental care. The children living in orphanage do not receive adequate preventive health care.[2] Many significant problems go undetected, or if diagnosed, they are not evaluated and treated.[3] The children residing in orphanages suffer from poor oral health as the health care of them is often neglected. This is because the orphanage homes can barely meet the needs of the children due to poor funding and low caretaker to child ratio.[1] Studies have observed a higher prevalence of dental caries, gingivitis, and dental trauma in these children.[4],[5],[6],[7],[8] Early identification of oral diseases is at most necessary in these high-risk group children so that the prevention and controlling of the diseases can be done at the earliest.

Although the exact number of orphans is unknown, the gravity of the situation can be assessed by the fact that there are around 143.4 million orphans worldwide, among whom, nearly 87.6 million are in Asia alone.[9] The National Family Health Survey-3 (2005–06) reported that about 4% of Indian population is orphans which constitute about 20 million children.[10] Although they contribute to 2% of worlds' population, there is a paucity of literature regarding their oral health status, particularly in Southern India. Hence, the aim of the present study was to assess the oral health status of children residing in orphanages of Hassan city, India. The objective of the study was to assess the status of oral hygiene, dental caries, gingival health, oral mucosa, and dental trauma in these children.


  Materials and Methods Top


The present descriptive cross-sectional study was conducted over 6 months during January–June 2017. Prior to the commencement of the study, ethical clearance was obtained from the Institutional Ethical Committee, Hassan Institute of Medical Sciences, India. (IEC/HIMS/030/2016 Dated 14.09.2016) The lists of orphanages were obtained from the Department of Women and Children welfare, Hassan District. Hassan district has eight taluks. There are two orphanages in Hassan District situated in Hassan city. The children aged 6 years and above are admitted to these orphanages, and they are sheltered here up to their 18 years. The written permission was obtained from the concerned government authorities and the head of the orphanages. The caretakers of orphanages offered written proxy consent for the children selected from orphanages. Before clinical examination, children were assured that the information collected from them would be kept confidential and will be reported in aggregate form. A written assent was obtained from each study participant prior to their clinical oral examination. Based on the reports of previous studies conducted at different cities of India,[1],[4],[5] the sample size was calculated.

n = N/(1 + Ne2), where n is the sample size, N is the population size and e is the margin of error



The estimated sample size was 86 which was rounded off to 100.

Training and calibration for oral examination and diagnosis of the selected oral diseases were carried out in the Department of Dentistry, Hassan Institute of Medical Sciences, India. Oral health status was recorded by a dental surgeon sitting beside the examiner so that the codes given by the examiner could be easily heard. Ten percent of children were examined twice for intra-examiner reliability. The kappa value for intra-examiner agreement was 0.88.

Children without parents, aged 6–14 years, were selected. Inclusion criteria include (1) normal, healthy, and cooperative children; (2) children residing in orphanages from 6 years of their age; and (3) children with all the indexed teeth for assessing oral hygiene status. Exclusion criteria include (1) children who are not willing to participate; (2) children with missing indexed teeth; (3) medically compromised children; (4) children with physical disability; and (5) children with mental disability.

Written consent was taken from the management of orphanage homes. All children were informed about the study purpose and method. Children willing to participate were included. Each child was examined by a single investigator. Prior to the examination, the child was asked to rinse the mouth thoroughly. The teeth were cleaned and dried with cotton pellet to eliminate any food debris on teeth. Each child was examined on an upright chair in an adequate natural light using sterilized mouth mirror and probe. Oral hygiene status was assessed using oral hygiene index (OHI) given by Greene and Vermillion.[11] Gingival status was assessed using gingival index by Loe and Silness.[12] The status of oral mucosa, dental carries, and dental trauma was assessed according to the WHO criteria (2013).[13] The data obtained were subjected to statistical analysis using Student's t-test and Chi-square test. SPSS software 19.0 (IBM Corp., Released 2010. IBM SPSS Statistics for Windows, version 19.0. Armonk, NY, USA: IBM Corp.,) were used for the analysis of the data.


  Results Top


A total of 62 males and 38 females participated in this study. The mean oral hygiene score among males was 1.32 ± 0.69 and among females was 0.89 ± 0.80. The difference was statistically significant. On comparison of mean gingival index score between male and females, it was not statistically significant ( P = 0.160). The mean deft score was 0.69 ± 1.25. The decayed, missing and filled teeth (DMFT) score of males was 0.41 ± 0.86 and females was 0.68 ± 1.49 and the difference was statistically significant [Table 1]. Frequency table for OHI-simplified showed 66% of children with good and 44% of children with fair oral hygiene [Table 2]. Frequency table of gingival health status showed that 45%, 39%, and 16% of children had normal, mild, and moderate gingival score, respectively [Table 3]. The prevalence of dental caries in primary dentition among males was 27.69%; among females, it was 23.68%; and the overall prevalence was found to be 26.21%. In permanent dentition, the prevalence of dental caries among males was 23.07%; among females, it was 44.73%; and the overall prevalence was 30.47% [Table 4]. The prevalence of fractured tooth among males was 10.76%; among females, it was 5.26%; and the overall prevalence was found to be 8.57% [Table 5].
Table 1: Oral health status of children living in orphanages

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Table 2: Frequency of oral hygiene score of children living in orphanages

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Table 3: Frequency of gingival index score of children living in orphanages

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Table 4: The prevalence of dental caries of children living in orphanages

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Table 5: The prevalence of dental fracture of children living in orphanages

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  Discussion Top


The children living with their family are provided with physical security, food and shelter, and psychological security. However, orphan children are not so fortunate. The orphans are ones who have lost one or both the parents and are socially and economically deprived.[14] Orphan children are usually sympathized but hidden away in the community.[15] The complete unfolding of potentialities of these children is hampered by certain elements in their social environment such as parental inadequacy, environmental deprivation, and emotional disturbances.[16] Young children in orphanage do not receive adequate preventive health care and thus many significant problems go undetected, or, if diagnosed, are not evaluated and treated. Thus, many orphan children suffer from chronic ill health, developmental, and psychiatric disorders.

Oral health is an integral part of general health and quality of life, so its neglect will give rise to negative health consequences and unpleasant social life of the individuals. Neglect of oral health care among this group of children leads to increased risk of developing oral diseases. Many researchers have reported a compromised oral health in children and adolescents suffering from sociopathies. [3, 5, 7, 8, 17] This has been attributed to overcrowding, lack of adequate staff, poor oral hygiene, improper dietary habits, inadequacies in the orphanage system, and inadequacies in the health-care system.[3],[18] Studies reporting the oral health status of orphan children are very scarce,[4],[15] particularly in Southern India. Hence, the present study was taken up to assess the oral health status of children residing in orphanages of Hassan city, India.

Oral hygiene status is often determined by the amount of deposits on the surfaces of teeth. The oral hygiene status of most of the orphans examined was good. The knowledge of oral health care among the caretakers who encouraged and motivated these children, oral hygiene aids provided by the nongovernmental organizations (NGOs) and frequent visit of dental health facilities for regular checks would have assisted them to maintain their oral hygiene. Ojahanon et al. reported a similar finding among most of the orphan children in Benin city, Nigeria.[7] However, Al-Jobair et al. observed a worse oral hygiene in Saudi Arabian orphan children.[19] This finding was attributed to ineffective brushing techniques, lack of close supervision, and rendering dental treatment only during an emergency. Most of the children (66%) had a good oral hygiene in the current study. Similarly, in a study, almost 74% of children presented with fair oral hygiene.[7] However, Shanbhog et al. reported only 19.7% of children to have a good oral hygiene score.[6] Other studies reported increasing score with increasing age.[20],[21] The poor oral hygiene in them may be due to increased prevalence of gingivitis associated with teeth eruption and hormonal changes at puberty.[7] In the present study, females had better oral hygiene than males which may be due to the growing awareness about esthetics among females than males.

Poor oral hygiene has been implicated in the etiology and progression of gingival and periodontal diseases. In the present study, orphan children did not show any significant gingival bleeding. This finding is in accordance to Sushanth et al., who observed a significantly lower gingival index score among orphans.[15] Good oral hygiene among them and healthy oral hygiene habits would have contributed for better gingival health. Contrary to our observation, Thetakala et al.,[4] Al-Jobair et al.,[19] and Khedekar et al.,[8] reported a significantly higher prevalence of gingival bleeding among orphans and it was relatively higher among males compared to females. This finding was attributed to nonavailability of oral hygiene aids (toothbrush and toothpaste), improper brushing techniques, and lack of close supervision of their oral hygiene practices.

Dental caries is caused due to the interaction between genetic and environmental factors, in which biological, social, behavioral, and psychological components are expressed in a highly complex and interactive manner.[22] According to the National Oral Health Survey (2002–2003), the mean DMFT/deft is 1.8 in the 12 years of age groups in India.[23] In the present study, the mean dental caries in primary and permanent dentition was low. In accordance with this, Thetakala et al.[4] and Pratap et al.[24] also reported a low dental caries scores among orphan children. This low caries experience may be due to following: strict food selection by government authority to make sure that these children are given proper healthy, nutritious, and fibrous food with low sugar content; absence of frequent snacking of carbohydrate-rich sticky foods; fixed time for breakfast, lunch, and dinner; and giving sweets made of jaggery only during lunch. Along with these, the oral health services provided by some of the philanthropic institutions, dental colleges and NGOs by providing toothbrush and fluoridated toothpaste and compulsorily making them to brush their teeth twice daily would have contributed for the lower caries experience in these children.

The prevalence of dental caries in primary dentition was 26% with mean DMFT of 0.69. Pratap et al.[24] and Khare et al.[25] observed a prevalence of 40.5% and 49.6%, respectively, which are very much higher than the present study. Orphans in Yemen had a mean DMFT of 2.28.[26] The prevalence of dental caries in permanent dentition was 30%. However, other studies have reported a higher mean caries experience in permanent dentition.[4], 20, [27],[28],[29] A very high caries prevalence of 84.7% and 78% was reported by Al-Maweri et al.,[26] and Seow et al.,[30] respectively. The authors related the high prevalence of dental caries to the poor oral hygiene status of children, underlying medical conditions, particularly psychological problems and the use of medications. Other causes were negligence toward oral health, nonavailability of health-care facilities, overcrowded and underfunded orphanages, lack of supervision and reinforcement, and high cost of dental health care. The mean DMFT score observed was 0.41. Orphan children of other parts of India had a mean DMFT score ranging from 0.96 to 3.56[6],[24],[31],[32] However, Romanian orphan children had a mean DMFT/DMFT of zero.[33]

Males had higher caries experience in primary dentition, whereas females had higher caries experience in permanent teeth. The early eruption of teeth followed by prolonged exposure to the deleterious oral environment would have resulted in higher caries experience in permanent dentition among females.[34] This finding is in accordance with the results of other researchers' reporting from various parts of India.[1],[34],[35] Contradictory to our findings, many authors observed a higher caries experience among males.[4],[26],[27],[36] The authors stated that the females had lower caries experience as they were more conscious about maintaining esthetics, appearance, cleanliness, and hygiene. However, Sudha et al. and Lagana et al. found no statistically significant difference in caries prevalence between genders.[37],[38]

Al-Maweri et al. reported nine types of oral lesions in their study.[26] The most common being fissured tongue, recurrent herpes labialis, traumatic ulcers, and geographic tongue. However, in the present study, no such lesion was observed as the children had a good oral hygiene and proper psychological support and care. Other reasons could be recording of oral mucosal status only at the time of examination. The validity of self-reports given by children regarding previous oral lesions is questionable, and hence, it was not considered in this study.

Around 9% of children experienced the incidence of dental trauma, and male children had a higher traumatic teeth experience than females. This finding is in accordance with the observation made by Khare et al.[25] and Al-Maweri et al.[26] The higher prevalence of traumatic teeth among orphans may be due to overcrowding in the orphanage and the psychological stress of orphans. The psychological stress may increase the violence between children. Male children spend more time in physical activity and fights with each other; this would have resulted in higher traumatic experience among them than females.

The results of the present study showed that orphan children had a fair oral health status. This emphasizes the need of conducting regular dental health programs and creating awareness about preventive oral health measures. Primary caretakers should also be trained by conducting educational programs on “importance of oral health and its maintenance.” Along with these, utilization of resources of the dental colleges, NGOs, and encouragement of public–private partnership will help to improve the oral health of these unfortunate children.

As this was a cross-sectional study, the cause of dental caries cannot be easily determined. Furthermore, we did not include a control group as it would be unethical to create a group who would not receive oral health care. Future longitudinal studies with a control group should be carried out to improve the oral health of these orphan children.


  Conclusions Top


  1. The oral hygiene status and gingival health status of the orphan children were good
  2. The prevalence of dental caries and dental trauma was low among them.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma A, Gaur A, Pareek S, Raja V, Sanadhya S, Sharma AV. Oral health status and treatment needs among orphanage children of Jaipur City. Sch J Appl Med Sci 2014;2:1776-80.  Back to cited text no. 1
    
2.
Petersen PE. The World Oral Health Report. Geneva, Switzerland: World Health Organization; 2003.  Back to cited text no. 2
    
3.
Camacho GA, Camacho E, Rodriguez RA, Guile A, Juarez HM, Perez GM. Predisposing factors for dental caries in girls at an orphanage of Mexico City. Acta Pediatr Me×2009;30:71-6.  Back to cited text no. 3
    
4.
Thetakala RK, Sunitha S, Chandrashekar BR, Sharma P, Krupa NC, Srilatha Y, et al. Periodontal and dentition status among orphans and children with parents in Mysore city, India: A comparative study. J Clin Diagn Res 2017;11:ZC115-ZC118.  Back to cited text no. 4
    
5.
Shah AF, Tangade P, Ravishankar TL, Tirth A, Pal S, Batra M, et al. Dental caries status of institutionalized orphan children from Jammu and Kashmir, India. Int J Clin Pediatr Dent 2016;9:364-71.  Back to cited text no. 5
    
6.
Shanbhog R, Godhi BS, Nandlal B, Kumar SS, Raju V, Rashmi S, et al. Clinical consequences of untreated dental caries evaluated using PUFA index in orphanage children from India. J Int Oral Health 2013;5:1-9.  Back to cited text no. 6
    
7.
Ojahanon PI, Akionbare O, Umoh AO. The oral hygiene status of institution dwelling orphans in Benin city, Nigeria. Niger J Clin Pract 2013;16:41-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Khedekar M, Suresh KV, Parkar MI, Malik N, Patil S, Taur S, et al. Implementation of oral health education to orphan children. J Coll Physicians Surg Pak 2015;25:856-9.  Back to cited text no. 8
    
9.
Available from: http://www.thechildrenarewaiting.org/orphan-care/about-orphans. [Last accessed on 2018 Apr 19].  Back to cited text no. 9
    
10.
Available from: https://www.soschildrensvillages.ca/india-now-home-20-million-orphans-study-finds. [Last accessed on 2018 Apr 19].  Back to cited text no. 10
    
11.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 11
    
12.
Loe H, Silness J. Periodontal disease in pregnancy. I. prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 12
    
13.
World Health Organization. Oral Health Surveys, Basic Methods. 5th ed. Geneva: World Health Organization; 2013.  Back to cited text no. 13
    
14.
Cluver L, Gardner F, Operario D. Psychological distress amongst AIDS-orphaned children in urban South Africa. J Child Psychol Psychiatry 2007;48:755-63.  Back to cited text no. 14
    
15.
Sushanth VH, Krishna M, Babu AM, Prashant GM, Chandu GN. A peer group approach model of oral health promotion among orphans at Puduchery, South India. J Int Soc Prev Community Dent 2011;1:71-5.  Back to cited text no. 15
    
16.
Park K. Park's Text Book of Preventive and Social Medicine. Jabalpur: Banarasidas Bhanot Publishers; 2000. p. 632-8.  Back to cited text no. 16
    
17.
Adamowicz-Kleplaska B, Burkiewicz B. Oral condition in children and adolescents exposed to sociopathies. Czas Stomatol 1990;43:679-84.  Back to cited text no. 17
    
18.
Siddiqui NJ. Adolescent Orphan Girls in New Delhi: A Sociological Profile. New Delhi: Regency Publications; 1997. p. 143.  Back to cited text no. 18
    
19.
Al-Jobair AM, Al-Sadhan SA, Al-Faifi AA, Andijani RI. Medical and dental health status of orphan children in central Saudi Arabia. Saudi Med J 2013;34:531-6.  Back to cited text no. 19
    
20.
Bolin AK. Children's dental health in Europe. An epidemiological investigation of 5 and 12-year-old children from eight EU countries. Swed Dent J Suppl 1997;122:1-88.  Back to cited text no. 20
    
21.
Freitas-Fernandes LB, Novaes AB Jr., Feitosa AC, Novaes AB. Effectiveness of an oral hygiene program for Brazilian orphans. Braz Dent J 2002;13:44-8.  Back to cited text no. 21
    
22.
Zero DT. Dental caries process. Dent Clin North Am 1999;43:635-64.  Back to cited text no. 22
    
23.
Dixit S, Chaudhary M, Singh A. Molluscum contagiosum and dental caries: A pertinent combination. J Indian Soc Pedod Prev Dent 2009;27:197-201.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Pratap R, Puranik MP, Uma SR. Caries experience and its relationship with oral health related quality of life among orphanage children in Bengaluru city: A cross-sectional study. J Indian Assoc Public Health Dent 2016;14:397-402.  Back to cited text no. 24
  [Full text]  
25.
Khare V, Koshy A, Rani PJ, Srilatha S, Kapse SC, Agarwal A. Prevalence of dental caries and treatment needs among the orphan children and adolescents of Udaipur district, Rajasthan, India. J Contemp Dent Pract 2012;13:182-7.  Back to cited text no. 25
    
26.
Al-Maweri SA, Al-Soneidar WA, Halboub ES. Oral lesions and dental status among institutionalized orphans in Yemen: A matched case-control study. Contemp Clin Dent 2014;5:81-4.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Gaur A, Sujan SG, Katna V. The oral health status of institutionalized children that is, juvenile home and orphanage home run by Gujarat state government, in Vadodara city with that of normal school children. J Indian Soc Pedod Prev Dent 2014;32:231-7.  Back to cited text no. 27
[PUBMED]  [Full text]  
28.
Mohan A, Misra N, Umapathy D, Kumar S, Srivastav D, Mohan U. Oral and dental health status in orphan children of Lucknow. Ind J Community Health 2014;26:170-3.  Back to cited text no. 28
    
29.
Singh A, Sequiera P, Acharya S, Bhat M. Oral health status of two 12-year-old socially disadvantaged groups in South India: A comparative study. Oral Health Prev Dent 2011;9:3-7.  Back to cited text no. 29
    
30.
Seow WK, Amaratunge A, Bennett R, Bronsch D, Lai PY. Dental health of aboriginal pre-school children in Brisbane, Australia. Community Dent Oral Epidemiol 1996;24:187-90.  Back to cited text no. 30
    
31.
Muralidharan D, Fareed N, Shanthi M. Comprehensive dental health care program at an orphanage in Nellore district of Andhra Pradesh. Indian J Dent Res 2012;23:171-5.  Back to cited text no. 31
  [Full text]  
32.
Hans R, Thomas S, Dagli R, Bhateja GA, Sharma A, Singh A, et al. Oral health knowledge, attitude and practices of children and adolescents of orphanages in Jodhpur city Rajasthan, India. J Clin Diagn Res 2014;8:ZC22-5.  Back to cited text no. 32
    
33.
O'Sullivan EA, Stephens AJ. The oral and dental status of children residing in a Romanian orphanage. Int J Paediatr Dent 1997;7:41-2.  Back to cited text no. 33
    
34.
Shailee F, Girish MS, Kapil RS, Nidhi P. Oral health status and treatment needs among 12- and 15-year-old government and private school children in Shimla city, Himachal Pradesh, India. J Int Soc Prev Community Dent 2013;3:44-50.  Back to cited text no. 34
    
35.
Saravanan S, Kalyani V, Vijayarani MP, Jayakodi P, Felix J, Arunmozhi P, et al. Caries prevalence and treatment needs of rural school children in Chidambaram Taluk, Tamil Nadu, South India. Indian J Dent Res 2008;19:186-90.  Back to cited text no. 35
[PUBMED]  [Full text]  
36.
Rao A, Sequeira SP, Peter S. Prevalence of dental caries among school children of Moodbidri. J Indian Soc Pedod Prev Dent 1999;17:45-8.  Back to cited text no. 36
[PUBMED]  [Full text]  
37.
Sudha P, Bhasin S, Anegundi RT. Prevalence of dental caries among 5-13-year-old children of Mangalore city. J Indian Soc Pedod Prev Dent 2005;23:74-9.  Back to cited text no. 37
[PUBMED]  [Full text]  
38.
Lagana G, Fabi F, Abazi Y, Kerçi A, Jokici M, Nastasi EB, et al. Caries prevalence in a 7- to 15-year-old Albanian schoolchildren population. Ann Stomatol 2012;3:38-43.  Back to cited text no. 38
    



 
 
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