Rome III diagnostic criteria for functional dyspepsia [1]
\\n\\n
These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\\n\\n\\n\\n\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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Organized into five sections and written by experts in their respective fields, Biological Research in Aquatic Sciences covers topics including cryobiology, spermatology, climate change, migration of aquatic species, and plankton in aquatic ecosystems. 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This chapter is an updated overview of the signaling pathways going from external signals such as osmolarity and ionic concentration and their membrane reception to their transduction through the membrane and their final reception at the flagellar axoneme level. Additional factors such as energy management will be addressed as they constitute a limiting factor of the motility period of fish spermatozoa. Modern technologies used nowadays for quantitative description of fish sperm flagella in movement will be briefly described as they are more and more needed for prediction of the quality of sperm used for artificial propagation of many fish species used in aquaculture. 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Extended growth season will benefit recruitment of less cool adapted species, total fish density may increase and growth will decrease of some species. Lakes dominated by salmonid fish may become dominated by cyprinids and percids. Primary production will increase due to extended growth season and increased precipitation. This can reduce the oxygen level in the deep layer of lakes when the organic matter decomposes, whereas the upper layer is too warm for cold-water species. In addition, increased density of small plankton feeding fish will reduce the algae feeding zooplankton. Lakes should be monitored by means of modern and sophisticated methods, monitoring lakes from satellites and in situ loggers, and pelagic fish may be counted by echosounding. To counteract increasing density of plankton feeding fish, fish biomass removal is a possible measure, though the effect is limited in time.",signatures:"Arne N. 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We describe migratory/dispersal behavior in four types of taxa from the Canadian Arctic: anadromous and freshwater fishes, marine fishes, marine invertebrates, and marine mammals. Patterns of migration are remarkably different between these groups, in particular between distances migrated, seasonal timing of migrations, and the degree of reproductive isolation. Migratory anadromous and freshwater fishes become adapted to specific locations resulting in complex life histories and intra- and inter-population variation. Marine mammals not only migrate longer distances but also appear to have distinct demographic populations over large scales. Marine fishes tend to be panmictic, probably due to the absence of barriers that would restrict gene flow. Migratory patterns also reflect feeding or rearing areas and/or winter refugia. 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Dyspepsia is currently defined by Rome III criteria for the diagnosis of functional gastrointestinal disorders (FGIDs), as the presence of one or more of the following symptoms: bothersome postprandial fullness, early satiation, epigastric pain and epigastric burning [1] These are symptoms thought to originate from the gastroduodenal region. Bloating and nausea often coexist with dyspepsia but are considered nonspecific and are thus not included in the Rome III criteria. However, there have been attempts by some researchers to broaden this definition to include more symptoms. The Asian consensus guideline includes bloating, nausea, vomiting and belching in the definition of dyspepsia [2]
Dyspeptic patients who have not undergone any investigations are defined as having uninvestigated dyspepsia. An organic cause is found in only a minority who seek medical care [3, 4]. The remaining group is labeled as having functional dyspepsia (FD). Organic dyspepsia means there is a clear anatomic or pathophysiologic reason for the dyspeptic complaints, such as peptic ulcer or cancer. In contrast, when a diagnosis of functional dyspepsia has been made, it means that a number of investigations were performed including upper gastrointestinal endoscopy, and were found to be normal [5].
The need for more systematic description of FGIDs gave rise to the Rome process, which has evolved from Rome I in 1991 [6], Rome II in 1999 [7], to the most recent, which is Rome III [1]. According to Rome I and Rome II definitions, FD was defined as the presence of pain or discomfort centered in the upper abdomen, in the absence of organic disease that readily explained the symptoms [7]. While the meaning of pain is readily understood, the lack of an accurate definition for discomfort was a major limitation of Rome I. Rome I also included reflux symptoms in FD, and recognized a subgroup called “reflux-like dyspepsia”. Rome II tried to correct this by excluding patients with predominant heartburn from the definition of FD. Rome I and Rome II criteria did not account for meal-related symptoms and this was the fundamental change in Rome III criteria [8, 9].
Rome III criteria made a distinction between meal-induced symptoms and meal-unrelated symptoms, and this forms the basis of newly defined subcategories of FD:
Meal-induced dyspeptic symptoms (postprandial distress syndrome, which is characterized by postprandial fullness and early satiation)
Epigastric pain syndrome or EPS, characterized by epigastric pain and epigastric burning.
The traditional definition of FD portrays it as an idiopathic condition [10]. However, recent studies suggest that this condition have some pathophysiologic correlates. A diversity of changes in gastrointestinal structure and function has been described in this heterogeneous disorder. In this chapter, the author attempts to provide an overview of structural and physiological alterations in FD beyond those demonstrable by conventional tests used to separate organic dyspepsia from its functional counterpart.
According to Rome III criteria, FD must include one or more of the following symptoms: bothersome postprandial fullness, early satiation, epigastric pain and epigastric burning; with no evidence of structural disease, including use of upper gastrointestinal endoscopy, which is likely to explain the symptoms. Criteria should be fulfilled for at least 3 months with symptom onset at least 6 months previously [1].
Older terms that represent FD are non-ulcer dyspepsia, idiopathic or essential dyspepsia. The term non ulcer dyspepsia is still popular but no longer recommended because it implies that the patient has symptoms similar to peptic ulcer disease without having an actual ulcer on endoscopic examination. The spectrum of symptoms in FD includes epigastric pain syndrome and postprandial distress syndrome
At least 3 months, with onset at least 6 months previously, of one or more of the following: | \n\t\t
• bothersome postprandial fullness • early satiation • epigastric pain • epigastric burning | \n\t\t
AND | \n\t\t
No evidence of structural disease (including upper endoscopy) that is likely to explain the symptoms. | \n\t\t
Rome III diagnostic criteria for functional dyspepsia [1]
The Rome III committee proposed a distinction between meal-induced symptoms and meal-unrelated symptoms to be pathophysiologically, clinically and therapeutically relevant.
Epigastric pain syndrome:
Epigastric pain
Epigastric refers to the region between the umbilicus and lower end of the sternum, and marked by the midclavicular lines. Pain refers to a subjective, unpleasant sensation; some patients may feel that tissue damage is occurring.
Epigastric burning
Epigastric refers to the region between the umbilicus and lower end of the sternum, and marked by the midclavicular lines. Burning refers to an unpleasant subjective sensation of heat.
Postprandial distress syndrome:
Recent research findings indicate that postprandial distress syndrome and epigastric pain syndrome overlap in majority of patients with FD [11]. The implication of this is that the value of dividing FD into the subgroups of postprandial distress syndrome and epigastric pain syndrome is thus questionable [11]
The introduction of Rome criteria and Rome process was a milestone in the management of FGIDs. However, the high turnover of Rome criteria is a testimony to the fact that symptom-based diagnosis has limitations. Symptoms may be perceived differently within different cultures and languages. It has been recommended that the current Rome III questionnaire be translated into local languages [12]. Symptoms are poor predictors of FD and significant overlaps are often seen with functional disorders including functional heartburn and irritable bowel syndrome. [13-22].
One of the difficulties encountered in evaluating a patient with dyspepsia is that symptoms are nonspecific and cannot accurately differentiate an organic process from a functional disorder. Neither clinical impression, nor computer models incorporating patient demographics, risk factors, history items, and symptoms can distinguish between organic and functional disease in patients referred for endoscopic evaluation of dyspepsia( [23].
There is also a high degree of overlap between FD symptoms and those of gastroparesis [1, 24-29]. In FD, the predominant sensation of early satiety was found to be closely associated with impaired accommodation, although it was also present in more than 30% of patients with delayed gastric emptying [26]. Nausea and vomiting, thought to be cardinal symptoms of gastroparesis, are present in at least 20-50% of patients with FD [25, 30, 31]. Epigastric pain thought to be a cardinal symptom of FD is also present in up to 90% of patients with gastroparesis (GP) [32, 33]. Generally, common symptoms of gastric neuromuscular dysfunction are nonspecific and cannot reliably predict the underlying pathophysiology [24-26, 34]. Furthermore, recent research data indicate that rapid gastric emptying has been implicated in functional dyspepsia symptoms, especially in the postprandial distress syndrome [35, 36]. Enhanced antral contractility, decreased duodenal feedback inhibition and impaired accommodation represent the underlying mechanisms [37, 38].
The current approach is to view functional dyspepsia and idiopathic gastroparesis, not as completely distinct disorders, but as a broad, continuous spectrum, with significant overlap. It has been proposed that these 2 entities be reclassified under the umbrella term of functional dyspepsia with or without disordered gastric emptying [39], to enable clinicians and researchers to focus on predominant symptoms expressed by the majority of patients with this disorder.
Older age is an important predictor for the presence of organic disease. The American Gastroenterological Association recommends proceeding directly to endoscopy in patients older than 55 years [40], however, there has been debate about a lower cut-off age of 35 to 45 years in men [41]. The optimal age threshold for endoscopy is unclear but 55 years seems a reasonable cut-off because cancer is rare in younger patients but no age threshold is absolute [42] Age specific thresholds to trigger endoscopic evaluation may differ by sex and locality [43, 44] Prompt endoscopy in patients over 50 years regardless of alarm status has been shown to increase the proportion of curable cases of upper gastrointestinal malignancies by as much as 30% [45-47], but the cost-effectiveness of initial endoscopy in this age group for improving survival of cancer patients is uncertain [47, 48]. Distinct upper gastrointestinal malignancy incidence rates and various distributions of its topographical types in different populations [49-52], as well as differences in Helicobacter pylori infection rates [53, 54] could partly explain the variable results.
Alarm features include unintended weight loss, family history of upper gastrointestinal cancer, gastrointestinal bleeding, progressive dysphagia, odynophagia, unexplained iron deficiency anemia, persistent vomiting, palpable mass, lymphadenopathy and jaundice. These features are useful in identifying high risk patients who need early endoscopy. The absence of alarm features makes the likelihood of finding important structural causes for dyspepsia very low. However, a meta-analysis found that negative predictive value of alarm features was poor (6%) [55]. Worse still, subjects with organic pathologies may also have FD. [56]
Testing for Helicobacter pylori in dyspepsia may be used to select the subgroup of dyspeptic patients who have Helicobacter-related dyspepsia. The Asian consensus guideline posits that this is strictly not a form of FD. Proponents of this argue that gastritis can now be identified easily with advanced endoscopic techniques, and that Helicobacter pylori-dyspepsia is a form of post-infectious FD [2]. Exclusion of Helicobacter pylori infection should be an important part of diagnostic exercise in parts of the world where the burden of infection is high [2]. The effect of Helicobacter pylori eradication on the amelioration of symptoms in patients with FD has been evaluated in several large, well-designed, randomized controlled trials, but the results were conflicting [57-61]. Eradication of Helicobacter pylori in FD appears to improve dyspeptic symptoms more in the Chinese population than in Western populations [2]
The accommodation reflex is a vagally mediated volume response of the upper part of the stomach after a meal. After ingestion of food, the gastric fundus spontaneously dilates and begins to store food [62]. Impairment of this accommodation reflex is known to correlate well with dyspeptic symptoms especially early satiation [63, 64]. Enhanced perception of physiological signals arising from the stomach (visceral hypersensitivity) is considered a hallmark of functional gastrointestinal disorders including FD [65]. Such hypersensitivity can be reproduced acutely by different types of mechanical gastric distension [66, 67]. However, it has not been possible to conclusively identify the site and mechanisms underlying visceral hypersensitivity in FD.
Gastric barostat is gold standard for investigating gastric accommodation. It is however, invasive, time-consuming and uncomfortable to patients. Newer techniques include single photon emission computed tomography (SPECT) [64], 2- and 3- dimensional gastric ultrasound [68] and magnetic resonance imaging [69]. These are noninvasive but their high cost, sophistication and radiation exposure make them less attractive.
Drinking test is simpler [70]. It is based on the assumption that gastric volume is reduced with impaired accommodation and therefore limits the drinking volume. This test has been validated against the gastric barostat but the reproducibility is limited due to differences in types of drink and rates of drinking. In general these tests are poorly associated with dyspeptic symptoms and cannot predict a response to treatment in FD. Therefore they are not yet available for routine clinical use.
Gastroparesis is a syndrome characterized by delayed gastric emptying in absence of mechanical obstruction. Its causes include diabetes mellitus, post-surgical and idiopathic [71]. Delayed gastric emptying occurs in 23-59% of patients with FD [72]. Research has shown that delayed gastric emptying may be related to postprandial fullness and vomiting with symptoms being more frequently found in female patients than in males [73-75]. Other studies have failed to confirm any difference in the occurrence of FD symptoms between patients with normal or delayed gastric emptying [76, 77]
Assessment of gastric emptying is commonly performed for such indications as nausea, vomiting and dyspepsia. However, there is a poor correlation of symptoms to observed abnormalities.
Techniques of gastric emptying include scintigraphy, which is the standard method in clinical practice, but is associated with radiation exposure. Newer non-invasive methods include wireless motility capsule and gastric emptying breath testing. Ultrasound, single-photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) are predominantly research tools.
The duodenum is implicated in the pathophysiology of FD. Duodenal hypersensitivity and abnormal responses to various substances have been observed in FD.
Buspirone challenge test [81] is another chemical hypersensitivity test. This chemical is a serotonin 1A agonist that acts at the hypothalamic level to stimulate prolactin release. The extent of prolactin release following Buspirone challenge is a reliable measure of central 5HT sensitivity which can be impaired in patients with FD [82, 83].
Therapeutic trial may be employed as a means of diagnosis. This has proved successful in the management of GERD but the story in FD is entirely different because its pathogenesis is poorly understood and there is no effective treatment. Also, there is often a substantial placebo effect. The new drug, Acotiamide, an acetylcholinesterase inhibitor is promising and has been shown to be efficacious and safe in the elimination of meal-related FD symptoms [86]. Though not yet approved for treatment of FD, it holds high promise as no adverse events were recorded.
Eosinophils and mast cells may be specifically recruited to the duodenum, altering sensation and motility [87]. The duodenum, which is often ignored in the search for pathophysiologic explanations for FD may be key to the symptom experience in FD. Mast cells induce eosinophil migration and eosinophils activate mast cells [88]. Degranulation from mast cells and eosinophils leads to neural stimulation and smooth muscle contraction, which in turn results in gastrointestinal symptoms, such as abdominal pain and bloating [89]. While a significant increase in mast cells has not been observed in the duodenum of patients with FD, duodenal eosinophilia in FD has been described [90, 91]. This finding is exciting, because, in patients undergoing endoscopy, duodenal biopsy is safe and easy to perform. This finding also has a potential therapeutic implication which further research would unravel.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
Helicobacter pylori testing | \n\t\t\tUseful in identifying patients who have Helicobacter pylori – associated dyspepsia | \n\t\t
Gastric accommodation test | \n\t\t\tSeveral tests have been developed. Invasiveness, high cost, patient discomfort and radiation exposure remain challenges | \n\t\t
Gastric emptying test | \n\t\t\tScintigraphy is currently available for clinical use. | \n\t\t
Empirical treatment | \n\t\t\tNot a viable option because of poorly understood pathogenesis and lack of effective treatment | \n\t\t
Duodenal eosinophilia | \n\t\t\tInitial studies promising. Larger studies needed. | \n\t\t
Duodenal acid infusion | \n\t\t\tResults controversial | \n\t\t
Duodenal lipid infusion | \n\t\t\tDuodenal hypersensitivity to lipids consistently obtained from most studies | \n\t\t
Chemical hypersensitivity tests | \n\t\t\tSeveral candidate chemicals at various stages of development | \n\t\t
Summary of structural and functional abnormalities of the gastrointestinal tract in functional dyspepsia
In conclusion, dyspepsia is a very common clinical problem globally. Majority of patients with this problem have FD, defined traditionally as dyspepsia in which investigations, including upper gastrointestinal endoscopy fail to reveal a structural, biochemical or other pathophysiologic reason for the symptom. The pathophysiology of FD remains poorly understood.
Recent information from research shows that there are structural and physiological changes in FD that may hold the key to further understanding of the pathogenesis of this disease. These include Helicobacter pylori infection, abnormalities of gastric accommodation, abnormalities of gastric emptying, duodenal eosinophilia duodenal hypersensitivity to acid and lipids. These changes have prospects of being deployed in future for the diagnostic evaluation of FD. The implication of this is that FD may not be idiopathic after all. Research is likely to shed more light on this in future.
Aphasia that acquired central disorder of language, which alters the patient’s capacity of understanding and/or producing spoken and written language, occurs in about one-third of the patients with acute stroke (ischemic or hemorrhagic). The language disturbances are frequently combined into aphasic syndromes, contained in different vascular syndromes. Still, aphasia subtype is changeable and may undergo variations over time: in the acute stage of the recovery, the most common type of aphasia is the global one; during the first year after stroke, anomic aphasia seems to be the most common aphasia subtype. In fact, anomia denotes the most important aphasia manifestation and long-term vascular aphasia consequence [1].
Broca’s aphasia (after Goodglass-Kaplan classification), known also as “motor cortical aphasia” (Lichtheim), “efferent or kinetic motor aphasia” (Luria), “expressive aphasia” (Déjerine, Albert, Pick, Weissenburg, McBride), “phonematic aphasia” (Hécaen), “Broca aphasia—the common form” (Lecours & Lhermitte), “verbal aphasia” (Head), “syntactic aphasia” (Wepman & Jones) is a non-fluent aphasia, comprising the widest range of symptoms: articulatory disturbances, paraphasias, agrammatism, evocation disorders, and discrete comprehension disorders of spoken and written language. It is a type of aphasia whose primary, trademark feature is considered to be the disability of spelling words (word evocation disorder), leading thus to impaired fluency and agrammatism (deficit in formulating and processing syntax) [2, 3]. Several studies concluded that in acute first-ever stroke, the frequency of Broca’s aphasia is from 10 to 15%, being the third most frequent type of aphasia after global aphasia (almost 30%) and Wernicke’s aphasia (almost 16%) [2, 4, 5, 6].
The different levels of the language (phonetic, phonemic, morphemic, morpho-syntactic, semantic, and pragmatic) can be differentially affected in the various types of language disturbances. For instance, Broca’s aphasia is significantly associated with grammatical defects (so-called agrammatism in Broca’s aphasia), whereas the semantics of nouns is impaired in posterior fluent aphasias [3].
The different aphasia subtypes are characterized by specific language disturbances. In the evaluation of each patient who presents with aphasic language disorders, the following aspects must be followed: the assessment of oral output/spontaneous speech, the assessment of repetition, the assessment of comprehension, and last but not least, the assessment of reading (lexia) and writing (graphia).
In the absence of aphasic mutism or when mutism has regressed, the patient presents a non-fluent, unwieldy verbal output, characterized by difficulties to initiate spontaneous speech, effortful, with hesitations and slow output (10–15 words/min), and interrupted by frequent word-finding pauses. Sometimes, he presents dysprosody, remarking a monotonously oral expression, with the absence of melodic modulation [2, 5, 6, 7, 8, 9, 10, 11].
Sound/arthric level (incorrect articulation of a sound)—dysarthria.
Phonemic level (omission, addition, substitution, inversion of a phoneme)—phonemic paraphasias.
Verbal level (naming):
Semantic (verbal) paraphasias;
Word-finding difficulty (anomia), especially in spontaneous speech;
Deficits in action naming being more severe than deficits in object naming.
Syntactic level:
Agrammatism (frequently more obvious afterward the acute phase): oversight of functional/grammatical words (conjunctions, articles, prepositions, auxiliary verbs/e.g., “the,” “an,” and inflections), while conceptual words (verbs, adverbs, and nouns) are used more frequently, resulting in the so-called “telegraphic speech.” From time to time, the oral output can be limited to a few stereotypical terms (e.g., “tan tan”) [2, 8, 11, 12, 13].
In patients with Broca’s aphasia, the humble repetition is characteristic. The repetition of operational words and flexional endings is difficult, resulting in phonemic and verbal paraphasias (e.g., “My mother reads a book”/“mother-read-book”). Repetition and naming are impaired, although this is less marked than spontaneous speech.
Automatic speech consisting of numbering from 1 to 10, enumerating the days of the week, the months of the year, repeating a poem, can spectacularly ameliorate the verbal fluence [11, 14, 15].
Comprehension is preserved in most Broca aphasic patients. Good oral comprehension (the patient easily manages to perform the examiner’s tasks/commands) allows the complete evaluation of language components. In some cases, syntactic comprehension can be more difficult, especially when the examiner requests for understanding more complex sentences or to perform multiple commands [6]:
Distinguishing between different operational words (“in,” “on,” “under,” “over”) is almost impossible.
Comprehension of passive reversible sentences can be affected [12, 16].
Examples:
(Q): “The girl was kissed by the boy. Who kissed whom?
(A): Girl kiss boy.”
(Q): “The chicken was eaten by the dog. Who ate whom?
(A): Chicken eat dog.”
Reading and writing are furthermore compromised [14]. Receptive lexia is more affected than oral comprehension. Frontal alexia—literal alexia, was first described by Benson [8] and represents the incapacity in recognizing and naming individual letters, though full words are well recognized. In some cases, a deep central alexia is noticed, with incapacity of reading nonexistent words [17]. Lexia of abstract words or operational words is more difficult than that of concrete or conceptual words [17].
Regarding the graphia, it is also impaired in patients with Broca’s aphasia. It is not only the result of right hemiplegia, as long as it is also present in patients without motor deficit. Graphia shows changes similar to those of the oral expression, but with different intensity. There are troubles of writing spontaneous or dictated texts, while the copied graphia is relatively well conserved. Agraphy has central (linguistic) and peripheral elements [11]. Discaligraphy, literal and/or grapheme paragraphs are observed; there is a tendency toward agrammatism of variable intensity (thus operational words and inflectional endings are omitted) [18]. After a while, dissociation between a reduced oral language, with agrammatism, and jargon-agraphia phenomena occurs, causing a succession of incomprehensible paragraphias [19].
In conclusion, there are three determinant characteristics representing the essence of Broca’s aphasia: preserved comprehension, agrammatism, and dysarthria [2, 5, 6, 7, 8].
Lesions that cause Broca’s aphasia also interrupt adjacent cortical motor fibers and deep fiber tracts, this type of aphasia being usually associated with a motor defect in the right hemi body. The hemiparesis [20]:
affects especially the hand and the face, the leg being less affected;
moreover, it is more distal than proximal (affecting the hand muscles more than the shoulder ones);
being caused by a lesion situated at the level of the upper motor neuron, in most cases, the hemiparesis is characterized by an increased muscle tone (spastic hemiparesis);
its severity is variable, depending on the extension of the cerebral lesion;
may have impact over the articulatory organs (lips, tongue, cheeks), usually leading to a spastic dysarthria (upper motor neuron injury). This type of dysarthria is characterized by imprecise consonants, monotonous tone, reduced stress, rough voice, mono loudness, and a sluggish speech rate.
Apraxia of speech represents a deficiency in planning and programming the sequences of movements necessary in speech production. Along with agrammatism, it is considered as another essential clinical element in the diagnosis of Broca’s aphasia.
It is characterized by abnormalities in phoneme production (phonetic deviations), omissions, and substitutions of speech sounds, leading to decreased speech rate (non-fluent speech, evoked with difficulty). Automatic language (counting from 1 to 10, counting the days of the week, the months of the year) is preserved; instead, repetition is clumsy [20]:
It can be associated with bucco-facial apraxia (difficulties in planning and performing facial and mouth movements on request: to open the mouth, to blow air, to move the tongue) and/or dysarthria.
The patient is aware of his problem, unsuccessfully trying to correct his disturbance by effort. Instead, he presents difficulty in initiating statements, awkwardness articulatory movements. The patient is presenting articulatory variation, repeating attempts of the same expression.
Patients with prefrontal injuries frequently develop calculation difficulties that are not easily detected. Patients with damage in the prefrontal areas of the brain may display serious difficulties in mental operations, successive operations (particularly backward operations; e.g., 100–7), and solving multistep numerical problems. Written arithmetic operations are notoriously easier than mental operations. Difficulties in calculation tasks in these patients correspond to different types [20]:
Attention difficulties
are reflected in the patient’s difficulty in maintaining concentration on the issue;
result in defects in maintaining the conditions of the tasks and impulsiveness in answers;
Perseveration
is observed in the tendency to continue presenting the very same response to different conditions;
can be found in extrasylvian (transcortical) motor (dysexecutive) aphasia;
Deficiency of complex mathematical concepts.
The patient with Broca’s aphasia is aware of his oral expression disorder, developing feelings of helplessness and frustration, with a slightly irascible frame of mind, eventually leading to anxiety and depression [5, 6, 7], adding much more struggle in the recovery process of language.
Broca’s aphasias are generally the consequence of infarcts (usually embolic) in the anterior superficial sylvian territory of the dominant hemisphere for language. Other causes are cranio-cerebral trauma, cerebral hemorrhage, and less frequently, multiple brain metastases or infiltrative multiform glioblastomas. In the last two conditions, the spontaneous evolution is toward global aphasia.
Lesions or dysfunctions usually involve the left side of the brain in right-handed individuals [21], precisely the following structures:
Broca’s area:
the posterior part of the third frontal gyrus (F3)—Brodmann areas 44 and 45.
lesions in this area determine transitory apraxia of speech.
larger lesions, involving besides Broca’s area the subjacent white matter, produce transient mutism, quickly followed by an improving syndrome with noticeable arthric distortions and difficulties in action naming rather than in object naming.
Rolandic operculum:
inferior part of the motor area: Fa.
Lesions can extend or individually affect:
the insular cortex and subjacent white matter;
centrum semiovale;
capsulostriatum (head of caudate nucleus and putamen);
periventricular areas.
Ischemic lesions comprising together these structures and Broca’s area can produce the complete syndrome of Broca’s aphasia. Broca’s aphasia is produced by infarcts/severe hypoperfusion of the superior division of the left middle cerebral artery (MCA) (Figures 1 and 2) [2, 5, 6, 22, 23, 24].
Example of native brain CT scan of a Broca aphasic patient, showing a hypodense area of 3.5/3 cm arranged in the left frontal region, affecting the frontal operculum (
Example of native brain CT scan of a Broca’s aphasic patient, revealing a hypodense area of 5/4 cm with left frontal location [
During the last two decades, there were conducted different studies that were meant to study the hypothesis that during the acute period of the stroke, the lesion’s location is the main conclusive factor in establishing the type of aphasia. Kreisler et al. pointed out in their study that imaging supported the classical anatomic localization (for example: lesions situated in the left inferior frontal gyrus might lead to Broca’s aphasia and lesion situated in the left superior temporal gyrus might lead to Wernicke’s aphasia). Furthermore, their study concluded that non-fluent aphasia was correlated with lesions of postero-inferior frontal gyrus, the putamen, centrum semiovale, and the inferior parietal lobule; repetition disorders were associated with injuries of external capsule and posterior internal capsule, and difficulty in finding words was related with injuries of anterior and posterior language areas or with the subcortical structures [25]. There are other studies conducted by Godefroy et al. and Z.-H. Yang et al., which also pointed out that the most significant factor in establishing the aphasia type was the lesion’s site [26, 27].
On the other hand, there are some studies that found out that a great number of aphasia types were not concordant with the classical neuroanatomical site of expression and comprehension [28, 29].
Concluding, there are two hypotheses [30]:
One that sustains that the language center is the liable core for language (though, the brain mechanism of language functions is not restricted to that limited area of the cerebral cortex);
Another one that sustains that wide-ranging areas related to language are the connection of the language functions and that coordination and close interconnection between these two components have made it possible for people to carry out complex and various language activities, so necessary for human communication.
Language system of the brain is a wide, complex network, and this topic requires further investigation.
Different imaging techniques have been used to precisely specify the site of the brain lesion responsible for aphasic syndromes: diffusion MRI (diffusion tensorimaging—DTI: tractography—used in detecting the course of a specific nerve fiber bundles), MRI diffusion-weighted imaging (especially helpful in detecting the areas of acute infarction, soon after the clinical stroke onset—within 15–20 min), functional MRI (fMRI—quantifies hemodynamic changes associated with active metabolism during ongoing neuronal activity; as the linguistic areas are activated, more oxygen is consumed in those areas, resulting in release of greater amounts of deoxyhemoglobin), positron emission CT (PET—detects radioisotopes injected into the bloodstream and reaching to specific areas of the brain). However, there are still needed complex studies to establish this multifaceted language process [31].
Primarily, the patient is unable to release any sound (mutism), with a tremendously impaired comprehension (global aphasia) or, in opposition, almost normal. In evolution, stereotypes can sometimes be installed, which consist of the involuntary repetition of a syllable, a word, or even a phrase, in the absence of any other expression [6, 8, 18, 19, 32, 33, 34].
In rare situations, the regression of language disturbances stops at the level of monotonous permanent stereotypes (without prosody) and without semantic significance. In some old Broca aphasias, stereotypes with semantic significance, with hyperprosody and, possibly, with rich gestures can be observed. In most cases, however, the evolution is favorable, the patient developing the typical clinical picture of Broca aphasia [18, 32]. Subsequently, there is a partial restoration of verbal fluency (hereinafter, slow fluency), with decreased articulation disorders and those of evocation of conceptual words (lexical enrichment) [2]. Voluntary-automatic dissociation occurs and the language begins to convert into propositional [2]. Sometimes, the evolution is toward agrammatism, other times toward motor transcortical aphasia or motor amnestic aphasia [19].
Studies have reported better recovery in Broca’s and conduction aphasia, lower rates of recovery in global and anomic aphasia [4, 35, 36]. A study completed by Mazzoni et al. supported the idea that comprehension has a better recovery than expression [37], whereas Basso et al. reported that transcortical sensory aphasia had a worse prognosis than Broca’s or transcortical motor aphasia [38]. El Hachioui et al. related that different levels of the language improve at different times, as phonology recovers earlier than semantic or syntactic language, and comprehensive language recovers earlier than expressive language [39].
At the moment, in acute ischemic stroke, the rapid reestablishment of cortical perfusion (i.v. thrombolysis/endovascular therapy—thrombectomy) during the first 4.5 h (thrombolysis), and 6–12 h (thrombectomy) from the clinical onset, represents the most efficient acute treatment approach. Several large randomized clinical trials have shown significant value in outcome with intravenous thrombolysis [40] or endovascular therapy [41]. Although all these studies were not designed to specifically assess the language’s evolution, a secondary investigation of a large randomized clinical trial of endovascular therapy (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; MR CLEAN) [42] has proven that the language score on NIHS Scale gained points (0–2 points) in the intervention group, compared with the control group. Hillis et al. conducted a small randomized clinical trial, which demonstrated that temporary rise of blood flow early after left hemisphere stroke due to large vessel occlusion or severe stenosis was related to language improvement [43].
In chronic post-stroke Broca’s aphasia, no other pharmaceutical intervention has proven its efficacy, since no randomized study has been able to demonstrate their efficiency [44]. Nevertheless, there are some trials that showed that there are some medications that have improved the results of speech therapy. The main idea of these studies is that recovery of language depends on neuroplasticity, which might be stimulated by administrating medications that modulate neurotransmitters [45]. Studies have proven that behavioral interventions can lead to neural reorganization. Even more, this process is facilitated by some neurotransmitters such as: acetylcholine, dopamine, norepinephrine, and serotonin [46, 47]. In conclusion, medications that increase the availability of these neurotransmitters may strengthen the process of neuroplasticity. The main studied medications are donepezil (cholinesterase inhibitors), memantine (noncompetitive antagonist of the Nmethyl-D-aspartate receptor), and piracetam. Preliminary positive results were found using piracetam in nonfluent aphasias (Broca’s aphasia), but it has not been proven to be effective in long-term use [48].
Consequently, a series of drugs targeting improving language deficits have been studied during the last years. Until now, the conclusion is that some agents may be mainly suitable for treating speech output deficits and picture naming with poor influence over comprehension, particularly in severe cases [49]. There are some theories that support the idea that selective serotonin reuptake inhibitors (SSRIs) might be useful for persons with non-fluent aphasia (e.g., Broca’s aphasia), which are also associating depression and frustration, but probably they are less suitable for persons with fluent aphasia (coursing with excitement and reduced awareness) [44].
Another promising therapeutic strategy is represented by using biotechnologically prepared peptides that stimulate neurotrophic regulation in the central nervous system (with neurotrophic and neuroprotective activities). Between 2005 and 2009, a large Romanian study has been conducted in four departments of neurology, analyzing 2212 consecutive Broca’s aphasics following a first acute ischemic stroke. The purpose of this study was to evaluate the efficacy of Cerebrolysin administration (30 ml Cerebrolysin mixed with 70 ml of normal saline/day/iv infusion, for 21 days) in Broca’s aphasics with acute ischemic stroke (n = 156: 52 in cerebrolysin and 104 in placebo) [50]. The conclusion of this study was that spontaneous (voluntary and automatically) speech, repetition, and naming in acute Broca’s aphasia have been positive influenced [44, 50]. Our study clearly demonstrated that intravenous adjuvant treatment with cerebrolysin results in statistically significant and clinically important improvements of language function in patients with Broca’s aphasia with a first acute ischemic stroke [50]. Further larger studies are crucial for sustaining this pertinent hypothesis.
While pharmacological approach produces unreliable results, with small/moderate language improvements, speech therapy is nowadays considered the gold standard in recovery of aphasias. Brady et al. analyzed 57 randomized controlled trials, comparing patient group with speech therapy and other without it and demonstrated that speech therapy led to clinically significance improvements in patients’ ability of communicating. The intensity and duration of speech therapy are very important, the longer the duration of therapy, the more effective the recovery [51]. In patients with chronic aphasia secondary to stroke, intensive speech and language therapy has proven superiority over delayed or even the absence of treatment [52]. Breitenstein et al. concluded that 3 weeks of intensive speech and language therapy of 10 or more hours per week can be considered an evidence-based intervention for patients with chronic aphasia after stroke (aged 70 years or younger) [52].
Transcranial magnetic stimulation (TMS) is a noninvasive method of brain stimulation that relies on electromagnetic induction using an insulated coil placed over the scalp, focused on the specific, desired area of the cortex, which offers a promising alternative approach in amplifying neuroplasticity processes involved in language recovery after stroke. Repetitive transcranial magnetic stimulation (rTMS) modulates neural activity using two mechanisms: by decreasing the cortical excitability with low-frequency rTMS (⩽1 Hz) applied on nondominant hemisphere or by releasing the inhibition of the dominant hemisphere with high-frequency rTMS (⩾5 Hz).
Most trials of low-frequency or high-frequency rTMS in subacute stroke have reported significantly greater language improvement in the rTMS than in the sham group or condition [53].
Regarding rTMS in rehabilitation of Broca’s aphasic patients, few studies have been conducted targeted on recovering one single type of aphasia. The meta-analysis conducted by J. Zhang and his collaborators indicated that rTMS groups had a superior language recovery than sham rTMS groups and conventional rehabilitation groups. Low-frequency rTMS brought greater improvement in language recovery (excepting comprehension) than the sham rTMS. Conversely, high-frequency rTMS did not improve the evolution of rTMS groups compared with sham rTMS and conventional rehabilitation groups (speech therapy) [54].
The entire neuroscience community is still studying different methods of stimulating the reestablishment of network connections that could finally improve language disturbances, using transcranial magnetic stimulation.
Broca’a aphasia is the third most common form of aphasia due to acute stroke. Given the severe disability suffered by aphasic patients and the complexity of language recovery (taking into consideration all forms of aphasia), studies are still insufficient to elucidate clear treatment strategies for aphasias at this time. Regarding the current clinical and imaging diagnosis, the anatomical correlations with different forms of aphasia still remain poorly understood. Several studies have demonstrated that it is possible to draw a neuroanatomical map of aphasic syndromes, which are superimposable on a significant percentage of cases reported in the literature. This concludes to the idea that the main determining factor of aphasic disorders is the neuroanatomical location of the lesion. This does not mean that the injury of one restricted area with certain language or speech functions is going to determine the same aphasic syndrome in different individuals. Examining language disturbances should focus more on aphasic symptoms rather than on aphasic syndromes.
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Subtle changes that occur over time in periodontal tissues that are below the detection limit of visual examination or periodontal probing can be found and tracked accurately over time using 3D imaging, fluorescence spectroscopy, and optical coherence tomography. During debridement of teeth and dental implants, the effective removal of subgingival microbial biofilms and dental calculus deposits can be enhanced using magnifying loupes and operating microscopes and by novel methods based on the interactions of light with bacterial deposits, such as differential reflectometry and light-induced fluorescence. While such techniques can also be used using initial case assessment, their primary purpose is for checking debridement procedures, since the point when bacterial deposits are no longer present represents an endpoint for treatment. The concept of real-time feedback has been developed, using fluorescence readings to control the removal of deposits. Overall, optical methods can support traditional periodontal diagnosis and improve treatment planning and clinical periodontal care.",book:{id:"7244",slug:"periodontology-and-dental-implantology",title:"Periodontology and Dental Implantology",fullTitle:"Periodontology and Dental Implantology"},signatures:"Fardad Shakibaie and Laurence Walsh",authors:[{id:"179467",title:"Prof.",name:"Laurence",middleName:null,surname:"Walsh",slug:"laurence-walsh",fullName:"Laurence Walsh"},{id:"235443",title:"Dr.",name:"Fardad",middleName:null,surname:"Shakibaie",slug:"fardad-shakibaie",fullName:"Fardad Shakibaie"}]},{id:"24363",title:"Biomechanics of Tooth-Movement: Current Look at Orthodontic Fundamental",slug:"biomechanics-of-tooth-movement-current-look-at-orthodontic-fundamental",totalDownloads:26816,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"277",slug:"principles-in-contemporary-orthodontics",title:"Principles in Contemporary Orthodontics",fullTitle:"Principles in Contemporary Orthodontics"},signatures:"Joanna Antoszewska and Nazan Küçükkeles",authors:[{id:"50158",title:"Prof.",name:"Joanna",middleName:null,surname:"Antoszewska",slug:"joanna-antoszewska",fullName:"Joanna Antoszewska"}]},{id:"71271",title:"Flap Techniques in Dentoalveolar Surgery",slug:"flap-techniques-in-dentoalveolar-surgery",totalDownloads:2628,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Most dentoalveolar procedures involve the reflection of mucosal flaps. This step is crucial for exposure or removal of impacted teeth, implant bed preparation, exposure of the alveolar bone for augmentation, periodontal surgeries, and repair of mucosal soft tissue defects, such as oroantral fistula. Because of the rich vascularity of the oral mucosa, great freedom is allowed for flap design, but it tends to result in carelessness and lack of thoughtful planning, which may lead to uneventful outcomes or/and complications. In this chapter, we review oral anatomy, classification, indications, and complications of common oral flap techniques; common flap designs are illustrated, and their fundamental principles are highlighted. The review has covered various flap designs based on their indications. Yet the common flap’s principles are fundamental for all types of flaps regardless of their application, namely, it should provide wide exposure, clear vision, good access, and assure rich vascularity and good final aesthetic outcome.",book:{id:"9387",slug:"oral-diseases",title:"Oral Diseases",fullTitle:"Oral Diseases"},signatures:"Randa Abdulmoein AlFotawi",authors:[{id:"308701",title:"Dr.",name:"Randa",middleName:"Abdulmoein",surname:"Alfotawi",slug:"randa-alfotawi",fullName:"Randa Alfotawi"}]},{id:"65088",title:"Evaluation and Management of Mandibular Fracture",slug:"evaluation-and-management-of-mandibular-fracture",totalDownloads:2903,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The mandibular bone is an important component of the facial bone, which has a unique role in digestive system, speech, and facial esthetics. For these important functions of mandibular bone, it is vital that surgeons should not only treat function but also consider the esthetics together. Mandibular fractures are among the most common traumatic injuries of the maxillofacial region. Even though treatment modalities are well established and being practiced for a long time, untreated and postoperative complications still decrease the patient’s quality of life. This chapter aims to describe the cause, clinical presentations, diagnoses, and current treatment methods on the basis of resent literature.",book:{id:"7572",slug:"trauma-in-dentistry",title:"Trauma in Dentistry",fullTitle:"Trauma in Dentistry"},signatures:"Guhan Dergin, Yusuf Emes and Buket Aybar",authors:[{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin"},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes"},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar"}]},{id:"56461",title:"Permanent Maxillary and Mandibular Incisors",slug:"permanent-maxillary-and-mandibular-incisors",totalDownloads:2715,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The permanent incisors are the front teeth that erupt between 6 and 8 years of age. They are eight in number, four upper and four lower, two centrals and two laterals. They have sharp biting surfaces designed for shearing and cutting of food materials into small chewable pieces. They are the teeth most visible to the others during eating, smiling and talking, and thus, they have high aesthetic value for the individuals. The unique characteristics, arch position, function, development and chronological age of each tooth will be highlighted. In addition, the different aspects with their geometric outlines, outlines and surface anatomy of these teeth will be described. A brief explanation about the pulp cavity, tooth socket and normal occlusion for each tooth will be included.",book:{id:"5814",slug:"dental-anatomy",title:"Dental Anatomy",fullTitle:"Dental Anatomy"},signatures:"Mohammed E. Grawish, Lamyaa M. Grawish and Hala M. Grawish",authors:[{id:"82989",title:"Prof.",name:"Mohammed",middleName:"E",surname:"Grawish",slug:"mohammed-grawish",fullName:"Mohammed Grawish"}]}],onlineFirstChaptersFilter:{topicId:"174",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80964",title:"Upper Airway Expansion in Disabled Children",slug:"upper-airway-expansion-in-disabled-children",totalDownloads:43,totalDimensionsCites:0,doi:"10.5772/intechopen.102830",abstract:"Breathing is essential for life in all of its stages. Cellular, mitochondrial respiration requires an adequate supply of oxygen, provided by the air we breathe, after airway conduction, treatment by the lungs, and transport to tissues. At different stages of life, pediatric dentists and orthodontists can intervene in the upper airway, expanding it, which helps with ventilation. The greater airway space, if used, contributes in different ways to the child’s development and the recovery of respiratory problems and should always be present as a weapon that physicians and the population should know. The value of the techniques becomes even more important when applied to children and young people with disabilities who can significantly improve their development and performance. Rapid Maxillary Expansion and Extraoral Traction Appliances are two important pediatric resources to treat these children. Clinical practice of the authors, is discussed, emphasizing the importance of early intervention and the need for multi and interdisciplinary collaboration in the follow-up of disabled people.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"David Andrade, Joana Andrade, Maria-João Palha, Cristina Areias, Paula Macedo, Ana Norton, Miguel Palha, Lurdes Morais, Dóris Rocha Ruiz and Sônia Groisman"},{id:"80963",title:"Pain Perception in Patients Treated with Ligating/Self-Ligating Brackets versus Patients Treated with Aligners",slug:"pain-perception-in-patients-treated-with-ligating-self-ligating-brackets-versus-patients-treated-wit",totalDownloads:32,totalDimensionsCites:0,doi:"10.5772/intechopen.102796",abstract:"This study compared the perception of pain experienced by patients undergoing orthodontic treatment with conventional, self-ligating brackets and aligners, and investigated the impact that pain had on their daily lives. 346 consecutive patients were included in the study: 115 patients treated with conventional brackets, 112 Patients treated with self-ligating brackets, and 119 patients treated with aligners. The quantitative aspect of pain was assessed using the Visual Analogue Scale, while the qualitative aspect of pain was evaluated using the Moroccan Short Form of McGILL Pain questionnaire. In all three groups experienced pain after activation tended to decrease in the following week. This pain was greater in patients with conventional braces and less in patients with aligners. Using the M-SF-MPQ to describe the qualitative aspect of the pain revealed that the “cramping مزير,” “aching تيألم ” aspect was most accentuated in the 3 groups. Medication intake was correlated with the intensity of pain experienced in all 3 systems. As for the impact of pain on daily activities, patients in groups of conventional and self-ligating braces showed more pain than those in the aligners group. Overall, aligners were less painful than conventional and self-ligating appliances. Patients did not suffer from an alteration in their quality of life due to orthodontic treatment.",book:{id:"10780",title:"Current Trends in Orthodontics",coverURL:"https://cdn.intechopen.com/books/images_new/10780.jpg"},signatures:"Farid Bourzgui, Rania Fastani, Salwa Khairat, Samir Diouny, Mohamed El Had, Zineb Serhier and Mohamed Bennani Othmani"},{id:"80839",title:"Herbs and Oral Health",slug:"herbs-and-oral-health",totalDownloads:69,totalDimensionsCites:0,doi:"10.5772/intechopen.103715",abstract:"Herbal medicine has long been used to prevent and control disease, and it can minimize the potential side effects of chemical products. However, side effects from herbs do exist. Most of the challenges with herbal medicine revolves around inadequate information about the effect of herbs in the oral cavity, the mechanism of action, and potential side effects. There are several herbs described in this chapter have anti-inflammatory, anti-bacterial, anti-viral, anti-fungal in oral micro-organisms. It includes aloe vera, ginger, clove, cinnamon, garlic, neem, miswak, turmeric, tulsi, green tea, chamomile, fenugreek, anise plant, peppermint, bloodroot, caraway, eucalyptus, phyllanthus emblica, black seed, myrrh, rosemary, sage, and thyme; some may act as an alternative management option to current treatments for oral conditions such as caries prevention, gingivitis, periodontitis, oral burn, ulcers and inflammation, after extraction, dry mouth, pain reduction, anesthesia, intracanal medications, ill-fitting dentures, peri-implant mucositis and peri-implantitis. It can be used in several forms such as mouthwashes, toothpastes, topical agents or local drug delivery devices. However, more research is needed to understand their mechanisms and potential side effects.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Zuhair S. Natto"},{id:"80441",title:"Periodontitis and Heart Disease: Current Perspectives on the Associative Relationships and Preventive Impact",slug:"periodontitis-and-heart-disease-current-perspectives-on-the-associative-relationships-and-preventive",totalDownloads:65,totalDimensionsCites:0,doi:"10.5772/intechopen.102669",abstract:"Due to the important advancement and the accumulation of new evidence on the periodontitis-cardiovascular disease (CVD) relationship as well as the major medical, economic and social burden caused by both diseases this chapter aims to review existing epidemiological and pathogenetic links related to this topic. Also, this chapter aims to highlight the impact of the periodontitis-CVD relationships on clinical practice and on the preventive approaches targeting to decrease the impact of periodontitis on CVD. Periodontitis is an infectious disease eliciting local and general inflammation, which leads to periodontal destruction and systemic involvement. Several pathways could explain the link between periodontitis and CVD such as bacteraemia, chronic persistent systemic inflammation and oxidative stress. The first step in the treatment of periodontitis addresses the elimination of microbial components, which lead to a decrease in local and systemic inflammation. Periodontal therapy seems to positively impact CVD. Specialists should inform patients with CVD on the negative impact of periodontitis on their systemic status and refer patients to the periodontist for an extensive examination as routine management of CVD. Some possible risks of periodontal therapy should be considered in patients undergoing antithrombotic medication.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Alexandra Roman, Andrada Soancă, Bogdan Caloian, Alexandru Bucur, Gabriela Valentina Caracostea, Andreia Paraschiva Preda, Dora Maria Popescu, Iulia Cristina Micu, Petra Șurlin, Andreea Ciurea, Diana Oneț, Mircea Viorel Ciurea, Dragoș Alexandru Țermure and Marius Negucioiu"},{id:"79498",title:"Oral Aspects and Dental Management of Special Needs Patient",slug:"oral-aspects-and-dental-management-of-special-needs-patient",totalDownloads:108,totalDimensionsCites:0,doi:"10.5772/intechopen.101067",abstract:"Individuals with special needs are the most underserved regarding healthcare needs in almost all populations. Special needs patients with intellectual disability have muscle coordination disorder, impaired oral motor function, drooling, weak muscles that cause chewing and swallowing problems. Also, soft diet consumption makes this population more prone to dental disease. They have more caries, missing teeth, orthodontic and periodontal problems. Besides more difficulties obtaining professional dental care than other segments of the population. Though many countries developed community-based systems to improve oral health for people with special needs, providing good oral health mainly depends on the effort of the families. Therefore the education of the caregiver about oral hygiene provision is also critical for the special needs patient to enjoy a lifetime of oral health the same as other members of the society.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Pinar Kiymet Karataban"},{id:"79699",title:"Metabolomics Distinction of Cigarette Smokers from Non-Smokers Using Non-Stationary Benchtop Nuclear Magnetic Resonance (NMR) Analysis of Human Saliva",slug:"metabolomics-distinction-of-cigarette-smokers-from-non-smokers-using-non-stationary-benchtop-nuclear",totalDownloads:56,totalDimensionsCites:0,doi:"10.5772/intechopen.101414",abstract:"Implementations of high-field nuclear magnetic resonance (NMR) facilities into metabolomics studies are unfortunately restricted by their large dimensions, high costings, and specialist technical staff requirements. Therefore, here the application and practical advantages offered by low-field (60 MHz), compact NMR spectrometers for probing the metabolic profiles of human saliva was explored, as was their value in salivary metabolomics studies. Saliva samples were collected from cigarette smoking (n = 11) and non-smoking (n = 31) human participants. 1H NMR spectra were acquired on both low-field (60 MHz) and medium-field (400 MHz) spectrometers. Metabolomics analyses were employed to evaluate the consistencies of salivary metabolite levels determined, and their abilities to distinguish between smokers and non-smokers. Low-field 1H NMR analysis detected up to 15, albeit permitted the reliable quantification of 5, potentially key diagnostic biomolecules simultaneously (LLOQ values 250–400 μmol/L), although these were limited to those with the most prominent resonances. Such low-field profiles were also found to be suitable for salivary metabolomics investigations, which confirmed the successful discrimination between smoking and non-smoking participant sample donors. Differences observed between these groups were largely ascribable to upregulated salivary levels of methanol, and its metabolite formate, in the smoking group, but higher smoking-mediated concentrations of acetate, propionate and glycine may arise from a diminished salivary flow-rate in these participants. In conclusion, determination of salivary biomolecules using low-field, benchtop 1H NMR analysis techniques were found to be valuable for bioanalytical and metabolomics investigations. Future perspectives for the applications of this non-stationary NMR technique, for example for the on-site ‘point-of-care’ testing of saliva samples for diagnostic oral disease screening purposes at dental surgeries and community pharmacies, are considered.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Benita C. Percival, Angela Wann, Sophie Taylor, Mark Edgar, Miles Gibson and Martin Grootveld"}],onlineFirstChaptersTotal:36},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403",scope:"Artificial Intelligence (AI) is a rapidly developing multidisciplinary research area that aims to solve increasingly complex problems. In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"July 5th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). In addition to a number of research articles, he has written two books, Computational Intelligence: An Introduction and Fundamentals of Computational Swarm Intelligence.",institutionString:null,institution:{name:"Stellenbosch University",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. He is a Senior Member of the IEEE Computer, the IEEE Computational Intelligence, and the IEEE Systems, Man, and Cybernetics Societies, and the Association of Computing Machinery (ACM). Finally, his main research interests include data science, computational intelligence, and their applications.",institutionString:null,institution:{name:"University of Córdoba",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"26",title:"Machine Learning and Data Mining",coverUrl:"https://cdn.intechopen.com/series_topics/covers/26.jpg",isOpenForSubmission:!0,editor:{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. (Eng.) in Telematics from the Universidad de Colima, Mexico. He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. 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Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:20,paginationItems:[{id:"82526",title:"Deep Multiagent Reinforcement Learning Methods Addressing the Scalability Challenge",doi:"10.5772/intechopen.105627",signatures:"Theocharis Kravaris and George A. 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Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Bacterial Infectious Diseases",value:3,count:2},{group:"subseries",caption:"Parasitic Infectious Diseases",value:5,count:4},{group:"subseries",caption:"Viral Infectious Diseases",value:6,count:7}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:2},{group:"publicationYear",caption:"2021",value:2021,count:4},{group:"publicationYear",caption:"2020",value:2020,count:3},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:229,paginationItems:[{id:"318170",title:"Dr.",name:"Aneesa",middleName:null,surname:"Moolla",slug:"aneesa-moolla",fullName:"Aneesa Moolla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/318170/images/system/318170.png",biography:"Dr. Aneesa Moolla has extensive experience in the diverse fields of health care having previously worked in dental private practice, at the Red Cross Flying Doctors association, and in healthcare corporate settings. She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\r\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\r\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Orthodontist, Assoc Prof in the Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. 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