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Lasers in Dental Science

, Volume 2, Issue 4, pp 193–200 | Cite as

Antibacterial effect of diode lasers in the treatment of peri-implantitis and their effects on implant surfaces: a literature review

  • Khaled Smeo
  • Riman Nasher
  • Norbert Gutknecht
Review Article

Abstract

The aim

The present study aims to conduct a descriptive analysis by reviewing in vivo and in vitro studies concerned with the antibacterial effect of diode lasers (810 nm, 940 nm, and 980 nm) and their effects on implant surfaces at different parameters for peri-implantitis treatment.

Materials and methods

The PubMed and Google Scholar had been used to search for articles focused on the antibacterial effect of diode lasers (810 nm, 940 nm, and 980 nm) in the treatment of peri-implantitis and their effects on implant surfaces. This literature search was limited to 10 years (January 2007–March 2017).

Results

Diode laser is an effective adjunctive tool in treatment of peri-implantitis in combination with a conventional therapy without any negative effect on the surrounding soft and hard tissues, and on the implant surfaces where the favorable settings regarding to vivo and vitro studies are 810 nm in non-contact continuous wave mode at 1 W for 20 s, five times with 30-s pause after each 20-s application time, and 600-μm fiber tip or 810 nm in non-contact pulse wave mode at 1 W, 50 Hz and a pulse duration of 100 ms/pulse, 30-s application time (2 times for each side).

Conclusion

Eight hundred ten-nanometer diode laser wavelength with a low average power and appropriate irradiation time treat the peri-implantitis significantly without affecting the surrounding tissues or alteration of the implant surfaces.

Keywords

Dental implant Peri-implantitis Peri-implantitis Peri-implant Dental implant surface Decontamination Disinfection Antibacterial effect Bactericidal effect Diode laser Laser treatment Laser therapy 

Introduction

A dental implant is a metal anchor that is placed into the jaw bone to support a dental prosthesis such as a crown, bridge, and denture or to act as an orthodontic anchor [1, 2]. Dental implant is an ideal option for people in a good oral health who have a loss of tooth or teeth due to periodontal disease, an injury, or other reasons [1]. However, there are many factors which affect the success of dental implant and its fusion with bone (osseointegration). These factors include misunderstanding the anatomy and the dental implant fundamentals, in addition to factors related to the patient such as uncontrolled diabetes, cancer, radiation to the jaw, smoking, alcoholism, and uncontrolled periodontal disease [3].

There are risks and complications related to implant therapy which are divided into three stages based on their time of occurrence (during surgery, in the first 6 months and long-term complications including biological complications such as peri-implant mucositis and peri-implantitis) [2, 4].

Biofilm play a significant role in the initiation and progression of peri-implant diseases [5, 6] and is essential for the development of infections around dental implants. On the other hand, the process of creating implant surface roughness, such as by sandblasting or titanium spraying, improves the bone implant contacts but also causes an increase in bacterial adherence [7]. Moreover, peri-implant diseases have been associated with Gram negative anaerobic bacteria (such as Staphylococcus aureus which may be an important pathogen in the initiation of peri-implantitis) similar to those found around natural teeth in patients with severe chronic periodontitis [5].

Peri-implantitis is an inflammatory process affecting soft and hard tissues surrounding an implant, which is associated with the loss of supporting bone, deep probing depth, bleeding on probing, and occasionally suppuration from the peri-implant space [7, 8].

There are many risk factors which have been identified that may lead to the establishment and progression of peri-implantitis [5, 9, 10] such as previous history of periodontal disease [11, 12], poor oral hygiene [13, 14], residual cement stagnation in or around the gingiva after implant prosthesis cementation [15, 16], smoking [17, 18, 19], genetic factors [20], occlusal overload [21], systemic disease such as poorly controlled diabetes, cardiovascular disease, and osteoporosis [13, 22], and potential emerging risk factors including alcohol consumption, tobacco, and rheumatoid arthritis with concomitant connective tissue disease [23, 24].

Peri-implantitis can be classified into three categories based on the pocket depth and bone loss (Table 1) [25].
Table 1

Classification of peri-implantitis

Early

Probing depth ≥ 4 mm (bleeding and/or suppuration on probing).

 

Bone loss < 25% of the implant length.

Moderate

Probing depth ≥ 6 mm (bleeding and/or suppuration on probing).

 

Bone loss 25 to 50% of the implant length.

Severe

Probing depth ≥ 8 mm (bleeding and/or suppuration on probing).

 

Bone loss > 50% of the implant length.

Peri-implantitis can be diagnosed early or once clear clinical evidence has developed. The most common signs and symptoms of peri-implantitis are color changes in keratinized gum tissue or in the oral mucosa, bleeding on probing, increased probing depth of peri-implant pocket, suppuration, peri-implant radio-transparency, and progressive loss of bone height around the implant [26].

The primary objective for treating peri-implantitis is to eliminate the biofilm from the implant surface and decontaminate it [27]. Both surgical and non-surgical approaches have been evaluated for the management of peri-implantitis. A non-surgical approach involves surgical detoxification using mechanical, chemical, lasers, and antibiotic therapy (locally and/or systematically). Surgical approach includes access flap, as well as respective and regenerative surgical techniques. In addition, lasers have been used in combination with a surgical therapy [28, 29, 30].

Laser therapy has been used as a non-surgical treatment of peri-implantitis. The laser wavelengths which may be used in the treatment of peri-implantitis include CO2 laser, Er:YAG laser, Er,Cr:YSSG laser, diode lasers (810 nm, 940 nm, and 980 nm), and several wavelengths used in photodynamic therapy.

Diode lasers are manufactured in different wavelengths including 810 nm, 940 nm, and 980 nm. They may be operated in continuous wave mode (energy emitted as a constant beam) or in a gated pulse mode (energy emitted as a constant but interrupted beam) [31]. Diode laser energy is delivered by a fiber in a contact mode which is heated up to between 500 and 800 °C by conditioning or carbonizing; this heat transferred to the tissue and effectively cuts by vaporizing the tissue because of the physical contact of the heated tip of the laser with the tissue rather than from the optical properties of the laser light itself [31].

The most commonly used wavelengths in the treatment of peri-implantitis are the gallium-aluminum-arsenide (GaAlAs) laser (810 nm) and the indium-gallium-arsenide (InGaAs) laser (980 nm) [32]. Diode lasers are absorbed by two main chromophores which are hemoglobin and melanin (Fig. 1). Because of the low absorption in water, these diode laser wavelengths achieve a high degree of penetration into biological tissues and may bear the risk of inducing potential thermal side effects [32]. However, 980-nm diode laser is absorbed in water at a slightly higher rate than 810-nm diode laser [34, 35] (Fig. 1). The use of 810-nm diode laser adversely changes the implant surface, but it has excellent coagulation properties that are similar to those of the Nd:YAG laser, and it is characterized by a superficial tissue absorption with penetration to the underlying tissues (less penetration depth than Nd:YAG laser) [35]. There is a study stated that a 810-nm diode laser irradiation with a tip of 0.4 mm at 3 W for 10 s in continuous wave mode did not cause any alteration on the implant surface [31]. Therefore, the use of 980-nm diode laser is more advantageous around dental implants even at a higher power settings, since the peak absorption in water will help avoid temperature increase at the implant surface [34, 36]. Furthermore, studies have confirmed the bactericidal effect of this wavelength on implant surfaces without changing the implant surface pattern [35, 37, 38]. The diode laser also stimulates fibroblasts and osteoblasts, which in turn cause increased production of RNA messengers, leading to significant collagen production during periodontal tissue healing that may be a feasible alternative approach for the management of peri-implantitis [29].
Fig. 1

Absorption coefficient of laser wavelengths [33]

Generally, the advantages of diode laser application include bloodless surgery, minimal swelling, scarring and coagulation, suturing is not needed, surgical time reduction, and less or no post-surgical pain [36].

Materials and methods

PubMed and Google Scholar had been used to search for articles focused on the antibacterial effect of diode lasers (810 nm, 940 nm, and 980 nm) in the treatment of peri-implantitis and their effects on implant surfaces. This literature search was limited to 10 years (January 2007–March 2017) and include all human articles (in vivo and in vitro) published in English language. Moreover, this literature excludes all studies in animals, literature reviews, systemic reviews, and histological studies, as well as, all studies not related to the antibacterial effect of diode lasers or its effect on implant surfaces (Fig. 2, Table 2).
Fig. 2

How many articles had been used in the review (in general, in vivo, and in vitro)

Table 2

Demonstrate the abbreviations which had been used in this review

Icon

Meaning

Icon

Meaning

Icon

Meaning

W

Watt

DL

Diode laser

CW

Continuous wave

PD

Pocket depth

PI

Plaque index

Ti

Titanium

BOP

Bleeding on probing

SLA

Sand blasted, large grit, acid-etched

N info

No information

s

Second

Y-TZP

Yittrium stabilized tetragonal zirconia polycrystal

μs

Microsecond

LS

Low settings

HS

High settings

ms

Millisecond

The keywords which was used in the search are dental implant, peri-implantitis, peri-implantitis, peri-implant, dental implant surface, decontamination, disinfection, antibacterial effect, and bactericidal effect. All these words are followed by diode laser, laser treatment, and laser therapy.

Results

In vivo, antibacterial effect of diode lasers in the treatment of peri-implantitis, Table 3.
Table 3

Antibacterial effect of diode lasers in the treatment of peri-implantitis, in vivo

Author and year

Study type

Laser type and parameters

PD and PI

BOP

Bone level

Finding

Sennhenn-Kirchner et al., [39], 2007

In vivo

DL 810 nm, CW, 1 W, 20 s, 600-μm fiber tip.

N info

N info

N info

˃ 98% of bacterial colonization reduction in a biofilm on intraoral rough titanium surfaces.

DL 810 nm, CW, 1 W, 600-μm fiber tip, 30-s pause after 20 s, 5 times.

DL 980 nm, CW, 1 W, 500-μm fiber tip, 20 s.

DL 980 nm, CW, 1 W, 500-μm fiber tip, 30-s pause after 20 s, 5 times.

DL 980 nm, PW, 1.5 W, 500-μm fiber, 20 Hz, 3 ms pulse duration, 5 times, 30-s pause after 20-s application time.

Efeoglu et al., [40], 2008

A case report

DL 810 nm, CW,1 W, 600-μm fiber, AT(?).

N info

N info

N info

During non-surgical therapy,

DL cease the disease activity and eliminate infection.

Roncati et al., [29], 2013

A case report

DL 810 nm, CW, 0.5 W, 30 s in duplicate for each site, 6 sites, 1.98 J/cm2.

PD reduced from 7 to 3 mm.

no

Improved

In a combination with non-surgical conventional treatment, DL can be effective alternative treatment modality forperi-implantitis.

Roncati et al., [41], 2015

A clinical report

DL 980 nm, PW, 2.5 W, 30 s, 120 J/cm2, 10 Hz, 300-μm fiber tip.

PD reduced from 9 to 3 mm.

no

Improved

DL seems to be effective alternative treatment modality with traditional protocol of non-surgical periodontal therapy for peri-implantitis.

Arisan et al., [42], 2015

Randomized clinical trials

DL 810 nm, PW,1 W, 60 s, 400-μm fiber tip, 1.5 J, 3 J/cm2, 400 mW/cm2, non-contact mode and in non-surgical therapy.

PD decreased after 1 month and increased again after 6 months. PI reduced from 91.7% at BL to 29.2% after 1 month.

Reduced from 100 to 58.3% after 1 month and increase again to 95.8% at 6 months.

Improved from 2.13 to 2.79 mm at 6 months

DL not yield any additional positive influence on peri-implant microbiota treatment compared with conventional scaling only.

Mettraux et al., [43], 2016

2-year clinical outcomes

DL 810 nm, PW, 2.5 W, 50 Hz, 30 s,3 times within 14 days, 10 ms pulse duration.

PD reduced from 7.5 ± 2.6 to 3.6 ± 0.7 mm at the deepest buccal, and from 7.7 ± 2.1 to 3.8 ± 0.9 mm at the deepest oral sites.

Reduced from 100 to 43% at 2 years and to 100% in 57% of cases after 2 years.

Bone fill

Significant clinical benefits of DL in conjunction with non-surgical mechanical therapy.

Lerario et al., [44], 2016

Preliminary clinical study

DL 810 nm, PW,1 W,50 Hz,100 ms pulse duration, 24.87 J/cm2, 30 s application time, 2 times for each inflamed site, non-contact mode.

PD reduced from 5.2 ± 1.3 to 2.5 ± 0.98 mm.

Reduced from 90.09 to 4.95%

N info

DL with conventional non-surgical periodontal instrumentation seems to be a valuable tool in mucositis and peri-implantitis treatment.

In vitro, antibacterial effect of diode lasers in the treatment peri-implantitis, Table 4.
Table 4

Antibacterial effect of diode lasers in the treatment peri-implantitis, in vitro

Author and year

Laser type and parameters

Type of implant material

Finding

Stübinger et al., [45], 2009

DL 810 nm, 1 W, 10 s, 50 J/cm2, 200-μm fiber tip. (LS)

Titanium and zirconia.

DL with (HL) effectively reduce the viability of adhered S. sanguinis or P. gingivalis, independent of the material (titanium or zirconia).

DL 810 nm, 3 W, 10 s, 150 J/cm2, 200-μm fiber tip. (HS)

Both in non-contact mode.

In vitro, effect of diode lasers on the dental implant surface, Table 5.
Table 5

Effect of diode lasers on the dental implant surface, in vitro

Author and year

Laser type and parameters

Type of implant material & properties

Finding

Castro et al., [46] 2007

DL, 980 nm, 1 W, pulsed, non-contact.

Titanium implant surfaces

DL did not modify the Ti surfaces whatever the power setting or mode pattern used.

DL, 980 nm, 15 W, CW.

Both with continuous saline cooling and for 60 s.

Stübinger et al., [47] 2008

DL 810 nm, 1 W, 10 s, 200-μm fiber tip, 90° angle, non-contact mode.

Y-TZP disks

No surface alteration at both settings.

DL 810 nm, 3 W, 10 s, 200-μm fiber tip 90° angle, non-contact mode.

Stübinger et al., [31] 2010

DL 810 nm, 1 W, 10 s, 400-μm fiber tip, 90 angle, non-contact mode.

Polished and SLA titanium disks

DL did not cause surface alteration.

DL 810 nm, 3 W, 10 s, 400-μm fiber tip, 90 angle, non-contact mode.

Geminiani et al., [48], 2012

DL, 810 nm, CW, 2 W, 60 s, non- contact mode.

SLA titanium implant

After 10 s, a temperature of the implant surface increased above the critical threshold (10°).

DL, 810 nm, PW, 2 W, 1 Hz, 500 ms pulse duration, non-contact mode.

DL, 980 nm, CW, 2 W, 60 s, non- contact mode.

DL, 980 nm, PW, 2 W, 25 s, 4 kHz, non-contact mode.

Giannelli et al., [49], 2015

For CW mode: DL, 808 nm, 30 s, 0. 5–2.0 W, 600-μm fiber tip.

Titanium disks (TiUnite and anodized, machined surfaces)

TiUnite more susceptible to thermal rise than the machined surfaces.

For pulsed mode: DL, 808 nm, 30 s, 1–-45 μJ, 20 KHz, 5–20 μs pulse duration, 600-μm fiber tip.

In contact mode with (2 W, CW, airflow cooling), deep grooves and microfusion were observed, but in non-contact mode with same setting, no changes was observed.

Both in contact and non-contact mode, with and without airflow cooling.

Kushima et al., [50], 2016

DL, 808 nm, 1 W, 20 s, 50 Hz, 600-μm fiber tip, ton = 100 ms and toff = 100 ms, 28.29 J/cm2, contact mode, PW.

Y-TZP, machined Ti and SLA.

DL increase the temperature of zirconia and Ti without surface alteration.

Discussion

The biofilm plays a significant role in the initiation and progression of peri-implant diseases such as peri-implantitis which is characterized by inflammation of the implant surrounding tissues and loss of bone [5, 6]. The main goal of peri-implantitis treatment is to remove the biofilm from the implant surfaces and decontaminate it, in addition to reduce or eliminate the signs of inflammation and pocketing such as BOP, PD, suppuration, and bone loss [27]. The most common method for treatment of peri-implantitis is a mechanical debridement of implant surface using curettes, ultrasonic devices and air abrasive devices, but it is not sufficient to remove bacteria and improve the healing [27, 28, 29]. Recently, a laser therapy is used alone or in combination with a mechanical method in the treatment of peri-implantitis; whereas, it has been suggested as an alternative or an adjunctive tool to the conventional mechanical method. The laser has a bactericidal effect, which achieve complete or almost complete elimination of bacteria from the implant surfaces without altering the surface characteristic itself [29, 47]. The decontamination capability of all areas of implant surfaces even within threads can be explained by the physical properties of each laser wavelength and its interaction with tissues and implant surface [35]. Among the most common laser types which are used in the treatment of peri-implantitis are diode laser, Er:YAG laser and Er,Cr:YSGG laser. In the present study, we reviewed 14 of published paper investigating the use of DL in peri-implantitis.

Six of the reviewed studies in vivo suggested that both diode laser wavelengths (810 nm and 980 nm) have an ability to eliminate more than 98% of bacteria from the implant surface, completely or almost completely removal of the inflammatory signs such as BOP, PD, suppuration within 1 or 2 years and improve bone formation around the implant. In addition, they suggested that the diode laser seems to be a valuable tool in the treatment of peri-implantitis.

Sennhenn-Kirchner et al., [39] found that ceasing the disease activity and elimination of infection with 99.98% of bacterial reduction such as Staphylococci, Streptocci, Aerococcus urinae, and Lactococcus lactis was achieved by using diode laser 810-nm wavelength, CW, 1 W, 30-s pause after 20-s irradiation time for 5 times, 600-μm fiber tip. Roncati et al., [29, 41] found that the periodontal pocket depth reduced from 7 to 3 mm with no bleeding on probing and the bone level was improved by using DL 810 nm at 0.5 W, CW for 30 s and in duplicate in each side (that means 60 s for each side) with a dose of 1.98 J/cm2. In addition, they found that the periodontal pocket depth reduced from 9 to 3 mm with no BOP and within 1-year bone improvement by using diode laser 980 nm at 2.5 W, PW, 10 Hz for 30 s with a fluence of 120 J/cm2 and 300-μm fiber tip. Mettraux et al. [43] found that a clinical improvement was detected within 2 years by using diode laser as adjunctive tool following a non-surgical mechanical method with 810 nm at 2.5 W, PW, 50 Hz, 10 ms pulse duration, 30-s application time, 3 times within 2 weeks. Lerario et al. [44] showed that 810-nm diode laser at 1 W in PW for 100 ms pulse duration, 30-s application time, 2 times for each inflamed site and 50 Hz seems to be an alternative tool in combination with a mechanical method, whereas they demonstrated that within 1 year, the PD reduced from 5.218 ± 1.342 to 2.543 ± 0.9811 mm and BOP reduced from 90.09 to 4.95%.

But there is one study [42] in vivo showed that the adjunctive use of diode laser following mechanical therapy did not yield any additional positive influence on the peri-implantitis microbiota when compared with conventional therapy alone. Despite the author found that within 1 month, a PD reduced and BOP reduced from 100 to 58.3%, but these values were increased again after 6 months, where BOP increased to 95.8% and PI increased to 54.2%. In the same time, bone level improved from 2.13 to 2.79 mm. That may be as a result of many factors such as individual host response and confounding factors in the healing mechanism of the peri-implant alveolar bone; in addition, a more exposure time which has been used in this study and uncontrolled temperature increase might jeopardize healing. Efeoglu et al. [40] achieved positive results with 810-nm diode laser at 1 W in CW but they did not mention a time of application which is an important value to know which safe settings can be used without negative effect on the implant and the surrounding tissues.

One study was done in vitro by Stübinger et al. [45], where they found that the use of diode laser 810-nm wavelength, 3 W for 10 s and 200-μm fiber tip (The author not specified a mode of operation) was effective in elimination of bacteria causing peri-implantitis (such as Streptococcus sanguinis and Porphyromans gingivalis) independent of the implant material. On the other hand, a Streptococcus sanguinis is less sensitive to laser irradiation with same settings at 1 W. Moreover, these setting (1 W) is effective for killing P. gingivalis. However, we must take in consideration that an irradiation time should be less than 10 s when an average power 2 or 3 W are used to avoid increase of temperature above the critical threshold which in turn lead to a negative effect on the soft and hard tissues around the implant during peri-implantitis treatment.

On the other hand, two of the reviewed studies in vitro demonstrated that 810-nm diode laser did not alter the surface characterization of the implant surface as they reported by Stübinger et al. [31, 47], which revealed that 810-nm diode laser did not cause any visible surface alteration on either polished and SLA titanium or zirconia when at 1 and 3 W in non-contact continuous wave mode for 10 s and 90° angle with a fiber tip of 200 and 400 μm respectively. Nevertheless, they did not mention a thermal effect at these settings, where which may lead to temperature increase of titanium or zirconia at 3 W which in turn may lead to a negative effect on the surrounding soft and hard tissues. One study by Geminiani et al. [48] found that both diode laser wavelengths 810 and 980 nm cause increase of temperature of SLA titanium implants above the critical threshold (10 °C) just after 10 s of irradiation at 2 W and 60-s application time, whether in CW or in PW. Two studies investigated that the distance between the laser tip and the surface and the type of implant play a role in the effectiveness on the implant surface, where Giannelli et al. [49] observed that an 808-nm diode laser in PW (10–45 μJ, 20 KHz and 5–20 μs pulse duration) or CW (0.5–2 W) causes an increase of temperature in non-contact mode but it cause surface alteration in contact mode for titanium implant surfaces, but Kushima et al. [50] found that 808-nm diode laser increase the temperature without alteration of zirconia and titanium implant surfaces in contact mode at 1 W for 20-s duration time and 100-ms pulse duration, 50 Hz and 600-μm fiber tip. Castro et al. [46] found that a 980-nm diode laser did not modify the titanium surface of dental implant with continuous saline cooling, but without stating clear values on which to base it, where they said from one side that the energy power of the device is 2 W (it should be a power, not energy power) and use it in pulse wave mode and in non-contact (the distance between the tip and the implant surface was kept at 2.5 mm) but on the other side, they said that the titanium implant had irradiated with two parameters. The first one was 1 W, 60 s, non-pulsed (that means CW) and in contact mode (0 mm distance). The second one was 15 W (where a device power is 2 W, it may mean 15 J as a total applied energy!), 60 s, CW. It is not clear and there are contradicts between the device values and the values which had been used on the implant surfaces in this study.

From above, we can say that diode lasers are an effective adjunctive tool in treatment of peri-implantitis in combination with a conventional therapy, whereas a conventional therapy cannot remove a bacteria completely and effectively alone. The best settings concluded from the reviewed articles for treatment of peri-implantitis without any negative effect on the surrounding soft and hard tissues and on the implant surfaces according to the authors are 810 nm in non-contact continuous mode (that means the procedure must be in a surgical approach to get a good field for peri-implantitis treatment especially between implant threads) at 1 W for 20 s five times with 30-s pause and 600-μm fiber tip or 810 nm in PW at 1 W, 50 Hz, 100-ms pulse duration and 30-s application time (2 times for each side). So, we can note that 810-nm diode laser with a low average power and appropriate irradiation time treats the peri-implantitis without affecting the surrounding tissues or alteration of the implant surfaces, but when we increase an average power to 2 W, then the irradiation time must be not more than 10 s due to the possible of thermal damage.

Conclusion

Complete or almost complete elimination of bacteria from the implant surface needed for treatment of peri-implantitis without increase of temperature or surface characteristic changes of the implant surfaces according to the reviewed vivo and vitro studies can be achieved by using a diode laser 810 nm as adjunctive tool and in combination with a conventional therapy with a power not more 1 W in continuous wave mode for 20 s five times with 30-s pause (after each 20-s application time) or pulse wave mode for 100-ms pulse duration to ensure completely removal of inflammatory signs such as BOP, PD, suppuration, and bone loss, whereas a conventional therapy can not eliminate a bacteria completely and effectively alone.

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of Periodontology and Preventive Dentistry, Faculty of DentistryAl Asmarya UniversityZlitenLibya
  2. 2.Department of Conservative Dentistry, Periodontology and Preventive DentistryRWTH Aachen University HospitalAachenGermany

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