Evaluation of clinical and radiographic outcome of premixed injectable mineral trioxide aggregate and conventional mineral trioxide aggregate as pulpotomy medicaments in primary molars - A split-mouth randomized control trial U. S. Aiswarya, Sharan S. Sargod, Sundeep K. Hegde, H. T. Ajay Rao, Nanditha Hegde Journal of Indian Society of Pedodontics and Preventive Dentistry, 2025 Background: Materials for pulpotomy have evolved to materials which can regenerate the pulp. Mineral trioxide aggregate (MTA) potentially shifts the pulpal status and promotes dentin bridge formation. Newer MTAs in premixed form are resistant to dislodgment providing excellent sealability. Premixed Injectable MTA can be directly applied on the pulpal stumps promoting ease of workability and patient convenience. Aim and Objectives: To evaluate and compare the clinical and radiographic outcome of premixed injectable MTA and conventional MTA as pulpotomy medicaments in primary teeth. Materials and Methods: Thirty teeth requiring pulpotomy from 15 subjects aged between 5 and 9 years were included. After LA administration and rubber dam application, the access cavity was prepared and the coronal pulp was amputated. Premixed injectable MTA (Endocem) was applied on the pulpal stumps in one side and conventional MTA was mixed and placed on the pulpal stumps on the other side. Glass ionomer restoration was done and stainless-steel crowns were given. Clinical and radiographic follow-up was done at 3 and 6 months. Results: At 3 months, a 100% success rate was observed in Endocem and Angelus group, clinically and radiographically. At 6 months’ follow-up, clinical success was seen in 86.67% in Angelus group and 93.33% in Endocem group. Radiographic success was seen in 86.67% in Angelus and 93.33% of Endocem group. The success rate was greater in Endocem group than Angelus group but was not statistically significant. Conclusion: Premixed Endocem MTA can be a better alternative to conventional MTA for pulpotomy with better handling properties and faster setting time.
Remineralization of Enamel Using Topical Agents among Patients with Orthodontic Brackets: In Vivo and In Vitro Randomized Control Trial Sham S Bhat, Sundeep K Hegde, Shaniya Sain, Gayathri J Satheesh International Journal of Clinical Pediatric Dentistry, 2024 Aim and background To evaluate the in vivo and in vitro effects of three topical agents in reducing enamel demineralization around orthodontic brackets. Postorthodontic enamel demineralization persists to be undesirable and common complication. Materials and methods Twenty patients, who consented, were included into three experimental and a control group, following screening for inclusion, exclusion, and randomization. The experimental group was intervened with either GC Tooth Mousse Plus®, Clinpro® Tooth Cream, or Amflor® toothpaste. The baseline values were recorded using DIAGNOdent® following oral prophylaxis and brackets were bonded. The intervention group received the respective topical application of agents. Posttreatment values were recorded after 90 seconds of intervention and 20th day postintervention. Extraction of respective tooth was done on the 21st day to evaluate the microhardness using the Vickers hardness test. Results The results show the effectiveness of GC Tooth Mousse Plus® over Amflor® toothpaste followed by Clinpro® Tooth Cream for remineralization among patients undergoing orthodontic treatment and microhardness was highest for GC Tooth Mousse Plus®. Conclusion Topical agents can be used effectively as remineralizing agents in patients undergoing orthodontic treatment. Clinical significance Advanced diagnostic tools like the DIAGNOdent Pen® and remineralizing agents contribute to a comprehensive and proactive approach to dental care, particularly in populations with specific risk factors like children with high sucrose consumption. How to cite this article Sain S, Hegde SK, Bhat SS, et al. Remineralization of Enamel Using Topical Agents among Patients with Orthodontic Brackets: In Vivo and In Vitro Randomized Control Trial. Int J Clin Pediatr Dent 2024;17(10):1093-1098.
Analysis of Dental Caries Experience and Parents Perception on the Oral Health Status of Children with Autism Spectrum Disorders From South India Sundeep K Hegde, Onashri Ranjit, Sham Subraya Bhat, Bhuvanesh Sukhlal Kalal Medical Journal of Bakirkoy, 2024 Objective: Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that can significantly affect various aspects of an individual's life, primarily communication and behavior.Poor oral health in children with ASD can further exacerbate these challenges and negatively affect their overall health and quality of life.This study aimed to investigate and analyze the experiences of dental caries and parental perceptions of the oral health status of children with ASD. Methods:The study involved 20 children with autism who were residing in a special school in Mangaluru.Clinical recordings, including the calculus index-simplified (CI-S), oral hygiene index-simplified (OHI-S), caries status [decayed missing and filled teeth (DMFT) and debris indexsimplified (DI-S), treatment needs, and periodontal status community periodontal index (CPI).Additionally, parents' perceptions of their children's OHI-S were collected through a pre-designed questionnaire.Special diet recommendations and oral hygiene counseling were provided to the parents, followed by a 3-month follow-up.The chi-square test was applied to the discrete data, whereas One-Way ANOVA was used for the continuous data analysis.Results: Initial dental counseling showed mean scores for CI-S, DI-S, DMFT, and OHI-S was 0.130.23,0.350.27,2.403.18,and 0.460.37,indicating important components for tooth decay.Half of the parents did not have proper knowledge of their teeth and gums.However, after the 3-month follow-up, the parents' perceptions regarding oral health were positive, with a decrease in DI-S and OHI-S scores, suggesting improvement in oral health. Conclusion:Children with autism exhibited poor oral hygiene and a high prevalence of dental caries, indicating substantial unmet dental treatment needs.Routine parental counseling and training on proper oral care can play a crucial role in promoting the oral health of children.
Prosthodontic management of congenital hypothyroidism with anodontia: A case report Sham S Bhat, Sundeep K Hegde, Vidya S Bhat, Varsha Bhat, Jamsheera Vadakkan, Sanath Shetty International Journal of Clinical Pediatric Dentistry, 2021 Thyroid dysfunction has various manifestations which include orofacial abnormalities like delayed eruption, retained deciduous teeth, etc. Early detection of this deregulation of thyroid homeostasis can prevent associated complications. This report is a case of congenital hypothyroidism (CH) in a 4-year-old boy who presented with a completely edentulous maxilla and hypodontic mandible. Based on various biochemical and radiographic investigations, a diagnosis of CH was established. He was prosthodontically rehabilitated with removable dentures.
Comparative evaluation of two remineralizing agents on artificial carious lesion using DIAGNOdent Sham S Bhat, Sundeep K Hegde, Vidya S Bhat, Dilip Shirly Arjun, Hejamady Tati Ajay Rao, Shenoy S Ramdas International Journal of Clinical Pediatric Dentistry, 2021 Purpose The current in vitro study was conducted to assess the remineralization potential of CPP-ACP and a customized dentifrice (tricalcium-phosphate) on artificial carious lesions using DIAGNOdent. Materials and methods Fifty-one extracted premolars that satisfied the inclusion criteria were painted using acid-resistant nail varnish. A window of 4 × 4 mm was exposed on the center of the buccal surface of each tooth. After 20 minutes of drying, the baseline reading of enamel specimens was assessed using DIAGNOdent. The teeth were then immersed in a bath of demineralizing solution. An incubation period of 96 hours at 37°C resulted in artificial caries-like lesions on the specimen. Readings of the specimen within the window after demineralization were recorded using DIAGNOdent for all the samples. The specimens were divided into three groups randomly [group I—casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), group II—customized dentifrice, group III—artificial saliva]. Samples were subjected to the daily treatment regimen for a period of 30 days. The samples were evaluated for remineralization by laser fluorescent device (DIAGNOdent) on the 15th and 30th day, respectively. Results The statistical analysis was done using the Friedman test, Kruskal–Wallis test, Wilcoxon sign rank test, and Mann–Whitney test. The results showed that both CPP-ACP and customized dentifrice showed almost similar remineralization potential but CPP-ACP showed significant remineralization (p < 0.001). Conclusion The DIAGNOdent observation conclusively proves that CPP-ACP and customized dentifrice remineralizes the demineralized tooth samples in vitro with CPP-ACP showing significant remineralization. How to cite this article Arjun DS, Bhat SS, Hegde SK, et al. Comparative Evaluation of Two Remineralizing Agents on Artificial Carious Lesion Using DIAGNOdent. Int J Clin Pediatr Dent 2021;14(2):192–195.
Estimation of salivary sCD14 in children with early childhood carries in association with pneumonia Reports of Biochemistry and Molecular Biology, 2019
Evaluation of the effect of extraction and restorative procedures on blood pressure and pulse rate due to anxiety in 6-to 12-year-old children: An in vivo study Nanditha Hegde, SundeepK Hegde, ShamS Bhat, GobichettipalayamJegatheeswaran Anbuselvan, DhanrajPawan Kumar Bhandari, Senthilnathan Radhakrishnan Journal of Pharmacy and Bioallied Sciences, 2019 Background: The objective of this study was to determine the changes in the cardiovascular parameters, blood pressure, and pulse rate due to anxiety in children undergoing dental extraction and restorative treatment. Materials and Methods: A total of 150 children were included in the study based on inclusion and exclusion criteria. The parameters were measured at four and three intervals for the extraction and restorative group, respectively. The obtained data were analyzed using repeated measures analysis of variance test. Results: In the extraction group, the change in blood pressure in female children (144mm Hg) was significant compare to male children (141mm Hg). In the restoration group, the change in blood pressure in male children (140/84mm Hg) was found to be statistically more significant when compared to female children (139/85mm Hg).The pulse rate change in both sexes was equally significant in restorative and extraction group. Conclusion: It can be inferred that pain and fear anxiety play important roles in the cardiovascular changes during dental treatment because there was significant change in blood pressure and pulse rate over time during dental treatment.
An in vitro evaluation of nickel and chromium release from different commercially available stainless steel crowns ShamS Bhat, EvetteNatasha Amanna, SundeepK Hegde Journal of Indian Society of Pedodontics and Preventive Dentistry, 2019 Aim: The aim of the present study was to estimate nickel and chromium release from commercially available stainless steel crowns (SSCs) in artificial saliva. Materials and Methods: Ten crowns from three manufacturers were immersed in 10 ml of artificial saliva and stored in separate tubes in an incubator at 37°C for 28 days. The crowns were removed from each tube on every 7th day, and placed in other tubes with fresh artificial saliva. Flame type atomic absorption spectrophotometer was used to check for the release of metal ions in the solution inside each tube at the end of 1, 7, 14, 21, and 28 days and the control samples. Results and Statistical Analysis: Two-way analysis of variance and pairwise comparison using Bonferroni test was used for statistical analysis. There was statistically verified difference in the release of nickel and chromium on different days in each of the group of SSCs tested. However, no significant difference was seen in the release of both metals among the groups. Conclusion: In all the SSCs tested, there was the release of nickel and chromium, but the total release of both the metals even at a period of 28 days was below the critical level to cause any toxic effects. Hence, the release of metal ions should not be an alarming concern for the use of any of the group of commercially available SSCs.
Effectiveness of precooling the injection site using tetrafluorethane on pain perception in children NithashaN Hameed, SharanS Sargod, ShamS Bhat, SundeepK Hegde, MuhsinMohammed Bava Journal of Indian Society of Pedodontics and Preventive Dentistry, 2018 Background: Injection of local anesthesia is one of the most important reasons for avoidance behavior in children. Applying a topical anesthetic before injection is the most popular way to control pain; however, topical anesthetics have some shortcomings such as longer duration of action, displeasing taste, and spread of the anesthetic agent to noninjection site areas. Cryoanesthesia using refrigerant as a topical anesthesia is being studied as an alternative to overcome the shortcomings of topical anesthetics and has shown promising results. Materials and Methods: In this split-mouth design study, 50 children of aged 8–10 years who required bilateral mandibular local anesthesia administration were selected. In the first visit, application of topical anesthetic spray (lidocaine) on one side and during the second appointment cryoanesthetic tetrafluorethane on the other side was used before local anesthetic administration. Patients were asked to report their discomfort and pain using visual analog scale (VAS) (subjective method). Patients' pain perception during injection is assessed by sound, eye, and motor (SEM) scale by the dentist (objective method). Results: The results were statistically analyzed using paired Wilcoxon signed-rank test and Mann–Whitney tests. In VAS scale (subjective method), pain scores were significantly lower in tetrafluorethane group when compared with lidocaine group. In SEM scale (objective method), pain scores were lower in tetrafluorethane group when compared with lidocaine group, but it was statistically insignificant. Conclusion: Precooling the injection site using refrigerant tetrafluorethane spray has shown to be effective in eliminating pain before local anesthesia administration in children when compared with topical anesthetic lidocaine spray.
Assessment of maternal risk factors and its relationship with early childhood caries among preschool children in Mangaluru city KM Ramya, ShamS Bhat, Sundeep Hegde, Vidya Bhat, Praveen Jodalli Journal of Indian Society of Pedodontics and Preventive Dentistry, 2017 Aim: The aim of this study is to assess the maternal risk factors and its relationship with early childhood caries (ECC) among preschoolchildren in Mangaluru city. Methods: Children aged 3–5 years attending preschool (Anganwadi) and their mothers were included in the study. A total of 120 child–mother pairs participated in the study. The maternal risk factors were assessed by a pretested questionnaire. After obtaining the consent, the mother and their children were clinically examined for dental caries using the WHO criteria (1997). Results were analyzed using SPSS 18.0. Results: Significant difference was found in mother's caries activity, high level of Streptococcus mutans, brushing frequency, diet of the mother, and their child's caries experience. Conclusion: A relationship between maternal risk factors and ECC is a result of a multifactorial and a comprehensive model that includes psychological and behavioral aspects. Caries prevention strategy should be that every child should receive oral care before age of one so that needful children can be instituted with preventive measures and their parents can be targeted for educational programs.
Oral melanotic macule--a case report. Journal of the Indian Society of Pedodontics and Preventive Dentistry, 2004
RECENT SCHOLAR PUBLICATIONS
Evaluation of clinical and radiographic outcome of premixed injectable mineral trioxide aggregate and conventional mineral trioxide aggregate as pulpotomy medicaments in … US Aiswarya, SS Sargod, SK Hegde, HTA Rao, N Hegde Journal of Indian Society of Pedodontics and Preventive Dentistry 43 (4 … , 2025 2025
Abstract No. 200 Comparative Efficacy and Complication Rates of n-BCA Glue Partial Splenic Embolization in Patients with Varying Extent of Parenchymal Embolization K Hegde, S Kalva, V Wu, E Wehrenberg-Klee, P Sutphin Journal of Vascular and Interventional Radiology 36 (3), S92 , 2025 2025
Awareness and Knowledge of Artificial Intelligence in Pediatric Dentistry: A Cross Sectional Survey among Indian Pediatric Dentists S Santhosh, S Shenoy, SK Hegde, M Ashmil International Journal of Research and Innovation in Applied Science 10 (8 … , 2025 2025
Tech Bytes—Harnessing Artificial Intelligence for Pediatric Oral Health: A Scoping Review DA Tanna, S Bhandary, KS Hegde International Journal of Clinical Pediatric Dentistry 17 (11), 1289 , 2024 2024 Citations: 5
Remineralization of Enamel Using Topical Agents among Patients with Orthodontic Brackets: In Vivo and In Vitro Randomized Control Trial S Sain, SK Hegde, SS Bhat, GJ Satheesh International Journal of Clinical Pediatric Dentistry 17 (10), 1093 , 2024 2024
Güney Hindistan’da Otizm Spektrum Bozukluğu Olan Çocuklarda Diş Çürüğü Deneyiminin ve Ebeveynlerin Ağız Sağlığı Durumuna İlişkin Algılarının Analizi SK Hegde, O Ranjit, SS Bhat, BS Kalal Medical Journal of Bakirkoy , 2024 2024
Analysis of dental caries experience and parents perception on the oral health status of children with autism spectrum disorders from South India SK Hegde, O Ranjit, SS Bhat, BS Kalal Medical Journal of Bakirkoy , 2024 2024 Citations: 4
Abstract No. 385 Efficacy of Percutaneous Balloon Angioplasty for Residual Venous Stenosis Following Surgical Decompression for Venous Thoracic Outlet Syndrome K Bhave, K Hegde, P Sutphin, S Kalva Journal of Vascular and Interventional Radiology 35 (3), S171 , 2024 2024
Abstract No. 282 Doppler Velocities in Patent Transjugular Portosystemic Shunts: An Analysis of 10-mm versus 8-mm Shunts M Mitchell, K Hegde, A Som, P Sutphin, S Kalva Journal of Vascular and Interventional Radiology 35 (3), S124-S125 , 2024 2024
Early Intervention with Clear Aligners: A New Frontier in Paediatric Dentistry R Tiwari, AHT Rao, SS Sargod, SK Hegde, RK Ballal, S Sharief Manipal Journal of Medical Sciences 9 (1), 3 , 2024 2024
RECENT TRENDS & ADVANCES IN CLINICAL PEDIATRIC DENTISTRY A Sheikh, KR Ballal, L PAI, SHS BHAT, S HEGDE INTERNATIONAL JOURNAL 10 (4), 254-261 , 2024 2024 Citations: 1
Energy-Efficient Bio-Inspired Hybrid Deep Learning Model for Network Intrusion Detection Based on Intelligent Decision Making SK Hegde, P William, MS Basvant, A Deepak, A Badhoutiya, ALN Rao, ... International Journal of Intelligent Systems and Applications in Engineering … , 2024 2024 Citations: 41
The COVID-19 pandemic and mental health outcomes–A cross-sectional study among health care workers in Coastal South India T Rekha, N Kumar, K Hegde, B Unnikrishnan, P Mithra, R Holla, ... F1000Research 11, 676 , 2023 2023 Citations: 4
Comparison of knowledge and attitude among medical postgraduates and general medical practitioner in management of tooth avulsion A Devan, S Hegde, SS Bhat, R Suvarna, V Radje, G Pradeep International Journal of Oral Health Dentistry 6 (4), 299-302 , 2023 2023
Effectiveness of virtual reality eyeglasses as a distraction technique in managing anxious paediatric patients undergoing dental treatment-A cross-sectional study A Devan, S Hegde, SS Bhat, R Ballal, AR HT International Journal of Oral Health Dentistry 7 (2), 131-137 , 2023 2023 Citations: 2
Comparative evaluation on clinical success rate of prefabricated zirconia crowns and stainless steel crowns in primary molars K Harshitha, HTA Rao, KS Hegde, SS Sargod, SS Mahaveeran, A Devan International Journal of Oral Health Dentistry 7 (3), 180-186 , 2023 2023 Citations: 6
A Case Report of Fanconi Anemia: A Literature Review and Dental Perspective of Rare Disease A Mathirat, M Ejas, A Devan, SS Bhat, SK Hegde, SS Sargod Oral & Maxillofacial Pathology Journal 14 (1) , 2023 2023 Citations: 1
A Case Report on Beckwith Wiedemann Syndrome G Roshila, M Pooja, SS Bhat, KS Hegde international journal of research and reports in dentistry 5 (2), 182-186 , 2022 2022
Effect of Fluoride-based varnishes with added calcium and phosphate on microhardness of esthetic restorative materials: an in vitro study RS Shetty, SS Bhat, SK Hegde, VS Bhat International Journal of Clinical Pediatric Dentistry 15 (2), 187 , 2022 2022 Citations: 2
Evaluation of antimicrobial activity of aqueous extract of “Ocimum Sanctum-Queen of Herb” on dental caries microorganisms: An in vitro study KR Pai, LK Pallavi, SS Bhat, SK Hegde International Journal of Clinical Pediatric Dentistry 15 (Suppl 2), S176 , 2022 2022 Citations: 19
MOST CITED SCHOLAR PUBLICATIONS
Influence of mouth breathing on the dentofacial growth of children: a cephalometric study B Basheer, KS Hegde, SS Bhat, D Umar, K Baroudi Journal of international oral health: JIOH 6 (6), 50 , 2014 2014 Citations: 174
Potential of mobile phones to serve as a reservoir in spread of nosocomial pathogens SS Bhat, SK Hegde, S Salian Online Journal of Health and Allied Sciences 10 (2) , 2011 2011 Citations: 92
Microbial contamination of Toothbrushes and their Decontamination. DGRM Dr.Bhat SS, Dr. Hegde SK Journal of Indian Society of Pedodontics and Preventive Dentistry 21 (3 … , 2003 2003 Citations: 71
Characteristics of primary dentition occlusion in preschool children: an epidemiological study SS Bhat, HTA Rao, KS Hegde, BSK Kumar International journal of clinical pediatric dentistry 5 (2), 93 , 2012 2012 Citations: 63
Oral findings in newborn children in and around Mangalore, Karnataka State, India D George, SS Bhat, SK Hegde Medical Principles and Practice 17 (5), 385-389 , 2008 2008 Citations: 56
Comparative evaluation of bactericidal potential of four root canal filling materials against microflora of infected non-vital primary teeth P Harini, S Bhat, K Sundeep Hegde Journal of Clinical Pediatric Dentistry 35 (1), 23-29 , 2010 2010 Citations: 53
Comparative evaluation of remineralization potential of two varnishes containing CPP–ACP and tricalcium phosphate: an in vitro study V Varma, KS Hegde, SS Bhat, SS Sargod, HTA Rao International Journal of Clinical Pediatric Dentistry 12 (3), 233 , 2019 2019 Citations: 47
Evaluation of resistance of teeth subjected to fracture after endodontic treatment using different root canal sealers: An: in vitro: study SS Bhat, SK Hegde, A Rao, AKS Mohammed Journal of Indian Society of Pedodontics and Preventive Dentistry 30 (4 … , 2012 2012 Citations: 46
Sealing Ability of ProRoot MTA and MTA-Angelus Simulating a One-Step Apical Barrier Technique- An in vitro Study N Lolayekar, S Bhat, S Hegde Journal of Clinical Pediatric Dentistry 33 (4), 305-310 , 2009 2009 Citations: 46
Effectiveness of precooling the injection site using tetrafluorethane on pain perception in children NN Hameed, SS Sargod, SS Bhat, SK Hegde, MM Bava Journal of Indian Society of Pedodontics and Preventive Dentistry 36 (3 … , 2018 2018 Citations: 42
Energy-Efficient Bio-Inspired Hybrid Deep Learning Model for Network Intrusion Detection Based on Intelligent Decision Making SK Hegde, P William, MS Basvant, A Deepak, A Badhoutiya, ALN Rao, ... International Journal of Intelligent Systems and Applications in Engineering … , 2024 2024 Citations: 41
Comparison of proximal caries detection in primary teeth between laser fluorescence and bitewing radiography: An in vivo study R Mepparambath, SS Bhat, SK Hegde, G Anjana, M Sunil, S Mathew International journal of clinical pediatric dentistry 7 (3), 163 , 2015 2015 Citations: 38
Effect of propolis on Streptococcus mutans counts: An in vivo study KS Hegde, SS Bhat, A Rao, S Sain International journal of clinical pediatric dentistry 6 (1), 22 , 2013 2013 Citations: 37
Preclinical screening of phyllanthus amarus ethanolic extract for its analgesic and antimicrobial activity SM Sham S Bhat, k Sundeep Hegde, Sharath Chandrashekar, S N Rao Pharmacognosy Research 2 (11), 639-47 , 2015 2015 Citations: 32
Comparative evaluation of Mangifera indica leaf mouthwash with chlorhexidine on plaque accumulation, gingival inflammation, and salivary streptococcal growth SS Bhat, KS Hegde, C Mathew, SV Bhat, M Shyamjith Indian Journal of Dental Research 28 (2), 151-155 , 2017 2017 Citations: 31
A cross sectional study of the prevalence and dental caries among 12-15 year old overweight school children S S kottayi, SS bhat, KS hegde, FC Peedikayil, TP Chandru The journal of contemporary dental practice 17 (9), 750-754 , 2016 2016 Citations: 31
Direct pulp capping in an immature incisor using a new bioactive material SS Bhat, SK Hegde, F Adhikari, VS Bhat Contemporary Clinical Dentistry 5 (3), 393-396 , 2014 2014 Citations: 29
Antibacterial activity of turmeric against Enterococcus faecalis an in vitro study R Suvarna, SS Bhat, KS Hegde Int. J. Curr. Microbiol. App. Sci 3 (2), 498-504 , 2014 2014 Citations: 26
Remineralization potential using calcium sucrose phosphate (Enafix) on artificial carious lesion - A Polaroid Microscopic study DRK Dr. Sharan S Sargod, Dr. Sham S Bhat, Dr. Sundeep Hegde Indian Journal of Applied Research 5 (1), 421-23 , 2015 2015 Citations: 23
Efficacy of garlic extract and chlorhexidine mouthwash in reduction of oral salivary microorganisms, an in vitro study VJ H.T Ajay Rao, Sham S Bhat, Sundeep Hegde Ancient Science of Life 34 (2), 85-88 , 2014 2014 Citations: 23
