Dentinal hypersensitivity

[Anonymous]

Priorities for research vary depending upon the disease burden and socioeconomic conditions. Hence, thrust areas of research are not the same for the developed and underdeveloped countries. The goals on oral health for the 21 ^st century was outlined and approved by the World Health Organization (WHO), Federation Dentaire Internationale (FDI) and International Academy for Dental Research (IADR) in the year 2003.  In working towards these goals, it is fundamentally important to recognize that oral health is inseparable from the health of whole human body, mind and spirit and from the society in which the individuals’ function.

The prevalence of disease in Africa and Asian countries including India are different. The WHO has thus emphasized the worldwide spread of chronic non-communicable diseases, cardiovascular disorders, diabetes, musculoskeletal disorders and cancer. For developing countries like India with a moderate morbidity rate, considerable attention has to be focused on unsafe sex, unsafe drinking water, sanitation and hygiene, tobacco use, high blood pressure, alcohol and high serum cholesterol levels.
Diseases of affluence that dominate the developed countries include those associated with tobacco, blood pressure, alcohol, cholesterol, overweight and physical inactivity. The genetic predisposition and environmental agents in pathogenesis of oral disease, and risk factors contributing to dental caries, periodontal disease, oral cancer and human immunodeficiency (HIV)-associated diseases should also be recognized.

        

[drmithila]

 PREVALENCE OF DENTIN HYPERSENSITIVITY

 

Dentin hypersensitivity is a condition that affects a wide spectrum of patients. The statistics below demonstrate the pervasiveness of this common condition. Varying data exist regarding the worldwide occurrence of dentin hypersensitivity. Clinical findings demonstrate, however, that approximately 1 in 5 people in the United States suffer from the condition.² Although sensitivity affects people of all ages, those between the ages of 25 and 50 are more commonly affected,³ and the condition is slightly more prevalent in women.⁴ In the United States, periodontal patients experience sensitivity at very high rates,⁵ and patients undergoing professional tooth whitening also are especially prone to tooth sensitivity. In fact, 55% to 75% of patients suffer from whitening-related sensitivity.⁶

Clearly, dentin hypersensitivity is more prevalent than dental professionals may realize. Data show that 42% of patients do not report consulting their dentist about their condition, and only 27% of those suffering report using a desensitizing dentifrice to help manage the condition.⁷ Instead, many patients modify everyday behaviors to avoid sensitivity, and may not even be aware they are doing so. For example, some patients avoid hot or cold foods or beverages. Others may avoid brushing sensitive areas, placing them at risk for plaque buildup, calculus formation, and even gingivitis.

DIAGNOSING DENTIN HYPERSENSITIVITY

 

Making the proper diagnosis is the first step in assisting your patients suffering from dentin hypersensitivity. Identifying patients who are sufferers can be achieved through close examination of existing conditions and by careful analysis of patient behaviors.

In addition to periodontal patients and those undergoing professional tooth-whitening procedures, other groups at risk for dentin hypersensitivity include those who exhibit gingival recession due to aggressive oral hygiene habits, consumers of high-acid food and drink, patients with parafunctional habits, and patients suffering from xerostomia.

In addition to paying special attention to these circumstances, a comprehensive and thorough examination is necessary to diagnose dentin hypersensitivity. Care must be taken to exclude other conditions such as  dental caries, pulpitis, cracked tooth syndrome, marginal leakage, fractured restoration, and restoration polymerization shrinkage.

        

[drsushant]

Introduction

In a typical workday, the retail pharmacist may field several questions about oral care and oral discomfort. Patients may complain about one or more teeth that are intermittently painful. The pain is invariably triggered by actions such as drinking a hot or cold beverage, eating a sweet or sour food, or dental manipulations such as touching the tooth or directing an air blast on it.

The patient may have concern that the tooth requires a filling or that it may need to be extracted. However, the problem, known as dentinal hypersensitivity, may be a relatively simple one to treat.

        

[drsushant]

Dental Anatomy

The crown is the section of tooth normally exposed to the interior of the mouth; the section below the gingival line, buried in alveolar bone, is the root. The crown is covered with enamel, the hardest substance in the human body. Enamel is 96% to 97% inorganic. The root is covered with a softer substance known as cementum. Cementum resembles bone in that it is composed of 45% to 50% organic material. Beneath the enamel and cementum is a material known as dentin, which encloses the tooth’s sensory mechanisms, such as the dental pulp or nerve root. Dentin is 70% inorganic material, 18% organic material, and 12% water. Dentin is riddled with thousands of small channels known as dentinal tubules. Dentinal tubules contain odontoblastic processes (portions of the dentin-producing cells, also known as Tomes’ fibers), tissue fluids that bathe the processes and fill the tubules, and minerals.

Prevalence

A significant portion of the aged population is edentulous (lacking natural teeth). Prior to the advent of fluoridated water, it was expected that people would begin a pernicious process of tooth loss as they reached the age of 30. This loss usually accelerated during the patient’s thirties and forties until a full set of dentures was required to masticate food. Widescale fluoridation, which was first introduced in the baby boomer generation, dramatically reduced the incidence of edentulousness; thus people have kept their natural teeth for longer periods than before. However, cumulative damage from years of exposure to mechanical and environ- mental insults increases the incidence of problems peculiar to aged teeth. Recent reports place the prevalence of dentinal sensitivity at 40% to 45%, a figure that is certain to rise as the average age of the population increases.

        

[drsushant]

Hydrodynamic Theory

Why should certain teeth in certain people become hypersensitive? This question was elegantly answered by a set of facts and suppositions that collectively became known as “the hydrodynamic theory.” While this theory is not yet regarded by all as completely factual, it explains most of the available clinical observations and anatomical realities.

The first component of the theory is the observation that dentin is normally covered by cementum or enamel. When this covering is in place, the teeth are not hypersensitive. However, when cementum or enamel are absent due to erosion, abrasion, dental manipulation or a tooth defect, dentin is exposed.

The second part of the theory focuses on the dentinal tubules, which are open at the surface of the dentin, allowing a direct channel to the nerve pulp. Supposedly, any of the abrasive or erosive forces that expose dentin also open these tubules to the oral interior. When any trigger is present, the tissue fluids inside the tubules move slightly inward or outward. Cold causes the tissue fluid volume to shrink slightly, and heat causes it to expand. Strongly osmotic sugar or sour solutions cause fluid to be drawn out of the tubules. An air blast on the tooth (by a dental instrument) dries a tiny portion of fluid at the distal end of the tubule, causing a significant outer flow of fluid in the tubule. Touching the tooth with a dental instrument or periodontal cleansing aid forces a small amount of fluid into the tubule. Intratubular fluid shifts are interpreted as pain by the Tomes’ fibers and/or central nerve root of the tooth.

        

[drsushant]

Causes of Dentinal Hypersensitivity

The hydrodynamic theory also explains many of the epidemiological observations on the causes of dentinal hypersensitivity.

Brushing Habits

Sustained and overzealous brushing (especially with harder-bristled brushes) is known to thin enamel and cause gingiva to recede, exposing the softer subgingival cementum, which is also damaged by brushing. Right-handed people tend to brush their left teeth more zealously and vice versa, which results in hypersensitivity in those teeth. Also, since people tend to brush the front teeth and outer tooth surfaces more zealously, those areas are more likely to be sensitive than back teeth and inner surfaces, mirroring the incomplete brushing habits of most people.

Tooth Grinding

Patients who grind their teeth experience a higher incidence of dentinal hypersensitivity. This action wears down the enamel on teeth, exposing the dentin.

Gender

Women are more prone to dentinal hypersensitivity. This is because women of any age, generally speaking, are more attentive to basic hygiene than an age-matched group of males. Since this includes dental care, female teeth are more likely to have exposed dentinal tubules as a result.

Age

There is also an age link to dentinal hypersensitivity. The problem does not occur in most people until they reach their late twenties, thirties or forties because overzealous brushing and other factors begin to take their toll at this time.

Diet

Habitual ingestion of acidic substances causes erosion of enamel and dentin, subsequently opening dentinal tubules. The citric acid in citrus fruits (e.g., lemons) dissolves enamel. Similarly, ingestion of other acidic foods and beverages (e.g., ginger ale, which has the lowest pH of any drink commonly available) discussed in this month’s patient information should be avoided whenever possible, since they effectively strip away the tooth’s protective smear layer (a layer of dead organic material that occludes the dentinal tubules, preventing the outward flow of tubular solution). Further, brushing directly after ingestion of these substances causes direct damage to enamel and must be avoided.

Smokeless Tobacco

Users of smokeless tobacco more frequently experience dentinal hypersensitivity. The “quid” of smokeless tobacco placed between the gum and cheek is a well-known cause of gingival recession. As the gingiva recede in response to this noxious chemical, softer subgingival cementum is exposed. Continual brushing erodes the cementum, opening the dentinal tubules.

Disease

There is an increased risk of dentinal hypersensitivity in bulimics and those afflicted with gastroesophageal reflux disease. Both conditions increase intraoral acidity, subsequently causing the type of enamel erosion that leads to dentinal hypersensitivity.

Periodontal disease and gum disease may also result in dentinal sensitivity. With these conditions, the tooth’s root surface is exposed through recession of the gums or loss of supporting ligaments.

        

[Anonymous]

Treatment of Dentinal Hypersensitivity

Several approaches have been investigated for treating dentinal hypersensitivity. One option is simply to occlude the dentinal tubules through the use of a particulate toothpaste ingredient, such as abrasive silica. Hypothetically, even partial tubule occlusion could be of great benefit, since Poiseuille’s law holds that reducing the tubule radius by 50% reduces the flow through the tubule to 6.25% of its original value. However, the use of toothpastes containing silica particles is widespread, and does not appear to have substantially affected the prevalence of dentinal hypersensitivity. Therefore, any special toothpaste ingredient must demonstrate the ability to desensitize teeth to a statistically greater extent than the toothpaste alone. To date, only potassium nitrate has met this requirement. It is thought to act directly on the pulpal sensory nerves. After an initial depolarization of sensory nerve fiber membranes, excess potassium halts repolarization. Thus, the ability of potassium nitrate to quell dentinal hypersensitivity may be due to an irreversible depolarization.

Many products are available to treat dentinal hypersensitivity. Potassium nitrate-containing toothpastes include Aqua-fresh Sensitive, Colgate Sensitive, Crest Sensitivity Protection, Dental Care Sensitive Formula, Sensodyne Extra Whitening, and Sensodyne Fresh Mint. One toothpaste, Sensodyne Tartar Control Plus Whitening, also contains tartar control and whitening ingredients. Other products for sensitive teeth are Protect Sensitive Teeth Gel Toothpaste, Rembrandt Whitening Toothpaste for Sensitive Teeth, and Orajel Sensitive Pain Relieving Toothpaste for Adults. All of these toothpastes contain fluoride to strengthen dental enamel and protect against cavity formation.

A dentist can relieve dentinal hypersensitivity by applying fluoride paste, bonding agents or dentin sealer to the exposed root surface.

        

[Anonymous]

The Dos and Don’ts of Brushing

DO

Brush twice daily, with a soft-bristled toothbrush
Use a toothpaste containing fluoride
Brush inner, outer and chewing surfaces with a back-and-forth motion
Hold brush at 45° angle to the gums to clean gumline
With the ‘toe’ of the toothbrush, clean the inner surface of the front teeth using an up-and-down stroke
Brush the tongue gently
Replace toothbrush every three months

DON’T:

Brush too vigorously
Brush too frequently
Use a toothbrush too large to easily clean all surfaces.

Patient Information

Help For Hypersensitive Teeth

Many people notice a painful sensation when they consume a food or beverage that is hot, cold, sweet or sour, or when brushing their teeth, or when a dentist cleans or dries the tooth with an air blast. The teeth may not hurt at any other time. This condition is dentinal hypersensitivity.

Treatment

If you already have dentinal hypersensitivity, you may find relief in any of several brands of toothpastes for sensitive teeth. They contain potassium nitrate plus a fluoride. Potassium nitrate is the only ingredient presently proven to be effective for the problem. To use the toothpaste, you should choose the softest bristle brush you can find (this is also the best advice for patients without dentinal hypersensitivity, unless advised otherwise by a dentist). Place a one-inch strip of toothpaste on the brush and brush for at least one minute twice daily, morning and evening. Make sure that you allow the toothpaste to come into all areas where you noted dental pain. Brush no more than twice daily. Avoid excessive force when brushing.

Do not use these toothpastes for more than four weeks without a diagnosis of dentinal hypersensitivity from a dentist. The reason is that your tooth pain may be due to a much more serious problem, such as a chipped tooth, a cracked filling, erosion underneath a dental filling, bruxism (i.e., tooth grinding), or damage from malocclusion (i.e., an uneven bite). Once a dentist has ruled out these serious problems, you may continue to use the toothpastes for as long as hypersensitivity is present.

Prevention

It is best to avoid causes of dentinal hypersensitivity. Acidic food and drinks can damage tooth enamel. From most acidic to least, some of the foods and drinks to use cautiously include ginger ale, limes/lemons and their juices, wine, cranberry sauce, coffee, vinegar, pickles, cola and citrus-based drinks, apples, rhubarb, raspberries, root beer, relish, strawberries, fruit jams/jellies, peaches, sauerkraut, blueberries, pineapples/pineapple juice, cherries and grapes. It is especially important not to brush right after ingesting these foods, because they strip away the tooth’s protective layer, and you will be brushing naked enamel, which is more prone to damage. Never suck directly on limes/lemons or allow these to be placed into a baby bottle given at night. This permits them to be in prolonged contact with the teeth, causing “nursing bottle mouth” (i.e., there are severe cavities in the section of the mouth bathed by the milk).

Avoid buying small packets of sour, acidic powders or candies coated in them. Their acidity is too high for tooth health.

Do not use smokeless tobacco. Constantly exposing the gums to this toxic substance causes them to recede, exposing the softer tooth sections below the gumline. They are then more prone to damage during brushing.

Follow proper oral hygiene and see your dentist regularly for evaluation and professional care.

        

[DrAnil]

 Images

        

[Drsumitra]

 I would like to know, what is the exact way of advising a patient to use an anti-sensitivity toothpaste, as in what is the correct mode of its application?

Does one advise brushing with it or mere application and brushing with a regular paste?

 

        

[drmithila]

usage and application of a particular sensitivity paste varies according to manufacturers instructions, however generally we ask patient to brush with a regular paste followed by apllication of the anti-sensitivity paste on sensitive teeth for few mins [5-10mins] and then rinse it off…

However there are a few brands that can be used to brush like a regular paste

        

[drmithila]

Tooth sensitivity is one of the chief complaints patients have when undergoing tooth whitening. Now a study has found that using a nano-hydroxyapatite (n-HAP) paste may significantly reduce the number of days a patient will experience tooth sensitivity during active bleaching (Journal of Esthetic and Restorative Dentistry, August 2012, Vol. 24:4, pp. 268-276).

None of the study authors disclosed a financial interest in any of the companies or products used in this article. However, the project was supported by a grant from Sangi, which makes Renamel AfterBleach, the n-HAP paste used in the study.

Several manufacturers have added desensitizing agents to their dentist-prescribed whitening products, said study author William Browning, DDS, professor of restorative dentistry at the Indiana University School of Dentistry, in an interview with DrBicuspid.com.

“This is the first high-level evidence available to confirm its efficacy.”
— William Browning, DDS
Direct-to-consumer whitening agents, by contrast, generally do not contain desensitizers, noted the study authors, adding that their study investigates a desensitizing agent that follows application of the tooth whitener and is used as a separate step.

Because a significant percentage of people whiten their teeth using direct-to-consumer products that do not contain a desensitizer, a product that could reduce sensitivity and be used as an adjunct to bleaching would be of great benefit, explained Dr. Browning.

Whitening-related tooth sensitivity has been associated with the presence of microscopic defects in the tooth structure, and the theory is that occluding/repairing these defects would lead to a reduction in sensitivity, he added.

"Lower-level-evidence lab studies indicating repair of these defects in vitro and anecdotal clinical reports of reduced sensitivity indicated that nano-hydroxylapatite was effective," said Dr. Browning. "This is the first high-level evidence available to confirm its efficacy."

Double-blind study

Dr. Browning and his colleagues used a randomized, placebo-controlled, parallel-group, double-blind clinical trial to investigate the efficacy of n-HAP paste in reducing bleaching-related tooth sensitivity. They assigned the n-HAP paste and a placebo to 42 study participants who were divided into two groups of 21 each.

The study participants bleached with a 7% hydrogen peroxide gel twice daily for 14 days. They wore the bleaching agent for 30 minutes, and the desensitizer was applied in a separate step immediately following bleaching. The paste n-HAP — Renamel AfterBleach — contained n-HAP crystals. The paste zero-HAP (the placebo) was identical, except that it did not contain the nano-sized particles of hydroxyapatite.

The study participants used their assigned desensitizing agent during the two weeks of active bleaching and for one week after the end of active bleaching for five minutes at a time.

Due to concerns about introducing a confounding factor into the study, all participants were warned against using any oral healthcare products that contained a desensitizer.

The study participants maintained a daily diary for four weeks: one week prior to bleaching, during the two weeks of active bleaching, and for the one week after bleaching ended.

Three aspects of tooth sensitivity were investigated: percentage of participants who experienced sensitivity, number of days that sensitivity was experienced, and intensity level of the sensitivity, which was measured on a visual analog scale (VAS). Each of these measures investigates a different aspect of tooth sensitivity and each has value, the study authors noted. They also measured the degree of color change at baseline, immediately after bleaching, and six weeks after the end of active bleaching.

Here are some of the key results:

For groups zero-HAP and n-HAP, respectively, 51% and 29% of participants reported tooth sensitivity.
The number of days of sensitivity was 76 for zero-HAP and 36 for n-HAP.
The change in VAS score from baseline trended higher for the zero-HAP group.
Color change was equivalent between the groups.
"The data trend indicated group n-HAP experienced less sensitivity over all three measures," noted the study authors.

However, only the number of days of sensitivity was statistically significant.

High-level clinical evidence

Dentists can tell patients who are whitening their teeth with a product that does not contain a desensitizer that n-HAP can be applied after bleaching as an adjunctive therapy, Dr. Browning noted.

There are also plans to incorporate n-HAP into the whitening agent itself, he added.

The results both supported a theory of whitening-related sensitivity and supported the efficacy claims of a commercial product, Dr. Browning noted. For many products, efficacy is assumed based on an extrapolation of lab testing results; that is, that the product will perform in clinical use as it did in lab testing. However, the relevance of such testing to clinical performance is unknown, he added.

"Having high-level clinical evidence to support a product’s claims is very reassuring, but it is also unusual," he concluded. "It should be a norm."

 

        

[drmithila]

The natural ‘glue’ used by mussels to stick to rocks could help cure sensitive teeth, new research claims.
The sea creatures’ sticky secretions have inspired scientists to create a compound which could be used to help repair damaged teeth.
Three out of every four people have teeth which are sensitive to hot, cold, sweet or sour foods and drinks.
The condition occurs when the hard outer enamel layer on teeth and the softer underlying dentine wear away, stimulating the nerves inside.
Sugar free gums and certain toothpastes help ease pain, but Quan-Li Li, of China’s Anhui Medical University, and Chun Hung Chu, of the University of Hong Kong, searched for a substance which could restore both enamel and dentine at the same time.
They drew inspiration from the glue used by mussels, and reasoned that a simliar material could help keep minerals in contact with dentine long enough for the teeth to rebuild.
They created a sticky polydopamine material mixed with the minerals calcium and phosphate.
In tests in the lab, reported in journal Applied Materials and Interfaces, teeth bathed in the sticky material and minerals reformed dentine and enamel.
In contrast, teeth bathed just in minerals reformed only enamel.
They authors say that the substance ‘may be a simple universal technique to induce enamel and dentine remineralisation simultaneously’.
The breakthrough comes after research last year showed that human teeth are just as strong as those of sharks – a discovery which could assist in the design of stronger dentures.
Scientists made the surprising discovery after comparing the micro-structure of human and shark teeth.
They found that despite the teeth of the top ocean predator being coated with super-tough enamel, they are no stronger than the teeth found in your average human being.
Shark teeth have an interior of elastic dentine and an outer layer of hard enamel toughened by the fluorine-based mineral fluoroapatite.
Human enamel is softer, consisting of the mineral hydroxyapatite, which is also present in bones.
But because of their structure, the overall strength of human teeth was on a par with that of the shark, the scientists found.
The research, published in the Journal of Structural Biology, could assist the design of stronger and longer lasting dentures.
‘It would be great if, sometime in the future, one could repair teeth with a material which is more natural than today’s provisional solutions,’ said Professor Matthias Epple, from the University of Duisburg-Essen in Germany, lead author of the study

        

[drmithila]

Scientists are now trying to do everything they can to treat tooth sensitivity. That’s why they recently developed a report on trying to prevent tooth sensitivity from occurring.

A report on tooth sensitivity pinpointed a substance, similar to an adhesive that mussels use to attach to rocks, that could thwart sensitivity. The information appears in the journal ACS Applied Materials & Interfaces.

Roughly three out of four people have some kind of tooth sensitivity when it comes to hot, cold, sweet or sour foods or beverages. The tooth sensitivity results from the enamel and dentin wearing away. There are currently some sugar-free gums and special toothpastes that could reduce the levels of sensitivity, but not enough to fully solve the issue.

It’s essential to discover something that can help restore the enamel and dentin. That’s where the sticky adhesive from mussels comes in. The goal would be to use the adhesive to keep minerals connected to dentin for a long enough time to promote the rebuilding of the dentin.

The researchers concluded the adhesive could be effective after testing human teeth, which had the enamel worn down, with dentin in liquid that had the sticky material and minerals on it. The tests showed that the dentin and enamel eventually did reform. The teeth with just minerals, however, only saw the enamel be rebuilt, not the dentin.

More research is necessary before the adhesive would be used on a person’s teeth.

        

[drsnehamaheshwari]

A recent study in the Journal of the American Dental Association found that one in eight general practice patients have dentin hypersensitivity (DH). With those odds, it’s inevitable that practitioners will have to manage it. Could lasers be a treatment option?

A new study in General Dentistry (May-June 2013, Vol. 61:3, pp. 66-71) comparing the efficacy of diode lasers (DL) with stannous fluoride and potassium nitrate gels in the treatment of DH found that the "940-nm DL was not only efficacious, but also brought about improved immediate relief as compared to stannous fluoride and potassium nitrate gels in the reduction of DH."

Now, a meta-analysis to be published next month in the Journal of Dental Research lends additional support to the use of certain lasers to treat DH (June 2013, Vol. 92:6, pp. 492-499). Researchers at the University of L’Aquila School of Dentistry compared the effectiveness of several different types of lasers, and the results were promising: Two middle-output-power lasers and one low-intensity laser performed well.

"Er:YAG, Nd:YAG, and GaA1As [diode] lasers appear to be efficacious in reducing DH," the researchers wrote.

While those lasers performed better than a placebo, another laser included in the study did not fare so well: "Meta-analyses of the baseline-end of follow-up changes in pain revealed no differences for Er,Cr:YSSG vs. placebo," the researchers noted.

 

Multiple treatment options

Several approaches have been proposed for in-office treatment of DH, including desensitizing agents, iontophoresis, adhesives, and resins, according to the study authors. More recently, lasers have been added to the list. While recent studies have established laser DH treatment as safe, there remained a need to evaluate their efficacy, the authors noted.

For this systematic review, they stratified the data according to laser type and changes in pain level, when compared with a placebo or no treatment. They also paid attention to the safety of laser application while noting adverse events.

To find usable studies, the researchers searched multiple databases: MEDLINE, Cochrane Controlled Clinical Trial Register, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), CINAHL, Science Direct, and SCOPUS.

Included studies had to have adult test subjects in randomized clinical trials that compared DH laser treatment with a placebo or no treatment. They were excluded if the subjects’ pain perception was altered by drugs or systemic diseases, if DH was not assessed by scale or score, or if they did not report numerical data.

Upon completion of the search, the study authors were left with 13 randomized, controlled trials with four laser types that were compared to a placebo: Er,Cr:YSSG, Er:YAG, Nd:YAG, and GaA1As. A quality assessment and statistical analysis was performed.

Er,Cr:YSSG did not fare well in three studies in which researchers demonstrated a nonsignificant change in DH (p = 0.07), although the small number of included studies made detecting significant differences difficult.

The rest performed better in studies that were appropriately similar. The results from four studies of Er:YAG versus placebo (p = 0.0002), three studies of Nd:YAG versus placebo (p = 0.02), and eight stud ies of GaAlAs versus placebo (p < 0.00001) indicated a significant change in pain level in favor of laser use. High and significant heterogeneity was present in all four comparisons.

The researchers found only one adverse incident recorded in all of the included studies: One patient reported postlaser application pain.

For now, it appears as though lasers are an effective option in the DH treatment toolkit.

 

 

        

[Author]

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