Results showing GAS scores pre and post-treatment.
\r\n\tGlobalization does not represent a pure and generous process for humanity or other species, but rather it implies social exclusion and also provokes situations of vulnerability in groups of people, forced exclusion, and apartheid: poor job opportunities, lack of access to education, worse socio-sanitary conditions. Specifically, it can be said that social segregation entails the apartheid of social groups of different ages, genders, and ethnicities; these groups live a reality manifested through the deepening of poverty, in terms of increased vulnerability of the poor and groups with little economic, social, cultural, labor and health stability.
\r\n\r\n\tThis book aims to talk about some topics that are neglected in the discourses of academic communities and political elites. The inequality process is deeply rooted among humans and is part of many people's lives in the form of modern apartheid, gender segregation, lack of health access, and cultural gap. All those structural inequality processes are the product of the biopower perpetuated and produced in the macrosystem, exosystem, mesosystem, and microsystem. For many people from the academy, the information-consuming public, and the society in general, it is a problem to talk about these processes, since they have either lost interest or have normalized the structural and social inequity. For this reason, we see it as transcendental to explain how this situation occurs from the most internal fibers to the most evident processes, intending to make it more visible and thus expose the situation for possible solutions.
",isbn:"978-1-83768-406-9",printIsbn:"978-1-83768-405-2",pdfIsbn:"978-1-83768-407-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"cefab077e403fd1695fb2946e7914942",bookSignature:"Ph.D. Yaroslava Robles-Bykbaev",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11473.jpg",keywords:"Wage Gap, Gender Segregation, Fundamental Human Rights, Health Access, Social Inequity Processes, Modern Apartheid, Resilience, Cultural Gaps, Globalization, Geopolitics of Social Inequality, Public Policies, Social Vulnerability",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 15th 2022",dateEndSecondStepPublish:"July 13th 2022",dateEndThirdStepPublish:"September 11th 2022",dateEndFourthStepPublish:"November 30th 2022",dateEndFifthStepPublish:"January 29th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"13 days",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Bykbaev is a member of the UNESCO Chair of Politecnica Salesiana University. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"57824",title:"Waste in the City: Challenges and Opportunities for Urban Agglomerations",doi:"10.5772/intechopen.72047",slug:"waste-in-the-city-challenges-and-opportunities-for-urban-agglomerations",body:'Since 1950 the world’s urban population has grown from 746 million to 3.9 billion in 2014 [1]. In the global South, most cities, particularly the metropolitan areas are rapidly expanding into large urban and suburban agglomerations, with so called “in-between cities,” where some of the rural characteristics are still mixed into the urban fabric. Cities attract people for many reasons, and most often unemployment and the prospect of a better life with improved and safer living conditions is the key driver to urban growth. Migration, particularly from rural to urban, but also different forms of population movement from other cities, regions and even from other countries are responsible for rapidly changing the urban population [2]. In some parts of the world natural population increase is still on the rise and coupled with higher average life expectancies, population sizes are still becoming bigger. This dynamic urban growth can generate significant stress on city administrations who need to provide the necessary basic infrastructure and public services to expanding neighborhoods and new settlements. As a result of the incapacity to provide these, part of the population lives in extreme poverty and under critically neglected living conditions, often causing sever health challenges to their families and surrounding community [3].
This chapter draws on many years of research and outreach experience with informal and organized waste pickers in different cities of the world. I have learned through participatory action research lenses and in community based research approaches focusing on everyday praxis in the city in the global South, with a particular eye on waste. This reseach practice uncovers post-colonial contexts of waste and value, including gender, class and race perspectives, urban transformation and infrastructure impacts or related challenges in the global South. I am informed by feminist theory, which uncovers power relations and embraces the concepts of equality and equity as crucial in the outcomes of urban development. The research seeks to empower vulnerable populations and value their knowledge grounded in everyday experiences and takes into consideration masculinist power and representation. I acknowledge that the local expertise and understanding cannot be fully realized from the outside [4]. Political Ecology is relevant to urban analysis, because it is inclusive of these multiple layers and actors that shape urban landscapes over time.
Section 1 of the chapter introduces the concept global South and the Urban Political Ecology (UPE) framework. Then, in Section 2 I provide a brief contextualization of waste management in urban agglomerations in the global South, in terms of characteristics of waste and prevailing forms of dealing with waste. I present some of the current social and environmental challenges linked to waste. Section 3 presents the idea of social grassroots innovations, coming from waste pickers. The UPE lens situated in the global South context looks at household waste and some of the grassroots actors, the processes and transformative practices they bring to waste management. There are concrete livelihood opportunities attached to collecting, separating, trading, adding value, and in performing environmental education and technical training in waste management. The final Section 4, highlights some of the insights gained from waste pickers and their organizations that contribute to a place-based understanding of working with waste, grounded in their concrete experiences. The key recommendation in this chapter underlines the important role of public policies in stimulating grassroots development and to address the serious challenges waste and disposal pose in urban agglomerations.
The global South is a spatial and historical concept used to facilitate the understanding of commonalities and differences between countries. However, as a category of places, there is the risk of presenting a rather dualist perspective on development, opposing the South with the North, or even interpreting the term as geographic location, which of course is not the objective. The term recognizes the shared characteristics related to the historical processes experienced under colonialism and imperialism, which have strongly shaped their economies and cultures. The term recognizes situated differences in the multi-scalar processes and transformative practices observed among countries, regions and places. Global South is a term that provides a telling difference from countries we call the global North. Yet, the lived experiences in these locations (both in the North and in the South) are multiple, temporal and place specific. Cities differ immensely from each other and cannot be put together under the same banner. Therefore, a dichotomous division between two worlds would not be tenable empirically and also not desirable politically. It is a contested term, but yet it helps us grasp common causes and consequences of unequal power relations, manifested in everyday urban politics with high levels of inequality and persistent poverty.
Conceptualizing the global South brings to life the specific historical social, economic and political processes unfolding, that find their epicenter in urban experiences in the global South. The bulk of urban growth is now happening in that part of the world and we see urban imaginations, based on processes that are primarily taking place in the global North shifting to patterns that evolve from the global South, as becoming more relevant [5, 6].
With urban growth consumption rates are also on the rise globally. Worldwide cities generate over 720 billion tons of wastes every year [3]. In cities people mostly rely on industrialized and heavily packaged food, significantly adding to the quantity of household waste generated every day. Waste is not yet perceived as a critical challenge, as a socio-ecological issue of highest priority to city administrators nor to the community, and waste is treated mostly with “end of pipe” measures, rather than pro-actively curbing generation and discard of waste, thus reducing the use of virgin resources and stimulating circular resources flows. Yet, in many cities waste is an obvious and visible problem, with uncollected waste amounting in public space, affecting the water quality and environmental health in the city. Waste collection services are often unequally provided within cities, with observable patterns of social and environmental injustices related to waste accumulation and availability of waste infrastructure and services. Those services that are provided usually focus primarily on collection and disposal [3].
UPE sees urbanization as a political process of socio-ecological change, which can also be studied as a process of socio-metabolic transformations [9]. The metaphor of
How is it, that certain values prevail, whereas others are undermined, and, how do these “value regimes” [12] operate in different ontological, cultural, material, and political settings? Urban metabolism analysis studies the entry, transformation and storage of materials and energy and the discharge of any kind of waste and unwanted products. Here, infrastructures and services play crucial roles in maintaining cities and providing for the residents. Cities surely are complex systems. With a dynamic and cyclical perspective applied to planning and development, this approach shows where cities are not livable, are unhealthy and unsustainable or are unjust and inequitable [13].
The UPE focus directs attention to social power relationships and how these produce historically specific social and physical natures. Related to waste management different actors, with more or less levels of inclusion and power can be mapped. The scope of those dealing with waste is wide, ranging from small to large and even multinational contractors, government officials, recycling businesses, middlemen (scrap dealers), organized recycling cooperatives and associations to informal waste pickers. In addition, there are the everyday experiences with waste of ordinary people, governmental and non-governmental actors, contractors, developers, and so on. What are the values embedded in the roles played by the diverse institutions and actors? Where do they locate and where do they position themselves, in the local and global processes of treating, sorting, trading, and recycling waste? There are apparent and hidden social justice issues related to control, ownership, and appropriation of waste management resources and technologies. As already hinted, there are uneven geographical processes at play, inherent to the production of urban environments. In the formal part of the city waste is regularly collected, while in the informal neighborhoods these services are neglected. Sometimes the infrastructure and service gap is filled by grassroots initiatives. The following section will describe some of the key challenges city dwellers in the global South are currently facing.
Waste constitutes a key developmental and environmental issue. It is an almost unavoidable consequence of human activity. Today humans generate more waste than ever before, not only because of dramatic population increase over the past centuries, but also because of the changed nature of consumption and the different composition of solid waste. A shift toward waste minimization and away from depositing it at landfills is important. Per capita consumption of packaged goods and consumer products has skyrocketed after World War II, with the rapidly expanding adoption of growth and consumption oriented economic development. This is when material consumption gained momentum on a global scale [14]. Waste in the city is a transversal theme; it affects water quality, causes flooding (e.g., urban storm waterlogging due to trapped waste in water drainages), generates public health issues by hosting disease vectors, affects the perception of public space (e.g., as a space of neglect and lack of citizenship) and furthers the sense of exclusion. But waste also has other social, economic and environmental facets, which will be discussed further on.
Post-consumer waste generation has more than doubled worldwide, between 1971 and 2002. In the global South, growth in municipal solid waste generation has become exponential from the 1980s onwards, and it continues to steadily grow in most of the global North, except for Central and Eastern European countries and the Former Soviet Union [15]. While Western Europe and North America on average already experienced municipal solid waste (MSW) rates between 1.4 and 1.8 kg/capita/day over the past decade, the population in many large cities in the global South is now also reaching values between 1 and 1.4 kg/capita/day [16]. The urban lifestyle contributes to higher waste generation not only in people’s homes but also outside. Particularly the food service industry thrives on disposables. Today, people consume more in the streets and their consumption leaves more disposable waste in public waste bins. In 2012, urban residents globally generated about 1.2 kg/capita/day of MSW, compared to 0.64 kg in 2002 [17]. In Brazil, the average daily quantity of MSW generated per person is currently about 1.1 kg. For major cities in Africa MSW generation is estimated to range from 0.3 to 1.4 kg/capita/day [18]. Differences in waste generation can be large, as demonstrated by data for Bamenda and Yaounde (the capital) in Cameroon, which generate 0.5 and 0.8 kg/capita/day, respectively [18]. Population size and growth rates are important factors that influence municipal solid waste management. There is a positive correlation between population size and both, the rate of waste produced and the percentage of households enjoying regular waste collection. Yet, it is clear that rapidly growing cities have a hard time in providing consistent waste collection services.
Under the current era, industrial production of consumer goods is characterized by a reduction in product life spans, growing product variety, material component diversity, and increased packaging. All these characteristics are drivers for increased use of natural resources and are responsible for generating waste and producing water, soil and air contaminants. The rise in solid waste is linked to increased levels of urbanization and wealth. Between 1997 and 2007, the Gross Domestic Product (GDP) in India has increased by 7%, while estimates indicate a rise in municipal solid waste over these 10 years by 45%, from a total of 48 million to 70 million tons [19]. The figures for Brazil demonstrate a similar correlation between wealth and solid waste generation. From 2009 to 2010, GDP rose by 7.5%, while MSW increased by 6.8%. In the following year, GDP slowed down with an increase of 2.7%, and MSW generation increased only by 1.8% [20].
Population growth comes with an increase in consumption and waste. More affluent segments of the population consume more and generally their consumption also produces a larger environmental impact. China, India and Brazil alone have added another 509 million new consumers between 1990 and 2000, with an average purchasing power of 839 billion US$ [21]. These “new consumers” are defined as
Waste composition reflects cultural and technological trends and varies greatly between different continents and regions over time. There are many technical aspects involved in creating more sustainable and equitable waste management services. While ashes from heating and cooking, e.g., were reported as large components of household waste in North America until the middle of the last century, plastic appears only since the 1970s as a separately recorded substance [23]. Urban waste in the global North currently contains more recyclable goods and electronics, while municipal waste in the global South still has a larger biodegradable fraction and less recyclable material content. Often these valuable materials have already been reclaimed by the household or by informal recyclers for reuse or trading.
In African cities, the organic content of household waste is still much higher and tops 70% [18]. The household waste composition in Brazil is still typical for the global South, with large fractions of organic (51.4%) and recyclable (31.9%) materials (metals, paper and cardboard, plastics, and glass), and a small proportion classified as other materials (16.7%) [24]. Yet, here the amount of electronic waste is quickly growing, increasing the demand for E-waste recycling.
Most municipal solid waste generated worldwide is still deposited at landfills and waste dumps (70%), while 19% is officially recycled or treated by mechanical or biological treatments and a small proportion is incinerated (11%) [25]. Landfill technologies differ from open dumping to sanitary landfills, with methane capturing. The burning of waste is common, particularly in and around informal settlements and in rural areas. Although worldwide many countries are upgrading their landfills to sanitary landfills, as has happened, for example, in South Africa, Uganda, Ghana and Egypt a decade ago, at the time raised the concern that most landfills in Africa are
Some cities in the global South also adopt expensive waste management models, e.g., mechanized separation systems for recycling or high tech
Informal collection of recyclable and reusable materials is widespread in the global South and significant amounts are recovered. At the same time formal recycling programs are still rare and are most often insignificant in terms of the percentage of recovered materials. There are environmental (and health) impacts as well as benefits of various degrees involved in the act of informally collecting, separating, redirecting and recycling materials contained in waste. Organized door-to-door selective collection of recyclable materials, in particular, embodies opportunities for environmental education in the community; helping shift attitudes and values away from current wasteful consumption patterns and habits, toward reuse and informed, educated consumption and disposal.
In the case of Brazil, 80% of the country’s household waste is regularly collected, and the primary final destination for it is sanitary landfills (58.1%) and controlled landfills (24.2%). The rest gets deposited at unprotected waste dumps (17.7%) [24]. In 2016, only 927 municipalities (17%) in Brazil had some sort of official selective waste collection in place [26]. As in most countries in the global South, selective waste collection happens primarily through informal waste collectors. They have historically been stigmatized and denied epistemic agency. It is crucial that research interrogates how shifts in the waste and recycling systems can change how society perceives waste pickers and also how waste pickers construct themselves and their praxis, in order to build up an efficient and inclusive waste management system.
Landfills are still necessary, but when uncontrolled they are a source for environmental impacts on soil, water and air. They are located close to urban agglomerations, sometimes competing with environmentally protected areas. Landfills and dumps generate significant greenhouse gases (GHGs), primarily methane (5–10% of global methane is emitted by landfills) and carbon dioxide, as microbial communities decompose the organic matter contained in the waste [27]. Converting open dumping and burning to sanitary landfills implies
Mismanaged and uncollected waste is a public health hazard. Abandoned waste attracts disease vectors (including rats, mosquitoes) and if carried into waterways leads to storm waterlogging, causing inundations [28] and consequent public health hazards. When burned, a number of toxic substances are emitted, impacting local neighborhoods.
Waste incineration (including
Morris [31] argues that recycling mixed solid waste saves more energy than generated by
Another urban environmental issue relates to the fact that waste and recyclable materials often travel long distances. De-regulation and globalization re-shape the movements of these materials. Transportation uses energy and adds to air pollution, traffic and noise in large urban agglomerations. Worldwide, half of all plastics, paper and scrap metals are exported to South East Asia. China is leading dealing with recyclable material, with importing over 7.4 million tons of plastic waste, 28 million tons of waste paper and 5.8 million tons of steel scrap; mostly treated in backyard shops or small-scale industries [25]. More recently, particularly the transcontinental shipping of electrical and electronic equipment waste (WEEE) has become a serious challenge, especially as it is shipped to global South cities. 70% of the global WEEE ends up in Chinese cities [33]. While the rough dismantling of E-waste (recovering plastics, copper and other metals, etc.) happens in the global South, reclaiming the high value components (rare earths) happens in the global North, who is in possession of the specific recycling technology. Waste trafficking is often illegal and
The bulk of material recovery in the global South is informal, grassroots and involves a wide spectrum of domestic reuse of bottles, cans, plastics, paper, cardboard and many other discarded materials. Yet, its role is largely unrecognized in waste management and by city authorities. In Delhi, India 15–20% of the MSW (daily 1,275 to 1,700 tons) is collected by informal recyclers. The waste pickers also redirect 200 tons per day of separated organic material to a large-scale composting plant. They collect organic waste from households in the affluent neighborhoods, where they compost it in a series of community composting pits [35]. Often, the lack of local markets for recyclables is still a prevailing limitation for the recycling activity to further flourish [18].
A well-known example for informal grassroots recycling is the work of the
The study by GIZ/CWG has translated the environmental benefits associated with informal material recovery as reduced negative externality costs, expressed in Euros. According to their studies the informal recyclers generate 97.6% of these externality costs in the case of Lima, Peru and 83.4% in Cairo, Egypt [38], p. 21. There is evidence in most big cities that informal workers perform a service that saves city expenditures.
Innovations in waste management from the grassroots level bring many social and environmental benefits that tackle the UN sustainable development target # 11.6,
Several questions remain prominent for a paradigm shift in waste management. One of these questions is how we can get the true recognition for the creation of jobs and improvement of livelihoods from informal and organized recycling. Particularly organized waste pickers are a grassroots source of innovation.
Another question addresses how we can stimulate behavioral change toward prevention, reuse and recycling. Informal sector recycler are those individuals or enterprises that are involved in private sector recycling and waste management activities which are not sponsored, financed, recognized, supported, organized or acknowledged by the formal solid waste authorities, or which operate in violation of or in competition with formal authorities [40]. Waste pickers are carriers of grassroots innovations and have many lessons to share that can help improve municipal waste management systems. In many countries waste pickers have organized in cooperatives, associations, networks or social movements.
Amid the pressures of climate change, population growth, industrialization and urbanization, one of the major challenges faced in global communities is the sustainable and equitable access to infrastructures, services and resources. There is usually a complex network of actors in waste governance, including residents, waste pickers, waste managers, engineers, bureaucrats, consultants, businesses, but also activists, journalists and scientists. These actors often do not agree on how waste related problems are defined or get solved, nor do all of these actors unanimously recognize that different sources of knowledge are needed to solve these problems. There might even be divergence on what type of knowledge to use, how it is produced and communicated across different societal sectors and actors.
People’s relationships to waste and the meanings attributed to waste reveal about culture and society. In order to achieve a fundamental shift in how we see, generate and manage material waste we need to involve other stakeholders and their knowledge. Waste pickers contribute to developing, understanding and solving waste management problems. Innovative governance models can potentially emerge from a dialog with organized waste pickers creating collaborative relationships in providing waste services. Transdisciplinary understanding of waste encompasses this collective approach, bringing together the formal and non-formal actors for creation, communication and use of waste-related knowledge.
In this chapter, I have provided diverse examples for informal recycling activities, highlighted within different situated contexts.
Social aspects of waste management, or the socio-economic advantages of recycling, as highlighted by [44, 45, 46], are not yet widely recognized and comprehensive social indicators demonstrating the social contributions of organizing waste pickers are yet to be developed, in order to be able to clearly measure the benefits deriving from that work to society. From practice, we know that inclusive waste management generates positive contributions to democracy. During the negotiation process between recycling cooperative and local government for waste management service contacts, e.g., waste pickers as citizens affirm their rights to have a voice and to participate in these decisions, thus strengthening democracy. Waste governance decisions can also undermine democratic relations between citizens and the state and even further deepen inequality and poverty. In contrast, good waste governance embraces the following building blocks, as shown in Figure 1.
Major components of good waste governance.
Waste constitutes a major challenge to city administrators and urban populations at large. However, waste is not perceived as an “issue” yet. Waste is treated through the engineering lens rather than from an interdisciplinary perspective. We need to move beyond seeing waste as a merely technical issue and move towards a complex socio-environmental-technical understanding of waste. Learning from the praxis of a wider range of stakeholders (including waste pickers, elected officials, waste managers, private companies and middlemen or scrap dealers) is critical to either facilitating or hindering transformations in the waste and recycling systems.
Urban communities have a say in what happens to their waste and who has access to waste. They must have a say in the decision-making whether to invest in expensive waste management technology, without prioritizing job creation or whether to support labor intensive, inclusive forms of waste management and resource reclamation. Cities can promote a shift towards waste minimization and resource recovery. Waste governance decisions need to also be based on “good governance” principles, including democracy and consensus orientation, participation, accountability, transparency, responsiveness, equity and inclusiveness, be effective and efficient and following the rule of law [1]. These guiding principles should also be applied to waste governance and specifically applied in waste management.
When it comes to deciding over which waste management process and technology to favor and the design of specific policies, the following questions are relevant for local governments.
(1) Who should be involved in policy and decision-making (key stakeholder, e.g., waste picker organizations, local business associations, educational sector, NGOs, experts)?
Participation is not without challenge and stakeholders have to ask what is their mandate? What are the local political realities? What is the available budget? What are the priorities within the city? and so on.
(2) What technology is most appropriate in terms of:
environmental concerns (air pollution, water and soil contamination)
poverty reduction and employment generation
economic sustainability (cost – benefit, short to long term)
environmental sustainability (resource savings and reclamation, reduction in GHG emissions, etc.)
According to the Intergovernmental Panel on Climate Change (IPCC), solid waste and its management are considered key contributors to climate change. Greenhouse gases are emitted or avoided in the upstream and downstream stages in the life cycle of municipal solid waste management systems [47]. Upstream emissions can be avoided when recycled resources replace virgin resources in the fabrication of metal, glass, plastic and paper products. In addition, landfill gas (CH4) and deforestation represent other upstream impacts that are reduced with recycling [48, 49, 50, 51]. Fossil fuel greenhouse gas emissions are of course also associated with recycling operations, as energy and some virgin resources are consumed during the collection and transportation of materials, processing, and re-manufacturing [52]. With recycling, however, both methane (CH4) and carbon dioxide (CO2) emissions are avoided through the diversion of resources from landfills, through resource recovery and recycling of paper, cardboards and other biodegradable material [47, 53], and through reducing the amount of waste to be deposited at landfills.
Research underlines the need to redefine clean development mechanisms (CDMs) to allow for the recognition of resource recovery for reuse and recycling as measures to reduce GHG emissions, save natural resources and energy [54]. Recycling has not yet been considered a CDM, while
There are challenges and limitations related to recycling (down-cycling, up-cycling) which governments should discuss and act on. There are often not enough down-cycling alternatives for many waste materials and waste flows. Here too, cities can become drivers for innovative forms of reuse and recycling. Not to forget is the fact that collection, transportation and processing of waste and recyclables also generate fossil-derived carbon dioxide and other pollutants from the fuel used in transportation, and therefore also needs to enter the equation.
Millions of informal waste pickers collect household waste daily in cities around the globe to earn a living. In doing so they contribute to reducing the carbon footprint of cities, recover resources, improve the environmental conditions and health in the city. The research discussed in this chapter points towards a radical economic and social shift away from growth centered urban development and
Dysphagia is a widely prevalent phenomenon that brings the risk of other conditions like malnutrition, pneumonia, and even the necessity for non-oral feeding solutions [1, 2, 3]. It always leads to reduced quality of life, and can even be fatal [4].
The ways that patients with dysphagia are cared for fall into two broad categories, of which the first is by far the most common. Patients are often provided with compensatory care, [5, 6] which allows them to live with the disabilities that dysphagia brings. These therapies may include modified often puréed solid foods that are easier to swallow, and thickened drinks that can be swallowed more safely with less risk of aspiration. Instruction on posture, eating habits, oral hygiene and more, are also common.
The second category of care is rehabilitation treatment [7, 8, 9, 10, 11] to address the causes of the dysphagia. In general they focus on increasing muscle strength in the affected organs.
This chapter introduces a simple neuromuscular treatment using an oral therapy - IQoro (Figure 1) - that can usually be self-administered by the patient. The treatment has clinical evidence and scientific proof of striking success in treating people of all ages with all forms of dysphagia: oral-, pharyngeal- and esophageal [12, 13, 14]. When used with stroke survivors, the research shows equally good outcomes regardless of whether treatment started immediately, or long after the onset of stroke [10]. In scientific studies, the observed improved outcomes were still present at long-term follow-ups performed up to 18 months after the end of treatment [11, 12, 15, 16, 17].
The IQoro neuromuscular training device.
Associate professor Mary Hägg started her professional life as a hospital dentist where she became fascinated with the swallowing problems that some of her patients presented with. In Sweden, the remit of the dentist is wider than in some other countries and can encompass more orofacial issues than just teeth and gums. The more she worked with patients with swallowing difficulties some after stroke the more fascinated she became. She worked with exercises to strengthen the delinquent muscles and became more and more renowned for her focus on dysphagia.
In 1990, Mary founded a specialist multi-disciplinary unit within the ENT department of a Swedish teaching hospital and has managed it since its inception. The purpose of this speech and the swallowing unit is to encourage and ensure cooperation across a range of clinical specialties to deliver improved patient outcomes.
In 1997 she was awarded a stipend to visit and study the subject more deeply with Dr. Castillo Morales, Cordoba, Argentina, and in 2001 with Professor Bronwyn Jones, Dept. of Radiology, The Johns Hopkins Hospital, medical center in Baltimore, Maryland, USA.
As she treated more and more patients that were referred to her, she came to two conclusions: firstly, those swallowing difficulties manifest themselves as a muscular deficiency, but usually have a neurological dysfunction at the root; and secondly, that there were few effective treatment options. In many cases, patients received only compensatory care which allowed them to function with their disability, but with no active plan to address the underlying problem.
To address the first issue Mary decided that she must study to be a doctor in order to understand the neurology that lies behind dysphagia. It is clear that the day before a patient has a stroke that his or her swallowing can be fine and that it is the neurological event that causes the immediate onset of dysphagia. Mary’s Ph.D. thesis “Sensory-motor brain plasticity in stroke patients with dysphagia. A methodological study on investigation and treatment” 2007, used massage to restore muscular strength by stimulating brain activity. Mary invented and had manufactured a validated scientific instrument to measure the strength of certain components in the swallowing chain by measuring resistance in the pharyngeal sling or buccinator mechanism [18, 19]. She also developed and validated orofacial motor test methodologies [20].
The second problem, the lack of suitable treatments [21, 22] that could be easily and widely used even by the patients themselves was a harder task. Her journey took her through working with all types of dysphagia in people from premature babies through children, adults, and to end-of-life. The journey resulted in her inventing, developing, and patenting the revolutionary IQoro device that is now, July 2021, used by over 50,000 people in many countries.
Decades later Natalie Morris came across the IQoro device, and it set her wondering if it would help her patients too. Natalie is a Speech and Language Therapist working in the UK and is the founder and CEO of The Feeding Trust a not-for-profit multi-disciplinary feeding clinic in the Midlands. During her 20-year career as an SLT, Natalie has become specialist in the assessment and treatment of communication and swallowing difficulties in children and young people (CYP) with neuro-developmental disabilities and acquired brain injuries. She is the founder of Integrated Therapy Solutions Ltd. where she and her team help CYP with swallowing difficulties.
She looked at the scientific evidence supporting IQoro and was disappointed to find that there was none that was directly relevant to one of her main patient groups: CYP clients with Cerebral Palsy (CP). This was significant because NICE guidelines for the management of saliva control in CP [23] offer few options:
Assess contributory factors before starting drug therapy
Medication
Botulinum toxin injections
Surgery
In other words, the only treatment options after considering compensatory strategies such as positioning, are drug therapy or surgery. But the Cochrane review of interventions for drooling in children with CP according to Walshe M, Smith M, Pennington L 2012 [24] concludes: “
Natalie reasoned that if IQoro could help patients with neurological problems such as after a stroke, then it might help her patients with CP too. And if there was no evidence to prove that it worked, then she would have to investigate it herself.
This chapter will show the success of these two clinicians’ work.
This is a brief description of the four different physiological phases of the swallowing process, the following section will look at the neurology of the swallow in detail [5, 25].
During a day, a normal person swallows approximately 600 times: 350 of these are during the day, 200 when eating or drinking, and 50 times when asleep. We use our voluntary muscles to transfer food to our mouths and chew it, after this our reflexive systems take over to complete the swallow unconsciously. When we swallow whilst asleep it is, of course, an entirely reflexive process.
Simply described, the swallowing process starts when we transfer food from the plate to the mouth. (Figure 2). This phase is negatively affected when postural control or arm and hand motility are reduced, possibly after stroke [17].
The four phases of the swallowing process.
Functional and dysfunctional swallow.
The oral phase (Figure 2) starts when we close our lips, chew, reduce the food to manageable pieces and mix it with saliva. As the food is formed into a bolus the tongue’s backward and upwards movements propel it towards the pharynx, at the same time the floor of the mouth rises. And then immediately before the swallowing reflex is triggered we press our lips together creating a low pressure in the mouth. This activity normally takes up to 10 seconds [5]. The decrease in pressure in the mouth eases the transport of the food mixture from the mouth to the pharynx.
The phases employ a mixture of voluntary and involuntary commands.
Once the bolus has passed the anterior palatal arch towards the pharynx, the swallow reflex takes over. This is controlled by the brain stem no longer consciously controlled as the pre-oral and oral phases were. The interplay between the voluntary and involuntary processes is described in the following section on the neurology of the swallow.
A normal swallow requires a balance between the infrahyoid and suprahyoid muscles to stimulate the swallowing reflex [20, 26].
In a later section “The neurology of the swallow” we will see that these muscles are triggered by the following nerves - Infrahyoidal muscles: CN XII hypoglossus.
– Suprahyoidal muscles: CN VII facialis, CN V trigeminus, CN XII hypoglossus.
The swallow reflex is then triggered when the hyoid bone is pulled forwards and upwards (blue arrow) by the digastricus anterior abdomen (CN V), m. mylohyoideus (CN V), and m. geniohyoideus (CN XII). At the same moment, a breathing suspension is caused as the epiglottis closes the laryngeal air pathway, and tongue forward movement is initiated. The chewing muscles are active throughout the swallow.
The pharyngeal phase (Figures 2–4) is a critical part of the swallow controlled purely reflexively and takes between 0.5 and 1 second. It requires a precise interplay between breathing and swallowing functions [5, 13]. When the bolus is to be swallowed, the tongue moves it back towards the anterior palatal arch and the smooth palate which seals against the nasal passages. The larynx raises reflexively, and the tongue starts its forward movement.
The pharyngeal phase - a critical phase requiring coordination of swallowing and breathing.
The first of four security levels to prevent aspiration of food or drink is now activated. The constrictor muscles:
There is perhaps more crossover in dysfunction in the different phases than is often thought. Misdiagnosis is a risk when healthcare professionals concentrate too much on their own specialities without considering a more holistic approach.
For example:
Mis-directed swallowing, post-nasal drip, aspiration, hoarse or gurgly voice, persistent non-productive cough, something stuck in the throat, and blockage are all symptoms often thought of as being caused by a brain injury. Causes of such brain damage can be a stroke, trauma, progressive neurological diseases, or other. In fact, all the symptoms described could equally well be caused by a Hiatal hernia [14].
Patients exhibiting voice changes are often referred in firsthand to a speech and language therapist. If the SLT is not aware that the cause of the problem may be dysfunction in the esophageal phase - like a Hiatal hernia - then optimal outcomes may not be achieved. This problem is aggravated by the fact that SLTs in some countries are not routinely concerned with esophageal dysfunction.
Patients with symptoms of Hiatal hernia are often referred to a medical consultant to rule out the possibility of stroke. When this has been done, then the finger may be pointed at a brain tumor, ALS, or some other neurological condition. Examination for these conditions is both alarming for the patient whilst waiting for examination and results, and expensive. Around 20% of the world’s population suffers from a reflux-based condition, and it is thus logical in many cases to start treating for a Hiatal hernia as soon as stroke has been ruled out.
The esophageal phase (Figure 2) concerns the movement of food and drink from the esophagus down to the stomach. The esophagus’ longitudinal musculature is activated, forming a stiff pipe and allowing the entrance to the Upper Esophageal Sphincter (UES) to relax and open to allow the passage of the bolus into the esophagus. At the same time, the Lower Esophageal Sphincter (LES) opens to allow the entrance of the bolus to the stomach. [5, 29] This phase takes around 7 seconds to complete.
As well as the outer longitudinal layer of muscles, the esophagus also has an inner layer of circular muscles. To transport the food down to the stomach, these circular muscles produce coordinated peristaltic wave motions - this explains why we can swallow even if we were hanging upside down.
The four phases of the swallowing process described above involve 148 muscles and six cranial nerves. Of course, the muscular activities described are not separate from the nerve and brain activity that control them, the entire neurophysiology [25] of the swallowing process must work correctly. Understanding how is fundamental to appreciating how a dysfunctional swallow can be treated.
Figure 5 illustrates four important areas of the brain [25].
Brain stem: It controls non-voluntary “unconscious” automatic functions such as breathing, blood pressure, heart rhythm, the reflex swallowing phases; and also functions as a communication node between the cerebrum, the cerebellum, the spinal cord, and the peripheral nervous system.
Cortex: It controls our voluntary “conscious” most advanced functions such as language, thinking, fine-motor skills, and the voluntary swallowing phases.
Cerebellum: It co-ordinates our movements, our balance, and our ability to act in response to our immediate surroundings.
Corpus callosum: It connects the two brain hemispheres’ cortex areas with each other. It consists of some 200 to 800 million nerves that coordinate the activities of the brain’s two hemispheres.
The brain.
The sensory nerves report perceptions of pressure, texture, taste, and temperature, and these are transmitted by these afferent nerves to the brain. The primary source of these stimuli is from the nerves in the lips and then, in turn, the tongue, soft palate, and pharynx (Figure 6
The cranial nerves and reflex points of the oral cavity.
The five cranial motor nerves that are important for swallowing are CN V Trigeminus, CN VII Facialis, CN IX Glossopharyngeus, CN X, Vagus, and CN XII Hypoglossus. The first four are both sensory (afferent), and motor (efferent) nerve pathways; which send information both to and from the brain - the sensory-motoric reflex arc.
In the brain stem (Figure 7) we find the Nucleus Tractus Solitarius (NTS): the afferent nucleus. The NTS is the core that gathers all incoming sensory signals via the afferent nerve pathways as described (Figure 7). The NTS then transmits the signals onwards either to the brain’s cortex or directly to the network-like system in the brainstem called the Formatio Reticularis (FR). These efferent motor signals are transmitted to the musculature of the face, mouth, esophagus, diaphragm, down to the stomach, the intestines, and the rectum. The process by which the incoming sensory signals trigger afferent commands is known as the sensory-motoric reflex arc (Figure 7) [5, 25, 26, 29].
The sensory-motor reflex arc (level 1).
The three swallowing centers’ interactions - from the brain stem to muscles.
In the FR, the afferent signals from the NTS and the cortex (Figure 7) are first interpreted and then passed through various distribution nodes to the efferent nuclei: the Nucleus Ambiguus (NA), and the Nucleus Dorsalis Nervi Vagi (NDNV).
The NA (Figure 7) sends impulses to the skeletally striated musculature in the oral and pharyngeal regions; and the NDNV (Figure 7) to the smooth musculature of the esophagus and beyond. How these function during swallowing we will explain in more detail below.
In the FR there are three distribution nodes (swallowing centers) that are key to the swallowing process; as well as a number of other centers that control breathing, speech, chewing, coughing, vomiting, evacuation of the bowels and bladder, and those muscles that control the body’s posture (Figure 8). [5, 25, 26, 29].
The Formatio Reticularis (FR) is the control centre for a variety of vital functions.
The Formatio Reticularis is the control centre for several vital functions including breathing, speech, chewing, coughing, vomiting, evacuation of the bowels and bladder, and those muscles that control the body’s posture.
The incoming information is routed by the Nucleus Tractus Solitarius (NTS) in two pathways: some directly to the first of the three swallowing centers in the brain stem, whilst the remainder of the information continues upwards to the cortex to be processed before being also directed to the first swallowing center (Figure 7).
If the combination of information received by the first swallowing center (Figure 9) from the NTS and from the cortex is interpreted as that something is to be swallowed, this instruction is sent to the second swallowing center.
The sensory-motoric reflex arc (level 1–3).
The second swallowing center (Figure 9) transmits signals to the muscles via the motor nerves – the downward-transmitting efferent nerve pathways. Here, there is a pre-programmed “swallow / don’t swallow” stereotypical muscle response.
If the food is to be swallowed, a command is sent to the NA, which in its turn sends the instruction via the efferent nerve pathways to the striated musculature in the oral and pharyngeal regions of the swallowing chain. Concurrently, impulses are also sent to the third swallowing center.
The third swallowing center (Figure 9) transmits information to the NDNV - an efferent nucleus and then onwards to the esophagus’ smooth musculature to complete the swallowing action and to transport the bolus downwards to the stomach.
The three swallowing centers´ interactions from the 2nd center to the striated muscles, and the 3rd center to the smooth muscles is illustrated here.
The 3rd swallowing center transmits information to the Nucleus Dorsalis Nervi Vagi (NDNV), and then onwards to the smooth muscles including those in the esophagus (Figures 9 and 10).
Three types of motor neurons.
The motor signals are transmitted via efferent nerves that can be thought of as cables containing various fibers and motor neurons to the muscles and glands. There are three different kinds of motor neurons that are important in the swallowing process (Figure 10) [5, 25, 29].
The General Somatic Efferent (GSE) motor neurons are present in the CN Hypoglossus (XII) and CN Oculomotorius (III) which transmit signals onwards to the tongue’s and the inner eyes’ voluntary skeletal striated musculature.
The Special Visceral Efferent (SVE) motor neurons act through the CN Trigeminus (V), CN Facialis (VII), CN Glossopharyngeus (IX), CN Vagus (X) and CN Accessorius (XI) which transmit signals to the voluntary musculature in the mouth, chewing muscles, facial musculature, pharynx, larynx, esophagus, and diaphragm.
The General Visceral Efferent (GVE) motor neurons act via CN Facialis (VII) and CN Glossopharyngeus (IX) which transmit signals to the glands, blood vessels, and smooth muscles in the pharynx, stomach, and rectum.
The sum of all the above signals executes pre-programmed cooperation between the 148 muscles that are involved in the transport of each food bite from the mouth down to the stomach.
The efferent nerves send signals via the three different motor neuron fiber types to the muscles and glands.
As we have said earlier, the oral phase is consciously controlled (voluntary) and is managed by the brain’s cortex region [5, 25]. But when the bolus has passed the anterior palatal arch towards the pharynx, the swallow reflex takes over and this is controlled by the brain stem – no longer consciously or voluntarily controlled.
The tongue’s movement backward and upwards transports the food towards the pharynx. When the bolus reaches the anterior palatal arch and the smooth palate, the reflexive phase of the swallow starts [5, 6] causing the larynx to rise, As the tongue begins its return movement forward, the epiglottis seals the airway and the food passes into the pharynx. The pharyngeal phase takes between 0.5 and 1 second.
In this phase, the coordination between breathing and swallowing is crucial to avoid food ‘going down the wrong way’ [5, 25, 30, 31]. Breathing and swallowing are guided by different centers in the brain stem, however, all the muscles that are active in these two functions are controlled from the same concentrated grouping of specialized nerves nucleus in the brain stem. This allows the swallowing center to take control of breathing during a crucial phase in the act of swallowing. When the 1st and 2nd Swallowing Centers signal that swallowing is underway, the body breathes in. During the subsequent exhalation, the food portion is driven to the back of the tongue and the exhalation stops as the bolus crosses the airway. Breathing ceases for 2 seconds about twice as long as it takes for the bolus to pass the pharynx then breathing is resumed with a continued exhalation.
The esophagus’ longitudinal musculature forms a stiff pipe, the UES relaxes and opens to allow the passage of the bolus into the esophagus. The sphincter to the stomach – LES - opens to enable the entrance of the food.
The muscle function and the downwards transport of the bolus are controlled by the Vagus CN X and a branch of the Glossopharyngeal CN IX. Together these nerve pathways build a local network in the esophagus’
Both types of muscle: voluntary skeletal striated muscles and involuntary smooth muscles are present in the esophagus. The voluntary musculature is the same type as we have, for example, in our arms and legs: so-called skeletal striated muscles which are attached to the skeleton or tissue, and that are voluntarily controlled. The smooth musculature cannot be controlled voluntarily but is instead controlled by the autonomic nervous system: functioning unconsciously and involuntarily. These muscles are stimulated via the GVE motor neurons (Figure 10) in the brain stem which sends signals to the involuntary musculature.
The esophagus’ upper third consists of skeletal striated muscles, the middle third is a mixture of skeletal striated muscles and smooth musculature, and the bottom third is solely smooth muscle.
This chapter has so far focussed mostly on the swallowing process of conveying food and drink to the stomach successfully, Hiatus hernia has been mentioned only in passing. Here we explain more about this condition. IQoro treats all dysfunctions in the process of swallowing food and drinks safely and successfully, and in retaining it in the stomach without reflux [14, 32]. A distinction between these two areas although often regarded as separate from a healthcare perspective is artificial. The same neuro-physiological processes are common to both dysfunctional swallowing and reflux.
Reflux-based diseases are thought to affect around 20% of the world’s population [33, 34]. Reflux is a condition in which stomach acids sometimes bubble up from the stomach, through the esophagus, and into the throat, larynx, and pharynx. The effect of these acids is to cause the symptoms of [35]:
Heartburn
Burning sensation in the chest
Acidic reflux
Swallowing difficulties
Feeling of a lump in the throat
Feeling of a blockage in the chest when eating
Chest pains
Pain under the breastbone (sternum)
Stomach pains before eating
Stomach pains after eating
Reduced appetite
Early “Full up’\' feeling
Feeling sick
Constipated, gassy
Vomiting
Persistent dry or phlegmy cough
Food or drink ‘goes down the wrong way’
Hoarseness
Breathing difficulties
It should be noted that if some of the above symptoms are chronic, and especially if they do not respond to medication, they could be caused by cancer or other diseases [36], and this should be considered before diagnosing reflux as the sole cause.
Refluxing stomach acids is the underlying cause of several conditions: LPR, GERD (or GORD), Silent Reflux, IED, Dyspepsia, etc. These conditions are sometimes known by their full names: Laryngopharyngeal Reflux, Gastroesophageal Reflux Disease, and Intermittent Esophageal Dysphagia. These various conditions exhibit some or all of the symptoms listed above, they vary slightly but are all caused by the corrosive effect of the refluxed stomach acids.
These symptoms occur when stomach acids reflux into the esophagus. The normal position of the stomach and the LES - the valve at the mouth of the stomach - is below the diaphragm. The esophagus passes through the diaphragm muscle through an aperture called the hiatus canal. In functional anatomy the muscle grips tightly around the esophagus and holds the stomach down in its correct position. The LES behaves like a trapdoor in this position, swinging downwards to let food and drink into the stomach before closing again. The LES cannot open upwards to allow reflux. An exception to this is if we need to belch or vomit; then the LES intrudes through the diaphragm slightly into the chest cavity and can flap open upwards and allow stomach gases, liquids or solids to reflux.
A Hiatal hernia is a weakening in the muscle that grips around the esophagus where it passes through the diaphragm. When this occurs the mouth of the stomach and the LES can intrude in an unwanted and uncontrolled fashion and allow reflux to occur.
The treatment options for reflux-based diseases fall into two broad camps: reducing the symptoms, or addressing the underlying cause.
In the former category, symptom reduction can be achieved by lifestyle changes or medication. Changing poor living, smoking, drinking, eating and diet habits can improve the impact of reflux, but lifestyle changes have an inconclusive effect [37].
Many Over the Counter (OTC) medications have a base pH and address the problem of reflux by reducing the acidity of the stomach acids which are being refluxed. Although the unpleasant sensations of reflux are reduced, the harmful effects on the vulnerable esophagus and other organs continue. Long-term use of OTC medication is generally regarded to be free from harmful side effects.
Prescribed PPI medications act by inhibiting the amount and strength of the acids produced in the stomach. PPI medications have significant known side effects and hence long-term PPI usage is generally discouraged and several countries insist that clinicians perform a medication review before renewing PPI prescriptions. At least once per year is recommended in the UK [38]. PPI medication is usually not expensive in itself, but the costs of repeat Healthcare Professional (HCP) interventions build to a considerable amount when prescribed for rest-of-life.
PPI drugs belong to one of the safest medication groups, but some research suggests a list of unwanted side effects [39, 40] include increased risk of cardiovascular disease, osteoporosis, dementia, male infertility, diabetes, and increased vulnerability to severe covid19 infection.
In addition, harmful bacteria in the stomach like Helicobacter pylori (HP) that would not survive in normal circumstances, can thrive in the weakened acids after PPI treatment. These germs can enter the body and live in the digestive tract. After many years, they can cause sores, called ulcers, in the lining of the stomach or the upper part of the small intestine. For some people, an infection can lead to stomach cancer.
In the case of all medications, there is no expectation that the underlying cause of the reflux – the weakened diaphragm musculature [34, 41]– will be addressed, merely the severity of the reflux symptoms.
The muscular deficiency at the root of the problem can sometimes be remedied by a surgical operation [42] that re-wraps muscles in the hiatal canal around the esophagus, or a similar procedure. Clearly, addressing the underlying cause is preferable in many ways to long-term medication and IQoro, as presented here, offers a simple non-invasive alternative to a surgical operation.
As discussed, patients with a dysfunctional swallow sometimes after stroke are often treated with compensatory treatments [5, 6]. These care pathways allow patients to live within the limitations of their conditions. Direct and successful treatment of the dysfunctional swallowing chain is to be preferred and is presented in this chapter.
If the cause of both dysphagia and reflux is known to be neuromuscular, why are the most common treatments medication or surgical intervention? It is easy to grasp the idea that rebuilding muscle strength will improve swallowing, and allow the muscles in the Hiatal canal to regain their ability to grip around the esophagus.
If a patient presented with an arm that had atrophied because it had been in a plaster cast for some weeks, we might expect a rehab program based on weights and exercises. However, the atrophied-arm parallel has an important disconnect. As we have explained earlier, there are key differences between the arm muscles and many of the muscles that are needed to ensure an effective swallow and to prevent LES intrusion through the diaphragm allowing reflux. The arm is made up of skeletally striated muscles that can be commanded by the individual to flex, and can therefore be consciously exercised; whereas most of the muscles in the swallowing chain cannot, they are controlled and commanded through other nerve types and command systems. The paradox then is how to exercise muscles that cannot be commanded to flex.
IQoro (Figure 1) is a simple hand-held plastic device that is inserted pre-dentally (inside the lips and in front of the teeth) by a patient and pulled forward against lip pressure to exercise the swallow. At the time of writing, July 2021, it has been used by more than 50,000 individuals and is used by healthcare professionals to treat patients in hospitals and other settings across several countries. It is a CE-marked Class 1 Medical device, internationally patented and costing around USD 150.
The patient inserts the device pre-dentally and seals the lips against the handle, then pulls forward firmly displacing the lips forward slightly. This position is held for 10 seconds, followed by a short pause to relax, and then the action is repeated twice more. This 30-second training session should be carried out three times per day, preferably before mealtimes (Figures 11–13).
(a, b): IQoro training action. (a) the IQoro is inserted pre-dentally, behind closed lips. (b) the patient presses his lips firmly together whilst pulling straight forward strongly for 5–10 seconds, and does this 3 times with 3 seconds rest between each pull. These sessions are performed three times per day, preferably before mealtimes.
Video 1. [
Neurological and physiological considerations in muscle stimulation when eating or during neuromuscular training with IQoro.
Where a patient initially lacks lip strength or has diminished hand or arm function – perhaps after stroke - an assistant can help with this procedure. The vast majority of IQoro users self-treat without assistance.
IQoro causes all the muscles in the swallowing chain to be flexed and thus retrained and strengthened.
Training with IQoro triggers the sensory-motor reflex arc.
The muscles in the chain from the lips through to the upper third of the esophagus are mostly skeletally striated and are voluntarily activated [5, 29] when eating normally. Smooth musculature is present in the lower part of the esophagus, and down through the hiatus canal, LES, stomach, intestines, and rectum, and these muscles can only be activated by signals from the autonomic system [5, 29]. It is thus the case that striated musculature is activated by voluntary neurological and physiological commands, but the smooth muscle can only be activated and exercised via commands from the autonomic system.
Studies show that rehabilitation of the smooth musculature traditionally takes longer [14, 32, 44] and requires ongoing maintenance training after treatment.
When you close your lips tightly against the handle and pull the device forward, a low pressure is created in the mouth, making the tongue retract and seal against the anterior palatal arch and the soft palate. The effect of this is to strongly stimulate the sensory nerves in the oral cavity which send afferent signals to the brainstem as described in the neurology section above. Here they provoke a so-called sensory-motor reflex arc which causes intense efferent motor signals to exercise the muscles in the swallowing chain. In this way, IQoro training reaches and strengthens even the smooth musculature that cannot be voluntarily commanded by the patient.
Training with IQoro activates all the muscles in the swallowing chain, including the outer longitudinal muscles that run along the sides of the esophagus and fasten under the diaphragm. As they are activated by IQoro training they exercise the muscles at the site of the rupture, strengthening the weakened muscles back into a functional condition.
In other words, the training action and regime used to treat dysphagia [10] are equally appropriate for Hiatal hernia and reflux-based conditions [14, 32, 44].
This section presents the scientific support for the efficacy of IQoro in treating the two closely related conditions of dysphagia and reflux-based diseases caused by a hiatal hernia. For reasons of space and readability, most studies have been reduced to short summaries of their purpose and conclusions and a link to the full article. Exceptions to this are 8.1.4 and 8.1.5 which are presented in more detail, having not been published in a scientific journal previously.
The evidence behind the efficacy of IQoro as a treatment for dysphagia includes more than a dozen peer-reviewed and internationally published scientific research papers.
Peer-reviewed, prospective, cohort pre and post-study designed according to Good Clinical Practice (GCP) [15].
This study showed that IQoro is effective in improving swallowing ability, facial activity in all four facial quadrants in patients, and pharyngeal sling force after stroke, irrespective of time from stroke debut to start of treatment. Improvements were still present at late follow-up (>1 year after the end of treatment).
The 31 patients were grouped according to having had a stroke with recent onset, or a long time before. By implication, the similarly successful results in the two groups rule out spontaneous recovery as a likely cause of the improvements seen.
IQoro is effective in improving swallowing ability, facial activity in all four facial quadrants, and pharyngeal sling force after stroke, irrespective of time from stroke debut to start of treatment.
Peer-reviewed, prospective, cohort pre and post-study [17].
The study used IQoro as a treatment for 12 weeks in a patient group that had pathological levels for both Impaired Postural Control (IPC) and Oropharyngeal Motor Dysfunction (OPMD).
The 26 adults recruited to the study were divided between those with recent stroke, and those who had stroke onset a long time before. Results were equally positive in both groups showing the efficacy of IQoro in immediate intervention or in chronic sufferers. Once again, the similar results in the two groups rule out spontaneous recovery as a likely cause of the improvements seen.
At end of training significant improvement (p < 0.001) in tongue and velum function, velopharyngeal closure, and swallowing ability were recorded in the late intervention group. Almost all other outcome improvements in this group showed a (p < 0.01) statistical significance, as did all measures in the early intervention group.
Improvements were maintained at late follow-up (median 59 weeks after the end of training).
Two patients showed no improvement in either IPC or OPMD, all others regained normal abilities in both functions. Five patients presented with Percutaneous Endoscopic Gastrostomy (PEG) feeds at recruitment; all five PEGs were removed by/at end-of-training and all recovered the ability to eat and drink unmodified foods and liquids.
IQoro successfully treats impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke.
PEGs can be removed after several years of use, after 3 months’ IQoro treatment.
Velum function is significantly improved by IQoro training.
Improvements made are still present at long-term follow-up.
The similarity of results in the two intervention groups further supports the contention that improvement is not due to spontaneous remission.
The effectiveness of IQoro treatment is not affected by the time from stroke to the start of treatment, nor the age or gender of the patient.
The positive effect on muscle groups not directly accessed by IQoro neuromuscular training supports the contention that the improvements are triggered by neurological rehabilitation.
Peer-reviewed, prospective, cohort pre and post-study, Randomized Controlled Trial (RCT) [12].
385 elderly participants in intermediate care units were screened, and 116 with impaired swallowing were randomly assigned to IQoro neuromuscular training or usual care. Standard IQoro training was employed: 3 x 10 seconds, three times per day for 5 weeks and patients, were measured at three-time points: before training, at end of training, and at late follow up (6 months post-treatment).
At end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (
Signs of aspiration were significantly reduced in the intervention group compared with controls (
At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (
No significant between-group differences were found for swallowing-related quality of life.
Treatment ended at discharge from the residential facility in order that a long-term follow-up could determine that the improvements seen at end-of-treatment were sustained. Oral neuromuscular training is a new promising swallowing rehabilitation method for older people in intermediate care. Better clinical results would likely have been achieved if IQoro treatment had continued for longer than 5 weeks.
This study is that performed by Natalie Morris and her team and referred to at the beginning of this chapter.
Difficulty in controlling saliva is a common problem for people with Cerebral Palsy (CP). Drooling is not normally a result of overproduction but inefficient control of salivary secretions due to:
Inadequate lip closure / habitual open mouth posture
Reduced or impaired sensory feedback
Atypical muscle tone
Underlying swallowing difficulties
Dental problems
Side effects from other medications
Impaired postural control
Natalie’s own clinical observations and experiences of working with children and young people (CYP) with CP were that difficulty with saliva control is a persistent problem with no real effective treatment. The Cochrane review of interventions for drooling in children with cerebral palsy concludes, “
The UK’s National Institute for Health and Care Excellence (NICE) guidance [23] on the assessment and management of CP in under 25 s recommends clinicians assess factors that may affect drooling in children and young people with cerebral palsy, these include:
Compensatory strategies and management of contributory factors such as positioning - Multi-Disciplinary Teams (MDT) working with Occupational Therapists (OT) and Physiotherapists to promote head control.
Increasing awareness of saliva - behavioral approaches to prompt children to swallow more often and wipe their faces. However, many people with CP have reduced sensory feedback and are often unaware that their chin is wet. Furthermore, the physical action of wiping their own chin can be difficult.
Oral-motor therapy - aims to target musculature that can be voluntarily trained to improve muscle strength, tonicity, and coordination. However, from a neurological point of view, it is important to consider that although some of our swallows are initiated during the conscious process of eating, drinking, and specific exercises, the majority are reflexive: swallowing away our saliva without conscious involvement. The autonomic nervous system is responsible for the overall control of salivation: these nerves are not under conscious control.
Improving oral health - reducing reflux and maintaining good oral hygiene will reduce the bacterial load of saliva and reduce the risk of infection.
Eliminating mouthing behaviors - some tools that are provided to improve oral skills e.g., chewy tubes for jaw stability, can precipitate difficulties with saliva control if used incorrectly and not as part of a structured program.
Most CYP with CP is given some form of medication to help with saliva control.
NICE produced guidelines in 2017 [23] on the treatment of drooling in children with CP.
The most common medications prescribed are:
Oral Glycopyrronium Bromide
NICE concludes there is moderate evidence for the effectiveness of this treatment and no evidence for the long-term safety. Side effects include dry mouth, vomiting, constipation, and thickening of secretions, which may increase the risk of respiratory infection and pneumonia. Many children are kept on this medication for years, at great cost to the NHS (NICE gives an average of GBP 320 per bottle, around GBP 430 for 28 days’ treatment, approx. GBP 5160 per year).
Hyocine patches + Trihexyphenidyl Hydrochloride
Although commonly prescribed, at the time of publication (January 2017), neither medication had a UK marketing authorization for use in CYP under 18 for treatment of hypersalivation.
Finally, if other treatment methods have been investigated, Botulinum Toxin injections into the salivary glands or surgery to remove the glands may be considered. Although these would obviously be highly aversive experiences and considered only as a last resort.
In 2018, Natalie attended the Association of Speech and Language Therapists in Independent Practice (ASLTIP) conference in London and came across IQoro neuromuscular training device that exercises and strengthens the muscles needed for feeding and swallowing by activating the nervous system to and from the brain. The manufacturers suggest that while traditional oral-motor therapy can target.
The musculature that can be voluntarily trained to improve muscle strength, tonicity, and coordination, it does not target the two-thirds of the swallowing process that is controlled by the autonomic nervous system. IQoro claimed to trigger the sensory-motoric reflex arc which enables messages to be sent to musculature beyond the reach of voluntary control. The sensory-motoric reflex arc [5, 25], (Figure 14) effectively has a “leveraging” effect on direct muscular training and can improve the entire swallowing process.
The sensory-motoric reflex arc.
IQoro could point to an impressive amount of research that had been conducted on adults with acquired swallowing difficulties, but no evidence to support its use with children. The question that interested Natalie was: “
The programme used a case series design: 10 participants aged between 6 and 22 years old all had a primary diagnosis of CP. A single case study design was applied to each individual and in addition to individual outcomes, inferences were drawn from the collective data.
Several measures were taken to establish baselines, and these were compared to the measurements taken after the treatment phase.
She and her team used a mixed-method strategy, producing quantitative data regarding oral motor and swallowing ability as well as collecting qualitative data about how the patients/carers / MDT members perceived the value of the tool.
Natalie chose to use a Goal Attainment Scaling in Rehabilitation (GAS) method; GAS statistically scores the extent to which each patient’s individual goals are achieved in the course of intervention. There is substantial literature that demonstrates its usefulness, both as part of the communication and decision-making process and as a person-centered outcome measure for rehabilitation [45]. Original: [46].
Baseline assessments were taken of swallowing ability, oral motor function, and speech.
Rating scales were used that allowed for skill breakdown and functional description of each area.
The baseline assessment scores were used to set for intervention.
An individual program for using the IQoro was designed for each patient and then carried out 3 x per day (by parents/carers) for 20 weeks.
The composite GAS is transformed into a standardized measure with a mean of 50. If goals are set in an unbiased fashion, one would expect a normal distribution of scores, and the GAS thus performs at the interval level. If goals have been fully achieved, we would expect to see a score of 50 (Table 1).
GAS Score | Swallowing | Oral Motor | Speech |
---|---|---|---|
Baseline | 35.1 | 34.5 | 32.2 |
Range | 34.9–35.8 | 31.3–36.3 | 26.5–35.2 |
Achieved | 53.7 | 48.1 | 32.2 |
Range | 44.3–60.3 | 45.8–51.6 | 26.5–35.2 |
Change | 18.8 | 13.6 | 0 |
Range | 8.5–25.3 | 10.6–20.3 | 0 |
Results showing GAS scores pre and post-treatment.
Results indicated that IQoro does improve saliva control in children with CP, with improvements also demonstrated with oral motor skills. Using the measures of articulation, there was no change to speech. However, changes to voice were observed in the qualitative analysis (Table 2).
Improved outcomes in swallowing and oral motor skills, but not speech.
In this study, it has been possible to demonstrate an improvement with saliva control resulting from treatment using IQoro. On average, ratings reduced from 4 (“unable to control”, saliva loss 75–100% of the time) to 2 (“moderate difficulty”, saliva loss 25–50% of the time). However, at least half of the participants improved further to a score of 1 (“mild difficulty”, saliva loss 10–25% of the time).
Qualitative data reported (but not measured) saw improvements with: teeth brushing; nasal breathing; breath control for speech; reduction in chest infections; sensory feedback (perception of saliva on chin) and tongue retraction. Positive feedback has been received from schools (less damage from saliva to IT equipment and worksheets) and physio colleagues (able to work in supine for longer periods due to an increase in swallowing of secretions).
Future plans include creating an assessment protocol and running a training program. Further research is indicated to see if this would be a cost-effective treatment that could be made available on the NHS.
It has been the case that there is a severe lack of options in treating children and young people with Cerebral Palsy with dysfunction that leads to drooling. Existing medication and surgical intervention alternatives are often ineffective, invasive, and even not strictly approved for patients in these age groups. Many medication alternatives are expensive when compared with IQoro treatment.
IQoro has been proved to be a suitable treatment for the group studied, including those at the higher end of the scale of motoric and other difficulties. In the case of some of the latter, two assistants were required to perform the training.
Swallowing and oral motor competence improved significantly to a level around the 50-point target of the GAS goals, although the measured speech ability did not. Other functions and abilities important in daily life also improved as reported above.
Much-improved drooling and saliva control had great influence in improving the patients’ quality of life, not least where it allowed the use of laptops, books, and other educational material in schools.
Roseanne, Exell 1; Hayley McBain 2; Sam Turvey 2; Gill Hardy 1
Royal Devon and Exeter NHS Foundation Trust
South West Academic Health Science Network
A service evaluation was carried out in southern England in 2020 resulting in the following abstract.
This evaluation explored the introduction of IQoro into a National Health Service (NHS) setting.
Patients with chronic dysphagia were recruited from acute and community settings and completed a 12-week program using IQoro. Clinical and well-being measures were taken pre and post-training. Feedback was gained from the Speech and Language Therapists delivering this program.
25 patients were recruited into the evaluation, 21 completed the program. There were significant improvements in self-reported quality of life scores, including the overall scores and burden of dysphagia and mental health subscales. There was a significant improvement in functional measures of dysphagia, including the consistencies of food and drink that patients could safely manage. There was also a significant improvement in the facial movement and symmetry of the lower half of the face. Feedback from SLTs indicated that IQoro improved the range of therapy options available and many planned to use it again. Qualitative feedback suggested that the use of IQoro may change SLTs clinical thinking, including in relation to intervention or compensation for dysphagia.
IQoro can be successfully introduced into an NHS team and can be effective in supporting patients with chronic dysphagia. However, factors such as the ability to follow patients across different settings and the individual risk of further decline need to be considered.
In an email survey in June 2021 of all IQoro users that had purchased within the previous 1–15 months, users were canvassed on the effectiveness of IQoro treatment for dysphagia. Totally 4440 responses were received, 983 were specifically treating symptoms associated with dysphagia after stroke. Patients had trained for 1 month or more (Table 3).
Symptom free | Big improvement | Small improvement | No improvement yet | ||
---|---|---|---|---|---|
Difficulty in swallowing liquids safely | 11% | 42% | 33% | 14% | 100% |
Difficulty in swallowing solid foods | 7% | 35% | 38% | 21% | 100% |
Drooling | 9% | 24% | 44% | 23% | 100% |
Facial or speech weakness | 4% | 28% | 47% | 21% | 100% |
Improved outcomes in swallowing and facial abilities.
This survey of a large population of people using IQoro to treat various types of dysphagia and facial weakness is that their outcome experience is positive. This survey differs from the studies quoted elsewhere in this chapter in that the results shown are not at end-of-training in all cases. Many had not trained long enough at the time of the survey to experience the full effect in symptom reductions: some having only trained for as little as 1 month. Nevertheless, 79% - 86% reported symptom improvements since starting training.
The UK’s National Institution for Health and Care Excellence (NICE)), was commissioned by the UK government and advises and supports National Health Service and social care commissioners and have made a review of IQoro and its claims and effectiveness. They have issued a Medtech Innovation Briefing [47] that recognized “
Reflux occurs when the neck of the stomach and the Lower Esophageal Sphincter (LES) intrude through the diaphragm into the chest cavity. In this position, the LES can open upwards and allow stomach contents to reflux, in its correct position it can only allow one-way traffic downwards. This intrusion or hernia is made possible when the musculature of the diaphragm around the hiatal canal is weakened (Figure 15).
(A) Sliding hiatal hernia. The upper part of the stomach and the LES has slid up through the hiatal canal. This allows gastroesophageal reflux and also causes difficulties with opening the PES at the top of the esophagus. (B) Normal anatomy. The neck of the stomach is correctly held below the diaphragm promoting normal LES function and preventing reflux.
IQoro is an effective treatment for reflux-based diseases and their various symptoms: heartburn, pain behind the sternum, persistent unproductive cough, blockage in the throat, and more. Training with IQoro provokes stimuli from the brainstem to flex and strengthen all the muscles in the swallowing chain including those allowing a Hiatal hernia.
The evidence behind the efficacy of IQoro as a treatment for Hiatus hernia includes the following three peer-reviewed and internationally published scientific research papers which are briefly summarized here.
Peerreviewed, Prpospective, cohort pre and post-study [14].
43 patients who had esophageal dysphagia for a median of 3 years (range: 1–15 years) were recruited to this study. All displayed the symptoms of a Hiatal hernia, but only 21 had had their condition confirmed by examination. All had been prescribed Proton Pump Inhibitor (PPI) medication for more than 1 year without any effect, all medication ceased at the start of IQoro treatment.
A validated test battery was employed at baseline and at end of training including questionnaires and tests for all patients. In addition to these measures 12 patients with confirmed hiatal hernia were measured using High Resolution Manometry (HRM) [48] to measure pressure at resting and during IQoro traction.
No statistical difference (p = NS) between symptoms or outcomes between those with or without confirmed Hiatal hernia diagnosis – both before and after treatment.
Esophageal dysphagia was present in all 43 patients at start of treatment, and 98% of patients showed improvement after IQoro neuromuscular training (p < 0.001).
Reflux symptoms were reported before training in 86% of the patients, 100% of these showed improvement at end of training, (p < 0.001) and 58% were entirely symptom free. All patients ceased PPI medication at recruitment to the study.
VAS scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQoro neuromuscular training (p < 0.001).
Pharyngeal sling force and velum closure test values were both significantly higher (p < 0.001) after IQoro neuromuscular training.
Those tested with HRM showed the following results:
During IQoro traction there was an increase in mean pressure in the diaphragmatic hiatus region and in the Upper Esophageal Sphincter (UES) (Table 4).
Items Pressures in mmHg | UES | Hiatus |
---|---|---|
Normal pressure | >30 | 10–35 |
Resting pressure | 68 (40–110) | 0 (0–0) |
During IQoro traction | 95 (80–130) | 65 (20–100) |
High-resolution manometry (HRM) results in UES and hiatus both at rest and during IQoro traction.
Data are mean (range) mmHg.
IQoro neuromuscular training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence. The similarity of the results in the two groups suggests that many people suffer from Hiatus hernia despite this not having been confirmed by diagnosis.
Peer-reviewed, prospective, cohort pre and post-study [17].
The study investigated whether 28 patients with hiatal hernia and misdirected swallowing and esophageal retention symptoms could be successfully treated with a 6-month regime of standard IQoro training: 30 seconds three times per day. Patients had had their condition for median of 4 years (range 1–28).
Reflux symptoms were reported before training in all patients,
100% of these showed improvement (p < 0.001) at end of the training, and 61% were entirely symptom-free despite ceasing PPI medication at the start of training.
All hiatal hernia patients were improved after training with IQoro and showed significant improvements (p < 0.001) in
misdirected swallowing,
cough,
hoarseness,
esophageal retention,
globus sensation,
scores for VAS, pharyngeal sling force, VCT, and TWST.
Traction during the training action with IQoro resulted in a 65 mmHg increase in the mean pressure of the diaphragmatic hiatus as measured by high-resolution manometry (Table 4).
IQoro training significantly improves all the symptoms of hiatus hernia, likely through improved hiatal competence.
Peer reviewed, prospective, clinical study, cohort pre and post-study [32].
It has been thought that treatment of Hiatus hernia in overweight patients can be unproductive and that weight loss should be a prior step to interventions.
In this study 86 adult patients with verified hiatal hernias and long-standing Intermittent Esophageal Disease (IED) and other Gastro-Esophageal Reflux Disease (GERD) symptoms were grouped according to their Body Mass Index (BMI), before entry into the study (Table 5): Group A: normal weight, Group B: moderately obese, Group C: severely obese.
Items | Group A; | Group B; | Group C; |
---|---|---|---|
Median age | 69 yrs. (20–85) | 57 yrs. (22–85) | 62 yrs. (44–87) |
Gender | 19 women, 18 men | 16 women, 12 men | 11 women, 10 men |
5 yrs. (1–75) | 6 yrs. (1–15) | 3 yrs. (1–29) | |
BMI before/after IQNT | 23 (17–24) /23 (20–25) | 28 (26–29) / 27 (24–29) | 33 (30–37) / 31 (27–38) |
Analysis of subjects by BMI grouping - age, gender, and GERD symptom duration.
Ranges in parentheses. BMI and GERD: median values; IQNT: Neuromuscular training with an oral IQoro.
At entry into the study there were no significant differences between the three BMI groups in baseline testing for swallowing ability, or for IED and GERD symptom severity, except that:
Heartburn and cough were significantly more common in Groups B (moderately obese) and C (severely obese).
Misdirected swallowing was significantly more common in Group C.
After IQoro neuromuscular training, the following was observed in all three BMI groups:
All IED and GERD symptom scores were significantly improved or reduced (p < 0.001).
Median BMI was not significantly changed.
Self-assessed GERD symptom improvement showed no significant difference across the groups, except for heartburn, cough, and misdirected swallowing which were significantly (p < 0.01) more reduced in obese patients than in normal bodyweight patients.
The swallowing tests showed significant improvement (p < 0.001) in median values, with no significant difference between the BMI groups except for:
Timed Water Swallow Test (TWST) values, which were significantly (p < 0.01) more improved in Group C (severely obese) than in Group A (normal weight).
pharyngeal sling force, which was significantly (p < 0.05) more improved in Group B (moderately obese) than in Group A.
IQoro neuromuscular training (IQNT), a non-surgical treatment for IED and other GERD symptoms in hiatal hernia patients, is equally successful in treating moderately or severely obese patients as in treating sufferers of normal weight. Obesity in itself does not, therefore, seem to be a handicap in treating IED and other GERD symptoms by IQNT.
In an email survey in June 2021 of all IQoro users that had purchased within the previous 15 months, users were canvassed on the effectiveness of IQoro treatment for dysphagia. Totally 4440 responses were received of which 3436 were specifically treating classic reflux symptoms caused by Hiatus hernia, the rest of the responses were from people treating symptoms associated with dysphagia after stroke or snoring and sleep apnoea. Patients had trained for 1 month or more.
76%–84% of respondents reported symptom improvement, it can be assumed that some of those not yet reporting improvements had only trained for a short while (Table 6).
Symptom free | Big improvement | Small improvement | No improvement yet | ||
---|---|---|---|---|---|
Reflux / acid reflux | 6% | 40% | 37% | 17% | 100% |
Heartburn | 9% | 42% | 34% | 15% | 100% |
A sensation of something stuck in your throat | 12% | 38% | 34% | 17% | 100% |
Excessive or thick phlegm | 4% | 30% | 42% | 24% | 100% |
Dry, persistent cough | 8% | 34% | 36% | 22% | 100% |
Gassy, burping often | 4% | 35% | 39% | 22% | 100% |
Pain in your chest or esophagus | 11% | 39% | 33% | 17% | 100% |
Food that you have swallowed comes up again | 15% | 38% | 31% | 16% | 100% |
Hoarseness | 8% | 29% | 39% | 24% | 100% |
Improved outcomes in hiatal hernia related symptoms.
A large population, 3436 people, using IQoro to treat reflux symptoms showed positive outcome experiences. This survey differs from the studies quoted elsewhere in this chapter in that the results shown are not at end-of-training in all cases. Many had not trained long enough at the time of the survey to experience the full effect in symptom reductions: some having only trained for as little as 1 month. Nevertheless, 76% - 85% reported symptom improvements since starting training.
In March 2019 the UK’s National Institute for Health and Care Excellence (NICE) developed a Medtech Innovation Briefing (MIB) [49] regarding the use of IQoro to treat Hiatus hernia, it points out the innovative nature of the device and its potential to save the NHS money.
All versions of dysphagia have an unsatisfactory range of treatment options. Swallowing difficulties, reflux, and other manifestations are often met with compensatory strategies instead of the treatment of the underlying causes. IQoro is simple, inexpensive, non-invasive, and takes just 90 seconds per day.
IQoro is proven both in clinical practice and in research studies to be highly effective in treating the underlying causes of the conditions and symptoms described in this book. The evidence base for its efficacy is strong.
This innovative device and treatment are shown to be effective in treating all types of dysphagia in the pre-oral, oral, pharyngeal, and esophageal phases. Similarly, Hiatus hernia and its resulting reflux symptoms can be addressed successfully. In all of these conditions, it is shown that time from onset of the condition stroke or Hiatus hernia for example, to the time when IQoro treatment starts, does not affect the positive outcome results of the treatment. The stroke studies show that improvements achieved at end-of-treatment persist at long-term follow-up. Several studies and evaluations show that patients with PEG feeding tubes have had them removed after IQoro therapy.
All healthcare professionals working with dysphagia and its related conditions should want to know more about IQoro and how it improves patient outcomes and gives clinicians an important and powerful new treatment option.
The authors would like to thank Terry Morris (no relation to the author) for his assistance in authoring this chapter, for creating the summary of abstracts from which several of the above studies are copied, and for performing the data analysis on the customer survey referred to above.
The authors would also like to thank Gill Hardy, Speech and Language Therapist, Clinical Lead Neurology, and her colleagues at the Royal Devon and Exeter NHS Foundation Trust and also Roseanne Exell and Hayley McBain at the South West Academic Health Science Network for their kind permission to reproduce the abstract of their service evaluation shown above.
Some studies reproduced above were supported by grants from The Centre for Research & Development, Uppsala University/County Council of Gävleborg, Gävle, Sweden, and The Council for Regional Research in Uppsala and Örebro region, Sweden.
IQoro is patented in Sweden - SE 1350314-9, 2014 July 14 - and widely internationally. It is CE-marked as a Class 1 Medical Device for therapeutic use by the manufacturer MYoroface AB. Mary Hägg is the inventor.
The authors, Mary Hägg and Natalie Morris declare that they have no conflict of interest.
All studies were performed according to the Helsinki Declaration. Informed written and verbal consent was obtained from all the participants in the studies. All images are kindly provided by MYoroface AB.
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Sharma"}]}],mostDownloadedChaptersLast30Days:[{id:"74297",title:"Optimization, Validation and Standardization of ELISA",slug:"optimization-validation-and-standardization-of-elisa",totalDownloads:1712,totalCrossrefCites:1,totalDimensionsCites:3,abstract:"The enzyme-linked immunosorbent assay (ELISA) is a commonly used analytical immunochemistry assay based on the specific bond between the antigen and the antibody. The application of this test has significantly changed the practice of medical laboratories in which it is used for detection and quantification of molecules such as hormones, peptides, antibodies, and proteins. Various technical variants of this test can detect antigen (native or foreign) or antibody, determine the intensity of the immune response whether pathological or not; the type of induced immune response as well as the innate immunity potential; and much more. These capabilities, as well as the high sensitivity and robustness of the test and a small price, make it possible to quickly and reliably diagnose diseases in most laboratories. Besides, ELISA is a test that is also used in veterinary medicine, toxicology, allergology, food industry, etc. Despite the fact that it has existed for almost 50 years, different ELISA tests with different technical solutions are still being developed, which improves and expands the application of the this exceptional test. The aim of this chapter is to empower the rider to optimize, standardize and validate an enzyme linked immunosorbent assay.",book:{id:"9850",slug:"norovirus",title:"Norovirus",fullTitle:"Norovirus"},signatures:"Rajna Minic and Irena Zivkovic",authors:[{id:"325806",title:"Ph.D.",name:"Irena",middleName:null,surname:"Zivkovic",slug:"irena-zivkovic",fullName:"Irena Zivkovic"},{id:"325839",title:"Dr.",name:"Rajna",middleName:null,surname:"Minic",slug:"rajna-minic",fullName:"Rajna Minic"}]},{id:"56750",title:"Laboratory Approach to Anemia",slug:"laboratory-approach-to-anemia",totalDownloads:6181,totalCrossrefCites:2,totalDimensionsCites:4,abstract:"Anemia is a major cause of morbidity and mortality worldwide and can be defined as a decreased quantity of circulating red blood cells (RBCs). The epidemiological studies suggested that one-third of the world’s population is affected with anemia. Anemia is not a disease, but it is instead the sign of an underlying basic pathological process. However, the sign may function as a compass in the search for the cause. Therefore, the prediagnosis revealed by thorough investigation of this sign should be supported by laboratory parameters according to the underlying pathological process. We expect that this review will provide guidance to clinicians with findings and laboratory tests that can be followed from the initial stage in the anemia search.",book:{id:"5942",slug:"current-topics-in-anemia",title:"Current Topics in Anemia",fullTitle:"Current Topics in Anemia"},signatures:"Ebru Dündar Yenilmez and Abdullah Tuli",authors:[{id:"183998",title:"Ph.D.",name:"Ebru",middleName:null,surname:"Dündar Yenilmez",slug:"ebru-dundar-yenilmez",fullName:"Ebru Dündar Yenilmez"},{id:"209103",title:"Prof.",name:"Abdullah",middleName:null,surname:"Tuli",slug:"abdullah-tuli",fullName:"Abdullah Tuli"}]},{id:"33133",title:"Waist Circumference in Children and Adolescents from Different Ethnicities",slug:"waist-circumference-in-children-and-adolescents-from-different-ethnicities",totalDownloads:8e3,totalCrossrefCites:4,totalDimensionsCites:7,abstract:null,book:{id:"642",slug:"childhood-obesity",title:"Childhood Obesity",fullTitle:"Childhood Obesity"},signatures:"Peter Schwandt and Gerda-Maria Haas",authors:[{id:"29867",title:"Prof.",name:"Peter",middleName:null,surname:"Schwandt",slug:"peter-schwandt",fullName:"Peter Schwandt"}]},{id:"54411",title:"Isolation and Characterization of Escherichia coli from Animals, Humans, and Environment",slug:"isolation-and-characterization-of-i-escherichia-coli-i-from-animals-humans-and-environment",totalDownloads:6141,totalCrossrefCites:5,totalDimensionsCites:8,abstract:"Working on a diverse species of bacteria that have hundreds of pathotypes representing hundreds of strains and many closely related family members is a challenge. Appropriate research design is required not only to achieve valid desired outcome but also to minimize the use of resources, including time to outcome and intervention. This chapter outlines basics of Escherichia coli isolation and characterization strategies that can assist in research designing that matches the set objectives. Types of samples to be collected, collection and storage strategies, and processing of samples are described. Different approaches to isolation, confirmation and concentration of various E. coli strains are summarized in this chapter. Characterization and typing of E. coli isolates by biochemical, serological, and molecular methods have been explained so that an appropriate choice is made to suite a specific E. coli strain/pathotype. Some clues on sample and isolate preservation for future use are outlined, and general precautions regarding E. coli handling are also presented to the researcher to avoid improper planning and execution of E. coli-related research. Given different options, the best E. coli research design, however, should try as much as possible to shorten the length of time to outcomes.",book:{id:"5493",slug:"-i-escherichia-coli-i-recent-advances-on-physiology-pathogenesis-and-biotechnological-applications",title:"Escherichia coli",fullTitle:"Escherichia coli - Recent Advances on Physiology, Pathogenesis and Biotechnological Applications"},signatures:"Athumani Msalale Lupindu",authors:[{id:"185959",title:"Dr.",name:"Athumani",middleName:"Msalale",surname:"Lupindu",slug:"athumani-lupindu",fullName:"Athumani Lupindu"}]},{id:"53085",title:"Malaria in Pregnancy",slug:"malaria-in-pregnancy",totalDownloads:3194,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Malaria infection during pregnancy is an important public health problem with substantial risks to both the mother and foetus. Pregnant women are the most vulnerable group of malaria‐associated morbidity and mortality. A pregnant woman has an increased risk (up to four times) of getting malaria and twice the chances of dying from malaria, compared to a non‐pregnant adult, becuase the immune system is partially suppressed during pregnancy. Malaria in pregnancy not only affects the mother but also has a dangerous sequel for the developing foetus, resulting in premature delivery or intrauterine growth retardation. Diagnosis of malaria in pregnancy remains a challenge due to the low parasite density and placental sequestration of Plasmodium falciparum. Thus, there is an urgent need for new diagnostic methods to detect malarial parasites in the pregnant women. Though antimalarial drugs are available, which can be safely given in the pregnancy, increasing drug resistance of malarial parasite may pose a big problem in the future. In this chapter, we review the burden of pregnancy‐associated malaria (PAM), its pathogenesis, diagnostic issues during pregnancy and recent guidelines for chemoprophylaxsis and treatment.",book:{id:"5270",slug:"current-topics-in-malaria",title:"Current Topics in Malaria",fullTitle:"Current Topics in Malaria"},signatures:"Kapil Goyal, Alka Sehgal, Chander S. Gautam and Rakesh Sehgal",authors:[{id:"181967",title:"Prof.",name:"Rakesh",middleName:null,surname:"Sehgal",slug:"rakesh-sehgal",fullName:"Rakesh Sehgal"}]}],onlineFirstChaptersFilter:{topicId:"1046",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81939",title:"Translational Research on Chagas Disease: Focusing on Drug Combination and Repositioning",slug:"translational-research-on-chagas-disease-focusing-on-drug-combination-and-repositioning",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.104231",abstract:"Chagas disease, caused by the protozoan Trypanosoma cruzi, is a major neglected disease endemic to Latin America, associated to significant morbimortality comprising a remarkable socioeconomic problem mainly for low-income tropical populations. The present chapter focuses translational research on Chagas disease, approaching drug combinations and repositioning, particularly exploiting the parasite oxidative stress by prospecting prooxidant compounds combined with antagonists of antioxidant systems, for developing low-cost and safe therapies for this infection. The pertinent literature on protozoal parasitic diseases is reviewed as well as on repurposing disulfiram aiming the combination with the Chagas disease drug of choice benznidazole. Both disulfiram and its first derivative sodium diethyldithiocarbamate (DETC) are able not only to inhibit p-glycoprotein, possibly reverting resistance phenotypes, but also to reduce toxicity of numerous other drugs, heavy metals, etc. Therefore, this innovation, presently in clinical research, may furnish a novel therapeutic for T. cruzi infections overcoming the adverse effects and refractory cases that impair the effectiveness of Chagas disease treatment.",book:{id:"11377",title:"Chagas Disease - From Cellular and Molecular Aspects of Trypanosoma cruzi-Host Interactions to the Clinical Intervention",coverURL:"https://cdn.intechopen.com/books/images_new/11377.jpg"},signatures:"Marcos André Vannier-Santos, Ana Márcia Suarez-Fontes, Juliana Almeida-Silva, Alessandra Lifsitch Viçosa, Sandra Aurora Chavez Perez, Alejandro Marcel Hasslocher-Moreno, Gabriel Parreiras Estolano da Silveira, Luciana Fernandes Portela and Roberto Magalhães Saraiva"},{id:"81702",title:"The Saga of Selenium Treatment Investigation in Chagas Disease Cardiopathy: Translational Research in a Neglected Tropical Disease in Brazil",slug:"the-saga-of-selenium-treatment-investigation-in-chagas-disease-cardiopathy-translational-research-in",totalDownloads:8,totalDimensionsCites:0,doi:"10.5772/intechopen.103772",abstract:"This chapter describes the steps from basic research to the definition of a putative public health recommendation in the clinical protocols and therapeutic guidelines for selenium (Se) supplementation for patients with Chagas disease. From 1998 to 2018, we conducted a translational research project to test the concept that chronic Chagas disease cardiopathy (CCC) severity could be associated with low levels of blood selenium (Se), and if oral Se supplementation could help to sustain the asymptomatic cardiac stage and reduce disease severity. Pre-clinical studies in mice and a clinical trial conducted in the early asymptomatic cardiac stage of CCC patients (B stage) were performed, identified as “Selenium Treatment of Chagasic Cardiopathy (STCC)” trial. The roadmap of the selenium project was/is a real saga, with important obstacles that tested team resilience and revealed Brazilian conditions of science development. We discuss the main possible mechanisms involved in the physiopathology of CCC and the lessons learned in this process. In this chapter, we also organized the timeline of the translational project and described the crucial moments of the journey, as well as the next steps driving the research teams and their international and health industry connections.",book:{id:"11377",title:"Chagas Disease - From Cellular and Molecular Aspects of Trypanosoma cruzi-Host Interactions to the Clinical Intervention",coverURL:"https://cdn.intechopen.com/books/images_new/11377.jpg"},signatures:"Tania C. de Araujo-Jorge, Anna Cristina C. Carvalho, Roberto R. Ferreira, Luciana R. Garzoni, Beatriz M.S. Gonzaga, Marcelo T. Holanda, Gilberto M. Sperandio da Silva, Maria da Gloria Bonecini-Almeida, Mauro F.F. Mediano, Roberto M. Saraiva and Alejandro M. Hasslocher-Moreno"},{id:"81938",title:"How Do Mouse Strains and Inoculation Routes Influence the Course of Experimental Trypanosoma cruzi Infection?",slug:"how-do-mouse-strains-and-inoculation-routes-influence-the-course-of-experimental-trypanosoma-cruzi-i",totalDownloads:11,totalDimensionsCites:0,doi:"10.5772/intechopen.104461",abstract:"Chagas’ disease outcomes depend on several factors including parasite and host genetics, immune response, and route of infection. In this study, we investigate the influence of inoculation route and host genetic background on the establishment and development of Chagas disease in mice, using an isolate of Trypanosoma cruzi SC2005 strain (TcII), which was obtained from an oral Chagas’ disease outbreak in Santa Catarina, Brazil. Comparative analysis of the immunopathological, histopathological, and hematological profiles of mice was performed demonstrating the influence of the route of infection in disease severity. In outbred mice, intraperitoneal (IP) infection led to higher infection and mortality rates and more severe parasitaemia, when compared with intragastric (IG) infection. Nevertheless, tissue colonization was similar, showing severe damage in the heart, with intense lymphocytic inflammatory infiltrates, regardless of the route of infection. On the other hand, in mice IG-infected, the host genetic background influences the start timing of immune response against Trypanosoma cruzi. The susceptible BALB/c inbred mouse strain presented an earlier development of a cytotoxic cellular profile, when compared with A mice. We hypothesize that the cytotoxic response mounted before the parasitaemia increase allowed for a milder manifestation of Chagas’ disease in intragastrically infected mice.",book:{id:"11377",title:"Chagas Disease - From Cellular and Molecular Aspects of Trypanosoma cruzi-Host Interactions to the Clinical Intervention",coverURL:"https://cdn.intechopen.com/books/images_new/11377.jpg"},signatures:"Flávia de Oliveira Cardoso, Carolina Salles Domingues, Tânia Zaverucha do Valle and Kátia da Silva Calabrese"},{id:"81814",title:"Evaluation of Molecular Variability of Isolates of Trypanosoma cruzi in the State of Rio de Janeiro-Brazil",slug:"evaluation-of-molecular-variability-of-isolates-of-trypanosoma-cruzi-in-the-state-of-rio-de-janeiro-",totalDownloads:11,totalDimensionsCites:0,doi:"10.5772/intechopen.104498",abstract:"Trypanosoma cruzi, the etiological agent of Chagas disease, presents considerable heterogeneity among populations of isolates within the sylvatic and domestic cycle. This study aims to evaluate the genetic diversity of 14 isolates collected from specimens of Triatoma vitticeps from Triunfo, Conceição de Macabu, and Santa Maria Madalena cities (Rio de Janeiro—Brazil). By using PCR based on the mini-exon gene, all isolates showed a profile characteristic of bands zymodeme III and with a lower intensity characteristic of TcII. To verify possible hybrids among the strains analyzed, the polymorphisms analysis of the MSH2 gene was performed. HhaI restriction enzyme digestion products resulted in characteristic TcII fragments only, demonstrating the absence of hybrids strains. In our attempt to characterize isolation in accordance with the reclassification of T. cruzi into six new groups called DTUs (“discrete typing unit”), we genotyped the mitochondrial cytochrome oxidase subunit two gene, ribosomal RNA gen (24Sα rDNA), and the spliced leader intergenic region (SL-IR). This procedure showed that TcII, TcIII, and TcIV are circulating in this area. This highlights the diversity of parasites infecting specimens of T. vitticeps, emphasizing the habit of wild type and complexity of the region epidemiological study that presents potential mixed populations.",book:{id:"11377",title:"Chagas Disease - From Cellular and Molecular Aspects of Trypanosoma cruzi-Host Interactions to the Clinical Intervention",coverURL:"https://cdn.intechopen.com/books/images_new/11377.jpg"},signatures:"Helena Keiko Toma, Luciana Reboredo de Oliveira da Silva, Teresa Cristina Monte Gonçalves, Renato da Silva Junior and Jacenir R. Santos-Mallet"},{id:"81252",title:"Modulation of Host Cell Apoptosis by Trypanosoma cruzi: Repercussions in the Development of Chronic Chagasic Cardiomyopathy",slug:"modulation-of-host-cell-apoptosis-by-trypanosoma-cruzi-repercussions-in-the-development-of-chronic-c",totalDownloads:31,totalDimensionsCites:0,doi:"10.5772/intechopen.103740",abstract:"Trypanosoma cruzi is an intracellular parasite, which causes Chagas disease, affecting millions of people throughout the world. T. cruzi can invade several cell types, among which macrophages and cardiomyocytes stand out. Chagas disease goes through two stages: acute and chronic. If it becomes chronic, its most severe form is the chagasic chronic cardiomyopathy, which accounts for most of the fatalities due to this disease. For parasites to persist for long enough in cells, they should evade several host immune responses, one of these being apoptosis. Apoptosis is a type of programmed cell death described as a well-ordered and silent collection of steps that inevitably lead cells to a noninflammatory death. Cells respond to infection by initiating their own death to combat the infection. As a result, several intracellular microorganisms have developed different strategies to overcome host cell apoptosis and persist inside cells. It has been shown that T. cruzi has the ability to inhibit host cells apoptosis and can also induce apoptosis of cells that combat the parasite such as cytotoxic T cells. The aim of this chapter is to present up-to-date information about the molecules and mechanisms engaged by T. cruzi to achieve this goal and how the modulation of apoptosis by T. cruzi reflects in the development of chronic chagasic cardiomyopathy.",book:{id:"11377",title:"Chagas Disease - From Cellular and Molecular Aspects of Trypanosoma cruzi-Host Interactions to the Clinical Intervention",coverURL:"https://cdn.intechopen.com/books/images_new/11377.jpg"},signatures:"Fiordaliso Carolina Román-Carraro, Diego Maurizio Coria-Paredes, Arturo A. Wilkins-Rodríguez and Laila Gutiérrez-Kobeh"},{id:"80917",title:"Digestive Disorders in Chagas Disease: Megaesophagus and Chagasic Megacolon",slug:"digestive-disorders-in-chagas-disease-megaesophagus-and-chagasic-megacolon",totalDownloads:25,totalDimensionsCites:0,doi:"10.5772/intechopen.102871",abstract:"Chagas disease, also known as American trypanosomiasis, caused by Trypanosoma cruzi and transmitted by hematophagous vectors, is a parasitic disease, which according to the WHO ranks fourth as a cause of loss of potential years of life due to complications that can occur in multiple body systems. According to the reports presented by the World Health Organization, there are between 16 and 18 million infected people in the world, predominantly in endemic areas of Latin America, of which only 1% receives an adequate diagnosis and full treatment, thereby that the chronic phase comes to present digestive disorders that are one of the main causes of loss in the quality of life of patients, as well as complications that can lead to life-threatening surgical emergencies.",book:{id:"11377",title:"Chagas Disease - From Cellular and Molecular Aspects of Trypanosoma cruzi-Host Interactions to the Clinical Intervention",coverURL:"https://cdn.intechopen.com/books/images_new/11377.jpg"},signatures:"Víctor Hugo García Orozco, Juan Enrique Villalvazo Navarro, Carlos Solar Aguirre, Carlos Manuel Ibarra Ocampo, César Iván Díaz Sandoval, Carlos Alejandro Ortíz Gallegos, Diego Javier Oregel Camacho and Araceli Noriega Bucio"}],onlineFirstChaptersTotal:6},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"June 25th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"3",title:"Bacterial Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/3.jpg",isOpenForSubmission:!1,editor:null,editorTwo:null,editorThree:null},{id:"4",title:"Fungal Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",isOpenForSubmission:!0,editor:{id:"174134",title:"Dr.",name:"Yuping",middleName:null,surname:"Ran",slug:"yuping-ran",fullName:"Yuping Ran",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9d6QAC/Profile_Picture_1630330675373",biography:"Dr. Yuping Ran, Professor, Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China. Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. 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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}}]}},subseries:{item:{id:"20",type:"subseries",title:"Animal Nutrition",keywords:"Sustainable Animal Diets, Carbon Footprint, Meta Analyses",scope:"An essential part of animal production is nutrition. 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