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Dental wear and oral pathology Possible evidence and consequences of habitual use of teeth in a Swedish Neolithic sample.

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Dental Wear and Oral Pathology: Possible Evidence
and Consequences of Habitual Use of Teeth in a
Swedish Neolithic Sample
Petra Molnar*
Osteoarchaeological Research Laboratory, Department of Archaeology and Classical Studies, Wallenberglaboratoriet,
Stockholm University, 106 91 Stockholm, Sweden
Pitted Ware Culture; Gotland; Ajvide; dental lesions; extramasticatory wear
Atypical wear and oral lesions were
studied in the dental remains from the Middle Neolithic
Pitted Ware Culture site Ajvide on the island of Gotland
in the Baltic Sea. Teeth (n 5 764) from 17 males and 11
females were examined microscopically to document unusual wear, assess wear patterns and oral lesions as evidence of habitual behavior, and determine their effect on
the oral health of this population. Five atypical wear
types were observed: occlusal facets, occlusal excessive
load, labial vertical striae, labial horizontal striae, and
interproximal striae. Three oral lesions were recorded:
chipping, periapical lesions, and dental tilting. Results
indicate that teeth were used in a habitual manner at
Ajvide, based on the morphology and regularity of the
patterns of atypical wear. Differences were observed
between the sexes, indicating gender-related differences
in the habitual use of teeth. Some wear categories
showed a significant correlation with age, signifying
increased or accumulated wear with age. Statistically
significant positive correlations were found in the molars
between occlusal excessive load wear and periapical
lesions as well as tilting. Other apparent links were also
observed between chipping and vertical striae as well as
excessive load, although these were not significant. This
suggests a relationship between dental wear and dental
pathologies at this site, suggesting that habitual use of
teeth indirectly affected the general oral health at the
site. Wear patterns, furthermore, seem to mirror both
frequent activities as well as single events. Am J Phys
Anthropol 136:423–431, 2008. V 2008 Wiley-Liss, Inc.
Dental remains and dental wear patterns observed in
prehistoric remains have provided valuable information
for deducing past lifeways. Particularly, expressions such
as ‘‘using teeth as tools’’ and ‘‘as a third hand’’ have been
used to describe dental modification in dental samples
indicative of habitual behavior, as well as social factors
such as sexual division of labor and specific physical
activities (Molnar, 1971; Schultz, 1977; Larsen, 1985;
Lukacs and Pastor, 1988; Milner and Larsen, 1991;
Larsen et al., 1998; Bax and Ungar, 1999).
The impact of dietary and social habits on dental wear
has also been studied in association with environmental
stress and dental and other oral pathology. Lesions of
the teeth and jaws have also been linked to dental wear;
for example, chipping, periapical lesions, tilting, and
temporomandibular joint disease (Merbs, 1983; Reinhardt, 1983; Comuzzie and Steele, 1989; Clarke and
Hirsch, 1991; Larsen, 1997; Alt et al., 1998; Kieser et al.,
2001; Bonfiglioli et al., 2004; Eshed et al., 2006). The
documented relationship between certain dental wear
patterns and oral pathology raises questions regarding
the effects of habitual use of teeth on the oral and general health in prehistoric society.
The dental sample for this study is derived from the
burial ground at Ajvide on Gotland off the east coast of
southern Sweden in the Baltic Sea (see Fig. 1). Individual graves have been dated to ca. 2750-2300 BC (Burenhult, 2002), that is, Middle Neolithic Pitted Ware Culture in Sweden. The proximity to the sea, stable isotope
analyses of human remains, and the archaeofauna
strongly suggest a marine diet of mainly seals and fish
(Lidén, 1996; Lindqvist and Possnert, 1997; Storå, 2001;
Eriksson, 2003). There is no evidence of the domestication of animals or the use of cereals at the site.
Owing to the calciferous soils, the skeletal remains
and material culture from Pitted Ware Culture settings
on Gotland are exceptionally well preserved in comparison with contemporary sites along the Swedish eastern
coastline. The sample from Ajvide, therefore, provides
the means for a more detailed study of the physical lifestyles of a hunter-gatherer and fishing population living
in Baltic area during the Neolithic.
During the initial examination of the Ajvide remains,
several atypical dental wear features were observed.
This wear varied notably from ‘‘normal’’ mastication
wear in location, intensity, direction of striae, and in the
general appearance. Dental pathologies such as periapical lesions, tilting, and chipping were also recorded, and
C 2008
Grant sponsors: Berit Wallenbergs Foundation, Emil and Lydia
Kinanders Foundation, Gunvor and Josef Anérs Foundation, DBW’s
Foundation, Wilhelmina von Hallwyhls Gotlandsfond, Mårten Stenbergers Stipendiefond.
*Correspondence to: Petra Molnar, Osteoarchaeological Research
Laboratory, Department of Archaeology and Classical Studies,
Wallenberglaboratoriet, Stockholm University, 106 91 Stockholm,
Sweden. E-mail:
Received 30 March 2007; accepted 24 January 2008
DOI 10.1002/ajpa.20824
Published online 26 March 2008 in Wiley InterScience
Fig. 1. The location of Gotland and Ajvide in the Baltic Sea.
some of the oral lesions furthermore seemed to co-occur
with certain wear patterns. There was a complete absence of carious lesions, and low levels of calculus formation, indicating a generally good oral health.
In addition, a previous study on musculoskeletal stress
marker patterns from the site indicated a division of
labor between the sexes (Molnar, 2006). Sex-related differences in patterns of dental wear and oral lesions
would further substantiate this proposal and aid in
improving our understanding of lifeways on Middle Neolithic Gotland.
Inconsistencies in wear patterns were noted between
upper and lower dentitions using Brothwell’s (1981) classification, potentially presenting a dilemma in interpreting dental wear patterns that may be related to age.
These features prompted a detailed study to gain insight
into the general dental wear patterns and possible relationships between wear and oral pathology observed in
the hunter-gatherer and fishing community at Ajvide.
Such a link would highlight the possible effects of extramasticatory use of teeth on the general oral health status of a population.
The aims of this study are to a) document atypical
dental wear patterns as well as dental pathologies at
Ajvide; b) assess probable extramasticatory behavior at
Ajvide through noted wear patterns and oral lesions;
and c) explore a possible link between specific wear patterns and dental pathologies, and thus gain some insight
into the oral health status at Ajvide.
A total of 764 teeth from 17 adult males and 11 adult
females from Ajvide were included in the study. All teeth
were examined under a Motic binocular microscope at
310–340 magnification. Individuals with five teeth or
less were omitted (n 5 32). Three age groups were
employed to study age-related changes in wear patterns
and associated dental lesions: young adults, 17–24 years;
American Journal of Physical Anthropology
middle adults, 25–39 years; and old adults, [40 years.
For ageing and sexing of the skeletal remains, methods
described in Buikstra and Ubelaker (1994) were mainly
used. For sexing the coxae, the ventral arc, subpubic
concavity, and ischiopubic ramus ridge was used (Phenice, 1969). The greater sciatic notch and preauricular
sulcus was scored according to Milner (1992). For the
cranium, the nuchal crest, mastoid process, supraorbital
margin, glabella, mental eminence were used (Acsadi
and Nemeskeri, 1970). For age assessment, the pubic
symphysis (Brooks and Suchey, 1990) and the auricular
surface (Lovejoy et al., 1985; Meindl and Lovejoy, 1989)
were used. Cranial suture closure was also used according to Meindl and Lovejoy (1985). Brothwell’s classification of age, based on the molar wear was used for age
estimation, even though it proved complex with some
inconsistent results for upper and lower dentitions
(Brothwell, 1981).
All individuals were assigned to the same age groups,
whether dental wear was included or not as an age criterion in the age assessments. This suggests accordance
between dental wear and postcranial age assessment
methods, and reduces potential problems related to the
effects of age on dental wear.
Correlations between wear types and pathological features were carried out using Spearman’s rank order correlation coefficient. Furthermore, v2 tests were employed
for comparisons of absolute frequencies between the
sexes. SPSS for windows, version 15.0 was used and
accepted a values were set at 5%.
Observed dental wear at Ajvide
‘‘Normal’’ wear was present on all dental surfaces in
the sample and distinguished by faint irregular striae
and abrasive marks resulting from mastication and from
food substances being present in the oral cavity.
Five distinctive types of atypical dental wear were
documented by morphology and location: two on the occlusal surfaces, two on the labial surfaces, and one interproximally. Three dental lesions were recorded; chipping,
periapical lesions, and dental tilting. All wear types and
lesions were recorded as present or absent on each tooth
for every individual. Relative frequencies for tooth type
were calculated by the number of cases displaying the
particular wear, divided by the number of present teeth
in that tooth category for males and females independently.
Occlusal facets. This wear is characterized by two or
more facets of striations with rough or smooth appearance on the same occlusal dentine surface in worn teeth
(see Fig. 2).
Occlusal excessive load. Homogenous, excessive wear,
i.e., little or no enamel is present on the occlusal surface
of molars and on occasion premolars. The excessive wear
is in many cases oblique and more severe in the lower
jaw than the upper. This wear is equivalent to Brothwell’s (1981;72) categories 51, 511, 6, and 7 (see Fig. 3).
Extensive molar wear has been discussed previously
and also in relation to habitual use of teeth (see for
example Reinhardt, 1983; Clarke and Hirsch, 1991;
Kamegai, 1993; Littleton and Frohlich, 1993; Kieser
et al., 2001).
Labial vertical striae. This wear is distinguished by
vertical or occasionally slightly angled striations on the
Fig. 2. Occlusal facets. Left: old adult male, upper left first incisor; Right: old adult female, upper right first incisor. Outer limits
of facets are outlined.
Fig. 3. Occlusal excessive load. Left: middle adult male; Right: old adult male. Affected teeth indicated by arrows.
Fig. 4. Labial vertical striae. Left: middle adult female, upper right second incisor; Right: middle adult male, upper left
labial surface adjacent to the occlusal surface. These can
range from a few thin and short striae on the enamel to
very marked, long, and numerous scrapes on the enamel
or dentine (see Fig. 4).
Labial horizontal striae. One or a few labial horizontal cut marks are close to the occlusal surface. The wear
is equal to what has been referred to as ‘‘stuff and cut’’
wear, attributed to the holding of a piece of meat
between the front teeth and cutting it off with a sharp
instrument (Koby, 1956; Brace, 1975; Bax and Ungar,
1999) (see Fig 5).
Interproximal striae. Striations located on both mesial
and distal surfaces of the teeth at the cement-enamel
junction and in a labial/lingual direction. Interproximal
wear (or grooving) has commonly been interpreted as the
result of ‘‘toothpicking,’’ or fibers or sinews being worked
between the teeth (Ubelaker et al., 1969; Lukacs and Pastor, 1988; Brown and Molnar, 1990; Bonfiglioli et al.,
2004) (see Fig. 6).
American Journal of Physical Anthropology
Fig. 5. Horizontal striae. Left: old adult male, upper left first incisor; Right: young adult male, upper left first incisor.
Fig. 6. Interproximal striae. Left: old adult male, upper left second incisor; Right: old adult male, upper left first premolar.
Oral lesions
Chipping. ‘‘Chipping is an antemortem irregular crack,
involving enamel or enamel and dentine, situated on the
buccal, lingual, or interproximal edge or crest of the
tooth’’ (Bonfiglioli et al., 2004). It has been attributed to
the ‘‘crushing of hard substances such as bone’’ by the
Inuit (Turner and Cadien, 1969) and the presence of
seeds and gravel in grains (Molleson and Jones, 1991).
Small lesions often occur in prehistoric dental remains
and, according to Lukacs (2006), are not usually limited
to any region of the dental arch (see also Milner and
Larsen, 1991). During examination, dental chipping was
recorded according to the grades (1–3) of Bonfiglioli et
al. (2004). However, presence or absence of the lesion
was recorded for better comparability with methods used
to record wear patterns and other lesions in this study.
Periapical lesions. Periapical lesions are initiated by
an infection in the pulp (pulpitis), followed by bacteria
spreading through the apical foramen. A range of pathological conditions can cause pulpitis, for example, caries
infections, severe wear, or dental trauma. The result is a
radicular cyst, periapical granuloma, or an abscess. An
infection of this kind can result in severe pain, and Alt
et al. (1998) suggested that on occasion periapical lesions
and subsequent osteomyelitis would have been fatal in
prehistory (see also Dias and Tayles, 1997). In anthropological studies, the term ‘‘abscess’’ is often used to
describe all cavities in the radicular area. Making a correct diagnosis is difficult; therefore, the term ‘‘periapical
lesion’’ is more suitable. Periapical lesions were recorded
according to Lukacs (1989). However, only the presence
American Journal of Physical Anthropology
or absence was used to record this lesion for more accurate comparisons within the present study.
Lingual tilting. The force of severe attrition and/or abrasion may bring a tooth to become dislocated from its
original position in the jaw. Emerging periapical lesions
around worn teeth, probably, also contributed to this process. Lingual tilting has been noted to occur in association with excessive wear under the term ‘‘severe attrition
syndrome’’ (Reinhardt, 1983). Presence and absence of
tilting was recorded for each tooth.
The frequencies and distributions of the five wear patterns are presented in Figures 7 and 8. Atypical wear
was noted in the entire dental arch; however, there were
differences between the wear types in frequency and
location. Occlusal excessive load occurred in the distal
regions of the jaw, while the other four wear categories
occurred in the mesial regions and some in the premolar
area as well. The interproximal striae seemed were more
randomly spread, but with an inclination to the front
part of the mouth. Tilting and periapical lesions occurred
in the distal regions, mainly the first and second molars,
whereas chipping was present in the entire dental arch
(see Fig. 7). One individual only, a middle adult male
lacked atypical wear, however exhibited chipping.
Sex-related wear patterns
The distributions and frequencies of each wear type
exhibited similar patterns for males and females (Table 1).
Fig. 7. Regional distribution of the five atypical wear types and three oral lesions.
Fig. 8. Relative wear frequencies for (A) occlusal facets, (B) occlusal excessive load, (C) labial vertical striae, (D) labial horizontal striae, and (E) interproximal striae.
Females, however, had notably higher frequencies of labial horizontal striae, and males had higher frequencies
of periapical lesions; however, none of these differences
were statistically significant. Noteworthy differences
between males and females were observed in
bution of labial vertical striae in both upper
dentitions. Females had significantly higher
of this wear type in the incisor areas in the
the distriand lower
upper jaw
American Journal of Physical Anthropology
(v21 5 3.84, P \ 0.01), and males had significantly higher
frequencies in the canine areas in the lower jaw (v21 5
3.831, P \ 0.01). Both occlusal facets and interproximal
striae displayed a narrow central distribution for the
females, while the males had a wider spread of these
wear types. However, none of these differences were
statistically significant (see Fig. 8).
Atypical dental wear patterns
At Ajvide, males and females showed similar patterns
of dental wear and oral lesions. However, there were
obvious and significant differences in the atypical wear
distributions. In males, the occlusal facets (Fig. 8A), occlusal excessive load (Fig. 8B), and interproximal striae
(Fig. 8D) showed a wider regional spread in the dental
arch, whereas females showed a wider spread of labial
horizontal striae (Fig. 8E). For most wear types, female
wear patterns displayed a smaller range than the males.
There were two exceptions in the case of labial horizontal striae, the situation was reversed, and in labial vertical striae, where both sexes exhibited similar intensity
of wear.
Age-related wear patterns
Frequencies of occlusal facets, occlusal excessive load,
and interproximal grooving increased from the young
age group to the old. Chipping, periapical lesions, and
tilting also increased with age in both males and females
(Table 2). Patterns for horizontal striae and vertical
striae displayed the opposite pattern with decreasing frequencies with older age, though not as apparent. However, small sample sizes prevented significance testing
and further statistical treatment.
Extramasticatory wear at Ajvide?
A number of features imply that the wear patterns are
results of extramasticatory use of teeth at Ajvide: The
morphology of the dental wear, the noted differences
between the sexes, the increase and decrease of expressions with age, and the link of certain wear types to oral
pathology. The wider wear distribution seen in males of
occlusal facets, occlusal excessive load, and interproximal striae indicates that they may have used their teeth
more intensely during certain activities than females. A
larger proportion of the females, on the other hand,
seem to have used the ‘‘stuff and cut’’ technique. The
diverging distribution of the labial vertical striae
between the sexes suggests a similar activity, but evidently carried out in a different manner by males and
females (see Fig. 8C).
Occlusal facets, occlusal excessive load, and interproximal striae increased with older age, which indicates an
intensification and/or accumulation with age. In the case
of labial horizontal striae, the circumstances were
reversed. The horizontal striae were located close to the
occlusal surface and the place of impact when clenching
teeth. Progressively, when teeth were worn down and
the horizontal marks wore away, new marks were produced. The older individuals from Ajvide, however, may
no longer have carried out the action, or acquired precision with age. The absence of certain wear does not substantiate that it was never present. What is observed is
recent behavior, and traces of activities performed earlier in life are replaced by newer ones. If a particular
wear is not observed, the activity has not been performed lately or, indeed, at all.
The occlusal facets were not caused by an antagonist
tooth, as many facets occurred and often overlapped on
Wear patterns and oral pathology
High frequencies of chipping occurred in the incisor
areas for females and in the canine regions for males.
High incidences were also noted in the molar regions for
both sexes. Similar distributions were also observed for
labial vertical striae and chipping as well as for occlusal
excessive load and chipping (see Fig. 9) for both sexes.
However, no statistically significant positive correlations
were obtained in the molar region neither between chipping and vertical striae nor between chipping and occlusal excessive load.
The distribution for excessive load wear coincided with
both periapical lesions and tilting (see Fig. 10), where
significant positive correlations were obtained for most
molars in the lower jaw for both sexes (Table 3).
TABLE 1. Sex distribution of wear patterns at Ajvide, absolute,
and relative frequencies
(n 5 17)
(n 5 11)
(n 5 28)
Wear type
Occlusal facets
Occlusal excessive load
Labial vertical striae
Labial horizontal striae
Interproximal striae
Periapical lesions
TABLE 2. Age distribution of wear patterns at Ajvide, absolute, and relative frequencies
(n 5 4)
(n 5 6)
(n 5 7)
(n 5 3)
(n 5 5)
(n 5 3)
Wear type
Occlusal facets
Occlusal excessive load
Labial vertical striae
Labial horizontal striae
Interproximal striae
Periapical lesions
American Journal of Physical Anthropology
Fig. 9. Relative frequencies for each tooth type for chipping,
occlusal excessive load, and labial vertical striae for (A) males
and (B) females.
Fig. 10. Relative frequencies for each tooth type for periapical lesions, tilting, and occlusal excessive load for (A) males and
(B) females.
the same tooth, and did not match the antagonist. The
striations in the facets had a distinct lateral or forward
direction, which indicates a sideways or forward movement during purposeful actions.
The most probable origin for the occlusal excessive
load is a combination of both masticatory and extramasticatory wear. Molars were undeniably used for the mastication of food substances, and were in constant use.
The first molar, in most cases the most worn tooth,
erupts at 6 years of age and was in use over a long time.
Nevertheless, extreme wear and occlusal excessive load
may also have been a result of preparation of fibers, sinews, or other materials by chewing or pulling them
between clenched teeth. Whether extramasticatory in origin or not, the severe wear has led to pathological conditions causing infections and distortion of the teeth and
jawbone in 50% of this population (83% in the combined
old adult age groups). This implies a more severe strain
than from regular mastication alone.
Labial vertical striae occurred in small numbers and
up into the hundreds, and were sometimes very marked
(see Fig. 4). Such severe scratch marks on the enamel
could have been made with a forceful motion using a
hard substance made of wood, bone, or even stone. Based
on the striae morphology and position, a proposal for a
causing agent is an implement being held steady against
the labial surface, close to the occlusal surface of a tooth
TABLE 3. Excessive load wear correlations with periapical
lesions and tilting in molars
Right side
Left side
Periapical lesions n.s.
n.s. n.s.
n.s 0.427*
n.s. n.s.
Periapical lesions n.s. 0.527** 0.527** 0.632** n.s. n.s.
n.s. 0.512** 0.673** 0.714** 1.0** 1.0**
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).
in the lower jaw, moving the upper jaw up and down (or
vice versa). The severity of the single scratch marks indicates that the tooth would have worn down entirely, had
it been caused by a very frequently performed activity.
This suggests that it was not an action that was performed on a daily basis.
The horizontal striae appeared as distinct features and
occurred only in few numbers, usually between one and
three on one tooth. These characteristics support the ‘‘stuff
and cut’’ hypothesis. Their distribution was somewhat different between the sexes, being more central in the males,
in both upper and lower dentitions. Offering explanations
American Journal of Physical Anthropology
for these patterns would be merely speculative; however,
the difference between the sexes is noteworthy.
Plausible etiologies for interproximal grooving in a Pakistani sample were discussed by Lukacs and Pastor (1988)
as follows: the use of a toothpick for therapeutic or habitual reasons; the working of fibrous material between the
teeth; and chemical erosion. They conclude that habitual
probing was the most common cause of interproximal
grooving in the sample. At Ajvide, the appearance of the
interproximal striations and their entirely labial/lingual
orientation, do not indicate either occupational working of
fibers or chemical erosion. This conclusion is based on
their orientation as well as the fact that the striae occur in
a limited area on the interproximal surface. These areas
are well defined, excluding chemical erosion as a probable
cause. When sinews or fibers are pulled between the teeth,
the marks extend to include adjacent labial or lingual surfaces, as the fiber is being drawn around the base of the
crown. In addition, task-related grooves are often found in
the molar and premolar areas (Brown and Molnar, 1990).
At Ajvide, the interproximal striae occur in the easily accessible canines, incisors, and premolars.
Oral pathology
The dental pathologies examined in association with
extramasticatory wear have shown clear patterns and
correlations. For females, chipping was associated with
labial vertical wear, and high frequencies were recorded
in the incisor areas (Fig. 9B). For males, relatively
higher frequencies of chipping as well as vertical striae
were observed in the canine and first premolar areas.
However, frequencies were notably lower than those of
the females in the incisor areas. Statistical testing
showed no significant positive correlations, although the
pattern is noteworthy. A further relationship between
chipping and occlusal excessive load wear was observed
in both sexes, though less evident than between chipping
and vertical striae (Fig. 9A,B).
Activities that cause severe wear, thus, exposing and
accessing the pulp can lead to periapical infection. The
infection then causes reduction of bone around the apex,
and this in turn may lead to severe tilting. As in other
studies (Clarke and Hirsch, 1991; Kieser et al., 2001),
the present one has also shown statistically significant
correlations between severe attrition attributed to functional strain and periapical lesions as well as tilted
teeth. The patterns of dental wear that were found to
correlate with dental and oral lesions are thus likely to
be results of the same actions that also produced chipping, periapical lesions, and tilting.
The use of teeth as tools seem to have affected the
general oral health by causing dental lesions such as
periapical lesions, and also indicating a division of labor
or varying practices between the sexes, as described earlier (Molnar, 2006).
The observed patterns of dental wear suggest the use
of teeth in a habitual manner at Ajvide. In general, the
atypical wear noted in the sample show similar patterns
for males and females. However, sex-specific differences
were observed between wear types indicating genderrelated diversity in the extramasticatory use of teeth at
Ajvide. A social division of labor by age is furthermore
implied by age differences observed in several wear patAmerican Journal of Physical Anthropology
terns. Activities performed regularly are visible in excessive load wear, which is more severe in individuals of old
age and most likely has been produced over a long time.
The horizontal striae, in contrast, are solitary cut marks
created during one or a few events.
The five wear types that were distinguished are each
likely to have represented a corresponding physical
action. Some patterns were interpreted as the results of
a specific activity, for example, the ‘‘stuff and cut’’ technique or tooth picking, while other causing agents
remain tentative.
The similar patterns of occlusal excessive load, periapical lesions, and tilting in molars furthermore suggested
a relationship between habitual use of teeth and its
effects on general oral health. Furthermore, occlusal excessive load as well as labial vertical striae were linked
to dental chipping and thus likely also a common causing agent.
The author thanks Jan Storå for his committed support. The author also thanks Göran Burenhult and the
late Inger Österholm for graciously providing the skeletal remains from Ajvide and Noël Layton Goksör for
proof reading and improving the English language. The
anonymous reviewers and the editors are acknowledged
for their valuable comments. The late Ebba During is
also recognized for all her support.
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pathologic, wears, habitual, possible, swedish, evidence, dental, samples, oral, consequences, use, teeth, neolithic
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