Temporomandibular disorders associated with orotracheal intubation procedures: a narrative review

Introduction

Temporomandibular disorder (TMD) is a term that describes a collection of painful and non-painful disorders related to alterations in the structure, function, or physiology of the masticatory system that can be associated with other systemic and comorbid medical conditions (1). These conditions are known to cause pain and disability in the general population and can become chronic if left untreated (2). The prevalence of TMD has been estimated to be between 4.8–16.2 percent among the adult general population in the United States and worldwide (1-5). The incidence of TMD in the United States has been reported at 4%, with a 19% incidence of subclinical TMD symptoms that exponentially increases upon annual follow-up over subsequent years (6). Pathoanatomically, TMDs can be classified as involving the muscles of mastication, temporomandibular joint (TMJ) structures including the intraarticular disc and joint capsule, or a mixture of muscle and joint involvement (1). Diagnostic criteria exist to help guide clinical diagnosis and research in the field (7,8). However, beyond mechanical issues, the pathophysiology of TMD is biopsychosocial and multifactorial (1).

Known risk factors for the development of first onset TMD or exacerbation of existing TMD include direct trauma or activities that overstress local tissues (e.g., yawning and dental procedures) (9,10), and a history of jaw locking (11). Such trauma can also include orotracheal wide diameter jaw opening associated with intubation and extubation procedures (12). Specific guidelines have been identified by the American Society of Anesthesiologists regarding the management of a difficult airway for intubation procedures (13), but there is no existing clinical guideline regarding strategies to reduce the risk of intubation related TMD. A difficult airway may include individuals with structural issues that can make intubation or extubation activities more difficult such as limited jaw opening prior to surgery (13). However, oral intubation, even when performed not in the case of suspected difficult airway, may cause trauma to the masticatory system since it is associated with wide diameter, sustained jaw opening, two factors which have been associated with the development of jaw pain (12,14). TMD risk may also be higher in some individuals undergoing non-maxillofacial surgical procedures that involve general anesthesia and sedation. There have been sporadic reports in the literature of jaw dislocation associated with anesthesia use during non-maxillofacial surgical procedures independent to the use of orotracheal intubation, possibly because of reduced masticatory muscle tone under sedation (15-18).

It is unclear what the specific risk incidence is related to the development of first onset TMD or exacerbation of existing TMD associated with orotracheal intubation, and how this risk could be mitigated. The general lack of awareness or standardization regarding TMD prevention leaves anesthetist providers clinically siloed and unprepared to problem-solve this issue. Negative consequences could include functional limitation and decreased quality of life for patients, for which the provider could be held liable. The aim of this narrative review is to summarize incidence of and provide clinical guidance concerning the development of first onset TMD or exacerbation of existing TMD following orotracheal intubation or extubation anesthetic procedures. Clinical recommendations for screening, prevention, and management of pain-related TMD for patients undergoing orotracheal intubation procedures will be discussed. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-23-38/rc).

Methods

A literature search was performed to guide this narrative review in November 2023 of Medline (EBSCO), CINAHL (Cumulative Index to Nursing and Allied Health Literature) (EBSCO), DOSS (Dentistry and Oral Science Source) (EBSCO) and Cochrane CENTRAL (Central Register of Controlled Trials) (EBSCO). Search terms included “Temporomandibular Joint Diseases+, Temporomandibular Joint Syndrome, Temporomandibular Joint, Sedation, Intubation, Extubation, Postoperative Complications OR Intraoperative Complications OR Treatment Complications, Delayed”. See Table 1 for the specific databases, terms, and criteria used for the literature search with inclusion and exclusion criteria. The Table S1 provides an example of the detailed search strategy of a database. The search produced 90 potential papers related to TMD complications associated with orotracheal intubation or extubation which reduced to 81 papers following title and abstract screening (Figure 1). Following full text review this was reduced to 13 papers.

Figure 1 Summary of search strategy results, screening, and exclusion criteria. CINAHL, Cumulative Index to Nursing and Allied Health Literature; DOSS, Dentistry and Oral Science Source; CENTRAL, Central Register of Controlled Trials; TMD, temporomandibular disorder.

Results

First onset TMD associated with orotracheal intubation

Twelve of the 13 identified papers were case report (19-25) or cohort studies (12,26-29) and 1 paper was a systematic review (30). Across included studies, 7 patients contributed data to case reports and 956 patients to cohort studies. Table 2 details the demographics of these patients, surgical type, TMD subtype and TMD symptoms if known. Four included cohort studies examined the development of TMD symptoms following intubation (Table 2). Agrò et al. (26) reported a 5% incidence of first onset TMD in a small cohort of 68 patients examined for TMD signs and symptoms before and after surgery. This is similar to results from a larger three-year prospective cohort study of five hundred ninety-five patients by Ângelo et al. (27) who reported that 4% of patients developed TMD symptoms following intubation. To put this number in perspective, 6% of the cohort developed TMD symptoms following jaw trauma and 19% following wisdom teeth removal. Within the intubation group, there was a weak association between a limitation of mouth opening and past intubation, but no association between intubation and TMJ pain, joint clicking or crepitus, and myalgia or arthralgia on clinical examination (27).

In contrast, Rodrigues et al. (29) in a sample of 100 patients undergoing orotracheal intubation during scheduled surgery reported an incidence of 8% for the development of one specific form of TMD, anterior disc displacement with reduction (DDWR), and a 10% incidence of development of articular sounds following intubation. They calculated a risk ratio of 0.73 [95% confidence interval (CI): 0.54–0.99] for the development of DDWR and 0.80 (95% CI: 0.57–1.13) for the development of joint sounds following intubation in their sample (29). These numbers suggest that while intubation is not a top risk factor for the development of TMD, a small subset of patients will develop TMD symptoms with intubation. Further investigation to understand the factors that may drive this and mechanisms to prevent it are needed.

Talaván-Serna et al. (30) conducted a systematic review of temporomandibular damage directly related to general anesthesia and sedation. The majority of the included 28 studies were case reports and case series. General anesthesia with intubation was addressed in 4 non case report analytical studies available in English (12,26,29,31). Complications related to TMD and intubation in those studies ranged from joint dislocation, subluxation, jaw locking, disc displacement, joint sounds, reduced mouth opening and condylar resorption (30). The majority of joint dislocations were found to occur during intubation (30) although it should be noted that there have been isolated case reports of condyle dislocation during extubation procedures also (25). Several other single case reports detail development of TMD problems with intubation activities including inability to open the mouth (19,20,24), facial pain (20), development of joint clicking (24) and joint changes (21). In the case of Mareque Bueno et al. (21), development of significant structural changes in the TMJ may have been linked to difficult intubation during surgery and it resulted in the need for a total joint replacement.

A prospective cohort study (29) examined the potential for development of one specific form of TMD, DDWR and identified 8/100 patients who developed signs and symptoms consistent with DDWR, specifically pain and a reciprocal click on opening and closing. Ten out of 100 patients developed non-classifiable joint sounds post intubation, although if these sounds were associated with pain was not specified (29). Non-painful joint sounds alone can be present in individuals without TMD and are not pathological by themselves (11). The multiyear Orofacial Pain: Prospective Evaluation and Risk Assessment project identified that around 60% of TMD cases and 30% of controls reported noises in either TMJ (11). Martin et al. (12) did not find a relationship between intubation duration and TMJ symptoms in a prospective cohort study of 122 patients. They did find that pre-surgical interincisal distance inversely correlated with TMD pain at 7 days post-surgery but not at 14 days post-surgery (12). Taken together, the results of these studies support a risk for the development of novel TMD symptoms in patients without previous history of TMD who undergo intubation procedures. These symptoms may range in severity from the development of non-painful joint noises to structural changes requiring surgical intervention. Given this, it seems feasible that an existing history of TMD symptoms in patients undergoing intubation procedures might increase the incidence of TMD related complications.

Exacerbation of pre-existing TMD following orotracheal intubation

Less has been reported linking intubation to exacerbation of pre-existing clinically established TMD. Battistella et al. (28) compared the incidence of signs and symptoms of myalgic TMD in elective surgery patients who underwent orotracheal intubation compared to patients without intubation. A small proportion of both groups screened positive for TMD signs or symptoms pre-surgically, but despite this, there was no difference between groups immediately post surgically or at 3 months post-surgery in the development of signs and symptoms of TMD. In contrast, Agrò et al. (26) reported worsening of symptoms in 44% (95% CI: 13.6–78.8%) of nine patients who had a documented functional disturbance of the TMJ prior to intubation. The difference in findings between Agrò et al. (26) and Battistella et al. (28) may lie in the clinically confirmed TMD signs and symptoms in Agrò et al. (26) compared to patient remembered presurgical symptoms in the study by Battistella et al. (28).

One case report by Liang and Lagasse (20) detailed a case of exacerbation of pre-existing TMD following oral intubation that ultimately ended in litigation. In that case, the patient reported a history of TMJ symptoms prior to surgery and requested nasal intubation rather than oral intubation which was not accommodated by the anesthesiologist. The patient subsequently reported increased face pain and filed a claim of medical battery against the anesthesiologist. Martin et al. (12) in their prospective cohort study found that the most reliable predictor of TMD pain post-surgery was a history of TMD pain either without or without headache within a year preoperatively. Taken together, these studies suggest that clear pre-surgical TMD screening guidelines are needed to help anesthesiologists make informed decisions about pursuing oral intubation versus consideration of other techniques such as nasal intubation to avoid prolonged wide diameter mouth opening that can occur during oral intubation procedures.

Discussion

Pre-surgical screening for TMD

Including the TMJ in the pre-operative airway assessment could identify potential problems and help reduce the risk of developing TMD after intubation. Updated guidelines for the management of the difficult airway by the American Society of Anesthesiologists (13) include noting anatomical measurements and landmarks pre-surgically but these guidelines do not specifically mention screening for risk of developing TMD. Some suggested clinical signs of a difficult airway include a modified Mallampati score of greater than II, limited neck mobility with head extension <90°, decreased jaw protrusion classified by a score of III on the upper lip bite test, limited mouth opening <3.5 cm, decreased thyromental distance <6.5 cm, and decreased sternomental distance <12.5 cm (32). However, it is unclear if these standard risk factors included in a difficult airway assessment specifically identify a risk for development of TMD with intubation and extubation procedures. For example, examining limited mouth opening and protrusion only assesses TMJ mobility but leaves joint pain, muscle pain, or the presence of an intraarticular TMJ disorder unaddressed.

There is no accepted standard of practice for comprehensive TMJ assessment by anesthetists. A 2020 survey of 108 anesthetists in Florida by Gadotti et al. (14) revealed that 25% of anesthetists were unaware that orotracheal intubation could cause or worsen TMD. Of the 72% who reported consistently screening the TMJ, screening methods used were maximal mouth opening measurement (45% of the sample) and/or TMJ pain assessment via history (31%) or palpation (11%) (14). Reliable and valid TMJ screening methods are required, especially since interobserver reliability of visualizing mouth opening and determining the modified Mallampati score (33) and does not give information about intraarticular TMJ disorders or painful TMD.

The gold standard for TMD diagnosis is the Diagnostic Criteria for TMD (DC/TMD) (7) but it would be burdensome and impractical for anesthetists to use this tool in clinical practice. Battistella et al. used the 10-question American Academy of Orofacial Pain screening questionnaire for pre- and post-surgical TMJ assessment in their randomized controlled trial (28) though no metrics were presented for the scale. The shorter TMD Pain Screener (TPS) has six questions and has high sensitivity (99%) and specificity (97%) for identifying painful TMD (34) although it does not assess for the presence of intraarticular TMJ disorders. The DC/TMD 14-item symptom questionnaire (7) investigates 5 symptoms of TMD (5Ts): TMD/facial pain, headaches, jaw noise, and both forms of TMJ locking (Table 3). Yap et al. validated the 5Ts as a screening questionnaire and found high sensitivity (96.2%) and specificity (100%) for identification of all forms of TMD (35). The 5Ts screen is positive for TMJ compromise if any one of the five questions are answered positively and is negative if all answers are negative. This short screen covers pain and intraarticular symptoms and combined with current practice recommendations of measuring interincisal opening and assessing protrusion, the 5Ts would allow for comprehensive and efficient TMD screening. Future research to examine how screening for TMD specifically alters risk of development of TMD symptoms following oral intubation procedures is needed. At a minimum, documenting TMD screening pre-surgically may protect the anesthetist liability related to the development of post-surgical TMJ related complications.

Prevention and management of TMD associated with orotracheal intubation procedures

There are accessible strategies that can help prevent and manage first onset or exacerbation of pre-existing TMD related to orotracheal intubation procedures. Implementing pre-surgical TMJ screening should be accompanied by patient education related to the risk of developing TMD symptoms post-surgically. Anesthetists routinely consider the most appropriate anesthetic strategy for each surgical case, but the addition of complementary interventions to reduce the risk of developing TMD after intubation may be appropriate for some patients. From the 2020 Gadotti et al. survey of Florida anesthetists, only 18% of the sample reported that they inform patients about the risks of intubation for the TMJ, and while 72% reported screening the TMJ, only 56% reported using alternate techniques when the TMJ is compromised (14). The incidence of first onset TMD could be decreased by implementing pre-surgical patient education related to post operative pain particularly for individuals with preexisting TMD. Additionally, specific interventions could be employed pre-surgically to minimize the risk of development of TMD and improve patient satisfaction with their surgical care.

Patient education

Pre-surgical patient education including a discussion about risks associated with anesthesia is standard of practice. However, education on the specific risk of developing TMD symptoms when orotracheal intubation is employed is important to include especially if patients are screening positive for TMD or have a prior history of TMD. Anxiety is a known comorbidity in TMD (5) and traditional biomedical education focusing on anatomy and biomechanics can increase fears about surgical outcomes and negatively affect surgical outcome (36,37). Implementing specific pain education strategies can address some of the factors that contribute to patient anxiety and fear by empowering patients and introducing coping strategies to self-manage post-surgical pain.

Pain neuroscience education (PNE) is an interventional educational approach that focuses on educating individuals with chronic pain beyond the traditional biomechanical model of pain or local tissue injury (38). It is rooted in an understanding that knowledge is power, and that each person’s pain experience is unique. Teaching a patient why they will hurt post surgically, why their pain may persist, and what can be done for it, is a way to modulate the pain and disability associated with chronic pain conditions (38). Patients with pre-existing TMD may have fears about the prolonged opening necessitated by orotracheal intubation procedures. PNE in this instance would focus on explaining the mechanism of pain and how the patient can help prevent development or exacerbation of pain related to prolonged opening. The provider can involve patients in the discussion by asking how they manage pain for other activities such as dental procedures and by asking about their preferred coping strategies for management. A randomized controlled trial assessing PNE compared to traditional biomedical education in patients undergoing surgery for lumbar radiculopathy revealed a significant improvement in overall function, pain catastrophization, and kinesiophobia in the PNE group compared to the traditional group with improvements lasting after 1 year (36). While the effects of pre-surgical PNE have not specifically been studied in patients with TMD or other forms of orofacial pain, researchers are beginning to investigate it as an intervention in this population. A mixed methods case series by Von Piekartz et al. (39) reported that 8 patients with chronic unilateral facial pain had a significant reduction of their Graded Chronic Pain Scale scores (P=0.03) after multimodal individualized PT including PNE, manual therapy and brain training.

Prehabilitation

Beyond education related to pain, undergoing physical therapy (PT) before surgery when screening positive for painful TMD can address specific pre-existing TMD issues such as pain or reduced mouth opening. Proactive PT before surgery or treatment (known as “prehabilitation”) can improve tissue adaptability and contribute to successful post-intervention outcomes (40). This topic is gaining recent interest with a need for more high-quality evidence investigating its effectiveness, as prehabilitation can empower patients to participate in their care and improve the chances of successful surgical outcome. A systematic review of prehabilitation before knee anterior cruciate ligament reconstruction revealed low to moderate quality evidence of improved knee strength, function, and return to sport that persisted at long-term follow-up after prehabilitation as compared to pre-surgical usual care (40). Full-body prehabilitation including cardiovascular exercise and resistance training before any kind of surgery has been associated with decreased post-surgical pain, shorter lengths-of stay, and improved physical function (41).

Specific to the TMJ, prehabilitation has the potential to improve hypomobility and teach pain management strategies to reduce the risk of developing TMD following intubation, especially when the patient is at risk of developing painful TMD. For example, oral appliance therapy (OAT) for sleep apnea includes overnight use of a device that holds the mandible forward to passively dilate the upper airway, and use of this device has been associated with the development of TMD in some individuals (42). While OAT provides more prolonged exposure to abnormal jaw positioning than orotracheal intubation, both procedures have the potential to injure TMJ structures. A randomized controlled trial of patients performing daily jaw or neck stretches for 1 month prior to beginning overnight use of a mandibular advancement device for sleep apnea revealed significantly less morning pain with function in the jaw stretching group compared to the neck stretching group, leading the authors to conclude that jaw stretching prior to beginning OAT can mitigate the effects of the prolonged strain created by passive airway opening (43). A similar approach could benefit patients scheduled to undergo orotracheal intubation, particularly if they exhibit limited mandibular motion pre-surgically.

The timing of pre-surgical screening must also be considered when prehabilitation is involved. It can take 2–6 weeks to see progress toward therapy goals to gain improvement in range of motion or pain management (40,43). In the systematic review examining prehabilitation before knee ligament reconstruction, average prehabilitation length was 4.8 weeks across all included studies (40). If risk factors for TMD are identified too close to the surgical procedure, there will be insufficient time to see the necessary improvements for risk mitigation in response to preventative strategies. This strategy does not apply in emergency intubation situations, but rather with procedures scheduled with sufficient time in advance. In these situations, screening the TMD at the time of surgery scheduling would be appropriate to identify individuals likely to benefit from early intervention.

Management of post-surgical TMD

The most recent guidelines for management of the difficult airway include recommendations for post-surgical airway assessment with appropriate follow-up, but do not give details regarding options for management (13). Involving PT as part of the interdisciplinary care team has been shown to be an effective management strategy for patients with TMD (1,2), using an individualized treatment plan including patient education, exercises, stretching, manual therapy, and movement retraining strategies to address functional limitations and faulty movement patterns affected by pain or dysfunction. Gadotti et al. (14) suggested anesthetists collaborate with PTs to provide comprehensive care for patients with TMJ compromise. Whether introduced before surgery to improve the response to intubation, or upon post-surgical follow-up if TMJ difficulties arise, interdisciplinary collaboration could improve outcomes while reducing the burden of management on the anesthetist or surgical provider.

An experimental study by Gawade and Schinde (44) assessed the effect of PT in 40 patients diagnosed with TMD post-extubation. After 1:1 randomization to either a treatment group of comprehensive PT for TMD or a control group with medical care and chest PT for 14 days, the treatment group reported significantly less pain than the control group (44). The TMD PT treatment included a comprehensive range of manual therapy, physical modalities, home exercises and stretches. Post-treatment range of motion measurements were all significantly improved in the treatment group, most notably average mouth opening which was 41.5±3.3 mm in the treatment group compared to 34.8±0.57 mm in the control group (P=0.093) (44). While the interventions in that study were not individualized to each participant, the results provide compelling evidence that early intervention upon post-extubation diagnosis of TMD can manage symptoms to prevent progression of pain and future exacerbation of the condition.

Patients are often advised on post-surgical exercises or activities to engage in or avoid via handouts at discharge. However, patient outcomes may differ when supervised exercise or education is used versus unsupervised handout-based approaches, particularly for patients with orofacial pain who have been shown to experience high levels of affective distress, somatic awareness, pain catastrophization, and psychosocial symptoms such as depression, anxiety, and stress (45). A supervised rehabilitation program implemented by a PT post TMJ surgery showed significantly better outcomes for pain at rest and with activity, and improved jaw motion post-surgery compared to a home-based unsupervised exercise program (46). Education and supervision during exercise prescription allows for individualization to patient needs, and an individual approach to PT care for patients with TMD has been shown to have high patient satisfaction and positive outcomes (47). Factors affecting post-surgical satisfaction in individuals undergoing TMJ related surgical procedures have been linked to the degree of patient expectations, the presence of depression in the present or recent past, and the need for further TMJ treatment (48). Thus, for some patients, particularly those at higher risk for developing first onset TMD or those with prior history of TMD or other pain related comorbidities, a different pre- and post-operative strategy using education and supervised PT may be beneficial.

Limitations

This narrative review was limited to articles in English published in the last 20 years, that related to adults only without consideration of special populations. It also excluded surgical procedures involving the TMJ or those that were likely to cause TMD. While this helped to focus the review, it also limits generalizability to pediatric populations or to adult populations with specific conditions such as TMJ ankylosis or those undergoing TMJ surgical procedures or orthognathic surgery where the incidence of TMD problems post surgically is likely to be higher, regardless of anesthetic method used. The quality of evidence was generally low, with only one systematic review, and the remaining studies cohort or case reports.

Conclusions

This narrative review identified key considerations regarding the development of TMD related to orotracheal intubation procedures and management of intubation induced TMD in adults undergoing non-TMJ related surgical procedures. The literature quality is generally low consisting mostly of case studies, four low to moderate quality cohort studies and one systematic review identified for inclusion. Findings suggest the need for higher quality research studying the association between orotracheal intubation and TMD and widespread implementation of TMJ screening tools and management recommendations to direct anesthetist practice patterns and facilitate successful patient outcomes.

While there are low incidence rates of first onset TMD associated with these procedures [4–5% of any TMD (26,27) and 8% for intraarticular TMD (29)], the risk exists and these rates align with the 4% rate of TMD incidence reported in the general population (6). Documented complications related to TMD and intubation ranged from joint dislocation, subluxation, jaw locking, disc displacement, joint sounds, reduced mouth opening and condylar resorption (30). Of concern related to TMD is the potential for symptoms to become chronic if left untreated (2,49). There was less evidence available regarding exacerbation of pre-existing TMD with papers of varied methodology and results, but the maximal and prolonged mouth opening associated with orotracheal intubation and extubation procedures are likely to exacerbate existing TMD.

Appropriate TMD screening prior to using orotracheal intubation during anesthesia delivery is needed, and validated TMD screening tools like the 5Ts screening questionnaire (35) should be implemented. While existing guidelines include some assessment of the TMJ, comprehensive early pre-surgical screening including patient history, palpation, and maximum mouth opening measurement is necessary to cover risk factors for all forms of TMD. Additional consideration may be needed when using orotracheal intubation in individuals who are known to be at risk of developing first onset TMD due to their associated comorbidities or for those with a prior history of TMD. Screening prior to surgery may alter the choice of intubation method or anesthetic procedures if an individual screens positive for TMD, potentially protecting the protect the patient from harm and the medical team from litigation. Screening early, such as when the surgery is first scheduled, would also allow for adequate time to employ education or prehabilitation strategies with a reasonable expectation for success. Future research should specifically investigate the effect of screening on post-operative rates of developing TMD after orotracheal intubation.

Literature consensus recommends that a multidisciplinary biopsychosocial approach is best for managing individuals with TMD. Regardless of association with orotracheal intubation procedures, development of post-operative TMD will be best managed with an interdisciplinary team including surgeons, rehabilitation specialists, and dentists. At-risk patients must be informed about the possibility of developing or exacerbating TMD symptoms after orotracheal intubation, and provider awareness must increase for appropriate patient education to occur. For individuals at risk of developing chronic pain, a PNE approach implemented prior to surgery may be beneficial to address fear and anxiety that can exacerbate TMD. Pre- or post-operative intervention including supervised exercise instruction may be beneficial for some patients, and specific prehabilitation may be appropriate for individuals with limited mouth opening. Specific clinical questions needing further research include determining pre-operative prehabilitation protocols for individuals with existing TMD and delineating the most appropriate post-operative strategies for managing acute onset TMD. Future research in these areas will fill knowledge gaps related to clinical management of individuals at risk of developing TMD after orotracheal intubation to support healthcare providers and improve patient outcomes.

Acknowledgments

We thank Colleen Bannon, MLIS—Research & Instruction Librarian, Midwestern University, for assistance with design of the literature search and Loren Thomas Keeler, DPT, NRP, ACLS, for practical consultation regarding orotracheal intubation procedures and clinical applications.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-23-38/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-23-38/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-23-38/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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