Reported adverse events in studies involving TMS use in Parkinson’s disease patients.
\r\n\tApplied and basic studies - Field studies and lab assays of fungicides can be discussed. We also look for examples of application methods, which may include timing of application, tools for application, fungicide compatibility, phytotoxicity, etc. Field trials have to have at least two years of data;
\r\n\tAdaptation of Integrated Plant Disease Management - How the IPM practice has been adapted in the field. Application of disease risk models, or use of fungicide application aids, which can be hardware or software. The introduction of a new tool for growers can also be included;
\r\n\tNovel fungicides - In addition to the traditional chemical approach, alternative materials (enzymes, oils, extracts, etc.), biological control agents, or plant defense activators can be discussed;
\r\n\tAdaptation of new technologies - Examples will be the use of unmanned vehicles, sensor technologies, advanced sprayers, or disease forecast systems for precision agriculture;
\r\n\tFungicide resistance - Unfortunately, we cannot ignore the fact that fungicide-resistant strains are widespread. Documentation of fungicide-resistant strains, the introduction of new technologies and methods can be discussed.
Parkinson’s disease (PD) affects as many as 1.5 million people in the United States, with about 60,000 additional patients newly diagnosed each year. PD is a chronic, progressive syndrome in which a large number of dopaminergic neurons located within the basal ganglia circuitry degenerate. This dopamine depletion contributes to clinical motor symptomatology, including bradykinesia, tremor, rigidity, postural instability and gait dysfunction. Despite currently available treatments, PD symptoms progress along with cortical dysfunction, leading to cumulative disability. The pharmacotherapy of PD is based on the restoration of dopamine levels through the administration of its precursor, levodopa (L-DOPA). Less powerful therapeutic strategies involve the direct stimulation of post-synaptic dopaminergic receptors through dopamine-agonist compounds or the inhibition of dopamine breakdown through catabolic inhibitors. A good control of symptoms is commonly obtained, leading to a good functional recovery, as well as to a general betterment of quality of life. Nonetheless, the results are maintained for a limited period, and, after a few years, certain complications related to the medication may arise, thus limiting the tolerability and the effectiveness of the treatment. At this point, doses are often limited by side-effects such as drowsiness, orthostasis, nausea, confusion, hallucinations, and the emergence of motor complications like fluctuations and dyskinesias. Furthermore, some symptoms known to be poorly responsive to available medications, such as freezing of gait, balance impairment and postural abnormalities, tend to emerge as the disease progresses. In the last decade, different therapeutic strategies have been developed in the effort to address the advanced stage of the disease, typically characterized by a progressive functional decline and decrease in quality of life with an unsatisfactory response to conventional pharmacological treatments. These “advanced strategies” show a variable profile of effectiveness and invasiveness. A recently introduced therapy is the duodenal administration of a gel formulation of L-DOPA (Duodopa), which is continuously released though a duodenal tube connected to a portable pump through a percutaneous endoscopic gastrostomy. This device permits a continuous delivery of the drug, with a stable kinetics, resulting in a significant reduction of the OFF-time and a marked simplification of the oral therapy. There are also more invasive surgical options that could offer symptomatic benefits. Deep brain stimulation (DBS) is the most commonly performed surgical treatment for Parkinson’s, but it is not recommended for all patients. DBS has been demonstrated to be effective in remodulating the pathological activity of the basal ganglia motor circuit by acting on specific nuclei, including the subthalamic nucleus, the
NIBS is an area of rapid growth in neuroscience. The term “non-invasive brain stimulation” encompasses different modalities of intervention involving the administration of energy to modify the bioelectrical state of neuronal cells and influence brain regional activity. There is some controversy surrounding the name; some have suggested that the term “non-invasive” misrepresents both the possibility of side effects from the stimulation, and the longer-term effects (both adverse and desirable) that may result from brain stimulation [1]. The “non-invasive” denomination, as used in this review, is derived from the fact that the intervention does not require the insertion of instruments through the skin or into a body cavity.
The different sub-modalities of NIBS are named based upon how energy is physically delivered to the brain. In transcranial magnetic stimulation (TMS), transient rapid changing magnetic fields are utilized to induce secondary electric currents in the underlying cortical surface, which, in turn, trigger neuronal action potentials [2]. By contrast, in transcranial electric stimulation (tES), a weak electrical current is directly applied to the scalp to modulate neuronal membrane potentials without directly inducing synchronized neuronal discharge [3]. These different modalities of NIBS have shown a clear capacity to modify cortical excitability and potentially harness neuroplasticity for therapeutic applications, and they will be revised separately. The substantially safe, reproducible and non-invasive nature of NIBS makes these techniques of appealing interest for the study and treatment of various neurological and psychiatric disorders including PD. NIBS has proven efficacy in depression and chronic pain. NIBS in Parkinson’s disease have led to numerous publications and variable results that we intend to summarize and review with a focus in research clinical trials (RCT). The chapter will be a narrative review describing the latest advancements in utilizing transcranial magnetic stimulation (TMS) and transcranial electric stimulation (tES). The proposed mechanisms of neuromodulation, its safety, therapeutic results and challenges will also be reviewed.
The biological effects of NIBS are essentially determined by two types of factors: extrinsic (related to the intervention) and intrinsic (related to the stimulated subject). On one hand, extrinsic factors are related to the amount of energy and to the pattern of current flow delivered to the brain. These include specific parameters that can be actively controlled by the operator, such as current intensity, stimulation frequency, number of pulses, number of sessions, coil design, electrode montage, etc. However, for the same dose of energy delivered, different intrinsic factors inherent to the stimulated subject contribute to the individual’s biological outcome. For instance, the subject’s pharmacological profile can affect the brain’s activation state and connectivity by modulating neuronal propensity to fire and undergo plastic phenomena. In patients with Parkinson’s disease (PD), this is particularly noteworthy, as changes in cortical excitability and neuroplasticity are critically influenced by dopamine bioavailability, and the institution of a dopaminergic therapy can influence the subsequent neurophysiologic and behavioral effects of stimulation [4].
TMS is a focal modality of NIBS where an intermittent, high intensity, electrical current of brief duration is generated through a capacitor to induce transient magnetic fields spreading from the coil to the underlying surface. TMS has an FDA cleared indication for the treatment of medication refractory depression. As described by Michael Faraday’s electromagnetic principle, the temporal variation of such magnetic fields—namely their exchange rate—is associated with the induction of secondary electrical currents. These currents are capable of triggering neuronal action potentials; the volume of the stimulated area roughly falls into that of a golf ball, and the transfer of energy is maximal with parallel orientation of conductors. Due to the anatomical structure of the cortical layers, most of the neurons whose firing can be manipulated through TMS are parallel to the scalp and, as such, are mainly represented by interneurons. These cells can trans-synaptically modify the activity of interconnected pyramidal cells through indirect descendent volleys known as “I-waves” [5]. Descending volleys originating from the motor cortex (M1) can be recorded with electrodes from the peripheral muscle and the recordings are regarded as motor evoked potentials (MEPs). When TMS is delivered repetitively in trains of sufficient intensity and duration (e.g. 10–30 minutes), it is able to exert modulatory effects as evidenced by changes in MEPs amplitude, with an effect that outlasts each stimulation train. Therefore, the neurophysiological effects of trains of repetitive TMS (rTMS) can be quantified in light of some indirect neurophysiologic parameters, which are regarded as markers of cortical excitability. In healthy subjects, different stimulation frequencies are associated with opposite changes in local cortical excitability. More specifically, repetitive TMS (rTMS) at a frequency of one pulse/second (1 Hz) is associated with “inhibition-like” effects over the stimulated area, while higher frequencies of five or more Hz are associated with “excitatory-like” phenomena [6]. Newer TMS paradigms have been developed that are able to modify cortical excitability in significantly less time (20–190 seconds) [7]. Of those, one of the most popular is the theta burst stimulation, where high frequency pulses (3 pulses at 50 Hz) are applied repeatedly at intervals of 200 ms, delivered as a continuous (cTBS) or intermittent (iTBS) train. The former protocol is characterized as being “inhibitory” and the latter being “excitatory,” according to the changes produced in MEPs size (Figure 1). This is admittedly an oversimplification, as there is a wide heterogeneity of response between subjects. The final biological effect of TMS is determined by the vector summation of all changes in the excitability of cortical interneurons, the status of the neurons prior to stimulation, the intrinsic properties and geometrical orientation of fibers within the cortical region, pharmacotherapy interactions, etc.
Illustration of motor evoked potential (MEP) changes induced by different types of NIBS over motor cortex. Blue colored arrow (left side) represents inhibitory and red colored arrow (right side) excitatory effects on MEPs.
While a single session of TMS induces rather short-term effects (minutes up to hours) [9], the application of rTMS over time (several days/weeks) generates significantly longer lasting biological outcomes (in the order of weeks or a few months) [10]. The evidence of clinical changes that persist well beyond the time of stimulation is the foundations of therapeutic and rehabilitative perspectives. Two types of TMS-induced effects are essentially recognized: short-term and medium-term. Although the molecular mechanisms underlying these changes are not yet conclusive, several theories have been postulated. Short-term effects appear to be related to immediate changes in neuronal ionic conductivity induced by electrolysis phenomena resulting from propagating electromagnetic currents [11]. An additional proposed mechanism behind short-term effects is the release of neurotransmitters. It has been demonstrated that high-frequency rTMS applied over the left dorsolateral prefrontal cortex is associated with a tonic release of dopamine in the ipsilateral caudate and orbitofrontal cortex [12]. Meanwhile, medium-term effects of TMS are believed to be mediated by neuroplastic phenomena. The term “neuroplasticity” defines the ability of the CNS to respond to a broad spectrum of extrinsic and intrinsic stimuli through a functional, dynamic reorganization of its structures and connections. The epicenter of neuroplastic phenomena is the synapse. Increased synaptic strength, synaptogenesis and enhanced selectivity in the recruitment of neural pathways are some of the main mechanisms involved in neuroplasticity (Figure 2). It is believed that TMS can harness plastic phenomena by modulating long-term potentiation (LTP) and long-term depression (LTD) like phenomena. The molecular bases of such phenomena are likely to be found in the activation of the postsynaptic N-methyl-D-aspartate (NMDA) receptor [2, 8]. The calcium-mediated signal moderated by this receptor involves the activation of a complex subcellular pathway leading to downstream changes in protein synthesis and, consequently, to functional and structural changes in synaptic efficiency.
Schematic representation of the cascades of events involved in long-term potentiation (LTP) and depression (LTD). Reproduced with permission from Udupa and Chen [
Finally, changes in gene expression of neurotrophic molecules as well as increased neurotrophic signaling are considered to be involved in the induction of more sustained effects of TMS. The knowledge concerning these effects at the molecular and cellular level is still very limited. Brain-derived neurotrophic factor (BDNF) is a member of the neurotrophic family that has been demonstrated to exert neurotrophic and neuroprotective effects both
Transcranial electric stimulation (tES) includes different NIBS techniques increasingly used for modulation of CNS excitability in humans. The principal mechanism of action of tES is a subthreshold modulation of neuronal membrane potentials, which alters cortical excitability depending on the current flow direction through the target neurons [15]. For these reasons, tES techniques are more properly regarded as “neuromodulation” techniques, as, instead of inducing an activity in resting neuronal networks, they modulate spontaneous neuronal activity depending on the previous physiological state of target cells. Among different tES techniques, transcranial direct current stimulation (tDCS) is the best characterized and most widely used in both clinical and research settings. tDCS involves the application of a low amplitude direct current (DC) via surface electrodes on the head for a predetermined time in a painless, safe manner (Figure 3) [3]. tDCS offers many advantages over other NIBS devices due to a favorable non-invasive, safe profile, portability, tolerability, and cost effectiveness. Several studies have shown that tDCS modulates cortical excitability in the human motor [16, 17] and visual cortex [18]. Studies in young-adult, healthy controls showed that 13 minutes of motor cortex tDCS modifies the amplitude of motor evoked potential (MEP) for the subsequent 90 minutes [16]. Furthermore, pharmacological blocking of N-methyl-D-aspartate (NMDA) receptors prevents long lasting effects of tDCS on cortical excitability, suggesting tDCS may recruit NMDA receptor-dependent plasticity. However, in animal models of tDCS, stimulation intensities comparable to those modeled in humans are not directly associated to LTP phenomena [19]. It is believed that tDCS alone produce only a subliminal neural hyperpolarization (under the cathode) or depolarization (under the anode), reducing/increasing in turns the responsiveness of the target neurons to the on-going afferent brain activity. Importantly, when combined with a second input, tDCS could results in powerful induction of LTP or LTD like phenomena. The mechanisms underlying this potential synergistic effect are not fully known, but they may rely on associative plasticity. It is known that task-specific training can induce task-specific neuronal changes based on use-dependent plasticity phenomena [20]. Therefore, the combination of behavioral tasks and tDCS may offer significant chances to achieve neuroplastic changes. The task-dependency of tDCS may influence the inter-individual variability of behavioral or neurophysiologic outcome observed after stimulation [21].
Example of transcranial direct current stimulator (tDCS) setup; mini-clinical trials (mini-CT) Unit, Soterix Medical©.
Many strategies are currently under investigation with the aim of boosting neurorehabilitation: NIBS, motor learning theories, behavioral interventions, robot-assisted rehabilitation, pharmacological agents, and neural engineering. It is likely that the optimal combination of these different approaches shall modify the science of neurorehabilitation in the future.
Since there are several methodological and technological differences between the different NIBS types, the tolerability, adverse effects and safety are addressed separately.
Different side effects resulting from the application of TMS have been reported in the literature. The international safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research [6] have listed them according to their respective frequency. Common side effects include transient headache, local pain, neck pain, toothache, and paresthesia. Pain duration is usually limited, lasting up to few hours after the session, and it can be commonly relieved with acetaminophen or other over-the-counter medications. Less common adverse effects include transient hearing changes, transient cognitive/neuropsychological changes, syncope (as epiphenomenon and not related to a direct brain effect), and transient acute hypomania (after left prefrontal rTMS). Rare adverse effects reported include changes in blood levels of thyroid stimulating hormone and lactate, and seizures. Seizure activity has been reported mostly with high-frequency (HF) rTMS. TMS-induced seizures are self-limited and are not reported to have permanent sequelae. High frequency TMS has 1.4% crude risk estimate of inducing seizures in epileptic patients and less than 1% in non-epileptic subjects [22]. There is a theoretical risk of inducing currents in electrical circuits when TMS is delivered in close proximity of electric devices (e.g., pace-makers, brain stimulators, pumps, intra-cardiac lines, cochlear implants) which can cause malfunction of these devices.
From 211 studies published in PubMed regarding the use of TMS in Parkinson’s disease patients from 1993 to October 2017, the most common adverse events (AEs) were scalp pain and headache. Most of these happened during high frequency rTMS sessions. Other less commonly reported AEs in PD include neck pain, tinnitus, and facial twitching. One study reported subclinical worsening of complex and preparatory movement as measured by spiral drawing impairment in patients after rTMS and worsening of resting tremor in one patient [41]. Rare AEs possibly related to TMS reported were transient fatigue, mild transient visual hallucinations, and transient hypotension [28]. One study reported a subject who experienced worsening in pre-existing lower back pain (Table 1) [37]. In our neurostimulation lab, we had one report of mild transient low mood [23] and one serious AE represented by an ischemic stroke. The ischemic stroke event was due to carotid disease (atherosclerosis) and was deemed unrelated to the study, though [26]. As an important note, to date, there are no reports of seizures induced by TMS among Parkinson’s disease patients.
Study | TMS parameters | N | Adverse events (AEs) |
---|---|---|---|
ExerTMS (2017) [23] | HF rTMS | 8 | Scalp pain (n = 2), neck pain (n = 2), low mood (n = 1) |
LocoTMS (2017) [24] | HF rTMS | 5 | Neck pain (n = 1) |
Chang et al. (2017) [25] | HF rTMS ± tDCS | 32 | Headache (n = 1) |
Brys et al. (2016) [26] | HF rTMS | 61 | Headache and neck pain (n = 34), ischemic stroke (n = 1) |
Shin et al. (2016) [27] | HF rTMS | 18 | Facial twitch (n = 1), headache (n = 1) |
Cohen et al. (2016) [28] | HF rDTMS | 19 | Scalp discomfort (n = 9), transient fatigue (n = 3), transient visual hallucinations (n = 1) |
Spagnolo et al. (2014) [29] | HF rDTMS | 27 | Transient hypotension (n = 1), headache (n = 1), mild dyskinesia affecting only with LID (n = 4) |
Shirota et al. (2013) [30] | LF rTMS | 106 | Tinnitus (n = 1), headache (n = 1) |
Murdoch et al. (2012) [31] | HF rTMS | 20 | Headache (n = 2) |
Benninger et al. (2011) [32] | iTBS | 13 | Transient tinnitus (n = 1), local scalp pain (n =?) |
Pal et al. (2010) [33] | HF rTMS | 12 | Headache (n = 2) |
Benninger et al. (2009) [34] | spTMS | 10 | Ipsilateral CN VII stimulation |
Rothkegel et al. (2009) [35] | LF/HF rTMS | 22 | Headache (n = 2), nausea(n = 1) |
Cardoso et al. (2008) [36] | HF rTMS | 11 | Headache (n =?) |
Hamada et al. (2008) [37] | HF rTMS | 55 | Increased lower back pain (n = 1) |
Khedr et al. (2006) [38] | HF rTMS | 55 | Headache (n =?) |
Lomarev et al. (2006) [39] | HF rTMS | 18 | Intolerable scalp pain (n = 1) |
Dragasevic et al. (2002) [40] | LF rTMS | 10 | Burning sensation in the scalp(n = 4), headache(n = 3) |
Boylan et al. (2001) [41] | spTMS HF rTMS | 10 | Worsening of tremor (n = 1), scalp discomfort(n = 3), subclinical worsening of complex and preparatory movement (n = 5) |
Reported adverse events in studies involving TMS use in Parkinson’s disease patients.
HF: high frequency; iTBS: intermittent theta burst stimulation; LF: low frequency; LID: levodopa induced dyskinesia; rDTMS: repetitive deep TMS; spTMS: single pulse TMS; rTMS: repetitive TMS; tDCS: transcranial direct current stimulation.
This technique utilizes deep TMS coils (called H-coils), which, due to a much slower decay of the electric field as a function of distance, allows for the stimulation of deeper brain regions. One study of deep rTMS [29] found that mild transient dyskinesias following stimulation to be a relatively frequent side-effect (15% of PD patients in that study). Dyskinesias happened while the patients were OFF-medication and only in patients suffering from levodopa-induced dyskinesias (LID) prior to the stimulation. The same study also reported headache and one case of transient hypotension [29]. In another study, common effects reported included scalp discomfort and transient fatigue, with one episode of mild visual hallucinations [28].
To date, 19 studies have applied different patterned theta burst TMS to patients with PD. Among these studies, there is only one report of transient tinnitus (<5 minutes) and local pain during stimulation [32]. Overall, these findings seem to indicate that TBS does not carry additional risks with respect to conventional TMS protocols in PD.
Both high frequency and low frequency rTMS preconditioned by tDCS have been used in PD. From these studies [25, 42, 43], only one occurrence of mild headache has been reported [25].
Eighteen studies have been conducted in DBS-implanted PD patients with no reported AEs. Of note, electroconvulsive therapy, which uses much higher current than TMS, has also been performed in DBS patients without adverse effects. There is currently no evidence supporting the risk of heating or displacing DBS leads, but TMS has demonstrated induction of secondary currents in a DBS wire if closely applied to it [44, 45]. The main factors in determining the risk of inducing eddy currents in the DBS device seem to be the distance between the TMS coil and the DBS lead, as well as the number of loops of the wire over the DBS lead [46, 47]. Additional safety studies should be conducted to evaluate the magnitude of induced voltages and induced currents generated by TMS in implanted stimulator systems like DBS and cortical stimulation with epidural electrodes. According to current international safety guidelines [6], TMS should only be done in patients with implanted stimulators if there are scientifically or medically compelling reasons justifying it.
Rossi and colleagues seminal paper in 2009 had shown safety consideration with HF rTMS only up to 25 Hz [6]. Benninger et al. performed 50 Hz sub-threshold rTMS over the motor cortex for up to 2 seconds in 10 PD patients with only one withdrawal due to uncomfortable facial muscle stimulation [34]. A second study was then carried out with 6-second train duration where 13 PD participants received 50 Hz rTMS. No AEs and no EMG/EEG pathological increases of cortical excitability or epileptic activity were reported [48].
The protocol of stimulation (therapeutic or experimental) constitutes a critical determinant of safety, as well as the inclusion/exclusion criteria and protocol technical execution. Bikson et al. reported that from aggregated data of 33,000 sessions over 1000 subjects receiving repeated tDCS sessions, no evidence for irreversible brain injury was produced by conventional tDCS protocols within a wide range of stimulation parameters (≤40 minutes, ≤4 mA, ≤7.2 Coulombs). This includes a wide variety of subjects, including persons from potentially vulnerable populations [49]. In contrast to TMS, tDCS does not trigger neuronal depolarization; this might account for the unlikelihood of tDCS causing seizures. Although one seizure was reported in an epileptic, 4-year-old boy with cerebral palsy while receiving tDCS [50], this has been, to date, the only possibly tDCS-associated seizure reported. Other plausible causes of his seizure, such as reduced antiepileptic medication at the time and possible interactions with serotonergic medication, were considered.
Commonly reported AEs appear to be of mild intensity and transient duration. In their meta-analysis, Brunoni and colleagues characterized the incidence of AEs in 209 studies published from 1998 until August 2010 [51]. Of these 209 studies, 117 were compared for active tDCS vs. 82 sham tDCS studies and showed side effects of tingling (22 vs. 18%), headache (15 vs. 16.2%), burning sensation (9 vs. 10%), itching (39 vs. 33%), and discomfort (10 vs. 13%) [51]. Results suggested that some AEs, such as itching and tingling, were more frequent in the tDCS active group, although this was not statistically significant. The authors disclosed a selective reporting bias for reporting, assessing, and publishing AEs of tDCS that hinders further conclusions. The authors raised awareness of the need to improve systematic reporting of tDCS-related AEs.
The local effects of tDCS on the skin are not believed to be necessarily linked to the hazards involving the underlying brain tissue. Several causative factors for skin lesions have been proposed, including electrode position (the front side of scalp due to curvature and lack of hair), skin conditions, allergic predisposition, skin preparations, high skin impedances, high electrical currents, duration of stimulation, repeated sessions, small electrodes (high current density), electrode shape, dry electrodes, inadequate fixation of electrodes, non-uniform contact pressure of electrodes to skin, extensive skin heating, solution salinity of electrode sponges, sponge shape, and deterioration of the sponges [52]. Other notable, non-skin AEs that have been reported are nausea, dizziness, and sleepiness [53, 54]. Several studies conducting tDCS over DLPFC reported hypomania or mania in unipolar and bipolar depression treatment trials, but these AEs cannot be fully attributed to tDCS [55, 56, 57]. The risk of hypomania or mania in depressed subjects receiving tDCS might not be generalizable to a different population or different brain location; however, it could be a risk if a study does not exclude depressed participants.
Recent trials have developed tDCS as a ‘telemedicine protocol.’ This paradigm utilizes computer videoconferencing for real-time monitoring between the study subject and a study technician [58]. This innovative approach is intended to increase compliance and facilitate research participation by allowing patients to receive therapy in the comfort of their homes. While traveling to clinic or research labs for a tDCS session can present an obstacle to subjects and their caregivers, with modified devices and headgear, tDCS can be administered remotely under clinical supervision, potentially enhancing recruitment due to convenience, while still maintaining clinical trial and safety standards [59]. Perhaps the most promising and tested paradigm is remotely supervised tDCS (RS-tDCS). RS-tDCS has been proven to be safe, feasible, and acceptable for patients with multiple sclerosis [60, 61, 62].
Current published studies utilizing tDCS in PD patients have shown mostly mild and expected adverse events [63], with only one reported event of skin burn (similar to first degree burn) [63]. The skin burn was deemed due to mal-positioned electrodes and resolved without sequela in 3 days. There is no specific provision or precautions for tDCS in PD. However, as previously pointed out by Brunoni et al., as almost half of studies do not report presence/absence of AEs, it is indispensable that clinical research document and report AEs in an active, systematic fashion in order to guarantee that tDCS is indeed a safe technique [51]. Our neurostimulation lab is currently conducting clinical trials with RS-tDCS for PD. Our experience has been very positive with regard to feasibility, safety, and acceptability of RS-tDCS in PD [64, 65]. Further trials of RS-tDCS need to be conducted to corroborate the feasibility and safety of remote videoconferencing tDCS sessions. At-home, tele-monitored tDCS therapy (e.g., RS-tDCS) could become crucial to ease the development of multicenter initiatives with longer period of stimulation and minimizing participant’s burden.
In summary, the safety and tolerability of tDCS can be maximized by following standard procedures, defining optimal stimulation parameters, and following good clinical and good research practice implying adequately trained personnel, constant checking of stimulation settings, careful selection of subjects, prompt and systematic reporting of AEs, and regular supervision of tDCS equipment. The international safety guidelines for tDCS neuromodulation [19] emphasizes the importance of adequately trained personnel in delivering the stimulation and overseeing all related procedures (i.e., for RS-tDCS). Overall, tDCS is a generally safe technique when used within standardized protocols in a research or clinical setting. However, generalization of safety beyond these settings into different clinical contexts or do-it-yourself (DIY) should be avoided [66]. RS-tDCS standardized framework for safety, tolerability, and reproducibility, once established, will allow for translation of tDCS clinical trials to a greater size and range of patient populations.
There has been cumulative evidence supporting beneficial effects of TMS and tDCS in PD. However, several limitations have obscured the evidence-based generalizability of these results. Main limitations are wide methodological heterogeneity in study designs (outcomes, eligibility criteria, intervention parameters, brain targets, etc.) and exploratory designs with small sample sizes in the majority of the studies. As TMS research is significantly more advanced in terms of number of studies and Class I multicenter initiatives, TMS and tDCS therapeutic evidence will be revised separately.
Several systematic reviews and meta-analyses support the positive therapeutic effect of TMS in PD [67, 68]. The wide use of the Unified Parkinson’s Disease Rating Scale (UPDRS) across most studies enabled results to be compared through meta-analysis [67, 69]. UPDRS is likely the most widely used assessment for PD and combines elements of four scales to produce a comprehensive and flexible tool to monitor the course of Parkinson’s and the degree of disability. The cumulative score will range from 0 (no disability) to 199 (total disability). Motor UPDRS (part III) is usually administered by a healthcare professional and scores the motor performance in a series of items, including rigidity, bradykinesia, and tremor. UPDRS part II, on the other hand, is a self-evaluation of activities of daily living “during the last week.” It is important to point out that the beneficial TMS effects are mostly seen in motor scores in the UPDRS part III; as such, this might question the overall functional relevance and impact in quality-of-life. The average improvement of motor UPDRS sub-score in these clinical trials ranged from −2.7 to −6.4 points and mainly reflected improvements in bradykinesia and rigidity. The minimal clinically important change of motor UPDRS sub-score has been proposed to be between 5 and 6 points [70, 71].
Chou and colleagues conducted subgroup analysis of clinical trials and showed that the effect sizes estimated from high-frequency rTMS targeting the primary motor cortex (SMD, 0.77; 95% CI, 0.46–1.08; P < .001) and low-frequency rTMS applied over other frontal regions (SMD, 0.50; 95% CI, 0.13–0.87; P = .008) were significant. The effect sizes obtained from the other 2 combinations of rTMS frequency and rTMS site (i.e., high-frequency rTMS at other frontal regions: SMD, 0.23; 95% CI, −0.02 to 0.48, and low primary motor cortex: SMD, 0.28; 95% CI, −0.23 to 0.78) were not significant. Meta-regression revealed that a greater number of pulses per session or across sessions are associated with larger rTMS effects [69].
The two more recent multicenter randomized clinical trials of TMS for PD were not included in the referenced reviews. Shirota et al. [30] explored the efficacy and stimulation frequency effect of rTMS over the supplementary motor area (SMA) in PD. Results showed a decrease (improvement) of 6.84 points in the UPDRS part III in the 1 Hz group at the last follow up (12 weeks post-intervention). Sham stimulation and 10 Hz rTMS improved motor symptoms transiently, but their effects disappeared in the observation period. The magnitude of improvement is similar to prior HF rTMS studies; however, it was only significant at the last follow up. Interestingly, the preliminary results of a prior trial from the same group showed that HF rTMS was significantly better than LF over SMA [37]. A final interesting observation is that rTMS was applied once weekly for 8 weeks rather than daily session. These findings have not been replicated yet.
The latest large multicenter clinical trial was published in 2016 by Brys et al. [26]; the study innovated “multifocal stimulation” in PD patients suffering from comorbid depression. It compared motor cortex stimulation with dorsolateral pre-frontal cortex (DLPFC) stimulation, both alone and in combination. The results provided Class I evidence of motor beneficial effects of HF rTMS over motor cortex, but failed to prove synergistic effects when combined with DLPFC. The magnitude of the improvement (−4.9 points in the UPDRS-III), was close to a minimal clinically important change on the UPDRS-III [71] but slightly below that found in meta-analyses (−6.4 and −6.3 points) [69, 72]. It is worth mentioning that the effects were only significant at 1-month follow up and not significant in the following observations at three and 6 months distance respectively. These extended follow-up period results raise concern on the sustainability of significant improvements beyond 1 month. Despite the amount of data regarding the efficacy and safety of this technique in relieving motor symptoms of PD, rTMS has not yet been systematically assessed as a potential treatment for FoG. An initial report by Rektorova and colleagues found no significant effect on OFF-related FoG in six PD patients treated with five sessions of high-frequency rTMS over the DLPFC and primary leg motor area [73]. However, a later double-blind cross-over study on 20 patients with FoG investigating the effects of a single session high frequency rTMS did suggest efficacy [74]. As recently observed, the contribution of NIBS alone or combined with neurorehabilitation to address this highly disabling phenomenon remains to be systematically assessed through well-powered, well-designed and reproducible studies [75].
The use of rTMS for the treatment of dyskinesias is limited to small studies showing contradictory findings, with either LF rTMS over M1 [76, 77] or LF rTMS over SMA [78, 79].
In 2014, a group of European experts in TMS were commissioned to revise all available trials to elaborate evidence-based guidelines for the therapeutic use of rTMS [80]. This included randomized controlled trials with at least 10 subjects receiving active stimulation, along with at least 2 comparable studies (same cortical target and same stimulation frequency), published by independent groups before the end of March 2014. Results concluded possible antiparkinsonian effect of HF rTMS over motor cortex delivered bilaterally. Other results were: no recommendation for dyskinesias and a probable antidepressant effect on HF rTMS over the left DLPFC in PD.
Novel paradigms of pairing TMS with other rehabilitation methods to try synergies and optimizing rehabilitation have recently been explored. Experimental protocols carried out in our neurostimulation lab have combined TMS with motor skill learning [81], physical therapy [35], aerobic exercise [23], and finally, with treadmill training [82]. Larger studies will need to be conducted to further validate these paradigms. Optimal treatment parameters remain elusive. Standardization of PD outcomes, of TMS methodologies and bigger multicenter collaborative initiatives with long follow-up periods are [12] needed to demonstrate the real therapeutic potential of TMS in PD.
tDCS has been tested to promote motor learning in healthy adults and stroke patients [83, 84]; this technique has also been explored as a treatment of migraines, aphasia, multiple sclerosis, epilepsia, tinnitus, schizophrenia, and dystonia with unclear or insufficient beneficial evidence for recommendation [85]. According to recent evidence-based guidelines for the therapeutic use of tDCS (including studies published before the end of the bibliographic search on September 1, 2016), only some types of chronic pain, fibromyalgia, depression, and craving have shown to benefit from the neuromodulation, with possible or probable recommendation levels. tDCS for PD has no formal recommendation; however, “no recommendation” means the absence of sufficient evidence to date, but not the evidence for an absence of effect [83]. Also to be noted, studies that have not been replicated were not included for analysis in this evidence-based review. tDCS seems to induce some beneficial effects in motor symptoms in PD, but studies are needed to replicate these results [86].
A Cochrane review by Elsner et al. [87], found no evidence of effect as measured by UPDRS global change in two studies and low quality evidence on motor impairment as measured by means of UPDRS Part III when real stimulation was compared vs. sham [63, 88]. Two studies specifically investigated the impact of tDCS on quantitative gait parameters [63, 89] and showed no significant changes in walking speed. There have been no reported studies exploring the efficacy of tDCS on tremor. The reduction of OFF-time and ON-time hampered by dyskinesias was analyzed in one study conducted on 25 subjects, resulting in no significant benefit [63]. In addition, health-related quality-of-life variables on both physical and mental domains were investigated, again with no significant effect [63]. As concluded by Elsner et al., “the methodological quality of these studies needs to be improved with particular respect to the risk of allocation concealment, blinding of personnel and intention to treat analysis” [87].
The importance of non-motor features in PD has been increasingly recognized. A particularly active area is the application of tDCS to enhance cognitive function. Cognitive impairment represents a highly disabling non-motor symptom in patients with PD, and several studies in patients with Alzheimer’s disease suggest that tDCS could improve memory performance [90, 91]. A few trials have been expressly designed to investigate the therapeutic potential of tDCS on cognitive function in patients with PD with mostly (but not exclusively) using neuromodulation of DLPFC [92, 93, 94]. Furthermore, fatigue is a frequently under-recognized non-motor symptom in patients with PD. So far, tDCS over DLPFC has been demonstrated to improve fatigue in other neurological conditions, including MS [95, 96, 97]. It seems therefore plausible that analogous stimulation settings could provide similar benefits in patients with PD, although this hypothesis remains to be confirmed through appropriately designed clinical trials (ClinicalTrials.gov identifier: NCT03189472).
The major limiting factors to the extensive clinical application of NIBS technologies are inherent to methodological properties of trials. The body of currently available data mainly rests on small-sized studies carried out with exploratory designs. As such, these studies are known to be prone to the risk of type I and type II statistical errors. Usually, a type I error leads to establish a supposed effect or relationship when, in fact, the null hypothesis is true. Conversely, a type II error leads to erroneous acceptance of the null hypothesis when this is, in fact, false. The best way to control for these errors is to design appropriately sized studies through power calculations based on the estimated magnitude of effects. Alternatively, adaptive designs can be conducted to allow for a flexible increase of the sample along with the trial implementation. This strategy, however, can further complicate the final interpretation of data. A second order of methodological limitation is represented by unavoidable differences in stimulation parameters between trials (i.e., stimulation location, frequencies, coil geometry, number of pulses, number of sessions, specific population, follow-up time, electrode montage, sponge sizes, etc.). These differences result in a commonly limited comparability between studies. At minimum, it is imperative for all NIBS trials to exhaustively disclose the followed stimulation protocol in all its components, thus maximizing comparability and reproducibility. Further, stimulation parameters should be chosen and refined on the basis of biologically plausible hypotheses, and experimental assumptions should be modeled on the pathophysiology of the targeted phenomena. Random target stimulation and “trawl fishing” experimental designs are likely to be inconclusive or to result in poor cost/effectiveness. Negative studies should be adequately reported and acknowledged to improve publication bias and expand knowledge among the scientific community. A clear description of placebo- or sham-controlled method should always be provided and all potential limitations of blinding procedure disclosed. For example, the use of non-realistic sham coils in a cross-over design can compromise the blinding of the study. Measures to assess adequate masking/blinding procedures should be incorporated into the trial, for example through the administration of specific questionnaires. Most of the original trials published in the literature lack double-blind controlled designs. This limitation has been conveniently weaning off over the past decade as a growing number of properly controlled NIBS trials flourished. Interestingly, newly designed coils can now allow for triple blinded designs where the subject, the investigator, and the technician are unaware whether real or sham stimulation is delivered. The use of appropriate and comprehensive clinical outcome to assess efficacy constitutes another significant challenge. A broad spectrum of symptoms could be potentially affected by NIBS. In order to capture clinically meaningful effects, quality-of-life scales and other tools exploring subjective improvements on ADLs should be incorporated to assess NIBS potential beyond the simple motor effect as quantified by UPDRS-III. Standardization of outcomes can also facilitate further meta-analysis. Finally, knowledge about NIBS and its therapeutic potential on movement disorders could be boosted by collaborations across involved laboratories and multicenter initiatives. In parallel, adequate training of personnel to refine operator’s expertise and skills should be provided in a standardized fashion across academic centers [19].
To summarize, clinical effects of NIBS can be attributed to complex and likely interconnected phenomena, including the normalization of cortical excitability, the modulation of connectivity between neuronal networks and the induction of neuroplastic phenomena. The substantially safe, reproducible, and non-invasive nature of NIBS makes these techniques of appealing interest for the study and treatment of various neurological and psychiatric disorders, including PD. For TMS, the pooled evidence suggests that rTMS improves motor symptoms of PD. Overall, HF rTMS over M1 and LF rTMS over SMA appears effective. The motor improvement in large multicenter clinical trials is around the minimal clinically important change of motor UPDRS. There are controversial findings in a few small studies for dyskinesias. There is insufficient data regarding the effects of rTMS for improving health-related quality-of-life, disability and activities of daily living. These data would help to better determine the clinical relevance for motor improvements. The currently available evidence supporting the use of tDCS neuromodulation in patients with PD is limited to small, single-center studies exploring different symptoms of the disease mainly through heterogeneous experimental methodologies. There is need for appropriately designed, directly comparable and well-powered trials to better characterize the therapeutic potential of this technique in this specific population. Despite these limitations, tDCS still holds much promise for a potential therapy as it is a relatively inexpensive, portable, and easy to perform technology.
The authors wish to acknowledge Miss Rebecca M. Friedes, for her contribution in editing the manuscript. Authors did not receive any funding or monies for the preparation of the manuscript.
The authors declare that they have no competing interests and report no disclosures relevant to the manuscript.
The authors would like to thank the Marlene and Paolo Fresco Institute for Parkinson’s and Movement Disorders and the Neurology department at NYU Langone Health for the support provided to the TMS and Neurostimulation laboratory.
Orthodontics is the specialty of dentistry which in brief deals with correcting the malaligned teeth with the application of force delivery system, which includes wires, brackets, elastics etc. It is just one branch of dentistry which is deeply interlinked with the engineering branch of mechanics. Application of force and its resultant effects are the key stones in orthodontics, hence the fundamentals of physics also applies to the physics such as the Newtonian physics. The intention of the Orthodontist is to make betterment in function and esthetics. The treatment is just not limited it and has intentions to correct things like a tooth implanted to the alveolar bone can lead to caries or other paraodontal infections or affect the oral hygeine), esthetics (of the dentition or the face), or prosthetic (orthodontic treatment preceding a prosthetic replacement/missing tooth or teeth) [1].
An Orthodontic treatment might be carried out with evidence based system or by a clinical experience or by a acquiring knowledge and experience from a postgraduate curriculum or even via specific trainings and hands on programmes. Orthodontics is a spectacular as well as brain buzzer branch in dentistry where the work undertaken by an orthodontist could be considered as solving a puzzle, when he or she treats each case. It is associated with logical reasoning and through knowledge about the basics of biomechanics and even common sense. Turner et al. in 1956 introduced Finite element analysis (FEA). From then it has been used in different sectors such as in building aircrafts to dams to bridges etc. The usage of computer software’s for the stressful calculations are used in order to find the stress and its distribution within a body for a given load. It also sketches the displacement of the body before and after the application of the load as well [2]. It could be a different dimensional opening for the chapter readers who are not familiar as well as to reinforce the knowledge for the readers who are already aware of this topic, so the chapter is designed to extremely simplify the concept of FEM and to integrate it with orthodontics from the very basic levels [2].
The Finite Element Method was introduced in orthodontics as a powerful tool for analyzing the biomechanical effects of various treatment modalities and is an approximation method to represent both the deformation and the 3Dstress distribution in bodies that are exposed to stress. The Finite Element Method is used to study the stresses and strains in engineering, it can be used to evaluate the biomechanical component such as displacement, strains and stresses induced in living structures from various external forces, the biomechanical response of the bone to external forces are quite complex. The FEM analyses the biomechanical effects of various treatment modalities and calculates the deformation and the stress distribution in the bodies exposed to the external forces. It should also be understood that the stress and strain in living tissues are thought to be key factors in biologic change, it is important to understand that stress and strain to understand its relationship to bone remodeling, the belief is such that the pattern of the stress will affect the localized proliferation of cells and growth activities [3]. The chapter is discussed from the fundamentals of FEM and further notes its usage in dentistry and particularly in orthodontics, followed by stepwise procedure explanations in detail.
The chapter further takes a road from its aspects such as construction of the models, which is the soul step in the FEM, with the help of scans such as the CT scans and FEM’s credibility is in question due to the complexity and accuracy of the model seems to represent from truth and reality in the oral cavity [4].
Many new concepts and terminologies are being introduced and explained to its best in this chapter. Keeping in mind that many of readers, being from a medical academic background, including Orthodontists and clinicians hesitate to understand and relate the formulas and equations which are quite natural, a few vital equations are presented with ease. Further the chapter goes in detail to bone remodeling concepts and the brief explanations of individual components of the dental organ and its reaction to force and the chapter sinks with the concepts of FEM and orthodontics in the body. Towards the end the advantages as well as the limitations of FEM is discussed with some insight. This chapter is well supported with scientific literature evidence for the assertion it implies and it credits each and every scientist for their contributions and valuable time in life they have devoted for the good of the mankind.
Orthodontics is periodically changing from an opinion-based practice to an evidence-based practice. Currently, it is necessary to have a scientific approach for any treatment modality and the evidence of tissue response to it [5]. Finite element analysis (FEA) has the ability of being applicable to solids of irregular geometry that contain heterogeneous material properties. It is therefore suited to evaluate the structural behavior of teeth. The use of FEM is wide seen in dentistry and in the field of orthodontics in the field of research in topics such as the geometry of the tooth, materials used, prosthetics etc. In the field of orthodontics, it’s used to find the stress values or its distributions in appliances used in orthodontics etc. FEA could be wisely used to estimate the stress and strain patterns within the tooth structure, Periodontal Ligament (PDL) and the bone which is subjected to tooth movement by the means of orthodontics [6].
The forces to single-tooth system can also be modeled with the FEA with ease. The centre of resistance (CR) of the tooth lowers and creates an altered stress pattern which is seen in the root as there is an experience of alveolar bone loss. The same effect could be experienced when there is an alteration of root length. The biomechanical properties of PDL are not the same for adult and adolescents respectively [7].
The principal of FEM is based on the division of a complex structure into smaller sub sections called as elements, in which the physical properties such as modulus of elasticity are applied to indicate the object response against an external stimulus which could be even an orthodontic force. It is said to be finite element analysis since, the elements are finite in count and the nodal points are the blocks which builds the model, which in turn connects to attribute to the formation of element [8]. A meshwork is considered to be a degenerated material which is subjected to modeling. There is an absolute control in the degree of simplification with this method which is an advantage to the FEM [9]. FEA techniques are potential to replace the stereo lithographic models for the presurgical planning. Every finite element is based on an assumed-shape function which expresses an internal displacement as a function of nodal displacement. Which means a certain element may give accurate answer for a particular type and location of support and loading but can give inaccurate answers for another type and location [10].
The geometric model construction
The geometric model to a Finite element analysis model conversion
Data representation of the material properties
The boundary condition defining
Application of the load
Solution to the linear algebraic equation system.
Analyzing the results [10].
Basic Steps in Finite Element Method for any solution corresponds to the steps involved in finite element to analyze a structure.
It is the first requirement for the analysis of the geometrical model. These can be created either in analysis software or the model can be created also in any CAD software and can be imported to the analysis software. The model has to be saved with extension *.iges or *.igs or *.sat to achieve this. The usage of a computed tomography image (fig ct img) can be done to serve as a geometrical model.
Discretization is a process of dividing the domain or component into number of elements & nodes. For this purpose, an assumption is made that the elements are interconnected by nodes. The idea behind the process is to improve the accuracy of the results. The entire component is divided into number of elements, then the stress distribution in each element will be almost the actual results and the operator gets accurate plot of the stress distribution in a component.
The mechanical properties such as young’s modulus, Poisson’s ratio etc., are defined to the component in this particular step. This is done to feed the values for calculation of the solution. These values mark the natural properties to the built up model so that it can behave and react in the same manner as that of a natural biologic body would, when subjected to external stimuli (stress). For the particular element, the property is to be defined. First of all the operator has to define the type of element. There are several types of elements available, which can be implemented to the domain component.
The boundary condition is chosen depending upon the mode of analysis such as structural, dynamic, thermal, fluid etc.
After the application of boundary conditions, the discretized domain is applied to the known loads. The application of loads will depend upon the geometry of the component used. The nodes are applied with loads. Different types of loads will include Forces or Moments, pressure, gravity. - For structural problems- Gravity, radiation, convection and temperature for thermal problems.
The results can be obtained instantly as well as in the most accurate manner. It will consist of model images which represent levels of stress by various colors signifying different stress for different colors respectively, which can be directly read from a color chart (provided below the image). The results can be further tabulated and subjected to analysis.
Computed Tomography or C.T is cross-sectional image of an object from either transmission or reflection data collected by illuminating (by any kind of penetrating radiation) the object from many different directions or angles. Frankly speaking, tomographic imaging deals with the reconstruction of an image from its projections. The technique constitutes of irradiating a section of a sample from a number of positional angles and then the intensity of the transmitted or reflected radiation is measured. For example, the projections symbolize the X-rays attenuation within a body, the bodies’ radioactive nucleoids decay as in the case of emission tomography, or the variation seen in refractive index in an ultrasonic tomography (USG).
When the X-ray is considered, the projections consist of line integrals of the attenuation coefficient. This attenuation of photons (tiny particles that constitute an electromagnetic radiation) are due to either being absorbed by the atoms of the material, or being scattered away from their original paths of travel. Photoelectric absorption involves an X-ray photon imparting all its energy to a tightly bound inner electron in an atom. The images are 2D maps of the distribution of the attenuation coefficient of the X-rays. By stacking the obtained 2D images, we can reconstruct 3D images. The attenuation coefficient is measured in Hounsfield Units (HU) [11].
This macroscopic response of the trabecular bone is closely related to the underlying microstructure. It is beyond scope of this book to describe in details the geometry and spatial arrangement of the trabeculae and its advised to refer standard textbooks for the same, The volume fraction which is considered one among the major parameter in characterization of microstructure of cellular materials geometrically, gives no much clue about the orientation as well as the organization of the above said microstructures. The material microstructure is modeled using tensors of higher rank which mimics the architecture of the microstructure and is the most common method adapted for the same. Fabric tensors are needed as a quantitative measure of the microstructural architecture, to serve as positive definite. The principal axes of a tensor whose principal axes coincide with the principal microstructural direction and its eigenvalues are proportional to the microstructure distribution with respect to its principal direction. It is a must thing to include the parameters which can define those orientations. Hence it requires acquiring a 3D representation of the bone first using tomography. It is then a morphological analysis used to describe the microstructure (Figure 1) [12].
Conversion of CT scan into a finite element model.
Three primary considerations in the development of the three-dimensional finite element tooth model are to be considered; which includes the tooth and other periodontal geometry, properties of different materials and as well as the configuration of the load applied. In a given tooth geometry and structures of the periodontium and its associated geometry, one can say nodes simply as points that occupies the corners of the elements which meet each other; further the boundary conditions are well defined at all peripheral occupying nodes. A specific material property is assigned to individual elements. Location of the centre of resistance and centre of rotation of the modeled tooth will be deeply affected by the modeling of the root as a symmetric parabolic structure or as a real tooth, as well as root conicity, buccopalatal vs. mesiodistal bone levels and bone insertion [11].
The problem with three-dimensional models is that the geometrical input needs to be generated. The bone structure replicated with a CT scan is preferred as the geometrical input data which should be generated for the 3-D model, which is considered as one among the problems. It is suggested to convert the CT image voxel to eight node hexahedral; but the possibility of numerous element creations in model and the unwanted change in the model’s external shape is the pay for this. In order to exempt the outer rough surfaces, it’s better to model the external geometrical contours. After these steps, automatically a mesh is produced out as the result of the software. Material properties are assigned to each element of the model, once the generation of the mesh is done (Figure 2).
FEA carried out on a modeled human skull.
Morphological analysis provides the tools to extract morphological parameters of an object. The actual values of the parameters extracted depend on the object as well as the quality of the object representation. Better way to say is voxel size affects the 3D images and pixel size would affect the 2D images. Higher the resolution better is the analysis quality. TV, BV, Tb.Th, and MIL are the four respective parameters of morphology which are taken into account.
TV does quantification of the volume in total at the region of interest (ROI). If bone is to be considered, the entire trabecular bone and the total volume of its pores along could be considered as the term ‘tissue’. It is a simple task to calculate TV, just by taking the product of the total number of voxels at the region of interest and the volume of a single voxel. The usage of 2-D images could be an option to obtain the volume. The volume is computed by assuming the cut thickness to be same as the pixel’s side length measurement.
By multiplying the number of voxels in the solid objects, one can find out this parameter and it’s the representation of the 3-D object’s volume in total. Bone volume (BV) will therefore be interpreted as the solid phase volume.
It is the thickness of the rods of the cellular solid [13].
The important parameter is the ratio of the two previous parameters.
It is the thickness of trabeculae and its associated distribution.
Locally when it comes to thickness specifically at a point within a state of body is said to be the biggest sphere which consoles the spot, the spot is not needed to be the centre of the body but within the surface of the object which is considered as a solid [14]. To calculate (Tb.Th), the idea of structuring the body of the object is carried out, where the trabecular midline is used [15].
The mechanics which is an engineering branch is the soul element in the field of (Figure 2) biomechanics; one can never understand biomechanics without understanding the fundamentals of mechanics. Mechanics deals with forces and the response of the object or body, whereas bio means study of living organisms, so the application of the forces and its response to the forces in living bodies are dealt in biomechanics. The hierarchical arrangement in organisms starts from sub atoms ending in organized living body. With the help of quantum mechanics, we can study at the cell or atomic levels and Continuum mechanics could be used in the higher levels such as the organ levels [16].
The Continuum Mechanics is the ideology where volume V(t) is the amount of matter contained by a body in the respective space at a given time T and the surface area of the body could be symbolized as S(t). Further when we look the reader must understand that the body undergoes change in dimension from its initial orientation for the respective boundary definition after a stress is being applied to the body. The fact is such that, the irrelevance of working with the same body with and without stress because of the obvious above said reason of reasonable transition in shape of the body from initial and final state of the body before and after applying stress. It is mandatory for the above said reasons a thorough understanding of the basis of kinematics is required [17].
Coming to the FEM we must strictly adhere to the principles of kinematics. The chapter is never complete without discussing few important equations in FEM, where shape functions (N) and the displacement of the nodes (q), which we are not certain about could attribute the displacement fields shape and could be equated as follows;
In Eq. (1) the nodal values (q) are determined by the method of calculating the equation which is already in a state of equilibrium via formulation which is made incrementally [18].
In Eq. (2) q represents the nodal accelerations, M the mass matrix and Fint and Fext the (nodal consistent) internal and external forces respectively
In Eq. (3) B = ∇NT and t represents the traction on the surface.
In Eq. (4) Foe denotes the residual or remaining forces and it’s not equal to zero. Prec is a user defined precision. The equilibrium equations are iteratively solved using Newton–Raphson method. Starting from a trial nodal displacement is given as, q0 (several possibilities to evaluate such a trial [19].
Field exist but will not be treated in this work), the displacement field is iteratively updated in such a way that:
Eq. (5) denotes KT = d Foe/dq, which is considered to be called as the tangent stiffness matrix.
The tangent stiffness matrix will be resolved into its parts as well as the shape. The shape aspect of this depends on the shape functions used in FEM [20].
By use of linearization of the small stress values with its corresponding strain values this can be obtained. Intergration tool is used to discrete the matrix of material stiffness [21].
Within the field of dentistry and to its related field, mathematical models are used for research and treatment planning. The tendencies in mathematical models (either numerical FE models or analytical models) for tooth movement and in particular the constitutive models used for dental tissues. Many contributions exist focusing on implant related problems, which are not our interest. The forces alone are only considered and it’s not about the means of force delivery system which may also include the brackets are to be considered in here [22].
The mechanism which is responsible for the asymmetrical behavior of the tooth when rotated around its main axis is at times assumed to be in the gingival tissue which is a complex fibrous structure that envelops the entire dental arch and it provides an additional anchorage to the teeth, tends to contract. This creates force acting on the different proximal teeth, which in turn produce an internal momentum and asymmetries. The gingiva has a viscous nature due to its composition of collagen. We do not consider or value much the mechanical activity of the gingiva during tooth movement in Finite element studies [23].
It is the hard as well as a brittle substance probably seen in the human body, which is composed of mainly inorganic materials. Enamel could be categorized as an elastic material which is linear in nature [24].
Very few studies focus on characterizing the cementum, either mechanically or histologically. The group of Darendelier provides a comprehensive body of work on the physical characteristics of cementum.
The Dentin is reinforced by radial microscopic tubules. These tubules are filled with fluid and this gives the dentin a viscoelastic character. Since the mid-1970’s, studies shows its viscoelastic property and this is a supporting evidence.
Dentin is also looked as a non-homogeneous and anisotropic material in various recent experimental model studies.
When there literature is reviewed, barely any studies are done to characterize the properties of the neither dental pulp nor acknowledges its existence [25].
The crown of the tooth is modeled as one material with 19 GPA modulus of elasticity, without even considering the 2 components of the crown (enamel, dentin) independently shows young’s modulus of 80 and 18 GPA respectively. The Poisson’s ratio is, regardless of the proposed study, taken as 0.3 [26].
The periodontium is a structure which constitutes the cementum, the PDL fibers and the alveolar complex. The PDL constitutes the tissues which are loose connective type. It is innervated as well as vascularized. It holds the teeth to the bone and compensates the wearing of the crown structure of the tooth at points in contact or the incisal/occlusal portion of the tooth. The functions of the PDL include the regulation of mastication as well because of the associated sensory nerve fiber innervations. It works well as an attached cushion between tooth and the alveolar bone, as well as act as a shock absorber. The load applied to the teeth during the functions like chewing and clenching is transmitted to the respective jaw bones through the PDL fibers [27].
Many studies on PDL take bilinear elastic nature of it; one can also find many studies which speak or valuate the anisotropy of the fibers of the PDL. There are advantages when it’s done so, as it provides more accurate and validity of the stress calculation for a better eccentricity of the movements of the teeth [28]. But studies talk about the PDL and its non- linear nature which is stated by the properties like Poisson’s ratio and the modulus of elasticity (Young’s) (Figure 3).
Mesh model after assigning the charecteristic material properties of each constituent of dento-alveolar complex independently.
A Young’s modulus around 0.1 MPa is most likely to represent best of the linear part of the PDL’s mechanical behavior. Bilinear elastic models are also found and are defined with three values which are tangential modulus, Young’s modulus and a limit value of about 7% strains in tension tests. Last but never the least, Cattaneo et al., Verna et al. introduced a multi-linear model, different in tension and in compression [29].
Many researchers consider the PDL as a hyper elastic material (Mooney-Rivlin material with, for Natali et al., reinforced fibers, expressed in an Ogden-type formulation) and estimated strain which corresponds well with the in vivo experimental data by Parfitt.
Models proposed by various other researchers, accounts for a time dependency through the use of viscoelastic models using up to four time-constants. These models are either generalized as Maxwell models [30].
There are instances where the periodontal ligament is believed to be composed of fibers which are arranged in linear nature [31]. The poroelastic model allows considering a time-dependent behavior through the fluid flow inside a porous matrix.
The finite element (FE) method is used in orthopedic biomechanics since the early 1970’s to evaluate and analyze and study the patterns of stress in the calcified tissues (bones). From then, this analytical tool of the modern era is being used in the field of Orthodontics as well. It very evident to find the use of FEM in the field of prosthodontics, implantology etc. as well to analyze the stress, the stress pattern and to optimize or go with the design of the appliances, to study the materialistic properties of the appliance as well as the reactions of the bone to it. We currently use for biomechanics in the field of orthodontics as well [32].
It is a wise decision to use the non-linear behavior of the periodontal ligament to study the wider aspects of tooth movements [33]. The initial design of models in Finite element methods FE models were 2 Dor axi symmetric models and now it’s no more used since it’s a 3-D era. The FEM can definitely analyze the stress and its patterns and can analyze the biomechanics and can determine the final position of the teeth from its initial positions [34]. Early models in the field of orthodontics were mainly directed to study the initial movement of the tooth in its socket (no bone remodeling included) following the implementation of a system of forces and moments by means of braces or fixed orthodontic appliances. Most current studies still follow the same principle, using geometry and a system of forces which is more complex. Within the initial tooth movement models, mainly fully linear elastic homogeneous isotropic models were used. How so ever, models with non uneven bone density is also used where modulus of elasticity is taken into account. Orthotropic behavior of the bone and the anisotropic nature of PDL also exist [35]. Studies consider the periodontal ligament to be elastic. All these could be applied to the posterior teeth, multi rooted and of different forms of roots as well [36].
The tooth movement due to bone resorption and apposition which obeys the pressure tension theory is not obeyed by the teeth initially and the early tooth movement is just the effect of the PDL fibers which instigate the tooth movement initially. After an initial tooth movement under the applied pressure the tooth tries to stay in that position and tries to attain stability in the newly moved position [37]. FEA models at times usually involve an update of displacement (in addition to that due to external forces) or of forces based on an empirical bone remodeling law: The stimulus for remodeling is either the strain energy density, strain dependent or stress dependent remodeling algorithms obey the laws of mathematical tools such as the integration under the limit of time. The FEM analyses the forces and the associated tooth movement with it in the model and it all obeys the laws of equilibrium from its initial to final position under the stipulated time.
Since the early 1980’s, finite element models of maxillary and mandible were used. The model is built with elements which is comparable or represents the bone structure and symbolizing its properties. The magnitude of the force levels applied by appliance like brackets or others like head gears or the expansion appliance etc. is taken into consideration. As a part of modeling the movement of the jaw, a great effort is made to characterize the temporomandibular joint (TMJ). In most cases, the type of materials used for the bone is linear elastic in nature. It is considered that cortical bone is distinguishable from trabecular bone. However, the presence/absence of teeth in the cranio-facial models is variable in nature. As for the models of the TMJ, the cartilage and the disks are modeled either as linear elastic materials or as hyper elastic ones. It can be also found out that the models include muscle activation of the jaw, either performing an inverse dynamic analysis to compute the activity of the large amount of muscles in the face, or modeling a given number of muscles, often by applying a spring model to describe the muscular forces. Finally, one can also find models of the facial bones and skull by analyzing the response to external orthopedic systems [38].
In addition to growth of the skeleton and resorption of fractures, which are of temporary in nature, the structure of bone is, stabilized by the action of osteoclast and osteoblast and its metabolism is a total different interest of subject which is to be discussed, which in turn is beyond the scope of this chapter. Through understanding of the remodeling process of the bone should be understood by an orthodontist to get an idea of how the teeth move in the maxilla or mandible during tooth movement. The Roux hypothesis claims the whole remodeling procedure is a self-organized procedure where the stiffness of the bone is achieved after a force is applied and stress is developed within the bone, the bone trabaculae obeys the Wolff’s law and last but not the least the bone reacts upon itself for load application. It is equally important to understand the Frost model of the bone which is stated as the mechanostat theory where is notes that if the stress range exceeds the limit, there is a chance of formation of a new bone, but if the same stress is lesser to the optimal value there is a bone loss associated to it as well. Both these goes hand in hand which creates a balance. The theory sounds simple for the readers but it’s simply an effective one and a tricky one when equations are derived from it mathematically and used for computing. Earlier the bone in a bone model was technically considered to be a poroelastic media which is pooled by a liquid. Later models have proposed the universal mechanical nature of a living substances, here the depth of biological activity is considered, where as there is also another model which does not propose the depth of remodeling within the bone (Phenomenological model) [39].
Now coming to the soul of this reading, the reader must understand the real fact initially that the FEM is a theoretical study concept and does not stand alone debates of scientific evidence based ideology without the gold standard of clinical trials. FEM deals with material properties and parameters, further the geometrical aspects are even being considered. The complete system with its constituent initial force, dimension of the body, stress developed is drastically different with respect to its final state. It is logical to think that it’s inevitable without mathematical formulations and definite numerical values one cannot calculate or predict the final position of the tooth from its initial one [40].
Before the application of the FEM, there were several other methods which were implemented to carry out the stress strain relations and its calculations over the PDL, but due to the complex nature of it the end results achieved or obtained stayed insignificant. When the sequence of reactive force developed after an implementation of load is checked, the root suffers the most, followed by the PDL and the alveolar bone the least (due to its higher density). These findings are due to the different mechanical properties of each structure: such as the tooth, periodontal ligament and alveolar bone. The stress applied on the bone is the active factor in the new configuration arrangement of the bone. There is a significant association of the PDL in the remodeling procedure of the bone due to its viscous nature and the storage of energy within it due to the same nature.
The stresses are of different types such as the longitudinal stress, compressive stress, or the shear stress depending on the type of the force and its line of action over the body, so it’s mandatory to specify it. There is always a chance for a tooth or teeth to undergo a combination of the above said stresses in various directions as well. When comparison is done among the types of tooth movements against each other, the tipping, extrusion and intrusion result in the greatest stress at the root apex. For extrusion and intrusion, the stress concentration is mainly at the apex of the root. Stresses at the root apex after intrusive tooth movement is seen but the distribution is different when compared to other types of tooth movement. When a vertical force is applied on the buccal surface of the tooth, some torque may be expected due to the relationship between the point of application of force and the centre of resistance of the tooth. In such cases, labial and lingual portion of the apical region of the root experiences way higher reactive forces to the applied tension.
After analyzing different FEM studies in orthodontics, studies show the stress distribution patterns are more in the crest of the alveolar bone, when compared to the periodontal ligament nor the crown or the root of the tooth. When the tipping forces where studied, it showed more or less the same feature of the stress distribution over the crest of alveolar bone. The tooth and the bone suffer greatest stress at the cervical level and the PDL at the apex.
The forces in rotation create the only difference of all the situations, where the apical stress is comparatively lesser. The FEM depends on the model and the property of the material assigned and boundary conditions, any change or errors creeping in these aspects will affect the foreseeing of the results. The type of the force delivered by each system is never the same, so there is change in the results. To get these right results the proper implementation of the force system and its understanding is inevitable. After all this there are other instances to point out like, up to 50% or more of the applied force can dissipate as friction in an edgewise bracket system; which can significantly affect the stress produced at the PDL of the tooth [41].
As with any theoretical model of a biological system, there are some limitations which need to be considered. A thorough reading and interpretation of this chapter would give the insight of the limitation of the FEM and it’s not much to emphasis on the same. But then as said before any errors in modeling or material property assignment or the boundary conditions application, even wrong forces applied to wrong formulation, will earn the wrong results. It’s a sophisticated and computer dependent or programme dependent analysis, so at most care should be taken during the modeling stages and the prior stages before the final run for the results to feed the correct input data for the expected outcome or results. It is highly difficult or impossible to be frank to replicate the exact living substance into mechanical models till date due to its complex nature [42]. The major limitation which you would have never guessed all through this chapter is that the cost of the FEM study. It should be highlighted that the FEM does not come with a reasonable price currently in many countries and it’s used more for the research purposes. It’s not a question to ask if FEM is considered in building bridges or dams or aircrafts but definitely when comes to field of dentistry or orthodontics, to use FEM for every single patient is never feasible.
The main fundamental in orthodontics is the movement of teeth or tooth within bones, which in other words means the movement of solid (tooth) in another solid (jaw bones bone) which is the toughest movement of all mediums and it’s a slow process which consumes time. If we are smart enough to estimate the final position of the teeth form its initial one, it’s like predicting the end result without the trial and error methods or without any unwanted disturbances which even if occurs could be foreseen and a right component of force. This ideology actually saves time and the pain to both the clinician as well as for the patient. The mechanical and biological/physiological reactions to orthodontic forces by the PDL and the alveolar bone are closely linked with each other. This coupling can be treated in biomechanical models, focusing on the mechanics and considering the phenomenological aspects of the biology. As a tool to describe the mechanics of orthodontic tooth movement due to remodeling, the Finite Element Method (FEM) can be definitely utilized. The FEM is an advanced engineering tool that has shown fruitful benefits in the field of dentistry, dental and biomedical research and as well as orthodontics. It is a highly precise technique which can expose various key research points in the research field.
It is a very big question to ask that have we discovered or implemented the complete aspect of the FEM and is it been used in our field. There are still researches going on. Clinically proved studies are rechecked with the software and after a series of studies, the FEM can be implemented in different cases to predict the results. Every person is unique, hence the bone density, the model etc. So definitely just one FEM study cannot predict all the results from that single result obtained from the unique model of a person. Running an FEM study for independently from person to person is also unique according to the author, which is not emphasized much in any of the literature ever before.
This humble chapter would be incomplete without words of gratitude to all those who have been a part of its existence. I would like to thank, Almighty and my parents and all my beloved ones,
The author declares no conflict of interest.
I sincerely thank
Also, from the bottom of my heart I thank
The Initial Graphics Exchange Specification Standard ACIS Text unit used in computed tomography (CT) (Dimension less unit) Modulus of elasticity (Gpa) Stress (Mpa)
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Ramakrishnan",coverURL:"https://cdn.intechopen.com/books/images_new/5183.jpg",editedByType:"Edited by",editors:[{id:"116136",title:"Dr.",name:"Srinivasan",middleName:null,surname:"Ramakrishnan",slug:"srinivasan-ramakrishnan",fullName:"Srinivasan Ramakrishnan"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:35,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"50801",doi:"10.5772/62898",title:"Performance Evaluation of Nanofluids in an Inclined Ribbed Microchannel for Electronic Cooling Applications",slug:"performance-evaluation-of-nanofluids-in-an-inclined-ribbed-microchannel-for-electronic-cooling-appli",totalDownloads:2508,totalCrossrefCites:52,totalDimensionsCites:95,abstract:"Nanofluids are liquid/solid suspensions with higher thermal conductivity, compared to common working fluids. In recent years, the application of these fluids in electronic cooling systems seems prospective. In the present study, the laminar mixed convection heat transfer of different water–copper nanofluids through an inclined ribbed microchannel––as a common electronic cooling system in industry––was investigated numerically, using a finite volume method. The middle section of microchannel’s right wall was ribbed, and at a higher temperature compared to entrance fluid. The modeling was carried out for Reynolds number of 50, Richardson numbers from 0.1 to 10, inclination angles ranging from 0° to 90°, and nanoparticles’ volume fractions of 0.0–0.04. The influences of nanoparticle volume concentration, inclination angle, buoyancy and shear forces, and rib’s shape on the hydraulics and thermal behavior of nanofluid flow were studied. The results were portrayed in terms of pressure, temperature, coefficient of friction, and Nusselt number profiles as well as streamlines and isotherm contours. The model validation was found to be in excellent accords with experimental and numerical results from other previous studies.",book:{id:"5150",slug:"electronics-cooling",title:"Electronics Cooling",fullTitle:"Electronics Cooling"},signatures:"Mohammad Reza Safaei, Marjan Gooarzi, Omid Ali Akbari, Mostafa\nSafdari Shadloo and Mahidzal Dahari",authors:[{id:"178854",title:"Dr.",name:"Mohammad Reza",middleName:null,surname:"Safaei",slug:"mohammad-reza-safaei",fullName:"Mohammad Reza Safaei"},{id:"179807",title:"Dr.",name:"Mostafa",middleName:null,surname:"Safdari Shadloo",slug:"mostafa-safdari-shadloo",fullName:"Mostafa Safdari Shadloo"},{id:"179809",title:"Dr.",name:"Mahidzal",middleName:null,surname:"Dahari",slug:"mahidzal-dahari",fullName:"Mahidzal Dahari"},{id:"179813",title:"MSc.",name:"Marjan",middleName:null,surname:"Goodarzi",slug:"marjan-goodarzi",fullName:"Marjan Goodarzi"},{id:"185093",title:"MSc.",name:"Omid",middleName:null,surname:"Ali Akbari",slug:"omid-ali-akbari",fullName:"Omid Ali Akbari"}]},{id:"5184",doi:"10.5772/6180",title:"From the Lab to the Real World: Affect Recognition Using Multiple Cues and Modalities",slug:"from_the_lab_to_the_real_world__affect_recognition_using_multiple_cues_and_modalities",totalDownloads:3753,totalCrossrefCites:39,totalDimensionsCites:56,abstract:null,book:{id:"3789",slug:"affective_computing",title:"Affective Computing",fullTitle:"Affective Computing"},signatures:"Hatice Gunes, Massimo Piccardi and Maja Pantic",authors:null},{id:"5197",doi:"10.5772/6167",title:"Generating Facial Expressions with Deep Belief Nets",slug:"generating_facial_expressions_with_deep_belief_nets",totalDownloads:3722,totalCrossrefCites:1,totalDimensionsCites:49,abstract:null,book:{id:"3789",slug:"affective_computing",title:"Affective Computing",fullTitle:"Affective Computing"},signatures:"Joshua M. Susskind, Geoffrey E. Hinton, Javier R. Movellan and Adam K. Anderson",authors:null},{id:"15948",doi:"10.5772/17600",title:"Phoneme Recognition on the TIMIT Database",slug:"phoneme-recognition-on-the-timit-database",totalDownloads:5783,totalCrossrefCites:29,totalDimensionsCites:37,abstract:null,book:{id:"144",slug:"speech-technologies",title:"Speech Technologies",fullTitle:"Speech Technologies"},signatures:"Carla Lopes and Fernando Perdigao",authors:[{id:"28842",title:"Mrs.",name:"Carla",middleName:null,surname:"Lopes",slug:"carla-lopes",fullName:"Carla Lopes"},{id:"34940",title:"Mr.",name:"Fernando",middleName:null,surname:"Perdigão",slug:"fernando-perdigao",fullName:"Fernando Perdigão"}]},{id:"9252",doi:"10.5772/7447",title:"Contact-free Hand Biometric System for Real Environments Based on Geometric Features",slug:"contact-free-hand-biometric-system-for-real-environments-based-on-geometric-features",totalDownloads:2483,totalCrossrefCites:12,totalDimensionsCites:35,abstract:null,book:{id:"3184",slug:"recent-advances-in-signal-processing",title:"Recent Advances in Signal Processing",fullTitle:"Recent Advances in Signal Processing"},signatures:"Aythami Morales and Miguel A. Ferrer",authors:[{id:"1659",title:"Mr.",name:"Aythami",middleName:null,surname:"Morales Moreno",slug:"aythami-morales-moreno",fullName:"Aythami Morales Moreno"},{id:"42778",title:"Mr.",name:"Miguel A.",middleName:null,surname:"Ferrer",slug:"miguel-a.-ferrer",fullName:"Miguel A. Ferrer"}]}],mostDownloadedChaptersLast30Days:[{id:"68505",title:"Research Design and Methodology",slug:"research-design-and-methodology",totalDownloads:24823,totalCrossrefCites:7,totalDimensionsCites:16,abstract:"There are a number of approaches used in this research method design. The purpose of this chapter is to design the methodology of the research approach through mixed types of research techniques. The research approach also supports the researcher on how to come across the research result findings. In this chapter, the general design of the research and the methods used for data collection are explained in detail. It includes three main parts. The first part gives a highlight about the dissertation design. The second part discusses about qualitative and quantitative data collection methods. The last part illustrates the general research framework. The purpose of this section is to indicate how the research was conducted throughout the study periods.",book:{id:"8511",slug:"cyberspace",title:"Cyberspace",fullTitle:"Cyberspace"},signatures:"Kassu Jilcha Sileyew",authors:[{id:"292841",title:"Ph.D.",name:"Kassu",middleName:null,surname:"Jilcha Sileyew",slug:"kassu-jilcha-sileyew",fullName:"Kassu Jilcha Sileyew"}]},{id:"70973",title:"Social Media, Ethics and the Privacy Paradox",slug:"social-media-ethics-and-the-privacy-paradox",totalDownloads:2517,totalCrossrefCites:3,totalDimensionsCites:7,abstract:"Today’s information/digital age offers widespread use of social media. The use of social media is ubiquitous and cuts across all age groups, social classes and cultures. However, the increased use of these media is accompanied by privacy issues and ethical concerns. These privacy issues can have far-reaching professional, personal and security implications. Ultimate privacy in the social media domain is very difficult because these media are designed for sharing information. Participating in social media requires persons to ignore some personal, privacy constraints resulting in some vulnerability. The weak individual privacy safeguards in this space have resulted in unethical and undesirable behaviors resulting in privacy and security breaches, especially for the most vulnerable group of users. An exploratory study was conducted to examine social media usage and the implications for personal privacy. We investigated how some of the requirements for participating in social media and how unethical use of social media can impact users’ privacy. Results indicate that if users of these networks pay attention to privacy settings and the type of information shared and adhere to universal, fundamental, moral values such as mutual respect and kindness, many privacy and unethical issues can be avoided.",book:{id:"8423",slug:"security-and-privacy-from-a-legal-ethical-and-technical-perspective",title:"Security and Privacy From a Legal, Ethical, and Technical Perspective",fullTitle:"Security and Privacy From a Legal, Ethical, and Technical Perspective"},signatures:"Nadine Barrett-Maitland and Jenice Lynch",authors:[{id:"311821",title:"Ph.D. Student",name:"Nadine",middleName:null,surname:"Barrett-Maitland",slug:"nadine-barrett-maitland",fullName:"Nadine Barrett-Maitland"},{id:"311822",title:"Ms.",name:"Jenice",middleName:null,surname:"Lynch",slug:"jenice-lynch",fullName:"Jenice Lynch"}]},{id:"76652",title:"Internet of Things and Machine Learning Applications for Smart Precision Agriculture",slug:"internet-of-things-and-machine-learning-applications-for-smart-precision-agriculture",totalDownloads:666,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Agriculture forms the major part of our Indian economy. In the current world, agriculture and irrigation are the essential and foremost sectors. It is a mandatory need to apply information and communication technology in our agricultural industries to aid agriculturalists and farmers to improve vice all stages of crop cultivation and post-harvest. It helps to enhance the country’s G.D.P. Agriculture needs to be assisted by modern automation to produce the maximum yield. The recent development in technology has a significant impact on agriculture. The evolutions of Machine Learning (ML) and the Internet of Things (IoT) have supported researchers to implement this automation in agriculture to support farmers. ML allows farmers to improve yield make use of effective land utilisation, the fruitfulness of the soil, level of water, mineral insufficiencies control pest, trim development and horticulture. Application of remote sensors like temperature, humidity, soil moisture, water level sensors and pH value will provide an idea to on active farming, which will show accuracy as well as practical agriculture to deal with challenges in the field. This advancement could empower agricultural management systems to handle farm data in an orchestrated manner and increase the agribusiness by formulating effective strategies. This paper highlights contribute to an overview of the modern technologies deployed to agriculture and suggests an outline of the current and potential applications, and discusses the challenges and possible solutions and implementations. Besides, it elucidates the problems, specific potential solutions, and future directions for the agriculture sector using Machine Learning and the Internet of things.",book:{id:"9977",slug:"iot-applications-computing",title:"IoT Applications Computing",fullTitle:"IoT Applications Computing"},signatures:"R. Sivakumar, B. Prabadevi, G. Velvizhi, S. Muthuraja, S. Kathiravan, M. Biswajita and A. Madhumathi",authors:[{id:"331479",title:"Prof.",name:"R.",middleName:null,surname:"Sivakumar",slug:"r.-sivakumar",fullName:"R. Sivakumar"},{id:"346727",title:"Dr.",name:"B.",middleName:null,surname:"Prabadevi",slug:"b.-prabadevi",fullName:"B. Prabadevi"},{id:"346729",title:"Dr.",name:"G.",middleName:null,surname:"Velvizhi",slug:"g.-velvizhi",fullName:"G. Velvizhi"},{id:"346730",title:"Dr.",name:"S.",middleName:null,surname:"Muthuraja",slug:"s.-muthuraja",fullName:"S. Muthuraja"},{id:"346731",title:"Dr.",name:"S.",middleName:null,surname:"Kathiravann",slug:"s.-kathiravann",fullName:"S. Kathiravann"},{id:"346732",title:"Dr.",name:"M.",middleName:null,surname:"Biswajita",slug:"m.-biswajita",fullName:"M. Biswajita"},{id:"346733",title:"Dr.",name:"A.",middleName:null,surname:"Madhumathi",slug:"a.-madhumathi",fullName:"A. Madhumathi"}]},{id:"56541",title:"Routing Protocols for Wireless Sensor Networks (WSNs)",slug:"routing-protocols-for-wireless-sensor-networks-wsns-",totalDownloads:5773,totalCrossrefCites:18,totalDimensionsCites:27,abstract:"Wireless sensor networks (WSNs) are achieving importance with the passage of time. Out of massive usage of wireless sensor networks, few applications demand quick data transfer including minimum possible interruption. Several applications give importance to throughput and they have not much to do with delay. It all rest on the applications desires that which parameter is more favourite. The knowledge of network structure and routing protocol is very important and it should be appropriate for the requirement of the usage. In the end a performance analysis of different routing protocols is made using a WLAN and a ZigBee based Wireless Sensor Network.",book:{id:"6038",slug:"wireless-sensor-networks-insights-and-innovations",title:"Wireless Sensor Networks",fullTitle:"Wireless Sensor Networks - Insights and Innovations"},signatures:"Noman Shabbir and Syed Rizwan Hassan",authors:[{id:"206600",title:"Mr.",name:"Noman",middleName:null,surname:"Shabbir",slug:"noman-shabbir",fullName:"Noman Shabbir"},{id:"206601",title:"Mr.",name:"Syed Rizwan",middleName:null,surname:"Hassan",slug:"syed-rizwan-hassan",fullName:"Syed Rizwan Hassan"}]},{id:"50065",title:"Heat Pipes for Computer Cooling Applications",slug:"heat-pipes-for-computer-cooling-applications",totalDownloads:5159,totalCrossrefCites:4,totalDimensionsCites:10,abstract:"There is an increasing demand for efficient cooling techniques in computer industry to dissipate the associated heat from the newly designed and developed computer processors to accommodate for their enhanced processing power and faster operations. Such a demand necessitates researchers to explore efficient approaches for central processing unit (CPU) cooling. Consequently, heat pipes can be a viable and promising solution for this challenge. In this chapter, a CPU thermal design power (TDP), cooling methods of electronic equipments, heat pipe theory and operation, heat pipes components, such as the wall material, the wick structure, and the working fluid, are presented. Moreover, we review experimentally, analytically and numerically the types of heat pipes with their applications for electronic cooling in general and the computer cooling in particular. Summary tables that compare the content, methodology, and types of heat pipes are presented. Due to the numerous advantages of the heat pipe in electronic cooling, this chapter definitely leads to further research in computer cooling applications.",book:{id:"5150",slug:"electronics-cooling",title:"Electronics Cooling",fullTitle:"Electronics Cooling"},signatures:"Mohamed H.A. Elnaggar and Ezzaldeen Edwan",authors:[{id:"178453",title:"Dr.",name:"Mohamed",middleName:null,surname:"Elnaggar",slug:"mohamed-elnaggar",fullName:"Mohamed Elnaggar"},{id:"184278",title:"Dr.",name:"Ezzaldeen",middleName:null,surname:"Edwan",slug:"ezzaldeen-edwan",fullName:"Ezzaldeen Edwan"}]}],onlineFirstChaptersFilter:{topicId:"90",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81690",title:"Your Vital Signs as Your Password?",slug:"your-vital-signs-as-your-password",totalDownloads:9,totalDimensionsCites:0,doi:"10.5772/intechopen.104783",abstract:"Cognitive biometrics (vital signs) indicate the individual’s authentication using his/her mental and emotional status specifically, electrocardiogram (ECG) and electroencephalogram (EEG). The motivation behind cognitive biometrics is their uniqueness, their absolute universality in each living individual, and their resistance toward spoofing and replaying attacks in addition to their indication of life. This chapter investigates the ability to use the vital sign as unimodal authentication in its status by surveying the recent techniques, their requirements and limitation, and whether it is ready to be used in the real market or not. Our observations state—that the vital signs can be considered as a PASSWORD due to their uniqueness, but it needs more improvements to be deployed to the market.",book:{id:"11195",title:"Recent Advances in Biometrics",coverURL:"https://cdn.intechopen.com/books/images_new/11195.jpg"},signatures:"Hind Alrubaish and Nazar Saqib"},{id:"81521",title:"Quantum Biometrics",slug:"quantum-biometrics",totalDownloads:17,totalDimensionsCites:0,doi:"10.5772/intechopen.103752",abstract:"It was recently proposed to use the human visual system’s ability to perform efficient photon counting in order to devise a new biometric authentication methodology. The relevant “fingerprint” is represented by the optical losses light suffers along different paths from the cornea to the retina. The “fingerprint” is accessed by interrogating a subject on perceiving or not weak light flashes, containing few tens of photons, thus probing the subject’s visual system at the threshold of perception, at which regime optical losses play a significant role. The name “quantum biometrics” derives from the fact that the photon statistics of the illuminating light, as well as the quantum efficiency at the light detection level of rod cells, are central to the method. Here we elaborate further on this methodology, addressing several aspects like aging effects of the method’s “fingerprint,” as well as its inter-subject variability. We then review recent progress towards the experimental realization of the method. Finally, we summarize a recent proposal to use quantum light sources, in particular a single photon source, in order to enhance the performance of the authentication process. This further corroborates the “quantum” character of the methodology and alludes to the emerging field of quantum vision.",book:{id:"11195",title:"Recent Advances in Biometrics",coverURL:"https://cdn.intechopen.com/books/images_new/11195.jpg"},signatures:"Iannis Kominis, Michail Loulakis and Özgur E. Müstecaplıoğlu"},{id:"81260",title:"Biometrics of Aquatic Animals",slug:"biometrics-of-aquatic-animals",totalDownloads:25,totalDimensionsCites:0,doi:"10.5772/intechopen.102957",abstract:"This chapter is a part of the book “Recent advances in biometrics” introduces the importance of biometrics in the aquatic studies in brief view. Biometric measurements (Morphometric, meristics and description) are widely used in various fields’ “taxonomy, species identifications, monitoring of pollution, species abnormalities, comparison, environmental changes, growth variation, feeding behavior, ecological strategies, stock management, and water quality of aquaculture. These data were collected from several articles and books of aquatic animals and presented both applications and required considerations for biometric implementations. It is important also to detect sexual dimorphism, adaptations during evolutionary time and diminishing intraspecific competition by increasing niche portioning. The biometrics could be applied for various aquatic organisms as dolphins, sharks, rays, mollusca, crustaceans, protozoa, … etc. and for specific organs like teeth, otolith and appendages by different techniques and preservations. Scientists are still applying these measurements even with the presence of advanced techniques like PCR as they are low in cost, faster and more applicable. This chapter also presented some recent trends including animal’s biometric recognition systems, followed by challenges and considerations for the biometrics implementations. It is recommended to apply biometrics in wide range together with modern techniques considering the specificity of its quality and preservation status.",book:{id:"11195",title:"Recent Advances in Biometrics",coverURL:"https://cdn.intechopen.com/books/images_new/11195.jpg"},signatures:"Mahmoud M.S. Farrag"},{id:"80748",title:"Behavioral Biometrics: Past, Present and Future",slug:"behavioral-biometrics-past-present-and-future",totalDownloads:66,totalDimensionsCites:0,doi:"10.5772/intechopen.102841",abstract:"Behavioral biometrics are changing the way users are authenticated to access resources by adding an extra layer of security seamlessly. Behavioral biometric authentication identifies users based on a set of unique behaviors that can be observed when users perform daily activities or interact with smart devices. There are different types of behavioral biometrics that can be used to create unique profiles of users. For example, skill-based behavioral biometrics are common biometrics that is based on the instinctive, unique and stable muscle actions taken by the user. Other types include style-based behavioral biometrics, knowledge-based behavioral biometrics, strategy-based behavioral biometrics, etc. Behavioral biometrics can also be classified based on their use model. Behavioral biometrics can be used for one-time authentication or continuous authentication. One-time authentication occurs only once when a user requests access to a resource. Continuous authentication is a method of confirming the user’s identity in real-time while they are using the service. This chapter discusses the different types of behavioral biometrics and explores the various classifications of behavioral biometrics-based on their use models. The chapter highlights the most trending research directions in behavioral biometrics authentication and presents examples of current commercial solutions that are based on behavioral biometrics.",book:{id:"11195",title:"Recent Advances in Biometrics",coverURL:"https://cdn.intechopen.com/books/images_new/11195.jpg"},signatures:"Mridula Sharma and Haytham Elmiligi"},{id:"80726",title:"Image Acquisition for Biometric: Face Recognition",slug:"image-acquisition-for-biometric-face-recognition",totalDownloads:45,totalDimensionsCites:0,doi:"10.5772/intechopen.102767",abstract:"Biometrics is mostly used for authentication purposes in security. Due to the covid-19 pandemic situation, nowadays distance-based authentication systems are more focused. Face recognition is one of the best approaches which can use for authentication at distance. Face recognition is a challenging task in various environments. For that taking input from the camera is very important for real-time applications. In this chapter, we are more focusing on how to acquire the face image using MATLAB. The complete chapter is divided into five sections introduction, definition of biometrics, image acquisition devices, image acquisition process in MATLAB.",book:{id:"11195",title:"Recent Advances in Biometrics",coverURL:"https://cdn.intechopen.com/books/images_new/11195.jpg"},signatures:"Siddharth B. Dabhade, Nagsen S. Bansod, Yogesh S. Rode, Narayan P. Bhosale, Prapti D. Deshmukh and Karbhari V. Kale"},{id:"80351",title:"Feature Extraction Using Observer Gaze Distributions for Gender Recognition",slug:"feature-extraction-using-observer-gaze-distributions-for-gender-recognition",totalDownloads:56,totalDimensionsCites:0,doi:"10.5772/intechopen.101990",abstract:"We determine and use the gaze distribution of observers viewing images of subjects for gender recognition. In general, people look at informative regions when determining the gender of subjects in images. Based on this observation, we hypothesize that the regions corresponding to the concentration of the observer gaze distributions contain discriminative features for gender recognition. We generate the gaze distribution from observers while they perform the task of manually recognizing gender from subject images. Next, our gaze-guided feature extraction assigns high weights to the regions corresponding to clusters in the gaze distribution, thereby selecting discriminative features. 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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. 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