The classification of resins according to DIN EN ISO 1567
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He has research training experience as a JSPS Research Fellow at Neurorehabilitation Research Center, Kio University, Japan, and Queensland Brain Institute, University of Queensland, Australia. Dr. Nakano has received 13 awards from academic organizations, has authored more than 120 journal papers and 10 book chapters, and was the editor member of 7 academic journals.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"196461",title:"Prof.",name:"Hideki",middleName:null,surname:"Nakano",slug:"hideki-nakano",fullName:"Hideki Nakano",profilePictureURL:"https://mts.intechopen.com/storage/users/196461/images/system/196461.jpg",biography:"Dr. Hideki Nakano is a physical therapist and associate professor at the Neurorehabilitation Laboratory, Graduate School of Health Sciences, Kyoto Tachibana University, Japan. He received his Ph.D. in Health Science from Kio University, Japan, and has accepted research training experience as a JSPS Research Fellow at Neurorehabilitation Research Center, Kio University, Japan, and Queensland Brain Institute, University of Queensland, Australia. He specializes in neuroscience, neurophysiology, and rehabilitation science and conducts research using non-invasive brain function measurement and brain stimulation methods such as electroencephalography, transcranial magnetic stimulation, and transcranial electrical stimulation. His current main research interest is developing rehabilitation evaluation and treatment methods using visualization and manipulation methods of brain functions for healthy, elderly, and diseased patients.",institutionString:"Kyoto Tachibana University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Kyoto Tachibana University",institutionURL:null,country:{name:"Japan"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"444318",firstName:"Nika",lastName:"Karamatic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/444318/images/20011_n.jpg",email:"nika@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Using various types of resins for restorations in the oral cavity is beneficial from childhood till geriatric period [1-4].
Thermopolymerizable acrylic resins were first used in dental technique in 1936, this being a great step forward. Acrylic resins are also known as polymethylmethacrylate or PMMA. These synthetically obtained materials can be modeled, packed or injected into molds during the plastic phase and become solid after chemical polymerization [5, 6]. Thermopolymerisable acrylic resins have many disadvantages as increased porosity, high water retention, volume variations and irritating effect due to the residual monomer, awkward wrapping system and difficult processing. Because of these, once polymers developed, alternative materials such as polyamides (nylon), acetal resins, epoxy resins, polystyrene, polycarbonate resins etc. [7-9] came on the market.
The main characteristics of the thermoplastic resins used in dentistry are as follows: they are monomer-free and consequently nontoxic and nonallergenic, they are injected by using special devices, they are biocompatible, they have enhanced esthetics and they are comfortable to wear [10].
The classification of resins according to DIN EN ISO 1567 is presented in Table 1:
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
Type 1 | \n\t\t\tThermopolymerizable resins (>65°C) | \n\tGroup 1: bicomponent powder and liquid Group 2: monocomponent | \n
Type 2 | \n\tAutopolymerizable resins (<65°C) | \n\tGroup 1: bicomponent powder and liquid Group 2: bicomponent powder and casting liquid | \n
Type 3 | \n\tThermoplastic resins | \n\tMonocomponent system grains in cartridges | \n
Type 4 | \n\tLight-cured resins | \n\tMonocomponent system | \n
Type 5 | \n\tMicrowave cured resins | \n\tBicomponent system | \n
The classification of resins according to DIN EN ISO 1567
Among the technologies for manufacturing removable complete and partial dentures we distinguish: heat-curing, self-curing, injection, light-curing, casting and microwave use [11].
Thermoplastic resins may be classified by their composition, as acetal resins, polycarbonate resins (belonging to the group of polyester resins), acrylic resins and polyamides (nylons).
The use of thermoplastic resins in dental medicine is continuously growing. The material is thermally plasticized and no chemical reaction takes place. The injection of plasticized resins into a mold represents a new technology in manufacturing complete and removable partial dentures [12].
At present, due to successive alterations in the chemical composition, thermoplastic materials are suitable for manufacturing removable partial dentures with no metallic components, resulting in the so-called “metal-free removable partial dentures” [13].
Indications for thermoplastic resins include removable partial dentures, preformed clasps [14], partial denture frameworks, temporary or provisional crowns and bridges, complete dentures, orthodontic appliances, anti-snoring devices, different types of mouth guards and splints. Some flexible myofunctional therapy devices, used for orthodontic purposes, may also be made of thermoplastic silicone polycarbonate-urethane.
Thermoplastic acetal is a poly(oxy-methylene)-based material, which as a homopolymer has good short-term mechanical properties but as a copolymer has better long-term stability [15]. Due to its resistance to wear and fracture, combined with a certain amount of flexibility, acetal resin is an ideal material for preformed clasps for partial dentures, single-pressed unilateral partial dentures, partial denture frameworks (Figure 1), provisional bridges, occlusal splints and implant abutments, artificial teeth for removable dentures and orthodontic appliances [16].
Because of their resistance to occlusal wear, acetal resins are also well suited for maintaining vertical dimension during provisional restorative therapy. Acetal is not translucent and does not match the esthetic appearance of thermoplastic acrylic and polycarbonate [17].
Removable partial denture with acetal frame and clasps
Thermoplastic polyamide (nylon) is a resin derived from diamine and dibasic acid monomers. Versatililty is one of its characteristics and makes it suitable for various applications. Nylon exhibits high flexibility, physical strength, heat and chemical resistance. It can be easily modified to increase stiffness and wear resistance. Because of its excellent balance of strength, ductility and heat resistance, nylon is an outstanding candidate for metal replacement applications [18]. Nylon is mainly used for tissue supported removable dentures. Its stiffness makes it unsuitable for usage as occlusal rests or denture elements that need to be rigid [7, 13]. Because it is flexible, it cannot maintain vertical dimension when used in direct occlusal forces. Adjustment and polishing is difficult but provides excellent esthetics due to its semitranslucency [19, 20].
Nylon is specially indicated for patients allergic to methyl metacrylate, being monomer-free, lightweight and impervious to oral fluids [21]. Some may also be combined with a metal framework (Figure 2).
Removable partial denture of polyamide combined with metal
Comparative properties of thermoplastic acetal and polyamide, the two types of resins suitable for manufacturing removable partial dentures, are shown in Table 2.
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Acetalic resin | \n\t\tpolioximetylen | \n\t\tvery good | \n\t\tvery high | \n\t\tmedium | \n\t\tgood | \n\t\tvery good | \n\t
Polyamidic resin | \n\t\tdiamine | \n\t\tgood | \n\t\thigh | \n\t\tmedium or very high | \n\t\tvery good | \n\t\tvery good | \n\t
Comparative aspects of acetalic and polyamidic thermoplastic resins
Thermoplastic polyester resins are also used in dentistry. They melt between 230°C and 290°C and the technology implies casting into molds. Polycarbonate resins are particularly polyester materials. They have good fracture strength and flexibility, but the wear resistance is lower than acetal resins. Polycarbonates have a natural translucency and finishes very well, which recommends them for temporary restorations, but they are not suitable for partial denture frameworks [22].
Thermoplastic acrylate consists of fully polymerized acrylate, its base component being methyl-metacrylate, the special blend of polymers giving it the highest impact rating of any acrylic. This material was developed for manufacturing complete dentures. It is not elastic, but its flexibility makes it practically unbreakable. The material has long-term stability, its surface structure being dense and smooth. Due to the absence of residual monomer its biocompatibility is very good. The denture has very good long-term adaptability because water retention is limited. You can bounce such denture off the floor without cracking the base [7, 21, 23].
Thermoplastic materials can be polymerized or prepolymerized and they can be found in granular form, with low molecular weight, already wrapped in cartridges that eliminate dosage errors (Figure 3).
(a, b) Cartridges of different thermoplastic resins (c) The granular aspect of the material
They exhibit a high rigidity despite their low molecular weight. Their plasticizing temperature is low (200°C-250°C). Thermal plasticization takes place in special devices afterward the material is injected under pressure into a mold, without any chemical reactions. After heating, the metallic cartridges containing thermoplastic grains are set in place into the injecting unit and the plasticized resin is forced into the mold at a pressure of 6-8 bars. Pressure, temperature and injecting time are automatically controlled by the injecting unit. Dentures obtained using this technology have excellent esthetics and good compatibility [7, 12, 13, 22].
Injecting thermoplastic resins into molds is not a common technology in dental laboratories because the need of expensive equipment and this could be a disadvantage.
The special injection devices we use are Polyapress (Bredent) and R-3C (Flexite) injectors (Figure 4).
(a) The Polyapress injection-molding device (Bredent) (b) The R-3C injector (Flexite)
The main characteristics of thermoplastic resins used in dentistry are as follows: they are monomer-free and consequently nontoxic and nonallergenic, they are injected by using special devices, they are biocompatible, they have enhanced esthetics and they are comfortable to wear.
Our experience with thermoplastic resins for dental use involves solving several different cases of partial edentations, with removable partial dentures without metallic framework, or combining the metallic framework with thermoplastic resin saddles, using different thermoplastic resins, selected according to their indications and manufacturing technology (Figure 5).
Different combinations between thermoplastic resins, with or without metal
The types of thermoplastic resins we used for manufacturing different types of removable partial dentures are acetal resins and polyamides of different flexibilities.
The acetal resin has optimal physical and chemical properties and it is indicated in making frameworks and clasps for removable partial dentures, being available in tooth color and pink [12]. Experimentally, in some cases, we combined an acetal resin frames with classic acrylic resins for the saddles (Figure 4). However, the resistance values for the acetal resin framework do not reach those of a metal one [16], consequently the main connector, the clasps and the spurs need to be oversized [12]. Injection was carried out using the R-3 C digital control device that has five preset programs, as well as programs that can be individually set by the user.
Acetal framework and clasp and removable partial dentures with acetal framework and clasps
The maintenance, support and stabilizing systems used are metal-free ones.
The significant aspects of the technical steps in the technology of removable partial dentures made of thermoplastic materials are described.
The master model is poured of class IV hard plaster, using a vibrating table (Figure 7).
Casting the master model
In order to assess its retentiveness and to determine the place where the active arms of the clasp are placed a parallelograph analysis is made (Figure 8). The abutment teeth are selected and the position of the cast is chosen and recorded so that a favorable path of insertion is obtained. To record the position of the cast tripod marks are used. The contour heights on the abutment teeth and the retentive muco-osseous tissues are marked. The abutments undercuts are measured and the engagement of the terminal third of the retentive arms of the clasps is established.
After the parallelograph analysis is carried out, the future frame design is drawn, including all extensions of saddles, major connector, retentive and bracing arms of the clasps, occlusal rests and minor connectors of Ackers circumferential clasps on abutment teeth. The design starts with the saddles, following the main connector, the retentive and opposing clasp arms, the spurs and the secondary connectors of the Ackers circular clasps [12, 13].
After designing the framework, the master model is prepared for duplication, including foliation and deretentivisation (Figure 9). At the beginning, blue wax plates are used as spacers in regions where the framework has to be spaced from the gingival tissue. [12].
Parallelograph analysis
Deretentivisation of the model
Block-out wax is applied between teeth cervices and gingival margin of the drawing representing the clasps arms. The block-out wax meets the spacing wax in a smooth joint. In order to duplicate the master model, a vinyl-polysiloxane silicone placed in a flask is used. After its setting, the duplicate model is poured (Figure 10), using class IV hard plaster.
(a) Duplication of the model (b) Casting of the duplicate model using class IV hard plaster
The elements of removable partial denture’s wax pattern are as follows (Figure 11a): the main connector, made of red wax (so that its thickness is twice as normal), the saddles and the Ackers circular clasps, made of blue wax. Injection bars are also required for those areas of the framework that are not visible in the finite piece. A large central shaft is necessary in order to connect with the main connector, through which the initial injection takes place. Unlike the pattern of a metallic framework, the patterns of the metal-free framework have to be 50% thicker (clasps, occlusal rests and main connector) [12, 13].
Spruing the framework is performed using minor sprues of 2.5 mm calibrated wax connected to one major sprue (Figure 11a).
(a) Wrapping the wax pattern frame of the removable partial denture (b) Insulation of the investment
Surface tension reducing solution is applied and the wax pattern is then invested in a vaseline insulated aluminum flask (Figure 11b). Class III hard stone is used as an investment. The gypsum paste is poured into one of the two halves of the flask and the duplicated model containing the framework pattern with sprues attached is centrally dipped base-face down. After setting, the gypsum surface is insulated and the second half of the flask is assembled. Class III hard stone is once more prepared and the flask is submerged in warm water in a thermostatic container. The two halves of the flask are disassembled and the wax is boiled out using clean hot water. The surface of the mold is then insulated and treated with a light-curing transparent varnish in order to obtain a shining aspect [12, 13].
Injection is carried out with the R-3C (Flexite) injector (Figure 4b), which does not take up much space as it can be mounted on a wall as well. The device has the following parameters: digital control, preset programs for different types of thermoplastic resins and programs that can be individually set by the user. The pressure developed is 6-8 Bar [23].
Schedule of “G” program of injecting the thermoplastic material (a) Start (b) Heating (c) Injecting (d) Cooling
Before starting injection, the valves of carbon dioxide tank are checked to make sure the injecting pressure is according to procedure demands (7.2-7.5 Bar). Preheating temperature and time are also checked (15 minutes at 220°C). The selected cartridge (quantity and color) is introduced into one of the two heating cylinders and the preheating process is then activated (Figure 12). After preheating ends, the two halves of the flask are assembled and fastened. Early assembling of the flask is not indicated because water vapor condensation might occur inside the mold, with negative effects on the quality of the injected material. The flask is inserted and secured in the injecting unit.
The injection process takes only 0.25 seconds and it is initiated by pressing the key on the control panel. The pressure is automatically kept constant for one minute so that setting contraction is compensated. This stage is indicated with the sign “----” on the screen. The cartridge is separated and the flask is then released and pulled out. In order to achieve optimal quality of the material, the flask is left to cool slowly for 8 hours [12, 13].
Before investment removal, screws are loosened and the flask is gently disassembled (Figure 13).
Disassembling the framework of the acetal resin removable partial denture (a) The framework is still in the flask (b) Disassembling is complete
The sprues are cut off using low-pressure carbide and diamond burs to avoid overheating the material. Finishing and polishing is performed using soft brushes, ragwheel and polishing paste (Figure 14).
(a) Tools used for processing the acetal framework (b) Tools used for finishing and polishing the acetal framework (c) Special polishing paste
Disassembling the framework of the future removable partial denture is followed by matching it to the model, processing and finishing this component of the removable partial denture (Figure 15).
(a) Matching the acetal framework to the model (b) The finished acetal framework
Once the framework is ready, the artificial teeth are set up. Wax patterns of the saddles are constructed by dropping pink wax over the framework. Teeth set up starts with the most mesial tooth, which is polished until it esthetically fits onto the arch [24].
After properly setting of all the teeth are the wax pattern is invested in order to obtain the acrylic saddles. An impression of the wax pattern placed on the master model is made by using a putty condensation silicone.
After setting, impression is detached, wax is removed, and the teeth, framework and the master model are thoroughly cleaned. Openings are being cut on the lateral sides of the impression and the teeth are set in the corresponding places inside the impression [13]. After insulating the master model, the framework is placed and the impression set in its original place. The acrylic component of the denture is wrapped as usual, using rectangular flasks and a class II plaster (Figure 16a).
(a) Wrapped wax pattern with teeth (b) Partial dentures made of acetal resin and acrylic resin
Self-curing acrylic resin is prepared and poured inside the impression through the lateral openings. The cast is introduced into a heat-pressure-curing unit setting a temperature of 50°C and a pressure of 6 bars for 10 minutes to avoid bubble development. Once the resin is cured, the impression is removed [12, 13]. Burs, brushes, ragwheels and pumice are used to remove the excess, to polish and finish the removable partial denture (Figure 16b).
The result is a consistent removable partial denture with no macroscopic deficiency even in the thinnest 0.3-0.5 mm areas of clasps, which means the technology is effective.
Making polyamide resin removable partial dentures does not require so many intermediary steps as those made of acetal resins. The steps are similar to those followed for acrylic dentures, but with thermoplastic materials the injecting procedure is used. The clasps are made of the same material as the denture base, when using superflexible polyamide or ready-made clasps, in the case of using medium-low flexibility polyamide [12] (Figure 17).
Polyamide removable partial denture with (a) pre-formed clasps (b) clasps made of the same material as the denture base
Using flexible polyamide is indicated in cases of retentive dental fields (Figure 18).
Removable partial dentures made of a super-flexible polyamide (a) The model with retentive tuberosity embedded in the flask (b) The denture immediately after unwrapping (c, d) The flexible removable partial denture
When manufacturing polyamidic dentures, the support elements blend in with the rest of the denture, as they are made of the same material [25, 26].
Medium-low flexibility thermoplastic polyamide denture
The superflexible polyamide resin is extremely elastic, virtually unbreakable, monomer-free, lightweight and impervious to oral fluids (Figures 18, 20, 21). The medium-low flexibility polyamide is a half-soft material mainly indicated for removable partial dentures. It offers superior comfort, good esthetics and no metallic taste (Figures 19 and 20). Polishing and adjusting is easy, it can be added to or relined in both dental practice and laboratory. In certain cases we used preformed clasps made of nylon. These clasps have the same composition as the polyamidic resin used for denture manufacturing, and they are heated in order to adapt (Figure 17a). This kind of clasp can be used for dentures with metal framework, or in association with injected thermoplastic resins [12, 23]. Another option we used was making the clasps of the same thermoplastic resin as the saddles or from acetal resin.
(a) Medium-low flexibility polyamide partial dentures (b) Superflexible polyamide partial dentures
(a) The superflexible polyamide denture (b) The final flexibility test
As an experiment, we managed partial reduced edentations with acetal Kemeny-type dentures (Figures 22 and 23) as an alternative to fixed partial dentures, mainly in order to test the physiognomic aspect, having the advantage of a minimal loss of hard dental substance, located only at the level of the occlusal rims, in case of posterior teeth.
Figure 22 shows wax patterning aspects and manufacturing a molar unidental Kemeny denture of acetal resin, while Figure 23 shows the way in which a frontal bidental edentation can be managed. The effectiveness of the technology is ensured by making artificial teeth of the same material.
As the material is not translucent, it is mainly suitable for dealing with lateral edentations. It can, however, be used temporarily, in the frontal area as well, in those clinical cases where short-term esthetic aspect is irrelevant [12, 23, 27].
Kemeny dentures: (a) Unimolar denture wax pattern (b) Denture made of acetal resin
Kemeny-type frontal denture
Thermoplastic resins are also indicated for manufacturing antisnoring devices, different types of mouthguards and splints. Parodonthotic teeth after surgery need immobilization. We experimentally manufactured acetalic resin splints (Figure 24) which turned out to be a viable solution because it matches the color of the teeth and thereby represents a temporary postoperative esthetic choice [18, 23].
Thermoplastic acetal splint
Mouth guards are dental appliances that can be manufactured using thermoplastic resins. The most satisfactory mouth protectors are custom-made mouth guards. This type of mouth guards is designed by the dentist. They adapt well and provide good retention and comfort. Being custom-made they interfere the least with speaking and have virtually no effect on breathing [28]. Custom-made mouth guards may be classified into two types: the vacuum mouth guard and the pressure-laminated mouth guard.
The vacuum mouth guard is manufactured using a model of the upper arch. The model is casted using an impression. The thermoplastic mouth guard material, usually a polyethylene vinyl acetate (EVA) copolymer, is adapted over the model with a special vacuum machine. The vacuum mouth guard is then trimmed and polished to allow for proper tooth and gum adaptation. All posterior teeth should be covered and muscle attachments should be unimpinged. Using a vacuum machine single-layer mouth guards are manufactured. More and more, multi- ple-layer mouth guards (laboratory pressure-laminated) are preferred to the single-layer vacuum ones. The laboratory pressure-laminated mouth guard, also made from a stone cast, is a custom-made multiple-layered mouth guard that is considered the state-of-the-art mouth guard in for years. It can be made by laminating two or three layers of material to achieve the necessary thickness. Lamination is defined as the layering of mouth guard material using high heat and pressure machines. The mouth guard material should be biocompatible, have good physical properties, and last for at least 2 years [29].
Laminating the custom-made mouth guard. Custom made mouth guard
We manufactured laminated custom-made mouth guards for 3 layers, with the inner layer made of a thermoplastic polyurethane which increases discoloration resistance and creates a soft inner surface feel (Figure 25).
Controlling dentofacial growth interferences is an important issue. The negative effects of mouth breathing, abnormal lip and tongue function and incorrect swallowing patterns on craniofacial development in the mixed dentition period is well known. Correcting these myofunctional habits improves craniofacial growth and decreases the severity of malocclusion [12].
Myofunctional therapy retrains the muscles of swallowing, synchronizes the swallowing movements obtaining a normal resting posture of the tongue, lips, and jaw. Myofunctional therapy may be rescheduled before, during or after orthodontic treatment [30]. The most typical age range for this type of therapy is between 8 and 16 years.
The main objective of the myofunctional appliances is to eliminate oral dysfunction and to establish muscular balance. These appliances play a certain role in orthodontics because they are simple and economical. The selection of the cases needs to be thorough and the specialist needs to be well trained in their use.
The universal size products, suitable for children between 6 and 11 years old (mixed dentition stage), allow implementing the orthodontic treatment earlier and at lower cost. These are made of a flexible thermoplastic silicone polycarbonate-urethane, a ground-breaking copolymer that combines the biocompatibility and biostability of conventional silicone elastomers with the processability and toughness of thermoplastic polycarbonate-urethanes. This type of appliances has good in vitro and in vivo stability. Its strength is comparable to traditional polycarbonate-urethanes, and the biostability is due to the silicone soft segment and end groups. Various fabrication techniques may be used in order to obtain to different. Additional surface processing after fabrication is not needed [12].
Errors might occur when manufacturing thermoplastic resins dentures: the insufficient pressure at injection, which leads to lack of substance, poor polishing, or too thick saddles being some of the causes (Figure 26). These errors lead to deficiencies of the denture, which might be unusable because of esthetic deficiencies, occlusal dysmorphia, exaggerated elasticity, and decubitus areas [31].
Errors that might occur when manufacturing dentures from thermoplastic resins (a) Lack of substance (b) Poor polishing
Thermoplastics used in dentistry have known a great diversification in the last years. Processing principles are similar to the injecting technology of chemoplastics, the main difference consisting in their chemical composition, liquefying temperature of grains, injecting pressure and the fact that thermoplastic resins are monocomponent.
Processing technology is based on the thermal plasticization of the material, in the absence of any chemical reaction. The technology of injection molding is not widely used in dental technique labs yet, as it requires special devices, but has opened new perspectives in the technology of total and partial removable dentures.
Solving partial edentations with metal-free removable partial dentures represents a modern alternative solution to classical metal framework dentures, having the advantage of being lightweight, flexible and much more comfortable for the patient. Metal-free removable partial dentures made of thermoplastic materials are biocompatible, nonirritant, sure, nontoxic, biologically inert, with superior esthetics, which make them rapidly integrate in dentomaxillary structure. They offer quality static and dynamic stability.
The clasps are made of the same material as the denture base or ready-made clasps from the same material may be used. Where the mechanical resistance of the structure comes first, the choice is an acetal resin for making the framework. Superflexible polyamide resin is especially indicated for retentive dental fields, which would normally create problems with the insertion and disinsertion of the removable partial dentures. The removable partial dentures with acetal resin frame are the most laborious to manufacture, requiring most working steps. Manufacturing the acetal framework is first, followed by the acrylic saddles and artificial teeth. A removable partial denture with an acetal resin frame is rapidly integrated into the dentomaxillary system and accepted by the patient. Such a removable denture is a comfortable solution for the partial edentulous patient, achieving the principles of static and dynamic maintenance and stability. These types of partial dentures are not bulky, the frameworks being 0.3-0.5 mm thin, and clasps are flexible and esthetic.
A particular advantage of a removable partial denture made of acetal resin applies to patients with large oral defects as a result of a maxillectomy procedure, who are due to have postoperative radiotherapy and need to have the density of the defect restored to ensure standardized radiation distribution. Different types of boluses may be used for restoration but a stent is usually needed as a support. Traditional metal-clasp retained stents are discarded in such cases as the clasps cause backscatter of the radiation beams. Acetal resin is a radiolucent material suitable for making a stent with clasps or even a removable partial denture to retain the bolus.
In the case of Kemeny-type acetalic dentures, the artificial teeth are made of the same material and in the same step as the rest of the denture. Because it is not translucent, its first indication is lateral edentations but it can be used for short periods, in the frontal area as well, if short-term esthetic aspect is not important.
Thermoplastic resins have several advantages: long-term performance, stability, resistance to deformation, resistance to wear, excellent tolerance, resistance to solvents, absence or low quantity of allergy-inducing residual monomer, and lack of porosity, thus preventing the development of microorganisms and deposits, all of which, together with maintaining size and color in time are very important characteristics, presenting a high degree of flexibility and resistance, permitting the addition of elastomers for increased elasticity or reinforcement with fiberglass, in order to increase their physical splinter quality; some of them can also be repaired or rebased.
The advantages of using the molding-injection system lay in the fact that the resin is delivered in a cartridge, thus excluding mixture errors with long-term shape stability, reduces contraction, and gives mechanical resistance to ageing.
As this class of materials, as well as the processing devices, has been continuously perfected, their future applicability in dental medicine will keep spreading.
Most probably, further chemical development of elastomeric and polymeric materials will enlarge the domain of clinical applications of thermoplastics in dentistry.
Acute Kidney Injury is a syndrome that consists of several clinical conditions, due to sudden kidney dysfunction (within a few hours to several days) that causes retention of residual nitrogen (urea-creatinine) and non-nitrogenous metabolism, with or without oligouria, and is affected by some underlying disease. The most common causes of AKI in patients with critical illness are sepsis and septic shock, accounting for more than 50% of AKI cases in the ICU. The incidence of sepsis and AKI in critical patients increases gradually and both shows poor prognosis. In various epidemiological studies, it is said that AKI occurs in 11-60% of sepsis patients, 23% of severe sepsis patients and 51 – 64% in septic shock patients [1, 2]. Sepsis is one of the causes of Acute Kidney Injury (AKI) in critically ill patients treated in the ICU known as Sepsis-Associated AKI (SA-AKI). The morbidity and mortality rate of SA-AKI is still quite high even though the development of supportive care technology has progressed. A good understanding of SA-AKI is expected to increase alertness and make appropriate decisions in initiating management so as to provide better outcomes for patients with SA-AKI in the ICU.
By definition, Sepsis is a life-threatening condition of organ dysfunction due to an uncontrolled body’s response to a systemic infection. Meanwhile, septic shock is part of sepsis with higher mortality characterized by hypotension requiring vasoactive therapy to maintain an average arterial pressure of at least 65 mmHg and serum lactate above 2 mmol/L despite adequate fluid resuscitation with a mortality rate of>40% [2]. Organ dysfunction caused by inflammatory response can be used to distinguish infections with sepsis, using Sequential Organ Failure Assessment (SOFA) scoring where a minimum of 2 points is the most recent associated with a mortality rate of 10% [3, 4, 5]. Critically ill patients with sepsis when patients are undergoing treatment in the Intensive Care Unit (ICU) may experience organ failure, especially in the respiratory system (43%) and the renal system (36%) [6, 7].
According to the latest definition, sepsis is characterized by suspicion or evidence of infection plus clinical signs and laboratory findings that indicate organ dysfunction (based on the SOFA/Sequential Organ Failure Assessment score) due to an immune response to the infection. The heart, liver, lungs and kidneys are organs that are often affected during this process [2]. For a longtime sepsis has been known as a cause of morbidity and mortality; the consensually agreed upon definition of sepsis has only been around for the last few decades [3]. The first consensual definition defined sepsis as a continuous physiological and serological disorder that causes progressive organ failure.
The consensual definition of Sepsis-3 is the response to the limitations of the old definition, where SIRS and severe sepsis are removed. Sepsis is defined as life-threatening organ dysfunction due to the body’s uncontrolled response to infection. Organ dysfunction can be identified by a condition of acute changes associated with infection with at least 2 points on a Sequential Organ Failure Assessment (SOFA score), increasing the mortality rate by 10% [2]. The determination of the sepsis diagnosis in patients with infection can use the quick SOFA score, where two of the three criteria can meet the criteria of sepsis. Meanwhile, septic shock is sepsis with hypotension that requires a vasopressor to maintain a minimum MAP of 65 mmHg and serum lactate above 2 mmol/L despite adequate fluid resuscitation; this condition has a mortality rate of 40% [4]. Based on the European Society of Intensive Care Medicine and the Society of Critical Care Medicine’s Third International Consensus Definition for Sepsis and Septic Shock in 2016, sepsis is defined as life-threatening organ dysfunction caused by dysregulation of the body’s response to infection. So, the criteria for sepsis must also include the three elements, namely, infection, body response and organ dysfunction. The criterion for the diagnosis of sepsis is established through a SOFA (Sequential/Sepsis-related Organ Failure Assessment) score ≥ 2 [5].
Given the significantly high mortality rates, AKI as one of the most frequent complications of sepsis is considered an important issue in clinical practice and especially for hospitalized patients treated in the ICU. This may be due to the limited understanding of the pathogenesis of SA-AKI sepsis, the lack of ability to assess kidney function in early diagnosis of AKI, and the absence of specific treatments other than supportive care [3].
AKI is characterized by a sudden decline in kidney function for several hours to days, resulting in the accumulation of creatinine, urea and other waste products. The latest definition was formulated in the consensus of Kidney Disease: Improving Global Outcome (KDIGO) in 2012, where the AKI was established if it met the criteria: an increase in serum creatinine levels ≥0.3 mg/dL (26.5 μmol/L) within 48 hours, an increase in serum creatinine at least 1.5 times the baseline value within the previous 7 days, or urine volume ≤ 0.5 ml/kg body weight for 6 hours [6].
The initial definition of AKI was the result of the international consensus of the Acute Dialysis Quality Initiative (ADQI) in 2004 that produced RIFLE (Risk, Injury, Failure, Loss, End stage Kidney disease) criteria based on an assessment of increased serum creatinine, decreased Glumerular Filtration Rate (GFR) urine production, loss if AKI lasts >4 weeks and end stage Kidney disease if AKI continues >3 months [7]. Then in 2007, the Acute Kidney Injury Network (AKIN), an international nephrological network or community in the USA and Europe, issued a more specific measure on RIFLE criteria focusing on the condition of the injury, i.e. Risk, Injury, and Failure were changed into stages (stage 1, stage 2, stage 3); Loss and end stage Kidney disease was eliminated; and an increase in serum creatinine of 0.3 mg/dL within 48 hours was added [8].
In 2012, the KDIGO issued clinical guidelines for the management of AKI and made a classification of AKI by combining RIFLE and AKIN criteria. This KDIGO-based classification defines AKI based on an increase in serum creatinine of 0.3 mg/dL within 48 hours or an increase of 1.5 x serum creatinine from baseline or urine production <0.5 ml/kg/hour for 6-12 hours. Baseline serum creatinine is the examination value obtained in the last 7 days. KDIGO also introduced the definition of Acute Kidney Disease (AKD), where an increase in serum creatinine >7 days and < 3 months. This condition occurs due to injury to the kidney and it can also occur slowly, different from AKI with a significant decrease in kidney function occurring within 7 days after the cause of injury to the kidney [9].
In patients who meet both the criteria for sepsis and AKI, it is called SA-AKI [10, 11]. Sepsis can be associated with >50% of AKI cases, and > 60% of sepsis patients can experience AKI. SA-AKI can also be interpreted as AKI which is caused or worsened by sepsis, so that it can be classified as a different condition in AKI which is usually caused by nephrotoxic regimens and ischemic conditions. The inflammatory response is more prominent in SA-AKI compared to nephrotoxic and ischemic AKI [12, 13]. SA-AKI is a clinical syndrome due to acute damage to organ function and damage. It is related to long-term adverse outcomes depending on the severity of the underlying organ damage. In general, SA-AKI should be considered a syndrome, characterized by fulfilling the criteria for sepsis and AKI [6].
Acute Kidney Injury (AKI) is a syndrome with a broad spectrum of etiology and various mechanisms; ischemia/hypoxia, nephrotoxics and inflammation play a role in the development of AKI. Among the various etiologies of AKI, sepsis is one of the main causes of AKI in the ICU. According to various reported data, 45-70% of all AKI cases are related to sepsis [8]. Among ICU patients in general, the incidence of AKI varies from 6–67% depending on the study population. The incidence of SA-AKI in patients treated in ICU varies from 13–78% depending on the severity of sepsis and the AKI criteria used. In patients with critical illness with AKI, as many as 20-67% also suffer from sepsis, severe sepsis or sepsis shock. Research conducted by Angus and others on 192,980 patients with severe sepsis from seven states in the United States found that AKI occurred in 22% of sepsis patients with a mortality rate of 38.2%. Whereas in the cohort study conducted by The Sepsis Occuring in Acutely Ill Patients (SOAP) on 3,147 patients treated in 198 ICUs throughout Europe, 37% of patients had sepsis and AKI occurred in 51% of them with a mortality rate in ICU of 41%. The FINNAKI study of 2,901 critically ill patients treated in ICU in Finland found that among 918 patients with severe sepsis, 53% met the KDIGO criteria for AKI [6].
SA-AKI is associated with a higher risk of death and mortality in hospitals. If the MMR has an overall mortality rate of 45%, the mortality rate of SA-AKI is much higher, which is above 70%. Bagshaw and others in their study found that mortality rates from SA-AKI cases in hospitals and intensive care units/ICUs had increased by 30% and 20% respectively, but it was also suggested that the severity of AKI had a positive correlation with morbidity and mortality rates of ICU patients, the higher the severity of AKI, the higher the mortality rate. Population at high risk for SA-AKI are elderly patients, females, and those with the presence of comorbidities such as diabetes mellitus, chronic kidney failure, congestive heart failure and malignancy. Sources of infection and side effects from treatment also contribute to risk factors for SA-AKI such as intra-abdominal infections, urosepsis, endocarditis and bloodstream infections [14, 15].
Acute Kidney Injury (AKI) is a syndrome with a broad spectrum of etiology. Based on the mechanism of the cause, AKI can be divided into pre-renal, renal, and post-renal AKI.
The cause of pre-renal AKI is renal hypoperfusion, due to hypovolemia or a decrease in effective circulation volume, such as in the case of sepsis and heart failure, and intrarenal haemodynamic disorders, such as the use of non-steroidal anti-inflammatory drugs.
Renal AKI is caused by abnormalities in the vascular or tubular components of the kidney directly, such as vasculitis, malignant hypertension, acute glomerular nephritis, interstitial nephritis, nephrotoxic substances, etc., causing intrarenal vasoconstriction, ischemia and decreased renal filtration rate.
Post renal AKI is usually caused by intrarenal and extra renal obstruction problems that interfere with kidney blood flow [14].
The pathophysiology of the SA-AKI is not yet fully known, and so far it has only been known from the results of studies on animal models that may be of relevance only to specific conditions in humans. From studies in animals and humans, SA-AKI occurs due to an excessive inflammatory response that causes injury to the kidneys, injury to the tubular tight junction, cell cycle arrest, cellular apoptosis and others [4].
The immune response to sepsis will cause microcirculation dysfunction (in tubular and glomerular capillaries) due to the proinflammatory response resulting in injury to endothelial cells. Vascular permiability will increase and there will be a decrease in endothelial Nitric Oxide Synthase (eNOS) activity, which functions to inhibit platelet aggregation and leukocyte activation. Meanwhile, induction of Nitric Oxyde Synthase (iNOS), which works otherwise, will increase its activity. This condition will cause ischemia and hypoxia. Inflammatory reactions will also cause a cycle cell arrest and apoptosis as a form of protection so that the damage is not widespread. As a result of ischemic and hypoxia, cells will lack energy so that the mitochondria work abnormally, causing injury to the mitochondria, so that injury to the kidneys continues and kidney function will be disrupted.
In sepsis the pathophysiological process of AKI can be caused by the following process:
Ischemic vasodilation, causing a decrease in Renal Blood Flow (pre renal AKI) due to an increase in Nitrides Oxyde induced by iNOS.
Endothelial leakage, causing edema and increased renal interstitial hydrostatic pressure (glomerulus and tubules), thereby reducing kidney filtration.
Nephrosis of the nephron due to the release of neutralizing agents triggered by the release of mediators in sepsis (the formation of ROS or the ischemic process itself causes necrosis of the nephron).
Capillary microtrombus due to coagulopathy and platelet leukocyte activation in the kidney endothelium.
Sepsis and AKI can each increase morbidity and mortality, length of stay, and treatment costs, so early detection of SA-AKI is very important to be able to intervene earlier and provide better outcomes for patients. Especially for AKI, given the definition and classification generated from the consensus, it can actually be easier to diagnose AKI by the method of assessing the increase in serum creatinine and urine production. However, this method has limitations, where changes in serum creatinine run slowly and assessment of urine production is usually only routinely done in the ICU. Therefore, several bio-markers have begun to be investigated to be able to detect SA-AKI earlier. Biomarkers can be categorized into two groups: 1. Assessment of renal function, 2. Detection of injury to kidney cells. Biomarkers for detecting SA-AKI include: Cystatin C (Cys-C), Neutrophil Gelatinase-Associated Lipocalin (NGAL), Kidney Injury Molecule-1 (KIM-1), Interleukin-18 (IL-18), Liver Type Fatty Acid -Binding (L-FABP), soluble-triggering receptor Expressed on Myeloid cells-1 (sTREM-1) and Activating Transcriptional Factor-3 (ATF-3). The sensitivity and specificity of the biomarkers varies depending on the time of measurement and the type of sample used. In general, biomarkers from blood (serum) are lower in sensitivity compared to biomarkers from urine samples [16, 17].
Neutrophil Gelatinase-Associated Lipocalin (NGAL) is currently the chosen biomarker in AKI cases, because it can be a biomarker for proximal tubular function and for kidney injury. Below (Table 1) are some biomarker studies that assess the time, sensitivity and specificity of several biomarkers derived from serum and urine to detect SA-AKI from the last few years.
Time | AUROC | Threshold value | Sensitivity | Specificity | References | |
---|---|---|---|---|---|---|
NGAL (ng/mL) | 12 hours after septic shock | 0.86 | >68 | 0.71 | 1.0 | Martensson et al. |
Cys-C (mg/L) | 8 hours after patients have been treated | 0.86 | 0.106 | 0.85 | 0.80 | Aydogdu et al. |
NGAL (ng/mL) | 7 hours after onset of sepsis | 0.86 | 402 | 0.89 | 0.74 | Fan et al. |
NGAL (ng/mL) | 24 hours after patients have been treated | 0.78 | 350 | 0.75 | 0.82 | Matsa et al. |
NGAL (ng/mL) | 12 hours after septic shock | 0.67 | >120 | 0.83 | 0.50 | Martensson et al. |
Cys-C (mg/L) | 8 hours after patients have been treated | 0.82 | 1.5 | 0.73 | 0.68 | Aydogdu et al. |
NGAL (ng/mL) | 24 hours after patients have been treated | 0.88 | 400 | 0.79 | 0.75 | Matsa et al. |
Research with NGAL and Cys-C biomarkers.
NGAL: Neutrophil Gelatinase-Associated Lipocalin.
Cys-C: Cystatine C.
From the above mention, it can be shown that both NGAL and Cyst C measurements from urine have higher sensitivity and specificity than serum and both of them can be detected earlier than creatinine. It can be also detected as urine biomarkers.
Signs and symptoms of sepsis vary not only with regard to organ involvement, but also from one individual to another because of the patient’s special characteristics, vulnerability, and disease. Signs of sepsis reflect the phase of the disease and vary from symptoms confined to the main organ (e.g pneumonia) to severe multi-organ dysfunction syndrome (MODS) and septic shock. Health care workers must be alert for signs of infection, sepsis or septic shock when evaluating patients for kidney failure. Conversely, it is important to frequently monitor kidney function (along with other organ involvement) in patients with documented or suspected sepsis.
Clinical studies based on physiological data and some postmortem reports have recently begun to define AKI caused by sepsis and how it differs from other types of kidney injury. Histologically, AKI induced by sepsis is characterized by heterogeneous tubular cell injury with apical vacuolization, but in the absence of tubular necrosis or even extensive apoptosis. All of these features can develop in the context of normal or increased renal blood flow (Renal Blood Flow/RBF) and represent a clinical phenotype characterized by decreased levels of glomerular filtration (GFR), creatininclearance, and uremia [18].
A diagnosis of AKI caused by sepsis requires a diagnosis of sepsis and subsequent events of AKI. This is considered a PIRO (predisposition, infection, response, organ dysfunction) system. The diagnosis of sepsis is more complex than the original. In the new definition, several other important aspects of sepsis are included such as hemodynamics and organ dysfunction [18].
A 2016 task force organized by the national community including the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) proposed a new definition of sepsis, called Sepsis-3. This consensus defines sepsis as life-threatening organ dysfunction caused by dysregulation of the responhost to infection. The new definition does not use the Systemic Inflammatory Response Syndrome’s (SIRS) criteria in the identification of sepsis and elimination of severe sepsis [18].
Sequential Organ Failure Assessment (SOFA) is a simple and objective score that allows for calculating both the number and severity of organ dysfunction in six organ systems (breathing, coagulation, liver, cardiovascular, kidney, and neurological), and the score can measure individual or aggregate organ dysfunction [19].
Early detection of AKI in ICU settings is very important. AKI has become a major issue with the increasing number of incidents, causing more than four million deaths per year worldwide. Also, the lack of a reliable initial biomarker for AKI causes a significant delay in starting an appropriate therapy. This is in contrast to the “biological revolution” in cardiology, which produces various markers (including troponin) for early diagnosis of heart damage that allows for early and effective treatments [19].
The diagnosis of AKI is based on an increase in serum creatinine and/or a decrease in urine output. The definition has evolved from the criteria of Risk, Injury, Failure, Loss, Endstage (RIFLE) (Table 2) in 2004 to the classification of the Acute Kidney Injury Network (AKIN) in 2007. In 2012, the two were merged, forming the Kidney Disease Improving Global Outcomes (KDIGO) classification [10].
Categories | Serum Creatinine Criteria | Urine Output Criteria |
---|---|---|
RIFLE* | ||
Risk | ↑ in SCr to 1.5 – < 2 x baseline | UO <0.5 mL/kg/hr. for 6 hrs |
Injury | ↑ in SCr to 2 – < 3 x baseline | UO <0.5 mL/kg/hr. for 12 hrs |
Failure | ↑ in SCr to ≥3 x baseline | UO <0.3 mL/kg/hr. for 24 hrs or Anuria for 12 hrs |
Loss | Loss of Kidney function for >4 wks | |
ESRD | Loss of Kidney function for >3 mos | |
AKIN** | ||
Stage 1 | ↑ in SCr to 0.3 mg/dL or to 1.5 – 2 x baseline | UO <0.5 mL/kg/hr. for >8 hrs |
Stage 2 | ↑ in SCr to >2 – 3 x baseline | UO <0.5 mL/kg/hr. for >12 hrs |
Stage 3 | ↑ in SCR to >3 x baseline or | UO <0.5 mL/kg/hr. for >24 hrs |
Stage 4 | SCr ≥ 4 mg/dL with an acute increase of ≥0.5 mg/dL | or Anuria for 12 hrs |
RIFLE and AKIN CRITERIA of AKI.
RIFLE: Risk, Injury, Failure, Loss, ESRD (End Stage Renal Disease; AKIN: Acute Kidney Injury Network.
AKIN Criteria require the increase of serum creatinine to occur within 48 hrs; SCr: Serum Creatinine; UO: Urine Output.
There are little bit differences between RIFLE and AKIN Criteria, LOSS and ESRD in RIFLE criteria are included in Stage 4 in AKIN criteria.
Combined with evidence-based medicine, KDIGO published KDIGO guidelines in March 2012 and established diagnostic criteria for AKI (Table 3): increase in serum creatinine >0.3 mg/dl (26.5 μmol/L) within 48 hours; or an increase in serum creatinine to 1.5 times the baseline, which is known or thought to have occurred within 7 days; or urine output <0.5 ml/kg/hour for 6-12 hours. According to the severity, this condition is divided into stages 1, 2, and 3, similar to the classification of AKIN [10].
Stage | Serum Creatinine and urine output criteria |
---|---|
1 | Serum creatinine increased 1.5 – 1.9 x baseline or increase ≥26.4 umol/L (0.3 mg/dL) or urinary output <0.5 ml/kg/h during a 6 hour block |
2 | Serum creatinine increased 2.0 – 2.9 x baseline or urinary output <0.5 ml/kg/h during two 6 blocks |
3 | Serum creatinine increased >3 x baseline or increased to ≥353 Umol/L (4 mg/dL) or initiation of renal replacement therapy or Urinary output <0.3 ml/kg/h during more than 24 hours or anuria For more than 12 hours |
KDIGO criteria of AKI.
KDIGO: the Kidney Disease Improving Global Outcomes.
KDIGO criteria is most simple than RIFLE and AKIN, there are only 3 stages of AKI, but still using creatinine serum and urine output criteria.
The KDIGO guidelines highlight early diagnosis and treatment of AKI and diagnostic markers remain at serum creatinine levels. Because serum creatinine tests are convenient and inexpensive, they can be used as practical clinical indicators. However, there are some limitations. Renal hypoperfusion due to prerenal causes can cause an increase in creatinine, although there is no interference with the renal parenchyma. When the renal parenchyma is injured, renal compensation can cause lag in creatinine increase. Further, injury to 50% of the kidneys can occur without an increase in creatinine levels, so diagnosis and intervention are delayed. Thus, new markers with higher sensitivity and specificity are expected to help the initial diagnosis of AKI. At present, many studies report the presence of early diagnostic markers of AKI. Some of them are clinical trials that show good sensitivity and specificity, with initial diagnostic values for AKI. In addition, different biological markers have been shown to show various mechanisms of injury [20].
Evidently, AKI occurs through complex mechanisms often due to several factors. Different mechanisms cause injury in various parts of the kidney. It is difficult to establish a clear diagnosis and accurate localization of the injury using the same marker to diagnose injury to all kidney subregions caused by all diseases. Discrete studies of certain diseases and related kidney injuries will definitely improve diagnostic accuracy. About 45 – 70% of MMR is associated with sepsis, which is one of the most important causes of MMR. Furthermore, the proportion of septic patients with secondary kidney injury is 16 – 50%, whereas the mortality of sepsis associated with AKI is up to 50 – 60%. As such, pursuing focused studies of sepsis-induced AKI and searching for biomarkers associated with early diagnosis will help in solving important clinical problems of septic patients and AKI disease [20].
As with sepsis management in general, the main therapy for SA-AKI is the provision of appropriate antibiotics and good supportive care. There are several things that must be considered in the management of SA-AKI:
Giving fluids is still fundamental in the treatment of sepsis. Patients who are responsive after being given fluids (fluid responder) can theoretically be interpreted as patients who have increased the stroke volume of 10-15% after giving a fluid challenge of 250-500 ml; in reality, there are less than 40% of sepsis patients who need fluids or fluid responder. Based on the Frank-Starling principle, if preload increases, the stroke volume will increase until it reaches the optimal preload volume. And if the preload given can no longer increase stroke volume, the volume of liquid given can be dangerous because it can increase arterial pressure, venous pressure, and ultimately pulmonary hydrostatic pressure. Further, the condition will stimulate the release of natriuretic peptide causing fluid transfer from the intravascular space to the interstitial space. Kidney function will also be affected by this condition where there is a decrease in GFR due to increased venous pressure, potentially increasing subcapsular pressure in the kidneys due to fluid transfer.
The “Fluid Expansion as Supportive Therapy” (FEAST) research can explain the dangers of giving fluid loading to patients with sepsis, where aggressive fluid therapy is associated with increased mortality.
In 2001, the concept of “early aggressive fluid resuscitation” was issued, known as the Early Goal Directed Therapy (EGDT). Following this, studies began using the EGDT protocol. It is interesting to find the reduction in mortality by reducing the volume of resuscitation fluid in the first 72 hours. Although the early sepsis phase shows an effective condition of circulating volume reduction, making it possible for fluid resuscitation to take place, the subsequent fluid therapy given can cause problems especially in the SA-AKI [21]. Besides being unable to improve septic shock, fluid therapy can also contribute to causing renal dysfunction through several mechanisms. The most rapid occurrence is an increase in venous pressure due to fluid therapy that directly increases the renal interstitial pressure and peritubular area in animal models [22]. Because the administration of large fluid boluses (20-30 ml/kg) is associated with the occurrence of fluid overload, it is currently recommended to use fluid volumes with lower volumes (200-500 ml) [22]. The 2014 Acute Dialysis Quality Initiative (ADQI) recommends giving fluid therapy to sepsis patients divided into 4 stages, namely using the rescue protocol, optimization, stabilization and de-escalation. A large liquid volume of 500 ml in a maximum of 15 minutes only at the rescue stage is given to overcome hypotension with close monitoring. At the optimization stage, a 100-200 ml fluid challenge for 5-10 minutes can be done. At the stage of stabilization, the patient is stable and fluid administration is a maintenance therapy of 1-2 ml/kg/hour.
The three stages above are followed by de-escalation, which is the stage to reduce total body fluids with the help of diuretics or Renal Replacement Therapy (RRT) with the target of negative cumulative fluid balance. Assessment of volume status during fluid therapy can proceed with the Passive Leg Raising method combined with measurement of stroke volume in real-time. This procedure is proven to be the most precise in assessing volume status clinically. The availability of ultrasound equipment in the ICU can prevent fluid overload by assessing the B-line on the Lung Ultrasound and the vena cava collapsibility index to assess the fluid responder. The MAP target of 65 – 75 mmHg is an adequate target for maintaining renal perfusion [22].
Fluid selection is also a consideration in the SA-AKI. Normal 0.9% saline is actually a non-physiological fluid and is less well administered to SA-AKI than other crystalloids. Normal saline can cause hyperchloremic metabolic acidosis, which can cause a decrease in Renal Blood Flow (RBF) by activating the mechanism of tubuloglumerular feedback and afferent vasoconstriction so as to increase the risk of further kidney injury. In a retrospective study involving 60734 adults with septic shock, normal single saline can increase mortality compared with crystalloid balance solution. Albumin has also been investigated for its use in sepsis patients with the risk of SA-AKI in the SAFE study, showing that albumin was not effective in reducing mortality and RRT requirements when compared with crystalloid fluids [23]. So that until now albumin cannot be recommended as a resuscitation fluid in SA-AKI. Hydroxyethyl Starches (HES) is not recommended and should not be used on SA-AKI.
Norepinephrine is still the main therapy for septic shock and has been shown to increase MAP and improve perfusion to the kidneys. Norepinephrine itself is the first choice in various clinical studies and provides better outcomes and fewer side effects than other vasopressors. However, due to animal studies showing that norepinephrine can cause medullary hypoxia renal in SA-AKI, researchers have begun to look for other vasopressors in the condition of sepsis and SA-AKI. Vasopressin is the most desirable vasopressor to study; Vasopressin and Septic Shock (VAST) research tries to compare norepinephrine with vasopressin with the same results on the outcome and no side effects are obtained. Further, VANISH research proceeds, the results of which showing the absence of AKI events and side effects of both. Based on these data, vasopressin is the second-line choice of the current vasopressor and has been included in the latest sepsis guidelines. Angiotensin II is a hormone in the renin-angiotensin-aldosterone system which has also begun to be studied in shock conditions. Angiotensin II for the Treatment of High Output Shock (ATHOS) study in 344 patients with shock due to vasodilation (259 with sepsis) found that Angiotensin II significantly increased MAP. Improvements were also seen in SOFA cardiovascular scores. Another smaller study of patients who needed RRT showed that patients who received angiotensin II had a greater 28-day survival rate and were free of RRT on the seventh day more than placebo. If these results can be validated by larger studies, there is a possibility that angiotensin II can be a meaningful therapy for SA-AKI [23].
Levosimendan is a calcium sensitizing drug and has an inotropic effect that is often used in cord decompensation. One small study showed an increase in creatinine clearance and urine production compared to dobutamine. However, in a larger scale study comparing it with placebo (MAKE-28), there was no difference in outcomes in the kidney. So, there is no data to support its use in the SA-AKI [24].
The survival rate in sepsis patients will decrease by 7.6% per hour if no appropriate antibiotic therapy is given. Regarding AKI, vancomycin antibiotics are reported to cause AKI even at the recommended dosage for infections caused by methicillin-resistance
There are several aspects that must be considered in kidney replacement therapy, namely indication, time, modality and dosage given. Clinical indications that have been known so far, which are Acidosis, Electrolyte disturbances, Intoxication, O-fluid Overload and Uremia (A-E-I-O-U), can be applied to SA-AKI. Severe metabolic acidosis, fluid overload and uremia are the three most common indications of RRT in SA-AKI [24].
Criteria for Renal Replacement Therapy (hemodialysis) in critically ill patients with AKI include:
Oligouria: urine output <2000 ml in 12 hours
Anuria: urine production <50 ml in 12 hours
Hyperkalemia: potassium levels>6.5 mmol/L
Severe acidemia (acid poisoning): pH <7.0
Azotemia: urea levels>30 mmol/L
Uremic encephalopathy
Uteric neuropathy/myopathy
Uremic pericarditis
Abnormalities of plasma sodium concentration > 155 mmol/L or < 120 mmol/L
Hypertemia
Drug poisoning
At the time of the RRT initiation, the available data give different answers. Although undesirable effects have been reported due to the late initiation of the RRT, leading to increased mortality and poor outcomes in the SA-AKI [25]. Up until this, the RRT initiation is still individual. Bouman et al. showed no significant difference in renal outcomes in early and late hemofiltration in patients who were able to survive. There are two large studies, with conflicting conclusions, specifically designed to determine the time of initiation of RRT in the condition of critically ill patients. The ELAIN study comparing early versus late initiation of the RRT shows the benefits of early strategy in reducing mortality. While in the AKIKI study, the results show the opposite, i.e. early strategy gives negative results. In both of these studies there were differences in inclusion criteria; in the ELAIN study, patients were in KDIGO stage 2 with a SOFA score of 15.6-16.0 while in the AKIKI study patients were in KDIGO stage 3 with a SOFA score of 10.8-10.9. Perhaps because of these different inclusion criteria, the opposite results were obtained. But at the moment there is an ongoing study, the STARRT-AKI study (standard vs. accelerated initiation of renal replacement therapy in acute kidney injury) that might reveal the best RRT initiation time. The most appropriate RRT modalities for SA-AKI are also still different. Some studies show the advantages of Continuous Renal Replacement Therapy (CRRT) compared to Intermittent Hemodialysis (IHD) on survival rates and time spent for the kidney function to improve. Although CRRT is superior to IHD based on its fluid removal ability, with a lack of hypotension in patients, it is more expensive than IHD.
The current CRRT dose is sourced from two large studies with sepsis patients but not specific to SA-AKI, which is 20-25 ml/kg/hour. In the condition of the SA-AKI, the dose given is 30–35 ml/kg/hour. Several studies have shown that increasing the CRRT dose does not provide benefits and improve patient survival.
CRRT significantly influences the pharmacokinetics and pharmacodynamics of most antimicrobial agents. This is not sufficiently anticipated by the currently recommended dosage guidelines. Patients are significantly at risk of receiving lower doses (underdosing), potentially causing treatment failure and increasing resistance.
The use of diuretics to induce or increase urine production in the absence of hypervolemia is associated with increased mortality. KDIGO does not recommend the use of diuretics in the prevention or treatment of AKI. Conversely, diuretics can be used to improve outcomes when fluid balance remains positive or in the case of excess fluid (volume overload). Research by Ho and Power reviewed the use of furosemide in AKI and found no beneficial effect in reducing mortality.
Compared with other AKI etiologies, SA-AKI may have specific prognostic implications. In most reports, this is associated with higher short-term mortality rates. In the analysis of the BEST Kidney trial subgroup, the likelihood of hospital death is 50% higher in SA-AKI compared to non-SA-AKI. Obviously, the different prognosis between SA-AKI and non-SA-AKI is largely influenced by the composition of the non-sepsis group and its proportion from conditions with a poor prognosis (such as cardiogenic shock). In addition, the confusing role in the relationship between SA-AKI and mortality needs to be overcome because all studies consistently report higher disease severity at onset, with patients requiring RRT more frequently [6].
In contrast, for patients who survive in the hospital, SA-AKI has been associated with improved kidney improvement compared to other etiologies of AKI. In the BEST Kidney study, there was a tendency for lower serum creatinine and RRT dependence (9 vs. 14%, P = 0.052). Clearly, many other factors may play a role in kidney recovery such as RRT modality, RRT time, and further nephrotoxic or ischemic inhibition. Kidney recovery is also strongly influenced by premorbid conditions as illustrated by a French multicentric observational study, which shows that diabetic patients with SA-AKI who have survived going to the hospital tend to need more long-term RRT and have higher serum creatinine levels. Apart from short-term recovery, however, it is now clear that even one episode of AKI is associated with a greater risk of subsequent CKD and even end-stage renal disease [4].
SA-AKI is a clinical syndrome due to acute damage to function and organ damage associated with long-term adverse outcomes depending on the severity of the underlying organ damage. Generally clinical manifestations of AKI are more dominated by factors of precipitation or its main disease. The main purpose of managing AKI is to prevent further kidney damage and keep the patient alive until his kidney physiology returns to normal function. SA-AKI is a condition that is often faced by patients with sepsis in the ICU. Understanding of sepsis and endotoxins that can cause SA-AKI is not yet fully known. Some evidence suggests that renal microcirculation hypoperfusion, lack of energy for cells, mitochondrial dysfunction, endothelial injury and cycle cell arrest can cause SA-AKI. Rapid identification of SA-AKI events, antibiotics and appropriate fluid therapy are crucial actions in the management of SA-AKI. The availability of modality for organ support such as CRRT in ICU care can help patients with sepsis, due to kidney failure that often occurs, survive. Further studies related to SA-AKI are still continuing and are expected to be the basis for making a clinical guide in the management of SA-AKI.
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K. D. Franco and Fabiano Yokaichiya",coverURL:"https://cdn.intechopen.com/books/images_new/7630.jpg",editedByType:"Edited by",editors:[{id:"176605",title:"Dr.",name:"Alessandro",middleName:null,surname:"Cunsolo",slug:"alessandro-cunsolo",fullName:"Alessandro Cunsolo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:66,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"50566",doi:"10.5772/63234",title:"Influences of Doping on Photocatalytic Properties of TiO2 Photocatalyst",slug:"influences-of-doping-on-photocatalytic-properties-of-tio2-photocatalyst",totalDownloads:5353,totalCrossrefCites:23,totalDimensionsCites:75,abstract:"As a kind of highly effective, low‐cost, and stable photocatalysts, TiO2 has received substantial public and scientific attention. However, it can only be activated under ultraviolet light irradiation due to its wide bandgap, high recombination, and weak separation efficiency of carriers. Doping is an effective method to extend the light absorption to the visible light region. In this chapter, we will address the importance of doping, different doping modes, preparation method, and photocatalytic mechanism in TiO2 photocatalysts. Thereafter, we will concentrate on Ti3+ self‐doping, nonmetal doping, metal doping, and codoping. Examples of progress can be given for each one of these four doping modes. The influencing factors of preparation method and doping modes on photocatalytic performance (spectrum response, carrier transport, interfacial electron transfer reaction, surface active sites, etc.) are summed up. The main objective is to study the photocatalytic processes, to elucidate the mechanistic models for a better understanding the photocatalytic reactions, and to find a method of enhancing photocatalytic activities.",book:{id:"5139",slug:"semiconductor-photocatalysis-materials-mechanisms-and-applications",title:"Semiconductor Photocatalysis",fullTitle:"Semiconductor Photocatalysis - Materials, Mechanisms and Applications"},signatures:"Fei Huang, Aihua Yan and Hui Zhao",authors:[{id:"178389",title:"Dr.",name:"Fei",middleName:null,surname:"Huang",slug:"fei-huang",fullName:"Fei Huang"},{id:"185126",title:"Dr.",name:"Aihua",middleName:null,surname:"Yan",slug:"aihua-yan",fullName:"Aihua Yan"},{id:"185127",title:"Ms.",name:"Hui",middleName:null,surname:"Zhao",slug:"hui-zhao",fullName:"Hui Zhao"}]},{id:"17184",doi:"10.5772/17039",title:"Polymer Nanocomposites: From Synthesis to Applications",slug:"polymer-nanocomposites-from-synthesis-to-applications",totalDownloads:17288,totalCrossrefCites:31,totalDimensionsCites:68,abstract:null,book:{id:"1045",slug:"nanocomposites-and-polymers-with-analytical-methods",title:"Nanocomposites and Polymers with Analytical Methods",fullTitle:"Nanocomposites and Polymers with Analytical Methods"},signatures:"S. Anandhan and S. Bandyopadhyay",authors:[{id:"27050",title:"Prof.",name:"Sri",middleName:null,surname:"Bandyopadhyay",slug:"sri-bandyopadhyay",fullName:"Sri Bandyopadhyay"},{id:"44992",title:"Prof.",name:"Anandhan",middleName:null,surname:"Srinivasan",slug:"anandhan-srinivasan",fullName:"Anandhan Srinivasan"}]},{id:"9725",doi:"10.5772/8508",title:"Biosynthesis and Application of Silver and Gold Nanoparticles",slug:"biosynthesis-and-application-of-silver-and-gold-nanoparticles",totalDownloads:27927,totalCrossrefCites:23,totalDimensionsCites:58,abstract:null,book:{id:"3621",slug:"silver-nanoparticles",title:"Silver Nanoparticles",fullTitle:"Silver Nanoparticles"},signatures:"Zygmunt Sadowski",authors:null},{id:"17194",doi:"10.5772/21694",title:"Properties of Nanofillers in Polymer",slug:"properties-of-nanofillers-in-polymer",totalDownloads:20385,totalCrossrefCites:9,totalDimensionsCites:56,abstract:null,book:{id:"1045",slug:"nanocomposites-and-polymers-with-analytical-methods",title:"Nanocomposites and Polymers with Analytical Methods",fullTitle:"Nanocomposites and Polymers with Analytical Methods"},signatures:"Damien M. Marquis, Éric Guillaume and Carine Chivas-Joly",authors:[{id:"44307",title:"Dr",name:"Damien",middleName:"Michel",surname:"Marquis",slug:"damien-marquis",fullName:"Damien Marquis"},{id:"44317",title:"Prof.",name:"Carine",middleName:null,surname:"Chivas-Joly",slug:"carine-chivas-joly",fullName:"Carine Chivas-Joly"}]},{id:"52860",doi:"10.5772/65937",title:"Cerium Oxide Nanostructures and their Applications",slug:"cerium-oxide-nanostructures-and-their-applications",totalDownloads:5365,totalCrossrefCites:23,totalDimensionsCites:55,abstract:"Due to excellent physical and chemical properties, cerium oxide (ceria, CeO2) has attracted much attention in recent years. This chapter aimed at providing some basic and fundamental properties of ceria, the importance of oxygen vacancies in this material, nano‐size effects and various synthesis strategies to form diverse structural morphologies. Finally, some key applications of ceria‐based nanostructures are reviewed. We conclude this chapter by expressing personal perspective on the probable challenges and developments of the controllable synthesis of CeO2 nanomaterials for various applications.",book:{id:"5510",slug:"functionalized-nanomaterials",title:"Functionalized Nanomaterials",fullTitle:"Functionalized Nanomaterials"},signatures:"Adnan Younis, Dewei Chu and Sean Li",authors:[{id:"191574",title:"Dr.",name:"Adnan",middleName:null,surname:"Younis",slug:"adnan-younis",fullName:"Adnan Younis"}]}],mostDownloadedChaptersLast30Days:[{id:"38951",title:"Carbon Nanotube Transparent Electrode",slug:"carbon-nanotube-transparent-electrode",totalDownloads:3985,totalCrossrefCites:3,totalDimensionsCites:5,abstract:null,book:{id:"3077",slug:"syntheses-and-applications-of-carbon-nanotubes-and-their-composites",title:"Syntheses and Applications of Carbon Nanotubes and Their Composites",fullTitle:"Syntheses and Applications of Carbon Nanotubes and Their Composites"},signatures:"Jing Sun and Ranran Wang",authors:[{id:"153508",title:"Prof.",name:"Jing",middleName:null,surname:"Sun",slug:"jing-sun",fullName:"Jing Sun"},{id:"153596",title:"Ms.",name:"Ranran",middleName:null,surname:"Wang",slug:"ranran-wang",fullName:"Ranran Wang"}]},{id:"49413",title:"Electrodeposition of Nanostructure Materials",slug:"electrodeposition-of-nanostructure-materials",totalDownloads:3733,totalCrossrefCites:1,totalDimensionsCites:7,abstract:"We are conducting a multi-disciplinary research work that involves development of nanostructured thin films of semiconductors for different applications. Nanotechnology is widely considered to constitute the basis of the next technological revolution, following on from the first Industrial Revolution, which began around 1750 with the introduction of the steam engine and steelmaking. Nanotechnology is defined as the design, characterization, production, and application of materials, devices and systems by controlling shape and size of the nanoscale. The nanoscale itself is at present considered to cover the range from 1 to 100 nm. All samples prepared in thin film forms and the characterization revealed their nanostructure. The major exploitation of thin films has been in microelectronics, there are numerous and growing applications in communications, optical electronics, coatings of all kinds, and in energy generation. A great many sophisticated analytical instruments and techniques, largely developed to characterize thin films, have already become indispensable in virtually every scientific endeavor irrespective of discipline. Among all these techniques, electrodeposition is the most suitable technique for nanostructured thin films from aqueous solution served as samples under investigation. The electrodeposition of metallic layers from aqueous solution is based on the discharge of metal ions present in the electrolyte at a cathodic surface (the substrate or component.) The metal ions accept an electron from the electrically conducting material at the solid- electrolyte interface and then deposit as metal atoms onto the surface. The electrons necessary for this to occur are either supplied from an externally applied potential source or are surrendered by a reducing agent present in solution (electroless reduction). The metal ions themselves derive either from metal salts added to solution, or by the anodic dissolution of the so-called sacrificial anodes, made of the same metal that is to be deposited at the cathode.",book:{id:"4718",slug:"electroplating-of-nanostructures",title:"Electroplating of Nanostructures",fullTitle:"Electroplating of Nanostructures"},signatures:"Souad A. M. Al-Bat’hi",authors:[{id:"174793",title:"Dr.",name:"Mohamad",middleName:null,surname:"Souad",slug:"mohamad-souad",fullName:"Mohamad Souad"}]},{id:"54226",title:"Localized Surface Plasmon Resonance for Optical Fiber-Sensing Applications",slug:"localized-surface-plasmon-resonance-for-optical-fiber-sensing-applications",totalDownloads:2265,totalCrossrefCites:2,totalDimensionsCites:5,abstract:"It is well known that optical fiber sensors have attracted the attention of scientific community due to its intrinsic advantages, such as lightweight, small size, portability, remote sensing, immunity to electromagnetic interferences and the possibility of multiplexing several signals. This field has shown a dramatic growth thanks to the creation of sensitive thin films onto diverse optical fiber configurations. In this sense, a wide range of optical fiber devices have been successfully fabricated for monitoring biological, chemical, medical or physical parameters. In addition, the use of nanoparticles into the sensitive thin films has resulted in an enhancement in the response time, robustness or sensitivity in the optical devices, which is associated to the inherent properties of nanoparticles (high surface area ratio or porosity). Among all of them, the metallic nanoparticles are of great interest for sensing applications due to the presence of strong absorption bands in the visible and near-infrared regions, due to their localized surface plasmon resonances (LSPR). These optical resonances are due to the coupling of certain modes of the incident light to the collective oscillation of the conduction electrons of the metallic nanoparticles. The LSPR extinction bands are very useful for sensing applications as far as they can be affected by refractive index variations of the surrounding medium of the nanoparticles, and therefore, it is possible to create optical sensors with outstanding properties such as high sensitivity and optical self-reference. In this chapter, the attractive optical properties of metal nanostructures and their implementation into different optical fiber configuration for sensing or biosensing applications will be studied.",book:{id:"5721",slug:"nanoplasmonics-fundamentals-and-applications",title:"Nanoplasmonics",fullTitle:"Nanoplasmonics - Fundamentals and Applications"},signatures:"Pedro J. Rivero, Javier Goicoechea and Francisco J. Arregui",authors:[{id:"69816",title:"Dr.",name:"Javier",middleName:null,surname:"Goicoechea",slug:"javier-goicoechea",fullName:"Javier Goicoechea"},{id:"188796",title:"Dr.",name:"Pedro J.",middleName:null,surname:"Rivero",slug:"pedro-j.-rivero",fullName:"Pedro J. Rivero"},{id:"197277",title:"Dr.",name:"Francisco",middleName:null,surname:"Arregui",slug:"francisco-arregui",fullName:"Francisco Arregui"}]},{id:"25297",title:"Nanofabrication of Metal Oxide Patterns Using Self-Assembled Monolayers",slug:"nanofabrication-of-metal-oxide-patterns-using-self-assembled-monolayers",totalDownloads:3443,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"860",slug:"nanofabrication",title:"Nanofabrication",fullTitle:"Nanofabrication"},signatures:"Yoshitake Masuda",authors:[{id:"12385",title:"Dr.",name:"Yoshitake",middleName:null,surname:"Masuda",slug:"yoshitake-masuda",fullName:"Yoshitake Masuda"}]},{id:"77225",title:"Piezoelectricity and Its Applications",slug:"piezoelectricity-and-its-applications",totalDownloads:510,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The piezoelectric effect is extensively encountered in nature and many synthetic materials. Piezoelectric materials are capable of transforming mechanical strain and vibration energy into electrical energy. This property allows opportunities for implementing renewable and sustainable energy through power harvesting and self-sustained smart sensing in buildings. As the most common construction material, plain cement paste lacks satisfactory piezoelectricity and is not efficient at harvesting the electrical energy from the ambient vibrations of a building system. In recent years, many techniques have been proposed and applied to improve the piezoelectric capacity of cement-based composite, namely admixture incorporation and physical. The successful application of piezoelectric materials for sustainable building development not only relies on understanding the mechanism of the piezoelectric properties of various building components, but also the latest developments and implementations in the building industry. Therefore, this review systematically illustrates research efforts to develop new construction materials with high piezoelectricity and energy storage capacity. In addition, this article discusses the latest techniques for utilizing the piezoelectric materials in energy harvesters, sensors and actuators for various building systems. With advanced methods for improving the cementations piezoelectricity and applying the material piezoelectricity for different building functions, more renewable and sustainable building systems are anticipated.",book:{id:"10511",slug:"multifunctional-ferroelectric-materials",title:"Multifunctional Ferroelectric Materials",fullTitle:"Multifunctional Ferroelectric Materials"},signatures:"B. Chandra Sekhar, B. Dhanalakshmi, B. Srinivasa Rao, S. Ramesh, K. Venkata Prasad, P.S.V. Subba Rao and B. Parvatheeswara Rao",authors:[{id:"335022",title:"Dr.",name:"B. Chandra",middleName:null,surname:"Sekhar",slug:"b.-chandra-sekhar",fullName:"B. Chandra Sekhar"},{id:"422021",title:"Dr.",name:"B.",middleName:null,surname:"Dhanalakshmi",slug:"b.-dhanalakshmi",fullName:"B. Dhanalakshmi"},{id:"422022",title:"Dr.",name:"B.Srinivasa",middleName:null,surname:"Rao",slug:"b.srinivasa-rao",fullName:"B.Srinivasa Rao"},{id:"422023",title:"Dr.",name:"S.",middleName:null,surname:"Ramesh",slug:"s.-ramesh",fullName:"S. Ramesh"},{id:"422024",title:"Dr.",name:"K.Venkata",middleName:null,surname:"Prasad",slug:"k.venkata-prasad",fullName:"K.Venkata Prasad"},{id:"422025",title:"Dr.",name:"P.S.V",middleName:null,surname:"Subba Rao",slug:"p.s.v-subba-rao",fullName:"P.S.V Subba Rao"},{id:"422026",title:"Dr.",name:"B.Parvatheeswara",middleName:null,surname:"Rao",slug:"b.parvatheeswara-rao",fullName:"B.Parvatheeswara Rao"}]}],onlineFirstChaptersFilter:{topicId:"1169",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81438",title:"Research Progress of Ionic Thermoelectric Materials for Energy Harvesting",slug:"research-progress-of-ionic-thermoelectric-materials-for-energy-harvesting",totalDownloads:24,totalDimensionsCites:0,doi:"10.5772/intechopen.101771",abstract:"Thermoelectric material is a kind of functional material that can mutually convert heat energy and electric energy. It can convert low-grade heat energy (less than 130°C) into electric energy. Compared with traditional electronic thermoelectric materials, ionic thermoelectric materials have higher performance. The Seebeck coefficient can generate 2–3 orders of magnitude higher ionic thermoelectric potential than electronic thermoelectric materials, so it has good application prospects in small thermoelectric generators and solar power generation. According to the thermoelectric conversion mechanism, ionic thermoelectric materials can be divided into ionic thermoelectric materials based on the Soret effect and thermocouple effect. They are widely used in pyrogen batteries and ionic thermoelectric capacitors. The latest two types of ionic thermoelectric materials are in this article. The research progress is explained, and the problems and challenges of ionic thermoelectric materials and the future development direction are also put forward.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Jianwei Zhang, Ying Xiao, Bowei Lei, Gengyuan Liang and Wenshu Zhao"},{id:"77670",title:"Thermoelectric Elements with Negative Temperature Factor of Resistance",slug:"thermoelectric-elements-with-negative-temperature-factor-of-resistance",totalDownloads:72,totalDimensionsCites:0,doi:"10.5772/intechopen.98860",abstract:"The method of manufacturing of ceramic materials on the basis of ferrites of nickel and cobalt by synthesis and sintering in controllable regenerative atmosphere is presented. As the generator of regenerative atmosphere the method of conversion of carbonic gas is offered. Calculation of regenerative atmosphere for simultaneous sintering of ceramic ferrites of nickel and cobalt is carried out. It is offered, methods of the dilated nonequilibrium thermodynamics to view process of distribution of a charge and heat along a thermoelement branch. The model of a thermoelement taking into account various relaxation times of a charge and warmth is constructed.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Yuri Bokhan"},{id:"79236",title:"Processing Techniques with Heating Conditions for Multiferroic Systems of BiFeO3, BaTiO3, PbTiO3, CaTiO3 Thin Films",slug:"processing-techniques-with-heating-conditions-for-multiferroic-systems-of-bifeo3-batio3-pbtio3-catio",totalDownloads:96,totalDimensionsCites:0,doi:"10.5772/intechopen.101122",abstract:"In this chapter, we have report a list of synthesis methods (including both synthesis steps & heating conditions) used for thin film fabrication of perovskite ABO3 (BiFeO3, BaTiO3, PbTiO3 and CaTiO3) based multiferroics (in both single-phase and composite materials). The processing of high quality multiferroic thin film have some features like epitaxial strain, physical phenomenon at atomic-level, interfacial coupling parameters to enhance device performance. Since these multiferroic thin films have ME properties such as electrical (dielectric, magnetoelectric coefficient & MC) and magnetic (ferromagnetic, magnetic susceptibility etc.) are heat sensitive, i.e. ME response at low as well as higher temperature might to enhance the device performance respect with long range ordering. The magnetoelectric coupling between ferromagnetism and ferroelectricity in multiferroic becomes suitable in the application of spintronics, memory and logic devices, and microelectronic memory or piezoelectric devices. In comparison with bulk multiferroic, the fabrication of multiferroic thin film with different structural geometries on substrate has reducible clamping effect. A brief procedure for multiferroic thin film fabrication in terms of their thermal conditions (temperature for film processing and annealing for crystallization) are described. Each synthesis methods have its own characteristic phenomenon in terms of film thickness, defects formation, crack free film, density, chip size, easier steps and availability etc. been described. A brief study towards phase structure and ME coupling for each multiferroic system of BiFeO3, BaTiO3, PbTiO3 and CaTiO3 is shown.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Kuldeep Chand Verma and Manpreet Singh"},{id:"78034",title:"Quantum Physical Interpretation of Thermoelectric Properties of Ruthenate Pyrochlores",slug:"quantum-physical-interpretation-of-thermoelectric-properties-of-ruthenate-pyrochlores",totalDownloads:78,totalDimensionsCites:0,doi:"10.5772/intechopen.99260",abstract:"Lead- and lead-yttrium ruthenate pyrochlores were synthesized and investigated for Seebeck coefficients, electrical- and thermal conductivity. Compounds A2B2O6.5+z with 0 ≤ z < 0.5 were defect pyrochlores and p-type conductors. The thermoelectric data were analyzed using quantum physical models to identify scattering mechanisms underlying electrical (σ) and thermal conductivity (κ) and to understand the temperature dependence of the Seebeck effect (S). In the metal-like lead ruthenates with different Pb:Ru ratios, σ (T) and the electronic thermal conductivity κe (T) were governed by ‘electron impurity scattering’, the lattice thermal conductivity κL (T) by the 3-phonon resistive process (Umklapp scattering). In the lead-yttrium ruthenate solid solutions (Pb(2-x)YxRu2O(6.5±z)), a metal–insulator transition occurred at 0.2 moles of yttrium. On the metallic side (<0.2 moles Y) ‘electron impurity scattering’ prevailed. On the semiconductor/insulator side between x = 0.2 and x = 1.0 several mechanisms were equally likely. At x > 1.5 the Mott Variable Range Hopping mechanism was active. S (T) was discussed for Pb-Y-Ru pyrochlores in terms of the effect of minority carrier excitation at lower- and a broadening of the Fermi distribution at higher temperatures. The figures of merit of all of these pyrochlores were still small (≤7.3 × 10−3).",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Sepideh Akhbarifar"},{id:"77635",title:"Optimization of Thermoelectric Properties Based on Rashba Spin Splitting",slug:"optimization-of-thermoelectric-properties-based-on-rashba-spin-splitting",totalDownloads:124,totalDimensionsCites:0,doi:"10.5772/intechopen.98788",abstract:"In recent years, the application of thermoelectricity has become more and more widespread. Thermoelectric materials provide a simple and environmentally friendly solution for the direct conversion of heat to electricity. The development of higher performance thermoelectric materials and their performance optimization have become more important. Generally, to improve the ZT value, electrical conductivity, Seebeck coefficient and thermal conductivity must be globally optimized as a whole object. However, due to the strong coupling among ZT parameters in many cases, it is very challenging to break the bottleneck of ZT optimization currently. Beyond the traditional optimization methods (such as inducing defects, varying temperature), the Rashba effect is expected to effectively increase the S2σ and decrease the κ, thus enhancing thermoelectric performance, which provides a new strategy to develop new-generation thermoelectric materials. Although the Rashba effect has great potential in enhancing thermoelectric performance, the underlying mechanism of Rashba-type thermoelectric materials needs further research. In addition, how to introduce Rashba spin splitting into current thermoelectric materials is also of great significance to the optimization of thermoelectricity.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Zhenzhen Qin"},{id:"75364",title:"Challenges in Improving Performance of Oxide Thermoelectrics Using Defect Engineering",slug:"challenges-in-improving-performance-of-oxide-thermoelectrics-using-defect-engineering",totalDownloads:214,totalDimensionsCites:0,doi:"10.5772/intechopen.96278",abstract:"Oxide thermoelectric materials are considered promising for high-temperature thermoelectric applications in terms of low cost, temperature stability, reversible reaction, and so on. Oxide materials have been intensively studied to suppress the defects and electronic charge carriers for many electronic device applications, but the studies with a high concentration of defects are limited. It desires to improve thermoelectric performance by enhancing its charge transport and lowering its lattice thermal conductivity. For this purpose, here, we modified the stoichiometry of cation and anion vacancies in two different systems to regulate the carrier concentration and explored their thermoelectric properties. Both cation and anion vacancies act as a donor of charge carriers and act as phonon scattering centers, decoupling the electrical conductivity and thermal conductivity.",book:{id:"10037",title:"Thermoelectricity - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10037.jpg"},signatures:"Jamil Ur Rahman, Gul Rahman and Soonil Lee"}],onlineFirstChaptersTotal:6},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:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,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:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,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:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"May 19th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. 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Two Years After",coverURL:"https://cdn.intechopen.com/books/images_new/11573.jpg",subseries:{id:"6",title:"Viral Infectious Diseases"}}},{id:"80546",title:"Streptococcal Skin and Skin-Structure Infections",doi:"10.5772/intechopen.102894",signatures:"Alwyn Rapose",slug:"streptococcal-skin-and-skin-structure-infections",totalDownloads:48,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Streptococcal Infections",coverURL:"https://cdn.intechopen.com/books/images_new/10828.jpg",subseries:{id:"3",title:"Bacterial Infectious Diseases"}}}]},subseriesFiltersForOFChapters:[{caption:"Parasitic Infectious Diseases",value:5,count:1,group:"subseries"},{caption:"Viral Infectious Diseases",value:6,count:1,group:"subseries"},{caption:"Bacterial Infectious Diseases",value:3,count:2,group:"subseries"}],publishedBooks:{paginationCount:9,paginationItems:[{type:"book",id:"10654",title:"Brain-Computer Interface",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/10654.jpg",slug:"brain-computer-interface",publishedDate:"May 18th 2022",editedByType:"Edited by",bookSignature:"Vahid Asadpour",hash:"a5308884068cc53ed31c6baba756857f",volumeInSeries:9,fullTitle:"Brain-Computer Interface",editors:[{id:"165328",title:"Dr.",name:"Vahid",middleName:null,surname:"Asadpour",slug:"vahid-asadpour",fullName:"Vahid Asadpour",profilePictureURL:"https://mts.intechopen.com/storage/users/165328/images/system/165328.jpg",institutionString:"Kaiser Permanente Southern California",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"10859",title:"Data Mining",subtitle:"Concepts and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/10859.jpg",slug:"data-mining-concepts-and-applications",publishedDate:"March 30th 2022",editedByType:"Edited by",bookSignature:"Ciza Thomas",hash:"63a4e514e537d3962cf53ef1c6b9d5eb",volumeInSeries:8,fullTitle:"Data Mining - 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Dr. Khalid\\'s research interests include leadership and negotiations, digital transformations, gamification, eLearning, blockchain, Big Data, and management of information technology. Dr. Bilal Khalid also serves as an academic editor at Education Research International and a reviewer for international journals.",institutionString:"KMITL Business School",institution:{name:"King Mongkut's Institute of Technology Ladkrabang",country:{name:"Thailand"}}},{id:"418514",title:"Dr.",name:"Muhammad",middleName:null,surname:"Mohiuddin",slug:"muhammad-mohiuddin",fullName:"Muhammad Mohiuddin",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038UqSfQAK/Profile_Picture_2022-05-13T10:39:03.jpg",biography:"Dr. Muhammad Mohiuddin is an Associate Professor of International Business at Laval University, Canada. He has taught at Thompson Rivers University, Canada; University of Paris-Est, France; Osnabruck University of Applied Science, Germany; and Shanghai Institute of Technology and Tianjin University of Technology, China. He has published research in Research Policy, Applied Economics, Review of Economic Philosophy, Strategic Change, International Journal of Logistics, Sustainability, Journal of Environmental Management, Journal of Global Information Management, Journal of Cleaner Production, M@N@GEMENT, and more. He is a member of CEDIMES Institut (France), Academy of International Business (AIB), Strategic Management Society (SMS), Academy of Management (AOM), Administrative Science Association of Canada (ASAC), and Canadian council of small business and entrepreneurship (CCSBE). He is currently the director of the Research Group on Contemporary Asia (GERAC) at Laval University. 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I graduated with a Doctor of Philosophy in Principalship Leadership from the University of Malaya (UM) in 2010. I am currently a senior lecturer in the Department of Nationalism and Civilization, Center for Basic and Continuing Education, Universiti Malaysia Terengganu. Prior to that, I had served in several educational institutions such as schools, the Institute of Teacher Education (IPG), and also the University of Malaya. I am also actively involved in paper presentation, writing and publishing. My research interests are focused on leadership, education, society and Islamic civilization. This area of research requires a detailed understanding of Islamic studies and research studies in leadership. 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