
==== Front
BMC Oral Health
BMC Oral Health
BMC Oral Health
1472-6831
BioMed Central London

4805
10.1186/s12903-024-04805-6
Research
Predicting oral hygiene practices through health behavior, perceived stress and self-efficacy in undergraduate dental students of Pakistan: a national survey
Tariq Khaloud khaloud.tariq@ucd.uol.edu.pk

1
Shakeel Sadia 1
Qureshi Ambrina 5
Unar Javaid 2
Qamar Areeba 4
Khan Athar 3
1 https://ror.org/051jrjw38 grid.440564.7 0000 0001 0415 4232 University College of Medicine and Dentistry (UCMD), The University of Lahore, Lahore, Pakistan
2 https://ror.org/01h85hm56 grid.412080.f 0000 0000 9363 9292 Dr. Ishrat-ul-ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Sindh Pakistan
3 https://ror.org/01h85hm56 grid.412080.f 0000 0000 9363 9292 Dow University of Health Sciences, Karachi, Sindh Pakistan
4 Private Practice, Islamabad, Pakistan
5 https://ror.org/01h85hm56 grid.412080.f 0000 0000 9363 9292 Dow International Dental College, Dow University of Health Sciences, Karachi, Pakistan
3 9 2024
3 9 2024
2024
24 103120 5 2024
23 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Dental students face the rigorous demands of coursework, which can lead to feelings of inadequacy and stress. These pressures can negatively influence self-efficacy and cause neglect in practicing healthy behaviors that encompass oral health. Identifying the associations of these variables with oral hygiene practices can help in the formulation of interventions tailored toward supporting young students. Therefore, this study aimed to investigate the impact of health behaviors, perceived stress and self-efficacy on oral hygiene practices among undergraduate dental students in Pakistan.

Methods

A national online survey was carried out among 904 students across the dental colleges of Pakistan. The survey assessed general health behaviors such as tobacco use, sleep, and exercise, among other demographic variables. Perceived stress was evaluated via the Perceived Stress Scale (PSS-10), and self-efficacy was evaluated via the General Self-Efficacy Scale (GSES). Twice daily brushing, brushing for 2 min, and changing toothbrushes after 3 months informed oral hygiene practice of the participants.

Results

The students experienced moderate perceived stress (20.82 ± 5.92) and high self-efficacy (29.19 ± 5.43). The majority of participants were in their third year (31.9%), were female (65.9%), and resided in home during their studies (64.4%). Perceived stress was observed to have no significant effect on the oral practice of participants. Female gender, non tobacco user, regular exercise, frequent dental visits and higher self-efficacy were associated with good oral hygiene practices.

Conclusions

The results highlight the importance of addressing stress, enhancing self-efficacy and encouraging healthy behaviors among dental students to improve their oral health, which could be reflected in their professional practice and personal well-being. This study contributes to the understanding of behavioral determinants and emphasizes the need for supportive measures to foster better health behaviors in future dental professionals.

Keywords

Oral health
Health behavior
Dental students
Perceived stress
Self-efficacy
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcBackground

Oral health is pivotal for maintaining overall well-being and affects the quality of life of individuals. Studies have described oral health as a gateway to general health; therefore, the role of optimum oral health cannot be undermined [1–3]. The oral health of individuals can be gauged by their oral and health behaviors. Good oral health behaviors, such as brushing twice a day for 2 min and changing brushes every 3–4 months, contribute to oral health-related quality of life [4]. Correspondingly, a bidirectional relationship has been demonstrated between oral health and health behavior; however, extensive research in this area is lacking [5]. Additionally, evidence suggesting the existence of such a relationship has shown inconsistency between different populations, indicating a need to explore this relationship [6]. Findings from the National Health and Nutrition Examination Survey (NHANES) revealed that moderate exercise affects dental clinic attendance [7]. Additionally, a significant association between nonsmoking status and good toothbrushing behavior was observed [7]. Studying the associations between health behaviors and oral health can provide valuable insight, informing stakeholders to direct attention toward them.

Dental students play a significant role in propagating oral health knowledge, whether through community field trips or clinics. Understanding their behaviors pertaining to health is crucial, as behavior reflects knowledge, which can impact patients’ provision of care, thus affecting their oral health [4]. Moreover, the oral hygiene practices of students warrant attention if they are significantly affected by elements unique to them, such as course of study, life transition, age, and stress.

While discussing the impact of health behaviors on sustaining oral health practices, the contributing role of perceived stress and self-efficacy cannot be ignored considering our population of interest. Perceived stress is “an individual’s subjective assessment of the level of stress they are experiencing in response to various situations and challenges [8].” It revolves more around feelings concerning the loss of control and unpredictability than the actual stressors themselves. The transition from college life to dental school marks a significant shift for undergraduate dental students. Students are not only exposed to adult learning methods but also expected to demonstrate independence in patient communication and objectivity in devising a treatment plan. Research has shown that undergraduate dental students experience moderate to severe stress [9–11]. The consequences of stress among dental students extend beyond academics, influencing their daily habits and overall health. The literature supports the notion that perceived stress negatively influences oral health and health behaviors [12–14]. Furthermore, healthy routines, such as tooth brushing and visits to a dentist, are also influenced by stress [13, 15]. The consequences of these actions may manifest as orofacial pain and ulcers owing to neglected oral health needs [16]. In essence, these factors may further exacerbate existing stress, with students becoming trapped in a vicious cycle of feeling ill, thereby compromising their quality of life.

Notably, every individual may have different reactions when exposed to the same circumstances throughout their life. While one student might thrive under the pressure of deadlines and patient interactions, another might find the same circumstances overwhelming. This can be associated with self-efficacy, which refers to “an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments [17].” In the context of our study of undergraduate dental students, self-efficacy relates to their confidence in their skills and capabilities in regard to tasks or challenges that they encounter in their dental education. As dental students undergo transitions in their education, their belief in themselves fluctuates. Interestingly, the literature has shown that self-efficacy has an impact on oral health behavior [18]. Hence, it is essential that this factor be assessed in undergraduate dental students and that they are adequately supported in this process.

Most of the studies conducted previously have focused on the causes of stress, the effects of the dental environment on students, and their coping strategies [10, 19–22]. In contrast, only few studies have evaluated the relationship between self-efficacy and oral health practices. A study such as ours has not been conducted before, thus indicating its novelty. Hence, this study aimed to assess the impact of perceived stress, self-efficacy, and health behaviors on oral hygiene practices. The findings from our study can help inform strategies for universities and regulatory bodies to emphasize students’ health and well-being through professional support services. Additionally, finding a substantial relationship between these factors can help educators inculcate and support healthy behaviors, which may also positively influence oral health.

Methods

A national-based online survey using Google Forms was conducted among dental students from private and public dental colleges across four provinces of Pakistan. There are 18 dental colleges in the public sector and 43 in the private sector, with 1217 and 2515 allocated seats, respectively, every year [23]. On the basis of the available data, a sample size was calculated for each private and public sector using a 50% anticipated frequency at a 95% confidence interval. Adding 20% for the missing data, a sample of 430 students was required from the public sector and 450 from the private sector. A simple random sampling method was used to choose dental colleges. The requests to fill out online forms were sent through the respective colleges’ administrative heads of Community Dentistry departments. Ethical approval for the study was granted by the Institutional Review Board of the University College of Dentistry, The University of Lahore (UCD/ERCA/401). The data were collected from June to October 2023. To ensure confidentiality, all identifiable information was omitted from the collected data, safeguarding participant anonymity.

Health behaviors and oral hygiene practice assessment

Health behavior information related to sleep patterns, smoking habits, physical activity and eating habits was collected [24]. Oral health practices such as tooth brushing frequency, frequency of brush change, and brushing duration were investigated while considering these variables as outcome variables. Demographic information (age, gender, year of study, and place of residence) was also collected.

Assessment of perceived stress and self-efficacy

The Perceived Stress Scale (PSS-10), which is a 10-item scale measuring the perception of stress, focusing on feelings of uncontrollability and overload, as well as direct queries about current levels of experienced stress, was used [8]. The responses were marked on a 5-point Likert scale ranging from “never” to “very often”, with corresponding scores ranging from 0 to 4. The total score was calculated on the basis of the sum of the minimum and maximum possible ranges between 0 and 40. The score was categorized as low perceived stress, with scores ranging from 0 to 13; moderate perceived stress, with scores ranging from 14 to 26; or high perceived stress, with scores ranging from 27 to 40.

The general self-efficacy scale (GSES) assesses an individual’s belief in his or her ability to cope with a range of demanding situations and is a validated tool in psychological and health-related research [25]. It consists of 10 questions; the responses range from “not true at all” to “exactly true”, with scores ranging from 1 to 4. The total score is denoted by the sum of all the items, with scores ranging between 10 and 40, where a higher score indicates greater self-efficacy.

Statistical analysis

All electronic data were transferred to the Stata version 17 data sheet for analyses. Categorical variables are reported as frequencies and percentages, and continuous variables are presented as the means and standard deviations. Simple logistic regression analyses were performed considering self-reported responses related to toothbrushing frequency (≤ once daily = 0, > twice daily = 1), duration (< 2 min = 0, ≥ 2 min = 1), and toothbrush replacement frequency (> 3 months = 0, within 3 months = 1) as dependent variables. The independent variables included age, gender, year of study, type of residence, smoking status, consumption of smokeless tobacco, daily exercise, weekly dining out, health motivation, number of dental visits in the previous year, level of stress and self-efficacy. The 95% confidence interval (CI) was calculated considering a p-value < 0.25 to indicate explanatory variables. Multiple logistic regression (MLR) was performed, including all explanatory variables, to determine whether the associations were statistically significant at a p-value < 0.05. The MLR diagnostics were performed via a link test to check if the link function was correctly specified where p > 0.05 was considered for the hat square, revealing that there was no problem with the specification.

Results

Out of the total 904 responses received from registered dental institutes, 571 [63.2%] were received from private sector dental colleges, and 333 [36.8%] were received from the public sector. On average, the students were approximately 21 years old [20.98 ± 1.49], with males being older [21.35 ± 1.57] than females [20.84 ± 1.37].

Table 1 presents the demographic and other self-reported response details of these students pertinent to the study variables. According to these details, approximately 1/3 of the participants were males and were residing in hostels during their professional studies. Only 1/4 of the students reported that they experienced mouth ulcers, and fewer than 1/4 of them experienced temporomandibular joint (TMJ) pain. Only approximately 13% of the students reported that they use tobacco products in combustible and/or noncombustible forms. More than 50% of the students reported that they did not perform regular exercise, and approximately half of the students responded that they dined out almost every week. About 80.4% [727] students reported that they were motivated to improve their health.

Table 1 Distribution of study participants (n = 904) according to the variables under study

Study Variables	Categories	Frequency (%)	
Gender	Male	308 (34.1)	
Female	596 (65.9)	
Current dental professional year of study	First year	226 (25.0)	
Second year	236 (26.1)	
Third year	288 (31.9)	
Final year	154 (17.0)	
Residence during studies	Home	582 (64.4)	
Hostel	322 (35.6)	
What is the usual frequency of your tooth brushing?	Once a day	240 (26.5)	
≥Twice a day	664 (73.4)	
What is the usual duration of your tooth brushing?	< a minute	253 (28.0)	
≥ a minute	651 (72.0)	
Do you change your toothbrush every 3 months?	No	430 (47.6)	
Yes	474 (52.4)	
Do you regularly visit a dentist at least once in a year for any dental solutions?	No	563 (62.3)	
Yes	341 (37.7)	
In last one month, did you experience any mouth ulcers?	No	675 (74.7)	
Yes	229 (25.3)	
In last one month, did you experience any temporo-mandibular joint dysfunction?	No	762 (84.3)	
Yes	142 (15.7)	
Do you use combustible tobacco products?	No	789 (87.3)	
Yes	115 (12.7)	
Do you use noncombustible tobacco products?	No	788 (87.2)	
Yes	116 (12.8)	
What is the usual frequency of consumption of tobacco products? (n = 129)	≤ 5 times a day	83 (64.3)	
> 5 times a day	46 (35.7)	
Have you tried to cut back on tobacco products? (n = 129)	No	59 (45.8)	
Yes	70 (54.2)	
Do you regularly exercise?	No	466 (51.5)	
Yes	438 (48.5)	
Do you regularly eat/dine out every week?	No	448 (49.5)	
Yes	456 (50.4)	
How many hours do you sleep at night?	< 6 h	407 (45.0)	
≥ 6 h	420 (46.5)	
Perceived Stress Level	Low stress	86 (9.5)	
Moderate stress	679 (75.1)	
High stress	139 (15.3)	

The mean perceived stress score reported by the participants was 20.82 ± 5.92, and the mean general self-efficacy score was 29.19 ± 5.43. The mean PSS score in males was 19.12 ± 5.9, whereas that in females was 21.7 ± 5.6. Furthermore, the mean GSES score was 29.92 ± 5.4 for males and 28.81 ± 5.4 for females.

Considering tooth brushing frequency, duration and change after every three months as binomial response variables, Table 2 presents the impact of each explanatory variable. The explanatory variables found to influence tooth brushing frequency ≥ twice daily were female gender (p < 0.001), hostel residence (p = 0.049), non-smokers (p = 0.093), regular exercise (p = 0.011), motivation toward health (p = 0.129) and regular visits to their dentist (p < 0.001). Similarly, the odds of having a tooth brushing duration ≥ a minute were significantly associated with female gender (p = 0.012), hostel residence (p = 0.061), not consuming smokeless tobacco (p = 0.100), regular exercise (p = 0.016) and regular visits to a dentist (p = 0.058). Other explanatory variables that were found to influence tooth brushing duration were ≥ 6 h of sleep (p = 0.099), perceived stress (p = 0.040) and self-efficacy (p = 0.058). Furthermore, changing toothbrushes every three months was influenced by a number of variables with p < 0.25 (Table 2).

Table 2 Model-1 (simple logistic regression) predictors for oral hygiene practices

Variables	Tooth brushing frequency	Tooth brushing duration	Toothbrush replacement	
COR	95% CI	p-value	COR	95% CI	p-value	COR	95% CI	p-value	
Gender	Male	--	--	--	--	--	--	--	--	--	
Female	1.94	1.435, 2.633	< 0.001*	0.66	0.482, 0.912	0.012*	0.75	0.568, 0.989	0.042*	
Year of study	--	1.03	0.896, 1.190	0.652	0.94	0.820, 1.084	0.415	0.89	0.789, 1.015	0.084*	
Residence	Home	--	--	--	--	--	--	--	--	--	
Hostel	0.73	0.544, 0.999	0.049*	1.34	0.986, 1.834	0.061*	1.60	1.216, 2.111	0.001*	
Combustible tobacco use	Yes	--	--	--	--	--	--	--	--	--	
No	1.43	0.942, 2.183	0.093*	0.89	0.574, 1.396	0.627	1.28	0.868, 1.902	0.209*	
Non-combustible tobacco use	Yes	--	--	--	--	--	--	--	--	--	
No	1.06	0.686, 1.644	0.786	0.67	0.422, 1.078	0.100*	1.53	1.037, 2.278	0.032*	
Exercise	No	--	--	--	--	--	--	--	--		
Yes	1.31	1.064, 1.634	0.011*	1.29	1.048, 1.594	0.016*	1.09	0.910, 1.309	0.344	
Dining out	Yes	--	--	--	--	--	--	--	--	--	
No	0.94	0.710, 1.282	0.756	1.17	0.879, 1.573	0.274	1.07	0.828, 1.396	0.585	
Night sleep	< 6 h	--	--	--	--	--	--	--	--	--	
≥ 6 h	0.89	0.661, 1.199	0.444	1.27	0.955, 1.709	0.099*	1.18	0.910, 1.538	0.208*	
Health motivation	No	--	--	--	--	--	--	--	--	--	
Yes	1.32	0.922, 1.892	0.129*	1.05	0.731, 1.513	0.785	1.02	0.736, 1.421	0.892	
Stress level	--	1.01	0.986, 1.037	0.355	0.97	0.955, 1.004	0.106*	0.96	0.943, 0.986	0.002*	
Self-efficacy	--	0.99	0.972, 1.027	0.970	1.02	1.001, 1.055	0.040*	1.02	1.004, 1.053	0.022*	
Dental visit	No/rarely	--	--	--	--	--	--	--	--	--	
Once a year	3.05	2.157, 4.338	< 0.001*	1.34	0.990, 1.825	0.058*	1.88	1.434, 2.484	< 0.001*	
*p < 0.25 (significant explanation), CORs = crude odds ratios

The variables that significantly predicted toothbrush frequency, duration and replacement status are shown in Table 3. According to this MLR analysis, only female gender [aOR = 2.45; CI = 1.722, 3.510], daily exercise [aOR = 1.92; CI = 1.392, 2.670] and a history of dental visits at least once a year [aOR = 3.22; CI = 2.246, 4.624] were found to be significant predictors of the frequency of tooth brushing ≥ twice a day. None of the explanatory variables were found to significantly predict a ≥ minute duration of tooth brushing. Replacing a toothbrush every 3 months was significantly associated with female gender [aOR = 0.36; CI = 1.148, 0.915] and increased general self-efficacy by 8% [aOR = 1.08; CI = 1.009, 1.172]. There was no specification error found in these models [_hatsq > 0.05].

Table 3 Model-2 (MLR) predictors for oral hygiene practices

Variables	Tooth brushing frequency	Tooth brushing duration	Toothbrush replacement		
AOR	95% CI	p-value	AOR	95% CI	p-value	AOR	95% CI	p-value	
Females	2.45	1.722, 3.510	< 0.001*	0.82	0.579, 1.167	0.274	0.36	0.148, 0.915	0.031*	
Year of study	--	--	--	--	--	--	0.85	0.591, 1.237	0.407	
Hostellers	0.91	0.657, 1.273	0.597	1.22	0.882, 1.692	0.227	1.98	0.874, 4.527	0.101	
Combustible tobacco use	1.01	0.637, 1.629	0.938	--	--	--	0.38	0.094, 1.548	0.178	
Non-combustible tobacco use	--	--	--	0.73	0.450, 1.192	0.210	0.57	0.252, 1.290	0.178	
Daily Exercise	1.92	1.392, 2.670	< 0.001*	1.23	0.911, 1.671	0.174	--	--	--	
Night sleep	--	--	--	1.26	0.941, 1.707	0.118	0.99	0.451, 2.179	0.984	
Health motivation	0.80	0.546, 1.176	0.260	--	--	--	--	--	--	
Stress level	--	--	--	0.99	0.969, 1.023	0.800	1.01	0.956, 1.081	0.589	
Self-efficacy	--	--	--	1.02	0.992, 1.050	0.158	1.08	1.009, 1.172	0.028*	
Dental visit	3.22	2.246, 4.624	< 0.001*	1.31	0.964, 1.801	0.083	2.04	0.886, 4.722	0.093	
*p < 0.05 (significant explanation), AORs = adjusted odds ratios

Discussion

The present study focused on identifying the effects of health behaviors, perceived stress, and self-efficacy on oral hygiene practices in dental students of Pakistan. This is the first comprehensive study to evaluate such a relationship, adding to the existing body of evidence regarding the role of external factors (stress), self-confidence (self-efficacy), and health behaviors in influencing the oral health of students.

According to the results, female students, who constituted 65.9% of the total participants, experienced more perceived stress than their male peers. Similarly, the results of several studies corroborate our findings [26–28]. Certain cultural norms and institutional environments may be less favorable for female students, thus inducing more perceived stress [29]. Overall, most students experienced moderate stress and exhibited higher self-efficacy.

The literature shows that continuous stress can manifest through oral lesions such as myofascial pain dysfunction syndrome (MPDS), aphthous ulcers, and temporomandibular joint (TMJ) disorders in young students [27, 28]. Our results revealed that only 25.3% of the students concurrently developed mouth ulcers, whereas only a minority of them suffered from TMJ pain. Since most of the students experienced only moderate stress and high self-efficacy, owing to these factors, the undesirable effects of stress on oral health may have been mitigated.

With respect to the effect on oral practices, females were likely to exhibit good oral hygiene practices, as they demonstrated a significant likelihood of brushing more than once a day and replacing their brush every three months. Similar findings were obtained from another study elucidating positive attitudes and good oral health behaviors among females compared with males [30]. Furthermore, students who demonstrated healthy practices, such as daily exercise, were also likely to brush twice a day. This provides evidence that students who were concerned about their physical health and who carried out physical activity despite the pressures of the course would also replicate the same habits toward their oral health. Examples of such students can be used to motivate their peers, and events involving physical activity should be included and promoted as a part of extracurricular activities.

In the absence of other explanatory variables, oral hygiene practices were not affected by perceived stress. This result may be explained by the fact that only 15.3% of the students experienced high perceived stress, whereas 75.1% experienced moderate stress. The association between self-efficacy and healthy behavior has been discussed previously; however, limited data is available with respect to oral hygiene practices. Research has shown a significant relationship between toothbrushing frequency and general self-efficacy [31]. Our results also revealed a positive relationship between self-efficacy and toothbrushing duration and the timely replacement of toothbrushes. Educators should provide guidance to students, especially those who are struggling, through group mentoring or one-to-one consultation. The student will feel supported and will likely improve performance by gaining confidence in his/her ability to overcome hurdles.

To maintain and improve oral health, the American Dental Association (ADA) has recommended at least one visit to a dentist in 6–12 months [32]. A study carried out among university students suggested that the majority of healthcare students did not visit any dental clinic in a year, which is similar to our findings [5]. Nevertheless, those students who visited the dentist were likely to brush their teeth twice a day. To reinforce regular dental attendance, dental faculty can perform oral screenings of their students every 6 months and highlight the importance of maintaining such a practice.

While this study adds to the literature by using a comprehensive approach, there are certain limitations associated with it. The reliance on self-reported data for assessing perceived stress, self-efficacy, and oral hygiene practices introduces the possibility of response bias, where the participants may overreport socially desirable behaviors or underreport undesirable ones. Additionally, the introduction of recall bias is a possibility where participants may not accurately remember or report their behaviors over a given period. Although the study considered various factors, there may be other unmeasured confounding variables that could influence the results, such as socioeconomic status or academic performance​. It is recommended that future research explore such relationships to account for these factors.

Conclusion

A positive impact of self-efficacy was observed on oral hygiene practices. Since females portrayed better oral hygiene practices, it is essential that they are reinforced regarding these behaviors whereas special attention should be given to male students. Students who depicted healthy behaviors were also likely to practice oral health behaviors. Promoting self-efficacy through education, awareness, and support can help individuals manage stress and develop healthy oral health habits to improve their quality of life. Additionally, the importance of adopting good practices for healthy living can be communicated by dental educators early in dental education to ensure the implementation of these practices by students.

Acknowledgements

We extend our gratitude to Dr. Aimen Khan, Dr. Ashfaq Ahmed, Dr. Hafsa Rehman and Heads of the Community Dentistry Department of various dental colleges for their help in data collection.

Author contributions

KT was involved in conceptualization, study design, data analysis and manuscript writing. SS was involved in manuscript writing. AQ carried out the analysis and interpretation of the data and supervised the study. JU & AK were responsible for data acquisition and reviewed the manuscript for final submission. AQ was involved in manuscript writing. All the authors read and approved the final manuscript.

Funding

None to declare.

Data availability

All the data generated or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethical approval and consent to participate

Ethical approval for the study was granted by the Institutional Review Board of the University College of Dentistry, The University of Lahore (UCD/ERCA/401). Written informed consent was obtained electronically from all participants prior to their participation.

Consent for publication

Not applicable.

Competing Interests

Not applicable.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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