BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 337
Purpose
Providing both primary and comprehensive preventive and
therapeutic oral health care to individuals with special health
care needs (SHCN) is an integral part of the specialty of pedi-
atric dentistry.
1
e American Academy of Pediatric Dentistry
(AAPD) values the unique qualities of each person and the
need to ensure maximal health attainment for all, regard-
less of developmental disability or other special health care
needs. ese recommendations are intended to educate health
care providers, parents
2
, and ancillary organizations about the
management of oral health care needs particular to individuals
with SHCN rather than provide specic treatment recom-
mendations for oral conditions.
Methods
Recommendations on the management of dental patients with
SHCN were developed by the Council on Clinical Aairs,
adopted in 2004
3
, and last revised in 2016
4
. is update is
based on a review of the current dental and medical literature
related to individuals with SHCN. A search was conducted via
PubMed
®
/
MEDLINE using the terms: special needs, disabil-
ity, disabled patients/persons/children, handicapped patients,
dentistry, dental care, and oral health; elds: all; limits: within
the last 10 years, human, and English. Papers for review were
chosen from the resultant list of articles and from references
within selected articles. When data did not appear sucient
or were inconclusive, recommendations were based on expert
and/or consensus opinion by experienced researchers and
clinicians.
Background
e AAPD denes special health care needs as “any physical,
developmental, mental, sensory, behavioral, cognitive, or emo-
tional impairment or limiting condition that requires medical
management, health care intervention, and/or use of specialized
services or programs. e condition may be congenital,
developmental, or acquired through disease, trauma, or envi-
ronmental cause and may impose limitations in performing
daily self-maintenance activities or substantial limitations in
a major life activity. Health care for individuals with special
needs requires specialized knowledge, as well as increased
awareness and attention, adaptation, and accommodative
measures beyond what are considered routine.”
5
Children with SCHN may include those with behavioral
(e.g., anxiety, attention decit hyperactivity disorder, autism
spectrum disorder), congenital (e.g., trisomy 21, congenital
ABBREVIATIONS
AAPD: American Academy of Pediatric Dentistry. AwDA: Ameri-
cans with Disabilities Act. HIPAA: Health Insurance Portability
and Accountability Act. SHCN: Special health care needs.
Management of Dental Patients with Special
Health Care Needs
Latest Revision
2021
How to Cite: American Academy of Pediatric Dentistry. Management
of dental patients with special health care needs. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 2023:337-44.
Abstract
This best practice presents recommendations regarding the management of oral health care for dental patients with special health care needs
(SHCN) rather than treatment for oral conditions. SHCN are defined as any physical, developmental, mental, sensory, behavioral, cognitive,
or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services
or programs. Nearly one in five U.S. children has a SHCN. The more severe their health conditions, the more likely they are to have unmet
dental needs. Barriers to care are discussed. Without professional preventive and therapeutic dental services, children with SHCN may
exacerbate systemic medical conditions and increase the need for costly care. Each oral health topic (e.g., dental home, scheduling appoint-
ments, patient assessment, planning dental treatment, informed consent, behavior guidance, preventive strategies) includes specific
recommendations. The document addresses patients with developmental or acquired orofacial conditions as a special cohort of children
with SHCN. Consultation and coordination of care with medical and other dental providers may be necessary for safe delivery of care and
to improve long term outcomes for these patients. As children with SHCN approach adulthood, planning and coordinating their successful
transition to an adult dental home ensures no disruption in the continuity of oral health care.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and guidance on the management of dental patients with special health care needs.
KEYWORDS: DENTAL CARE FOR CHILDREN; DENTAL CARE FOR DISABLED; DISABLED CHILD; PEDIATRIC DENTISTRY
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
338 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
heart disease), developmental (e.g., cerebral palsy) or cognitive
(e.g., intellectual disability) disorders, and systemic diseases
(e.g., childhood cancer, sickle cell disesase).
6
In some instances,
the condition primarily aects the orofacial complex (e.g.,
amelogenesis imperfecta, dentinogenesis imperfecta, cleft lip/
palate, oral cancer). While these individuals may not expe-
rience the same limitations as other patients with SHCN,
their needs are unique, aect their overall quality of life, and
require specialized, multidisciplinary oral health care. ese
individuals may be at an increased risk for oral diseases
throughout their lifetime.
6-11
Oral health conditions associated
with SHCN
11
include:
• build-up of calculus resulting in increased gingivitis
and risk for periodontal disease.
• enamel hypoplasia.
• dental caries.
• oral aversion and behavior problems.
• dental crowding.
• malocclusion.
• anomalies in tooth development, size, shape, eruption,
and arch formation.
• bruxism and wear facets.
• fracture of teeth or trauma.
Oral diseases can have a direct and devastating impact on
the general health and quality of life. Individuals with certain
systemic health problems or conditions such as compromised
immunity (e.g., malignancies, human immunodeciency
virus, history of organ transplantation) or cardiac conditions
at a high risk for infective endocarditis may be especially
vulnerable to the eects of oral diseases.
12
Patients with
cognitive, developmental, or physical disabilities that impact
their ability to understand, assume responsibility for, or co-
operate with preventive oral health practices are susceptible
as well.
13
Oral health is an inseparable part of general health
and well-being.
14
According to the National Survey of Children’s Health in
2017-2018, approximately 13.6 million children (18.5 percent)
had a special health care need.
15
One in four children with
SHCN (26.6 percent) had functional limitations, one in ve
(19.9 percent) were consistently or signicantly impacted by
their health condition(s), and nearly half (46.0 percent) were
sometimes/moderately impacted by their health condition(s).
15
e Surgeon General’s Call to Action to Improve the Health
and Wellness of Persons With Disabilities included a call to
double eorts in preventing disease and promoting the overall
health and well-being of persons with disabilities.
14
Because of
improvements in medical care, patients with SHCN are liv-
ing longer and require extended medical and oral health care.
11
Many of the formerly acute and fatal diagnoses have become
chronic and manageable conditions.
11
Oral health care is as
important as the provision of medical services.
Unmet dental needs are associated with SHCN status and
complexity.
16
Children aected with more severe conditions
have increased risk of having unmet dental needs.
11,16,17
Barriers
to care for children with SHCN may range from limitations
in access to a dentist willing to provide care, access to a pro-
fessional with experience and expertise, child’s cooperation,
and transportation issues. Because of these unmet dental care
needs, a dental home with comprehensive, coordinated services
should be established.
18,19
Optimal health of children is more likely to be achieved
with access to comprehensive health care benets.
20
Common
barriers for medically necessary oral health care include nan-
cial constraints.
21-25
Insurance plays an important role for
families with children who have SHCN, but it still provides
incomplete protection.
23-25
Many individuals with SHCN rely
on government funding to pay for medical and dental care
and lack adequate access to private insurance for health care
services.
26
Lack of preventive and timely therapeutic care may
increase the need for costly care and exacerbate systemic health
issues.
27
Nonnancial barriers such as language and psychosocial,
structural, and cultural considerations may interfere with
access to oral health care.
25
Eective communication is essential
and, for hearing impaired patients/parents, can be accom-
plished through a variety of methods including interpreters,
written materials, and lip-reading. Psychosocial factors associ-
ated with access for patients with SHCN include oral health
beliefs, norms of caregiver responsibility, and past dental
experience of the caregiver. Structural barriers include trans-
portation, school absence policies, discriminatory treatment,
and diculty locating providers who accept Medicaid.
21
Priorities and attitudes can serve as impediments to oral
care. e caregiver’s oral health promotion eorts and interest
in oral health-related education have been positively correlated
with the level of function, capabilities, and independence of
an individual with SHCN.
28
Parental and physician lack of
awareness and knowledge in the management of children with
SHCN may hinder an individual with SHCN from seeking
preventive dental care.
28,29
Other health conditions may seem
more important than dental health, especially when the re-
lationship between oral health and general health is not well
understood.
30
Persons with SHCN may express a greater level of anxiety
about dental care than those without a disability, which may
adversely impact the frequency of dental visits and, subse-
quently, oral health.
31
An assessment of anxiety or dental fear
is challenging in this population and, in some cases, an
estimation through parent or caregiver report is helpful.
Patients with SHCN require additional considerations for be-
havior guidance including the patient’s development, education
level, cognitive ability, cooperation in medical settings, triggers
for uncooperative behavior, soothing strategies, adherence to
schedule or routine, current therapies, and other benecial
accommodations
32
as these can complicate the delivery of care.
e use of basic and advanced behavior guidance techniques
33,34
allows the dentist to recognize the complexities of managing
patients with SHCN.
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 339
Managing patients with SHCN includes proper coordination
and transition into adult care. Pediatric dentists are concerned
about decreased access to oral health care for patients with
SHCN as they transition beyond the age of majority.
35
Finding
a dental home for nonpediatric patients with SHCN can be
challenging. Pediatric hospitals, by imposing age restrictions,
can create another barrier to care for these patients. is presents
diculties for pediatric dentists providing care to adult patients
with SHCN patients who have not yet transitioned to adult
primary care. Outpatient surgery centers and in-oce general
anesthesia may be alternatives, although they may not be appro-
priate for patients with medically complex special needs.
36
e
Commission on Dental Accreditation requires dental schools
to ensure that curricular eorts focus on educating students
on assessment of treatment needs of patients with SHCN.
37
Recommendations
Reducing the risk of developing oral disease is an integral
part of the comprehensive oral health care for children with
SHCN. e goals of care include: (1) establishing dental
home at an early age, (2) obtaining thorough medical, dental,
and social patient histories, (3) creating an environment con-
ducive for the child to receive care, (4) providing compre-
hensive oral health education and anticipatory guidance to
the child and caregiver, and (5) providing preventive and
therapeutic services including behavior guidance and a multi-
disciplinary approach when needed.
6
Attention to detail is
important for all aspects of care including scheduling appoint-
ments, assessment, treatment planning, consent, education
and anticipatory guidance, treatment, recalls, and transition of
care when the patient reaches adulthood.
Dental home
A dental home should be established by 12 months of age,
38
especially for children with SHCN. e dental home provides
an opportunity to implement individualized preventive oral
health practices, help establish routine dental care, and reduces
the child’s risk of preventable dental/oral disease.
38
Dentists
are obligated to be familiar with the regulations of the Amer-
icans with Disabilities Act
18
(AwDA) and ensure compliance.
Regulations require practitioners to provide physical access
to the dental oce (e.g., wheelchair ramps, disabled-parking
spaces).
Scheduling appointments
The caregiver’s and patient’s initial contact with the dental
practice allows both parties an opportunity to address the
child’s primary oral health needs and to conrm the appropri-
ateness of scheduling an appointment with that particular
practitioner. Along with the child’s name, age, and chief
complaint, the receptionist should determine the presence
and nature of any SHCN and, when appropriate, the name(s)
of the child’s medical care provider(s). e oce sta, under
the guidance of the dentist, should determine the need for an
increased length of appointment and/or additional auxiliary
sta in order to accommodate the patient in an eective and
ecient manner. e need for increased dentist and team time
as well as customized services should be documented so the
office staff is prepared to accommodate the patient’s unique
circumstances at each subsequent visit.
39
Consideration for
length of time, time of the appointment (e.g., morning, rst
appointment of the day, limited patients in the waiting room)
or need for introductory visits helps to ensure a positive
experience.
6
When scheduling patients with SHCN, familiarity and
compliance with Health Insurance Portability and Account-
ability Act (HIPAA) and AwDA regulations applicable to
dental practices are imperative.
18,50
HIPAA insures that the
patient’s privacy is protected, and AwDA prevents
discrimination on the basis of a disability.
Patient assessment
Familiarity with the patient’s medical history is essential. An
accurate, comprehensive, and up-to-date medical history is
necessary for correct diagnosis, eective treatment planning,
and decreasing the risk of aggravating a medical condition
while rendering care. e intake interview should address the
chief complaint, history of present illness, medical conditions
and/or illnesses, medical care providers, hospitalizations/surgeries,
anesthetic experiences, current medications, allergies/sensitivi-
ties, immunization status, review of systems, and family, social
and dental histories.
41,42
e interview should include patient’s
development, education level, and cognitive ability to help
predict cooperation.
32
Many children with SHCN may have
sensory considerations or limitations to communication that
can make the dental experience challenging; the dentist should
include such concerns during the history intake and be pre-
pared to modify the traditional delivery of oral care to address
the child’s unique needs. If the patient/parent is unable to
provide accurate information, consultation with the caregiver
or with the patient’s physician may be required.
At each patient visit, the dental team should consult and
verbally update the patient’s medical history, noting any recent
medical attention for illness or injury, change in health status,
newly diagnosed medical conditions, allergies/sensitivities, and
changes in medications. Obtaining a written update at each
recall visit enhances documentation and awareness of the
patient’s history and health status. e patient’s record should
identify any signicant medical conditions.
A comprehensive clinical examination includes evaluation
of the head, neck, and oral structures, along with caries- and
periodontal-risk assessment.
43,44
Caries-risk assessment pro-
vides a means of classifying caries risk at a point in time and,
therefore, should be applied periodically to assess changes in
an individual’s risk status.
43
e examination also should in-
clude assessments of occlusion, habits, and traumatic injuries.
e dentist should review all available adjunctive diagnostic
aids such as radiographs, photographs, or blood tests.
A summary of the oral ndings and specic treatment
recommendations should be provided to the patient and parent.
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
340 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
When appropriate, the patient’s other health care providers
(e.g., physicians, nurse practitioners, therapists) and caretakers
should be informed of any signicant ndings. An individ-
ualized preventive program, including a dental recall schedule,
should be recommended after evaluation of the patient’s caries
risk, oral health needs, and capabilities.
Medical consultations
e dentist should coordinate care via consultation with the
patient’s other care providers. When appropriate, the physician
should be consulted regarding medications, sedation, general
anesthesia, and special restrictions or preparations that may
be required to ensure the safe delivery of oral health care. A
multidisciplinary approach may be necessary in complex case
management. e dentist and sta always should be prepared
to manage a medical emergency.
Planning dental treatment
e goals of oral health care for individuals with SHCN align
with those for all children with careful consideration of the
risks, benets, and prognosis of the proposed plan to the indi-
vidual’s condition. Understanding the patient’s cognitive level,
sensitivities, oral aversion, and triggers to negative behavior
will help improve delivery of care and communication. Den-
tists should communicate with patients with SHCN at a level
appropriate for their cognitive development.
32
e dentist
should not assume that patients with impaired communica-
tion have associated intellectual disability, unless specied.
32
Patients with hearing or visual impairment may require non-
verbal communication and cues with the help of the caregiver.
Other considerations include treating active disease prior to
any major medically-necessary procedures (e.g., cardiac surgery,
initiation of oncology treatment), deferring all elective dental
treatment during active phases of medical care if a child is
immunocompromised or at hematologic risk
6
, and prescribing
antibiotic prophylaxis if risk for infective endocarditis or
distant site infection (e.g., in the presence of uncontrolled
systemic disease, if the individual is immunocompromised) is
high.
45
e practitioner should have a thorough knowledge of
indications and contraindications for the use of pharmacol-
ogic agents (e.g., antibiotics, analgesics, sedatives, anesthetics)
in relation to the patient’s medical condition. In some situa-
tions (e,g., anatomic airway issues; high risk of complications
with procedures, surgeries, or general anesthesia; the need for
high level specialist care), treatment in a tertiary hospital setting
is indicated. ere is anecdotal parental concern for increased
risk of development of neurodevelopmental disorders such as
autism with general anesthesia exposure. Research has shown
that exposure to general anesthesia before the age of two years
and the number of exposures were not associated with the
development of autism,
46
however, further research regard-
ing the risks associated with neurodevelopmental disorders is
warranted.
47
Indications for an orthodontic evaluation include facial
asymmetry, abnormalities in nasal breathing, malocclusion, and
diculties with chewing, swallowing, speech, and/or oral
functioning. e primary motivation for parents to have
their child with SHCN undergo orthodontic therapy is to
improve the child’s facial attractiveness, oral function, and
quality of life.
48,49
e decision to initiate orthodontic treat-
ment should factor in the child’s ability to tolerate treatment
and the expected outcomes of care.
Informed consent
All patients must be able to provide signed informed consent
for dental treatment or have someone present who legally can
provide this service for them. Informed consent/assent must
comply with state laws and, when applicable, institutional
requirements. Informed consent should be well documented
in the dental record through a signed and witnessed form.
50
Behavior guidance
Behavior guidance of the patient with SHCN can be challeng-
ing. Communication may be limited due to anxiety, intellectual
disability, or impaired hearing or vision. Because of dental
anxiety, a lack of understanding of dental care, oral aversion, or
fatigue from multiple medical visits and procedures, children
with SHCN may exhibit resistant behaviors. ese behaviors
can interfere with the safe delivery of dental treatment. With
the parent’s/caregiver’s assistance, most patients with physical
and intellectual disabilities can receive oral health care in the
dental oce. Protective stabilization can be helpful for some
patients (e.g., those with aggressive, uncontrolled, or impulsive
behaviors; when traditional behavior guidance techniques are
not adequate)
33,34
for safe delivery of care and with consent.
When non-pharmacologic behavior guidance techniques are
ineective, the practitioner may recommend sedation or gen-
eral anesthesia to allow completion of comprehensive treatment
in a safe and ecient manner.
Preventive strategies
Individuals with SHCN may be at increased risk for oral
diseases; these diseases further jeopardize the patient’s overall
health.
7
Education of parents/caregivers is critical for ensuring
appropriate and regular supervision of daily oral hygiene. e
team of dental professionals should develop an individualized
oral hygiene program that accommodates the unique disabil-
ity of the patient. Assistance from other health professions
(e.g., occupational therapy) may be benecial. Brushing with
a fluoridated dentifrice twice daily helps prevent caries and
gingivitis. If a patient’s sensory issues cause the taste or texture
of uoridated toothpaste to be intolerable, a toothpaste with-
out sodium laurel sulfate (SLS) to eliminate foaming nature, a
fluoridated mouthrinse, or an alternative (e.g., casein
phosphopeptide-amorphous calcium phosphate [CPP-ACP])
may be applied with the toothbrush.
51
Toothbrushes can be
modified to enable individuals with physical disabilities to
brush their own teeth. Electric toothbrushes and oss holders
may improve patient compliance. Caregivers should provide the
optimal oral care when the patient is unable to do so adequately.
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 341
Practitioners should encourage a noncariogenic diet for
long term prevention of dental disease.
52
When a diet rich in
carbohydrates or the use of high calorie supplements is medi-
cally necessary (e.g., to increase weight gain), the dentist
should provide strategies to mitigate the caries risk by altering
frequency of and/or increasing preventive measures. Medica-
tions and their oral side effects (e.g., xerostomia, gingival
overgrowth) should be reviewed as these can have an impact
on caries and periodontal risk.
6
Patients with SHCN may benefit from sealants. Sealants
reduce the risk of caries in susceptible pits and fissures of
primary and permanent teeth.
53
Topical uorides (e.g., sodium
uoride, silver diamine uoride)may be indicated when caries
risk is increased.
54
Interim therapeutic restoration (ITR),
55
using materials such as glass ionomers that release uoride, may
be useful as both preventive and therapeutic approaches in
patients with SHCN.
56
In cases of gingivitis and periodontal
disease, chlorhexidine mouthrinse may be useful.
57
Use of a
toothbrush to apply the chlorhexidine is an option if caregivers
are concerned about the child’s potentially swallowing the
antiseptic. An increased recall frequency for patients having
severe dental disease is indicated. Patients with aggressive
periodontal disease require referral to a periodontist for eval-
uation and treatment if the treatment needs are beyond the
treating dentist’s scope of practice.
Preventive strategies for patients with SHCN also should
address traumatic injuries. This would include anticipatory
guidance about risk of trauma (e.g., with seizure disorders or
motor skills/coordination deficits), mouthguard fabrication,
and what to do if dentoalveolar trauma occurs. Additionally,
children with SHCN are more likely to be victims of physical
abuse, sexual abuse, and neglect when compared to children
without disabilities.
58
Craniofacial, head, face, and neck injuries
occur in more than half of the cases of child abuse.
59
Because
of this incidence, dentists need to be aware of signs of abuse
and mandated reporting procedures.
58,59
Barriers
Dentists should be familiar with community-based resources
for patients with SHCN and encourage such assistance when
appropriate. While local hospitals, public health facilities,
rehabilitation services, or groups that advocate for those with
SHCN can be valuable contacts to help the dentist/patient
address language and cultural barriers, other community-based
resources may oer support with nancial or transportation
considerations that prevent access to care.
60
Patients with developmental or acquired orofacial conditions
e oral health care needs of patients with developmental or
acquired orofacial conditions necessitate special considerations,
and management of their oral conditions may present other
unique challenges. Some children with acquired orofacial
conditions may have an oral aversion which can increase
their anxiety and decrease cooperation in the dental setting.
Developmental defects, such as hereditary ectodermal dysplasia
with clinical manifestations of oligodontia and anomalies in
size or shape, can cause lifetime problems and be devastating
to children and adults.
8
From the rst contact with the child
and family, every eort must be made to assist the family in
adjusting to and understanding the complexity of the anomaly
and the related oral needs and provide an overview of goals
and progression of treatment.
61
e dental practitioner must
be sensitive to the psychosocial well-being of the patient, as
well as the eects of the condition on growth, function, and
appearance. Congenital oral conditions may entail therapeutic
intervention of a protracted nature, timed to coincide with
developmental milestones. Patients with conditions such as
ectodermal dysplasia, epidermolysis bullosa, cleft lip/palate,
and oral cancer may require a multidisciplinary team approach
to their care. Coordinating delivery of services by the various
health care providers can be crucial to successful treatment
outcomes.
Patients with oral involvement of conditions such as osteo-
genesis imperfecta, ectodermal dysplasia, and epidermolysis
bullosa often present with unique nancial barriers. Although
the oral manifestations are intrinsic to the genetic and con-
genital disorders, medical health benets may not provide for
related professional oral health care. e distinction made by
third-party payors between congenital anomalies involving the
orofacial complex and those involving other parts of the body
is often arbitrary and without merit.
62
For children with ecto-
dermal dysplasia, hypodontia, or oligodontia, removable or
xed prostheses (including complete dentures or over-dentures)
and or implants may be indicated.
63
Dentists should work
with the insurance industry to recognize the medical indication
and justication for such treatment in these cases.
Referrals
A patient may suffer progression of his/her oral disease if
treatment is not provided because of age, behavior, inability to
cooperate, disability, or medical status. Postponement or denial
of care can result in unnecessary pain, discomfort, increased
treatment needs and costs, unfavorable treatment experiences,
and diminished oral health outcomes. Dentists have an obli-
gation to act in an ethical manner in the care of patients.
64
If
the patient’s needs are beyond the skills of the practitioner,
the dentist should make necessary referrals in order to ensure
the overall health of the patient. In some cases, the complex
nature of disease and/or existing conditions necessitate mul-
tiple referrals and a team (e.g., cleft lip/palate team) approach
to providing comprehensive care.
Transition into adult dentistry
When patients with SHCN reach adulthood, their oral health
care needs may extend beyond the scope of the pediatric
dentist’s practice. The successful transition from pediatric
to adult dental care is integral to continuity of care and im-
proved long-term outcomes of children with SHCN.
65
Education and preparation before transitioning to a dentist
who is knowledgeable and comfortable in both adult oral
BEST PRACTICES: MANAGEMENT OF SHCN PATIENTS
342 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
health needs and managing SHCN are important.
66,67
Until
the new dental home is established, the patient should main-
tain a relationship with the current care provider and have
access to emergency services.
68
In cases where transitioning
is not possible or desired, the dental home can remain with
the pediatric dentist who should recommend appropriate
referrals for specialized dental care as needed.
60
A coordinated
transition from a pediatric to an adult dental home is critical
for extending the level of oral health and health trajectory
established during childhood.
36
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