{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T09:01:27Z","timestamp":1770022887778,"version":"3.49.0"},"reference-count":59,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2023,7,18]],"date-time":"2023-07-18T00:00:00Z","timestamp":1689638400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Bleeding disorders can be divided into three categories: congenital coagulation disorders (CCDs), antiplatelet-induced bleeding disorders (APBDs) and anticoagulant-induced bleeding disorders (ACBDs). Implant placement can be challenging in these kinds of patients. The aim of this study is to provide evidence on implant surgery in patients with bleeding disorders and to generate some practical recommendations for clinicians. Material and Methods: Pubmed\/MEDLINE, Scopus, Web of Science and Cochrane Library databases were screened. The latest search was performed in July 2022. Case reports, case series, cohort studies, cross-sectional studies, case control studies, reviews, consensus reports, surveys and animal studies were included in the analysis. Results: Seventeen articles on CCDs were found, fourteen on APBDs and twenty-six on ACBDs. Most of these articles were case reports or case series. Patients with CCDs can be treated after the infusion of the missing coagulation factor. Patients with APBDs can be treated without withdrawing the therapy. Patients with ACBDs should be treated depending on the anticoagulative medication. Conclusion: Despite the low level of evidence, dental implants can be safely placed in patients with bleeding disorders. However, careful preoperative evaluation and the adoption of local and post-operative bleeding control measures are mandatory.<\/jats:p>","DOI":"10.3390\/jcm12144757","type":"journal-article","created":{"date-parts":[[2023,7,19]],"date-time":"2023-07-19T00:54:01Z","timestamp":1689728041000},"page":"4757","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Bleeding Disorders and Dental Implants: Review and Clinical Indications"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6956-6227","authenticated-orcid":false,"given":"Christian","family":"Bacci","sequence":"first","affiliation":[{"name":"Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-9249-0956","authenticated-orcid":false,"given":"Claudia","family":"Schiazzano","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6149-1155","authenticated-orcid":false,"given":"Ezio","family":"Zanon","sequence":"additional","affiliation":[{"name":"Haemophilia Centre, General Medicine, Padua University Hospital, 35128 Padua, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Edoardo","family":"Stellini","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2222-5764","authenticated-orcid":false,"given":"Luca","family":"Sbricoli","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,7,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"S2","DOI":"10.1016\/S0049-3848(09)70150-1","article-title":"Classification of Inherited von Willebrand Disease and Implications in Clinical Practice","volume":"124","author":"Federici","year":"2009","journal-title":"Thromb. Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"418","DOI":"10.1016\/j.jclinane.2011.02.003","article-title":"Perioperative Management of von Willebrand Disease: A Review for the Anesthesiologist","volume":"23","author":"Mazzeffi","year":"2011","journal-title":"J. Clin. Anesth."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1016\/S0140-6736(15)01123-X","article-title":"The Past and Future of Haemophilia: Diagnosis, Treatments, and Its Complications","volume":"388","author":"Peyvandi","year":"2016","journal-title":"Lancet"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e18","DOI":"10.1016\/j.tripleo.2006.12.035","article-title":"Oral Surgery in Patients on Oral Anticoagulant Therapy: A Randomized Comparison of Different Intensity Targets","volume":"104","author":"Sacco","year":"2007","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1542\/pir.34.7.289","article-title":"Hemophilia: In Review","volume":"34","author":"Zimmerman","year":"2013","journal-title":"Pediatr. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2113","DOI":"10.1056\/NEJMra1206531","article-title":"Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures","volume":"368","author":"Baron","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1007\/s00277-015-2566-x","article-title":"How to Choose Appropriate Direct Oral Anticoagulant for Patient with Nonvalvular Atrial Fibrillation","volume":"95","author":"Schaefer","year":"2016","journal-title":"Ann. Hematol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1149","DOI":"10.1016\/j.joms.2006.11.015","article-title":"Oral Surgery in Patients on Anticoagulant Treatment Without Therapy Interruption","volume":"65","author":"Ferrieri","year":"2007","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1056\/NEJMoa1113697","article-title":"Extended Use of Dabigatran, Warfarin, or Placebo in Venous Thromboembolism","volume":"368","author":"Schulman","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Szumita, R.P., and Szumita, P.M. (2018). Hemostasis in Dentistry, Springer International Publishing.","DOI":"10.1007\/978-3-319-71240-6"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Sbricoli, L., Bazzi, E., Stellini, E., and Bacci, C. (2022). Systemic Diseases and Biological Dental Implant Complications: A Narrative Review. Dent. J., 11.","DOI":"10.3390\/dj11010010"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e104","DOI":"10.1055\/s-0041-1722866","article-title":"Regenerative Surgery with Dental Implant Rehabilitation in a Haemophiliac Patient","volume":"5","author":"Bacci","year":"2021","journal-title":"TH Open"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"622","DOI":"10.1097\/ID.0000000000000145","article-title":"Protocol for Oral Implant Rehabilitation in a Hemophilic HIV-Positive Patient With Type C Hepatitis","volume":"23","year":"2014","journal-title":"Implant Dent."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e229204","DOI":"10.1136\/bcr-2019-229204","article-title":"Infected Tooth Extraction, Bone Grafting, Immediate Implant Placement and Immediate Temporary Crown Insertion in a Patient with Severe Type-B Hemophilia","volume":"12","author":"Romanos","year":"2019","journal-title":"BMJ Case Rep."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1097\/01.id.0000144511.43654.d3","article-title":"Cementable Implant-Supported Prosthesis, Serial Extraction, and Serial Implant Installation: Case Report","volume":"13","author":"Rosen","year":"2004","journal-title":"Implant Dent."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1016\/j.joms.2005.01.009","article-title":"Rehabilitation of a Hemophiliac With Implants: A Medical Perspective and Case Report","volume":"63","author":"Gornitsky","year":"2005","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"33","DOI":"10.2478\/ahp-2018-0006","article-title":"Implantoprosthetic Rehabilitation of a Patient with Severe Form of Hemophilia B: A Case Report","volume":"49","author":"Bogusiak","year":"2018","journal-title":"Acta Haematol. Pol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1563\/aaid-joi-D-20-00043","article-title":"Delayed Bleeding in a Hemophilic Patient After Sinus Floor Elevation and Multiple Implant Placements: A Case Report","volume":"48","author":"Brondani","year":"2022","journal-title":"J. Oral Implantol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1097\/ID.0000000000000821","article-title":"Dental Implant Therapy on a Patient With von Willebrand Disease: A Case Study","volume":"27","author":"Kang","year":"2018","journal-title":"Implant Dent."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"80","DOI":"10.2174\/1874210601812010080","article-title":"Guided Implant Surgery to Reduce Morbidity in Von Willebrand Disease Patients: A Case Report","volume":"12","author":"Castet","year":"2018","journal-title":"Open Dent. J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"632","DOI":"10.19256\/d.cadmos.08.2021.08","article-title":"Riabilitazione Implantare Nel Morbo Di Von Willebrand: Un Caso Resistente Alla Desmopressina","volume":"89","author":"Bacci","year":"2021","journal-title":"Dent. Cadmos"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e04755","DOI":"10.1002\/ccr3.4755","article-title":"Perioperative Management of von Willebrand Patients at the Time of Implant Placement: Case Report","volume":"9","author":"Takashima","year":"2021","journal-title":"Clin. Case Rep."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s40902-018-0178-9","article-title":"Life-Threating Outcomes after Dental Implantation in Patient with Idiopathic Thrombocytopenic Purpura: A Case Report and Review of Literature","volume":"40","author":"Lee","year":"2018","journal-title":"Maxillofac. Plast. Reconstr. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e82","DOI":"10.1563\/AAID-JOI-D-13-00158","article-title":"Tranexamic Acid Tamponade to Control Postoperative Surgical Hemorrhage","volume":"41","author":"Flanagan","year":"2015","journal-title":"J. Oral Implantol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2092","DOI":"10.1016\/j.joms.2018.04.036","article-title":"Do Antiplatelet Drugs Increase the Risk of Bleeding After Dental Implant Surgery? A Case-and-Crossover Study","volume":"76","author":"Tabrizi","year":"2018","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/j.oooo.2019.04.005","article-title":"Postoperative Bleeding Associated with Antiplatelet and Anticoagulant Drugs: A Retrospective Study","volume":"128","author":"Rubino","year":"2019","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1007\/s12663-021-01510-7","article-title":"Assessment of Bleeding in Patients on Antiplatelets Undergoing Dental Implants","volume":"21","author":"Kaura","year":"2022","journal-title":"J. Maxillofac. Oral Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1274","DOI":"10.1111\/clr.12732","article-title":"Management of Anticoagulated Patients in Implant Therapy: A Clinical Comparative Study","volume":"27","author":"Clemm","year":"2016","journal-title":"Clin. Oral Implants Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1001","DOI":"10.1007\/s00784-020-03389-z","article-title":"A Retrospective Analysis of Dental Implantation under Anticoagulant Treatment","volume":"25","author":"Manor","year":"2021","journal-title":"Clin. Oral Investig."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e15","DOI":"10.1016\/j.bjoms.2014.01.006","article-title":"Risk of Bleeding after Dentoalveolar Surgery in Patients Taking Anticoagulants","volume":"52","author":"Broekema","year":"2014","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Buchbender, M., Schlee, N., Kesting, M.R., Grimm, J., Fehlhofer, J., and Rau, A. (2021). A Prospective Comparative Study to Assess the Risk of Postoperative Bleeding after Dental Surgery While on Medication with Direct Oral Anticoagulants, Antiplatelet Agents, or Vitamin K Antagonists. BMC Oral Health, 21.","DOI":"10.1186\/s12903-021-01868-7"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"434","DOI":"10.5312\/wjo.v10.i12.434","article-title":"Effect of Clopidogrel in Bone Healing-Experimental Study in Rabbits","volume":"10","author":"Lillis","year":"2019","journal-title":"World J. Orthop."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s40729-020-00283-x","article-title":"Effects of Low-Dose Aspirin on the Osseointegration Process in Rats","volume":"7","author":"Lupepsa","year":"2021","journal-title":"Int. J. Implant Dent."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1016\/j.oooo.2020.07.012","article-title":"Dental Implant Surgery and Risk of Bleeding in Patients on Antithrombotic Medications: A Review of the Literature","volume":"130","author":"Bajkin","year":"2020","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"702","DOI":"10.1055\/s-0041-1722845","article-title":"Risk of Bleeding during Implant Surgery in Patients Taking Antithrombotics: A Systematic Review","volume":"47","author":"Miziara","year":"2021","journal-title":"Semin. Thromb. Hemost."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Cervino, G., Fiorillo, L., Monte, I.P., De Stefano, R., Laino, L., Crimi, S., Bianchi, A., Herford, A.S., Biondi, A., and Cicci\u00f9, M. (2019). Advances in Antiplatelet Therapy for Dentofacial Surgery Patients: Focus on Past and Present Strategies. Materials, 12.","DOI":"10.3390\/ma12091524"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1080\/03602532.2016.1277737","article-title":"Systemic Drugs That Influence Titanium Implant Osseointegration","volume":"49","author":"Apostu","year":"2017","journal-title":"Drug Metab. Rev."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"143","DOI":"10.17245\/jdapm.2017.17.2.143","article-title":"Delayed Bleeding after Implant Surgery in Patients Taking Novel Oral Anticoagulants: A Case Report","volume":"17","author":"Kim","year":"2017","journal-title":"J. Dent. Anesth. Pain Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1563\/AAID-JOI-D-11-00105","article-title":"Flapless Dental Implant Surgery for Patients on Oral Anticoagulants\u2014The \u201cWarLess Procedure\u201d: A Report of 2 Cases","volume":"39","author":"Zoman","year":"2013","journal-title":"J. Oral Implantol."},{"key":"ref_40","first-page":"51","article-title":"Implant Surgery and Oral Anticoagulant Therapy: Case Report","volume":"7","author":"Miranda","year":"2014","journal-title":"Oral Implantol."},{"key":"ref_41","first-page":"e146","article-title":"Flapless Implant Surgery: A Review of the Literature and 3 Case Reports","volume":"7","year":"2015","journal-title":"J. Clin. Exp. Dent."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1016\/j.jobcr.2019.04.006","article-title":"MIDAS (Minimally Invasive Drilling And Styptic) Protocol\u2014A Modified Approach to Treating Patients under Therapeutic Anticoagulants","volume":"9","author":"Gandhi","year":"2019","journal-title":"J. Oral Biol. Craniofacial Res."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1016\/j.oooo.2012.04.017","article-title":"Risk of Postoperative Bleeding after Dental Procedures in Patients on Warfarin: A Retrospective Study","volume":"114","author":"Hong","year":"2012","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Galletti, G., Alfonsi, F., Raffaele, A., Valente, N.A., Chatelain, S., Kolerman, R., Cinquini, C., Romeggio, S., Iezzi, G., and Barone, A. (2020). Implant Placement in Patients under Treatment with Rivaroxaban: A Retrospective Clinical Study. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17124607"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1097\/ID.0000000000000753","article-title":"Factors Affecting the Occurrence of Complications in the Early Stages After Dental Implant Placement: A Retrospective Cohort Study","volume":"27","author":"Okamoto","year":"2018","journal-title":"Implant Dent."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1007\/s00784-018-2458-2","article-title":"Bleeding Related to Dental Treatment in Patients Taking Novel Oral Anticoagulants (NOACs): A Retrospective Study","volume":"23","author":"Kwak","year":"2019","journal-title":"Clin. Oral Investig."},{"key":"ref_47","first-page":"77","article-title":"Postoperative Bleeding in Patients Taking Oral Anticoagulation Therapy after \u201cAll-on-Four\u201d Rehabilitation: A Case-Control Study","volume":"13","author":"Sannino","year":"2020","journal-title":"Int. J. Oral Implantol. Berl. Ger."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1111\/j.1600-0501.2010.01963.x","article-title":"Safety of Dental Implant Surgery in Patients Undergoing Anticoagulation Therapy: A Prospective Case-Control Study: Dental Implant Therapy in Anticoagulated Patients","volume":"22","author":"Bacci","year":"2011","journal-title":"Clin. Oral Implants Res."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"730","DOI":"10.1111\/clr.12653","article-title":"Dental Implant Surgery in Patients in Treatment with the Anticoagulant Oral Rivaroxaban","volume":"27","author":"Markovic","year":"2016","journal-title":"Clin. Oral Implants Res."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1111\/clr.12785","article-title":"Dental Implant Surgery in Patients in Treatment by Dabigatran","volume":"29","year":"2018","journal-title":"Clin. Oral Implants Res."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1111\/j.1600-0501.2009.01770.x","article-title":"What Influence Do Anticoagulants Have on Oral Implant Therapy? A Systematic Review","volume":"20","author":"Madrid","year":"2009","journal-title":"Clin. Oral Implants Res."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1007\/s10266-015-0195-4","article-title":"Managing Dentoalveolar Surgical Procedures in Patients Taking New Oral Anticoagulants","volume":"103","author":"Sivolella","year":"2015","journal-title":"Odontology"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"154","DOI":"10.5005\/jp-journals-10015-1623","article-title":"A Systematic Review of Hemorrhage Risk in Patients on the New Oral Anticoagulant Therapy Postdental Implant Placement","volume":"10","author":"Pirlog","year":"2019","journal-title":"World J. Dent."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1111\/ger.12327","article-title":"Review: An Overview and Analysis of Novel Oral Anticoagulants and Their Dental Implications","volume":"35","author":"Fortier","year":"2018","journal-title":"Gerodontology"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"58","DOI":"10.3389\/fphar.2017.00058","article-title":"Post-Operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-Analysis of Observational Studies","volume":"8","author":"Shi","year":"2017","journal-title":"Front. Pharmacol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1038\/sj.bdj.2014.911","article-title":"Dental Implants in Patients Affected by Systemic Diseases","volume":"217","author":"Donos","year":"2014","journal-title":"Br. Dent. J."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1016\/j.jdent.2012.12.008","article-title":"Dental Implants in the Medically Compromised Patient","volume":"41","author":"Diz","year":"2013","journal-title":"J. Dent."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1111\/j.1834-7819.2011.01328.x","article-title":"Consensus Statement by Hospital Based Dentists Providing Dental Treatment for Patients with Inherited Bleeding Disorders*: Dental Care for Inherited Bleeding Disorder Patients","volume":"56","author":"Hewson","year":"2011","journal-title":"Aust. Dent. J."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"353","DOI":"10.1097\/01.id.0000247855.75691.03","article-title":"Medical Contraindications to Implant Therapy: Part I: Absolute Contraindications","volume":"15","author":"Hwang","year":"2006","journal-title":"Implant Dent."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/14\/4757\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:14:12Z","timestamp":1760127252000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/14\/4757"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,7,18]]},"references-count":59,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2023,7]]}},"alternative-id":["jcm12144757"],"URL":"https:\/\/doi.org\/10.3390\/jcm12144757","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,7,18]]}}}