Hemorrhagic diatheses–adapted from Vezeau [15] and Goswami et al. [16].
\r\n\tGlobalization does not represent a pure and generous process for humanity or other species, but rather it implies social exclusion and also provokes situations of vulnerability in groups of people, forced exclusion, and apartheid: poor job opportunities, lack of access to education, worse socio-sanitary conditions. Specifically, it can be said that social segregation entails the apartheid of social groups of different ages, genders, and ethnicities; these groups live a reality manifested through the deepening of poverty, in terms of increased vulnerability of the poor and groups with little economic, social, cultural, labor and health stability.
\r\n\r\n\tThis book aims to talk about some topics that are neglected in the discourses of academic communities and political elites. The inequality process is deeply rooted among humans and is part of many people's lives in the form of modern apartheid, gender segregation, lack of health access, and cultural gap. All those structural inequality processes are the product of the biopower perpetuated and produced in the macrosystem, exosystem, mesosystem, and microsystem. For many people from the academy, the information-consuming public, and the society in general, it is a problem to talk about these processes, since they have either lost interest or have normalized the structural and social inequity. For this reason, we see it as transcendental to explain how this situation occurs from the most internal fibers to the most evident processes, intending to make it more visible and thus expose the situation for possible solutions.
",isbn:"978-1-83768-406-9",printIsbn:"978-1-83768-405-2",pdfIsbn:"978-1-83768-407-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"cefab077e403fd1695fb2946e7914942",bookSignature:"Ph.D. Yaroslava Robles-Bykbaev",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11473.jpg",keywords:"Wage Gap, Gender Segregation, Fundamental Human Rights, Health Access, Social Inequity Processes, Modern Apartheid, Resilience, Cultural Gaps, Globalization, Geopolitics of Social Inequality, Public Policies, Social Vulnerability",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 15th 2022",dateEndSecondStepPublish:"July 13th 2022",dateEndThirdStepPublish:"September 11th 2022",dateEndFourthStepPublish:"November 30th 2022",dateEndFifthStepPublish:"January 29th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"13 days",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Bykbaev is a member of the UNESCO Chair of Politecnica Salesiana University. 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“Soma” means the body. “Psychosomatic” diseases in psychiatry are mainly due to psychological causes that are not based on an organic etiology or physical disorders.
\nIt is currently believed that conscious or unconscious emotions, thoughts, and behaviors are also effective in psychosomatic disease in biological organisms and should be evaluated together with the dual thoughts related to the body and mind status. The patient may use more atypical and exaggerated expressive words from time to time when defining psychogenic pain. The localization and periodicity of the patient’s pain can also be persistently atypical. The pain of the patient usually begins after some important life events and stresses. The emotional burden of the factors stimulating and triggering pain is reflected in the patient’s voluntary posture and the relevant muscle groups. A psychological dimension, depression and anxiety are usually noted among the accompanying symptoms. It is noteworthy that the characteristics of the pain do not conform to anatomical facts and physiological functioning. Besides, the response to analgesics is also often atypical. Accompanying symptoms such as anger, impatience, helplessness, boredom, and restlessness must be considered in patients with psychological pain.
\nBoth psychosocial and biological factors always play a role in the development and pathophysiological mechanism of psychogenic pain [1, 2, 3, 4].
\nThe
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The following criteria must be present to make a diagnosis of a psychosomatic disorder according to the DSM-IV:
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Stress is one of the major causes of psychosomatic diseases. Stress causes many bodily functions to deteriorate or not work properly.
The most common trigger of psychosomatic diseases is loss and separation.
The American Board of Medical Specialties and the American Psychiatry and Neurology Board have approved specialization in psychosomatic medicine in 2003. This decision has emphasized the importance of this field and also reintroduced the widespread use of the “psychosomatic” term [1, 2, 3].
\nThe Diagnostic Criteria for Psychosomatic Research (DCPR) are considered to be more explanatory than the DSM-IV [1, 2, 3].
\nPersistent somatization subjects with a psychosomatic disorder are believed to have a higher incidence of other nonfunctional system (chronic fatigue) syndromes in the future with this approach, and these are called “multisomatoform disorder,” “pure somatization,” or “chronic somatization.” The functional somatic symptoms secondary to a psychiatric disorder are as follows:
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It is important to have knowledge about the pain and its variety before psychosomatic pain, because pain can cause psychosomatic problems as well as result.
\nPain is thought to be an important clinical and socioeconomic problem all around the world. We investigated the incidence, prevalence, and economic burden of pain conditions in children, adolescents, and adults based on the electronic scanning of databases for articles published between 2000 and 2014 in this review. Differences in methodology and the epidemiological studies make it difficult to give precise predictions of prevalence and incidence; however, the economic burden of psychosomatic pain is clearly high. There is a need to develop concepts and methods to examine pain from a population perspective and to advance the development of pain prevention and management strategies. Family physicians and clinicians have great responsibilities in the diagnosis and treatment of pain and especially psychosomatic pain within this context. The participation of physicians in multidisciplinary training and studies is also a fundamental principle [3, 5].
\nIt is appropriate to explain psychosomatic pain primarily in accordance with general principles. Pain is a defining characteristic in the diagnosis of many diseases. It can serve as an index of the symptoms and activity of the disease or diseases and as a prognostic indicator and a predictor of the use of health care for the underlying etiology [1, 2]. The International Association for the Study of Pain (IASP) and the World Health Organization (WHO) describe pain as “an unpleasant sensory and emotional experience associated with or described in relation to real or potential tissue damage or associated with such damage,” “an unpleasant sensory and emotional experience associated with existing or possible tissue damage or associated with such damage,” and “a protection mechanism” [2].
\nAn overview of the epidemiology and economic burden of pain conditions in children, adolescents, and adults is summarized below under the relevant headings. The incidence and prevalence of pain conditions as well as the risk factors and the effect of pain on individuals have also been described. The wide range of pain conditions in clinical and research areas include pain in children and adolescents, spinal pain, neuropathic pain, musculoskeletal pain, and fibromyalgia/chronic diffuse pain. In addition to the factors associated with the prevalence of pain, the individual, economic, and social burden of pain conditions should also be considered.
\n\n
According to neurophysiological mechanisms
Nociceptive
Somatic
Visceral
Neuropathic (non-nociceptive) central or peripheral
Psychogenic
According to the duration
Acute
Chronic
According to the etiologic factors
Cancer pain
Postherpetic neuralgia
Pain due to sickle cell anemia
Arthritis pain
According to the pain region
Headache
Facial pain
Low back pain
Pelvic pain
Before making a diagnosis of
Describing the epidemiology of pain is difficult because of the subjective nature of symptoms and the lack of consensus on the definitions of specific diagnoses and conditions. It is problematic to identify pain areas, especially with musculoskeletal pain. Many pain conditions are episodic, and the majority of patients express recurrent symptoms at varying intervals and durations during periods with and without pain. The actual incidence of most pain conditions may therefore remain unknown.
\nSimilarly, study results vary due to differences in the identification of diffuse pain cases and the specific diagnosis. While case definitions may also vary depending on the duration, intensity, or psychological burden of pain in the patient, the diagnoses are based on subjective patient experience, clinical tests, or results of imaging and pathological studies. It may be difficult to compare studies reporting different periods of prevalence (e.g., timepoint, weekly, monthly, lifetime) [5].
\nPain conditions in children and adolescents have gradually become the focus of the scientific literature in recent years. The occurrence of pain in children evidence as indicates childhood or adolescence pain can predict adulthood pain. Children with pain discontinue their education or become withdrawn. Physical inactivity is a possible result. Low back pain, headache, and abdominal pain are the most common types of childhood and adolescence pain.
\nThe reported 1-year incidence of low back pain in children and adolescents varies from 11.8 to 33.0% (median, 22.4%), while the 1-month prevalence varies from 9.8 to 36.0% (median, 22.9%). Since there are a lower number of studies on the prevalence of neck pain (49.0%) and upper back pain (30.0%), some doubt remains about the accuracy of these predictions. A systematic review of chronic pain epidemiology in children and adolescents (pain continuing for more than 3 months) has reported that the 1-month prevalence of chronic back pain was between 18.0 and 24.0% (median, 21.0%) [6, 7, 8, 9]. In addition to these predictions obtained from systematic reviews, the 1-month prevalence of low back pain was reported to be 37.0% in more than 400,000 children and adolescents aged 11–15 years [10, 11, 12, 13, 14].
\nThe predicted 1-month headache prevalence in children and adolescents is 26.0–69.0% (median, 47.5%) in systematic investigations. Swain et al. have reported this figure to be 54.1% in a survey based on 312 schools [15]. Recurrent abdominal pain (at least three episodes that limit the child’s functions for at least 3 months) is the focus of most childhood and adolescence pain studies [16]. Recurrent abdominal pain prevalence has been reported as 0.3–19.0% (median, 8.4%) [17] and 3.8–41.2% (median, 12.0%) [7]. Childhood and adolescence monthly multiple pain prevalence was 12.1–35.7% (median, 23.9%).
\nFurther studies on pain epidemiology in children and adolescents are still required to evaluate the effect of age on the pain prevalence. The effects of the increased pain rates in childhood and adolescence and of the transition to adolescence on the incidence and prevalence of pain conditions are not clear at present [17].
\nSpinal pain, and especially low back pain, is a common problem that most people experience at a certain point in their lives. The lifetime prevalence of low back pain is reported to be between 51.0 and 84.0%. There are many studies on the epidemiology of low back pain compared to other pain conditions.
\nPredictions for the 1-year first low back pain events varied between 6.3 and 15.4% (median, 10.9%) in one review [18] and between 13.5 and 26.2% (median, 19.9%) in others [11, 16, 18, 19, 20, 21, 22]. Predictions of the 1-year incidence of low back pain events (including patients with previous episodes) vary between 1.5 and 38.9% (median, 20.2%). Many people who experience activity-limiting low back pain recover quickly [23], but some have recurrent pains [24]. Predictions for the 1-year recurrence vary between 24.0 and 80.0% (median, 52.0%) [18].
\nImportant information is present on the prevalence of low back pain. The 1-month prevalence is predicted to be between 24.0 and 49.5% (median, 36.8%) [25]. The prevalence of thoracic spine pain varies between 1.4 and 34.8% (median, 18.1%) [26], while the 1-month prevalence of neck pain varies between 15.4 and 45.3% (median, 30.4%) [27].
\nChronic low back pain (CLBP) is usually defined as low back pain continuing for more than 12 weeks [28]. The prevalence of CLBP in the general European population has been predicted as 5.9–18.1% (median, 12%).
\nNeuropathic pain has been defined by the International Association for the Study of Pain as “pain caused by a lesion or disease of the somatosensory nervous system” [29]. It is differentiated from other inflammatory conditions by characteristic signs and symptoms such as “burning” or “freezing,” numbness, tingling, or “pins and needles” sensations [29]. There are only a few studies on the incidence and prevalence of neuropathic pain in the population.
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Musculoskeletal system disorders are among the most common causes of disability and incapacity, especially in the elderly [32]. Upper extremity pain is also common; monthly shoulder pain symptoms are present in 18.6–31.0% (median, 24.8%) of adults [33]. Monthly knee pain prevalence in adults is 13.0–28.0% (median, 20.5%) [34]. The prevalence was 28.0, 15.0, and 14.0% for foot ankle and toe pain in a review combining the reported figures [35].
\nChronic diffuse pain is defined as the presence of chronic pain with diffuse localization [36]. The American College of Rheumatology defines chronic diffuse pain as bilateral axial skeleton pain continuing for 3 months or more in its 1990 guidelines [37]. Fibromyalgia diagnostic criteria have been defined using the same definition [38]. Some fibromyalgia prevalence figures are 2.0–5.0% in the USA, 0.7% in Denmark, and 10.5% in Norwegian women. Fibromyalgia is a clinical diagnosis similar to other chronic pain conditions, and the lack of a clear definition therefore limits the comparison of prevalence predictions. The diagnostic criteria for fibromyalgia in the American College of Rheumatology’s 2010 Criteria include the evaluation of diffuse pain together with the other symptoms (such as fatigue and cognitive symptoms) to develop a more specific case definition [38]. Future studies on the epidemiology of fibromyalgia are likely to increase the accuracy of current prevalence predictions by using this definition [39].
\nOnly a few studies have evaluated the prevalence of pain conditions, and most have focused on the prevalence of low back pain. Palmer et al. [40] reported that the 1-year prevalence of low back pain increased by 12.7% over a 10-year period from 1987 to 1997, and this increase was associated with gender, age group, social class, and residence area. A contrasting decrease in the 1-month prevalence from 26.1 to 22.6% has been reported over a 7-year period in another study [41]. The chronic low back pain frequency In the USA has increased from 3.9 in 1992 to 10.2% in 2006 [42].
\nPain, and especially chronic pain, creates a significant burden for patients and their families. It adversely affects the general health perception, significantly inhibits daily activities, is associated with depressive symptoms, and significantly and negatively affects the relationships and interactions with others. The World Health Organization Global Burden of Disease uses the term “disability” to assess the potential for non-mortality-related disease. They define disability as any short- or long-term loss of health [43]. Disability-adjusted life years (DALYs) and years lived with disability (YLDs) are needed to measure and compare the limitations of a wide range of disorders associated with pain. Pain-related disorders that are characterized or defined by the presence of pain (low back pain, neck pain, other musculoskeletal disorders, migraine, and falls) constitute 5 of the top 10 conditions responsible for YLDs in the world. Acute low back pain has caused 83 million DALYs, and according to the effects of the chronic types of back pain, this constitutes 10.7% of all YLDs [43]. Neck pain and migraine/headache each account for about 24 million DALYs. Other musculoskeletal disorders are responsible for 28 million DALYs and traumas due to falls for 19 million DALYs. Other important contributions include osteoarthritis (17 million DALYs) and accident-related injuries (13 million DALYs) [44]. These results for 1990 and 2010 supersede all previously published Global Burden of Disease results.
\nIt is difficult to determine the factors initiating pain episodes in the population as studies only specify an estimate due to the differences in the methodology and reporting. It is necessary to focus on the main risk categories such as age, gender, social group, and individual factors. Generally, there is no evidence for the risk factors of pain. Future studies that evaluate all aspects of the pain experience from both the individual and the population point of view are needed. These studies must employ multidimensional methods in the case of psychosomatic pain.
\nStudies on pain in children and adolescents have shown that females generally suffer more pain than males. The relationship between pain and gender is clear in adults. Females report more severe pain, more frequent pain, and longer-lasting pain than males in most studies. However, it is not known whether this gender difference is due to underlying biological pain mechanisms or the effects of psychological and social factors.
\nAs regards age, the prevalence of some pain disorders such as back pain increases from childhood to adolescence. The effect of age is not relevant on the pain prevalence in the elderly as some studies report that it increases, while others report it decreases with age. The effect also varies by gender and the pain location [41]. It is believed that musculoskeletal pain is most common in adults in the employment age and the prevalence therefore decreases from the middle of the sixth decade [41]. However, recent studies have shown that pain continues to be a widespread and serious problem in the elderly. The prevalence of chronic pain in the active elderly (>65 years) varies between 25.0 and 76.0%, while it is much higher in the sedentary elderly at between 83.0 and 93.0% [41].
\nThe role of social factors continuously increases throughout life [45]. The socioeconomic status is usually measured by the complex created by education, income, and occupation. Many studies in children and adolescents have evaluated the relationship between pain and socioeconomic status, but there is some evidence of a conflict between these studies [7]. An inverse relationship is present between the socioeconomic status and pain prevalence in adults. The data show that lower educational status, low income, and being unemployed are related to increased pain prevalence [5].
\nMore recently, pain prevalence studies have been conducted in populations of various cultural, ethnic, and socioeconomic statuses. Native Americans, Alaska Natives, and Aboriginal Canadians have been found to have a higher prevalence of pain than the general population of the United States [45]. Studies in Africa have found the 1-year prevalence of pain to be 33.0% in adolescents and 50.0% in adults [46]. This value is higher than reported in studies conducted in most Western countries (mean prevalence of 38.1%) [25]. However, it is difficult to make a definite comparison due to the differences in methodology. Another study based on the World Bank Human Development Index has reported the prevalence of chronic pain to be 24.8% in less developed countries and 28.1% in more developed countries [47].
\nVarious individual risk factors have been associated with the development of pain disorders. The demands of employment, lack of job security, an immobile job position, dissatisfaction with work, low levels of social support at work, and vibrating bodily work conditions have been associated with various occupational factors that lead to musculoskeletal pain. Individual lifestyle factors that create health problems such as smoking and obesity can also play a role in the development of pain disorders [34]. The psychosocial variables believed to influence the pain prevalence include stress, anxiety, lack of sleep, depression, low self-confidence, and the presence of chronic health problems (irregular heartbeat, dizziness, pain, cardiovascular problems, gastrointestinal discomfort, erectile dysfunction, feeling of lump or pressure in the throat, chest problems, hallucinations, and double vision).
\nPain and disorders that are not clearly attributable to an organic disease are called somatoform disorders. These disorders can be an expression of untreated mental pain and life experiences resulting from serious loss, profound personal injury, and disrespect. These symptoms occur in almost all humans, but they can become a serious problem in 4–20% of the population [1, 2, 3, 5, 6, 7, 8, 9, 48].
\nGenetic research on pain is increasing, and chronic pain is being seen as a classic example of the gene–environment interaction [49]. It is generally believed that the first trigger of chronic pain syndromes are inflammatory processes or nerve trauma. Once chronic pain develops, the pain intensity and response to analgesics are also quite variable. However, evidence is lacking regarding the influence of genetic effects and the interaction with psychosocial environmental factors as regards the development of chronic pain. Patients with chronic pain feel that the cause is life challenges, but the disease also makes life more difficult. This contradictory approach is related to the importance attributed to the pain. A person with intrapsychic conflict may not have to express the problem verbally and may have to use the organs to do so (alexithymia).
\nThe presence of enhancers in the environment: one example is caring for one’s wife when she has pain but not caring when she does not. Other examples are as follows: finding comfort by suffering pain for a bad action; excessive interest in pain and then relaxing when the test results are normal (somatization); and feeling sure an illness is present and changing physicians frequently (hypochondriasis).
\nType A persons (hasty, impatient, hyperactive) perceive pain more easily than type B persons (calm, cool), probably due to autonomic hyperactivity. The risk of hypertension and coronary heart disease is 3–5 times higher in type A persons [50, 51].
\nThe cumulative cost of chronic pain to the patient, the health-care system, and the economy is huge. In Australia, with a population of 22.7 million, the total annual cost of chronic pain was estimated as 34.3 billion dollars in 2007 or 10.847 dollars per person [52]. The total cost in Europe is estimated as 1.5–3.0% of the European GDP [53]. In the USA, approximately 100 million adults have been affected by chronic pain in 2008, including joint pain and arthritis [54]. The total cost in 2010 was 560–635 billion dollars. The annual cost of pain is higher than that of heart disease (309 billion dollars), cancer (243 billion dollars), and diabetes (188 billion dollars) [53, 55, 56, 57, 58, 59, 60].
\nThe term psychosomatic means the person. It combines two basic components, including the mind and the body. The reason is that physical complaints are at the forefront. However the research will investigate if there are any physical symptoms to explain such bodily complaints.
\nThere is no medical illness, and this is a definable psychiatric disorder.
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Pain experts still do not know whether pain is one of the senses or an experience. The fact that pain can be learned and that it can be affected by beliefs, expectations, and emotional states is quite important in its diagnosis and treatment. It is known that psychological disorders increase pain, while extreme fear, stress, and shock decrease pain. Many studies have reported that cultural norms and expectations play a major role in feeling pain and the related behavior.
\nThe gate control system that monitors pain is especially influenced by neurotransmitter modulation that is associated with cortical stimulants in anxious subjects. The lack of an adequate 5-hydroxyl tryptamine (5HT) level in the synapse disturbs pain perception and decreases the pain threshold and pain tolerance [50, 51].
\nThe physical and psychological problems of the person described under the following titles also play a role in psychosomatic pain.
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Emotional crises and chronic distress can lead to various psychosomatic complaints. The whole organism can be affected and the effects are therefore not listed here.
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Somatoform pain disorder is characterized by intense and agonizing pain that is subjectively felt in a part of the body for at least 6 months and that cannot be reasonably explained by a physical disorder or physiological event. The onset of the pain is related to a significant problem that has created serious emotional and/or psychosocial stress, conflict, or trauma. The increased interest in the person and the medical care received are the possible gains from the disorder. When compared with somatization disorders, these pains are long-lasting, and the patient focuses on them. The differential diagnosis of pain syndromes requires differentiation of organic physical pain from histrionic processing.
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The absence or modification of physical functions without a physical cause is usually the result of an intrapsychic conflict and can lead to psychogenic paralysis, coordination disorders, tremors, and myoclonus (muscle twitching).
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Major depression affects the entire body including the metabolism and the musculoskeletal system. Inactivity or pain syndromes may be present. The pain, lack of exercise, social withdrawal, smoking habits, and malnutrition lead to significant difficulties in the patient’s life.
\nThe patient comes to the doctor because of the somatic complaints as he/she has usually not noticed the depression: it is therefore not an independent disease. It is possible to determine the real psychic etiology during the examination if retrospective evaluations are also performed. Neurobiological studies have demonstrated that somatic symptoms are associated with brain dysfunction that is also responsible for depression. Psychological pain and emotional pain have been shown to cause activation of the same sites as physical pain stimuli on MR investigations.
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The documentation of neuroendocrine abnormalities in cases of depression and pain have revealed the parallel course of the functional changes in depression and pain and the hypothalamus-hypophysis-adrenal axis with excess production of corticotropin-releasing hormone (CRH). It is also known that a deficiency in the serotonin and norepinephrine monoamines can play an important role in the decreased inhibition of pain pathways and the development of somatic symptoms in depression [50, 51].
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Masked depression can have various symptoms. Urogenital system symptoms include dysuria, painful urination and defecation, signs of urinary and fecal incontinence, functional prostate problems (prostatitis), and bladder dysfunction in women without additional genital muscle weakness. There may also be upper abdominal discomfort, bloating, colic-like abdominal discomfort, stomach pain, and constipation [51].
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Negative emotions such as fear and anger permanently weaken our immune system and defense. The risk of catching infections such as influenza increases many times, and wounds heal slower and in a worse manner.
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Sleep problems are common when pain is present. Lack of sleep affects both the social life and performance of the patient. Fatigue can lead to depression and accidents. Sleep disorders have various signs such as difficulty falling asleep, waking up frequently and quickly, long period of staying awake during the night, being irritable, superficial sleep, loud and irregular snoring, leg restlessness, waking up early in the morning, and disturbing thoughts. Anger and hopelessness can also have a strong effect on sleep disorders.
\nIt has recently been found that our brain is active in a very special manner during sleep. The brain sends impulses, produces active substances, and is involved in coding and storing data 24 h a day with its 100 billion nerve cells, and it is the organ that benefits most from a good night’s sleep. This has been demonstrated with decreased brain capacity when we get little sleep. The first sign of cerebral fatigue is difficulty with concentrating and performing coordinated tasks such as driving or tasks that require a great deal of attention. We then become irritated and feel pain because of the related fatigue.
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Snoring during sleep is present in 10–30% of adults and it is usually not dangerous. However, pauses in respiration during sleep are an indicator of sleep apnea syndrome, which affects approximately 3 million people in Germany alone. The most common type of the disorder is “obstructive sleep apnea.” The pharyngeal muscles relax excessively and do not let air pass, leading to a pause in the respiration during sleep. This breathing problem goes on for about 2 min, usually with explosive snoring, and the subject then starts to breath normally again. In severe cases, these periods of paused respiration can recur hundreds of times every night. These patients are usually prone to falling asleep during the day, and the muscles can be weak and painful.
\nThe most important diagnostic step in the diagnosis of sleep apnea syndrome is talking to the patient and family. In case of increased sleep apnea suspicion, the next step is a sleep laboratory investigation. Electrodes record the ECG, blood pressure, and brain waves; observe movements of the eyes and legs; measure the oxygen content of the blood; and record each snoring and breathing sound during this test.
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Our breathing becomes quite shallow in case of stress, depression, or sadness. The lungs receive less oxygen and can provide less oxygen to the blood, increasing the risk of infection. Pneumonia is five times more common in the elderly than in healthy subjects.
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Somatization disorder and pain syndromes develop after a heart attack in approximately 30% of all patients. A heart attack is experienced as a “spontaneous infarction.” Physician appointments are frequently avoided and the recommended medication is not used. This increases the risk of new infarction development two to four times when added to the biological changes in the metabolism.
\nThe infarction risk is increased several times (deaths due to a heart attack are four to five times more common in depression patients). The more severe the somatization disorders, the worse the prognosis of a heart disorder. Factors such as emotional stress, dissatisfaction with work and the partner, anxiety, and long-term stress increase the heart attack risk more than classical risk factors such as smoking and high blood pressure.
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The reason for white hair is mineral deficiency in the hair and scalp, and there can be several causes: decreased nutrition due to age, acidity or nutritional disorder, and psychological reasons. Mineral intake is decreased with fear or stress, resulting in hair loss or white hair.
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The metabolism slows down and the body functions deteriorate during stress. Free radicals that attack the skin cells and slow down the regeneration of the natural protective layer are created. The skin ages faster and spots develop. The face appears stressed.
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Gastric absorption becomes difficult in patients with repressed emotions, anger, or anxiety. The stomach becomes tense with stress and anger, leading to increased gastric acid secretion. This in turn causes heartburn and can result in gastric ulcer, bloating, nausea, and cramps. Many subjects suffer from irritable stomach or irritable colon. Psychological components also play a role. Excitement and anxiety increase irritable stomach or irritable colon symptoms.
\nIt is very important to investigate the relationship of psychosomatic pain in many patients admitted between orthopedics and traumatology clinics. In this context;
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Depression leads to a long period of internal stress and increased muscle tension, causing a predisposition to motility disorders, immobility, and arthritis. The patient usually sees an orthopedist before going to a neurologist.
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Patients suffering from depression for a long time can be exposed to fractures more commonly as the mineral content of bone is decreased. Heavy psychological burdens can significantly decrease the blood oxygen content in the elderly as the breathing becomes superficial. The cells cannot receive adequate nutrition and renewal deteriorates. Inflammation and arthritis can develop in the joints.
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Orthopedic surgeons believe that back pain is the result of emotional problems, not organic ones, in most cases. If job dissatisfaction is high, the person feels overwhelmed and does not seek solutions to change the circumstances, leading to a high risk of pain as the spinal system reacts very strongly to mental stress.
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Approximately 6% of Germans are affected by neuropathic pain. At least 20% of the patients at pain centers suffer from neuropathic pain syndromes. Peripheral neuropathies can commonly develop after postherpetic neuralgia or trauma. Generalized neuropathies include those due to chemotherapy and diabetic neuropathies.
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Nociception is the perception of pain. The responsible receptors are called nociceptors. Nociceptors are present in all the pain-sensitive tissues of the body as the free nerve ends of sensitive neurons of the spinal cord. Nociceptors trigger various types of pain according to their localizations:
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Myofascial pain has local causes. Individual muscles are affected more intensely by chronic pain than muscle groups. Individual muscles contain trigger points that signify very sensitive areas. Overloading of the muscle can prevent excess calcium intake and the related muscle relaxation and therefore create localized oxygen deprivation.
\nLong-term contraction treatment becomes difficult in the case of myofascial pain. The sensitivity leads to the corresponding areas creating a perception of pain even with mild contact, and these areas are therefore called trigger points.
\nExcessive stress on such muscles can be the result of muscle damage, inadequate nutrition, hormonal imbalances, immobility, muscle weakness, hypothermia, contractions, and neurological damage.
\nMyofascial pain mainly develops in the
Psychotherapy in the treatment of pain can be explained as follows:
\nPatients with psychosomatic pain may have had a very disturbing experience in the past. This event can create links with the memory and senses, and the traumatic disorder may occur at any time when the present experience is once again dominant. Psychological stress may also cause physical illnesses. Within the soul-soma-soul sequence, an ever-growing chain of causes can be present. Life-threatening diseases such as cancer or myocardial infarction and the relevant medical interventions can also lead to mental trauma.
\nTraumas, undesirable social experiences, accidents, or stressful experiences have been scientifically proven to be the most common triggers and the causes of many physical disorders, pain, and other illnesses without a physical cause. Changes related to psychological trauma in the brain can now be scientifically demonstrated by imaging (such as fMRI, a magnetic resonance method) and other diagnostic methods. Brain structure and brain metabolism are altered by the corresponding changes in the autonomic nervous system during the stress process. The entire spectrum of mental trauma should be considered. Psychotherapy for psychosomatic pain due to trauma is performed in three stages and with multiple sessions.
\nThere are some fundamental differences between type I and type II trauma.
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The results of type II trauma include the consequences of childhood and long-term adult violence. This violence can also be mental as seen with coldness, extreme violence and indifference, emotional wounds, and frequently repeated trauma, especially in childhood. Type II traumas can lead to complex symptoms as in borderline disorder with comorbidities.
\nA three-stage model is used for the treatment of disorders that are psychosomatic or accompanied by pain. These stages consist of
It is not mandatory to include each stage in every treatment process. Stabilization is the foundation of all treatment steps. It can be integrated into other therapeutic methods such as specific interventions for trauma, behavioral therapy, systemic treatment, or deep psychology-associated therapies.
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Sufficient time is allocated to get to know the patient and to create the basis of trauma therapy while building a mutually trusting relationship.
\nThe stabilization stage creates a foundation for a common understanding of the clinical picture. An objective viewpoint is obtained about the emotions as much as possible. Anxiety and depression are responses to psychologically disturbing experiences and the emotional dissociations within the patient or those around him/her. An emergency state plan is developed together with the patient at this stage. Relaxation techniques such as meditation or Jacobson’s progressive muscle relaxation are then used as guides for self-passivation techniques, and the patient thus learns the relevant methods to use the powers of healing within.
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Behavioral therapy for the confrontation state has been specifically designed to treat phobias and anxiety. Cognitive behavioral therapy and especially systematic desensitization techniques are used. The aim is to re-evaluate the traumatizing event.
\nSpecial therapeutic procedures for trauma are also used such as eye movement desensitization and reprocessing (EMDR), imagery rescripting and reprocessing therapy (IRRT), and psychodynamic imaginative trauma therapy (PITT).
\nEye movement desensitization and reprocessing has been developed by the American psychologist Francine Shapiro (* 1948). The literary translation indicates “eye movement, desensitization and reprocessing.” This method is not hypnosis. When the patient focuses on an especially stressful stage of the emotionally traumatic experience, the therapist slowly asks the patient to perform rhythmic eye movements by slowly moving his fingers and gives the patient confidence. This stimulates cerebral processes. The aim is to decrease and even eliminate the fears produced by the memories. More than 20 controlled studies have shown the long-term effect of EMDR. EMDR is also included in guidelines as a preferred procedure.
\nImagery rescripting and reprocessing therapy has been developed by the American clinical psychologist Mervin Smucker (* 1949). A traumatizing experience is created together with the therapies as though it had happened today. The patient imagines how he dealt with it in the past and how he is dealing with it now. The patients no longer view themselves as helpless victims and feel they are the designers of the condition who can act and maintain control even in the most difficult situations. We can think about it as deleting an old text and then writing over it.
\nPsychodynamic imaginative trauma therapy has been developed by psychoanalyst Luise Reddemann (* 1943). PITT is based on the idea that people have self-regulating powers to cope with disturbing events even after terrible experiences. Establishing a supportive therapeutic relationship is very important for such self-understanding, and it is also important for helping oneself. At the heart of PITT’s therapeutic approach is the “internal phase” that the person is currently acting on.
\nIn this mental “imaginary” game, the patient confronts the previous ego states with the therapist’s support. Understanding the multiple egos in the consciousness comes from a scientific and philosophical tradition that has been present in all cultures for a thousand years, and the treatment relies on a systemic approach to therapy. With PITT, you can experience the injustice you have experienced and the area where you feel helpless from a safe distance. The patient learns to accept this part of his personality and to relax and make others relax at the same time. The patient also learns to heal his/her emotional wounds and therefore regains his/her confidence.
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This is the moment the joy of living and the relevant control are regained and understood.
\nThe aim of this stage is to gradually integrate the traumatic experiences of the patient into his/her consciousness. These events are parts of the person’s life, and control over life and social integration can be achieved once again by confronting these events [4, 61, 62, 63, 64].
\nOur understanding of the epidemiology of psychosomatic pain is limited to a small number of studies that provide estimates of the prevalence in the general population. These studies are usually difficult and costly to conduct and require very large samples. The way data is collected and reported may also have an impact on the estimates with various results obtained from studies that depend on surveys, interviews, or clinical investigations. Large-scale population-based studies can provide richer data related to the age and gender distribution of pain, and assessments over extended periods of time can provide comprehensive information about the incidence and risk factors. Epidemiological studies in various cultural, social, and ethnic groups can clarify the effects and also the interactions between the individual and population-based risk factors. Physicians should be able to understand the information related to psychosomatic pain, search the relevant information available, and perform research on the subject themselves.
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All surgical procedures, including dental surgery, present risk of complications, which may include pain, nerve injury, swelling, infections, and hemorrhage. Dental surgery is defined as any dental intervention including an incision in the oral mucosa or gingiva, including anything from a simple dental extraction to alveoloplasties [1]. Bleeding control is an important step during dental surgery procedures [2] because excessive bleeding complicates surgery and increases the risk of morbidity. To avoid such complications when long-lasting bleeding occurs, despite the proper use of traditional techniques for hemorrhage control, a broad range of hemostatic agents are available, as adjunctive measures to enhance hemostasis in the course of dental surgeries [3]. Despite the expressive rise in the amount and types of topical hemostats in the past decade, high-level evidence regarding the management of these agents during bleeding in dental surgery is still lacking.
\nThe periprocedual management of patients receiving therapeutic anticoagulation represents a challenge for dental practitioners, as the risk of bleeding must be counterbalanced against the risk of systemic or local thromboembolic phenomena. Recommendations for dental interventions in individuals receiving anticoagulation therapy remain quite unclear, in spite of practice guidelines from both dental [4] and medical [5] fields.
\nThis chapter aims to discuss the effective ways of managing bleeding complications in dental surgery, mainly in high-risk patients. The role of biosurgical materials to prevent or solve these complications, during and after dental surgery procedures, will also be addressed, as well as their modes of action, practical applications, adverse effects, and effectiveness.
\nThe physiological mechanism that prevents and hinders bleeding at the area of an injury while preserving regular blood flow everywhere else in the circulation is called hemostasis [6]. The hemostasis process has two major components. Primary hemostasis initiates promptly after vascular injury, and it can be divided into four consecutive and superposed stages: (A) vasoconstriction, (B) platelet adhesion, (C) platelet activation, and (D) platelet aggregation [7, 8, 9, 10]. Primary hemostasis results in the formation of a platelet plug [10]. Secondary hemostasis comprises a sequence of serine protease zymogens and their cofactors, which interact successively on phospholipid surfaces (damaged endothelial cells or platelets), leading to the development of covalently cross-linked fibrin [10, 11, 12]. This cross-linked fibrin mesh is then incorporated into and around the platelet plug. It strengthens and stabilizes the blood clot. These two processes are intertwined and occur at the same time [6]. These systems are regulated by multiple anticoagulant mechanisms, which are responsible for maintaining blood fluidity in the absence of injury, generating a clot that is consistent with the trauma. Hemostasis and the avoidance of bleeding or thrombosis are directly related to the adequate balance between procoagulant and anticoagulant systems [6].
\nHemorrhage in dental surgery can be categorized as:
Primary hemorrhage: bleeding occurs during surgery
Reactionary hemorrhage: bleeding occurs 2–3 hours after surgery
Secondary hemorrhage: bleeding occurs until 14 days after surgery, probably due to an infection
Hemorrhage can also be categorized according to the area injured: vascular, bone, and soft tissue [13, 14]. Bleeding diathesis is an unusual susceptibility to bleeding and may be genetic, autoimmune, or acquired (Table 1) [15, 17]. Selected bleeding disorders will be covered in this chapter.
\n\nThe most prevalent hereditary bleeding disorders are von Willebrand disease and hemophilia, affecting 1% of the population and 20,000 people in the USA, respectively [18, 19, 20, 21, 22]. Dental patients presenting inherited bleeding present a significantly higher risk of perioperative bleeding. The frequency and severity of bleeding are related to disease-related factors, such as the severity of the hemophilia. Factors related to the patient include the level of periodontal disease, vasculopathy or platelet dysfunction, and procedure-related factors (teeth extracted—type and the number—or the size of the wound area) [23].
\nOne example of autoimmune bleeding diathesis is the immune thrombocytopenic purpura (ITP), an idiopathic thrombocytopenic purpura condition, characterized by isolated thrombocytopenia without a clinically apparent cause [24].
\nThe most common acquired bleeding diathesis is the one related to hemostasis-altering medications. Anticoagulant agents are among the most prescribed medications in the USA [25]. For decades, anticoagulants have been prescribed to prevent arterial and venous thromboembolism [1]. Prolonged bleeding and bruising are some of the adverse events related with these medications [4]. The most frequently used drugs are therapeutic platelet inhibitors, vitamin K antagonists, or direct oral anticoagulants. Patients susceptible to hemorrhage may present severe bleeding resulting from dental surgery procedures. The use of biosurgical hemostatic agents to decrease or control bleeding may be beneficial for patients at risk for bleeding diathesis.
\nBleeding complications can occur either in healthy or systemically compromised patients. Some patients tend to bleed excessively during or after dental surgery, due to different factors, such as anticoagulant therapy, inherited bleeding disorders, uncontrolled hypertension, extreme trauma to soft tissues, and non-compliance to postoperative recommendations. In these cases, the use of an effective hemostatic agent enhances hemostasis, providing a wide spectrum of benefits, such as superior management of the anticoagulated patient, shorter operation time, as well as smaller wound exposure and shorter recovery time.
\nThe ideal topical hemostatic agent should be biocompatible, affordable, and effective [14, 26, 27]. In recent years, the number of different topical hemostatic agents has increased significantly (Table 2). Knowledge and familiarity with the wide range of topical hemostatic agents available are essential for dental practitioners, including their effectiveness, mode of action, and adverse effects. A well-informed professional will be able to opt for the most effective and practical agent for each situation. In relation to the use of local hemostatic in dental procedures, available scientific data is not homogenous. Most publications use one or more local hemostatic agents to compensate for the anticoagulant effect and prevent postoperative bleeding [29]. The most common local biosurgical hemostatic agents used in dentistry and approved by the Food and Drug Administration (FDA) are listed in Table 2.
\nTypes and trade name of some biosurgical agents–adapted from Pereira et al. [28].
Local biosurgical hemostatic agents can be classified into (A) passive or mechanical, (B) active, and (C) flowables [30].
\nConsidered as the most effective agents for small amounts of bleeding, passive or mechanical agents provide platelet activation and aggregation. This results in a matrix formation in the bleeding area that works as a barrier to stop bleeding, by activating the extrinsic clotting pathway and providing a surface that will allow coagulation to occur faster [30]. As these agents are biologically inactive, they rely on the individual’s own fibrin production to attain hemostasis. Passive hemostats are only indicated for individuals with an unscathed coagulation cascade [27]. They are generally applied as frontline agents, since they are readily available, do not require special storage or handling, and are relatively affordable [14, 27, 31].
\nGelatin is a hydrocolloid derived from acid partial hydrolysis of purified animal collagen. It is presented as a gelatin sponge, powder (mixed to form a paste), or film. Gelatin can be placed dry or after moistening it with saline [14, 28, 32, 33]. Gelatin-based products adapt effortlessly to wounds making it appropriate for application into irregular surfaces [27]. Although their mode of action is not completely understood, gelatin-based products likely act more physically than chemically in the coagulation cascade [28, 34]. Affordability, ease of use and good hemostatic activity make topical hemostats with gelatin matrix a popular tool for reducing the morbidity caused by hemorrhage [27, 28] after dental extractions and periodontal surgeries.
\nThe most popular absorbable gelatin sponge in dentistry is Gelfoam®. It is a hemostatic compressed sponge obtained from purified porcine skin gelatin. Gelfoam® is capable of absorbing many times its weight of whole blood [35]. Generally, when applied in soft tissues, its complete absorption occurs within 4–6 weeks.
\nCollagen absorbable products are nontoxic and non-pyrogenic. They are sourced from either bovine dermal collagen or bovine tendon. Collagen hemostats provide a matrix for clot formation and consolidation. These products also improve clotting factor release and platelet aggregation and degranulation, thereby breaking up clot formation. Their presentation in sheets and flours allows for easy adaptation and adhesion to irregular surfaces. Although they are commercialized at a higher price than gelatin-based hemostats, hemostasis can usually be accomplished relatively quicker (1–5 min). Collagen absorbable products are easily removed, reducing the risks of rebleeding and the need for various applications. They are absorbed in 8–10 weeks if remained in place. Adverse effects linked to bovine collagen products might include swelling and allergic reaction [30].
\nHelistat® is a collagen-based product originated from purified and freeze-dried bovine flexor tendon and is available as a spongelike structure [14, 27]. Helistat® can hold many times its own weight of fluid, as it is highly absorbent. Collagen induces platelet agglomeration when in contact with blood. In order to achieve hemostasis, Helistat® must be kept at the site (approximately 2–5 minutes). Subsequently, it can be removed, replaced, or left in place. It is easily manipulated, and it must be handled dry, and any excess must be removed. Complete reabsorption occurs within 14–56 days [14, 27, 36]. Helistat® may foster bacterial growth, acting as a nidus for abscess formation [14, 27, 37]; therefore, it should not be placed in wounds with any kind of contamination or infection. Possible adverse reactions of Helistat® or similar products are allergic reaction, foreign body reaction, and adhesion formation [27, 38].
\nSimple oxidized cellulose was first introduced in the early 1940s in the USA. In the 1960s, a new topical hemostatic-oxidized regenerated cellulose (ORC) was launched as a meshwork made from treated and sterilized cellulose—Surgicel®. ORC products are originated from vegetal-based alpha cellulose, available in absorbable knitted fabrics (low or high density), and prepared as sterile fabric meshworks. They are ready-to-use products that may be kept at room temperature and absorb 7–10 times its own weight [27, 30]. ORC cause contact activation and platelet activation, and, when absorbed, a gelatinous mass is created, assisting in the establishment of the clot formation [30]. Thrombin is ineffective with these agents due to low-pH factors. ORC are utilized in the management of capillary, venous, and small arterial bleeding, and they require dry application, without addition of saline or thrombin [27, 39] and are absorbed within 4–8 weeks, depending on the volume applied, the tissue bed, and the magnitude of blood saturation [27, 40, 41, 42]. To prevent delayed healing, excessive volumes should be removed [27]. ORC should not be used in osseous defects as it may intervene with bone regeneration [14, 27, 31]. Adverse effects also include reactions related to the acidic nature of ORC. This characteristic may induce necrosis and inflammation of the surrounding tissue and makes thrombin inefficient with these agents. When left in the wound, they may lead to fluid encapsulation and foreign body reaction [14, 27].
\nThe most common commercial products in this category are Surgicel®, Oxycel®, and Surgicel Nu-Knit®. Surgicel® and Surgicel Nu-Knit® come in knit, solid fiber form, whereas Oxycel® comes in knit, hollow fiber form; however, they function basically in a similar manner [30].
\nOxidized cellulose (OC) agents are produced from sterilized and treated cellulose, presented as a meshwork. In the presence of blood, they present a three- to fourfold increase in volume and are converted into gel. OC dissolve completely in 1–2 weeks into biodegradable end products glucose and water, and they do not interfere with wound healing [14, 27].
\nActCel® binds to calcium ions, resulting in more calcium available for the coagulation cascade [14, 27, 37]. Biochemically, it intensifies the coagulation process by increasing platelet aggregation and physically by 3D clot stabilization. ActCel® is especially indicated in third molar extractions, to avoid the occurrence of dry sockets, and in orthognathic and periodontal surgeries [27]. ActCel® is hypoallergenic, as it does not contain collagen, thrombin, or chemical additives. It also has important bacteriostatic properties [27, 43], which are particularity relevant in infected wounds [27].
\nGelita-Cel® is a relatively quick acting, oxidized resorbable cellulose hemostatic gauze of natural origin. It presents a decreased risk for encapsulation, as it resorbs as fast as 96 hours [14, 27, 37].
\nPolysaccharide hemospheres are a fairly new class of topical biosurgical hemostatic agents, produced from vegetable starch, and they contain no animal or human elements. They are commercially presented in powder form. Polysaccharide hemospheres increase barrier formation by creating a hydrophilic effect, dehydrating the blood, and concentrating its solid components [14, 27]. Due to their 3D scaffold, they are devised to enhance clot formation and organization, even in the absence of intrinsic coagulation activity [14, 44, 45]. Polysaccharide hemospheres should be used with caution in diabetic patients, as they consist of sugars [27].
\nArista™AH is the only FDA-approved product in the polysaccharide hemosphere category. It is used in dental surgery as an adjunctive hemostatic agent, when conventional mechanical procedures, such as pressure and ligature, are not effective or practical.
\nHemostatic adhesives are often used as adjuncts to standard hemostatic procedures to control bleeding from surgical areas [30]. One of the most well-known products in this category is BioGlue®. It consists of a solution of 10% glutaraldehyde and 45% bovine albumin solution purified by precipitation, heat, and chromatography radiation [28, 46]. BioGlue® has been extensively used for its sealants and hemostatic characteristics. The risk of leaking through the suture tracks is the main disadvantage of BiolGue® [27]. In the search for newly created adhesives with the chemical features and the safe reabsorptive profile required to benefit dental surgery patients, several clinical trials are currently in process.
\nActive hemostatic agents are biologically active, as they play a direct role in the coagulation cascade, inducing the formation of a fibrin clot [26, 27].
\nThrombin is key to hemostasis, as well as to the inflammatory and cell signaling processes. It is the base of the fibrin clot, fostering the transformation of fibrinogen to fibrin [28]. Topical thrombin hemostats are originated from either bovine or human plasma, and they can also be produced through recombinant DNA techniques [14, 27]. In the past, the only thrombin hemostat available was composed of bovine plasma (Thrombin-JMI). Although it has proven to be efficient in terminating bleeding, bovine thrombin induces an important immune response [28, 47]. Individuals on hemodialysis, with increased levels of antibodies against topical bovine thrombin, had higher incidence of vascular access thrombosis, severe coagulopathy, and bleeding after exposure to bovine thrombin [28, 48]. As an attempt to avoid these hazardous effects, thrombin derived from human plasma (Evithrom®) and recombinant human thrombin (Recothrom®) were developed. In 2010, Browman et al. [49] demonstrated, in a comparative study between recombinant human thrombin and bovine thrombin, that human recombinant thrombin showed the same efficacy in surgical hemostasis, a comparable safety profile, and a remarkably lower immune response than bovine thrombin. Thrombin may be applied topically, as a solution combined with gelatin sponges mixed with a gelatin matrix, as a dry powder, or as a spray [14, 27]. It is commonly used in conjunction with Gelfoam® to stop moderate to severe bleeding.
\nFibrin sealant or fibrin glue originates from bovine and/or human blood components and simulates the last phases of the coagulation cascade, generating a fibrin clot [30]. These agents control local, as well as diffuse, bleeding from the surgical area. Nevertheless, they are ineffective in controlling intense bleeding. Its use in dentistry includes tooth extraction sites, bone grafting, and periodontal surgery [14].
\nTisseel® was the first fibrin sealant approved by the FDA. It has in its composition human thrombin and fibrinogen, intermixed with aprotinin and CaCl2. Because aprotinin is a bovine protein, it is a potential allergen. Multiple exposures may cause allergic reactions, as well as anaphylactic reaction approaching lethality [30, 50]. As for its ideal application, a dry operating field is required; Tisseel® is particularly effective when applied prior to bleeding. In this situation, fibrinogen may polymerize before blood pressure increases local microcirculation flow. When used after the onset of bleeding, one should apply local pressure over the wound to allow polymerization [28, 51]. Tisseel® is available in a pre-filled syringe, allowing for effective application using the EasySpray and DuploSpray MIS systems.
\nAnother option for fibrin sealants, Evicel®, originates from pooled human plasma. It is available as two separate vials of fibrinogen and human thrombin. Prior to use, the two deep frozen solutions must be thawed and mixed after defrosting and heating up (20–30°C) [30].
\nCrosseal™ is a virally inactivated, second-generation surgical sealant. It is produced from concentrated human clottable proteins, namely, biological active component (BAC), which contains the active component fibrinogen, and human α-thrombin (1000 IU/ml) [52]. This fibrin sealant is applied using an application device which drips/sprays Crosseal™ onto the bleeding site.
\nThere are two main categories of flowable biosurgicals: products containing porcine gelatin, which can be combined with thrombins (bovine, human-pooled plasma thrombin, or rhThrombin), and bovine collagen-based agents, packed with human-pooled plasma thrombin. The flowable agents are deemed the most effective of all the local hemostatic agents [30, 53].
\nSurgiflo® is an absorbable, sterile, hemostatic porcine gelatin matrix, combined with Thrombin-JMI, a topical bovine-derived thrombin. It should be placed directly to the bleeding areas to activate the hemostatic process [30]. A compression period is required for polymerization of the sealant components [28].
\nFloseal® consists of a bovine gelatin matrix, plasma-extracted human thrombin, and CaCl2. Its gelatin granules expand (10–20%), as it comes in contact with blood, producing a seal when the product is applied to a bleeding area [27, 30]. The thrombin fraction of the product triggers the regular pathway of the coagulation cascade, converting fibrinogen to a fibrin polymer and creating a clot around the firm matrix [27], which is reabsorbed within the expected period of standard wound healing (6–8 weeks) [14, 27, 33, 42, 54]. A distinctive feature of Floseal® is the need for the presence of blood for activation [30, 55]. Neither compression, nor a dry surgical field is required for its application [28].
\nBecause of this biosurgical flowability, they can easily adapt to irregular wounds. Flowables have been utilized as frontline topical hemostats in major dental surgeries, in patients where conventional procedures are ineffective. They can be utilized as an adjunct to hemostasis in practically all dental surgical interventions. Flowables are effective on both hard and soft tissues [27, 30]. They have a risk of transmitting infectious agents and are contraindicated in patients who are allergic to materials of bovine origin [27].
\nAlthough traditional methods, such as ligature and manual pressure, can promote hemostasis, they are not an effective approach of bleeding control in less accessible sites and complex injuries. Furthermore, bleeding control is especially challenging in patients presenting acquired or congenital coagulation disorders.
\nTopical biosurgical hemostatic agents comprise a wide range of products aiming at minimizing the risk of bleeding. In recent years, several clinical trials have analyzed the effectiveness, advantages, and limitations of biosurgicals, as well as performed comparisons among the different types of biosurgicals and other non-biologic agents. Despite the beneficial effect of these local hemostatic agents in preventing bleeding in dental surgery, available data comparing their effectiveness and efficiency is still scarce and inconclusive. Methodological heterogeneities, such as the lack of a standard therapy and comparable treatment regimens, are noticeable among studies, as well as the reduced number of randomized controlled trials [2, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70].
\nIn summary, local hemostatic agents are very distinct products with diverse indications. Presently, there is no definite evidence-based approach to guide the dental practitioner when selecting a local hemostatic agent. They must be aware of the characteristics of each single hemostatic agent, to elect the most suitable product for every particular clinical situation. In addition, current available data shows that no topical agent can be regarded as superior or more effective than the others [2]. Further experimental research and controlled clinical trials are warranted to define the most cost-effective biosurgical hemostatic agents in dentistry.
\nThe dental practitioner should assess the bleeding risk of the patient, as well as the bleeding risk of the surgical intervention, preoperatively. After assessing both bleeding risks, the professional can then conceive an intraoperative and postoperative plan. The international normalized ratio (INR) must be evaluated in patients reporting an elevated risk of bleeding. While a standard parameter of coagulation has an INR of 1 [71], the therapeutic range runs from 2.0 to 3.5. In this case, it is recommended to use local hemostatic measures independently or in combination with conventional methods. These agents can be used before, during, and after dental surgeries.
\n\n
Comprehensive medical history, including all medications in the patient’s regimen, to identify potential bleeding issues prior to the surgery [26].
In order to decrease surgical bleeding, patients receiving anticoagulant therapy may need to break up exodontia into multiple appointments [26, 72].
Laboratory values such as platelet count, INR, and prothrombin time are of critical value in medically compromised patients [26].
Demographic risk factors (female sex and older age) [73].
Supplemental patient-related risk determinants: diabetes mellitus, hypertension, obesity, hemostatic disorders, renal impairment, and other major organ system failures [73, 74, 75].
Timing of the appointment: early morning visits allowing patients to return to the dental office in case of postsurgical hemorrhage [26].
Patients at a higher bleeding risk are those reporting family history of bleeding and previous bleeding problems after dental surgery or trauma and individuals using medications, such as aspirin, anticoagulants, and/or long-term antibiotics. Any illnesses associated with bleeding problems, such as leukemia, congenital heart disease, liver disease, or hemophilia, present a higher risk of bleeding. The dental professional needs to be aware and prepared for any intercurrence, during or after a surgical procedure. Individuals presenting advanced periodontal disease are also considered as having a higher risk of perioperative bleeding. In such cases, the surgical plan should include a preoperative phase, consisting of scaling and root planning and a proper chlorhexidine gluconate mouth rinse regimen, 2 weeks before an elective procedure [26].
\nThe risk of bleeding of a dental intervention may be ranked as high, moderate, and low [25, 76, 77, 78]. In most patients, antithrombotic therapy is not interrupted before dental interventions with low bleeding risk, due to the disastrous complications of thrombosis (Table 3) [25, 76, 77, 78]. Moderate and high bleeding potential interventions might need the temporary discontinuation of the antithrombotic therapy [25, 76, 77, 78].
\nDental interventions that do not require anticoagulation therapy interruption*–adapted from Kaplovitch and Dounaevskaia [25].
Dental surgical interventions are considered by most recommendations, as minor procedures presenting self-limited blood loss and low bleeding risk. Bleeding, in most cases, can be managed with local hemostatic agents [79, 80].
\nThe dental care of individuals receiving therapeutic anticoagulation becomes critical when invasive procedures are needed. At this time, the clinician must decide either to maintain the anticoagulation therapy and risk bleeding complications or withdraw the anticoagulation medication and risk developing systemic thrombosis [1]. After decades of controversial data, there is currently a nearly unanimous consensus that anticoagulation therapy, for most dental surgeries, should not be discontinued. The higher risk of bleeding complications is compensated by the elevated risk of developing thromboembolic complications [1, 81, 82, 83, 84].
\nNational dental and medical group statements and multiple evidence-based clinical guidelines have considered the issue independently and support the maintenance, for most dental patients, of anticoagulation therapy (American Dental Association; American Academy of Dental Sleep Medicine; American Heart Association; American College of Cardiology; American Academy of Neurology; American Society of Anesthesiologists; Society for Neuroscience in Anesthesiology and Critical Care; American College of Chest Physicians (ACCP)) [1]. In a 2012 statement [76], the ACCP recommended continuing anticoagulation therapy with warfarin, with the additional utilization of a local hemostatic. The ACCP advised a 2–3-day anticoagulation therapy suspension, in order to lower the INR levels to a range of 1.6 and 1.9 [76, 85].
\nLately, the dental care of patients receiving anticoagulant treatment has been the focus of expressive scientific interest, in both dental and medical fields. A recent literature review showed that only 31 (0.6%) of more than 5400 patients receiving over 11,300 dental surgical interventions while continuing to take vitamin K antagonist anticoagulants (warfarin in most cases) demanded more than local maneuvers for hemostasis. No cases of fatal hemorrhage were reported. In over 2600 individuals whose anticoagulation was discontinued for dental interventions, 22 thromboembolic complications (0.8% of medication withheld), including 6 fatal events (0.2% of medication withheld), were observed [83]. Similar results have been shown in a literature review of dental surgery and antiplatelet medications. Of more than 1200 patients receiving over 2300 dental surgical procedures while continuing their antiplatelet medications (aspirin in most cases), only 2 (0.2%) needed more than local measures for hemostasis. Conversely, in over 320 individuals undergoing 370 antiplatelet interruptions for dental procedures, 17 (5.3%) suffered thromboembolic complications [86].
\nAvailable data shows that the majority of dental interventions can be safely conducted in patients receiving anticoagulation treatment, when considering older medications [4]. However, there are fewer studies reporting the provision of dental care in individuals using newer direct oral anticoagulants. The clinical implications of these newer anticoagulant and antiplatelet therapies have only been recently investigated [80, 87]. The protocol followed by the dental practitioner when managing these patients varies significantly and shows inconsistencies reflecting the lack of large-scale studies and evidence-based clinical guidelines [80, 88, 89]. The risk of postoperative bleeding after invasive periodontal treatment in individuals using different anticoagulation therapies was assessed, retrospectively, in 456 individuals receiving an antiplatelet and/or anticoagulant therapy [90]. Data was collected after 484 invasive periodontal interventions, with 99.6% of patients continuing their medications during the procedures. Postoperative bleeding was reported only following three interventions (0.35%), and it was controlled with local hemostatic maneuvers. Although the authors did not specify which type of local hemostatic procedure was used, this retrospective study showed a very low risk of bleeding in patients receiving an invasive periodontal intervention while using an anticoagulant or antiplatelet medication [90]. These results support the recommendation that such medications do not need to be discontinued in anticipation to invasive periodontal interventions.
\nExtended inter- or postoperative bleeding following dental surgery is infrequent, seldom demanding anything more than the use of local hemostatic biosurgicals. The judgment of whether or not to interrupt anticoagulation treatment can be both intricate and dynamic, and it should be based on the indication for pharmacological therapy, as well as previous thromboembolic history. The discontinuation of anticoagulant therapy may be required in dental interventions with moderate and high bleeding risk [25, 76, 77, 78]. Currently, most clinicians dealing with anticoagulant management tend to personalize the periprocedural management of the bleeding potential, according to the individual risk of each procedure—low, moderate, or high—following the current clinical practice recommendations based on best evidence and maintaining the anticoagulant therapy. Thereby, the patient anticoagulant regimen should be continued in specific low-risk dental procedures, without consultation or fear of disproportionate bleeding demanding additional intervention (Table 3) [25].
\nUndoubtedly, anticoagulant agents are effective in preventing thromboembolism. Nevertheless, their potential for critical adverse effects cannot be ignored. The use of antithrombotic medications is the most frequent cause of an adverse drug event requiring individuals to seek out emergency care [25, 91]. The majority of drug interactions with anticoagulants lead to elevated risk of bleeding. The nature of the interactions cannot be predicted, as they are expressed through both pharmacodynamic mechanisms and pharmacokinetic properties [25].
\nRegarding patient safety, potential risk for interaction, as well as knowledge of appropriate prescribing and monitoring, is crucial. Equally decisive is selecting the appropriate anticoagulant agent and monitoring the potential for drug–drug interaction [10, 11, 12, 13, 14, 15, 17, 25]. Common anticoagulants and their interaction with the most common medications prescribed for dental patients are described in Table 4 [25, 92, 93, 94, 95, 96, 97, 98].
\nCommon anticoagulants and potential interactions with dental medications–adapted from Kaplovitch and Dounaevskaia [25].
Most studies evaluating the occurrence of peri- and postoperative bleeding show anticoagulation therapy can be maintained when adequate local hemostatic maneuvers are used.
\nAs an example, a controlled clinical trial compared the occurrence of bleeding following dental extractions in individuals receiving oral anticoagulants (experimental group) versus patients that had never received oral anticoagulant therapy (control group). Tooth extractions were performed, and a piece of oxidized cellulose was placed only into the sockets in the experimental group. The wound borders were sutured, and a gauze saturated with tranexamic for 30–60 minutes was applied with pressure in the wound. Both groups presented similar bleeding complications [99]. In a similar clinical trial [100], 161 tooth extractions were performed in patients undertaking warfarin. After tooth extraction, an oxidized cellulose gauze was placed in the socket, and the wound was sutured. Patients were assigned to four groups, according to their INR range (INR was 1.5–1.99 in group 1; 2.0–2.49 in group 2; 2.5–2.99 in group 3; and 3.0–3.7 in group 4). No significant differences were found in the postoperative bleeding among groups.
\nBased on the latest evidence and clinical practice recommendations on the perioperative management of dental patients receiving direct oral anticoagulants, on single or dual antiplatelet therapy or vitamin K antagonists, as well as on the current scientific knowledge on biosurgical hemostatic agents, the following conclusions can be made:
The majority of dental procedures can be securely executed without the withholding of anticoagulants, using only local hemostatic therapy. In fact, current recommendations and consensus support the continuation of antiplatelet or anticoagulant therapy. Discontinuing these drugs can increase the risk of thromboembolism, at the cost of minor bleeding, which can be restrained without difficulty. The appropriate use of local hemostatic measures, such as topical biosurgical hemostatic agents, should always be considered whenever indicated.
In order to safely treat a patient receiving anticoagulant therapy, familiarity with anticoagulants and with the potential for drug–drug interactions is required, in addition to knowledge about the topical hemostatic options available.
Topical biosurgical hemostatic agents are diverse agents with distinct indications. The dental practitioner must be aware of the properties of each single agent, in order to properly select the product needed in each different clinical condition.
Based on current available data, no topical hemostatic agent can be regarded as superior or more effective than the others. Further experimental research and controlled clinical trials are warranted to define the most cost-effective biosurgical hemostatic agents in dentistry.
A definite protocol for excessive bleeding is still required for dental surgery in patients with hemorrhagic diathesis. The most effective local hemostatic agent with lesser complications should be determined in future research, considering their availability and cost-effectiveness.
The authors are grateful to Kisa Iqbal BSc Hons, DDS Candidate c/o 2020, New York University College of Dentistry, for editing this article.
\nThe authors declare no conflict of interest.
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',metaTitle:"Terms and Conditions",metaDescription:"These terms and conditions outline the rules and regulations for the use of IntechOpen Website at https://intechopen.com and all its subdomains owned by Intech Limited located at 7th floor, 10 Lower Thames Street, London, EC3R 6AF, UK.",metaKeywords:null,canonicalURL:"/page/terms-and-conditions",contentRaw:'[{"type":"htmlEditorComponent","content":"By accessing the website at www.intechopen.com you are agreeing to be bound by these Terms of Service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. Use and/or access to this site is based on full agreement and compliance of these Terms. All materials contained on this website are protected by applicable copyright and trademark laws.
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Among these heavy metals, a few have direct or indirect impact on the human body. Some of these heavy metals such as copper, cobalt, iron, nickel, magnesium, molybdenum, chromium, selenium, manganese and zinc have functional roles which are essential for various diverse physiological and biochemical activities in the body. However, some of these heavy metals in high doses can be harmful to the body while others such as cadmium, mercury, lead, chromium, silver, and arsenic in minute quantities have delirious effects in the body causing acute and chronic toxicities in humans. The focus of this chapter is to describe the various mechanism of intoxication of some selected heavy metals in humans along with their health effects. Therefore it aims to highlight on biochemical mechanisms of heavy metal intoxication which involves binding to proteins and enzymes, altering their activity and causing damage. More so, the mechanism by which heavy metals cause neurotoxicity, generate free radical which promotes oxidative stress damaging lipids, proteins and DNA molecules and how these free radicals propagate carcinogenesis are discussed. Alongside these mechanisms, the noxious health effects of these heavy metals are discussed.",book:{id:"7111",slug:"poisoning-in-the-modern-world-new-tricks-for-an-old-dog-",title:"Poisoning in the Modern World",fullTitle:"Poisoning in the Modern World - New Tricks for an Old Dog?"},signatures:"Godwill Azeh Engwa, Paschaline Udoka Ferdinand, Friday Nweke Nwalo and Marian N. 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The traditional healer provides health care services based on culture, religious background, knowledge, attitudes, and beliefs that are prevalent in his community. Illness is regarded as having both natural and supernatural causes and thus must be treated by both physical and spiritual means, using divination, incantations, animal sacrifice, exorcism, and herbs. Herbal medicine is the cornerstone of traditional medicine but may include minerals and animal parts. The adjustment is ok, but may be replaced with –‘ Herbal medicine was once termed primitive by western medicine but through scientific investigations there is a better understanding of its therapeutic activities such that many pharmaceuticals have been modeled on phytochemicals derived from it. Major obstacles to the use of African medicinal plants are their poor quality control and safety. Traditional medical practices are still shrouded with much secrecy, with few reports or documentations of adverse reactions. 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Formal recognition and integration of traditional medicine into conventional medicine will hold much promise for the future.",book:{id:"6302",slug:"herbal-medicine",title:"Herbal Medicine",fullTitle:"Herbal Medicine"},signatures:"Ezekwesili-Ofili Josephine Ozioma and Okaka Antoinette Nwamaka\nChinwe",authors:[{id:"191264",title:"Prof.",name:"Josephine",middleName:"Ozioma",surname:"Ezekwesili-Ofili",slug:"josephine-ezekwesili-ofili",fullName:"Josephine Ezekwesili-Ofili"},{id:"211585",title:"Prof.",name:"Antoinette",middleName:null,surname:"Okaka",slug:"antoinette-okaka",fullName:"Antoinette Okaka"}]},{id:"76640",title:"Control of Clinical Laboratory Errors by FMEA Model",slug:"control-of-clinical-laboratory-errors-by-fmea-model",totalDownloads:1131,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Patient safety is an aim for clinical applications and is a fundamental principle of healthcare and quality management. The main global health organizations have incorporated patient safety in their review of work practices. The data provided by the medical laboratories have a direct impact on patient safety and a fault in any of processes such as strategic, operational and support, could affect it. To provide appreciate and reliable data to the physicians, it is important to emphasize the need to design risk management plan in the laboratory. Failure Mode and Effect Analysis (FMEA) is an efficient technique for error detection and reduction. Technical Committee of the International Organization for Standardization (ISO) licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. FMEA model helps to identify quality failures, their effects and risks with their reduction/elimination, which depends on severity, probability and detection. Applying FMEA in clinical approaches can lead to a significant reduction of the risk priority number (RPN).",book:{id:"9808",slug:"contemporary-topics-in-patient-safety-volume-1",title:"Contemporary Topics in Patient Safety",fullTitle:"Contemporary Topics in Patient Safety - Volume 1"},signatures:"Hoda Sabati, Amin Mohsenzadeh and Nooshin Khelghati",authors:[{id:"340486",title:"M.Sc.",name:"Hoda",middleName:null,surname:"Sabati",slug:"hoda-sabati",fullName:"Hoda Sabati"},{id:"348872",title:"M.Sc.",name:"Amin",middleName:null,surname:"Mohsenzadeh",slug:"amin-mohsenzadeh",fullName:"Amin Mohsenzadeh"},{id:"348874",title:"MSc.",name:"Nooshin",middleName:null,surname:"Khelghati",slug:"nooshin-khelghati",fullName:"Nooshin Khelghati"}]},{id:"64762",title:"Mechanism and Health Effects of Heavy Metal Toxicity in Humans",slug:"mechanism-and-health-effects-of-heavy-metal-toxicity-in-humans",totalDownloads:10236,totalCrossrefCites:100,totalDimensionsCites:229,abstract:"Several heavy metals are found naturally in the earth crust and are exploited for various industrial and economic purposes. Among these heavy metals, a few have direct or indirect impact on the human body. Some of these heavy metals such as copper, cobalt, iron, nickel, magnesium, molybdenum, chromium, selenium, manganese and zinc have functional roles which are essential for various diverse physiological and biochemical activities in the body. However, some of these heavy metals in high doses can be harmful to the body while others such as cadmium, mercury, lead, chromium, silver, and arsenic in minute quantities have delirious effects in the body causing acute and chronic toxicities in humans. The focus of this chapter is to describe the various mechanism of intoxication of some selected heavy metals in humans along with their health effects. Therefore it aims to highlight on biochemical mechanisms of heavy metal intoxication which involves binding to proteins and enzymes, altering their activity and causing damage. More so, the mechanism by which heavy metals cause neurotoxicity, generate free radical which promotes oxidative stress damaging lipids, proteins and DNA molecules and how these free radicals propagate carcinogenesis are discussed. Alongside these mechanisms, the noxious health effects of these heavy metals are discussed.",book:{id:"7111",slug:"poisoning-in-the-modern-world-new-tricks-for-an-old-dog-",title:"Poisoning in the Modern World",fullTitle:"Poisoning in the Modern World - New Tricks for an Old Dog?"},signatures:"Godwill Azeh Engwa, Paschaline Udoka Ferdinand, Friday Nweke Nwalo and Marian N. Unachukwu",authors:[{id:"241837",title:"Mr.",name:"Godwill Azeh",middleName:null,surname:"Engwa",slug:"godwill-azeh-engwa",fullName:"Godwill Azeh Engwa"},{id:"274194",title:"BSc.",name:"Paschaline Ferdinand",middleName:null,surname:"Okeke",slug:"paschaline-ferdinand-okeke",fullName:"Paschaline Ferdinand Okeke"},{id:"286975",title:"Dr.",name:"Friday",middleName:null,surname:"Nweke Nwalo",slug:"friday-nweke-nwalo",fullName:"Friday Nweke Nwalo"},{id:"286976",title:"Dr.",name:"Marian",middleName:null,surname:"Unachukwu",slug:"marian-unachukwu",fullName:"Marian Unachukwu"}]},{id:"65467",title:"Anesthesia Management for Large-Volume Liposuction",slug:"anesthesia-management-for-large-volume-liposuction",totalDownloads:5965,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The apparent easiness with which liposuction is performed favors that patients, young surgeons, and anesthesiologists without experience in this field ignore the many events that occur during this procedure. Liposuction is a procedure to improve the body contour and not a surgery to reduce weight, although recently people who have failed in their plans to lose weight look at liposuction as a means to contour their body figure. Tumescent liposuction of large volumes requires a meticulous selection of each patient; their preoperative evaluation and perioperative management are essential to obtain the expected results. The various techniques of general anesthesia are the most recommended and should be monitored in the usual way, as well as monitoring the total doses of infiltrated local anesthetics to avoid systemic toxicity. The management of intravenous fluids is controversial, but the current trend is the restricted use of hydrosaline solutions. The most feared complications are deep vein thrombosis, pulmonary thromboembolism, fat embolism, lung edema, hypothermia, infections and even death. The adherence to the management guidelines and prophylaxis of venous thrombosis/thromboembolism is mandatory.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Sergio Granados-Tinajero, Carlos Buenrostro-Vásquez, Cecilia\nCárdenas-Maytorena and Marcela Contreras-López",authors:[{id:"273532",title:"Dr.",name:"Sergio Octavio",middleName:null,surname:"Granados Tinajero",slug:"sergio-octavio-granados-tinajero",fullName:"Sergio Octavio Granados Tinajero"}]},{id:"30178",title:"Chest Mobilization Techniques for Improving Ventilation and Gas Exchange in Chronic Lung Disease",slug:"chest-mobilization-techniques-for-improving-ventilation-and-gas-exchange-in-chronic-lung-disease",totalDownloads:31193,totalCrossrefCites:0,totalDimensionsCites:5,abstract:null,book:{id:"648",slug:"chronic-obstructive-pulmonary-disease-current-concepts-and-practice",title:"Chronic Obstructive Pulmonary Disease",fullTitle:"Chronic Obstructive Pulmonary Disease - Current Concepts and Practice"},signatures:"Donrawee Leelarungrayub",authors:[{id:"73709",title:"Associate Prof.",name:"Jirakrit",middleName:null,surname:"Leelarungrayub",slug:"jirakrit-leelarungrayub",fullName:"Jirakrit Leelarungrayub"}]}],onlineFirstChaptersFilter:{topicId:"3",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82444",title:"Epigenomics in Malignant Pleural Mesothelioma",slug:"epigenomics-in-malignant-pleural-mesothelioma",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.105408",abstract:"Malignant pleural mesothelioma (MPM) is a tumor with a relatively low incidence, but whose carcinogenesis, for the most part, involves epigenetic factors that keep its heterogeneity and sometimes are a therapeutic target or an obstacle to the effectiveness of the newest treatments. This chapter summarizes the principal epigenetic dysregulation mechanisms involved in the MPM pathogenesis. The most studied mechanism is hypermethylation mediated by DNA methyltransferases (DNMTs) in different tumor suppressor genes, and the relation with asbestos fiber exposure, which represents the main risk factor. Physiopathology is related to chronic inflammation mediated by free radicals that produce chromosomal alterations, genomic instability, increased angiogenesis, and tumor invasion factors like EGFR, FGFR, TGF-B, and PDGF. Additionally, independent methylation pathways that produce gene silencing such as polycomb complex and SWI/SNF mutation are reviewed. Finally, other mechanisms are described such as hypomethylation with imprint loss and pro-oncogenic gene activation that induce immunological responses, as well as acetylation, deacetylation, and demethylation in the chromatin and histone context.",book:{id:"10831",title:"Mesothelioma - Diagnostics, Treatment and Basic Research",coverURL:"https://cdn.intechopen.com/books/images_new/10831.jpg"},signatures:"Aldo Manuel Alvarez Moran, Pablo Alejandro Ávila Sánchez, Jorge Alejandro Torres Ríos and Lorena Vega Castillo"},{id:"82383",title:"The Role of Immune Checkpoints in Cancer Progression",slug:"the-role-of-immune-checkpoints-in-cancer-progression",totalDownloads:2,totalDimensionsCites:null,doi:"10.5772/intechopen.105628",abstract:"Immune checkpoint proteins are like two-faced swords that first act as gatekeepers of the immune system to protect the host from tissue damage. In contrast, these proteins can corroborate cancer progression by inhibiting tumor-specific immune responses. Here, we summarized the regulation and signaling cascade of immune checkpoints molecules (PD-1/PD-L1, CTLA-4, TIM3, TIGIT, LAG3, and BTLA), including their role in providing co-inhibitory signals for regulating T-cell response. The involvement of immune checkpoint molecules to drive cancer growth is elaborated with explanations about various anticancer strategies, such as (1) the overexpression of immune checkpoints in cancer cells, immune cells, or the surrounding environment leading to incapabilities of the tumor-specific immune response, (2) immune checkpoints interference to metabolic pathways then deplete nutrients needed by immune cells, (3) the interaction between immune checkpoints and regulatory T cells. Lastly, future challenges of immune checkpoint inhibitors are discussed briefly to get insight into their applicability in the clinical setting.",book:{id:"11278",title:"Regulatory T Cells",coverURL:"https://cdn.intechopen.com/books/images_new/11278.jpg"},signatures:"Rahmad Aji Prasetya and Devyani Diah Wulansari"},{id:"82331",title:"Diseases of Medicinal Plants Cultivated in Karnataka and Their Management",slug:"diseases-of-medicinal-plants-cultivated-in-karnataka-and-their-management",totalDownloads:1,totalDimensionsCites:null,doi:"10.5772/intechopen.104632",abstract:"A broad spectrum of fungal diseases infecting selected 10 medicinal plants surveyed in Karnataka, India, was studied in the present research. We present a detailed review on previously reported as well as our present investigation’s details of fungal diseases, etiology, symptoms, and its management. Some of the commonly observed diseases are Anthracnose disease, Blight disease, Leaf spot, Root rot, Powdery mildew, Downy mildew, and Wilt disease. The detailed analysis of medicinal plants revealed that the medicinal plants are susceptible to diverse fungal phytopathogens. Therefore, sustainable management of the diseases is necessary for the successful cultivation of disease-free medicinal plants.",book:{id:"11299",title:"Medicinal Plants",coverURL:"https://cdn.intechopen.com/books/images_new/11299.jpg"},signatures:"P. Swetha and R. Sundararaj"},{id:"82446",title:"Possibility of Using a VR System as an Action Observation Therapeutical Technique",slug:"possibility-of-using-a-vr-system-as-an-action-observation-therapeutical-technique",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.105579",abstract:"In recent years, 3D virtual reality (VR) systems are increasingly finding their way into biomedical applications. Nevertheless, in most cases a 3D VR is being used as an interactive system (such as Xbox Kinect or Playstation VR). These interactive systems, however effective they may have proven, not only limit use of 3D VR in patients incapable to engage in these systems due to their physical or mental disability, but also put significant requirements on medical institutions for an equipment, medical personal, and therefore institutional budget. In this article, we are proposing a 3D VR as an stand-alone action observation training device, which could limit requirements associated with abovementioned interactive systems due to its capability to stimulate a mirror neuron system of human brain, while adding minimal demands on both patient and medical facility. Research studies that confirm activity in the motor cortex will be described. We focus on the literature that describes theories, models, and experimental studies dealing with the effects of motion observations that are involved in the control and final performance of motor skills.",book:{id:"11832",title:"Neurorehabilitation and Physical Therapy",coverURL:"https://cdn.intechopen.com/books/images_new/11832.jpg"},signatures:"Jaroslav Langer, Monika Šorfová and David Ravnik"},{id:"82439",title:"Cellular Cytotoxicity and Multiple Sclerosis",slug:"cellular-cytotoxicity-and-multiple-sclerosis",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.105681",abstract:"Multiple sclerosis (MS) is an autoimmune disease in which discrete central nervous system lesions result from perivascular immune cell infiltration associated with damage to myelin (demyelination), oligodendrocytes and neurons. This culminates in debilitating neurological symptoms, primarily affecting women in their child-bearing years. Both the innate and adaptive branches of the immune system have been implicated in disease initiation and progression, and although the underlying cause remains elusive, there is compelling evidence for a complex interaction between genetic and environmental factors, leading to inflammation and neurodegeneration. Both direct cellular toxicity and antibody-dependent cellular cytotoxicity (ADCC) involving several cell types have been identified in playing major roles. These cells and their interactions in the pathogenesis of MS will be discussed.",book:{id:"11678",title:"Cytotoxicity",coverURL:"https://cdn.intechopen.com/books/images_new/11678.jpg"},signatures:"Annie M.L. Willson and Margaret A. Jordan"},{id:"82430",title:"Hepatocellular Carcinoma",slug:"hepatocellular-carcinoma",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.105473",abstract:"Over 1 million cases of liver cancer are estimated to occur by 2025, making it a global health challenge. In almost 90% of cases of liver cancer, it is hepatocellular carcinoma (HCC). The main risk factors for HCC development are infection with hepatitis B and C viruses, although nonalcoholic steatohepatitis (NASH) associated with metabolic syndrome or diabetes mellitus is becoming more prevalent in the West. The molecular pathogenesis of nonalcoholic steatohepatitis-associated HCC is unique. A quarter of all HCCs present with mutations that are potentially actionable but have not yet been translated into clinical practice. In the advanced stages of the disease, systemic therapy is expected to be administered 50–60% of the time to HCC patients. In phase III trials, six systemic therapies have been approved (atezolizumab plus bevacizumab, sorafenib, lenvatinib, regorafenib, cabozantinib, and ramucirumab), and new trials are evaluating combination therapies, such as checkpoint inhibitors and tyrosine kinase inhibitors or anti-VEGF therapies. The findings of these clinical trials are expected to alter the landscape of managing HCC at all stages of the disease.",book:{id:"11265",title:"Hepatotoxicity",coverURL:"https://cdn.intechopen.com/books/images_new/11265.jpg"},signatures:"Rahmat Adetutu Adisa and Lateef Adegboyega Sulaimon"}],onlineFirstChaptersTotal:792},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"June 25th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"3",title:"Bacterial Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/3.jpg",isOpenForSubmission:!1,editor:null,editorTwo:null,editorThree:null},{id:"4",title:"Fungal Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",isOpenForSubmission:!0,editor:{id:"174134",title:"Dr.",name:"Yuping",middleName:null,surname:"Ran",slug:"yuping-ran",fullName:"Yuping Ran",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9d6QAC/Profile_Picture_1630330675373",biography:"Dr. Yuping Ran, Professor, Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China. Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. Vice-chief of the editorial board of Chinses Journal of Mycology, China. Board Member and Chair of Mycology Group of Chinese Society of Dermatology.",institutionString:null,institution:{name:"Sichuan University",institutionURL:null,country:{name:"China"}}},editorTwo:null,editorThree:null},{id:"5",title:"Parasitic Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",isOpenForSubmission:!0,editor:{id:"67907",title:"Dr.",name:"Amidou",middleName:null,surname:"Samie",slug:"amidou-samie",fullName:"Amidou Samie",profilePictureURL:"https://mts.intechopen.com/storage/users/67907/images/system/67907.jpg",biography:"Dr. Amidou Samie is an Associate Professor of Microbiology at the University of Venda, in South Africa, where he graduated for his PhD in May 2008. He joined the Department of Microbiology the same year and has been giving lectures on topics covering parasitology, immunology, molecular biology and industrial microbiology. He is currently a rated researcher by the National Research Foundation of South Africa at category C2. He has published widely in the field of infectious diseases and has overseen several MSc’s and PhDs. His research activities mostly cover topics on infectious diseases from epidemiology to control. His particular interest lies in the study of intestinal protozoan parasites and opportunistic infections among HIV patients as well as the potential impact of childhood diarrhoea on growth and child development. He also conducts research on water-borne diseases and water quality and is involved in the evaluation of point-of-use water treatment technologies using silver and copper nanoparticles in collaboration with the University of Virginia, USA. He also studies the use of medicinal plants for the control of infectious diseases as well as antimicrobial drug resistance.",institutionString:null,institution:{name:"University of Venda",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},{id:"6",title:"Viral Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/6.jpg",isOpenForSubmission:!0,editor:{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. 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Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Bacterial Infectious Diseases",value:3,count:2},{group:"subseries",caption:"Parasitic Infectious Diseases",value:5,count:4},{group:"subseries",caption:"Viral Infectious Diseases",value:6,count:7}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:2},{group:"publicationYear",caption:"2021",value:2021,count:4},{group:"publicationYear",caption:"2020",value:2020,count:3},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:229,paginationItems:[{id:"318170",title:"Dr.",name:"Aneesa",middleName:null,surname:"Moolla",slug:"aneesa-moolla",fullName:"Aneesa Moolla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/318170/images/system/318170.png",biography:"Dr. Aneesa Moolla has extensive experience in the diverse fields of health care having previously worked in dental private practice, at the Red Cross Flying Doctors association, and in healthcare corporate settings. She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}}]}},subseries:{item:{id:"20",type:"subseries",title:"Animal Nutrition",keywords:"Sustainable Animal Diets, Carbon Footprint, Meta Analyses",scope:"An essential part of animal production is nutrition. 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