An Update on Local Anesthesia for Pediatric Dental Patients
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AnesthEssaysRes.2013JanApr7(1):49.doi:10.4103/02591162.113977
PMCID:PMC4173488
AnupdateonlocalanesthesiaforpediatricdentalpatientsFaizalC.PeedikayilandAjoyVijayan
DepartmentofPedodonticsandPreventiveDentistry,KannurDentalCollege,Kannur,KeralaState,IndiaDepartmentofOralandMaxillofacialSurgery,KannurDentalCollege,Kannur,KeralaState,IndiaCorrespondingauthor:Dr.FaizalC.Peedikayil,DepartmentofPedodonticsandPreventiveDentistry,KannurDentalCollege,Kannur,KeralaState,India.Email:[email protected]
Copyright:Anesthesia:EssaysandResearches
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Abstract
Paincontrolisanimportantpartofdentistry,particularlyinthemanagementofchildren.Behaviorguidance,anddoseandtechniqueofadministrationofthelocalanestheticareimportantconsiderationsinthesuccessfultreatmentofapediatricpatient.Thepurposeofthepresentreviewistodiscusstherelevantdataontopicsinvolved,andonthecurrentmethodsavailableintheadministrationoflocalanesthesiausedforpediatricdentalpatients.
Keywords:Localanesthesia,paincontrol,pedodontics
INTRODUCTION
Fearrelatedbehaviorshavelongbeenrecognizedasthemostdifficultaspectofpatientmanagementandcanbeabarriertogoodcare.[1]Administeringlocalanesthesiabyinjectionisstillthemostcommonmethodusedindentistry.However,thereisaconstantsearchforwaystoavoidtheinvasiveandoftenpainfulnatureoftheinjection,andfindamorecomfortableandpleasantmeansofachievinglocalanesthesiabeforedentalprocedures.[2,3]
Chemically,thelocalanestheticagentsincommonclinicalusetodaymaybedividedintotwobroadgroups:(A)agentscontaininganesterlinkingand(B)agentscontaininganamide.Themostcommonlyusedlocalanestheticsforpediatricdentistryaretheamidetypeagents.Lidocainehydrochloride(HCl)2%with1:100,000epinephrineispreferredbecauseoftheirlowallergeniccharacteristicsandtheirgreaterpotencyatlowerconcentrations.[4]Table1showsthedosageper1.8mLcartridgeoflidocaine.
Table1Dosageperdentalcartridge
Localanestheticcarpulesalsocontainorganicsaltsandmaycontainvasoconstrictors.Vasoconstrictorsareusedtoconstrictbloodvessels,counteractthevasodilatoryeffectsofthelocalanesthetic,prolongitsduration,reducesystemicabsorptionandtoxicity,andprovideabloodlessfieldforsurgicalprocedures.[4,5]Theuseofthevasoconstrictorwillallowthemaximumtotaldoseoftheanestheticagenttobeincreasedbynearly40%.[6,7]Manyagentshavebeenemployedasvasoconstrictorswithlocalanesthetics.Butnonehasprovedtobeasclinicallyeffectiveasepinephrine.[6]
Themaximumdoseoflidocaineandmepivacaine,withoutvasoconstrictors,recommendedforchildrenis4.4mg/kgbodyweight,and7mg/kgbodyweightforlidocainewithvasoconstrictors.[8]
Theaveragedurationofpulpalanesthesiais60minutesfor20%lidocainewith1:100,000epinephrine,50minutesfor2%mepivacainewith1:20,000levonordefrin,and25minutesfor3%mepivacainewithoutvasoconstrictor.In
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T1/http://www.ncbi.nlm.nih.gov/pubmed/?term=Vijayan%20A%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T1/http://www.ncbi.nlm.nih.gov/pmc/about/copyright.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Peedikayil%20FC%5Bauth%5Dhttp://dx.doi.org/10.4103%2F0259-1162.113977http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T1/mailto:dev@null -
thepresentlocalanestheticagentsused,thesofttissueanesthesiaismorethanthatofpulpalanesthesia.[5]Attemptshavebeenmadetofindagentsthatreducethedurationofsofttissueanesthesia.However,nosuchreductionhasbeenobservedthus,theauthorsrecommendthat2%lidocainewith1:100,000epinephrinebeusedwhenadministeringlocalanesthesiainyoungchildren.
Ifalocalanestheticisinjectedintoanareaofinfection,itsonsetwillbedelayedorevenprevented.[3]TheinflammatoryprocessinanareaofinfectionlowersthepHoftheextracellulartissuefromitsnormalvalue(7.4)to56orlower.ThislowpHinhibitsanestheticactionbecauselittleofthefreebaseformoftheanestheticisallowedtocrossintothenervesheathtopreventconductionofnerveimpulses.Insertinganeedleintoanactivesiteofinfectioncouldalsoleadtoapossiblespreadoftheinfection.[3,4,6,8,9]
Safetyoflocalanestheticagentsandadversereaction
Theinherentuseoflocalanestheticinjectionsallowspractitionerstousethemfrequentlywiththeconfidencethatadverseeventsarerare.[10,11]Themostcommonreactionassociatedwithlocalanestheticsisatoxicreaction,resultingusuallyfromaninadvertentintravenousinjectionoftheanestheticsolution.[8]Table2showstheadversereactiontocommonlyusedlocalanesthetics.
Table2Adversereactionsofcommonlyusedlocalanesthetics
Overdosereactionsareaparticularriskintreatingchildren.[5,6]Thedosageofthelocalanestheticdependsonthephysicalstatusofpatient,areatobeanesthetized,vascularityoforaltissues,andthetechniqueofadministration.Itisdifficulttorecommendamaximumdoseforchildrenbecausedosevarieswithfunctionsofageandweight.Forpediatricpatientslessthan10yearswhohaveleanbodymassandnormalbodydevelopment,themaximumdosemaybedeterminedbyapplicationofoneofthestandardformulas(Clarksrule).Inanycase,themaximumdoseshouldnotexceed7mg/kgbodyweightforlidocainewithepinephrineand4.4mg/kgforplainadrenaline.Toxicityoccursprimarilyinthecardiovascularandcentralnervoussystemthistoxicreactioncouldstimulateordepressthecentralnervoussystem.Stimulationofthecentralnervoussystemcancauseatoxicvasoconstrictorreaction,andthesignsandsymptomsaretachycardia,apprehension,sweating,andhyperactivity.Depressionofthecentralnervoussystemmayfollow,leadingtobradycardia,hypoxia,andrespiratoryarrest.[3,8,10,11,12]
Epinephrineiscontraindicatedinpatientswithhyperthyroidism.[5]Itsdoseshouldbekepttoaminimuminpatientsreceivingtricylicantidepressantssincedysrhythmiasmayoccur.Levonordefrinandnorepinephrineareabsolutelycontraindicatedinthesepatients.Patientswithsignificantcardiovasculardisease,thyroiddysfunction,diabetes,orsulfitesensitivity,andthosereceivingmonoamineoxidaseinhibitors,tricyclicantidepressants,orphenothiazinesmayrequireamedicalconsultationtodeterminetheneedforalocalanestheticwithoutavasoconstrictor[5,10,11]
Localanesthetictoxicitycanbepreventedbycarefulinjectiontechnique,watchfulobservationofthepatient,andknowledgeofthemaximumdosagebasedonweight.Practitionersshouldaspiratebeforeeveryinjectionandinjectslowly.[11]Earlyrecognitionofatoxicresponseiscriticalforeffectivemanagement.Whensignsorsymptomsoftoxicityarenoted,administrationofthelocalanestheticagentshouldbediscontinued.Additionalemergencymanagementisbasedontheseverityofthereaction.
Allergicreactionstolocalanesthesiaarerare.Thelocalanestheticagentwiththehighestincidenceofallergicreactionsisprocaine.Itsantigeniccomponentappearstobeparaaminobenzoicacid(PABA).Crossreactivityhadbeenreportedbetweenlidocaineandprocaine.Allergiescanmanifestinavarietyofways,someofwhichincludeurticaria,dermatitis,angioedema,fever,photosensitivity,oranaphylaxis.[8,11,12]Emergencymanagementisdependentontherateandseverityofthereaction.[13]
Patients,withahistoryofallergytoalocalanesthetic,whocannotidentifythespecificagentused,presentaproblem.Thepatientshouldbereferredforevaluationandtesting,whichwillusuallyincludebothskintestingandprovocativedosetesting(PVT).Forpatientshavinganallergytobisulfates,useofalocalanestheticwithoutavasoconstrictorisindicated.[8,13]Localanestheticswithoutvasoconstrictorsshouldbeusedwithcautionduetorapidsystemicabsorptionwhichmayresultinoverdose.[13,14]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173488/table/T2/ -
Techniquesforadministeringthelocalanesthetic
Controlofthechild'shead
Topicalanesthesia
Needlesizeandlength
Durationofinjection
Postoperativesofttissueinjury
Failureinlocalanesthesia
Alongactinglocalanesthetic(i.e.,bupivacaine)isnotrecommendedforthechildorthephysicallyormentallydisabledpatientduetoitsprolongedeffect,whichincreasestheriskofsofttissueinjury.[14]
Paresthesiaispersistentanesthesiabeyondtheexpecteddurationinjuriestotheinferioralveolarnerve(IAN)andlingualnerve(LN)canbecausedbylocalanalgesicblockinjections.Thenerveinjurymaybephysicalfromtheneedleorchemicalfromthelocalanestheticsolution.Thepatientmayexperienceanelectricshockintheinvolvednervedistributionarea.Paresthesiaalsocanbecausedbyhemorrhageinoraroundthenerve.Reportsofparesthesiaaremorecommonwitharticaineandprilocainethanexpected,fromtheirfrequencyofuse.Mostcasesresolveineightweeks.[8,15]
Patientmanagementwhileadministeringlocalanestheticinjections
Inchildren,behaviormanagementiscriticaltothesuccessofdentalprocedures.Arelaxedandcalmchildduringtheadministrationoflocalanesthesiaisimportantforthesuccessoftheclinicalprocessaswell.[2,3,4]Manytechniqueshavebeendescribedformanagingchildbehaviorinthedentaloffice,includingbothpharmacologicalandnonpharmacologicalmethods.[5]
Thereisnoperfecttechniquethatguaranteessuccessinanesthetizingallchildren.However,thereareafewkeyproceduresthataremutualtoalladministrationsthatmaybevaluabletothesuccessofalltechniques.
Onceachildhasgrabbedthesyringeorbumpedtheoperator'shandanddriventheneedleintothetissueofthebone,itmaybetoolatetorespond,andalastingimpressionhasbeenmadeinthechild'smindrelativetopainassociatedwiththelocalanestheticinjection.[4]Therefore,someauthorsrecommendthatthepractitionershouldhaveacontrolofthechild'sheadandagoodfingerrest,tocontrolthesyringeincasethechildmovesorresists.Thedentalassistantshouldbepreparedtorestrainthechild'shand,gentlybutfirmly.[16]
Theprimarygoalinusingtopicalanesthesiaistominimizethepainfulsensationofneedlepenetrationintothesofttissue.Thetopicalanestheticagentmustbeplacedondriedmucosaandleftinplaceforatleastoneminutetoachievemaximumeffect.Theonsetdurationoflidocaineis35minutes.Arecentstudywhichcomparedtheefficacyofcommonlyusedtopicalanestheticsdemonstratedthesuperiorityof5%EMLAcream(eutecticmixtureoflocalanesthesiacontaininglidocaineandprilocaine)overallothertopicalanestheticagents.Thetopicalanestheticbenzocaineismanufacturedinconcentrationsupto20%lidocaineisavailableasasolutionorointmentupto5%andasasprayupto10%concentration.Localizedallergicreactions,however,mayoccurafterprolongedorrepeateduse.Topicallidocainehasanexceptionallylowincidenceofallergicreactionsbutisabsorbedsystemicallyandcancombinewithaninjectedamide.[17]
Ashort(20mm)orlong(32mm)27or30gaugeneedlemaybeusedformostintraoralinjectionsinchildren.Anextrashort(10mm)30gaugeneedlehasbeensuggestedformaxillaryanteriorinjections.Longneedlesarefrequentlyrecommendedforinferiordentalnerveblockanesthesia.However,theclinicalexperienceofmanydentistshasshownthatshorterneedlesareadequateandsafeespeciallyfortheyoungdifficulttomanagedentalpatients.[3,12]
Injectionoflocalanestheticsshouldalwaysbemadeslowly,precededbyaspirationtoavoidintravascularinjectionandsystemicreactionstothelocalanestheticagentorthevasoconstrictor.[8,16]
Selfinducedsofttissuetraumaisanunfortunateclinicalcomplicationoflocalanestheticuseintheoralcavity.Mostlipandcheekbitinglesionsofthisnatureareselflimitingandhealwithoutcomplications,althoughbleedingandinfectionmaypossiblyresult.[18]
Caregiversresponsibleforpostoperativesupervisionshouldbegivenarealistictimefordurationofnumbnessandbeinformedofthepossibilityofsofttissuetrauma.
Anumberoffactorscontributetothefailureoflocalanesthesia.Thesemayberelatedeithertothepatientortheoperator.Operatordependentfactorsare(a)badchoiceoflocalanestheticsolutionand(b)poortechnique.
Patientdependentfactorsare(a)anatomicalvariations,(b)thepresenceofinfection,thatis,theacidicenvironment
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preventsthelocalanestheticagentfromreachingandpenetratingthenerve,and(c)psychogenicfactors,thatis,severeanxietymayinfluencepainperception.[10,19,20]
Whenalocalanestheticfails,generally,itisbesttorepeattheinjectionthiswilloftenleadtosuccess.Inthecaseofrepeatblockinjections,itiseasiertopalpatebonylandmarksatthesecondattemptastheneedlecanbemaneuveredinthetissuespainfully.[19]
Conventionalmethodsofobtaininglocalanesthesia
Infiltrationisthechoicetoanaesthetizemaxillaryteethsuccessfully.Inthiscase,theneedleshouldpenetratethemucobuccalfoldandbeinsertedtothedepthoftheapicesofthebuccalrootsoftheteeth.Thesolutionisdepositedsupraperiosteallyandinfiltratesthroughthealveolarbonetoreachtherootapex,asthealveolarboneinchildrenismorepermeablethanitisinadults.Alittlelocalanestheticmaybesufficienttoproduceanesthesiaofteeth.[21]
Stretchingthemucosaoftheinjectionsiteandgentlypullingontotheobliquelyplacedbeveloftheneedleisrecommendedforbuccalinfiltrations.Insodoing,theinitialneedlepenetrationisshallow.Asmallamountofsolutionhastobeinjectedintothesuperficialmucosa.Afterafewseconds,theneedlecanbeslowlyadvanced12mmandafteranegativeaspiration,anothersmallamountofsolutioncanbedeposited.Thisshouldberepeateduntiltheremaininganestheticsolutioniscompletelyinjected.[21]
Anesthesiaofthemandibularprimarymolarsmayusuallybeachievedbyinfiltrationinchildrenuptotheageoffiveyears.Afewstudieshaveevaluatedtheeffectivenessofmandibularinfiltrationasapossiblealternativetomandibularblockfortherestorationofprimarymolars.Nosignificantdifferencesbetweeninfiltrationandblockwerefound.Inaddition,thequalityofanesthesiawasnotsignificantlyrelatedtotoothlocation,age,ortypeofanestheticagent.[22]
Mandibularblockisthelocalanesthesiatechniqueofchoicewhentreatingmandibularprimaryorpermanentmolars.Depthofanesthesiahasbeentheprimaryadvantageofthistechnique.Anesthesiaofallthemolars,premolars,andcaninesonthesamesideofinjectionallowsfortreatingmultipleteethofthesamequadrantatoneappointment.Fortheinferioralveolarblock,thechildisrequestedtoopenhismouthaswideaspossiblewhiletheoperatorpositionstheballofthethumbonthecoronoidnotchoftheanteriorborderoftheramus.Theneedleisinsertedbetweentheinternalobliqueridgeandthepterygomandibularraphe.[23]Thepositionoftheforamenchangeswiththechild'sage:Inayoungchild(4yearsoldandyounger)theforamenissometimeslocatedbelowtheplaneofocclusion.Inayoungchild,theforamenislocatedontheocclusalplane.Asthechildmatures,itmovestoahigherposition.[5,24]
Thebarrelofthesyringeoverliesthetwoprimarymandibularmolarsontheoppositesideofthearchandparalleltotheocclusalplane.Inthiscase,asmallamountofsolutionshouldbeinjectedand,afteranegativeaspirate,theneedleshouldadvanceuntilbonycontactismade,verygentlyandslowly.Whentheinferioralveolarnerveblockmaynotadequatelyanesthetizetheteeth,longbuccalanesthesiaisrequired.Thisisachievedbyinfiltratingafewdropsoftheanestheticintothebuccalsulcusjustposteriortothemolars.[5,22]
Theintraligamentaryinjectionisgivenintotheperiodontalligamentusingasyringespeciallydesignedforthepurpose.Intraligamentaryinjectionsalsocanbegivenwithaconventionalneedleandsyringe.Inthistechnique,theneedleisinsertedatthemesiobuccalaspectoftherootandadvancedinformaximumpenetration.Theneedledoesnotpenetratedeeplyontotheperiodontalligamentbutiswedgedatthecrestofthealveolarridge.A12mm30gaugeneedleisrecommended,andthebevelshouldfacethebone,althougheffectivenessisnotimpairedwithdifferentorientation.Intraligamentaryanesthesiahaslimitationsasaprincipalmethodofanesthesia,duetothevariableduration,buthasbeenusedtoovercomefailedconventionalmethodsorasanadjunct.[24]Intraligmentaryinjectionsproducesignificantbacteremiaandthereforeshouldnotbegiventoapatientattheriskofinfectiveendocarditisunlessappropriateantibioticprophylaxishasbeenprovided.[25]
Theintrapulpalmethodachievesanesthesiaasaresultofpressure.Salinehasbeenreportedtobeaseffectiveasananestheticsolutionwheninjectedintrapulpally.Whenasmallaccesscavityisavailableintothepulp,aneedlewhichfitssnuglyintothepulpisusedandasmallamount(about0.1mL)ofsolutionisinjectedunderpressure.Therewillbeaninitialfeelingofdiscomfortduringthisinjectionhowever,thisistransientandanestheticonsetisrapid.Whentheexposureistoolargetoallowasnugneedletofit,theexposedpulpshouldbebathedinalittle
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Computerizedlocalanesthesia
Electronicdentalanesthesia
Intraorallidocainepatch
Jetinjection
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localanestheticforaboutaminutebeforeintroducingtheneedleasfarapicallyaspossibleintothepulpchamberandinjectingunderpressure.[26]
Intraligamentaryanesthesiahasaroletoplayinlocalanesthesiainmoderndentistrybutitdoesnotfulfilalltherequirementsforaprimarytechnique.Aswithtraditionalmethodsofobtainingorallocalanesthesia,thealternativemethodsgenerallyaresafeifthepractitionerunderstandstheprinciplesfortheiruse.Alternativetechniquesforthedeliveryoflocalanesthesiamaybeconsideredtominimizethedoseofanestheticused,improvepatientcomfort,and/orimprovesuccessfuldentalanesthesia.Someofthesetechniquesaredesirable,especiallyininfants,children,adolescents,andpatientswithspecialhealthcareneeds,sincespecificteethmaybeanesthetizedwithlessresidualanesthesia(i.e.,avoiddiscomfortandpotentialselfmutilationofblockanaesthesia).Themandibularboneofachildusuallyislessdensethanthatofanadult,permittingmorerapidandcompletediffusionoftheanesthetic.Mandibularbuccalinfiltrationanesthesiaisaseffectiveasinferiornerveblockanesthesiaforsomeoperativeprocedures.Inpatientswithbleedingdisorders,thePDLinjectionminimizesthepotentialforpostoperativebleedingofsofttissuevessels.Intraosseoustechniquesmaybecontraindicatedwithprimaryteethduetothepotentialfordamagetodevelopingpermanentteeth.Also,theuseoftheperiodontalligamentinjectionorintraosseousmethodsiscontraindicatedinthepresenceofinflammationorinfectionintheinjectionsite.[5,10,16,21,27]
Newtechniquesforobtaininglocalanesthesia
TheWandsystemconsistsofadisposablehandpiececomponentandacomputercontrolunit.Thehandpieceisanultralightpenlikehandlewhichislinkedtoaconventionalanestheticcartridgewithplasticmicrotubing.
Thecoretechnologyisanautomaticdeliveryoflocalanestheticsolutionatafixedpressurevolumeratioisregardlessofvariationsintissueresistance.Thisresultsinacontrolled,highlyeffective,andcomfortableinjectioneveninresilienttissuessuchasthepalateandperiodontalligament.WhiletheWandhasbeenshowntoreducethepainassociatedwiththedeliveryoftheanestheticsolution,thetimeinvolvedintheprocedureappearstonegatetheeffectivenessofthedeviceareviewofcomputercontrolleddeliverydevicesaswellasotheralternativeanesthesiadeliverymethodsfoundthattheyeachpresentadversesideeffectsandgenerallyaremoreexpensivethanconventionalmethods.[28,29]
Theconceptofelectronicdentalanesthesia(EDA)involvestheapplicationofelectriccurrentthatloadsthenervestimulationpathwaytotheextentthatpainstimulusisblocked.AreviewoftheliteratureshowsasignificantreductioninpainobservedduringallthedentalproceduresconductedunderTENS(TENS:Transcutaneouselectricalnervestimulator).Thus,TENSshouldbeconsideredasausefuladjunctinthetreatmentofpediatricpatientsduringvariousminordentalprocedures.[29,30]
TherearemedicalcontraindicationstotheuseofEDA:Patientswithapacemakerorcochlearimplant,heartdisease,seizuredisorders,orcerebrovasculardisease,headtumor,neurologicaldisordersinvolvingtheheadandneck(e.g.,Bell'spalsy,trigeminalandpostherpeticneuralgia,multiplesclerosis,orTourette'ssyndrome),skinlesionsorabrasionsontheface,andpatientswithabnormalbruisingorbleedingdisorder.[31]
Theseareanestheticpatchescontainingalidocainebasethatisdispendedthroughabioadhesivematrixandapplieddirectlytotheoralmucosa.Thesepatchesareavailablein10and20%concentrations,eachcontainingapproximately23and416mgoflidocaineandcanreducethepainofinsertionofneedle.[29,32]
Thisinstrumentwasdevelopedtoachievelocalanesthesiafordentalprocedureswithouttheuseofaneedle.Thisisaccomplishedbydeliveringtheanestheticsolutionunderhighcompressiveforces.Anumberofuncontrolledstudiesofneedlelessdeviceshaveexaminedadultandchildpatients,typicallyfocusingontheanestheticpropertiesofthedeviceused.Inthesestudies,thepercentageofpatientswhoobtainedsufficientanesthesiawiththedevicesrangedfromabout50toabout90%.[33]Traditionalinfiltrationwasmoreeffective,acceptable,andpreferred,comparedwiththeneedlelessinjection.[34]
CONCLUSION
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Localanesthesiaformsthebackboneofpaincontroltechniquesindentistryandhasamajorroleindentistryforchildren.Thereisaconstantsearchforwaystoavoidtheinvasiveandoftenpainfulnatureoftheinjection,andtofindamorecomfortableandpleasantmeansofachievinglocalanesthesiabeforedentalprocedures.Despitetherecentinnovations,theinjectionremainsthemethodofchoiceinprovidinglocalanesthesia.
FootnotesSourceofSupport:Nil
ConflictofInterest:Nonedeclared.
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