***PLEASE NOTE THE INFORMATION IN THIS ARTICLE HAS NOW BEEN SUPERSEDED***
The policy of the Chief Dental Officers, which effectively applies in both private and NHS practices throughout the UK, is that:
- Routine dental care is not to be provided
- Urgent dental needs should predominantly be managed by phone with appropriate advice and prescriptions
- Aerosol Generating Procedures should not be undertaken outside of NHS-designated Urgent Dental Care centres
NHS England has published a fourth letter of preparedness, which provides clarification that in the absence of a local Urgent Dental Care centre to make referrals to, dental practices may undertake non-AGP face-to-face dental assessment and care with Level 2 PPE, if carried out when and as indicated by the accompanying Standard Operating Procedure for Urgent Dental Care.
The Chief Dental Officer for England and NHS England’s Director of Primary Care hosted a second webinar on dental services on Friday 24th April. A link will be added once available.
The public health agencies of the four UK nations issued updated policy on the use of Personal Protective Equipment (PPE).
The British Association of Oral & Maxillofacial Surgeons and British Association of Oral Surgeons have also updated their joint guidance on PPE which describes the government policy as ‘a useful minimum, not a mandated maximum level of PPE’.
The Scottish Dental Clinical Effectiveness Programme (SDCEP) has published guidance on drugs for the management of dental problems during the COVID-19 pandemic as a supplement to its guidance on the management of acute dental problems.
The government has updated its list of conditions defining people as ‘clinically extremely vulnerable’ to Covid-19 exposure.
We have added details of how these ’shielded’ individuals who need support for delivery of prescriptions can access help (see Remote prescribing and advice).
The Northern Ireland Department of Health has described its approach to redeployment, issued further clarification of financial support, and set out its policy on indemnity for GDPs during Covid-19. It has also issued an urgent request for expressions of interest in redeployment to support care homes.
The Covid-19 webinars jointly hosted by the Deans of the dental faculties of the UK Royal Colleges are available to watch online here and here. The third webinar will take place at 6pm on Tuesday 5 May.
Cochrane Oral Health has published a commentary for the dental and oral health care team on PPE, the Oxford Centre for Evidence-Based Medicine’s COVID-19 PPE rapid review team has published a commentary on the available evidence on PPE, and we have added a note about patient use of mouthwash prior to examination or treatment.
Health Protection Scotland has issued Covid-19 guidance for primary care.
The British Orthodontic Society (BOS) has released legal guidance for practice owners.
The National Association of Specialist Dental Accountants and Lawyers (NASDAL) has issued a guide to the current financial state of play for dentists and dental practices.
Practice Plan and DPAS are giving client practices half of their monthly admin fee back in April and May.
NHS Education for Scotland has published checklists of actions for dental practices at and during closure.
Dental Mentors UK is offering pro bono coaching and mentoring support during Covid-19.
Denplan is offering its dental teams free access to a virtual GP service, and a 24/7 helpline offering advice on a range of health, lifestyle, legal and wellbeing issues, until 31 July.
We have added a new section capturing the emotional and health support available to dentists.
The Dental Wellness Trust has called for dental practices to donate toothbrushes and toothpaste to local care homes and hospices.
We have added reference and/or links to:
- Access details for Urgent Dental Care sites in Wales
- The categorisation of dental conditions into routine, urgent and emergency in Wales
- UNW’s Viability Planning and 12week cashflow forecast templates
- Support available from the BDA Benevolent Fund
- Wesleyan’s business continuity infographic
- Dental Directory’s checklists for closing and reopening practices
- Urgent care recommendations for dental specialities
Further details are below.
Telephone triage and assessment
NHS practices throughout the UK are expected to make arrangements for patients with urgent dental needs to be triaged and assessed over the phone by a dentist during normal business hours.
Dentists should consult the Scottish Dental Clinical Effectiveness Programme's guidance on the Management of Acute Dental Problems during the COVID-19 Pandemic, which is the recognised protocol in England and Scotland. They should also familiarise themselves with the GDC’s principles for good practice in remote consultations and prescribing, the key element of which in the current context is risk assessment. The British Dental Association has published advice on risk assessments during the COVID-19 pandemic (this is only available to its members).
The official advice to practices in Wales and Northern Ireland allows for face to face assessments if strictly necessary (and subject to the clinical discretion of the dentist), so long as practice teams use ‘robust standard’ PPE procedures, and only see patients who are asymptomatic and who have a pre-agreed appointment following an initial assessment by phone. COVID-19 symptoms remain a new and continuous cough or a temperature of at least 37.8 degrees.
The advice given by the CDO for Scotland initially allowed for face to face assessments if strictly necessary and subject to the conditions described above. However we understand that subsequent advice issued by Health Boards, that no clinical care whatsoever should now take place outside of designated Urgent Dental Care centres, has superseded this.
Since the cessation of routine dental care, it has been understood that practices in England should not carry out face-to-face assessment or treatment under any circumstances, but no clear policy was articulated. In the CDO’s webinar on 3 April, it was briefly suggested that face-to-face care within general dental practice was appropriate in certain circumstances given the delays in establishing Urgent Dental Care centres, however it was then clarified that this should not take place. However the fourth letter of preparedness published on 15 April says that in the absence of a local Urgent Dental Care service, a dental practice may undertake non-AGP face-to-face dental assessment and care with Level 2 PPE and in accordance with the Standard Operating Procedure for Urgent Dental Care.
Remote prescribing and advice
Following triage and assessment, patients should be offered self-care advice by the dentist as necessary.
Appropriate prescriptions for analgesics and/or antimicrobials can be made by phone under the emergency supply provisions of the Human Medicines Regulations 2012, through which pharmacists can supply a medicine provided the dentist undertakes to provide a physical prescription within 72 hours. Photos of prescriptions do not fall within the definition of a legally valid prescription, but may be accepted pending provision of the hard copy. Dental prescribers experiencing difficulty in obtaining emergency supply of medicines from local pharmacies should contact their NHS Local Area Team and LDC as a matter of urgency.
As above, prescribing by phone should comply with the GDC’s principles for good practice in remote consultations and prescribing.
Antimicrobials should continue to be prescribed in a responsible manner and only where clinically indicated, and dentists should consult FGDP(UK)’s Antimicrobial Prescribing for General Dental Practitioners guidance.
This states that the prescribing of antibiotics for toothache, including acute pulpitis, is inappropriate as they are of no clinical benefit in managing dental pain. Analgesics can provide pain relief prior to provision of definitive treatment, and recommended drug regimens for dental pain relief in adults and children can be found here.
While non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can be prescribed, paracetamol is as effective for dental pain in most cases, and the government has advised on a precautionary basis that patients with suspected or confirmed COVID-19 take paracetamol in preference.
The guidance notes that antimicrobials may be appropriate where patients present with an acute dental infection for which definitive treatment has to be delayed because of a need to refer for specialist services due to an inability to establish drainage. It may therefore be appropriate to prescribe antimicrobials based on a provisional diagnosis, conducted remotely, of a swelling associated with an acute dental infection.
’Shielded’ / ‘clinically extremely vulnerable’ patients, who are those with these conditions, have been advised by the government not to leave home at all, so may need support for the delivery of prescriptions. Patients can register for shielding support as follows:
- England: register online or call 0800 028 8327
- Scotland: contact their local authority (details here) or call 0800 111 4000 (operates Monday to Friday, 9am to 5pm)
- Northern Ireland: email firstname.lastname@example.org, call 0808 802 0020 or text ‘ACTION’ to 81025
- Wales: patients are asked to first seek help from family, friends, carers or others in their community, or request help from voluntary organisations, before contacting their local authority
Ideally, any patient prescribed antimicrobials should be referred for definitive treatment in an urgent care setting to avoid repeat prescribing of antimicrobials. However, where urgent dental care are up and running, dentists are experiencing insufficient capacity to treat all dental patients who have been prescribed antimicrobials. In these circumstances, dentists in England and Scotland are expected to follow the SDCEP guidance on the Management of Acute Dental Problems during the COVID-19 Pandemic, which provides case definitions and recommendations in the context of remote assessment for self-care advice, prescribing, urgent care and emergency care for common dental presentations. SDCEP has supplemented this with guidance on drugs for the management of dental problems during the COVID-19 pandemic.
If a local Urgent Dental Care service is not available, the SDCEP guidance should still be consulted, and where necessary, a dental practice may undertake non-AGP face-to-face dental assessment and care in accordance with the Standard Operating Procedure for Urgent Dental Care (SOP). If the practice is unable to deliver face-to-face urgent care in accordance within the SOP, the local NHS Area Team should be asked to arrange referral to an out-of-area Urgent Dental Care centre.
Urgent care arrangements
In England, patients with urgent needs which cannot be provided remotely should be referred to new Local Urgent Dental Care arrangements, and referrals should identify those patients who are shielded. Most centres are now up and running, but where this not the case dental practices may undertake non-AGP face-to-face dental assessment and care with Level 2 PPE, but only when and as indicated by the accompanying Standard Operating Procedure for Urgent Dental Care (SOP).
The SOP states that conditions provided for by local Urgent Dental Care centres are likely to include, but are not limited to:
- Life-threatening emergencies, e.g. airway restriction or breathing/swallowing difficulties due to facial swelling
- Trauma including facial/oral laceration and/or dentoalveolar injuries, e.g. avulsion of a permanent tooth
- Oro-facial swelling that is significant and worsening
- Post-extraction bleeding that the patient cannot control with local measures
- Dental conditions that have resulted in acute and severe systemic illness
- Severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice
- Fractured teeth or tooth with pulpal exposure
- Dental and soft tissue infections without a systemic effect
- Suspected oral cancer
- Oro-dental conditions that are likely to exacerbate systemic medical conditions
In Scotland, patients with urgent needs which cannot be provided remotely should be referred to the designated local Public Dental Service or Hospital Dental Service urgent dental care centre. Centres are now up and running in every Health Board region, and practices should have been advised of local arrangements by their local Board.
In Wales, 15 urgent dental care centres are open. Details of how these work, including access details in each Health Board area, are here. Those with urgent needs which require, or have a high risk of requiring, an aerosol generating procedure, must have an appointment booked with the centre designated by their local Health Board.
In Northern Ireland, general dental practices are expected to continue delivering urgent care, following triage/assessment by phone and an examination, if it does not involve an aerosol generating procedure and the patient is asymptomatic for COVID-19. Out-of-hours centres are operating under the same restrictions as general dental practices, but for those requiring an aerosol generating procedure as amatter of urgency, five urgent dental care facilities have now been established.
The British Orthodontic Society has published a guide to orthodontic emergency centres.
Volunteering and redeployment
General dental practitioners throughout the UK are being asked to volunteer to be redeployed to support the NHS COVID-19 response. While an increasing number are staffing Urgent Dental Care centres, others will be asked to support NHS 111 as well as other types of healthcare in hospitals, care homes and other facilities.
The GDC supports the redeployment of dentists, including to undertake task beyond their usual scope of practice, but still requires them to ensure they are trained, competent and indemnified for the tasks they undertake. Under the Coronavirus Act 2020, the NHS provides indemnity for work undertaken while redeployed, but dental professionals are advised nonetheless to notify their usual indemnity provider of the roles they will be performing.
Those in England willing to be redeployed, whether for face-to-face or telephone-based work, should complete this online form. NHS England says over 15,000 dental professionals have volunteered so far.
NHS England’s publication, Deploying the clinical dental workforce to support the NHS clinical delivery plan for COVID-19, maps the skills of different members of the dental team to roles in which they might be redeployed, indicating what training, if any, would be necessary to fulfil them.
For those who cannot, or prefer not to, redeploy, another option is to sign up as an NHS Volunteer Responder to help with tasks such as transport and community support. There are also telephone-based roles for those deemed at higher risk.
The Dental Wellness Trust is asking dental practices to donate toothbrushes and toothpaste to local care homes and hospices.
Communications from the CDOs
Recent communications to dental practices from the Chief Dental Officers for England, Scotland and Wales, and the Acting Chief Dental Officer for Northern Ireland, are below:
8 April - Redeployment
25 March - Preparedness letter (issue 3)
20 March - Preparedness letter (issue 2)
6 March - Preparedness letter (issue 1)
27 February - Standard Operating Procedure for Primary Care (since withdrawn)
12 February - Interim advice for primary care (since withdrawn)
9 April - Redeployment
30 March - Enhanced financial support
23 March - Cessation of routine dental care
22 April - Redeployment
3 April - Red alert phase escalation
26 March - Financial support
23 March - Red alert
17 March - Amber alert
20 April - Clinical negligence indemnity for GDPs
28 March - Further update on COVID-19 preparation
26 March - Complaints handling
20 March - Financial support to General Dental Services
16 March - Practice preparations
5 March - Practice preparations
27 February - Face Mask Shortage
Routine vs urgent care
Definitions of routine, urgent and emergency care are provided in the SDCEP guidance on emergency dental care and NHS England commissioning standard for urgent dental care:
Routine dental problems are those for which self-help advice and/or access to treatment within seven days would normally be required, and include:
- Mild or moderate pain: that is, pain not associated with an urgent care condition and that responds to pain-relief measures
- Minor dental trauma
- Post-extraction bleeding that the patient is able to control using self-help measures
- Loose or displaced crowns, bridges or veneers
- Fractured or loose-fitting dentures and other appliances
- Fractured posts
- Fractured, loose or displaced fillings
- Treatments normally associated with routine dental care
- Bleeding gums
The SDCEP guidance suggests that approximately 25% of ‘emergency’ phone calls are likely to fall into its ‘advice, self-help and routine care’ category.
Urgent dental problems are those for which self-help and access to treatment within 24 hours would normally be required, and include:
- Dental and soft-tissue infections without a systemic effect
- Severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice
- Fractured teeth or tooth with pulpal exposure
The SDCEP guidance suggests that approximately 75% of ‘emergency’ phone calls are likely to fall into the ‘urgent care’ category.
Dental emergencies are those conditions that require contact with a dentist within an hour, and include:
- Trauma including facial/oral laceration and/or dentoalveolar injuries, for example avulsion of a permanent tooth
- Oro-facial swelling that is significant and worsening
- Post-extraction bleeding that the patient is not able to control with local measures
- Dental conditions that have resulted in acute systemic illness or raised temperature as a result of dental infection
- Severe trismus
- Oro-dental conditions that are likely to exacerbate systemic medical conditions such as diabetes (that is lead to acute decompensation of medical conditions such as diabetes)
The SDCEP guidance suggests that approximately 1% of ‘emergency’ phone calls are likely to fall into the ‘emergency care’ category.
A categorisation of common dental conditions into routine, urgent and emergency is also contained in Appendix 1 of the Red Alert advice issued in Wales.
Aerosol Generating Procedures
Public Health England’s COVID-19 guidance for infection prevention and control in healthcare settings states that ‘human coronaviruses can survive on inanimate objects and can remain viable for up to 5 days at temperatures of 22-25°C and relative humidity of 40-50% (which is typical of air-conditioned indoor environments)’, and highlights the risk of ‘extensive environmental contamination’ from the use of ‘potentially infectious Aerosol Generating Procedures’ including ‘some dental procedures’.
The CDOs previously advised a reduction in aerosol generating procedures, and have now – to the extent that dental practice is continuing - advised the cessation of all aerosol generating procedures. The non-exhaustive lists of procedures falling and not falling into this category, as previously advised by the CDO for Scotland, remain relevant:
Aerosol Generating Procedures (AGPs):
- Use of high speed handpieces for routine restorative procedures
- Use of Cavitron, Piezosonic or other mechanised scalers
- Polishing teeth
- High pressure 3:1 air syringe (“NB Risk of aerosols could be reduced when using a 3:1 if only the irrigation function is used, followed by low pressure air flow from the 3:1 and all performed with directed high volume suction. Dry guards, cotton wool or gauze can also help with drying and moisture control”)
Opening teeth for drainage has since been added to this list.
- Hand scaling with suction
- Non-surgical extractions (“NB If this became a surgical extraction, a slow speed reducing handpiece could be used for bone removal, with cooling provided using saline dispensed via a syringe along with high speed suction. If this is not a suitable option, temporisation or referral would need to be considered”)
- Removable denture stages
- Removal of caries using hand excavation or slow speed handpiece if necessary
However dental professionals providing face-to-face urgent care may wish to take note of guidance from the British Association of Oral Surgeons and British Association of Oral and Maxillofacial Surgeons which advises that all urgent dental procedures, including oral examination, are treated as aerosol-generating.
We understand that an official review of which dental procedures are classified as aerosol-generating, and their safety in the current context in view of the close proximity of dentists to their patients, is imminent, and that this will include consideration of the use of suction and 3-in-1.
Personal Protective Equipment
The public health agencies of the four UK nations issued updated policy on the use of personal protective equipment. This allows for disposable respirators, facemasks and eye protection to be used throughout a clinical session if not otherwise compromised (though aprons and gloves should continue to be changed on a single-use basis). Patients with possible or confirmed COVID-19 should now wear a surgical face mask in clinical areas, communal waiting areas and during transportation, except where this could compromise their clinical care.
The core government policy on equipment to be worn remains:
PPE for healthcare workers delivering or assisting with an aerosol generating procedure:
• FFP3 (filtering face protector, class 3) respirator
• long sleeved disposable gown
• eye protection (disposable goggles or full-face visor)
PPE for all other procedures - even for patients with possible or confirmed COVID-19:
• fluid repellent facemask
• eye protection if there is a risk of splashing or exposure to respiratory droplets
Dental professionals should also consider the updated joint guidance on PPE from the British Association of Oral & Maxillofacial Surgeons and British Association of Oral Surgeons. Their original advice recommended that:
- all urgent dental procedures, including oral examination, are treated as aerosol-generating in terms of PPE
- an FFP3 mask is covered by either a surgical mask or visor
- an FFP3 mask can be worn for an entire day or session
The updated advice states:
- Policy should not be compromised because of capacity. Public Health England guidance represents a useful minimum, not a mandated maximum level of PPE, and clinical judgement is always needed.
- Re-using FFP3 masks, in line with Public Health England guidance, creates additional risks which may in some cases be greater than using a surgical mask
- If your patient pathway does not support using a single FFP3 mask beneath a full face visor for a whole session that is likely to include an Aerosol Generating Procedure, consider using a waterproof surgical mask under the visor for short examinations or treatments with low Aerosol Generating Exposure potential.
Cochrane Oral Health has published a commentary for the dental and oral health care team on PPE. Dentists may also be interested to read the commentary from the COVID-19 PPE rapid review team at the Oxford Centre for Evidence-Based Medicine.
A number of practitioners have asked about the efficacy of patients using mouthwash prior to examination or treatment as a means of reducing transmission risk. We understand that NERVTAG (the New and Emerging Respiratory Virus Threats Advisory Group), which is advising the government on the threat posed by Covid-19, has considered this for NHS England and found no evidence to support it. However it is up to individual practitioners to consider whether to adopt this measure, in addition to other precautions, if there is no risk to the patient from doing so.
The Chief Dental Officers have instructed that all routine orthodontic care cease throughout the UK in both NHS and private practice.
The British Orthodontic Society has issued a Covid-19 guide to the management of orthondontic emergencies and advice for patients undergoing orthodontic treatment during the COVID-19 pandemic. Providers may also wish to consult its guidance on virtual consultations for emergency triage and advice and guide to orthodontic emergency centres.
The Chief Dental Officers have instructed that all routine endodontic care cease throughout the UK in both NHS and private practice.
The British Endodontic Society has published guidance for primary dental care on the triage and management of dental pain likely to be of endodontic origin and on the diagnosis and management of endodontic emergencies during COVID-19.
NHS dental practices are advised to maintain good audit trails tracking the effect of the pandemic on their service delivery.
Though there is no framework to claim for activity or apply patient charges for a service delivered by phone, NHS England has advised providers to keep a manual record of patient contact/triage with a view to informing contract management arrangements for 2020/21. NHS Greater Manchester advice includes:
- Maintaining records of staff and dentist absence and the reason for the absence
- Recording days when the practice is unable to open
- Maintaining records of other work carried out within the practice as a result of patients not being seen (updating policies and undertaking audits, for example) to demonstrate that time spent not seeing patients was used constructively and contributed to the improvement of patient services
- Maintaining records of any other work undertaken at the request of the NHS
The DDU recommends that:
- practitioners keep a log of when they checked the COVID-19 advice so they can demonstrate what they have done to stay up to date
- each practice or department appoints a lead person with responsibility for checking the relevant advice regularly and disseminating it
- practitioners make sure to view documents from a website rather than relying on a saved copy, to make sure you are working from the most up-to-date guidance.
The BDA has published advice on record keeping during the COVID-19 pandemic, though this is only available to its members.
To ensure the continued viability of practices, the NHS has given some reassurance of continued remuneration during the coronavirus pandemic, and practices may be able to access wider government support for small businesses.
Practices in England may continue to receive monthly NHS income, less a deduction for variable costs. However practices receiving continued NHS income must continue to pay 100% of the salaries of staff and associates, and will not be eligible to apply for wider coronavirus-related assistance for the NHS proportion of their revenue.
Practices in Scotland have been told that they will receive 80% of their usual NHS Item of Service and patient contribution income. The BDA has published a briefing on the financial support available for dentists and practices in Scotland.
Practices in Wales will continue to receive monthly NHS income, and should continue to submit FP17Ws for any patients with urgent care needs that they see. Earlier advice pledged that monitoring and UDA targets would be ‘relaxed or suspended’, however to date only a 4% relaxation, representing two weeks’ lost practice, has been offered. Significant concerns remain over the position of mixed NHS-and-private practices.
NHS practices in Northern Ireland can apply to receive 80% of their expected NHS income, though this may be recovered in future years.
Accountancy firm UNW has published advice on the financial impact of COVID-19 for dentists and dental practices, as well as Viability Planning Forecast templates for dental practices and a 12-week cashflow forecast template.
Wesleyan has published a business continuity infographic.
Details of the support available to dental practices are also available on the BDA’s coronavirus financial impact page.
The National Association of Specialist Dental Accountants and Lawyers (NASDAL) has issued a ‘guide to the current financial state of play’ for dentists and dental practices, covering:
- Local council grants
- Self-employed support (SEISS)
- NHS actions and 2020/21 payments
- Private practice
- Mixed practices and associate remuneration
- Associate Plan income
The British Orthodontic Society (BOS) has released legal guidance for practice owners – which may be of interest to the wider profession - to assist with Covid-19-related issues including:
- Holiday and Sickness Leave issues
- Associates and non-employees
- PDS contracts
- GDC obligations
- Employment issues
- Data Protection
The Care Quality Commission has said that dental providers do not need to inform it if they are closing temporarily, or only managing emergency cases, as a result of COVID-19.
The CQC has also said that providers can apply for a fast, free DBS check for staff or volunteers they need to start work urgently as a result of the pandemic.
The GDC has said that it will be sympathetic to those registrants who are unable to maintain their CPD responsibilities in present circumstances.
All healthcare staff, including NHS dentists and dental care professionals, are classified as key workers for the purposes of the pandemic. This means that otherwise-closed schools and nurseries should continue to provide education and childcare to their children so they can continue working.
Members of the Medical and Dental Defence Union of Scotland will have their subscriptions markedly reduced from April - by around 75% for full time dentists.
The Dental Defence Union is offering its members 'reduced subscriptions and prompt refunds tailored to individual circumstances' on application.
BDA Indemnity is reducing subscriptions by around 70-80% for Associate Dentists and 65-70% for practice owners.
Practice Plan and DPAS are giving client practices half of their monthly admin fee back in April and May. This will be paid into their accounts automatically on their normal payment date.
NHS Education for Scotland has issued checklists of actions for dental practices at and during closure.
Practitioners are also reminded that the BDA Benevolent Fund supports dental students, dentists and their families in financial need, irrespective of whether they are or were members of the BDA. Available 9.30am - 5.30pm Monday to Friday, call 020 7486 4994 or email email@example.com.
Emotional and health support
Confidental is a helpline offering emotional support and signposting for dentists from a team of trained volunteer dentists. Freephone 0333 987 5158, 24 hours a day.
Denplan is offering its dentists and their employees free access to a virtual GP service, and a 24/7 helpline offering advice on a range of health, lifestyle, legal and wellbeing issues, until 31 July. To access the service, email DenplanGP@simplyhealth.co.uk.
The NHS Practitioner Health Programme offers specialist therapeutic support to dentists in England experiencing mental ill health or addiction problems can (whether or not they practice under an NHS contract). Available 8am – 8pm Monday to Friday and 7.30am to 2.30pm on Saturdays, freephone 0300 030 3300.
Urgent care recommendations for dental specialities are available on the website of the Faculty of Dental Surgery (RCS England).
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