Treatment options for mucocutaneous manifestations.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"2278",leadTitle:null,fullTitle:"Advances in Wavelet Theory and Their Applications in Engineering, Physics and Technology",title:"Advances in Wavelet Theory and Their Applications in Engineering, Physics and Technology",subtitle:null,reviewType:"peer-reviewed",abstract:"The use of the wavelet transform to analyze the behaviour of the complex systems from various fields started to be widely recognized and applied successfully during the last few decades.\nIn this book some advances in wavelet theory and their applications in engineering, physics and technology are presented. The applications were carefully selected and grouped in five main sections - Signal Processing, Electrical Systems, Fault Diagnosis and Monitoring, Image Processing and Applications in Engineering. One of the key features of this book is that the wavelet concepts have been described from a point of view that is familiar to researchers from various branches of science and engineering. The content of the book is accessible to a large number of readers.",isbn:null,printIsbn:"978-953-51-0494-0",pdfIsbn:"978-953-51-4310-9",doi:"10.5772/2668",price:159,priceEur:175,priceUsd:205,slug:"advances-in-wavelet-theory-and-their-applications-in-engineering-physics-and-technology",numberOfPages:648,isOpenForSubmission:!1,isInWos:1,isInBkci:!0,hash:"43f8c4f3571860f51c18deef213fa8cb",bookSignature:"Dumitru Baleanu",publishedDate:"April 4th 2012",coverURL:"https://cdn.intechopen.com/books/images_new/2278.jpg",numberOfDownloads:85906,numberOfWosCitations:116,numberOfCrossrefCitations:111,numberOfCrossrefCitationsByBook:13,numberOfDimensionsCitations:164,numberOfDimensionsCitationsByBook:17,hasAltmetrics:1,numberOfTotalCitations:391,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 10th 2011",dateEndSecondStepPublish:"June 7th 2011",dateEndThirdStepPublish:"October 12th 2011",dateEndFourthStepPublish:"November 11th 2011",dateEndFifthStepPublish:"March 10th 2012",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7,8",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"105623",title:"Dr.",name:"Dumitru",middleName:null,surname:"Baleanu",slug:"dumitru-baleanu",fullName:"Dumitru Baleanu",profilePictureURL:"https://mts.intechopen.com/storage/users/105623/images/system/105623.jpg",biography:"Dumitru Baleanu received a B.Sc. degree in Physics from the University of Craiova, Romania, in 1988, an M.Sc. degree from the University of Bucharest, Romania, in 1989, and a Ph.D. degree from the Institute of Atomic Physics, Romania, in 1996. He is Professor at the Institute of Space Sciences, Romania, and since 2000 he is visiting staff member at Cankaya University, Turkey. He published 500 papers in journals indexed in SCI. He is a co-editor of five books published by Springer. He is coauthor of three books published by Elsevier and World Scientific. He is an editorial board member of six ISI journals and is on the 2015 Highly Cited Researcher list in mathematics. His Hirsch index is 33.",institutionString:"Cankaya University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Çankaya University",institutionURL:null,country:{name:"Turkey"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"611",title:"Signal Processing",slug:"numerical-analysis-and-scientific-computing-signal-processing"}],chapters:[{id:"34933",title:"Real-Time DSP-Based License Plate Character Segmentation Algorithm Using 2D Haar Wavelet Transform",doi:"10.5772/35448",slug:"real-time-dsp-based-license-plate-character-segmentation-using-2d-haar-wavelet-transform",totalDownloads:3924,totalCrossrefCites:3,totalDimensionsCites:3,hasAltmetrics:0,abstract:null,signatures:"Zoe Jeffrey, Soodamani Ramalingam and Nico Bekooy",downloadPdfUrl:"/chapter/pdf-download/34933",previewPdfUrl:"/chapter/pdf-preview/34933",authors:[{id:"104470",title:"Ms.",name:"Zoe",surname:"Jeffrey",slug:"zoe-jeffrey",fullName:"Zoe Jeffrey"},{id:"114432",title:"Dr.",name:"Soodamani",surname:"Ramalingam",slug:"soodamani-ramalingam",fullName:"Soodamani Ramalingam"},{id:"115245",title:"Mr.",name:"Nico",surname:"Bekooy",slug:"nico-bekooy",fullName:"Nico Bekooy"}],corrections:null},{id:"34934",title:"Wavelet Transform Based Motion Estimation and Compensation for Video Coding",doi:"10.5772/35998",slug:"wavelet-transform-based-motion-estimation-and-compensation-for-video-coding",totalDownloads:3409,totalCrossrefCites:3,totalDimensionsCites:4,hasAltmetrics:0,abstract:null,signatures:"Najib Ben Aoun, Maher El’arbi and Chokri Ben Amar",downloadPdfUrl:"/chapter/pdf-download/34934",previewPdfUrl:"/chapter/pdf-preview/34934",authors:[{id:"106700",title:"Dr.",name:"Najib",surname:"Ben Aoun",slug:"najib-ben-aoun",fullName:"Najib Ben Aoun"},{id:"106701",title:"Dr.",name:"Maher",surname:"El'Arbi",slug:"maher-el'arbi",fullName:"Maher El'Arbi"},{id:"106702",title:"Dr.",name:"Chokri",surname:"Ben Amar",slug:"chokri-ben-amar",fullName:"Chokri Ben Amar"}],corrections:null},{id:"34935",title:"Speech Scrambling Based on Wavelet Transform",doi:"10.5772/37350",slug:"speech-scrambling-based-on-wavelet-transform",totalDownloads:3925,totalCrossrefCites:6,totalDimensionsCites:6,hasAltmetrics:0,abstract:null,signatures:"Sattar Sadkhan and Nidaa Abbas",downloadPdfUrl:"/chapter/pdf-download/34935",previewPdfUrl:"/chapter/pdf-preview/34935",authors:[{id:"112347",title:"Prof.",name:"Sattar",surname:"Sadkhan",slug:"sattar-sadkhan",fullName:"Sattar Sadkhan"}],corrections:null},{id:"34936",title:"Wavelet Denoising",doi:"10.5772/37424",slug:"wavelet-denoising",totalDownloads:3840,totalCrossrefCites:15,totalDimensionsCites:23,hasAltmetrics:0,abstract:null,signatures:"Guomin Luo and Daming Zhang",downloadPdfUrl:"/chapter/pdf-download/34936",previewPdfUrl:"/chapter/pdf-preview/34936",authors:[{id:"112693",title:"Dr.",name:"Guomin",surname:"Luo",slug:"guomin-luo",fullName:"Guomin Luo"},{id:"113404",title:"Prof.",name:"Daming",surname:"Zhang",slug:"daming-zhang",fullName:"Daming Zhang"}],corrections:null},{id:"34937",title:"Oesophageal Speech’s Formants Measurement Using Wavelet Transform",doi:"10.5772/37555",slug:"oesophageal-speech-s-formants-measurement-using-wavelet-transform-",totalDownloads:1902,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:null,signatures:"Begona Garcia Zapirain, Ibon Ruiz and Amaia Mendez",downloadPdfUrl:"/chapter/pdf-download/34937",previewPdfUrl:"/chapter/pdf-preview/34937",authors:[{id:"104709",title:"Prof.",name:"Begona",surname:"Garcia Zapirain",slug:"begona-garcia-zapirain",fullName:"Begona Garcia Zapirain"},{id:"112389",title:"MSc.",name:"Amaia",surname:"Mendez",slug:"amaia-mendez",fullName:"Amaia Mendez"},{id:"113244",title:"Mr.",name:"Ibon",surname:"Ruiz Oleagordia",slug:"ibon-ruiz-oleagordia",fullName:"Ibon Ruiz Oleagordia"}],corrections:null},{id:"34938",title:"The Use of the Wavelet Transform to Extract Additional Information on Surface Quality from Optical Profilometers",doi:"10.5772/38154",slug:"the-use-of-the-wavelet-transform-to-extract-additional-information-on-surface-quality-from-optical-p",totalDownloads:2550,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Richard L. 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Behçet’s disease (BD) is a chronic, relapsing inflammatory multi-systemic disease of unknown etiology with a course of exacerbations and remissions [1–4]. Prevalence of BD is higher in countries lying along the ancient Silk Road, extending from eastern Mediterranean to East Asia [5]. Turkey probably has the highest occurrence level of the disease with prevalences of 110–420 cases per 100,000 population [6–8]. Today, due to immigrations, BD is encountered almost all over the world [9, 10].
\nThe disease was first defined in 1937 by the Turkish dermatologist named as ‘Hulusi Behçet’ with the presence of ‘triple symptom complex’ of recurrent oral ulcers (OU), genital ulcers (GU) and uveitis [1]. After the initial description, it now became increasingly evident that BD is a multi-systemic disease with involvement of mucocutaneous, vascular, neurological, musculoskeletal and gastrointestinal systems with significant morbidity and mortality [2, 3, 9, 11, 12]. The main histopathological finding is the vasculitis of the arteries and veins of any size or thrombophilia according to the site of involvement [13].
\nAlthough the exact etiopathogenesis of BD is still unknown, it has been hypothesized that in genetically predisposed individuals, a development of an inflammatory reaction against to an infectious, an environmental or an autoantigen and/or the presence of disturbances in molecular mechanisms in regulating immune responses may contribute to the disease [2, 3, 11, 14–17].
\nToday, most of the authors classify BD as a group of systemic vasculitis (under the title of variable vessel vasculitis) as a result of the consensus; ‘2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides’ [18].
\nThe first symptoms of BD usually occur in the third and fourth decade of life [2, 4, 9, 19]. However, childhood cases have also been reported [20]. Juvenile BD was found in 7.7% and family history was found in 11.6% of the patients in the study reported by Alpsoy et al. [21]. In another study by Gurler et al., the presence of family history in the first degree relatives of patients with BD has been reported as 7.3% [22]. Male patients, a younger onset and HLA-B51 positive patients are found to have more severe kind of the disease [11, 21, 23, 24]. Contrary to these results, Davatchi et al. found no association between severe organ involvement and male gender except vascular involvement [25]. Clinical features of BD include OU, GU, ocular inflammation, cutaneous lesions, as well as articular, vascular, neurological, pulmonary, gastrointestinal, renal and genitourinary manifestations [2–4, 11]. BD may start with just one or two symptoms but other symptoms may gradually appear over the years [19, 22, 24, 26–29].
\nAs there is no pathognomonic test, the diagnosis of BD depends on clinical criteria [3]. In 1990, the International Study Group (ISG) for BD defined new diagnostic criteria by reviewing the data of 914 patients from 12 centres in seven countries around the world. The ISG criteria for BD have a sensitivity of 92% and specificity of 97%, compared with previous sets of criteria. According to these criteria, the diagnosis of BD consists of the presence of recurrent OU in addition to two of the following features: GU, eye involvement, skin lesions and positive skin pathergy test. At minimum three episodes of oral aphthous ulcer in a year should be observed for the diagnosis of BD [30]. In order to increase the sensitivity and specificity, these criteria are re-assessed and revised [31]. Since patients may present with only OU for a long time showing a long prediagnostic duration [19, 22, 32].
\nVarious studies from different countries have documented that mucocutaneous manifestations are the most common, and often the first signs of the disease [2, 3, 9, 11, 21, 22, 24, 26–29, 33–37]. Mucocutaneous findings are the hallmarks of the disease and recognition of them have a great importance in confirming the diagnosis, in the follow up and in preventing both the morbidity and mortality [2, 3, 19, 21, 26, 28].
\nThis chapter aims not only to define the mucocutaneous lesions but also to elaborate the features of the mucosal and cutaneous lesions in detail. Furthermore, mucocutaneous lesions in paediatric BD, differential diagnoses and the management of the mucocutaneous lesions will briefly be reviewed.
\nMucocutaneous manifestations that are observed in the course of BD are as follows: OU, GU, erythema nodosum (EN)-like lesions, papulopustular (PPL) lesions, superficial thrombophlebitis (TFB), extragenital ulcers, Sweet’s syndrome-like lesions, cutaneous vasculitic lesions, pyoderma gangrenosum (PG)-like lesions, erythema multiforme-like lesions and skin pathergy test (SPT) [2–4, 9, 32].
\nThe above-mentioned mucocutaneous lesions may be the initial findings of BD or may be observed at any time during the course of the disease [21, 22, 24, 28, 29]. Especially, OU is the most commonly detected lesion and mostly emerges as the initial clinical finding of the disease [2, 3, 19, 21, 33–37]. OU and GU are mostly considered as the ’fingerprint lesions’. As there is yet no pathognomonic test for the diagnosis of BD, recognition of these mucocutaneous lesions let the clinician make an earlier diagnosis, which also enables an earlier treatment [2, 3].
\nOral ulcers (OUs) manifest in the majority of BD patients with a ratio of 92–100% in all countries [2–4, 6, 10, 21, 22, 27, 28, 33]. The majority of the patients experience OU as the most common presenting clinical manifestation [21, 22, 24, 26, 28, 34, 37]. For the diagnosis of BD, the presence of recurrent OU is obligatory according to criteria of ISG [4, 30].
\nOUs are recurrent and painful ulcerations of the oral mucosa characterized by a round or oval ulceration with sharp borders surrounded by a red erythematous inflammatory area (Figure 1).The base of the OU is necrotic with a yellowish-white colour. The most common sites are the mucous membranes of the lips, buccal mucosae, tongue, uvula and soft palate [2, 3, 22]. Clinically, they look like similar in appearance with conventional aphthae that may be seen in several systemic diseases such as inflammatory bowel disease, Sweet syndrome, systemic lupus erythematosus or recurrent aphthous stomatitis (RAS) [2, 12, 32]. OU in BD tends to recur more frequently and to be more in number [38]. Main and Chamberlain reported that OUs in BD have a more diffuse erythematous surrounding rim, they are localized more often in soft palate and oropharynx and they are more in number when compared with the aphthae of RAS [39]. However, no difference was found in terms of frequency of OU between the two groups [39].
\nAphthous ulcer on the tongue in the patient of Behçet’s Disease (Courtesy of MD. Assoc. Prof. Müzeyyen Gönül).
OUs are usually classified into three groups based on the diameter of the ulcer [2, 11]:
\nMinor aphthae are shallow mucosal ulcers with a diameter less than 10 mm. It usually spontaneously regresses in a couple of weeks without formation of scarring.
Major aphthae have a deeper morphology with a diameter larger than 10 mm. Healing usually occurs in 3–4 weeks with scarring.
Herpetiform aphthae are pinpoint shaped, very small and shallow mucosal ulcers and localized in crops.
The majority of the patients were found to have minor aphthous ulcer (75%) followed by herpetiform (20%) and major aphthae (5%) in the study of Vaiopoulos et al. [36]. Different sizes and types of OU may be seen at the same time in oral mucosa in BD [9]. A study comparing the characteristics of OU between BD and RAS was performed by Oh et al. They reported that major OUs were significantly more common in patients with BD, and initiation of OU in BD was more likely related to menstrual cycle when compared with OU in patients with RAS. In addition, they also concluded that patients with major aphthae who have accompanying articular symptoms as initial symptoms should be strictly followed for the possible development of BD [40].
\nIdeguchi et al. evaluated 412 BD patients’ data including 16 years follow-up. The results revealed that a mean of 7.5 years has been proceeded before a definitive diagnosis of BD. In the same study, 14% of the patients had suffered from OU for more than 20 years before the diagnosis of BD [19].
\nIn two different studies reported by Alpsoy et al., the mean duration between the OU and the fulfilment of diagnostic criteria was determined to be 4.3 ± 5.7 and 3.77 ± 4.43 years, respectively, and it has been concluded that the disease is often diagnosed with a delay of several years after the appearance of the first sign [21, 26].
\nAlthough OUs are the most common and earliest manifestation of BD, a few studies have been reported indicating a course without the presence of OU at the onset of BD [27, 41–44]. On the basis of this issue, Faezi et al. evaluated the clinical features on 175 patients with BD who do not have oral aphthosis (NOA) and compared them with the patients with OU. The results revealed that the first manifestation was uveitis with a ratio of 70.3% in the NOA group, and a pathergy test was more common in NOA group [41].
\nGenital ulcers (GUs) are generally the second most frequent disease manifestation [2, 9, 21, 26, 28, 45, 46]. GUs are observed in approximately 60–97% of the patients with BD at any time of the course of the disease [4, 19, 21, 22, 28, 36, 43, 47]. The lowest frequency was reported from Romania with a ratio of 55.5% [43]. As an initial symptom, GU was found in 14.2 and 7.4% of the patients with BD in two different studies from Turkey [21, 22] while in only 4% of the patients with BD in a study from Moscow [34].
\nGUs are usually localized on the scrotum and on the shaft of the penis in male patients while on the labium major and minor in females (Figures 2 and 3). They are rarely seen in the vagina and cervix in females and on the urethral orifice and glans penis in males [2, 3, 9, 11, 22]. They are usually painful or very rarely they can be asymptomatic [2]. They have mostly the same characteristic morphological features of OU. The clinical differences from oral aphthous ulcer include that GUs are larger and deeper, have more irregular borders and a longer healing duration. In addition, GU recurs less often and heal with scarring [3, 32, 48]. Therefore, in the suspicion of diagnosis of BD, scatris of GU on genital region should also be searched.
\nGenital, extragenital ulcers and their scars in male patient with Behçet’s Disease (Courtesy of MD. Assoc. Prof. Müzeyyen Gönül).
Genital ulcer in female patient with Behçet’s Disease (Courtesy of MD. Assoc. Prof. Müzeyyen Gönül).
While some studies have documented higher frequency of GU among one of the genders [21, 24, 35], some did not detect any difference between the two genders [23, 25, 34]. Gender differences (Male>female) at the onset of GU have been observed in the study by Vaiopoulos et al. [36].
\nGU may cause severe pain, difficulty in micturition, dyspareunia and marked difficulty in physical activity. Deep ulcers located in vagina may be complicated by fistulisation to bladder, urethra or rectum [2–4, 9].
\nMat et al. reported a prospective study investigating the frequency of scarring after GU. This study revealed that healing with scarring was observed in 49% of small GU while in 89% of large ulcers. They stated that ulcers on labium minors and vestibule may heal even without scar formation [48].
\nFaezi et al. reported 64.7% of 6935 cases with BD had GU during the course of the disease. They compared clinical and laboratory features between the patients with GU and patients who never developed GU (non-GU cases). As a result of their study, OU and other cutaneous manifestations such as pseudofolliculitis and erythema nodosum were found to be higher while eye involvement was found to be less common in the GU group [46].
\nPapulopustular lesions (PPLs), which are also called as pseudofolliculitis or Behcet’s pustulosis, are dome-shaped papules, which will convert into sterile pustule with an erythematous and edematous base [2–4]. Sometimes it can be localized around a hair follicle [9]. They are commonly seen lesions in BD [2–4]. Various studies have reported an incidence ranging between 25 and 55% [21, 22, 28, 33, 36]. PPLs have also been reported as an onset sign [22].
\nPPLs are usually localized on the trunk, buttocks and extremities [2, 3, 49]. However, they may be observed on any part of the body and even on palmoplantar regions [9]. In case of face and chest localization, especially in adolescence period, it may be hard to distinguish PPL from an ordinary papul/pustule of acne or folliculitis [2].
\nPPLs were found to occur more frequently in male patients than females in a study by Tursen et al. [35]. PPLs were found to occur more in patients with positive pathergy test [49].
\nSince PPLs are non-specific and resemble to ordinary acne pustules and/or folliculitis; some authors suggest that non-follicular lesions located other than face are more valuable for the diagnosis of BD [2, 27, 49] while some suggest that PPL should not be included as a diagnostic criteria [50]. It is suggested to accept PPL as a diagnostic criteria only if leukocytoclastic vasculitis or a neutrophilic reaction histopathologically is detected [2, 50].
\nA study by Kalkan et al. reported the histopathological evaluation of 42 biopsy specimens of papulopustular lesions of patients with BD. The results revealed leukocytoclastic vasculitis in seven specimens, lymphocytic vasculitis in three, superficial perivascular and/or interstitial infiltration in 15 and folliculitis/perifolliculitis in five. No histopathological finding of vasculitis was observed in the biopsy specimens of pustular lesions of the patients with acne vulgaris in the control group [51].
\nAnother study by Ilknur et al. reported a statistically higher ratio of lymphocytic/leukocytoclastic vasculitis pattern in the histopathological evaluation of pustular lesions of the patients with BD compared with the control group. However, direct immunofluorescence examinations investigating the deposition of IgM, IgG, IgA, C3 or fibrinogen in dermal blood vessels revealed no difference between the two groups [52].
\nChen et al. reported either lymphocytic or leukocytoclastic vasculitis of the 20 biopsy specimens performed from cutaneous lesions of BD. Eight of the 20 biopsy specimens in which vasculitis detected histopathologically was clinically compatible with PPL [53].
\nContrary to these studies, Kutlubay et al. compared the number and histopathological features of PPL between patients with BD and acne vulgaris, as a result, Kutlubay et al. assessed a higher number of PPL on the back and extremities in BD group. However, histopathological interpretation was not found to be useful in differentiating PPL between two entities [54].
\nErythema nodosum (EN)-like lesions are frequently observed skin lesions in patients with BD [9]. The incidences of EN-like lesions have been reported between 15 and 60% in various studies [21, 22, 24, 28, 55, 56]. In 2.8% of the patients with BD, EN-like lesions have been reported as an initial symptom [22]. They are more common in female patients [23, 24, 36, 55]. They are characterized by multiple painful subcutaneous nodules with different sizes. Although they are preferentially located on the lower limbs, they may also be localized on gluteal region, upper extremities and neck [2, 3, 9, 22, 55]. They heal within 10–20 days without secondary ulceration and scatris formation. The resolution generally results with residual hyperpigmentation [2, 3]. The clinical features of EN-like lesions resemble conventional EN [2, 3, 9, 11]. However, it has been noted that EN-like lesions have more erythema and oedema around the lesions than the classical EN [57]. Coskun et al. reported that the presence of EN-like lesions precede visceral involvement [55]. Faezi et al. found less common EN-like lesions among the group of BD without OA in their study in which they compared the two groups with OA and without OA [41]. Cebeci et al. compared the clinical features of two groups with and without deep vein thrombosis (DVT) in BD and found more common EN-like lesions in the group with DVT suggesting that patients with EN-like lesions should be followed up for a possible DVT [58].
\nThe evaluation of the histopathological features of biopsy specimens performed from EN-like lesions has been reported in various studies [57, 59, 60]. Chun et al. detected focal lymphocytic vasculitis in 40% of the cases with EN-like lesions of patients with BD and suggested this finding to occur secondary to severe lymphocytic infiltration. On the rest of the cases, the histopathological changes have been found similar to conventional EN [59]. In contrary, two different studies revealed the presence of vasculitis in biopsy specimens performed from EN-like lesions of patients with BD [57, 60].
\nMisago evaluated the clinicopathological features of EN-like lesions in 26 patients with BD and revealed the presence of vasculitis histopathologically in 73% of the cases. In addition, they suggested that the presence of severe vasculitis, especially phlebitis, was associated with a severe disease course [57].
\nA study by Demirkesen et al. compared the distinguishing histopathological features of the biopsy specimens taken from EN-like lesions of BD, nodular lesions of nodular vasculitis (NV) and conventional EN. Their results revealed neutrophil-predominating infiltrate in the sub-cutis and vein involvement to be more common in EN-like lesions when compared with NV and EN [60].
\nBD may affect all types of vessels [3, 11, 61]. The prevalence of vascular involvement in BD has been reported to be between 2.2 and 50% in different patient populations [4, 6, 43, 62–64]. The venous system is the major affected site [9, 11, 61–65]. Superficial thrombophlebitis (TFB) is seen in approximately 4.9–20% of the patients with BD, and it is more frequently seen in male patients [6, 28, 29]. Sarica-Kucukoglu et al. reported superficial TFB as the most common vascular symptom with a prevalence of 53.3% [62].
\nSuperficial TFB is mostly characterized by linearly arranged erythematous subcutaneous nodules in lower extremities that migrate from day to day. The vein can be palpated as a string-like hardening showing the thrombosis and vessel sclerosis [2, 3]. EN-like lesions and migratory TFB may be thought as the differential diagnosis [2, 3]. Superficial TFB is clinically important since it is frequently associated with other forms of vascular disease in BD [2, 63].
\nExtragenital ulcer (EGU) is usually a solitary, small, round ulcer with a red rim and yellow base; however, it may have various shapes and sizes [2, 3, 32, 65]. Although observed rarely, it is the most characteristic and specific lesions of BD [2, 65]. EGU may be localized anywhere on the body such as legs, axillae, breast, interdigital skin of the foot, neck and inguinal regions. EGU may persist for a long duration, may be painful and heals usually with scarring [2, 3]. In a report of Azizlerli et al., four cases of EGU were shown to reveal vasculitis histopathologically [65].
\nA study reported by Ozyurt et al. detected that the patients with family history of BD had more frequent EGU than patients with negative family history of BD [66].
\nFew series documented common EGU in children [67, 68]. However, due to rarity of BD in childhood and few reports concerning the clinical findings in children with BD, the characteristics of the disease in this age group are not completely described [67–69].
\nFew cases of Sweet’s syndrome-like lesions have been reported in patients with BD [70–77]. Sweet’s syndrome-like lesions are characterized by painful, edematous papules, plaques and nodules localized on face, neck and back [3, 70–75]. Fever and laboratory findings such as leukocytosis, elevated erythrocyte sedimentation rate and C-reactive protein accompany to the cutaneous lesions [73, 74]. Although clinical and histological overlap exists between Sweet’s syndrome and BD such as the presence of OU, arthralgia, arthritis, episcleritis, pathergy positivity and neutrophilic infiltrate in the dermis in both of the diseases, there are some distinguishing features. In BD, the development of OU is more frequent, fever is rarely seen, the pattern of articular and ocular involvement is different [3]. In addition, comparing two diseases by human leucocyte antigen (HLA) typing revealed that patients with BD had higher frequencies of HLA-B51 and HLA-Dqw3, while patients with Sweet’s syndrome had higher frequencies of HLA-Bw4 [77]. Sweet’s syndrome-like lesions have been reported to occur in the acute phase of BD or sometimes have been thought to point a flare in BD [73].
\nPyoderma gangrenosum (PG) is another rare neutrophilic dermatosis that may be associated with BD [78, 79]. Rare cases of PG-like lesions in patients with BD have been addressed [78–85]. The lesion is usually characterized by large superficial ulceration localized usually on the buttock or the lower limbs; however, it may reveal vegetative or bullous variants [9, 79, 81]. Both diseases may have clinical and histopathological overlap. The patients with PG may also have OU, GU and pathergy positivity [78, 79]. However, as mentioned above, the frequency of OU and GU is higher in BD. It has been reported that PG is associated with the activation of BD [78, 79, 85]. Also, Hali et al. reported two paediatric cases of BD and PG with a fatal outcome [84].
\nOther rare cutaneous lesions such as palpable purpura, haemorrhagic bullae, necrotizing vasculitic lesions, Henoch Schoenlein purpura, polyarteritis nodosa-like lesions, pernio-like lesions, erythema multiforme-like lesions, acral purpuric papulonodular lesions, furoncles and abscess may also occur in the course of BD [2, 3, 70, 86–97]. It has been suggested that lesions of periarteritis nodosa appear as a marker of the severity of BD [91, 92]. These cutaneous lesions are mostly presented as case reports [86–97]. It is not clear whether these dermatological manifestations are real associations or coincidental. Therefore, it has been postulated that only lesions of ‘leukocytoclastic vasculitis’ detected in histopathological examination should be evaluated as a cutaneous sign of BD [2, 53, 98, 99].
\nSkin pathergy test (SPT) is a non-specific hyperreactive reaction of the skin that occurs as a response to a minor trauma such as a needle prick [2, 3]. SPT was first described by Blobner in 1937 [70, 105]. It is used as an adjunctive test in the diagnosis of BD and according to the ISG criteria for BD, a positive SPT is a criteria needed for the diagnosis of BD [2, 3, 30, 70, 105].
\nPositive SPT is defined as the development of erythematous, indurated papule which usually evolves into a sterile pustule at the site of the needle puncture after 24–48 hours (Figure 4) [70, 105]. Although the exact mechanism of the SPT is still not known, it is thought to occur as a result of enhanced non-specific inflammatory response and aberrant release of cytokines triggered by the cutaneous injury [13]. A number of studies investigating the histopathological examinations of positive SPT reaction (papule/pustule) revealed findings ranging from mononuclear cell infiltration at varying densities in perivascular or periadnexal areas to leukocytoclastic vasculitis [106–110]. Ergun et al. evaluated a chronological histopathological study of sites of SPT and observed intraepidermal pustules and polymorphonuclear infiltrate at the beginning of the inflammation [108]. Androjen receptor levels were found higher in positive SPT sites when compared with normal skin [111].
\nPathergy positivity in Behçet’s Disease (Courtesy of MD. Assoc. Prof. Müzeyyen Gönül).
Although the positivity of SPT has been accepted as a criteria in the diagnosis of BD, there is no consensus about performing a standardized method of SPT [105, 112–117]. It is usually performed under sterile conditions with a 20-gauge needle inserted intradermally into the avascular area on the forearm skin of patient with an angle of 45° [105, 112, 113]. Various techniques such as pricking with multiple needles with various applying routes including intradermal, intravenous and subcutaneous methods have been reported [9, 105, 112, 114–116]. Multiple punctures are mostly required [9, 114, 115]. Davatchi et al. suggested three intradermal punctures perpendicular or diagonally one with a 25-gauge needle with intradermal injection of one drop of normal serum saline, one with a 25-gauge needle alone (just a puncture, with no injection) and the last with a 21 gauge needle (puncture, no injection) [115]. A study by Ozdemir et al. suggested that two needle pricks are sufficient for positive SPT [114]. Another study by Ozdemir et al. analysed the changes of SPT positivity in different body areas such as flexor surfaces of the forearms, the lateral aspect of the tibial area, the scapular areas on back, and the lumbar areas of the abdominal region. They concluded that forearm was the most frequent site positive for pathergy reaction whereas abdomen was the least [113]. Akmaz et al. reported higher rate of positivity in SPT by intradermal application compared with intravenous application [117]. Dilsen et al. performed SPT with different needles including sharp and blunt needles in which they confirmed higher frequency of positivity with blunt needles [112]. Sharquie et al. demonstrated an alternative method of which they inserted the needle inside the mucous membrane of the lower lip to the sub-mucosa. However, the sensitivity of the oral pathergy test has been reported lower than of the classical pathergy test [118].
\nVarious prevalence rates of SPT positivity in BD have been reported by several studies [21, 22, 119–123]. The positivity of SPT varies between 40 and 88% with a higher prevalence in Japan and Mediterranean countries, whereas it is lower in countries such as the United Kingdom and the United States [2, 3, 9, 22, 45, 98, 119–123]. Alpsoy et al. reported the positivity of SPT as 37.8% in their study including 661 Turkish patients with BD [21]. A study comparing the positivity of SPT between Turkish and British patients with BD revealed the positive reaction was only present among Turkish patients [119]. In a German study, SPT revealed positive results in 33.7% of patients with no significant difference between Turkish and German patients with BD [123]. The factors that may affect the rates of positivity of SPT include genetic variables, variations in ethnic origins of the patients, factors related to the method and materials used to perform the SPT and conditions of the patient and the disease [105, 112–114, 124–126].
\nContrary results have been reported about the relationship between positive SPT and clinical course of BD [22, 125–128]. Chang et al. found that positive SPT was specific for BD, but not associated with clinical severity [125]. Similarly, Krause et al. found no difference in terms of clinical manifestations and severity in the comparison of pathergy positive and negative patients with BD [126]. Although Yazici et al. have found no correlation between disease severity and positive SPT, they reported that male patients with BD have stronger pathergy reaction [127]. Jorizzo et al. reported a correlation between the histopathological pathergy results and clinical severity [109]. Koç et al. detected higher positive SPT test in patients with vascular involvement compared to patients without vascular involvement [128].
\nIt has been reported that the frequency of SPT positivity has decreased during the last years [115, 125, 129]. One of the best reasons for this issue is the use of disposable needles, which are less traumatic than non-disposable ones [105, 112, 125]. A study by Davatchi et al. investigated the sensitivity and specificity of SPT among 6607 patients followed between the years 1975 and 2010. Their results revealed that the sensitivity of pathergy test has declined, but it still preserves its specificity [115]. Moreover, positivity of SPT in many diseases other than BD has been detected. Neutrophilic dermatoses such as Sweet syndrome, PG, erythema elevatum or other diseases such as RAS, eosinophilic pustular folliculitis, inflammatory bowel diseases and spondyloarthropathies are some in which pathergy reaction positivity has been shown [70]. Despite everything, SPT has still a diagnostic value [115].
\nBD in childhood is rare, has a variable clinical course and less investigated [68, 69, 130–139]. Paediatric onset of BD was found in 5.3 and 7.6% of all the cases [130, 133]. In the study including 661 cases of BD, juvenile BD has been reported in 7.1% [21]. In paediatric cases, a family history of BD has been more frequently observed [21, 68, 130, 131, 136, 137].
\nThe diagnosis of paediatric BD in the reported studies was based on the criteria of ISG and ICD [30, 31]. A recent classification was proposed by Kone-Paut et al., and according to this classification, the presence of any three items among recurrent oral aphthosis, GU, ocular involvement, neurological and vascular signs makes the definitive diagnosis of BD [135, 140].
\nThe onset of BD has been reported at any age between 0 and 16 years [131, 136, 137]. The lowest mean age of 4.8 years old was reported by Nanthapisal et al. [134]. Similarly to clinical symptoms of adulthood BD, OU was present in most of the children and also constituted the initial symptom in most of the cases [68, 131–139]. The localization and morphology of OU in children were also similar to the characteristics of adulthood OU [136, 137, 140]. GU was detected between 55 and 94% of the paediatric cases [131, 135–138]. Distinctively from adult cases, the presence of GU has been reported significantly lesser than adults [131, 132]. However, Treudler et al. did not reveal any differences in the ratio of GU between childhood and adulthood BD [68], and Nanthapisal et al. detected recurrent GU more frequently in females [134]. The characteristics of GU were also found similar to the ones seen in adults [136, 137]. Another distinctive feature, perianal aphthosis was to be a specific feature of childhood BD [135].
\nSkin lesions were reported to occur between 64 and 92% of childhood BD [70, 135, 137, 138]. Kone-Paut et al. reported EN-like lesions in 40% and necrotic folliculitis in 58% [136], while Borlu et al. reported EN-like lesions in 18% and PPL in 47% of the patients [137]. Kone-Paut et al. reported necrotic folliculitis more frequently in male patients [136]. However, no gender differences were detected in terms of skin lesions in the study of Borlu et al. [137]. Erythema multiforme-like lesions and TFB have been less frequently reported [70]. Positive SPT has been reported in 37, 80 and 76% of the patients in three different studies [131, 136, 137].
\nNanthapisal et al. documented skin findings in 11 (23.9%) of 46 patients: These were pustular lesions in three, skin ulceration in two, EN in two, necrotic folliculitis in two, PPL in two and positive SPT in three of the five patients [134].
\nThe duration between the initial symptom and fulfilment of diagnosis of BD has been reported as 3.14 years in the study of Karincaoglu et al. [131], while a significant diagnostic delay up to 13.5 years has been reported in the study of Nanthapisal et al. [134]. This may be caused due to rarity and unfamiliarity of the disease in Northern Europe.
\nConflicting reports have also been found in the systemic expression of BD in children [130, 132, 133]. BD was usually reported to have a less severe disease [132, 140]. Pivetti-Pezzi et al. reported similar rates of OU, GU, skin lesions in the comparison of adulthood and childhood BD. In addition, no differences were observed in the incidence of arthritis, gastrointestinal and neurological involvement except more severe ocular involvement in childhood. Another study by Sarica et al. compared the patients with mild and severe diseases. An earlier onset and more systemic involvement were found in patients with severe form of the disease [130]. More frequent neurological and gastrointestinal involvements were observed in childhood BD in the study of Karincaoglu et al. [131].
\nGenerally, it can be interpreted that juvenile BD has a similar clinical spectrum to adulthood BD. The differences in frequency and clinical courses may reflect the geographic, ethnic and genetic variations.
\nThe differential diagnosis of mucocutaneous manifestations will not be addressed in detail as this subject does not constitute the main topic of this chapter. Only the essential differential diagnoses of OU, GU, EN-like lesions will be given below.
\n\nInfectious etiology: Herpangina, primary herpetic gingivostomatitis, hand-foot and mouth disease, HIV, syphilis, tuberculosis, etc.
Systemic diseases: Systemic lupus erythematous, Reiter’s disease, Wegener’s granulomatosis, blood disorders (neutropenia, leukaemia), iron deficiency, vitamin B12 deficiency, etc.
Gastrointestinal diseases: Inflammatory bowel diseases, Celiac Disease
Primary skin conditions: Sweet’s syndrome, RAS, autoimmune bullous disorders (pemphigus vulgaris, pemphigoid, linear IgA disease, etc.)
Medication induced: Cytotoxic agents, nicorandil, etc.
Malign neoplasms
Infectious etiology: Genital herpes simplex, syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, HIV, etc.
Non-microbial etiology: Erythema multiforme, fixed drug eruption, Lipschütz ulcers, metastatic Crohn’s disease, hidradenitis suppurativa, PG, pressure ulcers, sexual trauma, psoriasis and malignancies.
Infectious etiology: Gram-positive folliculitis, Gram-negative folliculitis, Pityrosporum folliculitis, Demodicidosis, viral plane warts
Eosinophilic pustular folliculitis
Acne vulgaris
Classical EN
Nodular vasculitis
Panniculitis
Cellulitis
Infectious etiology: Necrotizing fasciitis (Streptococcus haemolyticus), botryomycosis (commonly
Autoimmune diseases: Scleroderma, rheumatoid arthritis, cutaneous lupus erythematosus, vasculitis, etc.
Systemic disorders: Blood diseases (Polycythemia vera, sickle cell anaemia, thrombotic thrombocytopenic purpura, paraproteinemia, etc.)
Medication-induced: Hydroxyurea, methotrexate, chemotherapeutics and immunosuppressives
Primary skin conditions: Necrobiosis lipoidica, sarcoidosis, pyoderma gangrenosum, panniculitis, etc.
Factitial: Dermatitis artefacta, Munchausen by proxy, etc.
Oral and genital ulcers can be treated with topical and systemic treatments [3, 147–152]. In recurrent OU with or without GU, systemic colchicine (1–2 mg/day) must be started as a first choice of treatment [147–149]. Topical steroids, topical sucralfate, local anaesthetics, and tetracycline oral mouth washes are usually combined with oral colchicine treatment [147]. In case of more severe and painful OU and/or GU, a short duration of systemic steroids may be added with colchicine. Corticosteroids combined with systemic antibiotics can be used to decrease the severity of GU attacks [147–149]. In patients with severe mucocutaneous manifestations, immunosuppressive drugs such as azathioprine (AZA), methotrexate (Mtx), cyclosporine A may be used [149]. AZA has been found effective in preventing the recurrences of thrombophlebitis [147]. Thalidomide is another choice of therapy in recalcitrant OU and/or GU. However, it is not preferred due its high toxic effects [147, 149, 150]. Pentoxifylline, dapson, zinc sulphate, IFN-α and rebamipide are other alternative treatments worth for trying in OU. However, larger and well organized studies are needed in order to clarify their efficacies. In case of EN-like lesions, bed rest is usually required. Especially in female cases with GU and EN-like lesions, the combination of colchicine and benzathine penicillin is recommended [148]. This treatment combination has also been reported to decrease the frequency and duration of both OU and EN-like lesions [150]. IFN-α has been reported to decrease not only the frequency of GU and EN-like lesions but also the number of PPL [151]. Anti-TNF drugs are being used with success in patients with refractory mucocutaneous manifestations [151, 152]. Recent studies of interleukin-1 (IL-1) inhibitors (anakinra, canakinumab) have demonstrated efficacy in OU and GU resistant to conventional therapy [150]. Finally, apremilast, phosphodiesterase 4 inhibitor, has been reported to be effective in treating OU and GU [150, 152]. The treatment options can be seen more detailed in Table 1.
\nMucocutaneous manifestation | \nTopical | \nSystemic | \n
---|---|---|
Oral ulcer | \nTopical steroidsTopical sucralfate Local anaestheticsTopical amlexanox Local silver nitrate 5% | \nColchicineTetracyclineAzithromycinSystemic steroids (short term)RebamipideDapsonImmunosuppressive drugs (AZA, Mtx)ThalidomideAnti-TNF drugsIFN-αPentoxifyllineCyclosporine A (Cyc A)TacrolimusApremilastAnakinraCanakinumab | \n
Genital ulcer | \nTopical antibioticsTopical steroids Local anaesthetics | \nColchicineTetracyclineAZA, MtxCycAIFN-αAnti-TNFApremilastAnakinraCanakinumab | \n
Papulopustular lesion | \n\n | ColchicineAzithromycinCycAIFN-αThalidomide | \n
Eryhthema nodosum-like lesions | \nBed restWet dressings (aluminium acetat3 3–5%) | \nColchicineNSAIISystemic steroids (short term) Colchicine+benzathine penicillinDapsonAnti-TNF | \n
Treatment options for mucocutaneous manifestations.
Mucocutaneous lesions are the most important criteria in establishing the diagnosis of BD. In case of recurrent OU, GU and other cutaneous findings mentioned above, it is important to remind the possibility of BD in the diagnosis, which will permit an earlier diagnosis and enable a decrease in mortality and morbidity.
\nAZA | Azathiopurine |
BD | Behçet’s disease |
DVT | Deep vein thromboses |
EGU | Extragenital ulcer |
EN | Erythema nodosum |
GU | Genital ulcers |
HLA | Human leucocyte antigen |
IFN-α | Interferon-alpha |
ISG | International study group |
Mtx | Methotrexate |
NV | Nodular vasculitis |
PG | Pyoderma gangrenosum |
PPL | Papulopustular lesions |
RAS | Recurrent aphthous stomatitis |
SPT | Skin pahergy test |
TFB | Thrombophlebitis |
OU | Oral ulcer |
Most often from a speech signal the following features are distinguished [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]: power features (energy of a spectral bands); cepstrum; linear predictive parameters; fundamental tone and formant; mel-frequency cepstral coefficients (MFCC); bark-frequency cepstral coefficients (BFCC); parameters of perceptual linear prediction; parameters of the reconsidered perceptual linear prediction.
For features extraction of a speech signal usually use [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]: digital bandpass filters bank; spectral analysis (Fourier’s transformation, wavelet transformation); homomorphic processing; linear predictive coding; MFCC method; BFCC method; perceptual linear prediction; reconsidered perceptual linear prediction.
For calculation of the fundamental tone use methods which are based on a basis of the analysis of the following signal representations [3]: amplitude-time; spectral (amplitude-frequency); cepstral (maplitude-quefrency); wavelet-spectral (amplitude-time-frequency).
The autocorrelation function (ACF) method carries out search of the maximum value in autocorrelated function [3]:
1. For the chosen signal frame of length
2. Impulse response function initialization Is defined at what value
The period of the fundamental tone is defined in a form
where
The average magnitude difference function (AMDF) method carries out search of the minimum value as the average magnitude difference [3] that quicker than search of the maximum value in autocorrelated function.
For the chosen signal frame of length
Is defined at what value
The period of the fundamental tone is defined in a look
where
The simplified inverse filter transformation (SIFT) method carries out search of the maximum value in autocorrelated function of linear prediction error of the decimated signal [4]:
For the chosen signal frame of length
DFT (discrete Fourier transform)
extract of the lower frequencies
where
calculation of the inverse DFT
Decreases sampling frequencies to
where
The differences of two next samples of the decimated signal are calculated
Autocorrelated function is calculated
where
LPC coefficients are calculated
The error of linear prediction by means of LPC coefficients is calculated
where
Autocorrelated function of a linear error of prediction is calculated
where
Is defined at what value
where
Thus, length of the fundamental tone period is determined in a form
where
In Figure 1 the source signal, is presented on Figure 2
Initial signal.
The filtered signal.
The decimation signal.
As a signal the frame of a sound “A” length is chosen
A signal in the form of the weighed difference.
Prediction error.
Autocorrelated function of prediction error.
This method calculates distance between the next minimum a wavelet coefficients.
At the first stage the continuous wavelet transformation which is approximated according to a rectangles formula in a look is calculated
where
For Morle’s wavelet
As sequence
The period of the fundamental tone is defined in a form
where
This method carries out search of the maximum value in cepstrum [3].
For the chosen signal frame of length
Cepstrum is calculated, using the inverse DFT
Is defined at what value
where
The period of the fundamental tone is defined in a form
where
The harmonic product spectrum (HPS) method carries out search of the maximum value in the product of harmonicas of the decimated power spectrum [3].
For the chosen signal frame of length
The power spectrum of a signal is calculated
where
The product of harmonicas of the decimated power spectrum is calculated
Is defined at what value
Frequency of the fundamental tone is determined in a form
where
The SIFT, ACF, AMDF methods, based on the cepstral analysis depend on noise level.
The HPS methods, on a basis a wavelet analysis, are resistant to noise.
The SIFT methods, based on the cepstral analysis demand a threshold task.
The method on a basis a wavelet analysis demands the setting level of decomposition.
The HPS method demands a task of decimating quantity.
The linear predictive coding method uses the amplifier and the digital filter (Figure 11).
The block diagram of the simplified model of signal formation.
Thus, the signal can be presented in the signal form at the input of the linear system with variables on time parameters excited by quasiperiodic impulses or random noise.
Transfer function of a linear system with variable parameters
where
The input signal
This method as features linear prediction coefficients (LPC), reflection coefficients (RC), linear prediction cepstral coefficients (LPCC), log area ratio (LAR) coefficients are used [3].
Signal
where
For
where
For
For
For
For
For
At identification of the person or speech recognition for the analysis of vocalized sounds with a frequency range from 0 to 3 kHz are limited and the first 3 formant use
In Figure 12 the logarithmic power spectrum of the central frame of a sound “A” with different orders of prediction, at the same time length of a frame
The Logarithmic power spectrum of LPC of a sound “A” at different orders of prediction p.
Apparently from Figure 12, extraction a formant (maximum in a spectrum) perhaps already at
In Figure 13 it is given a sound “A”, and in Figure 14—its logarithmic power spectrum of LPC. In Figure 15 it is given the central frame of a sound “Sh”, and in Figure 16—its logarithmic power spectrum of LPC. At the same time length of a frame
Sound “A”.
Logarithmic power spectrum of LPC sound “A” at a prediction order p=30.
Sound “Sh”.
Logarithmic power spectrum of LPC sound “Sh” at an order of prediction p=30.
This method is based on homomorphic processing and uses as features mel-frequency cepstral coefficients (MFCC) [5, 6].
Signal
where
For
where
For
where
4. For
where
This method is based on homomorphic processing and uses as features are used a bark-frequency cepstral coefficients (BFCC) [7, 8].
Signal
where
The quantity of bark-frequency bands is calculated
where
For
where
For
where
For
For
where
In this method as features perceptual linear prediction coefficients (PLPC), perceptual reflection coefficients (PRC), perceptual linear prediction cepstral coefficients (PLPCC), perceptual log area ratio (PLAR) coefficients are used [9, 10].
Signal
where
The quantity of bark-frequency bands is calculated
where
For
where
For
where
For
For
where
For
For
For
For
In this method as features reconsidered perceptual linear prediction coefficients (RPLPC), reconsidered perceptual reflection coefficients (RPRC), the reconsidered perceptual linear prediction cepstral coefficients (RPLPCC), the reconsidered perceptual log area ratio (PLAR) coefficients are used [7, 8].
Signal
where
For
where
For
where
For
where
For
For
For
For
For the speech signals containing vocal sounds the sampling frequency 8 kHz and the number of quantization levels 256 was established. Sample length of a vocal sound of the speech is equal to 256.
A numerical research results of LPC, RC, LPCC, LAR coefficients, MFCC, BFCC, PLPC, PRC, PLPCC, PLAR coefficients, RPLPC, RPRC, RPLPCC, RPLAR coefficients received by methods of coding and used for biometric identification of people from the TIMIT database on vocal sounds by means of the Gaussian mixed models (GMM) are presented in Table 1.
Coefficient’s type | Identification probability | Coefficients number |
---|---|---|
LPC | 0.72 | 12 |
RC | 0.96 | 12 |
LPCC | 0.90 | 13 |
LAR coefficients | 0.82 | 12 |
MFCC | 0.97 | 13 |
BFCC | 0.98 | 13 |
PLPC | 0.74 | 4 |
PRC | 0.98 | 4 |
PLPCC | 0.92 | 5 |
PLAR coefficients | 0.84 | 4 |
RPLPC | 0.73 | 12 |
RPRC | 0.97 | 12 |
RPLPCC | 0.91 | 13 |
RPLAR coefficients | 0.83 | 12 |
Numerical research results of the coefficients used for personality biometric identification.
For coding methods for the analysis of a speech signal the filter order in case of linear prediction is equal 12, in case of perceptual linear prediction is equal 4, in case of the reconsidered perceptual linear prediction is equal 12, quantity mel-frequency bands equally 20, quantity a bark-frequency bands equally 17, the number of cepstral parameters based on subbands is equal to 13.
The result presented in Table 1 shows that the largest probability of identification and the smallest number of coefficients are provided by coding of a vocal sound of the speech based on PRC.
The preliminary stage of the biometric identification is speech signal structuring and extracting features.
For calculation of the fundamental tone are considered and in number investigated the following methods of digital signal processing—ACF (autocorrelation function) method, AMDF (Average Magnitude. Difference Function) method, SIFT (Simplified Inverse Filter Transformation) method, method on a basis a wavelet analysis, method based on the cepstral analysis, HPS (Harmonic Product Spectrum) method. For speech signal extracting features are considered and in number investigated the following methods of digital signal processing—the digital bandpass filters bank; spectral analysis (Fourier’s transformation, wavelet transformation); homomorphic processing; linear predictive coding. This methods make it possible to extract linear prediction coefficients (LPC), reflection coefficients (RC), linear prediction cepstral coefficients (LPCC), log area ratio (LAR) coefficients, mel-frequency cepstral coefficients (MFCC), bark-frequency cepstral coefficients (BFCC), perceptual linear prediction coefficients (PLPC), perceptual reflection coefficients (PRC), perceptual linear prediction cepstral coefficients (PLPCC), perceptual log area ratio (PLAR) coefficients, reconsidered perceptual linear prediction coefficients (RPLPC), reconsidered perceptual reflection coefficients (RPRC), reconsidered perceptual linear prediction cepstral coefficients (RPLPCC), reconsidered perceptual log area ratio (RPLAR) coefficients. Results of a numerical research of speech signal features extraction methods for voice signals people from the TIMIT (Texas Instruments and Massachusetts Institute of Technology) database were received. The features PRC proved to be the most effective.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:"Our business values are based on those any scientist applies to their research. We have created a culture of respect and collaboration within a relaxed, friendly and progressive atmosphere, while maintaining academic rigour.
\n\nCo-founded by Alex Lazinica and Vedran Kordic: “We are passionate about the advancement of science. As Ph.D. researchers in Vienna, we found it difficult to access the scholarly research we needed. We created IntechOpen with the specific aim of putting the academic needs of the global research community before the business interests of publishers. Our Team is now a global one and includes highly-renowned scientists and publishers, as well as experts in disseminating your research.”
\n\nBut, one thing we have in common is -- we are all scientists at heart!
\n\nSara Uhac, COO
\n\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
\n\nAdrian Assad De Marco
\n\nAdrian Assad De Marco joined the company as a Director in 2017. With his extensive experience in management, acquired while working for regional and global leaders, he took over direction and control of all the company's publishing processes. Adrian holds a degree in Economy and Management from the University of Zagreb, School of Economics, Croatia. A former sportsman, he continually strives to develop his skills through professional courses and specializations such as NLP (Neuro-linguistic programming).
\n\nDr Alex Lazinica
\n\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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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. 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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"}}},{id:"334239",title:"Prof.",name:"Leung",middleName:null,surname:"Wai Keung",slug:"leung-wai-keung",fullName:"Leung Wai Keung",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Hong Kong",country:{name:"China"}}}]}},subseries:{item:{id:"17",type:"subseries",title:"Metabolism",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11413,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. His teaching areas are energy metabolism and regulation, integration and organ specialization and metabolic adaptation.",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null,series:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983"},editorialBoard:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",slug:"anca-pantea-stoian",fullName:"Anca Pantea Stoian",profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"203824",title:"Dr.",name:"Attilio",middleName:null,surname:"Rigotti",slug:"attilio-rigotti",fullName:"Attilio Rigotti",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Pontifical Catholic University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"300470",title:"Dr.",name:"Yanfei (Jacob)",middleName:null,surname:"Qi",slug:"yanfei-(jacob)-qi",fullName:"Yanfei (Jacob) Qi",profilePictureURL:"https://mts.intechopen.com/storage/users/300470/images/system/300470.jpg",institutionString:null,institution:{name:"Centenary Institute of Cancer Medicine and Cell Biology",institutionURL:null,country:{name:"Australia"}}}]},onlineFirstChapters:{paginationCount:12,paginationItems:[{id:"82374",title:"The Potential of the Purinergic System as a Therapeutic Target of Natural Compounds in Cutaneous Melanoma",doi:"10.5772/intechopen.105457",signatures:"Gilnei Bruno da Silva, Daiane Manica, Marcelo Moreno and Margarete Dulce Bagatini",slug:"the-potential-of-the-purinergic-system-as-a-therapeutic-target-of-natural-compounds-in-cutaneous-mel",totalDownloads:2,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Purinergic System",coverURL:"https://cdn.intechopen.com/books/images_new/10801.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"82096",title:"An Important Component of Tumor Progression: Fatty Acids",doi:"10.5772/intechopen.105087",signatures:"Jin Wang, Qifei Wang and Guangzhen Wu",slug:"an-important-component-of-tumor-progression-fatty-acids",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Fatty Acids - 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In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. This topic will closely deal with all emerging trends in this discipline.",annualVolume:11411,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null,editorialBoard:[{id:"241413",title:"Dr.",name:"Azhar",middleName:null,surname:"Rasul",fullName:"Azhar Rasul",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRT1oQAG/Profile_Picture_1635251978933",institutionString:null,institution:{name:"Government College University, Faisalabad",institutionURL:null,country:{name:"Pakistan"}}},{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",fullName:"Sergey Sedykh",profilePictureURL:"https://mts.intechopen.com/storage/users/178316/images/system/178316.jfif",institutionString:null,institution:{name:"Novosibirsk State University",institutionURL:null,country:{name:"Russia"}}}]},{id:"17",title:"Metabolism",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",annualVolume:11413,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",fullName:"Anca Pantea Stoian",profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"203824",title:"Dr.",name:"Attilio",middleName:null,surname:"Rigotti",fullName:"Attilio Rigotti",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Pontifical Catholic University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"300470",title:"Dr.",name:"Yanfei (Jacob)",middleName:null,surname:"Qi",fullName:"Yanfei (Jacob) Qi",profilePictureURL:"https://mts.intechopen.com/storage/users/300470/images/system/300470.jpg",institutionString:null,institution:{name:"Centenary Institute of Cancer Medicine and Cell Biology",institutionURL:null,country:{name:"Australia"}}}]},{id:"18",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",annualVolume:11414,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",fullName:"Shymaa Enany",profilePictureURL:"https://mts.intechopen.com/storage/users/81926/images/system/81926.png",institutionString:"Suez Canal University",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/234916",hash:"",query:{},params:{id:"234916"},fullPath:"/profiles/234916",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var m;(m=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(m)}()