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Beyond OSA—Part 2 by Dr. Michael K. DeLuke

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Beyond OSA—Part 2   

Detecting the signs and symptoms of pediatric sleep-disordered breathing

by Dr. Michael K. DeLuke

Introduction
This two-part series aims to help dental practitioners better understand the essential role they can and should play in the detection and management of pediatric sleep-disordered breathing (pSDB). In Part I, which ran in the March 2025 issue of Orthotown, we discussed what SDB is, why using the AHI index as a sole determinant of airway compromise in children is a flawed methodology, the multitude of challenges and issues associated with pediatric sleep studies, and the comorbidities of pediatric sleep disordered breathing.

Here in Part II, we will review how to detect the signs and symptoms of pSDB during the clinical and radiographic examination, and detail the crucial role of the dental practitioner in the detection and management of pediatric airway disease.

To begin, I’d like to pose a question. What is the primary role of the orthodontist? Is it to give the patient an aesthetic smile and ideal occlusion? Or is it to help improve the patient’s overall health? I’m guessing most of my colleagues would answer it is the former, as that is how we have been trained to think. Yet while I acknowledge and agree that ideal occlusion and aesthetics are important, I contend that focusing primarily on these metrics to determine the success or failure of our treatment outcomes is deeply flawed. Further, it is representative of a purely mechanical approach that dissociates the mouth from the entirety of the patient. Instead, our treatment objectives should include a more comprehensive and holistic approach to patient care whereby we focus on improving the overall health and well-being of our patients.


Performing a comprehensive airway evaluation
Overview
The American Dental Association (ADA), the American Association of Orthodontists (AAO), and the American Association of Pediatric Dentistry (AAPD), all recommend that dentists screen every patient for the presence of airway disease.

To that point, in its 2017 position statement on The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders (SRBD), the ADA stated, “In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues.” They went on to say, “If risk of SRBD is determined, intervention through medical/dental referral or evidence-based treatment may be appropriate to help the SRBD and/or develop an optimal physiologic airway and breathing pattern.”1

Unfortunately, most dental professionals have never received formal education or training on how to screen pediatric patients for airway compromise. Additionally, if an airway issue is detected, most are ill-prepared to address it. To simplify the screening process, I will break it down into three components: patient history, clinical examination and radiographic examination. It should be noted that it is not possible to describe every diagnostic parameter in this format, and, as such, I will provide an overview of some of the common signs and symptoms of pSDB that dental professionals should be looking for in their patients. It is also important to remember that, as discussed in Part I, not every patient who suffers from pSDB will present with the same signs and symptoms.


Patient history
As part of our training, dental professionals are taught the importance of obtaining a thorough medical history on their patients. However, many orthodontists neglect to gather sufficient medical and behavioral information on the children who present to them for treatment. Standard orthodontic intake forms typically ask basic and broad questions about body systems, and after a cursory review, the provider quickly moves on to the clinical and radiographic examination. That must change. To gain a more comprehensive and holistic understanding of our pediatric patients’ health, it is essential to learn more about a child’s breathing, sleep, and neurocognitive and behavioral functioning.

One example of a diagnostic tool that can be used to assist in this process is the Chervin Pediatric Sleep Questionnaire (PSQ), a validated questionnaire that has been determined to be reliable in the identification of pSDB.2 It contains 22 questions, and more than eight positive responses are suggestive of the presence of SDB and indicative of the need for further investigation. One caveat, however, is that some parents will hastily fill it out and put a line through all the “No’s,” not reading or processing what is being asked.

I’ve also encountered parents who honestly don’t know the answers, as they have not paid significant attention to their child’s breathing. Still others may not understand why the orthodontist is asking them to discuss how their child breathes, sleeps, behaves and performs in school and, as a result, elect not to answer honestly, or at all.

For those reasons, I find it helpful to review the PSQ in person with the patient and parent(s). This allows you to provide context for the questions being asked and ask follow-up questions as indicated.

It is also helpful to ask the following questions:
  • Has the patient ever seen an ENT? Has the patient had their tonsils and/or adenoids removed? If yes, did it resolve all their breathing and airway problems?
  • Does the patient suffer from allergy symptoms, chronic congestion and/or frequent upper respiratory infections?
  • Has the patient ever seen an allergist? If yes, were any allergies detected and/or treatment recommended?
  • Does the patient grind their teeth? (Despite what many of us have been told, bruxism is not normal and is often a sign of sympathetic overdrive associated with airway obstruction.)3
This valuable background information provides great insight into whether the patient is suffering from pSDB. Furthermore, it should be taken into consideration when performing the clinical and radiographic examination.
Beyond OSA—Part 2
Fig. 2
Beyond OSA—Part 2
Fig. 3
Beyond OSA—Part 2
Fig. 4
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Fig. 5


Clinical exam
What are the first things you look at when you examine a new pediatric patient? For many orthodontists, it’s the Angle classification, overbite, overjet, crowding and the presence of any crossbites. However, in doing so, we tend to overlook what is staring at us—the patient’s face! The face of a child can provide us with tremendous diagnostic information about that patient’s overall health and well-being. Therefore, before looking in the mouth, it is essential to look at the story the child’s face is telling us.

Take the patient seen in Figure 2 as an example. At first glance, you may simply see a young child with an unaesthetic smile and crowded teeth. However, upon further examination, you will notice eyes that appear much too “tired” for a supposedly healthy 7-year-old (indicating she may not be getting deep, restful sleep), and venous pooling/allergic shiners, often the result of chronic nasal congestion and a sign of pSDB, are evident under the eyes.4,5

The patient in Figure 3 demonstrates the presence of Dennie-Morgan folds—bifold wrinkles—under the eyes that are highly suggestive of atopy and, more specifically, allergic rhinitis.6 The impact of allergic rhinitis on nasal breathing will be discussed in this article in more detail. The patient in Figure 4 exhibits a dolichofacial/vertical growth pattern, vertical maxillary excess and large buccal corridors (indicating a transverse deficiency), while the patient in Figure 5 demonstrates a convex soft-tissue profile and an open mouth at rest. These are all signs of pSDB.7-12

As we progress to the intra-oral exam, we must continue to look for signs and symptoms of airway dysfunction. Chronic mouth breathing can desiccate the peri- and intra-oral tissues, resulting in dry, cracked lips and adherent plaque on the anterior teeth (Fig. 6).13 It can also cause the gingiva in the anterior sextant to become thick, hyperplastic and inflamed (Fig. 7), and often leads to altered active and/or passive eruption (Fig. 8).14 Rampant decay and/or excessive restorations resulting from xerostomia secondary to chronic mouth breathing (Fig. 9) may also be noted in pediatric patients with SDB.15
Beyond OSA—Part 2
Fig. 6
Beyond OSA—Part 2
Fig. 7
Beyond OSA—Part 2
Fig. 8

Other intraoral signs that the patient may be suffering from pSDB include attrition, insufficient tongue space often accompanied by a steep curve of Wilson, narrow, V-shaped arches, a high and vaulted palate and dental crowding (Fig. 10).7-12, 16,17
Beyond OSA—Part 2
Fig. 9
Beyond OSA—Part 2
Fig.10

The Mallampati classification (Fig. 11) can be used to assist in evaluating tongue space, and it has been suggested that for every one-point increase in Mallampati score, the odds of having OSA increase more than twofold.18 The palatine tonsils should also be evaluated, as tonsils that score 3+ or 4+ on the Brodsky scale (Fig. 12) have been shown to increase the risk of OSA in children.19
Beyond OSA—Part 2
Fig. 11
Beyond OSA—Part 2
Fig. 12

One must also examine the tongue to detect the presence of ankyloglossia (Fig. 13), as a lowered, more posterior tongue position may lead to a reduction in pharyngeal airway space and resulting decrease in airflow during sleep, which can predispose the patient to pSDB.20-22

A postural and/or active thrust (Fig. 14) should also be noted, as it can be indicative of low tongue tone, which may contribute to obstruction of the posterior airway.23,24
Beyond OSA—Part 2
Fig. 13
Beyond OSA—Part 2
Fig. 14


Radiographic exam
I am frequently asked whether a 3D/CBCT image is required to evaluate a patient’s airway. My answer is that while you can still detect many of the clinical and radiographic signs and symptoms of pSDB without a CBCT image, conventional 2D imaging (panorex and lateral cephalogram) is limited in its ability to provide a three-dimensional view of the upper airway and thus lacks the data needed to perform a comprehensive airway evaluation.25 With CBCT, you can create cross-sectional views of the 3D image in sagittal, axial and coronal planes, thereby enabling in-depth evaluation of the nasal passageways, sinuses and pharyngeal airway, as well as transverse skeletal and dental relationships.

That being said, there are signs of airway compromise that can be detected with 2D imaging alone (Fig. 15), including excessive curvature of the C-spine, a convex skeletal profile secondary to a retrognathic mandible and excessive vertical growth as evidenced by a steep MPA and anti-gonial notching.7-12,20,26,27,28

In certain cases you can also detect enlargement of the adenoids and/or palatine tonsils. Additionally, a restricted oropharyngeal airway may be detectable on a lateral ceph (Fig. 16, same patient from Fig. 2).24,29
Beyond OSA—Part 2
Fig. 15
Beyond OSA—Part 2
Fig. 16

However, as evidenced by the patient in Figures 17–19, CBCT imaging offers a far superior view of the pharyngeal airway. When viewing the 2D construct of the patient’s 3D image (Fig. 17), the nasopharyngeal patency seems adequate, and there is no obvious evidence of adenoid enlargement. Additionally, there does not appear to be any obstruction of the oropharyngeal airway by the tonsils. Upon viewing the 3D image, it becomes obvious that the adenoids (Fig. 18) and tonsils (Fig. 19) are enlarged and obstructive. Interestingly, this patient had recently been seen by another orthodontist who did not take a CBCT and, as a result, completely missed the significant airway obstruction. According to the parents, the other provider also neglected to ask them any of the aforementioned airway questions during the intake process.
Beyond OSA—Part 2
Fig. 17
Beyond OSA—Part 2
Fig. 18
Beyond OSA—Part 2
Fig. 19

By asking the appropriate background questions and taking/evaluating the CBCT image, I was able to detect the airway obstruction and refer the patient to the ENT, who removed the patient’s adenoids and tonsils. The patient then underwent interceptive orthodontic treatment to address the transverse deficiency. Her mouth breathing and snoring were resolved, and her temperament significantly improved as a result of this holistic approach to diagnosis and treatment.

Three-dimensional imaging also allows for enhanced evaluation of the nasal passageways and detection of allergic rhinitis (AR), considered the most common immune-mediated disorder in children.30

AR has been estimated to affect up to 40 percent of all children and is a known risk factor for pSDB, as many patients with AR experience turbinate hypertrophy.31,32 When the turbinates are enlarged, nasal breathing is negatively impacted, and the patient is at greater risk of suffering from pSDB.33 Therefore, evaluation of nasal passageway obstruction should be part of our standard airway assessment. Unfortunately, this is not possible with 2D imaging alone.

An example of nasal passageway obstruction secondary to turbinate hypertrophy can be seen in the CBCT image slice in Figure 20. This is the same patient referenced in Figure 3, who demonstrated extraoral signs of atopy. You will notice significant turbinate hypertrophy and obstruction of the nasal passageways, a clear impediment to nasal breathing. Her deviated nasal septum further complicated the issue. I referred the patient to the allergist, who recommended an OTC antihistamine and a steroid nasal spray. I then initiated interceptive orthodontic treatment to address the transverse deficiency. Significant improvement in nasal passageway patency can be seen 15 months later (Fig. 21).
Beyond OSA—Part 2
Fig. 20
Beyond OSA—Part 2
Fig. 21


Patient referral and treatment
Referral
Now that you have gathered this valuable diagnostic information, what do you do with it? From a medical perspective, you must develop relationships with your otolaryngological and allergy colleagues, as they are invaluable team members. However, just like with dentists, not all physicians take the same approach to patient care, and I recommend meeting with various providers in your area to find those who share your vision of proactive, holistic care.

If nasal passageway obstruction, adenoid hypertrophy and/or tonsillar hypertrophy are noted, it is important to review the obstruction with the parent(s) and explain why it is cause for concern as it relates to airway patency, sleep, behavior, and craniofacial and neurocognitive growth and development. Then explain that you would like the child to see the ENT and/or allergist for evaluation and/or treatment. I prefer to send patients to the ENT when hypertrophy of lymphoid tissue is detected, and to the allergist when the patient’s nasal passageways are obstructed.

It is also important to send a comprehensive letter describing the issues you detected, including those related to the child’s sleep and behavior. If you have taken a CBCT image, I highly recommend either sending them a copy of the scan with an embedded viewer or allowing secure access to the patient’s image in the cloud. If neither of those options is available, I suggest printing slices of the relevant images that detail your findings and including them with the letter.

When ankyloglossia is detected, if you are not comfortable or familiar with performing a release, I recommend referring to a colleague who is, as it can be much more complicated than simply relieving the tethered tissue. Additionally, many patients require evaluation and treatment by an orofacial myofunctional therapist (OMT) before and/or after the release. Similarly, when a tongue thrust, anterior open bite, low tongue tone and/or low oral hypotonia are detected, working with an OMT to assist with correction of the neuromuscular imbalance can be extremely beneficial for the patient, as orofacial myofunctional therapy has been proven effective at assisting with the improvement of pSDB, as well as the reduction in relapse of anterior open bite after orthodontic treatment.34,35


Interceptive orthodontic treatment
Suffice it to say, the topic of whether interceptive orthodontic treatment can improve airway patency in pediatric patients is both heavily debated and highly contentious. Regardless of where you stand on this topic, it is important to make it clear that the role of the dental practitioner is not to treat the patient’s airway disease. Further, it is not advisable to tell parents that interceptive orthodontic treatment is going to improve their child’s breathing (even though that is oftentimes the case). Instead, simply explain that your objective is to normalize the child’s anatomy and help facilitate nasal breathing to decrease their risk of suffering from airway obstruction now and in the future.

Additionally, while I am not an advocate of expansion in the absence of a transverse deficiency for the sole purpose of improving airway patency, it is important to note that the absence of a posterior crossbite does not equate with the absence of a transverse deficiency, a sentiment beautifully described by McNamara in his article, “Maxillary transverse deficiency.”36 McNamara states that maxillary constriction is the most pervasive problem in the craniofacial region and is often not detected by orthodontists since it is frequently camouflaged by the dentition (i.e., the mandibular posterior teeth tip lingually). As such, maxillary transverse deficiency is oftentimes not associated with a posterior crossbite. When this is the case, it is necessary to expand both the mandibular arch and maxilla to achieve maximal correction of the transverse deficiency.37

The patient in Figure 22 demonstrates what is possible when you implement the holistic, patient-centered approach described in this two-part series. Her airway issues (snoring, mouth breathing, restless sleep, morning fatigue, daytime hyperactivity) were detected during the initial examination. She was referred to an ENT (who removed the hypertrophic tonsils and adenoids) and interceptive orthodontic treatment was performed (using full braces and wires) to address the transverse deficiency and normalize the anatomy. This treatment approach resolved all the patient’s airway, sleep and behavioral issues, and you can see change in her eyes! It’s amazing what can be accomplished when we focus on more than just the teeth!

For a more detailed description of my approach to interceptive orthodontic treatment, please see the two-part series I published in 2023 in Orthotown magazine.38,39
Beyond OSA—Part 2
Fig. 22


Conclusion
Learning how to detect and manage airway compromise in your pediatric patients is an essential skill that will allow you to have a profound impact on the health and lives of your patients and their families. Orthodontists have the knowledge and ability to be so much more than just tooth-straighteners. By taking the time to thoroughly diagnose your pediatric patients, working with your dental/medical colleagues as needed and performing interceptive orthodontic treatment when indicated, you can change a child’s life. Furthermore, the impact this approach has on the child, their family, and the souls of you and your team members is truly immeasurable.

We all entered into this wonderful profession to help patients live better lives. I contend that there is no better way to do this than by helping them breathe, sleep and thrive! To do so, we must stop focusing on symptom-driven, reactive treatment and move towards a new era of holistic, proactive and prevention-based patient care. The health of our children and the future of our wonderful specialty depend upon it.

References

1. ADA Position Statement: The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders.? Adopted by the ADA’s 2017 House of Delegates.??
2. Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000 Feb 1;1(1):21-32.?
3. Restrepo-Serna C, Wincour E. Sleep bruxism in children, from evidence to the clinic. A systematic review. Frontiers in Oral Health. Volume 4, 2023 https://doi.org/10.3389/froh.2023.1166091?
4. Marks MB. Nasal allergy in childhood. Observations in the south Florida area. Ann Allergy 1960;18:1110-6?
5. Liu J., Wu Y., Wu P., Xu Z., Ni X. Analysis of the impact of allergic rhinitis on the children with sleep disordered breathing. Int. J. Pediatr. Otorhinolaryngol. 2020;138:110380.?
6. Blanc S, Bourrier T, Albertini M, Chiaverini C, Giovanni-Chami L. Dennie-Morgan Fold Plus Dark Circles: Suspect Atopy at First Sight. J Pediatr 2015;166;1541.???
7. Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel S.?Mouth breathing in allergic children: Its relationship to dentofacial development. Am J Orthod. 1983;83(4),334-40.?
8. Huynh NT, Morton PD, Rompré PH, Papadakis A, Remise C. Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening examinations. Am J Orthod Dentofacial Orthop. 2011 Dec;140(6):762-70.??
9. Chowdhary K, Yadav G, Rai A, Saha S, Dhinsa K, Sharma A. Mouth Breathing Habit and Their Effects on Dentofacial Growth in Children in the Age Range of 6-14 Years: A Cephalometric Study. Int J Clin Pediatr Dent. 2024 May;17(5):545-551.?
10. Guilleminault C, Huang YS. From oral facial dysfunction to dysmorphism and the onset of pediatric OSA. Sleep Med Rev. 2018 Aug;40:203-214.?
11. Basheer B, Hegde KS, Bhat SS, Umar D, Baroudi K. Influence of mouth breathing on the dentofacial growth of children: a cephalometric study. J Int Oral Health. 2014 Nov-Dec;6(6):50-5.??
12. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981 Apr;79(4):359-72.?
13. Mizutani S, et al. Relationship between xerostomia and gingival condition in young adults. J. Periodontal. Res. 2015;50:74–79.??
14. Wagaiyu EG, Ashley FP. Mouthbreathing, lip seal and upper lip coverage and their relationship with gingival inflammation in 11–14 year old schoolchildren. J. Clin. Periodontol. 1991;18:698–702.?
15. Filho EN, Mayer MPA, Pontes P, Pignatari ACC, Weckx LLM. Caries prevalence, levels of mutans streptococci, and gingival and plaque indices in 3.0- to 5.0-year-old mouth breathing children. Caries Res. 2004;38:572–575.?
16. Restrepo-Serna C, Winocur E. Sleep bruxism in children, from evidence to the clinic. A systematic review. Front Oral Health. 2023 May 11;4:1166091., Ng DK, Kwok KL, Poon G, Chau KW. Habitual snoring and sleep bruxism in a paediatric outpatient population in Hong Kong. Singapore Med J. 2002;43:554–556.?
17. Guilleminault C, Partinen M, Praud JP, Quera-Salva MA, Powell N, Riley R. Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr. 1989 Jun;114(6):997-9.?
18. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep. 2006;29(7):903-8.?
19. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in children. Am Fam Physician. 2004;69(5):1147-54.?
20. Pirilä-Parkkinen K, Löppönen H, Nieminen P, Tolonen U, Pirttiniemi P. Cephalometric evaluation of children with nocturnal sleep-disordered breathing. Eur J Orthod. 2010 Dec;32(6):662-71.?
21. Dalmasso F, Prota R. Snoring: analysis, measurement, clinical implications and applications. EurRespir J. 1996;9(1):146-59.?
22. Eliza Brozek-Madry, et al. Short lingual frenulum and head-forward posture in children with the risk of obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2021;144:110699. https://doi.org/10.1016/j.ijporl.2021.110699.?
23. Durr ML, Meyer AK, Kezirian EJ, Rosbe KW. Drug-induced sleep endoscopy in persistent pediatric sleep-disordered breathing after adenotonsillectomy. Arch Otolaryngol Head Neck Surg 2012; 138:638.?
24. Villa MP, Evangelisti M, Martella S, Barreto M, Del Pozzo M. Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing? Sleep Breath. 2017 Dec;21(4):1025-1032.?
25. Ashique Abdulhameed S., et al. Assessing the Accuracy of Lateral Cephalogram in Quantifying Three-Dimensional Pharyngeal Airway Morphology Compared to Cone-Beam Computed Tomography. Cureus. 2024;16:e57301.?
26. Chaves TC, et al. Craniocervical posture and hyoid bone position in children with mild and moderate asthma and mouth breathing. Int J Pediatr Otorhinolaryngol. 2010 Sep;74(9):1021-7.?
27. Sabatucci A, et al. Breathing pattern and head posture: changes in craniocervical angles. Minerva Stomatol. 2015 Apr;64(2):59-74.?
28. McNamara JA. Influence of respiratory pattern on craniofacial growth. Angle Orthod 1981; 51(4): 269-300.?
29. Bronoosh P, Khojastepour L. Analysis of Pharyngeal Airway Using Lateral Cephalogram vs CBCT Images: A Cross-sectional Retrospective Study. Open Dent J. 2015 Jul 31;9:263-6.?
30. Kalaskar R, et al. Evaluation of the Average Nasal and Nasopharyngeal Volume in 10-13-year-old Children: A Preliminary CBCT Study. Int J Clin Pediatr Dent. 2021 Mar-Apr;14(2):187-191.?
31. Mir E, Panjabi C, Shah A. Impact of allergic rhinitis in school going children. Asia Pac Allergy.?2012 Apr;2(2):93-100.?
32. Ciprandi G, et al. Turbinate hypertrophy in children with allergic rhinitis: clinical relevance. Acta Biomed. 2020 Feb 17;91(1-S):43-47.??
33. Sullivan S, Li K, Guilleminault C. Nasal Obstruction in Children with Sleep-disordered Breathing. Ann Acad Med Singapore. 2008;37:645-8.?
34. Villa MP, et al. Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing? Sleep Breath. 2017 Dec;21(4):1025-1032.?
35. Smithpeter J, Covell D. Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. Am J Orthod Dentofacial Orthop. 2010;137:605-14.?
36. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop. 2000 May;117(5):567-70.?
37. O'Grady PW, McNamara JA Jr, Baccetti T, Franchi L. A long-term evaluation of the mandibular Schwarz appliance and the acrylic splint expander in early mixed dentition patients. Am J Orthod Dentofacial Orthop. 2006 Aug;130(2):202-13.?
38. DeLuke MK. Permission to Intercept. Orthotown. June 2023:55-61.
39. DeLuke MK. Expand Your Reality. Orthotown. November 2023:53-61.

Author Bio
Dr. Michael K DeLuke Dr. Michael K. DeLuke is a board-certified orthodontist who received his specialty training at the University of Connecticut. DeLuke practiced for 18 years before retiring from private practice to teach full time. He has served as a faculty member at several hospitals and orthodontic residencies and is currently an adjunct professor in the Department of Orthodontics at Nova Southeastern University. He is also host of The DOC Podcast.





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