Summary of information on the articles for initialization.
\r\n\t
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He published ten books or chapter books in national and international publishing houses and more than 140 papers in international and national journals and conferences proceedings.",coeditorOneBiosketch:"Prof. Dr. Daniel Tudor Cotfas received several awards - Gold medal at invention salon Euroinvent 2015; National Instruments Graphical System Design Achievement Awards 2013, USA, Austin: Education Winner, NI Community's Choice; Editor's Choice Award; Romania National Instruments NIDays Contest 2012 Romania, Bucharest. Prof. Dr. Cotfas published more than 65 papers in ISI journals or ISI conferences and over 50 papers in proceedings of international and national conferences.",coeditorTwoBiosketch:"Dr. Hedesiu authored over 100 papers in international journals, books, or communications to conferences. Horia Hedesiu is a co-author of two US patents in the field of embedded data acquisition systems. He is a managing director with National Instruments in Romania since 2005.",coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"460635",title:"Dr.",name:"Petru Adrian",middleName:null,surname:"Cotfas",slug:"petru-adrian-cotfas",fullName:"Petru Adrian Cotfas",profilePictureURL:"https://mts.intechopen.com/storage/users/460635/images/system/460635.jpg",biography:"Petru A COTFAS received his BSc degrees in mathematics and physics and also in computer science in 1997 and 2001 respectively, and MSc degree in mathematics and computer science at Transilvania University of Brasov, in 1998. He obtained the PhD degree in material science engineering at Transilvania University of Brasov, in 2007.\nHe is an Prof. Dr. at the Electronics and Computers Department, Transilvania University of Brasov, Romania. He has experience in several fields such as virtual instrumentation, PVs and hybrid systems characterization and testing, electronics circuit design, graphical programming and remote engineering. Dr. Cotfas published ten books or chapter books in national and international publishing houses and more than 140 papers in international and national journals and conferences proceedings (33 are in ISI journals and 30 are ISI conferences).\nORCID: https://orcid.org/0000-0002-6301-7841",institutionString:"Department of Electronics and Computer, Faculty of Electrical Engineering and Computer Science, Transilvania University of Brasov",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:{id:"465597",title:"Dr.",name:"Daniel Tudor",middleName:null,surname:"Cotfas",slug:"daniel-tudor-cotfas",fullName:"Daniel Tudor Cotfas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003RJpNAQA1/Profile_Picture_2022-04-06T09:45:51",biography:"Prof. Dr. Daniel Tudor Cotfas is Professor in Electronics and Computers Department, at the Transilvania University of Brasov, Romania. His research interest is in the characterization of the hybrid PV components, virtual instrumentation, and remote systems control. During his career he received several awards - Gold medal at invention salon Euroinvent 2015; National Instruments Graphical System Design Achievement Awards 2013, USA, Austin: Education Winner, NI Community's Choice; Editor's Choice Award; Romania National Instruments NIDays Contest 2012 Romania, Bucharest. Prof. Dr. Cotfas published more than 65 papers in ISI journals or ISI conferences and over 50 papers in proceedings of international and national conferences and has reviewed more than 100 papers for ISI and BDI journals.",institutionString:"Transylvania University of Brașov",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Transylvania University of Brașov",institutionURL:null,country:{name:"Romania"}}},coeditorTwo:{id:"465599",title:"Dr.",name:"Horia",middleName:null,surname:"Hedesiu",slug:"horia-hedesiu",fullName:"Horia Hedesiu",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003RJpRxQAL/Profile_Picture_2022-04-06T09:45:18.596",biography:"Horia Hedesiu received his B.Sc. and a Ph.D. degree in Electrical Engineering from the Technical University of Cluj-Napoca, Romania (formerly Polytechnic Institute of Cluj) in 1991 and 1999 respectively. He is currently a Professor with the Electrical Machines and Drives Department at the TUCN. He has authored over 100 papers in international journals, books, or communications to conferences. Horia Hedesiu is a co-author for two US patents in the field of embedded data acquisition systems. His research interests are in the information systems area, real-time simulation systems, Hardware-in-the-Loop, and also dedicating resources to industrial application implementations that involve machinery, graphical programming technologies and computer-based measurement systems. 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Therefore, there is justified interest in obtaining useful knowledge that can be extracted from those huge amounts of data, in order to help making better decisions and understanding the nature of data. Clustering is one of the fundamental techniques for getting insight on the underlying nature and structure of data. The purpose of clustering is organizing a set of data into clusters whose elements are similar to each other and different from those in other clusters.
\nOne of the clustering algorithms more widely used to date is
It is convenient to point out that
The solution to the
For selecting the most relevant articles, systematic review methodology was used. The filters used and the analysis of results allowed finding some of the most successful and referenced algorithm variants for each step of the algorithm.
\nThe chapter is organized as follows: Section 2 summarizes the pioneering works that originated the family of
During the decades of the 1950s and 1960s, several
According to the specialized literature [6, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20], four algorithms gave origin to this family. The following subsections describe the articles related to these algorithms and their authors.
\nMathematician Hugo Steinhaus, from the Mathematics Institute of the Polish Academy of Sciences, published an article titled “Sur la Division des Corps Matériels en Parties” [11], in which he presented the problem of partitioning a heterogeneous solid by the adequate selection of partitions. He also mentioned applications in the fields of anthropology and industry. Steinhaus was the first researcher that proposed explicitly an algorithm for multidimensional instances.
\nStuart Lloyd, from Bell Laboratories, in the article titled “Least Squares Quantization in PCM” [12] approached the problem of transmitting a random signal
James MacQueen, from Department of Statistics of the University of California, in his article titled “Some Methods for Classification and Analysis of Multivariate Observations” [6], proposed an algorithm for partitioning an instance into a set of clusters whose variance was small for each cluster. The term
Jancey, from the Department of Botany, School of Biological Sciences, University of Sydney, in one of his articles titled “Multidimensional Group Analysis” [19], presented a clustering method for characterizing species
Because the results from Jancey’s research will be used as reference for this chapter, his algorithm will be described in detail. The author stated that the similarity measures are based on the results published by the following authors: (a) Pearson in his article titled “On the Coefficient of Racial Likeness [21] published in 1926,” (b) Rao in the article named “The Use of Multiple Measurements in Problems of Biological Classification” [22] published in 1948, and (c) Sokal in his article titled “Distance as a Measure of Taxonomic Similarity” [23] in 1961.
\nPearson [21] in his article “On the Coefficient of Racial Likeness,” when studying craniology and physical anthropology, confronted the difficulty of comparing two types of races, in order to determine the membership of a limited number of individuals to one race or another or both. As a result, Pearson proposed a coefficient of racial likeness (CRL). For calculating this coefficient, it is necessary to obtain first the means and variances of each characteristic in each sample, since it is assumed that there is variability for each of the characteristics considered. This coefficient is used to measure the dispersion around the mean and the degree of association between two variables.
\nThe article published by Radhakrishna Rao [22] in the
Sokal [23] published his article titled “Distance as Measure of Taxonomic Similarity,” which is based on the methods for quantifying the taxonomy classification process, and he points out the importance of having fast processing and data calculation methods. The purpose of his work is to evaluate the similarities among taxa that have observed characteristic values, instead of phylogenetic speculations and interpretations.
\nThe similarity among objects is evaluated based on many attributes, and all the attributes are considered as equal taxonomic values; therefore, an attribute is not weighted more or less than any other.
\nFor performing the weighting of attributes, three types of coefficients are used: association, correlation, and distance, where the last one is of interest for this study. This distance coefficient is employed for determining the similarity between two objects by using a distance function in an
A measure of similarity between the objects 1 and 2 based on two attributes would be the distance in a two-dimensional space (i.e., a Cartesian plane) between the two objects. This distance
where
Similarly, when three attributes are needed for two different objects, it is now necessary to carry out the distance calculation in a three-dimensional space so that the exact position of the two objects can be represented regarding the three attributes. For calculating the distance between these two objects, an extension to the three-dimensional space of the formula for
The general formula for calculating the distance for two objects with
where
Once the object classification process is completed, then the matrix of similarity coefficients obtained (based on object distances) can be used in the usual methods for clustering analysis.
\nFinally, it is important to emphasize the feasibility of calculating distance as the summation of the squared differences of the attribute values of objects of different kinds.
\nThe clustering method proposed by Jancey consists of the following four steps:
Initialization. First,
Classification. The distances from all the objects to all the centroids are calculated, and each object is assigned to its closest centroid.
Centroid calculation. New centroids are calculated using the mean value of the objects that belong to each cluster.
Convergence. The algorithm stops when equilibrium is reached, i.e., when there are no object migrations from one cluster to another. While no equilibrium is reached, the process is repeated from step 2.
Let
Therefore, the clustering problem can be formulated as an optimization problem [24], which is described by Eq. (3):
\nwhere
The standard version of the
Standard
The pseudocode of the standard
1: | \n|
2: | \n | \n
3: | \n | \n
4: | \n|
5: | \n | \n
6: | \n Calculate the Euclidean distance from each centroids; | \n
7: | \n Assign object | \n
8: | \n|
9: | \n Calculate centroid | \n
10: | \n|
11: | \n iterations | \n
12: | \nStop the algorithm; | \n
13: | \n | \n
14: | \n Go to | \n
15: | \n
Since the pioneering studies conducted by Steinhaus [11], Lloyd [12], MacQueen [6], and Jancey [19], many investigations have been aimed at finding a
It has been shown that the clustering problem belongs to the NP-hard class for
It is important to emphasize that the establishment of useful gaps between the optimal solution of the problem
The computational complexity of
This section presents a classification of the most relevant articles on improvements to
The search for articles was carried out using four highly prestigious databases: Springer Link, ACM, IEEE Xplore, and ScienceDirect. Queries were issued to these databases using the following search string:
\n((({k means} OR {kmeans} OR {Lloyd algorithm} OR {k+means} OR {“k means”}
\nOR {“algoritmo de lloyd”}) AND ({improvement} OR {enhancement} OR
\n{mejora})) AND ({Initialization} OR {inicializacion} OR {beginning} OR {inicio}
\nOR {partition} OR {particion} OR {first step} OR {primer paso}
\nOR {centroide}) AND ({classification} OR {clasificacion} OR {sorting} OR
\n{assignment} OR {asignacion} OR {range search} OR {neighnour search} OR
\n{búsqueda en vecindario}) AND (OR {centroide calculation} OR {calculo de
\ncentroide}) AND ({Convergence} OR {Convergencia} OR {Stop criteria} OR
\n{criterio de paro} OR {Stop condition} OR {Condicion de parada} OR {convergence
\ncondition} OR {Condicion de convergencia} OR {final step} OR {Paso final})).
\nAs a result of the queries, 1125 articles were retrieved related to the
The flow chart in Figure 2 shows the steps of the process carried out for selecting the articles. In step “a,” the database queries were issued, and a document list was generated, and in step “b,” duplicate articles were identified and eliminated. In step “c,” based on article titles, those irrelevant to this research were identified and discarded. In step “d,” article abstracts were analyzed, and those with little affinity to the subject of study were excluded. In step “e,” those documents written in languages different from English or Spanish were eliminated. In step “f,” those articles that did not describe an improvement process were discarded. In step “g,” the text of the articles was reviewed, and those with little affinity to the subject of study were excluded. In step “h,” four articles were eliminated because of possible plagiarism. Finally, in step “i,” articles with a small number of citations were discarded; specifically, those with citations below a threshold adjusted by year and category.
\nProcess for selecting articles.
As a result of the analysis of the articles, those addressing an improvement to one of the algorithm steps were identified. However, several works were found that involved improvements to more than one step; therefore, the following groups or categories were defined: (a) initialization, (b) classification and centroid calculation, (c) convergence, (d) convergence and initialization, and (e) convergence and classification.
\nIn Figure 3, the number of articles for each of the aforementioned groups is shown. Notice that the step with the most articles is initialization and the step with the least attention by researchers is convergence. In the following subsections, the most important articles in each group are briefly described.
\nNumber of articles for each of the aforementioned groups.
The initialization step has received the most attention by researchers, because the algorithm is sensitive to the initial position of the centroids; i. e., different initial centroids may yield different resulting clusters. Consequently, a good initial selection might find a better solution and a reduction in the number of iterations needed by the algorithm to converge.
\nFor this step 38 documents were found about improvements proposed for generating better initial centroids. Table 1 summarizes information on the articles for this step. Column 1 shows the articles for this step. Columns 2 through 5 indicate the different strategies that researchers have used for obtaining improvements for this step. Finally, column 6 shows the number of articles for each of the strategies.
\nArticles | \nStrategy | \nNumber of articles | \n|||
---|---|---|---|---|---|
Algorithm/method | \nInstance information | \nData structure | \nOther | \n||
[24, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40] | \n● | \n\n | \n | \n | 15 (39.47%) | \n
[41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55] | \n\n | ● | \n\n | \n | 15 (39.47%) | \n
[56, 57, 58, 59] | \n\n | \n | ● | \n\n | 4 (10.53%) | \n
[60, 61, 62, 63] | \n\n | \n | \n | ● | \n4 (10.53%) | \n
Summary of information on the articles for initialization.
The second row shows articles on approaches that perform a preprocessing for generating the initial centroids by using particular algorithms or methods. The third row includes articles on methods based on information on data set. The fourth row shows articles on techniques that involve more effective data structures. Finally, the fifth row includes articles where the improvements use other strategies.
\nIn the rest of this subsection, some of the most important works on the initialization step are summarized. Several of these works mentioned can be used in other algorithms similar to
In [27] a clustering method is proposed, where the centroids of the final clusters are used as initial centroids for
In [28] a modification to Lloyd’s work [12] is developed in the field of quantization. The main idea is that objects that are farther from each other have a larger probability of belonging to different clusters; therefore, the strategy proposed consists in choosing an object with the largest Euclidean distance to the rest of the objects for being the first centroid. The following
In [29] two initialization methods are developed, which are aimed at being applied to large data sets. The proposed methods are based on the densities of the data space; specifically, they need first to divide uniformly the data space into
In [30] a preprocessing is performed called
In [31] a preprocessing method is proposed which uses a selection model based on statistics. In particular, it uses the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC) for selecting the set of objects that will be used as initial centroids.
\nIn [42] an algorithm is presented based on two main observations, which state that the more two objects are similar to each other, the largest the possibility that they end up assigned to the same cluster, so they are discarded from the selection of initial centroids. This method is based on density-based multiscale data condensation (DBMSDC) and allows identifying regions with large data densities, and afterwards a list is generated sorting the values by density. Next, select an object according to the sorted list as the first initial centroid, and all the objects that have a ratio inversely proportional to the density of the selected object are discarded. Afterwards, the second centroid is selected as the next object in the list that has not been eliminated, and its surrounding objects are excluded. This process is repeated until all the initial centroids needed are obtained.
\nA variance-based method for finding the initial centroids is proposed in [44]. First, the method calculates the variances of the values for each dimension, and it selects the dimension with the largest variance. Next, it sorts the objects by the values on the dimension with the largest variance. Finally, it creates
Other researchers have focused their works on using information on data set, such as the distribution of objects and statistical information of them, among others.
\nIn [45] a method is proposed for randomly generating the initial centroids as described next: the first centroid is randomly generated using a uniform probability distribution for the objects; subsequent centroids (
In [50] a method is proposed, which is based on a sample of the data set for which an average is calculated. Next, the objects whose distance is larger than the average are identified, and a distance-between-objects criterion is applied for selecting the objects that will constitute the initial objects. The authors claim that this method obtains good results regarding time and solution quality when solving large data sets.
\nIn [55] a method is proposed for eliminating those objects that may cause noise, as well as
By using particular data structures, in [59] a method is presented for estimating the data density in different locations of the space by using kd-tree type structures.
\nOther researchers [58, 60] have used a combination of genetic algorithms and
Of the four steps of the algorithm, classification is the most time-consuming, because for each object it is necessary to calculate the distance from each object to each centroid.
\nThe 33 articles that are the best proposals for this step are classified in Table 2. Column 1 shows the articles related to this step. Columns 2 through 6 indicate the different strategies that researchers have used for achieving improvements for this step. Finally, column 7 shows the number of articles for each of these strategies aiming at reducing the number of calculations of object-centroid distances.
\nArticles | \nStrategy | \nNumber of articles | \n||||
---|---|---|---|---|---|---|
Compression thresholds | \nInformation of previous steps | \nData structure | \nMathematical/statistical process | \nOther | \n||
[64, 65, 66, 67, 68, 69, 70, 71, 72] | \n● | \n\n | \n | \n | \n | 9 (27.27%) | \n
[73, 74, 75, 76, 77, 78, 79, 80] | \n\n | ● | \n\n | \n | \n | 8 (24.24%) | \n
[81, 82, 83, 84, 85, 86, 87] | \n\n | \n | ● | \n\n | \n | 7 (21.21%) | \n
[88, 89, 90, 91, 92] | \n\n | \n | \n | ● | \n\n | 5 (15.15%) | \n
[93, 94, 95, 96] | \n\n | \n | \n | \n | ● | \n4 (12.12%) | \n
Summary of information on the articles for classification.
The second row shows articles on approaches that use compression thresholds. The third row includes articles on methods that use information from the initialization step. The fourth row shows articles on techniques that involve more efficient data structures. The fifth row includes articles that present mathematical/statistical processes. Finally, the sixth row shows articles where the improvements use other strategies.
\nIn [64] an improvement is proposed, which reduces the number of calculations of object-centroid distances. For this purpose, an exclusion criterion is defined based on the information of object-centroid distances in two successive iterations:
In [69] a heuristic is proposed, which reduces the number of objects considered in the calculations of object-centroid distances; i.e., the objects with small probability of changing cluster membership are excluded. The rationale behind this heuristic derives from the observation that objects closest to a centroid have a small probability of changing cluster membership, whereas those closer to the cluster border have higher probability of migrating to another cluster. The heuristics determine a threshold for deciding which objects should be excluded. The calculation of the threshold is defined as the sum of the two largest centroid shifts with respect to the previous iteration. Another work with a similar strategy is presented in [66].
\nIn [72] an improvement is presented, which allows excluding from the calculation of object-centroid distances those objects in clusters that have not had object migrations in two successive iterations. This type of clusters is called
In [74] an improvement to
In [79] a heuristic is presented, which reduces the number of calculations of object-centroid distances. Specifically, it calculates the distances for each object only to those centroids of clusters that are neighbors of the cluster where the object belongs. This heuristic is based on the observation that objects can only migrate to neighboring clusters.
\nOne of the most representative works for this step is presented in [82], where an improvement is proposed, called
Centroid calculation was defined as another step in this analysis, because there exist two variants for this step that differentiate two types of the
The convergence step of the algorithm has received little attention by researchers, which is manifested by the small number of papers on this subject. It is worth mentioning that in recent years, research on this step has produced very promising results concerning the reduction of algorithm complexity at the expense of a minimal reduction of solution quality.
\nA pioneering work for this step was presented in [97]. The main contribution consisted in associating the values of the squared errors to the stop criterion of the algorithm. In particular, the proposed condition for stopping is when, in two successive iterations, the value of the squared error in one iteration is larger than in the previous one, which guarantees that the algorithm stops at the first local optimum.
\nOther articles for this step are [98, 99], from the point of view of mathematical analysis, aiming at proving when does the solution obtained reach a global optimum.
\nThis subsection summarizes two works on improvements for the convergence and initialization steps.
\nIn [100] the stop criterion is associated to the number
In [101] convergence is reached in two ways. In the first condition, the algorithm stops when it reaches a predefined number of iterations. In the second, the algorithm stops when there is no region with a density value larger than a predefined threshold. It is important to mention that in each iteration, the algorithm creates a new cluster guided by the density value in a region.
\nIn this subsection two works are summarized, which present improvements for the convergence and classification steps.
\nIn [102] a stop criterion is proposed, which stops the algorithm when, in ten consecutive iterations, the difference of the squared errors, between iterations
The work presented in [103] proposes an optimization by integrating the core (classification) of the
Preceding sections include articles published from the origins of the algorithm up to 2016. This section includes three types of articles: recently published articles on important improvements to
Regarding improvements to the steps of
Recently, in the specialized literature, the parallelization of
In recent years, a trend has been observed for modifying
This chapter presents three aspects of the
Regarding the origin of
The systematic review process involved accessing four large databases, from which 1125 documents were retrieved. After applying inclusion and exclusion criteria, 79 documents remained.
\nNext, we will mention the most important observations organized by subjects:
Initialization. Of the four steps of the algorithm, initialization is the step on which the largest number of investigations has focused. The reason for this interest is that the algorithm is highly sensitive to the initial positions of the centroids. Some of the most cited publications are [45, 59].
Classification. Most of the works related to this step aim at reducing the number of calculations of object-centroid distances by applying heuristic methods. Some of the most cited works are [73, 82]. Some promising and recently published articles are [72, 107].
Centroid calculation. No documents were retrieved related to this step.
Convergence. It is remarkable that for this step the number of articles is very small. However, some articles recently published present very promising results by reducing the algorithm complexity without decreasing significantly the solution quality.
Regarding the most recent publications on
Finally, because the nature of data clustering is exploratory and applicable to data from many disciplines, it is foreseeable that
According to Gillam [1], one of the challenges facing the clinician when examining a patient complaining of different types of dental pain is that the patient may be suffering from both physical or emotional discomfort. This may be very traumatic to them in terms of being unable to cope, resulting in the loss of sleep and work as well as in an economic cost to the health care provider [2, 3, 4]. This in turn may present difficulties for the clinician in determining a correct diagnosis of the cause of the patient’s pain. The importance of differentiating these different types of oro-facial pain based on the patient’s presenting clinical features and a thorough medical and dental history is a key to the successful management of the patient’s pain [1]. Furthermore, it should be recognized that pain is subjective in nature and is pertinent to the individual’s own perception of pain, which may also be influenced by several factors such as a previous history of pain, anticipation, or fear of the proposed dental treatment. Although dentine hypersensitivity (DH) may not be as severe as some of the other oro-facial conditions, it is a relatively common condition, which has an impact on the individual patient’s well-being and quality of life (QoL) [5]. There have been concerns regarding the awareness and confidence of clinicians to diagnose and successfully manage DH [1, 6, 7]. To address these concerns, several management and preventive strategies have been suggested to provide practical guidelines for clinicians [6, 8, 9, 10]. These guidelines include identifying the cause of the patient’s presenting problem based on a good medical and dental history with a thorough clinical examination using the appropriate diagnostic tests when distinguishing DH from other forms of oro-facial pain. Recommendations for the management of DH also included the importance of removing the aetiological and pre-disposing features to prevent further episodes of pain associated with DH to alleviate the impact on the patient’s QoL. The use and/or recommendations of the appropriate in-office (professionally applied) or over the counter (OTC; at-home) products and/or techniques depending on the severity of the problem should also be included in the clinician’s management strategy. The importance of a management plan that includes both a preventive strategy to reduce further damage to both the hard and soft tissues of the mouth, and with a monitoring component within the plan cannot be overstated [10]. This chapter, therefore, covers the relevant aspects for diagnosing and managing DH with an emphasis on adopting a preventive strategy that will attempt to minimize or eliminate the problem, thereby enabling the patient to have an improved QoL.
The published prevalence figures for dentine hypersensitivity range from approximately 1% to over 70% depending on how the figures are collected. For example, data from questionnaire studies report a higher prevalence of the condition, whereas data from clinical studies that examine the patient provide lower prevalence figures. The information from these types of studies may also depend on the location (university or hospital clinics, general dental practice, or specialist practice such as restorative or periodontics) and the country or culture of the population. For example, the traditional prevalence figures for DH
According to the findings of the Canadian Advisory Board on Dentin Hypersensitivity [6], 14 knowledge gaps were identified from the survey of participating clinicians, and these were classified as relating to either the causes and diagnosis or the management of the condition. It was evident from these findings that the prevalence of DH was underestimated, and this was due in part to the lack of routine screening for the condition by clinicians. Less than 50% of the participants considered a differential diagnosis to eliminate other dental conditions with similar pain characteristics to those of DH. There was also confusion regarding the nature of the predisposing factors associated with DH as well a misunderstanding of how desensitizing products work (mechanism of action). Furthermore, about 50% of the participants indicated that they lacked confidence in treating DH effectively with a similar percentage indicating that they would try to modify any predisposing factors prior to further treatment. A recent review of questionnaire studies on the awareness of DH by clinicians indicated that there are still areas of concern in the understanding of the underlying principles involved in the management of DH [7].
The currently accepted mechanism associated with DH as proposed by Brännström and Åström is hydrodynamic in nature [15]. This theory relies on minute fluid movements within the dentinal tubules in response to an external stimulus such as cold air or water to initiate pain in the dental pulp. There is also
The etiology of DH/RS is multifactorial in nature, and it is evident that the structure of dentine is altered because of a combination of the associated pre-disposing factors, which may include anatomical factors such as tooth position, quality of the buccal plate, and so on. For example, once the overlying hard and soft tissues have been removed exposing the underlying dentine surface through gingival recession, tooth surface loss through attrition, abrasion and possibly abfraction, over-zealous toothbrushing techniques, the effects of periodontal disease and its subsequent treatment, then these factors may play a part in widening the open dentinal tubules through erosion with the combination of over-zealous toothbrushing techniques. An epidemiological study in a population of young adults aged 18–35 years by West et al. [14] reported that there was a link between a healthy erosive diet and lifestyle and toothwear with DH.
Pain associated with DH is considered transient in nature and once the initiating stimulus, such as cold air from a dental air syringe or a cold drink, has been removed, the problem will have been resolved. The clinical features of DH as reported in the published literature primarily deal with the features associated with DH in patients with a well-maintained oral hygiene rather than clinical features associated with RS
Clinical features of a patient with gingival recession and dentine hypersensitivity (Acknowledgement N. Pandya [
It is important to recognize that two broad categories of patients attend a dental clinic: (1) patients who are regular attenders and have an established relationship with the clinician, and (2) patients who have not been previously attending a dental practice but may have decided to attend due to a dental problem such as toothache, esthetic concerns, or other dental problems which have arisen. In the first category of patients, the clinician will be aware of their personal medical and treatment history and to some extent, the consultation period including the examination may be straightforward. For example, a patient who has recently received dental treatment such as restoration of a tooth or had their teeth professionally cleaned may be experiencing discomfort from these procedures and such a problem can be swiftly identified and treated [16]. Patients who have not previously attended a dental practice, however, may require a more prolonged consultation to obtain the relevant medical, dental, and social history prior to the clinical examination and subsequent diagnosis of DH.
For patients with a more obscure orofacial problem, a persistent idiopathic facial pain (PIFP) may require a more extensive examination and it is advisable for the clinician to refer these patients to a Specialist Oral Medicine/Pain clinic [16].
Prior to a clinical examination, the clinician should obtain medical, dental, social, and dietary histories to supplement the information collected during the clinical examination and any subsequent tests such as radiographs. During the initial consultation, it is important to ask the patient why they have arranged the appointment. Toothache is one of the most common of oro-facial pains that prompts a patient to visit a dentist and where possible the clinician should determine the nature of the problem, the location of the pain (if the patient is able to pinpoint the exact location), duration, intensity, and any factors that may intensify or relieve the pain. For example, the clinician can ask if the patient is able to continue their daily activities such as eating, drinking, brushing their teeth without any discomfort. One suggestion would be to use visual analogue scale (VAS) scores (0-10), verbal descriptors, or Quality of Life Questionnaires (QoL) to determine the severity of the discomfort the patient is experiencing, and any impact DH/RS may have the patient’s QoL [5]. The clinical examination will involve a thorough evaluation of the patient’s oral status including a Basic Periodontal Examination (BSP) and a Basic Erosive Wear Assessment (BEWE) to determine the degree of tooth surface loss [10].
During the clinical examination, clinicians will use a dental explorer probe and air from a triple air syringe to screen any sensitive areas on the exposed cervical/root region. If the patient is prone to DH, then this mechanical or evaporative/thermal stimulus will elicit a response from the patient [1]. The response to these stimuli will be varied depending on the individual’s pain threshold and subjective perception of pain. This pain should be transient in nature, in that once the stimulus has been removed, the pain will be resolved. If the pain, however, is continuous in nature, then this may indicate that the problem is related to other dental problems such as dental caries, which will require more extensive testing using an ice stick, ethyl chloride, pulp testers, and so on to evaluate the status of the dental pulp (pulp vitality testing). A simple test at this stage of the initial evaluation for DH is to (1) ask the patient to indicate their perception of the pain they are experiencing with DH following blowing cold air on the tooth (or teeth) in question using a VAS score, (2) apply a varnish to the affected site of the identified tooth (or teeth), and (3) retest the tooth (or teeth) in question using cold air from a dental air syringe and ask the patient to indicate their pain perception using a VAS score. If there is an improvement in the VAS scores, then this may indicate that the initial diagnosis of the patient’s problem was DH (see management section).
According to Gillam [7], there are a variety of methodological approaches used in the dental clinic to identify (diagnose) DH such as tactile, evaporative, and thermal stimulation using cold air from a dental triple syringe as well as the patient’s self-reporting (VAS, patient history, etc.). An example of the range of methodological approaches recommended or used by clinicians can be observed in Figure 2 [18]. The use of these methodological approaches may, however, be difficult to justify [19].
Diagnostic steps used by clinicians to identify DH (Acknowledgement Exarchou et al. [
A useful device to aid clinicians in determining both a provision and definitive is the use of mnemonics such as ‘LOCATE’ or ‘SOCRATES’. This will help to ascertain the relevant information to identify the patient’s problem by asking the following questions:
Pain characteristics: What were the symptoms relating to pain experienced by the patient?
Location of the pain: Was the pain localized or generalized in nature and can the patient point to the site of the problem?
Pain onset: Was the patient able to relate to the clinician when the pain started?
Pain duration: Was the pain transient or long lasting in nature?
Pattern of pain: Was the patient able to recall the pattern of the pain?
Pain severity: What was the severity of pain and did it vary?
Relieving factors: Are there factors that relieve or worsen the pain such as the application of cold or heat, medication, changing position (lying down), and so on?
Associated factors: Are there any other factors that you might be aware of when you are experiencing pain?
The clinician, however, should be aware that depending on the longevity and severity of the patient’s pain, and particularly from severe toothache, they may have difficulties recalling some of these features due to being unable to cope with pain before attending the clinic [2].
The classic definition of DH was based on specific wording as ‘pain derived from exposed dentine in response to chemical, thermal tactile or osmotic stimuli which cannot be explained as arising from any other dental defect or disease’ [6]. In other words, DH is in essence a diagnosis of exclusion based on both the history of the problem and a clinical examination to exclude other forms of oro-facial pain and as such a thorough clinical examination together with a medical and dental history of the patient should enable the clinician to come to a correct diagnosis [1, 20].
There are, however, several problems facing the clinician when investigating oro-facial pain, for example, the time taken to identify the areas in the mouth causing the discomfort as well as the highly subjective nature of the pain response [20]. The clinician is, therefore, reliant not only on the patient’s self-reporting of the history of DH but also on the information that they have accumulated through their own analysis of the problem (medical, dental, and social history together with a thorough clinical examination, which may require further evaluation). For example, patients who have recently received restorative, bleaching, and periodontal procedures within the last few weeks before attending the clinic may in fact be suffering from post-operative sensitivity and this should be relatively easy to identify and reassure the patient that the pain should resolve within 4-6 weeks and if not to return for further investigation. For new patients or those with a recent complaint of DH, the clinician will spend more time discussing the problem with the patient, trying to determine the history of the problem using some of the diagnostic tests indicated in Figure 2. The clinician should be aware that as DH is an exaggerated response of the normal pulp-dentine, the patient may only be aware of the problem once an external stimulus such as a cold stimulus (cold air from a dental triple syringe, suction from a high-volume suction, etc.). The evidence identified during this process may enable to provide a provisional diagnosis of DH.
According to the Canadian Advisory Board on Dentin Hypersensitivity [6], there is a major problem in the diagnosis of DH where ≤50% of the clinicians participating in the survey considered using a differential diagnosis to eliminate other dental conditions with similar pain characteristics to those of DH. Other studies have also reported on the apparent reluctance by clinicians to consider in this aspect of the management of DH [7].
One of the reasons for this reluctance in making a definitive diagnosis of DH may be the complexity and time required to eliminate the other dental conditions that have similar pain characteristics to DH such as reversible and irreversible pulpitis, dental abscess, cracked tooth syndrome, periodontal disease, pericoronitis, idiopathic oral facial pain, and post-operative sensitivity [18] (Figure 2). It is, therefore, important for the clinician to make a definitive diagnosis of DH before undertaking any treatment of the patient’s problem. A useful summary of selected oro-facial conditions with their pain characteristics and presenting features is shown in Table 1 [20].
Aetiology | Pain character and timing | Pain intensity | Proving factors | Relieving factors | Associated features |
---|---|---|---|---|---|
Dentine hypersensitivity | Sharp, stabbing, stimulation evoked | Mild to moderate | Thermal, tactile, chemical, osmotic | Removal of the stimulus | Attrition, erosion, abrasion, abfraction |
Atypical odontalgia (persistent dentoalveolar pain) | Continuous, no paroxysmal, dull, aching and throbbing but occasionally sharp | Mild to moderate | Touch, heat and cold | Sleep and rest Topical agents: lidocaine, capsaicin. Systemic agents: antidepressants | May have no obvious clinical features |
Reversible pulpitis | Sharp, stimulation evoked | Mild to moderate | Hot, cold, sweet | Removal of the stimulus | Caries, restorations |
Irreversible pulpitis | Sharp, throbbing, intermittent/continuous | Severe | Hot, chewing, lying flat | Cold in the late stages | Deep caries |
Cracked tooth syndrome | Sharp intermittent | Moderate to severe | Biting, ‘rebound pain’ | — | Trauma, parafunction |
Periapical periodontitis | Deep, continuous boring | Moderate to severe | Biting | Removal of trauma | Periapical redness, swelling, mobility |
Lateral periodontal abscess | Deep continuous aching | Moderate to severe | Biting | — | Deep pockets redness and swelling |
Pericoronitis | Continuous | Moderate to severe | Biting | Removal of trauma | Fever, malaise, imprint of upper tooth |
Dry socket (acute alveolar osteitis | Continuous 4–5 days post-extraction | Moderate to severe | — | Irrigation | Loss of clot, exposed bone |
Differential diagnosis of dental pain (modified acknowledgement Aghabeigi [20]).
Once a definitive diagnosis has been determined, the clinician can then formulate a management strategy to treat the condition. The complexity of this treatment plan will depend on (1) on the extent and severity of the problem, (2) the willingness of the patient to comply with the recommendations provided by the clinician, and (3) the ability of the clinician to successfully diagnose the problem and provide the appropriate treatment including preventative strategies. Broadly speaking, the initial treatment will be either (1) professionally applied (in-office treatment) such as a fluoride varnish or more invasive strategy (composite, laser, periodontal surgery) for localized severe DH, or (2) patient applied/at home [over the counter treatment (OTC)] such as an OTC toothpaste for a mild-moderate discomfort (see Table 2 for examples). The clinician should also be aware of the impact of DH on the QoL of the patient and it is important for the clinician to monitor whether the recommended treatment has improved the patient’s QoL. For example, can the patient continue their daily routine of eating, drinking and oral hygiene practices without any interruption to their daily activities.
Gingival recession | Tooth wear | Periodontal treatment |
---|---|---|
Clinical evaluation
| Clinical evaluation
| Clinical evaluation
|
Patient education (including preventive advice)
| Patient education (including preventive advice)
| Patient education (including preventive advice)
|
Corrective clinical outcomes
| Corrective clinical outcomes
| Corrective clinical outcomes Initial phase Non-surgical periodontal procedure(s). DH treatment (including desensitizing polishing pastes/Fluoride varnishes) Re-evaluation Follow-up assessment on periodontal status and dentine hypersensitivity Corrective phase
Maintenance phase
|
Recommendations for home use (including toothpaste/mouth rinses)
| Recommendations for home use (including toothpaste/mouth rinses)
| Recommendations for home use (including toothpaste/mouth rinses)
|
Overall management strategy options for treating DH (Acknowledgement Gillam et al. [10] modified).
Several investigators have recommended treatment algorithms to help the clinician mange DH successfully [6, 8, 10]. An example of one of these algorithms is displayed inFigure 3 based on the recommendations from a UK Guidelines workshop, London, UK [10]. An important aspect of these guidelines was the recognition that the management of DH should be based on the presenting features of the problem rather than simply providing a blanket treatment plan to cover all aspects of DH. For example, three categories were presented for the clinician to consider: (1) patients with gingival recession in a well-maintained mouth, (2) patients with a tooth wear problem, and (3) patients with a periodontal problem (Table 2) [10]. This concept was utilized and developed by Gillam and Koyi [21] covering six clinical case scenarios in dealing with oro-facial pain with specific clinical presentations.
Selected responses from participants on what other dental conditions should be excluded when determining a differential diagnosis (Acknowledgement Exarchou et al. [
The management of DH can therefore involve both simple and complex cases to treat and it is important that the clinician is aware of both their expectations of success and the patient’s expectation of resolving their pain. There may be times when this aspiration can only be partially met to the satisfaction of both parties. The clinician should avoid simply handing out or recommending a treatment or technique without identifying the aetiological factors that initiated the problem in the first place. One of the concerns from the Canadian Advisory Board on Dentin Hypersensitivity [6] was whether clinicians had the confidence in the products that they recommended for treatment. This concern has also been highlighted by several investigators and it appears that this issue is still a matter of concern [7, 19].
Depending on the severity of the problem, the following products and techniques can be suggested (see Table 2). The question as to whether these products or techniques are effective in the treatment of DH has been the subject of several systematic reviews and meta-analysis [22, 23, 24, 25].
The importance of a preventive strategy for minimizing further episodes of DH cannot be overstated. It is not enough to simply provide a patient with a treatment such as a toothpaste or composite restoration without first eliminating or at least minimizing the aetiological or predisposing features that initiated the problem in the first place. This aspect will involve reviewing the clinical features implicated with the condition such as patients with a healthy mouth or patients with a periodontal or restorative problems. For example, patients with a healthy, plaque-free mouth may be over-zealous, or an enthusiastic brusher with a healthy diet that may include acidic drinks will need advice on modifying their tooth brushing technique and minimizing the effects of dietary acids. The patient with a periodontal or restorative problem will require more extensive and prolonged treatment and perhaps one way of initially alleviating post-operative pain following this treatment would be to apply a desensitizing polishing paste or dental varnish [16].
Traditionally, clinicians expect their patients to change their health behavior, which is a philosophy based on a top-down approach (clinician directed) where the patient was provided information that was considered beneficial to them by the clinician. This philosophy, however, not only failed to empower the patient but was also ineffective in motivating the patient to initiate any behavior changes to improve their health and well-being. It is, therefore, important for the clinician to adopt management strategies and goals that will effectively encourage the patient to take individual responsibility to initiate these behavioral changes in the lifestyle of their patients. According to Gillam and Ramseier [26], the introduction of patient-centred approaches such as Motivational Interviewing is ideal for motivating patients in dental practice. It is acknowledged, however, that for many clinicians, this approach may be difficult to implement, due to time constraints, although the process could be continued over several visits as in the periodontal maintenance phase [27]. There are several factors to consider when developing a strategy using this approach, for example, (1) the extent and severity of the patient’s problem, (2) acquiring the patient’s permission to discuss any proposed changes, (3) the availability of the patient and their willingness to engage with the consultation process, (4) the rapport between the patient and clinician, (5) the willingness of the patient to reflect on the proposed changes and to weigh up the advantages/disadvantages and decide whether to accept or reject these proposals, (6) the patient’s motivation to initiate these changes and subsequently adhere (comply) to the recommended changes to their behavior, and (7) the frequency of monitoring during the maintenance phase and subsequent reinforcement strategy in monitoring the patient’s progress [26, 27].
According to Gillam ([20] modified), the following key points may be useful in ascertaining whether a patient has DH and how much it impacts on their QoL and should enable the clinician not only to manage the problem in a structured manner but also to encourage to take personal ownership of their oral health by making the necessary changes/modifications in their behavior.
Ask patients if they have a history of DH
Ask patients if it is a current problem
Does it impact on their QoL? If ‘Yes’, ask them to elaborate on the extent and severity of the problem
Examine the patient for DH, particularly the buccal (facial) surfaces of the standing teeth using a probe and an air-blast from a dental triple syringe.
A good history of the complaint is important, listen to the patient and examine areas where the dentine is exposed, identify any aetiological and predisposing factors. Listen to the patient; they will give you the diagnosis.
The use of diet sheets will help in identifying potential risk factors in the diet (diet analysis).
Have a basic understanding of the mechanisms associated with dentine hypersensitivity, in particular, the Hydrodynamic Theory and its importance in choosing a suitable OTC/professionally applied product when treating the patient.
Educate the patient, indicating where they can reduce the impact of DH on their QoL, modifying their toothbrush technique, using a less abrasive toothpaste and avoiding consuming acidic food and drinks particularly around the time of brushing.
Encourage the patient to take ownership of their oral health to allow for any behavior changes to reduce the impact of DH on the QoL when undertaking their day-to day activities (Consider the use of Motivational Interviewing).
Remember there is no one treatment or procedure that will resolve all your patient’s problems and that simply providing a toothpaste or in-office procedure alone without correcting or modifying any underlining predisposing features that initiated the problem will not resolve the problem in the long term.
Apply the guidelines outlined in this chapter; in your practice, monitor patients DH within your practice’s recall procedure(s), avoid simply handing out or recommending dental products expecting the problem to resolve, without any further intervention by the clinician.
Use the algorithm (or similar examples; see references) illustrated in this chapter to aid you in the management of DH. It may be that despite all your efforts the patient still has oro-facial pain. The steps outlined in the algorithm will enable you to revisit the diagnosis of DH, which may result in further investigations to determine the cause (reversible/irreversible pulpitis) or a referral to a specialist oral medicine clinic if the problem is of a non-dental origin such as idiopathic facial pain (PIFP).
DH is an enigmatic dental condition that is often discounted or underdiagnosed by clinicians who may fail to appreciate its impact on the QoL of their patients, and therefore, screening for the problem should be included in a clinical examination.
Clinicians should recognize it is a diagnosis of exclusion and all other possible causes of the pain should be ruled out. This will require the clinician to collate the relevant medical, dental, social, and diet history from the patient, which will supplement the clinical examination. It is important for clinicians to acknowledge that the management is not just based on providing or recommending OTC products or in-office therapies and procedures but on the removal or modification of any predisposing feature together with involving the patient to make changes in their own behavior to minimize the impact of DH on their QoL.
The author declares no conflict of interest.
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Badria"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"716",title:"Clinical Use of Local Anesthetics",subtitle:null,isOpenForSubmission:!1,hash:"e8e4b699b914aa5fa2cf49f0ce8c42b9",slug:"clinical-use-of-local-anesthetics",bookSignature:"Asadolah Saadatniaki",coverURL:"https://cdn.intechopen.com/books/images_new/716.jpg",editedByType:"Edited by",editors:[{id:"88079",title:"Associate Prof.",name:"Asadoliah",middleName:null,surname:"Saadatniaki",slug:"asadoliah-saadatniaki",fullName:"Asadoliah Saadatniaki"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:3,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"66259",doi:"10.5772/intechopen.85270",title:"Antioxidant Compounds and Their Antioxidant Mechanism",slug:"antioxidant-compounds-and-their-antioxidant-mechanism",totalDownloads:7599,totalCrossrefCites:58,totalDimensionsCites:152,abstract:"An antioxidant is a substance that at low concentrations delays or prevents oxidation of a substrate. Antioxidant compounds act through several chemical mechanisms: hydrogen atom transfer (HAT), single electron transfer (SET), and the ability to chelate transition metals. The importance of antioxidant mechanisms is to understand the biological meaning of antioxidants, their possible uses, their production by organic synthesis or biotechnological methods, or for the standardization of the determination of antioxidant activity. In general, antioxidant molecules can react either by multiple mechanisms or by a predominant mechanism. The chemical structure of the antioxidant substance allows understanding of the antioxidant reaction mechanism. This chapter reviews the in vitro antioxidant reaction mechanisms of organic compounds polyphenols, carotenoids, and vitamins C against free radicals (FR) and prooxidant compounds under diverse conditions, as well as the most commonly used methods to evaluate the antioxidant activity of these compounds according to the mechanism involved in the reaction with free radicals and the methods of in vitro antioxidant evaluation that are used frequently depending on the reaction mechanism of the antioxidant.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Norma Francenia Santos-Sánchez, Raúl Salas-Coronado, Claudia Villanueva-Cañongo and Beatriz Hernández-Carlos",authors:[{id:"143354",title:"Dr.",name:"Raúl",middleName:null,surname:"Salas-Coronado",slug:"raul-salas-coronado",fullName:"Raúl Salas-Coronado"},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez"},{id:"193718",title:"Dr.",name:"Beatriz",middleName:null,surname:"Hernández-Carlos",slug:"beatriz-hernandez-carlos",fullName:"Beatriz Hernández-Carlos"},{id:"278133",title:"Dr.",name:"Claudia",middleName:null,surname:"Villanueva-Cañongo",slug:"claudia-villanueva-canongo",fullName:"Claudia Villanueva-Cañongo"}]},{id:"65331",doi:"10.5772/intechopen.83731",title:"Flavonoids and Phenolic Acids as Potential Natural Antioxidants",slug:"flavonoids-and-phenolic-acids-as-potential-natural-antioxidants",totalDownloads:2757,totalCrossrefCites:35,totalDimensionsCites:78,abstract:"For centuries, aromatic herbs and spices have been added to different foods to improve the flavor and organoleptic properties. The use of aromatic plants and spices in phytotherapy is mostly related to different activities of their essential oils, such as antimicrobial, spasmolytic, carminative, hepatoprotective, antiviral, and anticarcinogenic activities. Furthermore, many studies point to strong antioxidant activities of aromatic plants and their essential oils. Knowing that phenolic compounds are the most responsible for the antioxidant activity, the amount of total phenolic contents and content of flavonoids have also been determined. In order to examine the antioxidant properties of five different extracts of Laurus nobilis L. leaves, various assays which measure free radical scavenging ability were carried out: 1,1-diphenyl-2-picrylhydrazyl, hydroxyl, superoxide anion, nitric oxide and hydroxyl radical scavenger capacity test, and lipid peroxidation assay. In all of the tests, only the EtOAc extract showed a potent antioxidant effect.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Biljana Kaurinovic and Djendji Vastag",authors:[{id:"142369",title:"Prof.",name:"Biljana",middleName:null,surname:"Kaurinovic",slug:"biljana-kaurinovic",fullName:"Biljana Kaurinovic"},{id:"286918",title:"Prof.",name:"Djendji",middleName:null,surname:"Vastag",slug:"djendji-vastag",fullName:"Djendji Vastag"}]},{id:"65225",doi:"10.5772/intechopen.83544",title:"Antioxidant Categories and Mode of Action",slug:"antioxidant-categories-and-mode-of-action",totalDownloads:2330,totalCrossrefCites:7,totalDimensionsCites:20,abstract:"Oxidative stress has received a considerable scientific attention as a mediator in the etiology of many human diseases. Oxidative stress is the result of an imbalance between free radicals and antioxidants. Cells can be damaged by free radicals that are considered to play a main role in the aging process and diseases development. Antioxidants are the first line of defense against the detrimental effects of free radical damage, and it is essential to maintain optimal health via different mechanisms of action. Types of antioxidants range from those generated endogenously by the body cells, to exogenous agents such as dietary supplements. Antioxidant insufficiency can be developed as a result of decreased antioxidant intake, synthesis of endogenous enzymes, or increased antioxidant utilization. To maintain optimal body function, antioxidant supplementation has become an increasingly popular practice through improving free radical protection. In this chapter, we first elucidate the oxidative stress, and then define the antioxidant and its categories. Finally, introduce the antioxidants mode of actions for cell protection from free radicals.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Manal Azat Aziz, Abdulkareem Shehab Diab and Abeer Abdulrazak Mohammed",authors:[{id:"276717",title:"Associate Prof.",name:"Manal",middleName:null,surname:"Azat Aziz",slug:"manal-azat-aziz",fullName:"Manal Azat Aziz"},{id:"286369",title:"Dr.",name:"Abdulkareem",middleName:null,surname:"Shehab Diab",slug:"abdulkareem-shehab-diab",fullName:"Abdulkareem Shehab Diab"},{id:"312155",title:"Dr.",name:"Abeer Abdulrazak",middleName:null,surname:"Mohammed",slug:"abeer-abdulrazak-mohammed",fullName:"Abeer Abdulrazak Mohammed"}]},{id:"66504",doi:"10.5772/intechopen.85468",title:"Antioxidants as a Double-Edged Sword in the Treatment of Cancer",slug:"antioxidants-as-a-double-edged-sword-in-the-treatment-of-cancer",totalDownloads:1650,totalCrossrefCites:13,totalDimensionsCites:18,abstract:"Antioxidant compounds are thought to prevent and treat diseases, especially cancer, under any circumstances. For this purpose, nature-based antioxidants nowadays are being commonly used to prevent and treat diseases. Indeed, phenolic compounds found in medicinal plants have opened a new horizon to prevent and treat diseases because of having antioxidant properties. However, some recent studies have reported that antioxidants are not absolute anticancer compounds and certain drugs have been reported to reduce levels of reactive oxygen species (ROS) in the cancer cells, i.e., their main action mechanism. It has been argued that increasing levels of ROS cause an increase in apoptosis rate and therefore can be considered an approach to treat fatal and hard-to-treat cancers. This chapter seeks to partly explain the role of ROS in progression or inhibition of cancer growth in addition to the role of antioxidants in preventing and treating this disease.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Majid Asadi-Samani, Najmeh Kaffash Farkhad, Mohammad Reza Mahmoudian-Sani and Hedayatollah Shirzad",authors:[{id:"237542",title:"Dr.",name:"Majid",middleName:null,surname:"Asadi-Samani",slug:"majid-asadi-samani",fullName:"Majid Asadi-Samani"},{id:"275475",title:"Dr.",name:"Mohammad",middleName:null,surname:"Reza Mahmoudian-Sani",slug:"mohammad-reza-mahmoudian-sani",fullName:"Mohammad Reza Mahmoudian-Sani"},{id:"295230",title:"Dr.",name:"Najmeh",middleName:null,surname:"Kafash Farkhad",slug:"najmeh-kafash-farkhad",fullName:"Najmeh Kafash Farkhad"},{id:"295231",title:"Dr.",name:"Hedayatollah",middleName:null,surname:"Shirzad",slug:"hedayatollah-shirzad",fullName:"Hedayatollah Shirzad"}]},{id:"65067",doi:"10.5772/intechopen.82879",title:"Diseases Related to Types of Free Radicals",slug:"diseases-related-to-types-of-free-radicals",totalDownloads:1821,totalCrossrefCites:9,totalDimensionsCites:13,abstract:"The free radicals are reactive molecules with electron-rich groups produced during metabolic reactions occurring in the cells. These free radicals are collectively known as reactive oxygen species (ROS) and reactive nitrogen species (RNS). Lipid peroxidation products and protein carbonyls species are under the group of ROS, and nitric oxide and peroxynitrites are under the group of RNS. The malondialdehyde that reacts with LDL-C indirectly induced the risk of atherosclerosis. The protein carbonyls acts as marker of protein oxidation and exerts damage to proteins. The nitric oxide plays an important role in DNA damage, inflammation, proliferation of cancer cells, and dysfunction of apoptosis. The peroxynitrites could induce the process of lipid peroxidation, DNA damage, and may exert chronic damage to all biomolecules. The aim of the present study is that the free radicals may react with biomolecules of the cells and play an important role in the development of chronic disease conditions in the humans.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Narendra Maddu",authors:[{id:"272889",title:"Dr.",name:"Narendra",middleName:null,surname:"Maddu",slug:"narendra-maddu",fullName:"Narendra Maddu"}]}],mostDownloadedChaptersLast30Days:[{id:"66259",title:"Antioxidant Compounds and Their Antioxidant Mechanism",slug:"antioxidant-compounds-and-their-antioxidant-mechanism",totalDownloads:7587,totalCrossrefCites:58,totalDimensionsCites:152,abstract:"An antioxidant is a substance that at low concentrations delays or prevents oxidation of a substrate. Antioxidant compounds act through several chemical mechanisms: hydrogen atom transfer (HAT), single electron transfer (SET), and the ability to chelate transition metals. The importance of antioxidant mechanisms is to understand the biological meaning of antioxidants, their possible uses, their production by organic synthesis or biotechnological methods, or for the standardization of the determination of antioxidant activity. In general, antioxidant molecules can react either by multiple mechanisms or by a predominant mechanism. The chemical structure of the antioxidant substance allows understanding of the antioxidant reaction mechanism. This chapter reviews the in vitro antioxidant reaction mechanisms of organic compounds polyphenols, carotenoids, and vitamins C against free radicals (FR) and prooxidant compounds under diverse conditions, as well as the most commonly used methods to evaluate the antioxidant activity of these compounds according to the mechanism involved in the reaction with free radicals and the methods of in vitro antioxidant evaluation that are used frequently depending on the reaction mechanism of the antioxidant.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Norma Francenia Santos-Sánchez, Raúl Salas-Coronado, Claudia Villanueva-Cañongo and Beatriz Hernández-Carlos",authors:[{id:"143354",title:"Dr.",name:"Raúl",middleName:null,surname:"Salas-Coronado",slug:"raul-salas-coronado",fullName:"Raúl Salas-Coronado"},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez"},{id:"193718",title:"Dr.",name:"Beatriz",middleName:null,surname:"Hernández-Carlos",slug:"beatriz-hernandez-carlos",fullName:"Beatriz Hernández-Carlos"},{id:"278133",title:"Dr.",name:"Claudia",middleName:null,surname:"Villanueva-Cañongo",slug:"claudia-villanueva-canongo",fullName:"Claudia Villanueva-Cañongo"}]},{id:"65225",title:"Antioxidant Categories and Mode of Action",slug:"antioxidant-categories-and-mode-of-action",totalDownloads:2329,totalCrossrefCites:7,totalDimensionsCites:20,abstract:"Oxidative stress has received a considerable scientific attention as a mediator in the etiology of many human diseases. Oxidative stress is the result of an imbalance between free radicals and antioxidants. Cells can be damaged by free radicals that are considered to play a main role in the aging process and diseases development. Antioxidants are the first line of defense against the detrimental effects of free radical damage, and it is essential to maintain optimal health via different mechanisms of action. Types of antioxidants range from those generated endogenously by the body cells, to exogenous agents such as dietary supplements. Antioxidant insufficiency can be developed as a result of decreased antioxidant intake, synthesis of endogenous enzymes, or increased antioxidant utilization. To maintain optimal body function, antioxidant supplementation has become an increasingly popular practice through improving free radical protection. In this chapter, we first elucidate the oxidative stress, and then define the antioxidant and its categories. Finally, introduce the antioxidants mode of actions for cell protection from free radicals.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Manal Azat Aziz, Abdulkareem Shehab Diab and Abeer Abdulrazak Mohammed",authors:[{id:"276717",title:"Associate Prof.",name:"Manal",middleName:null,surname:"Azat Aziz",slug:"manal-azat-aziz",fullName:"Manal Azat Aziz"},{id:"286369",title:"Dr.",name:"Abdulkareem",middleName:null,surname:"Shehab Diab",slug:"abdulkareem-shehab-diab",fullName:"Abdulkareem Shehab Diab"},{id:"312155",title:"Dr.",name:"Abeer Abdulrazak",middleName:null,surname:"Mohammed",slug:"abeer-abdulrazak-mohammed",fullName:"Abeer Abdulrazak Mohammed"}]},{id:"62579",title:"Where and How in the mTOR Pathway Inhibitors Fight Aging: Rapamycin, Resveratrol, and Metformin",slug:"where-and-how-in-the-mtor-pathway-inhibitors-fight-aging-rapamycin-resveratrol-and-metformin",totalDownloads:2663,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"The molecular mechanisms underlying the quality and quantity of life extension appear to sometimes be orthogonal. For example, while resveratrol has continued to prove beneficial in reducing obesity, it has had less efficacy in extending lifespan. On the other hand, rapamycin and the chemically similar rapalogs extend lifespan across genera of life from yeast, to nematodes, to mice. Caloric restriction (CR) and bioavailable small molecules, which mimic a fasted state, upregulate autophagy, catabolism of fats over anabolism of carbohydrates, and decrease oxidative stress and inflammation. CR mimics are currently being investigated to elucidate the best dosage, route of administration, timing in life, where best to inhibit in the mTOR pathway, and effects of long-term use on mTORC1 verse mTORC2 complexes. Comparisons between rapamycin, resveratrol, and metformin targets, downstream pathway effects, dosage, and clinical trials will be discussed.",book:{id:"7258",slug:"resveratrol-adding-life-to-years-not-adding-years-to-life",title:"Resveratrol",fullTitle:"Resveratrol - Adding Life to Years, Not Adding Years to Life"},signatures:"Sage Arbor",authors:[{id:"245319",title:"Ph.D.",name:"Sage",middleName:null,surname:"Arbor",slug:"sage-arbor",fullName:"Sage Arbor"}]},{id:"65331",title:"Flavonoids and Phenolic Acids as Potential Natural Antioxidants",slug:"flavonoids-and-phenolic-acids-as-potential-natural-antioxidants",totalDownloads:2755,totalCrossrefCites:35,totalDimensionsCites:78,abstract:"For centuries, aromatic herbs and spices have been added to different foods to improve the flavor and organoleptic properties. The use of aromatic plants and spices in phytotherapy is mostly related to different activities of their essential oils, such as antimicrobial, spasmolytic, carminative, hepatoprotective, antiviral, and anticarcinogenic activities. Furthermore, many studies point to strong antioxidant activities of aromatic plants and their essential oils. Knowing that phenolic compounds are the most responsible for the antioxidant activity, the amount of total phenolic contents and content of flavonoids have also been determined. In order to examine the antioxidant properties of five different extracts of Laurus nobilis L. leaves, various assays which measure free radical scavenging ability were carried out: 1,1-diphenyl-2-picrylhydrazyl, hydroxyl, superoxide anion, nitric oxide and hydroxyl radical scavenger capacity test, and lipid peroxidation assay. In all of the tests, only the EtOAc extract showed a potent antioxidant effect.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Biljana Kaurinovic and Djendji Vastag",authors:[{id:"142369",title:"Prof.",name:"Biljana",middleName:null,surname:"Kaurinovic",slug:"biljana-kaurinovic",fullName:"Biljana Kaurinovic"},{id:"286918",title:"Prof.",name:"Djendji",middleName:null,surname:"Vastag",slug:"djendji-vastag",fullName:"Djendji Vastag"}]},{id:"66161",title:"Antioxidants: Natural Antibiotics",slug:"antioxidants-natural-antibiotics",totalDownloads:1607,totalCrossrefCites:5,totalDimensionsCites:8,abstract:"The aim of this current piece of writing is to draw the attention of readers and researchers toward the natural antioxidants that can take the place of synthetic antibiotics to avoid bacterial resistance and gastrotoxicity/nephrotoxicity. Antioxidants such as polyphenols, vitamins, and carotenoids are the organic compounds mainly extracted from natural sources and dominantly involved in boosting the defense system of organisms. The main public health-related issue over the globe is ever-growing bacterial resistance to synthetic antibiotics, which is being continuously reported during the last decade. Further, the pipeline of the development of new synthetic antibacterial agents to replace the resistant antibiotics in clinical set-up is gradually drying up. This scenario originated the concept to revive the interest toward natural antibacterial products due to their chemical diversity, which provide important therapeutic effect and make the microbes unable to copy them for creating resistance. Natural products, especially polyphenols had been seen in antioxidant, antibacterial, anticancer, anti-inflammation, and antiviral activities with encouraging results. In this chapter, we will focus over the role of natural antioxidants as antibacterial agents.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Syed Ali Raza Naqvi, Sana Nadeem, Sana Komal, Syed Ali Asad Naqvi, Muhammad Samee Mubarik, Sajid Yaqub Qureshi, Shahzad Ahmad, Ali Abbas, Muhammad Zahid, Naeem-Ul-Haq Khan, Syed Shujat Raza and Nosheen Aslam",authors:[{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi"},{id:"287649",title:"Ms.",name:"Sana",middleName:null,surname:"Nadeem",slug:"sana-nadeem",fullName:"Sana Nadeem"},{id:"287650",title:"Ms.",name:"Sana",middleName:null,surname:"Komal",slug:"sana-komal",fullName:"Sana Komal"},{id:"287652",title:"Dr.",name:"Muhammad Samee",middleName:null,surname:"Mubarik",slug:"muhammad-samee-mubarik",fullName:"Muhammad Samee 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