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Table of Contents
ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 3  |  Page : 167-173

A comparative analysis of staining characteristics of mouthrinses on provisional acrylic resin: An in vitro study


Department of Prosthodontics, Crown and Bridge. K.M Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Gujarat, India

Date of Web Publication21-Apr-2014

Correspondence Address:
Paranjay Prajapati
Department of Prosthodontics, Crown and Bridge. K.M Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.131213

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   Abstract 

Aim and Objective: Provisionalization is essential for tooth protection and treatment outcome evaluation. Utmost care should be taken to maintain the soft tissue health when provisionals are cemented. Mouthrinses are commonly used as an adjunct to protect against caries and periodontal diseases. Thesesolutions are responsible for discolouration of provisional materials. In the present study, the aim is to assess the staining potentials of a chlorhexidine gluconate rinse, a benzydamine hydrochloride rinse and a tea tree oil rinse on a provisional acrylic material in vitro by application of a digital system for colour analysis Materials and Method: In this study, the staining potentials of a tea tree oil, a chlorhexidine gluconate rinse, and a benzydamine hydrochloride rinse was investigated; whereas distilled water was used as the control. Results: Color change of a commercially available provisional restorative material was evaluated after 24 hours immersion in three different mouthrinses. ∆E values obtained were 1.76 for chlorhexidine gluconate, 1.55 for benzydamine hydrochloride and 1.88 for TTO. Conclusion: Within the limitations of the current study, it is concluded that benzydamine hydrochloride exerts the least perceptible change in colour of bisacryl composite provisional resin material.
Clinical Relevance to Interdisciplinary Dentistry

  • Dentistry today is vastly different from what it was before.
  • Today it is in the era of interdisciplinary approach from independent to interdependent.
  • It is more result oriented and more successful when any case or situation is handled combined by interdisciplinary experts.
  • Action and role of mouthrinses and their interdisciplinary outcome is evaluated in the present study.

Keywords: Benzydamine hydrochloride, chlorhexidine gluconate, mouth rinses, provisional restorations


How to cite this article:
Patel A, Sethuraman R, Prajapati P, Patel J, Naveen Y G. A comparative analysis of staining characteristics of mouthrinses on provisional acrylic resin: An in vitro study. J Interdiscip Dentistry 2013;3:167-73

How to cite this URL:
Patel A, Sethuraman R, Prajapati P, Patel J, Naveen Y G. A comparative analysis of staining characteristics of mouthrinses on provisional acrylic resin: An in vitro study. J Interdiscip Dentistry [serial online] 2013 [cited 2020 Jul 3];3:167-73. Available from: http://www.jidonline.com/text.asp?2013/3/3/167/131213


   Introduction Top


A provisional restoration provides protection, stabilization, and function before fabrication of the definitive prosthesis. It may also be used to determine the aesthetic, functional, and therapeutic effectiveness of a treatment plan. The topic of Provisionalization has been a subject of research ever since it was introduced and has increased with advances in materials and techniques. For years the need to place provisional restorations after preparation of teeth has been followed and reiterated. However, the maintenance of provisional restorations must be done in a way similar to the definitive restorations, for often it is seen that the abutment and the periodontium undergo regressive changes if these restorations are not taken care of. Provisional restorations are kept in the oral environment for several days, even months until the preparation of the permanent restorations as in cases of full mouth rehabilitation or when a complete mouth periodontal crown lengthening procedure has been performed. It is very important to maintain the health of periodontium and prepared teeth. Provisionalization has interdisciplinary role in on maintenance of oral health. Therefore, they should be both aesthetically and physically durable in order to meet the needs of the patient in the mean time. [1] Color stability is one of the substantial qualities of these materials, [2] and the in-service discoloration is considered as a major shortcoming of provisional restorative materials. [3] Dietary factors and medications are commonly reported among the agents that cause decolorization of the restorative materials. [2],[4],[5],[6],[7],[8]

Mouthrinses are mostly used reduce the local inflammation and tenderness and to hasten the mucosal healing. [9],[10],[11] However, extrinsic staining of teeth has emerged as an unpleasant effect of some common brands of mouthrinses. [12],[13] Chlorhexidine gluconate is a cationic oral antiseptic agent with bactericidal activity and acts by destabilizing and penetrating in bacterial cell membranes. It has been widely used due to its' antiseptic and antimicrobial effects in oral and dental diseases. [14],[15],[16],[17] On the other hand, its well-known staining potential is also documented as its major complication. [12],[18],[19],[20],[21],[22] Benzydamine hydrochloride is an indazole nonsteroidal anti-inflammatory drug (NSAID) with analgesic, antipyretic, and anti-edema properties. Unlike other NSAIDs, benzydamine hydrochloride does not inhibit cyclooxygenases, but stabilizes membranes, resulting in local anesthesia; inhibits the production of pro-inflammatory cytokines, the generation of reactive oxygen species by neutrophils, leukocyte aggregation and adhesion; and exhibits antimicrobial properties. [23],[24],[25],[26] The recent decade has envisioned the use of naturopathy in dental treatment and the use of TTO has been suggested for use as a mouthwash. It basically contains terpene hydrocarbons, mainly monoterpenes, sesquiterpens, and their associated alcohols. TTO includes antibacterial, antifungal, antiviral, and antiprotozoal activities. [27]

Color determination in dentistry can be divided into two categories: visual and instrumental. Visual color determination by comparison of a patient's tooth color with a color standard is the most frequently applied method in clinical dentistry. [28] However, visual determination of shade selection has been found to be unreliable and inconsistent and is a continuing problem in dentistry. [29] Hence, there is a need for a more scientific and consistent means of shade matching in restorative dentistry. [30] Since their introduction to dentistry, spectrophotometers and colorimeters have been used primarily in research and not in clinical practice.

Instrumental color analysis offers a potential advantage over visual color determination because instrumental readings are objective, can be quantified, and are more rapidly obtained. It is possible to quantify color by using instrumental measurements expressed in the coordinates of a color order system. [31] CIELAB units, which when analyzed mathematically compares the color parameters of different objects, have been used for color quantification. [32] In CIELAB system, the color space consists of three coordinates L*, a*, and b *. The L* refers to the lightness coordinate, and its value ranges from 0 for perfect black to 100 for perfect white. The a* and b* are the chromaticity coordinates in the red-green axis and the yellow-blue axis, respectively. Positive a* values reflect the red color range and negative values indicate green color range. Similarly, positive b* values indicate yellow color range while negative values indicate the blue color range. [33] The differences in the lightness and chromaticity coordinates (∆L*, ∆a*, ∆b*) as a result of UV light exposure are determined first, [33] and the total color change (∆E*ab) can be calculated using the following relationship: [31] ∆E* ab = (∆L* 2 + ∆a* 2 + ∆b* 2 ) 1/2 .

The staining potentials of various mouthrinses have already been established. [13],[14],[19],[20],[21],[22],[23] Up to date, the staining properties of mouthrinses have been established by using spectrophotometric analyses; nevertheless, the literature about this detrimental effect on provisional restorative materials is limited especially with tea tree oil mouthwash. In the present study, the aim is to assess the staining potentials of a chlorhexidine gluconate rinse, a benzydamine hydrochloride rinse and a tea tree oil rinse on a provisional acrylic material in vitro by application of a digital system for color analysis


   Materials and Methods Top


In this study, the staining potentials of a tea tree oil (TTO) (Emoform, potassium nitrate 1.25% w/v), a chlorhexidine gluconate (CHX) rinse (chlorhexide mouthwash B.P 0.10%, Hexidine ICPA), and a benzydamine hydrochloride rinse (Benzydamine mouthwash B.P 0.15% w/v Tantum oral rinse) was investigated, whereas distilled water was used as the control [Figure 1]a.
Figure 1: (a) Mouth rinses as test solution and distilled water as control, (b) Preparation of test specimens, (c) Pro-filo meter used in the study

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Preparation of specimens

Plastic discs 13 mm in diameter and 1 mm in thickness was luted on a slab of dental stone. A vacuum form sheet of 1.5 mm thickness was adapted on it . The vacuum form sheet was separated from stone and plastic discs were removed from it. Separating medium was applied to the stone slabs and in the wells of the vacuum form sheet. The provisional acrylic resin (Cooltemp {Bis-acryl resin based material}, Coltenewhaledent) was manipulated as per the manufacturers' instruction and it was loaded into the wells of the vacuum form sheet and cured. The provisional acrylic specimens were prepared by using the single shade (A1) of acrylic resin material used for temporary crowns and bridges as the provisional restorative material [Figure 1]b. The specimens were finished and polished using composite polishing kit (Compomaster finishing and polishing kit) and evaluated under a profilometer (SJ-102P, Mititoyo, Japan)[Figure 1]c] for surface roughness. Samples with a mean Ra value of 0.15 ± 0.05 μm were included for the study Before immersing the specimens in the mouthwashes, pre-treatment photographs were taken.

Immersion of specimens

The acrylic samples were randomly selected and immersed separately in vials, each containing 20 ml of the test or control solutions for 12 h, which was the equivalent time to 1 year of 2 min daily mouthrinse use [7] [Figure 2]a. All vials were kept at 37°C throughout the study were shaken occasionally to provide homogenity. At the end of the test period, the samples were removed and dried with tissue paper.
Figure 2: (a) Immersion of test specimen in mouth rinses and control solution, (b) specimens after immersion in test solutions PLACED ON black cardboard surface in order to acquire digital images: (c) use of Adobe Photoshop 6.0 for staining evaluation

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Digital photography

All specimens were placed on a black cardboard surface in order to acquire digital images, as suggested by Okubo et al. [32] [Figure 2]b. A white standard photograph paper was also used with the specimens as a calibration material to eliminate the environmental factors. A digital camera (Nikon 18 X optical zoom) was fixed on a tripod, with a 40 cm object-camera distance. This was oriented perpendicular to the test samples to acquire the digital images. The image was taken at 11:00 AM, on a clear day, saved in the TIFF format, and was later resolved on a 24-bit resolution screen for further analysis using a commercial graphic software (Adobe Photoshop 6.0††) [Figure 2]c.

Analysis of CIE Lab values

During the analyses, fixed circular areas with 74 pixels in diameter were selected in the middle third portion of each sample. The L*, a*, b* values of these areas were measured three times by application of the histogram function of the software, and the mean values were recorded. These values were divided by the L*, a*, b* values of the adjacent white photograph paper in order to eliminate the potential effects of the environmental factors, and the 'corrected' L*, a*, b* values of each specimen were recorded as the baseline color readings.

The post-treatment digital images of the test materials were obtained and analyzed to determine the L*, a*, b* values of each specimen as mentioned previously. The total color change (∆E*) of each single test specimen was then calculated using the relationship: [31]

∆E* ab = (∆L* 2 + ∆a* 2 + ∆b* 2 ) 1/2

The ΔE values were also expressed as National Bureau of Standards (NBS) units by the following formula in order to quantify the color changes according to this system: NBS unit = ΔE × 0.92. the interpretation of the NBS values are 0.0-0.5 for Trace, 0.5-1.5 is Slight, 1.5-3.0 is Noticeable, 3.0-6.0 Appreciable, 6.0-12.0 Much and if it is >12 indicates Very much.


   Observation and Results Top


Observation

∆E values of the control and test mouth washes are given in [Table 1].
Table 1: ÄE values of the control and test mouth washes


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The mean ∆ E values of samples immersed in chlorhexidine gluconate and benzydamine hydrochloride containing rinses were 1.76 and 1.55, respectively. The tea tree oil samples show a ∆E value of 1.88, which is very close to the mean of the ∆E value of the other two rinses.

Statistical analyses of the mean ∆ E values among the groups will be achieved by analysis of variance (ANOVA), and Tukey's tests. The level of significance was be set as 0.05 in all tests. The summary statistics of the comparison of the ∆ E values of the different groups is presented in [Table 2]. Calculated NBS values are tabulated in [Table 3]. Results of ANOVA test shows a statistically significant difference between the groups (P < 0.0001) [Table 4].
Table 2: Summary statistics of the comparison of ÄE values


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Table 3: NBS values


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Table 4: ANOVA test statistic


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Modified Tukey's test applied to confirm the significance level between the groups showed a significant difference between all the three mouthwashes when compared with water (P < 0.01) and between the mouthwashes (P < 0.01) test result of this is presented in [Table 5].
Table 5: Modified tukey's test result


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The results though show a statistically significant difference between the different mouthwashes however observation of the mean values shows that the samples immersed in tea tree oil show greatest color change among the three mouthwashes.


   Discussion Top


Provisional restorations provide protection, stabilization, and function before fabrication of the definitive prosthesis. It may also be used as diagnostic aids when correcting irregular occlusal planes, altering vertical dimension of occlusion, or planning for changes in the location and contour of the gingiva or the size, shape, and color of definitive restorations. [34],[35] The prognosis of a fixed prosthodontic restoration depends on the quality of this provisional restoration. Color stability of provisional materials is a concern, particularly when the provisional restoration is in the esthetic zone and must be worn for extended periods of time. Ideally, provisional materials should not change in color or appearance subsequent to fabrication. Materials available for fabricating provisional restorations include auto polymerizing polymethyl methacrylate, polyethylene methacrylate, polyvinyl methacrylate, urethane methacrylate, bis-acryl, and microfilled resin. These materials can be polymerized by chemical, light, or both chemical and light activation of these materials. Bis-acryl is used in this study because of its wide use in dentistry today. Bis-acryl composite contains Bis-GMA (bisphenol A-glycydyl methacrylate) resin matrix. The Bis-GMA molecule used in bis-acryl resin composites has a rigid central structure that reduces its ability to rotate and participate in the polymerization process. Materials that contain this molecule as its major component might be less influenced than other resins during the polymerization process. In addition, the better color stability of bis-GMA can be explained by the fact that bis-acryl resin composite materials contain bifunctional acrylates with cross-link to provide increased mechanical strength and resistance to weakening and stainability in the presence of solvents. Discoloration of provisional restorative materials for fixed prosthodontics may lead to patient dissatisfaction and additional expense for replacement. This is particularly problematic when provisional restorations are subjected to prolonged exposure to colorants during lengthy treatment. The degree of color change can be affected by a number of factors, including incomplete polymerization, water sorption, chemical reactivity, oral hygiene and surface smoothness of the restoration. Saliva, food components, different drinks, beverages and mouthrinses may affect the color of provisional restorations. Recently, mouthrinses have become popular. Besides being an effective caries and gingivitis control method, and topical relief measure in oral lesions, people tend to use mouthrinses for social and cosmetic reasons. However, frequent mouthrinse use may exert detrimental effects on oral and dental tissues but studies about their effects on restorative materials are limited. Chlorhexidine gluconate is a cationic oral antiseptic agent with bactericidal activity and acts by destabilizing and penetrating in bacterial cell membranes. It has been widely used due to its antiseptic and antimicrobial effects in oral and dental diseases.(Chlorhexidine gluconate 0.2% w/v, Propylene glycol, Menthol, Flavor, Color.) Benzydamine hydrochloride is an indazole nonsteroidal anti-inflammatory drug (NSAID) with analgesic, antipyretic, and anti-edema properties. Unlike other NSAIDs, benzydamine hydrochloride does not inhibit cyclooxygenases, but stabilizes membranes, resulting in local anesthesia; inhibits the production of pro-inflammatory cytokines, the generation of reactive oxygen species by neutrophils, leukocyte aggregation and adhesion; and exhibits antimicrobial properties. [24],[25],[26],[27] Benzydamine hydrochloride BP 0.15% w/v, alcohol IP 10% w/v, tartrazine and brilliant blue FCF). TTO is a complex mixture of hydrocarbons and terpenes, consisting of approximately 100 components. The concentration of each component can vary strongly in different preparations, which may also influence their antibacterial activity. Today, TTO is a component of numerous products for oral hygiene, including toothpastes and mouthrinse solutions, and is said to be an effective agent against dental plaque. Therefore, it was included in the study. (Tea tree oil 0.22% w/v, sodium bicarbonate, sodium sulfate, sodium chloride, potassium nitrate 1.25% w/v, potassium sulfate, quinoline yellow ws, Brilliant blue FCF, ethanol IP 6% w/v). In assessing chromatic differences, two of the most frequently used color systems are the Munsell and the Standard Commission Internationale de L'Eclairage (CIE Lab). Colorimeters often report color using the CIELabcolor system, which is a method developed in 1978 by the Commission Intèrnationale de l'Eclairage for characterizing color based on human perception. It designates color according to three spatial coordinates, L*, a* and b*, where L represents the brightness (value) of a shade, a* represents the amount of red-green color, and b* represents the amount of yellow-blue color. Absolute measurements can be made in L* a* b* coordinates and color change calculated as ΔE (L*a*b*). In principle, if a material is completely color stable, no color difference will be detected after its exposure to the testing environment (ΔE = 0). Thickness and smoothness of the specimen surface also affect color. In the present study, provisional material specimens were prepared at standard thickness of 13/1 mm standardized by the vacuum formed template. For color measurement a specially constructed mould was fabricated for each specimen to eliminate any contact with the resin-composite restorative materials. The specimens were packed against a vacuum formed matrix to minimize the oxygen inhibition layer (Finger and Jorgensen, in 1976), and to obtain the smoothest possible surface (Dietschiet al., in 1994; Yap et al., in 1997; Stoddard and Johnson, in 1999). Before initial color measurement, surface roughness of samples was measured with a profile meter. All roughness values of samples were smaller than 1 μm. Also, Chung stated that surfaces appear optically smooth when their roughness is smaller than 1 μm. Investigator bias was also removed by the use of random allocation of the samples to the test of control solution. Provisional restorative materials were immersed in different mouthrinses for 24 h in this study. This period (24 h) is set as the proper length of time to determine the effect of 1-year use of two times daily mouthrinse. Each sample was then evaluated for color change. This can be done by various computer-assisted image color analyses. In this study digital shade analysis systems have been administered using a commercial graphic software adobe Photoshop 6.0.The literature indicates that with visual inspection there is another threshold regarding the color stability of materials. This threshold is considered to be at higher levels of ΔE* and justifies the clinical acceptability of stained materials. Johnston and Kao evaluated the assessment of appearance match by visual observation and clinical colorimetry and stated that the average color difference between compared teeth rated as a 'match' in the oral environment was 3.7 (ΔE*). Seghi et al. also presumed that an acceptable color difference can often be two or three times greater than the detectable limits. The upper limit of acceptability in subjective visual evaluations has been confirmed by Ruyter et al. and Um and Ruyter, who suggested that a perceptible discoloration must be referred to as acceptable up to the value ΔE* = 3.3. It is reported that approximately one CIELAB unit of color change could be perceived by 50% of the normal human observers, and a ∆ E value greater than 2 is always detectable. However, presuming that an acceptable color difference can be two or three times of the detectable limits, color differences less than 3.7 CIELAB units are generally stated as clinically acceptable. Considering that provisional restorations shall be aesthetically acceptable during in service period, a ∆ E value of 3.7 is recorded as the cut-off point. All test solutions produced clinically acceptable value on the provisional material, with ∆ E values under 3.7.

In the present study, discoloration below or above the value ΔE*=3.7 is referred to as 'acceptable' or 'unacceptable,' respectively. The ΔE values were also expressed as National Bureau of Standards (NBS) units by the following formula in order to quantify the color changes according to this system: NBS unit = ΔE × 0.92. The staining potential of chlorhexidine gluconate has already been reported in the literature. Our results confirmed the results of the studies done by Cal, Guneri and Kose [36],[37],[38] that showed that chlorhexidene containing mouthrinses stained provisional acrylic specimens more than the control. However, according to the result of NBS unit it falls under the noticeable change. ΔE value of benzydamine hydrochloride shows no significant color change but according to the NBS value it falls in slight change. Tea tree oil shows noticeable change as per the NBS value. Mouthrinse factors that can affect the color stability of provisional resins are two, namely: composition of the mouthrinse and coloring material incorporated in the mouthrinse. Most alcohol-containing mouthrinses have shown color changes in the provisional resin. Alcohol has been attributed to the softening of the polymer matrix, which results in its partial removal from the surface. The partial removal of the resin matrix may result in the degradation of the filler-matrix interface, which can contribute to the decrease in hardness values, [39] and this may be effect the increase color changes. [40] As a result, it may be suggested that mouthrinses with alcohol content may compromise the color stability of the provisional restorations and the clinician should warn the patients regarding the possible effects of alcohol-containing mouthrinses on their provisional prostheses especially if their prostheses are expected to function over an extended period of time. Of the three mothrinses used in the study, benzydamine hydrochloride and tea tree oil contain alcohol as 10% and 6% w/v, respectively. The fact that benzydamine hydrochloride contains more alcohol content should relate to more color change in the samples immersed in this mouthrinse and less color change in the samples immersed in tea tree oil. But this was not observed in the study as tea tree oil specimens exhibited more color change as compared to benzydamine hydrochloride specimens. Thus, the color change may be attributed to the type of colorant used in the two mouthrinses. Benzydamine hydrochloride contains methyl parahydroxy benzoate and tea tree oil mouthrinse contains potassium nitrate. As Brilliant blue is common to both the mouth rinses the possible component that causes more color change may be quinoline yellow ws.

As already stated most mouthwashes have an effect on the hardness of the provisional resins. The effect of more color change seen with samples immersed in tea tree oil may also be due to alteration of the surface of the resin samples by tea tree oil. But no studies exist in the literature till date to explain the effect of tea tree oil on surface hardness of provisional resins. Hence, future studies should be directed toward evaluating the effect of tea tree oil on hardness of provisional resins.

The effect of chlorhexidene mouthwash in comparison to benzydamine hydrochloride is significantly more as seen by the NBS value interpretation. However, this effect was larger than with benzydamine hydrochloride as against non-significant difference as seen in the study by Cal et al. The only explanation that suits this situation would be the type of provisional resin material used in the two studies. The present study used bis-acryl composite as against acrylic resin used by Cal et al. Most studies have indicated that resin mouthwash combination also affects the color stability. Hence, it may probably mean that chlorhexidene does not affect acrylic resin to the amount that it does with bis-acryl composites.

Hence, benzydamine hydrochloride may be a suitable mouthwash to be used in combination with both acrylic resin and bis-acryl composite provisional resins. In clinical conditions, effective patterns of mouthrinses on provisional materials may be different depending on many factors that could not be replicated in vitro. Saliva, salivary pellicle, foods and beverages consumed may have additive or mitigating effects on the physical and aesthetic properties of this group of restorative materials. Color stability is only one variable that must be considered when choosing a provisional material, but it may be of great importance to patients and clinicians when working in the esthetic zone. Studies are therefore necessary to determine the effect of tea tree oil mouthwash on other properties as well as on other types of provisional acrylic resin and also to evaluate the effects of mouthrinses in vivo.


   Conclusion Top


Color change of a commercially available provisional restorative material was evaluated after 24 h immersion in three different mouthrinses. ∆E values obtained were 1.76 for chlorhexidine gluconate, 1.55 for benzydamine hydrochloride and 1.88 for TTO.

According to the results of the present study, effects of the mouthrinses on the color change of the materials were statistically different from that of control solution. The resin restorative materials showed color difference after immersion in tested solutions but these differences were perceptible with chlorhexidine and TTO mouthwash. Within the limitations of the current study, it is concluded that benzydamine hydrochloride exerts the least perceptible change in color of bis-acryl composite provisional resin material.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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