Acute and late effects of RTP.
\\n\\n
These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\\n\\n\\n\\n\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"10207",leadTitle:null,fullTitle:"Sexual Abuse - An Interdisciplinary Approach",title:"Sexual Abuse",subtitle:"An Interdisciplinary Approach",reviewType:"peer-reviewed",abstract:"Sexual assaults are special crimes that require an inter-multidisciplinary approach. This book brings together the work of distinguished scientists on sex crimes and their prevention. It is organized into two sections on the behavioral aspects of sexual abuse/assault and the methods of responding to these types of cases. Chapters address such topics as child abuse, dating violence in the online era, marital rape, and much more.",isbn:"978-1-83969-398-4",printIsbn:"978-1-83969-397-7",pdfIsbn:"978-1-83969-399-1",doi:"10.5772/intechopen.90974",price:119,priceEur:129,priceUsd:155,slug:"sexual-abuse-an-interdisciplinary-approach",numberOfPages:176,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"e1ec1d5a7093490df314d7887e0b3809",bookSignature:"Ersi Kalfoğlu and Sotirios Kalfoglou",publishedDate:"May 25th 2022",coverURL:"https://cdn.intechopen.com/books/images_new/10207.jpg",numberOfDownloads:1950,numberOfWosCitations:0,numberOfCrossrefCitations:1,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:1,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:2,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 23rd 2020",dateEndSecondStepPublish:"December 21st 2020",dateEndThirdStepPublish:"February 19th 2021",dateEndFourthStepPublish:"May 10th 2021",dateEndFifthStepPublish:"July 9th 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"68678",title:"Dr.",name:"Ersi",middleName:null,surname:"Kalfoglou",slug:"ersi-kalfoglou",fullName:"Ersi Kalfoglou",profilePictureURL:"https://mts.intechopen.com/storage/users/68678/images/system/68678.jpg",biography:"Prof. Ersi Abacı Kalfoğlu obtained a Ph.D. in Forensic Sciences, following a graduate degree in Medical Biochemistry. She taught at the Institute of Legal Medicine and Forensic Sciences, Istanbul University, as a full-time professor for 20 years. Currently, she is the head of the Forensic Medicine Department, Medical Faculty, İstanbul Yeni Yüzyıl University. She also directs the Institute of Health Sciences at the same university. Sexual assault is her specialty and she has authored numerous journal articles on the subject.",institutionString:"Istanbul Yeni Yüzyıl University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"2",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"339142",title:"Dr.",name:"Sotirios",middleName:null,surname:"Kalfoglou",slug:"sotirios-kalfoglou",fullName:"Sotirios Kalfoglou",profilePictureURL:"https://mts.intechopen.com/storage/users/339142/images/system/339142.png",biography:"Sotirios Kalfoglou studied Political Sciences and International Relations at the University of Marmara, Istanbul, Turkey. Following his undergraduate studies, he obtained his graduate degree from the Terrorism, Security and Policing Program, Criminology Department, University of Leicester, England. Currently, he is lecturing Criminology at Istanbul Yeni Yüzyıl University where he is the general coordinator of the Forensic Sciences Laboratory of the Medical Faculty.",institutionString:"Yeni Yüzyıl University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Yeni Yüzyıl University",institutionURL:null,country:{name:"Turkey"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"281",title:"Sociology",slug:"sociology"}],chapters:[{id:"77037",title:"Female Offenders in Child Sexual Abuse",doi:"10.5772/intechopen.98499",slug:"female-offenders-in-child-sexual-abuse",totalDownloads:362,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"In the United States criminal justice system, female sexual offenders are among the most unrepresented groups of individuals, and they have evaded detection and/or prosecution for many reasons. This chapter explores the characteristics and patterns of female sexual offenders based on the collection of available literature. We will discuss how personal trauma histories, mental health, substance abuse, and motivations of female sexual offenders differ from their male counterparts. Additionally, we cover how social perception presents female sexual offenders in a light that adversely impacts their interactions with the social systems and explore empirically validated myths, risks, and interventions for this population.",signatures:"David A. McLeod, Zackery D.O. Dunnells and Burcu Ozturk",downloadPdfUrl:"/chapter/pdf-download/77037",previewPdfUrl:"/chapter/pdf-preview/77037",authors:[{id:"343511",title:"Associate Prof.",name:"David A.",surname:"McLeod",slug:"david-a.-mcleod",fullName:"David A. McLeod"},{id:"416656",title:"Mr.",name:"Zackery D.O.",surname:"Dunnells",slug:"zackery-d.o.-dunnells",fullName:"Zackery D.O. Dunnells"},{id:"416657",title:"Dr.",name:"Burcu",surname:"Ozturk",slug:"burcu-ozturk",fullName:"Burcu Ozturk"}],corrections:null},{id:"77769",title:"School Employee Sexual Misconduct: Red Flag Grooming Behaviors by Perpetrators",doi:"10.5772/intechopen.99234",slug:"school-employee-sexual-misconduct-red-flag-grooming-behaviors-by-perpetrators",totalDownloads:147,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"The sexual exploitation of students is a worldwide problem. In the U.S., the problem is three-fold: (1) Ten percent of public school students report being sexually abused by a school employee. (2) There is little in the existing research that identifies and describes the school culture, patterns, and conditions in which educator sexual misconduct occurs. (3) Because no one has systematically documented the school culture and the behaviors and patterns of adults who sexually abuse children in schools, school professionals fail to understand what patterns and behaviors should trigger concern, supervision, investigation, and/or reporting. Stopping sexual misconduct directed toward students means understanding the process that adults use to prepare students to be abused so that they do not tell, do not fight, and acquiesce. This process, called grooming, has the purpose of gaining student trust, as well as the trust of parents and colleagues. This study examines school employee sexual misconduct toward students in school in the United States and is based upon an analysis of 222 cases of school employee sexual misconduct toward a student where a school employee was convicted of student sexual abuse. The findings identify red flag grooming patterns used with students, colleagues, and parents.",signatures:"Charol Shakeshaft, Mitchell Parry, Eve Chong, Syeda Saima and Najia Lindh",downloadPdfUrl:"/chapter/pdf-download/77769",previewPdfUrl:"/chapter/pdf-preview/77769",authors:[{id:"345271",title:"Prof.",name:"Charol",surname:"Shakeshaft",slug:"charol-shakeshaft",fullName:"Charol Shakeshaft"},{id:"420043",title:"Mr.",name:"Mitchell",surname:"Parry",slug:"mitchell-parry",fullName:"Mitchell Parry"},{id:"420044",title:"Ms.",name:"Syeda",surname:"Saima",slug:"syeda-saima",fullName:"Syeda Saima"},{id:"420045",title:"Ms.",name:"Eve",surname:"Chong",slug:"eve-chong",fullName:"Eve Chong"},{id:"420046",title:"Ms.",name:"Naijia",surname:"Lindh",slug:"naijia-lindh",fullName:"Naijia Lindh"}],corrections:null},{id:"76355",title:"Under the Cover of Silence: The Burden of Marital Rape among Immigrant, Muslim, South Asian Survivors of Domestic Violence",doi:"10.5772/intechopen.97277",slug:"under-the-cover-of-silence-the-burden-of-marital-rape-among-immigrant-muslim-south-asian-survivors-o",totalDownloads:288,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"This chapter looked at the experiences of marital rape among immigrant South Asian Muslims domestic violence survivors who are living in Texas, USA. Based on qualitative interviews with 20 participants, this chapter discusses the hidden nature of marital sexual abuse. Specific themes include: abuse took place in a larger context of domestic violence; duality in sexual behavior allowed for husband and wife; submission through threat and intimidation; it is not rape but, I feel the same as a rape victim; shame of talking about something so private; and divorce and vulnerability from sexual advances by outside men. Implications to advocates and human service workers, especially those living in Western countries and work with Muslim communities are discussed, as well as how to effectively assist these diverse communities in a culturally sensitive manner, being mindful of their religious background.",signatures:"Dheeshana S. Jayasundara, Durdana Ahmed, Prita Das Gupta, Susan Garcia and Sarah Thao",downloadPdfUrl:"/chapter/pdf-download/76355",previewPdfUrl:"/chapter/pdf-preview/76355",authors:[{id:"343854",title:"Associate Prof.",name:"Dheeshana",surname:"Jayasundara",slug:"dheeshana-jayasundara",fullName:"Dheeshana Jayasundara"},{id:"345665",title:"Dr.",name:"Dudana",surname:"Ahmed",slug:"dudana-ahmed",fullName:"Dudana Ahmed"},{id:"345667",title:"Dr.",name:"Susan",surname:"Garcia",slug:"susan-garcia",fullName:"Susan Garcia"},{id:"473378",title:"Dr.",name:"Prita",surname:"Das Gupta",slug:"prita-das-gupta",fullName:"Prita Das Gupta"},{id:"473379",title:"Dr.",name:"Sarah",surname:"Thao",slug:"sarah-thao",fullName:"Sarah Thao"}],corrections:null},{id:"76408",title:"Sexual Violence and Women Empowerment in India: Findings from a Nationally Representative Sample Survey",doi:"10.5772/intechopen.97456",slug:"sexual-violence-and-women-empowerment-in-india-findings-from-a-nationally-representative-sample-surv",totalDownloads:163,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Promoting gender equality and the empowerment of women and elimination of violence against women was recognised as an important component in the United Nations 2030 Agenda for Sustainable Development. Intimate partner violence is one of the most common forms of gender based violence throughout the world. Empowering women is an effective measure required to tackle the problem of domestic violence. There are various parameters that are used to measure women empowerment like education, work force participation, women’s decision making capacity in the family etc. In this paper we have analysed the relationship between women’s experience of spousal sexual violence and women empowerment using the ecological model of domestic violence proposed by Heise. We have used the data of the 4th National Family Health Survey (NFHS-4) conducted in India in 2015–2016. Our results show that common empowerment related factors like education was not significantly associated with women’s experience of sexual abuse. Moreover, the likelihood of facing sexual abuse by husband was found higher among working women. We observe that relational and contextual factors like husband’s assertion of control over wife, cultural norms that condone wife abuse significantly increased women’s likelihood of experiencing sexual violence by husband.",signatures:"Shewli Shabnam",downloadPdfUrl:"/chapter/pdf-download/76408",previewPdfUrl:"/chapter/pdf-preview/76408",authors:[{id:"342199",title:"Assistant Prof.",name:"Shewli",surname:"Shabnam",slug:"shewli-shabnam",fullName:"Shewli Shabnam"}],corrections:null},{id:"76901",title:"An Integrative Exploration of Sexual, Physical, Psychological, and Cyber-Digital Relationship Abuse in Adolescent and Young Adult Relationships",doi:"10.5772/intechopen.98233",slug:"an-integrative-exploration-of-sexual-physical-psychological-and-cyber-digital-relationship-abuse-in-",totalDownloads:166,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Although detrimental for any age group, rates of experiencing sexual assault (SA) are found to be the highest among young adults; with nearly 25% of young adult women indicating to have experienced SA at least once in their romantic relationship. SA is also common among adolescents, as 33% of young women between the ages of 11–17 indicated to have been raped. The effects from SA include depression, trauma, and interpersonal distress, which are similar to the effects of other forms of intimate partner violence (IPV) (i.e., physical and psychological aggression), suggesting a covariation between these various forms of aggression. Additionally, a new form of dating violence has emerged; cyber-digital relationship abuse (CDRA). This behavior is commonly expressed via means of social media (e.g., Facebook, Twitter, & Snapchat) and through digital means (e.g., texting and email) whereby youth and young adults harass, threaten, control, and monitor their partners whereabouts. Recent studies have indicated that CDRA may serve as a precursor to physical violence in dating relationships. The purpose of this chapter is to provide an integrative exploration of sexual, physical, psychological, and CDRA by tracking the progression and concurrence across these various forms of IPV among youth and young adults. Implications for interventions will also be discussed.",signatures:"Hans Saint-Eloi Cadely and Tiffani Kisler",downloadPdfUrl:"/chapter/pdf-download/76901",previewPdfUrl:"/chapter/pdf-preview/76901",authors:[{id:"346564",title:"Dr.",name:"Hans",surname:"Saint-Eloi Cadely",slug:"hans-saint-eloi-cadely",fullName:"Hans Saint-Eloi Cadely"},{id:"346565",title:"Dr.",name:"Tiffani",surname:"Kisler",slug:"tiffani-kisler",fullName:"Tiffani Kisler"}],corrections:null},{id:"76469",title:"Sexual Abuse and Mental Health in Humanitarian Disasters",doi:"10.5772/intechopen.97457",slug:"sexual-abuse-and-mental-health-in-humanitarian-disasters",totalDownloads:149,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"This chapter provides an overview of the importance of addressing mental health issues due to sexual violence in humanitarian disasters. It provides an overview of the relevance of sexual violence in conflict and its connection to mental health concerns and a heightening of the impacts of the humanitarian disaster. Sexual violence further destroys societies and increases the repercussions of the humanitarian disaster for decades after the conflict has ended. The very high levels of sexual violence that accompany humanitarian disasters are not inevitable. Underlying cultural and societal beliefs that exist before the humanitarian disaster occurs can be aggravated and brought to surface to further exasperate the negative impacts. Large scale public health initiatives that use marketing such as radio, billboards, social media, and television advertisements for example can be helpful and impactful for changing awareness and consciousness of societal norms and assumed inevitabilities that happen in societies. Humanitarian disaster research has revealed that it is common for individuals to view sexual violence as normal and for perpetrators to minimize the effects of it. However, this is a coping strategy that does not take away from the individual, societal and familial mental health effects of sexual violence from humanitarian disasters.",signatures:"Sara Spowart",downloadPdfUrl:"/chapter/pdf-download/76469",previewPdfUrl:"/chapter/pdf-preview/76469",authors:[{id:"342190",title:"Ph.D.",name:"Sara",surname:"Spowart",slug:"sara-spowart",fullName:"Sara Spowart"}],corrections:null},{id:"81281",title:"Sexual Assault Crisis Center: The First Interdisciplinary Effort in Turkey",doi:"10.5772/intechopen.104531",slug:"sexual-assault-crisis-center-the-first-interdisciplinary-effort-in-turkey",totalDownloads:25,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Sexual violence and assault has a wide range of negative consequences that affect the victims for the rest of their lives. Proper medical as well as psychological care is essential for the survivors who have experienced a traumatic process. One-step institutions that deal with all related issues following the victimization are established in various countries. We took the responsibility to organize such a center for the first time in our country. The designed “Sexual Assault Crisis Center” is active in legal history taking, medical-forensic examination, professional evidence collection by trained personnel, and detailed evidence analysis (DNA, drugs of abuse, trace evidence, etc.). Thus, the victims do not have to go to various institutions one after the other to prove the case. Care providers, law officers, and the legal system are satisfied with the outcomes. An organized collaboration of different organizations is archived to the benefit of the sufferer. Furthermore, a training program for four different related parties, such as medical doctors, nurses, psychologists, and healthcare managers, has been developed in order to train other personnel for the sustainability of the project. The basic aim is to develop this first model as a prototype and contribute to its spreading throughout the country.",signatures:"Taner Güven, Sotirios Kalfoglou and Ersi Kalfoğlu",downloadPdfUrl:"/chapter/pdf-download/81281",previewPdfUrl:"/chapter/pdf-preview/81281",authors:[{id:"68678",title:"Dr.",name:"Ersi",surname:"Kalfoglou",slug:"ersi-kalfoglou",fullName:"Ersi Kalfoglou"},{id:"339142",title:"Dr.",name:"Sotirios",surname:"Kalfoglou",slug:"sotirios-kalfoglou",fullName:"Sotirios Kalfoglou"},{id:"448855",title:"Dr.",name:"Taner",surname:"Güven",slug:"taner-guven",fullName:"Taner Güven"}],corrections:null},{id:"75990",title:"Intervention Strategies for Promoting Recovery and Healing from Child Sexual Abuse",doi:"10.5772/intechopen.97106",slug:"intervention-strategies-for-promoting-recovery-and-healing-from-child-sexual-abuse",totalDownloads:235,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The deleterious effects of child sexual abuse (CSA) on youth’s social, emotional, physical, cognitive, neurobiological, sexual and developmental functioning are pervasive. Early targeted interventions for both the child who experienced CSA and their nonoffending caregivers are essential for healing and recovery. Effective interventions which are tailored to the youth’s developmental level can help mitigate or even prevent some of the serious and enduring negative effects of CSA, including symptoms of posttraumatic stress disorder (PTSD). This chapter is not comprehensive, but examines evidence based interventions for children and adolescents who have been sexually abused including Trauma-Focused Cognitive Behavioral Therapy. Additionally, this chapter will address systemic factors in CSA, recommending coordinated and trauma informed efforts utilizing an interdisciplinary approach, which may include a forensic medical team, investigators, prosecutors and other disciplines. This professional collaboration can prevent retraumatization of the child as the child and family navigate the sequela of CSA.",signatures:"Tara Shuman",downloadPdfUrl:"/chapter/pdf-download/75990",previewPdfUrl:"/chapter/pdf-preview/75990",authors:[{id:"342305",title:"Assistant Prof.",name:"Tara",surname:"Shuman",slug:"tara-shuman",fullName:"Tara Shuman"}],corrections:null},{id:"76279",title:"Why Cleveland Still Matters: Connections with a New Era",doi:"10.5772/intechopen.97368",slug:"why-cleveland-still-matters-connections-with-a-new-era",totalDownloads:149,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"This chapter explores the lasting impact of 1987 Cleveland child abuse crisis in the UK in which 127 children were diagnosed by two paediatricians as having been sexually abused. It highlights how this resulted in tensions, misunderstandings and stresses in the interface between the public and the child protection system, and persistent challenges of creating and sustaining a successful multidisciplinary approach to intervention and protection. It argues that the experience in Cleveland provided unique information about the effects of intervening in child sexual abuse, especially where children are trapped in silence and only come to light by way of a proactive intervention. These children remain difficult to help and the best way of intervening remains contentious. The authors challenge the ethos that leaves sexually abused children vulnerable in the face of investigative and evidential hurdles and suggest ways forward.",signatures:"Heather Bacon and Susan Richardson",downloadPdfUrl:"/chapter/pdf-download/76279",previewPdfUrl:"/chapter/pdf-preview/76279",authors:[{id:"344652",title:"Mrs.",name:"Susan",surname:"Richardson",slug:"susan-richardson",fullName:"Susan Richardson"},{id:"345153",title:"Dr.",name:"Heather",surname:"Bacon",slug:"heather-bacon",fullName:"Heather Bacon"}],corrections:null},{id:"76450",title:"Counseling Sexually Abused Children: Lessons from Ghana and Zambia",doi:"10.5772/intechopen.97413",slug:"counseling-sexually-abused-children-lessons-from-ghana-and-zambia",totalDownloads:266,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"The scourge of child sexual abuse has been on the increase world over, Ghana and Zambia inclusive with millions of children being sexually abused every year at a global prevalence rate of 34.4%. Using the qualitative narrative approach, the interview guide was used to gather data purposively from 112 participants made up of 40 Domestic Violence and Victims Support Unit officers, 32 parents and 40 victims aged 8–17 years who reported their abuse at 15 police stations across Central Region and Lusaka Province of Ghana and Zambia respectively. Data were thematically analyzed. The study found among others that children in both countries received safety nets and pieces of advice on legal and medical procedures. It also found that some victims expressed happiness at their abuses being reported and heard. However, lack of professional counseling training and power imbalances inhibit the police officers’ efforts. The study concludes that though officers use some skills and provide a kind of trauma counseling more is needed in the areas of individual and group therapy for comprehensive and effective counseling. Skills such as encouragement, assertiveness, and re-assurance can lead to disclosure, prevent future sexual abuse, reduce anxiety and fear, promote healing and empowerment. When children receive adequate counseling immediately after abuse they do immediate damage repair both of their psychological and social “self”. The study recommends training in counseling for the officers in both countries for effective counseling of abused individuals. 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\r\n\tMicrofluidics and Nanofluidics referred to a technology where fluid flows are from the macroscale down to the nanoscale traditionally used as key components of control and sensing systems. Nowadays, the research and application areas of Microfluidics and Nanofluidics have been greatly expanded to advanced materials, biochemistry, new energy, single-cell/single-molecule studies, human health, and so forth. Microfluidics and Nanofluidics deal with transport phenomena, i.e., mass, momentum, and heat transfer, in the micrometer or nanometer range, and conventional fluid dynamics cannot be directly used in this area. The possible challenge in fluid properties must be considered. Thus, in the last two decades, the fundamental theories, as well as their application, have been rapidly in Microfluidics and Nanofluidics. Therefore, this book aims to host original research or review works addressing the fundamentals and applications of any functional flow in Microfluidics and Nanofluidics. The potential topics include all aspects of microfluidics, nanofluidics, and lab-on-a-chip science and technology, it might be (but are not limited to) fundamental principles of micro-and nanoscale phenomena like flow, mass transport and reactions, theoretical models, and numerical simulation with experimental and/or analytical proof, micromixer device, and particle manipulation. Experimental and numerical studies are welcome.
\r\n\t
The term oral cancer is used as a synonym for squamous cell carcinoma, which constitutes 90% of malignant neoplasms. Surgery, radiotherapy and chemotherapy are the election treatments. The selection of an only treatment or combination depends principally on the location of the tumour, its size, histological subtype, stage and the patient\'s general state of health. Surgery and RTP tend to be used alone to treat cases of non-metastatic disease (stages I and II), whereas more advanced cancers (III and IV) are treated by surgery in combination with radiotherapy and/or chemotherapy. It is important to bear in mind that the surgeries these patients undergo are aggressive. They provoke aesthetic and functional alterations that affect the patient’s quality of life.
Prior to undergoing radiotherapy treatment, it is important that patients with head and neck cancer undergo a dental evaluation. This is because surgery provokes big aesthetic and functional alterations. Therefore, patients who already show deficient oral health before treatment are likely to leave their oral hygiene, increasing the gravity of complications.
There are a number of complications that appear in the head and neck region, not only during treatment but also, after. These include mucositis, dental caries and xerostomia. In this paper, we will describe the adverse, acute and late complications, as well as the treatment guidelines. Furthermore, we will develop a patient management protocol for before, during and after radiotherapy.
The term oral cancer is used as a synonym for oral squamous cell carcinoma (OSCC), which accounts for 90% of all head and neck cancers and 3-4% of malignancies [1, 2]. The incidence of head and neck cancer has increased significantly over the past 20 years. Over 575,000 new oral cancer cases are annually diagnosed in the world [3]. According to data published in 1998 by Spanish National Epidemiology Centre, in our country, the number of deaths by oral, pharyngeal and labial cancer amounted to 1,891 of men and 374 of women. In Spain, incidence accounts for 12 to 15 cases per 100,000 men/year and two to four cases per 100,000 women/year [4]. However, the figures are now matching up. This is because some women are adopting harmful habits, which were traditionally attributable to men. The disease mainly affects men over 40 years of age, with a peak of maximum incidence in their 60s [5, 6].
The etiology of cancer has multiple factors. The main risk factors are smoking and alcohol. Despite showing synergistic effects, these are independent risk factors, as shown in a study by Castellsagué et al. [6, 7]. In some cases of solar ultraviolet radiation in lip cancer, infections, diets low in fruit and vegetables, immunodepression, bad oral hygiene and the presence of genetic factors can have a relevant effect.
Patients diagnosed with this cancer are treated by surgery, radiotherapy (RTP), chemotherapy (QTP) or a combined treatment. The choice of a unique or combined treatment depends on the location of the tumour, its extension, histological subtype, tumour stage and the patient\'s general condition. Surgery and RTP are used in isolation to treat cases of non-metastatic disease (stages I and II). However, advanced stages (III and IV) require concomitant RTP and QTP. In the early stages, the treatment of choice is surgery. With this, the tumour is eliminated with safety margins. This is achieved with or without cervical emptying, depending on the location, size or suspicion of regional metastasis. Once the cervical emptying is completed and analysed, if the structures are affected, subsequent treatment with RTP is evaluated. Advanced stages can be treated with surgery followed by RTP but this combination only cures a minority of patients and fewer than 30% will be alive at five years. With these treatments, tumour control and survival rates are unsatisfactory. Only 30% of patients will be alive after three years, while 60-70% of patients will have a loco-regional recurrence and/or will develop distant metastasis, which, ultimately, is the main cause of death in these patients [8].
QTP, in addition to RTP and surgery, is associated with a better general survival rate in patients with oral or oropharyngeal cancer. Induction QTP can extend survival from 8% to 20% and concomitant adjuvant chemo-radiotherapy can prolong survival up to 16%.
QTP consists of the administration of cytotoxic drugs that are capable of destroying and inhibiting the growth and reproduction of malignant cells [9]. In head and neck cancers, the most extensively used drugs are bleomycin, cisplatin, methotrexate, 5-fluorouracil, vinblastine and cyclophosphamide [10]. QTP can be developed by administering one or more chemotherapeutic drugs. The use of isolated drugs (mono-chemotherapy) has proven useless in the induction of significant complete or partial responses. Thus, the current trend is polychemotherapy, which affects the cellular populations in different cell-cycle phases. This is achieved by using the synergistic action of the drugs, decreasing the development of resistance to them and promoting a higher response per administered dose [10]. The most used combinations include cisplatin and 5-fluorouracil; cisplatin, 5-fluorouracil and taxol or cisplatin, bleomycin and methotrexate. Cytostatic drugs offer better results in tumours with a significant growth fraction and/or early distant or frequent dissemination such as lymphomas (90% growth fraction). This is not the case for squamous cell carcinoma, which is the most common head and neck malignancy (25% growth fraction). Therefore, QTP is usually associated with another therapeutic modality [11].
RTP can be applied locally (brachytherapy) or externally (teletherapy). The external radiotherapy is the classic way to administer radiotherapy with a remote radiation source of the organism. Sources of external irradiation are low voltage (X-ray), supervoltage (cobalt 60), megavoltage (linear accelerator) and electron beam (power source). Of these, the most widely used treatments for head and neck therapy are cobalt-60 and the linear particle accelerator [12]. External radiotherapy requires a division of the dose and a longer period to carry it out, consisting of a weekly dose of 10 Gy, 2 Gy daily for five days and two days of rest, usually spread out over a period of 5-7 weeks. Fractioned RTP allows a full high dose in the tumour, respecting the normal adjacent tissue and decreasing toxicity. It also conditions the response in healthy and tumour tissues by repairing injuries. This is because, compared to tumour tissue, normal tissue repairs damaged DNA better, especially at low doses. It also promotes the reoxygenation of tumour cells, increasing their radiosensitivity and the repopulation of the tissue between fractions. This is particularly the case during weekends when the area is not irradiated, thereby reducing the early effects [13]. The radiation dose depends on the location and type of tumour and whether the RTP is used alone or combined with other treatment modalities. When the RTP is exclusive, the dose is usually between 60 Gy and 80 Gy, whereas the dose administered post-surgically is 50-60 Gy [1].
On the other hand, brachytherapy is a method that uses ionizing radiation. It places radioactive material in the proximity of or within the tumour. There are different modalities of brachytherapy, of which interstitial RTP is the most frequently used for head and neck tumours. In this modality, Iridium 192 (Ir192) and Iodine 125 (I125) are the most frequent radioactive sources.
RTP and QTP are combined to improve therapeutic results, increasing loco-regional tumour control and distant metastasis [14].
There are different ways to classify the effects produced by RTP on head and neck regions, as are shown in Table 1,2, 3 [10, 15-17].
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t | Mucositis | \n\t\t\tNecrosis of soft tissue | \n\t\t
\n\t\t\t | Radiodermatitis | \n\t\t\tTrismus | \n\t\t
\n\t\t\t | Opportunist infections | \n\t\t\tOsteoradionecrosis (ORN) | \n\t\t
\n\t\t\t | Xerostomia | \n\t\t\tPost-radiation caries | \n\t\t
\n\t\t\t | Alteration in taste | \n\t\t\t\n\t\t |
Acute and late effects of RTP.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t | Mucositis | \n\t\t\tPost-radiation caries | \n\t\t\tOsteoradionecrosis | \n\t\t
\n\t\t\t | Alteration in taste | \n\t\t\tOpportunist infections | \n\t\t\tTooth disorder | \n\t\t
\n\t\t\t | Xerostomia | \n\t\t\tNecrosis of soft tissue | \n\t\t\t\n\t\t |
\n\t\t\t | Radiodermatitis | \n\t\t\tTrismus | \n\t\t\t\n\t\t |
Chronology of RTP: immediate, medium term and long term effects.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t | Mucositis | \n\t\t\tXerostomia | \n\t\t
\n\t\t\t | Radiodermatitis | \n\t\t\tAlteration in taste | \n\t\t
\n\t\t\t | Xerostomia | \n\t\t\tPost-radiation caries | \n\t\t
\n\t\t\t | Alteration in taste | \n\t\t\tOsteoradionecrosis | \n\t\t
\n\t\t\t | Opportunist infections | \n\t\t\tTooth disorder | \n\t\t
\n\t\t\t | Necrosis of soft tissue | \n\t\t\t\n\t\t |
\n\t\t\t | Trismus | \n\t\t\t\n\t\t |
Evolution of RTP: reversible and irreversible effects.
Mucositis is the inflammation of the oral-oropharynx as a result of the cytotoxic effects of RTP. It is the most common complication that appears among patients who have been irradiated with neck and head cancer, with an incidence of 80 %. Mucositis is dose-dependent and therefore, it disappears with the end of the aggression [18]. The risk and its gravity depend on the characteristics of the treatment such as doses, size of the irradiated zone and its division.
The first sign is erythema, which appears when a dose of 10 Gy is accumulated (first week) and persists up to 15 days after the end of the RTP treatment. The point of maximum symptomatology is when there are accumulated doses of 60-70 Gy [19, 20]. Clinically, the mucosa is erythematous and edematous so it can become ulcerated and infected by fungi [19, 21]. The pain that accompanies mucositis can be so intense that it alters the patient\'s quality of life, limiting their basic oral functions such as speaking, swallowing saliva or eating [21].
Mucositis can be classified in four degrees, according to the intensity of the mucosa [16, 22]:
Grade 0: None (Figure 1).
Grade 1: Erythaema (Figure 2 and 3).
Grade 2: Erythaema, ulcers but capable of ingesting solids (Figure 4).
Grade 3: Ulcers, requiring liquid diet (Figure 5).
Grade 4: Oral feeding is impossible (Figure 6).
Grade 0.
Grade 1.
Grade 1.
Grade 2.
Grade 3.
Grade 4.
RTP facilitates the surge of opportunist infections, mainly Candida (Figure 7 and 8) as a result of the reduction of saliva, the use of dentures, deficient oral hygiene and the persistence of habits such as smoking or drinking [23]. These types of infections tend to disappear with topical anti-fungal drugs. However, irradiated patients frequently have to use more effective systemic drugs [24].
Candidiasis during RTP.
Candidiasis during RTP.
Radiodermatitis is considered as skin and subcutaneous tissue toxicity. Depending on its severity, it is classified in three different levels. Transitory erythaema is produced by the congestion of dermal papillae within the first 24 hours. A dose of 3 Gy is enough to trigger it (Figure 9 and 10). A dose of 25 Gy will produce an acceleration of the skin flaking process, which is manifested as a significant decrease of thickness. This will then become dark, atrophic and flaky, which is called dry radiodermatitis (Figure 11). A 50-70 Gy dose will cause a delayed erythaema, followed by a superficial necrobiosis and the formation of skin scabs. If these lesions progress, bleeding vesicula easily appears, which is called wet radiodermatitis (Figure 12). These lesions are cured when the RTP treatment has ended, leaving scars on the skin. These can be white and esclerotic telangiectastic. Follicles are destroyed and, on occasions, pigmentations can appear [10].
Radiodermatitis: Grade 0, 5 sessions of RTP.
Radiodermatitis Grade I, 10 sessions of RTP.
Radiodermatitis: Grade II, 17 sessions of RTP.
Radiodermatitis Grade III, 24 sessions of RTP.
Most patients suffer xerostomia or salivary hypofunction due to RTP in head and neck cancers. This usually appears within the first weeks of radiation. In low doses (under 30 Gy), it is believed that the damage can be reversible. However, higher doses (over 60-70 Gy) result in an irreversible and permanent xerostomia. With the latter, there is a significant degeneration of the acini, which is reflected by concomitant inflammation and fibrosis of the interstitium (Figure 13).
Rough tongue due to salivary hypofunction.
Salivary hypofunction (a resting saliva flow of less than 0.2 ml per minute or a stimulated flow of less than 0.7 ml per minute) is caused by the damage of direct ionizing radiation of the salivary glands’ cells [25]. This is the most persistent effect in patients submitted to RTP for head and neck tumours. It is characterized by changes in the amount and quality of saliva (more viscous and scarce). It produces oral discomfort and pain, a higher risk of dental caries, oral infection, difficulty of speech and disfagia. This has a damaging effect on the patient’s quality of life [26-28]. The reduction of salivary flow can also increase the susceptibility of the dental caries and takes into account the integrity of the mucosa [29].
The alteration in taste is a result of direct radiation of the taste buds and receptors of taste, as well as changes in the saliva [30-32]. It contributes to loss of appetite, which results in the patient’s weight loss. It appears 15 days after the treatment starts from the 4 Gy and it reaches its maximum once the RTP is finished. In most cases, the sense of taste gradually returns to normal or almost normal levels one year after radiotherapy [33]. However, some patients can experience a residual reduction of taste (hypogeusia), permanent damage to the sense (disgeusia) and the loss of taste (ageusia) [34, 35].
There is a necrosis of soft tissue characterized by an ulcer located in the irradiated tissue, without the presence of residual malignancy (Figure 14 and 15). It is usually a painful condition and the tissues present a pale colour and lack of flexibility [36].
Necrosis of soft tissue two months after finishing RTP.
Necrosis of soft tissue two months after finishing RTP.
Trismus is characterized by a reduction in the opening due to the contraction and even fibrosis of the masticating muscles and the ATM (Figure 16). It appears between three and six months after radiation [23]. It can result in eating and communication problems. It also impacts oral hygiene and the use of prosthesis, as well as the development of dental treatments.
Still suffering from trismus one and a half years after finishing the RTP.
Osteoradionecrosis could be the most severe RTP complication [38]. It is defined as an area of bone exposure in a previously irradiated area, of at least six weeks of evolution and in absence of tumour recurrence [37]. ORN is the result of reduced vascularity of periodontal bone, the periosteum. It causes hypovascular, hypocellular and hypoxic tissue, where the capacity of bone repair and regeneration is severely compromised [38-40]. It can be asymptomatic or it can produce pain, dysaesthesia or anesthesia, depending on its relation with the dental nerve. Patients report halitosis, trismus and dysgeusia. Patients find that ORN impacts food in the lesion and they have difficulties in chewing and swallowing, as well as exhibiting phonation [36]. In most cases, the condition is chronic, developing gradually and becoming wider and painful [38, 41].
There are risk factors that can bring about ORN. These can be related to the tumour, with the patient and with the treatment. With regard to factors that depend on the patient, we fundamentally focus on the realization of post radiotherapy extractions. In fact, the development of ORN with no previous surgery has proved to be extremely strange (incidence of 2.7% after five years). Some other determinant factors are poor oral hygienic, previous irradiations of the zone and the presence of periodontitis. Further factors include bad habits such as tobacco and alcohol. Depending on the treatment, the risk factors are the administrated dose, its division, the RTP type and the irradiated zone. Ultimately, the risk factors, depending on the tumour, include the anatomical localization, the proximity of other bone structures and the size of the tumour. These factors must be taken into account because they increase the risk of ORN and if we are aware of them, we can prevent it.
Most ORN cases take place in the jaw. Here, vascularization is deficient and there is high bone density (Figure 17, 18 and 19). Clinical manifestations of ORN may include pain, orofacial fistulas, exposure of the necrotic bone, pathological fractures and suppuration [42].
ORN in the jaw after extraction post-RTP.
ORN in the jaw after extraction post-RTP.
ORN after four months of finishing the RTP. Extraction had been carried out pre-RTP.
One third of ORN cases are spontaneous, although most cases occur due to teeth removal during radiotherapy or during an insufficient healing time after pre-RTP extractions. According to Starcke, Shannon, Murray and Makkonen, when the pre-RTP tooth removal is performed correctly and a certain period passes, a significant increase of osteorradionecrosis is not observed [43-45].
Spontaneous ORN in the jaw after RTP.
ORN after extraction post-RTP.
Incidence of ORN is two times higher in patients with teeth, although poor dental hygiene and continued drinking and smoking can also contribute to its quick appearance [46]. A higher incidence of osteoradionecrosis has been observed after receiving doses of over 65 Gy. This depends on the fractioning of radiation and the treatment with QTP or surgery in the irradiated area [47] (Figure 22 and 23 - case report of ORN that, after seven months of treatment, positively developed chlorhexidine.).
ORN two months after finishing the RTP, without previous extractions.
After seven months of good oral hygiene and rinses with chlorhexidine and chlorhexidine gel, it has progressed favourably.
Dental caries are very frequent in post-radiation starting three months after RTP has ended. There is a collapse and detachment of the enamel prisms that mainly affect the incisal edges, cuspids and cervical region of the teeth [10] (Figure 24). This is the result of a quantitative and qualitative alteration in the saliva, with a decrease of its stopping capacity. This favours the development of an acidogenic-cariogenic bacterial flora. A change towards a soft carbohydrate-rich diet, poor dental hygiene and the deterioration of motivation also influences this (Figure 25).
For irradiated patients, dietary changes - a softer or liquid diet with a higher concentration of carbohydrates - combined with a decrease in saliva, results in a change in the microbiota. This becomes increasingly cariogenic. This, in addition to poor dental hygiene, results in a demineralization of the enamel and the destruction of crowns and the cervical area. Here, the cement and dentin is exposed to the oral environment, producing increased dental sensitivity [48].
Dental wear during RTP.
Accumulation of plaque due to poor hygiene during RTP.
In literature of this subject area, there are articles published on the management of complications in patients with head and neck cancer. These mainly focus on mucositis, radiodermatitis and osterradionecrosis. However, in order for this to be prevented, we must monitor the patient before, during and after radiotherapy. In this chapter, therefore, we will focus on the management of the radiated patient, mainly before radiotherapy. This is because there are few protocols and we believe that these are necessary in order to minimize the risks during treatment.
Figure 26 and 27: Orthopantomography of a patient before beginning the RTP and two years after finishing the RTP.
Before RTP.
After RTP.
During the first visit, we collect the clinical history including the patients’ personal data: age, gender, family medical history, personal medical history, current medical problems, medication, allergies and harmful habits. All patients are referred with an oncological report, including their medical history: tumour diagnosis, tumour stage and tumour treatment. A mouth X-ray is also included to evaluate the dental status. A bucodental exploration is developed to assess the oral situation of the patient and evaluate different therapeutic needs, covering the RTP protocol.
All patients must bring orthopantomography and report your oncological data.
Medical history is covered.
On each visit, a radiographical series from the patient is necessary - extraoral (mouth closed, neck and maximum opening of the mouth) and intraoral (maxima intercuspidation, lateral intercuspidation, top and lower arcades, buccal mucosa and tongue), as is shown in Figures 28-38.
An exploration of the mucosa is developed (yugal mucosa, lips, tongue, gums, bottom of the vestibule, floor of the mouth, palate, etc.), in order to discard any pre-existing lesion.
A dental and periodontal exploration is developed with the assistance of a probe and mirror. The degree of dental hygiene is determined using the Silnesloe index [49].
Grade 0: Absence of dental plaque.
Grade 1: Plaque not visible but could be extracted from the gingival third of the tooth using the probe.
Grade 2: Moderate build-up of plaque in the gingival region that could easily be seen.
Grade 3: Abundance of plaque in the same region, possibly covering the neighbouring teeth.
The maximum interincisal distance is measured with callipers (a trismus is a bucal opening of less than 40 mm).
A culture is carried out. The sample is taken from the back of the tongue and the readings are at 24-48-72 hours. The sample is taken from the back of the tongue using a cotton swab, depositing it in an agar-sabourand plate and placing it in the furnace for 72 hours.
The status of the saliva function is assessed using a chart paper strip (1 cm thick by 17 cm length, with 1 cm not charted), introduced in a polyethylene bag. This is called a Global Saliva Test, in rest and stimulated [50]. The section of non-charted strip is extracted from the bag for testing. The end is then folded in a right angle and inserted in the oral cavity, below the tongue. When closing the lips, these will slightly touch the polyethylene bag. The saliva produced is accumulated in the lingual vallecule during the five minutes of the test’s duration. During this time, the strip slowly soaks. Once this time has ended, it is retrieved from the mouth and the wet charted strip is immediately read. Subsequently, the stimulation test is carried out by depositing some drops of citric acid at 4% in the oral cavity and repeating the same process.
Figures 28-39: Radiographical series from the patient going to treatment with RTP.
Mouth closed.
Neck.
Maximum opening of the mouth.
Maximum intercuspidation.
Right lateral intercuspidation.
Left lateral intercuspidation.
Top arcade.
Lower arcade.
Right buccal mucosa.
Left buccal mucosa.
Tongue.
Once the odontogram is covered, with the assistance of an ortopantomography, the therapeutic needs will be defined:
Extraction (if this is necessary, all patients will sign an informed consent explaining all the possible complications).
Seals/endodontics.
Treatment for oral candidiasis (mycostatin - mouth wash three times a day for three minutes for four weeks).
Tartar removal, scaling and root planning.
Remove irritants that graze (traumatic prosthesis and sharp teeth).
Motivation in oral hygiene - strongly recommend a daily teeth brushing for at least three times a day with toothpaste with high fluoride content. Apart from Fluoridation plan in patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and mouth wash with chlorhexidine.
If extractions are recommended [51, 52], the prognosis of the tooth itself, the patient\'s motivation and their ability to follow oral hygiene instructions plays a role. All teeth with a questionable prognosis should be extracted before RTP:
Caries (non-restorable).
Active periodontal disease (symptomatic teeth).
Moderate and severe periodontal disease (≥ 5 mm bags) especially with advanced bone loss, mobility and furcation involvement.
Partial impaction or incomplete eruption, especially of third molars, which are not fully covered by the alveolar bone or in contact with the oral cavity.
Extensive periapical lesions (if not chronic or well localized).
Root fragments that are not completely covered by alveolar bone or show radiolucency.
Teeth near the tumour or in the tumour.
Lack of opposing teeth.
Compromised hygiene.
When developing extractions, patients should be handled as follows [52-54].
Antibiotic prophylaxis for patients who need it, as recommended by the ADA.
Rinse with antiseptic mouthwash - chlorhexidine digluconate 0.12% for one minute.
Anaesthetic technique:
Anaesthesia with vasoconstrictor.
Minimal trauma - regularization of the alveolar process by approximation of edges.
Non-absorbable 4.0 silk suture.
Antibiotics, Amoxicillin 750 mg 1/8 hours /7 days is prescribed.
Post-operative treatment: analgesic-anti-inflammatory medication (ibuprofen 600 mg) and antiseptic mouthwash, chlorhexidine digluconate 0.12%.
Minimum number of sessions, starting with mandibular extractions.
Most authors agree that the minimum delay time for RTP treatment is 15-20 days [39, 44, 52, 55]. While others indicate that, in the case of complex surgical procedures, patients must wait four to six weeks [10, 54].
\n\t\t\t\t | \n\t\t
1. Report your oncological data. | \n\t\t
2. Clinical history and bucodental exploration. | \n\t\t
3. Orthopantomography. | \n\t\t
4. Bucodental exploration. | \n\t\t
5. The therapeutic needs will be defined: seals, endodontics and extractions. | \n\t\t
6. Instructions and motivation in oral hygiene. | \n\t\t
7. Global Saliva Test, in rest and stimulated. | \n\t\t
8. Maximum interincisal distance. | \n\t\t
9. Culture and identification of candidiasis. | \n\t\t
Patients who are to receive radiation therapy experience three main acute complications that cause functional disability and hinder the development of normal life. These are mucositis, radiodermitis and xerostomia. Weekly monitoring is required, i.e., we must see the patient once a week during the eight weeks that the treatment usually lasts. The main symptoms appear after the fifth dose of radiation. Thus, on each visit, we usually develop the following measurements covered in the protocol.
Degree of mucositis.
Degree of radiodermatitis.
Degree of oral hygiene - Silnesloe index [49].
Presence of ORN.
Eliminate possible graze, if the patient has removable/complete prosthesis.
Dental state and instructions in oral hygiene.
Saliva amount by means of TSG I and TSG II [50].
Culture at mid-treatment and at the end.
Maximum interincisal distance at mid-treatment and at the end.
Radiographical series from the patient is necessary - extraoral (mouth closed, neck and maximum opening of the mouth) and intraoral (maxima intercuspidation, lateral intercuspidation, top and lower arcades, buccal mucosa and tongue).
Motivation in oral hygienic, strongly recommend a daily teeth brushing for at least three times a day with toothpaste with high fluoride content. Apart from Fluoridation plan in patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and mouth wash with clorhexidine
During the radiotherapy treatment - and even 18 months later - no surgery technique should be used with these patients and if an endodontic treatment is necessary, dental apex cannot be surpassed. We advise exercises and jaw movements in order to prevent trismus and, in this way, the maximum opening can be kept.
We must insist on instructions on oral hygienic to prevent rampant caries. As these patients suffer from intense pain in the oral cavity, we can advise a soft brush so as not to irritate the mucosa, accompanied by a soft diet and anticariogenic.
Fundamentally, these patients report dryness of the mouth and less saliva. The quality of saliva changes - it feels thicker which causes rampant caries. That, added to the functional disability produced by mucosistis, leads patients to abandon oral hygiene. As a result, their dental status worsens. Therefore, our treatment is based on prescribing oral rinses and insisting on the acquisition of oral hygiene habits. Basically, the purpose of it is to relieve symptoms using a formula. This includes using lidocaine hydrochloride 1% and chlorhexidine digluconate 0.12% before meals to help reduce swallowing pain [56-61].
Patients must drink at least half a litre of water a day to get a good hydration. There is a possibility of cryotherapy, above all in mucositis and occasioned by quimotherapics. Therefore, patients must thaw ice in their mouths every 30 minutes [62, 63].
Nowadays, there are saliva substitutes (sprays or gels that temporarily wet the oral mucosa - these are palliative) and stimulants (lemon drops, chewing gum with xylitol and sialogogues, among which the pilocarpine is the most important). Pilocarpine is an on-selective cholinergic agonist, which stimulates the salivary secretion. However, in our protocol, it is not recommended due to its various side effects [64, 65]. We recommend drinking water to hydrate, diet tips and good oral hygiene
As saliva decreases, the sense of taste disappears. Thus, a zinc element can be useful for the restoration of protein responsible for the regulation of pores in taste buds. It is also important to drink an abundance of liquids with meals and to slowly chew. This will liberate flavours and stimulate saliva [32, 66].
As for mucositis, large ulcerations appear in the mucosa of the oropharynx and oral cavity. Curing this disease usually takes three weeks. However, up to two months may pass before they start to subside [15, 56-58, 67]. In terms of management, we must differentiate pain control [68] and functional disability [60, 62, 69] by combining oral solutions (lidocaine hydrochloride 1% and chlorhexidine digluconate 0.12%) and a liquid or soft diet.
The election of treatment in the first phase of ulceration is to prevent infection. This can be achieved through good oral hygiene and antimicrobial agents, such as clorhexidine mouthwash, povidone iodine and hyaluronic acid gels, which form a film that restructures the epitelio. With these measures, the bacteria colonization in injuries with ulcerous mucositis is prevented but its apparition is not [70].
As previously stated, these patients experience a lot of pain and so it is necessary to use anti-inflammatories. These include Benzydamine, which is used as a mouthwash and reduces concentrations of tumour necrosis factors. This is efficient in the reduction of intensity and the lasting of injuries in the mucosa [71].
There are cytoprotective agents that eliminate free radicals acting as antioxidants. In this group, we have amifostine, prostaglandins and sucralfalte. The amifostine is a protector against the xerostomia during the radiotherapy treatment. It reduces its gravity and duration. However, it has multiple adverse effects and so its use is limited [72, 73]. Sucralfate adheres to the walls of the ulcer and constitutes a superficial barrier in the gastrointestinal tract. As a result, the oropharingeo pain is reduced but mucositis is not prevented. Sucralfate has some antibacterial activity so it aids the healing of injuries and stimulates the synthesis of the prostaglandins [74-77].
It is difficult to specify which treatment should be elected as each patient responds differently to radiotherapy. Our experience is that chlorexidine and hyaluronic acid [78] do no aid aggressive injuries. Thus, in different cases of mucositis III and IV, we recommend the use of, topic corticoids, mainly 0.5% Triamcinolone Acetonid, three times a day for three weeks. We also recommend oral rinses or creams, depending on whether the injuries are unique or multiple. The injuries develop favourably but as it is a corticoid, we have to suspend it gradually [79, 80]. Keefe et al. affirm that the high-level mucositis pain can be relieved with potent analgesic such as opiaceous [81].
Furthermore, we reviewed written studies on this subject and found that there are currently no published articles referring to the association between the administration of cortisone and the presence of recurrences in the head and neck. Moreover, if there are references in other locations, such as the prostate or the skin, it remains the treatment of choice [82-84].
Nowadays, there are new therapies (biological response modifiers) conducted in the investigation phase. These eliminate the mucositis, mainly reducing the minimum development of the mucositis and, specifically, various growth factors. They also contribute to the biological process of mucosity destruction [85]. In this group, we mention palifermine keratinocyte growth factor. In advanced degree cases, this sees reduced mucositis but has secondary effects and thus, its use is restricted [86-88].
Low-energy laser therapy is an effective method for the prevention and management of mucositis. It is used to accelerate the regeneration of tissues and stop swelling and pain [89-92].
It is also important to get a basic medium so that there is no mycosis. Thus, as a preventative measure, we recommend bicarbonate water rinses before meals (dilute a spoonful of bicarbonate in 200 ml of water). Additionally, in the case of candidiasis, the treatment of choice is Nystatin (topical antifungal). Here, we suggest rinsing three times a day, for three minutes over a period of four weeks. Optimal oral hygiene is crucial in order to reduce the risk of oral mucositis [89]. In cases that do not respond to the topical treatment or severe infections, we recommend systemic antifungal such as fluconazole, 150 mg. - daily doses for two weeks [93].
Little can be done to improve the toxicity of the skin, aside from moisturizing several times a day and not covering the area so it does not keep moisture. We also recommend leaving it to air dry.
Patients usually experience weight loss due to difficulties in swallowing caused by mucositis. Taste alterciones causes a loss of appetite and dietary recommendations are necessary.
\n\t\t\t\t | \n\t\t
1. Revisions, once a week, during treatment with radiotherapy valued: a) Degree of mucositis. b) Degree of radiodermatitis. c) Degree of oral hygiene. d) Presence of ORN. e) Eliminate possible graze, if the patient has removable/complete prosthesis. f) Dental state and instructions in oral hygiene. g) Saliva amount by means of TSG I and TSG II. h) Culture at mid-treatment and at the end. i) Maximum interincisal distance at mid-treatment and at the end. | \n\t\t
2. Treatment of complications. | \n\t\t
3. Instructions of oral hygiene. | \n\t\t
4. Liquid or soft diet. | \n\t\t
5. Avoid extractions. | \n\t\t
6. Remove toxic habits. | \n\t\t
7. Remove any mechanical trauma to the oral mucosa. | \n\t\t
8. Exercise to reduce trismus. | \n\t\t
Patients are monitored one month after finishing RTP treatment, as well as at three months, six months, nine months, 12 months and 18 months. From then onwards, patients are reviewed semi-annually. A new OPG requested 12 months after ending RTP.
In each of the reviews, the oral condition of the patient is assessed to establish treatment needs, developing the following examinations that are covered in the protocol.
Odontogram with the current situation after undergoing RTP, dental and periodontal status.
Rating of oral hygiene: the Silnesloe index [49]
Grade 0: Absence of dental plaque.
Grade 1: Plaque not visible but can be extracted from the gingival third of the tooth using the probe.
Grade 2: Moderate build-up of plaque in the gingival region that can easily be seen.
Grade 3: Abundance of plaque in the same region, possibly covering the neighbouring teeth.
Maximum interincisal distance is measured with a calliper (trismus is a mouth opening of <40mm). Different exercises, which should be carried out in order to increase the oral opening, are explained to the patient.
The state of the salivary function is quantitatively assessed by a Global Saliva Test (TSG), both at rest (TSG I) and stimulated (TSG II), following the technique described by López-Jornet et al. [50].
A culture of the lingual dorsum is developed for isolation and identification of the candida species. The clinical form of candidiasis (subclinical, erythaematous, pseudomembranous) is assessed.
Mucositis and residual radiodermatitis are evaluated.
Avoid complete or removable prosthesis until six months post RTP. Weekly monitoring is essential to prevent damages in the mucosa and always add soft filler.
An exhaustive inspection of the oral cavity to early diagnose the recurrences.
Radiographical series from the patient is necessary - extraoral (mouth closed, neck and maximum opening of the mouth) and intraoral (maxima intercuspidation, lateral intercuspidation, top and lower arcades, buccal mucosa and tongue).
Motivation in oral hygienic - strongly recommend a daily teeth brushing for at least three times a day with toothpaste with high fluoride content. Apart from Fluoridation plan in patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and wash mouth with clorhexidine.
Follows the same pattern (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral intercuspidation, top and lower arcade, right and left buccaal mucosa and tongue).
The first Figure 39 shows the patient\'s condition before the RTP. Siguentes figures show the patient’s current state (mouth closed, neck, maximum opening of the mouth, maximum intercuspidation, right and left lateral intercuspidation, top and lower arcade, right and left buccaal mucosa and tongue).
Before RTP
It is classified according to the grade of bone affectation [94, 95]. The time of apparition after RTP and the association to exodoncias are valued either pre or post RTP.
Stage I: Osteoradionecrosis superficial - soft-tissue ulceration is minimal and only the exposed cortical bone is necrotic.
Stage II: Osteoradionecrosis localized - the exposed cortical bone and underlying medullary bone are necrotic.
IIA: Soft-tissue ulceration is minimal.
IIB: Soft-tissue necrosis (including orocutaneous fistulation).
Stage III: Osteoradionecrosis diffuse - bone necrosis full thickness of a segment (ability to pathological fracture).
IIIA: Soft-tissue ulceration is minimal.
IIIB: Soft-tissue necrosis (including orocutaneous fistulation).
Diagnosis
It is based on the clinical findings and medical history of the patient with the confirmation of a radiology study and biopsy - exposed area of bone necrosis due to tissue-irradiation, minimum cure of three to six months, without evidence of local healing and neoplastic absence enfermdad [38, 41, 96].
The symptoms can manifest months or years after the radiation of the patient. The injuries appear as ulcerations, with the exposure of rough and necrotic bone. In some cases, the injuries are discovered during a visual inspection of the cavity or due to the incommodity in a determined part of the mouth.
Treatment
In the first stage, a conservative treatment must be carried out. First, all irritants of the mouth are eliminated such as tobacco, alcohol and removable/complete prosthesis. Then, good oral hygiene and oral rinse with clorixidine 0,12 is carried out three times a day and a gel of clorhexidine is applied on the injuries three or four times a day.
In stage II, there is symptomatology and so the previous actions must be completed with an antibiotic treatment. In these cases, we can do a curettage of the exposed part until vital and vascular zone [97].
In stage III, pain can be intense and fistulization, suppuration and fractures can occur. Here, more radical surgery is needed to eliminate the osteolytic zone remaining vascularized [98].
The criteria established by Sulaiman et al. and Jansma et al. should be followed. After radiation therapy, it is necessary to delay any surgery for 18 months in order to reduce risks. The recommendations below should be followed [52, 53]:
Rinse with antiseptic mouthwash - chlorhexidine digluconate 0.12%, one minute.
Anaesthetic technique:
-Anaesthesia without vasoconstrictor - truncal block, infiltrative anaesthesia, never intraligamental anaesthesia.
Minimal trauma, alveolectomy, regularization of the alveolar process with no rotary instruments.
Primary sealing with mucoperiosteal flaps.
Non-absorbable 4.0 silk suture.
Always prophylactic antibiotic (Amoxicillin 750mg 1/8 hours/10 days, if allergic to penicillin, a combination of spiramycin and metronidazole (Rhodogil®) is prescribed - two every eight hours, for 10 days).
Post-operative treatment: analgesic-anti-inflammatory medication (Ibuprofen 600mg) and antiseptic mouthwash chlorhexidine digluconate 0.12%, plus antibiotics.
Space the extractions in time.
\n\t\t\t\t | \n\t\t
1. Patients are monitored one month after finishing RTP treatment, as well as at three months, six months, nine months, 12 months and 18 months. From then onwards, patients are reviewed semi-annually. A new OPG is requested 12 months after the end of the RTP. a) Residual mucositis and radiodermatitis. b) Grade of oral hygiene - oral hygiene motivation. c) Presence of ORN. d) Oral dental status. e) Global Saliva Test (TSG), both at rest (TSG I) and stimulated (TSG II). f) Culture. g) Maximum interincisal distance. | \n\t\t
2. Avoid extractions at least 18 months after finishing the RTP. | \n\t\t
3. Avoid performing or complete/removable prosthesis for three to six months post-RTP. | \n\t\t
4. Stimulate oral apertuta through exercises. | \n\t\t
9. Treatment of Complications. | \n\t\t
10. Diagnosis of recurrences. | \n\t\t
Prior to initiating RTP treatment, all patients should be protocoled to ensure that they present optimal oral conditions. In this way, local and systemic complications can be minimized during and after treatment and measures that can be adopted to reduce adverse effects can be established. We consider it vital to quantify resting and stimulated saliva production prior to the commencement of RTP, as any previously existing xerostomia must be treated to prevent complications during RTP. The utility of an oral assessment should be explained and the importance of maintaining good oral health should be stressed.
When discussing smart mobility, there is an ever-increasing presence of autonomous vehicles (AVs) on the roadway and in development. Interest in the design and implementation of AVs increases each year as this innovative technology is applied to new contexts and user groups [1]. While there are many specifics that could be discussed regarding the hardware and function of AVs, this chapter will focus on parents’ opinions of the use of AVs for their teenage children in various contexts and transportation scenarios.
The design and intended use of any vehicle largely depends on the user group the vehicle is targeted at. In the case of AVs, specific applications such as the creation of an innovative personal vehicle or improved long-haul trucking have received attention in recent years [2, 3]. Applications such as a shared autonomous bus (AB) or autonomous shuttle (AS) have also been examined both theoretically and in practice with potential riders [4, 5, 6]. Potential benefits for the implementation of AV on the roadways include an increase in safety and convenience, as well as the possibility of increased mobility [7, 8]. Automation makes the very inaccessible task of driving available to many groups who are currently unable to drive or have limited access to driving such as the elderly, disabled individuals, and children [7]. While some research examines the potential for this mobility increase, one particular area that has yet to be explored thoroughly concerns family mobility and the potential for AVs to increase it.
When considering the transportation of children of all ages in an AV, the relationship between parents and children’s mobility must be examined. Generally, children have a large number of transportation needs such as school, extracurriculars, and social activities. For a number of reasons, parents are reliant on their personal vehicles to meet all of their families transportation needs, often seeing personal vehicle use as the only acceptable way to take their children to activities [9, 10]. In the context of school, the number of children who are able to transport themselves through walking or biking has decreased drastically over time due to increasing travel distances and parent concern regarding traffic dangers [11, 12]. Children who live close to their school are often still driven by a parent out of concern for the child’s safety [13]. Even while many parents report issues managing these rides alongside their work and personal transportation needs, many still elect to transport their children personally [13, 14].
After school, tasks like extracurriculars, medical appointments, and social events add even more trips to a family’s schedule. The use of public transportation options brings up concerns of safety with strangers and the difficulty of navigating some systems, while considering that many of these options do not allow unaccompanied minors [10]. Even rideshare services which utilize a private vehicle, such as Uber, do not allow for the transportation of unaccompanied children [15, 16]. For many families, a personal vehicle is the only available transportation method that meets the need for convenience and flexibility, while also quelling parent safety concerns. The option of utilizing an AV offers a solution to help lighten the load of transportation needs on the parent, while addressing many of their concerns regarding other methods of transportation.
In order to offer this potential solution to parents, AVs must be designed with parent concerns in mind. Prior research has suggested that parents are gatekeepers to this mobility and dictate the methods by which their children travel and therefore must feel that their children are safe in an AV [8, 17, 18]. Some research has been conducted to examine parent opinions of transporting young children in AVs independently which has uncovered several perceived concerns and benefits from parent groups. Prior literature suggests that parents were most interested in the possibility that this presented a convenient option to transport their children when they are unable to drive and that their children could carpool with other families children [8, 18, 19]. Excluding general barriers to acceptance of AV such as hacking, parents were often concerned about child maturity level and the distance of the journey [19]. Reported concerns about child safety included issues of how the AV would respond to threats and ensuring that a child gets to their final destination after exiting the vehicle [8].
Additionally, issues of technological acceptance and social desirability may play a role in parents’ standpoint on transporting their children in AVs [20, 21]. Previous research suggests that children influence parent’s decisions to adopt digital technologies [22]. Adoption of technology refers to an individual deciding to make use of a technology in their lives [23]. In this case, early adoption would refer to individuals who decide to use new technologies before the majority of the population. Parents who identify with this concept of early adoption may be more likely to make use of AVs, as they are an emerging technology.
When considering child transportation, teenagers present a unique challenge. Teenagers have more transportation needs than young children, as many have the addition of a work schedule and increased social obligations, but many are able to drive themselves after the age of 15 depending on the state. Despite this vastly different scenario, there is no research solely focused on transporting teenagers in AVs. Due to their ability to become licensed, it may be thought that teenagers have a lesser need for AVs than young children, but teenagers would also benefit from this technology in unique ways.
One way that parents overcome traditional barriers to child mobility is encouraging their teenagers to receive learner’s permits. Whether parents are busy or simply do not want to drive their older children around, learning to drive removes the need for a parent to be involved in their transportation. This also creates another driver in the family to transport younger children or individuals in the family who are unable to drive. Unfortunately, teenagers are among the most high-risk drivers. Some of this is due to lack of experience, but teenagers are also more likely to exhibit risk-taking behavior than their adult counterparts [24, 25]. CDC data collected from 2016 to 2017 shows that 16 year-old drivers were 1.5 times more likely to have an accident per mile driven than drivers in the 18–19 year-old category [26]. While some may attribute this to driving experience, it has also been found that teenagers who waited longer to obtain their learner’s permits were shown to exhibit less risky driving behavior [27]. This suggests that the difference in driving behavior and accident rates are due to more than just experience gained. Adoption of AV transportation would lessen the need for these teenagers to get licensed as soon as they are of age while still offering independent mobility.
Teenagers who have already been licensed would also benefit from this technology, as they fall under the same high accident and risky driving behavior statistics. In the case of these teenagers, or teenagers who would still like to get their license and use an AV, this would create a unique group of users who are qualified to drive the vehicle should an emergency arise that requires a driver. Parents may also feel safer transporting young children in AVs if an older, teenaged sibling is there to monitor the ride, enforce safety rules, and ensure that the younger child reaches their destination. Overall, the use of personal AVs for transporting teenagers would greatly increase the entire family’s mobility. To make this a reality for families, the needs and wants of parents must be addressed first.
The current study is an attempt to begin to understand parent opinions on transporting teenagers in AVs unaccompanied. Parent willingness will be measured, along with data regarding their child’s transportation needs and driving habits. Additionally, parent opinions on teenagers using AV as a way to delay the need to drive will be examined.
Participants were recruited through Amazon Mechanical Turk to take a survey hosted on Qualtrics from January 5th to February 7th, 2022. They were required to be between the ages of 18 and 99 years old, live in the United States of America, and be the parent of at least one child above the age of thirteen to participate in the study. Compensation was provided (4 USD per valid, complete response). This research was approved by the author’s university Institutional Review Board.
Of the initial 315 responses, 38 participants were removed due to not meeting the participant criteria or declining to participate at the informed consent stage of the questionnaire. An additional 50 responses were removed due to failure of attention checks such as “What is the current month?” or “Please respond no to this question.” Lastly, a final 34 participants were removed due to responding to the survey questions for a child that was not within the acceptable age range of 13–19 years old. A total of 191 valid responses were used for the analysis.
Before beginning the demographic section, participants were asked to confirm that they met the criteria to participate and agree to the terms laid out by an electronic informed consent form. Then, participants were asked to first answer a set of demographic questions regarding themselves. Parent demographic questions included age, sex, gender, ethnicity, and education level. Participants were also asked if they held a valid driver’s license, which state this license was issued in, how many years of driving experience the participant had, and how many accidents they have caused. These questions were asked to gather information regarding the participants’ driving experience.
Participants were next asked to answer a set of questions regarding their general opinions about AVs. Willingness to adopt new technologies plays a role in opinions of AVs, as it is a relatively new innovation [23]. Parents were given a description of an early adopter of technology and then were asked if they considered themselves to be an early adopter. A description of AVs was given to define and frame the concept for the duration of the study [28]. Participants were then asked how familiar they were with AVs, how useful they found them, how safe they felt AVs were, and how likely they were to ride in one. Lastly, they were asked how likely they would be to purchase an AV if cost was no issue. The phrasing of this question aims to understand which participants would be inclined to purchase an AV if the issue of cost was removed, as this is one of the larger barriers to adoption [29].
Parents were asked to answer the next section with information regarding their teenager. If the parent had more than one teenager, they were instructed to choose one to answer the questions for. Information was then collected regarding the demographics of the teenager such as sex, gender, ethnicity, and age. It was then asked what type of license this child had, if they held one and which state this was issued in. Years of driving experience and number of accidents were asked as well. Parents were then asked to subjectively rate their child’s driving performance on a 5-point scale ranging from “far below average” to “far above average.”
Having an older child who is able to drive has the potential to help increase the ability to meet a family’s mobility needs. For this reason, parents were also asked if their child’s ability to drive is helpful for meeting the family’s transportation needs. Additionally, the number of vehicles a family has is relative to the number of drivers in the household with some families having as many vehicles as drivers [30]. Therefore, it was asked if the child has a designated vehicle to use when driving or if they would be using a car that would otherwise be used by the parent. In the case of the latter option, this indicates a potential need for more options for mobility within the family. Lastly, the parent was asked to rate how often their child needed transportation to various activities per week, regardless of how this transportation is achieved, Activities including school, work, extracurriculars, and others were rated on a 5-point scale ranging from “Never” to “5+ times a week”.
In the final section of the survey, parents were asked several questions to indicate their willingness to allow a teenager to use an AV in various contexts without a parent present. This included different destinations as well as different statuses of licensing, such as a learner’s permit or a full license. As many parents have more than one child, questions were also posed to gauge willingness to allow younger children to ride with a teenager in an AV unaccompanied by an adult. Parents were then asked if they would prefer for their child to wait to learn to drive until they are older if AVs were a readily available alternative for them. The final question gave a brief explanation of a take-over request, which occurs when an AV needs competent human driver to take over the task of driving due to an unexpected situation [31]. They were then asked if they would feel comfortable letting their child ride unattended in an AV if take-over request training were included in the curriculum to get the learner’s permit.
Data cleaning was conducted using R. JASP was used to examine demographic information and descriptives of the sample. It was also used to conduct Chi-Square tests regarding early adopter status, perceived safety of AVs, and delayed licensing for teenage drivers. The Chi-Square statistic is used to analyze whether there is a statistically significant difference between the expected frequencies and the observed frequencies in one or more categories between groups in a contingency table. If significant, this test suggests that the distributions across categories and between groups are truly and significantly different [32].
Of the valid 191 responses, just over half of the sample were male (53.40%). As for ethnicity, 72.78% of the participants were White, 12.57% were Asian, and 6.28% were Black or African American, 4.71% of participants identified as Mixed or Other, 2.09% were American Indian or Alaskan Native, 1.05% were Hispanic or Latino, and 0.52% were Native Hawaiian or Pacific Islander.
Education levels varied, with the largest grouping being a bachelor’s degree (52.88%), followed by an associate degree and a high school graduate, diploma or the equivalent (11.52% each). About one tenth (10.99%) of the sample held a master’s degree and 8.90% held some college credit. The smallest two groups included 2.62% holding a doctorate and 1.57% having trade, technical, or vocational training.
All participants were licensed drivers, with an average of 21.74 years of driving experience (SD = 9.35). When asked about the number of accidents they have personally caused, nearly half of the participants responded with none (47.64%). Less than 3.68% of respondents reported causing more than 2 accidents in their lifetime.
The average age of the 191 teenagers that participants responded for was 15.75 years old (SD = 1.90). Slightly more than half (57.07%) of the sample was male. They also had a very similar breakdown of ethnicities as the parent group.
As some of the participants’ children were not yet of legal driving age, 25.13% (n = 48) of the teenage sample consisted of non-drivers, 49.74% (n = 95) had their learner’s permit or equivalent provisional license and the remaining 25.13% (n = 48) were fully licensed drivers (Figure 1). Among these teenagers, there was an average of 0.97 years of driving experience, with a standard deviation of 1.47 years (Figure 2). In parent’s subjective report of their child’s driving performance, over half of participants rated their child as an average driver as seen in Figure 3 (52.88%, n = 101). Participants also reported that 85.23% (n = 164) of the teenage sample had never caused an accident (Figure 4).
Teenager license status.
Number of years of driving experience for teenagers.
Parent rating of driving performance for teenagers.
Number of accidents teenagers have caused.
When asked if their child’s ability to drive helps the family’s overall transportation needs, many parents “somewhat agreed” (36.65%, n = 70) or “strongly agreed” (20.94%, n = 40) that it was helpful to them. Parents were also asked if their child has their own personal vehicle (28.27%, n = 54), shares with siblings (5.24%, n = 10), or uses a vehicle that would otherwise be used by a parent (51.83%, n = 99); 11.52% (n = 22) of the sample indicated that their teenager typically used other vehicles outside of the immediate family when driving.
Finally, participants were asked if they would prefer for their child to wait to learn to drive until they are older if they could use an AV to retain the same level of mobility: 31.94% (n = 61) of parents said “yes,” 50.26% (n = 96) said “no,” and 17.28% (n = 33) were unsure (Figure 5).
Participant responses to delayed licensing.
Participants were asked a number of questions regarding their familiarity with AV as well as if they considered themselves to be early adopters. All responses fell on a 5-point Likert scale ranging from positive to negative, in relation to the nature of the question. When asked about usefulness, 80% of participants responded with “somewhat useful” (n = 114) or “extremely useful” (n = 40). Respondents also largely felt that AVs were safe, with 89 saying “somewhat safe” and 23 saying “extremely safe.” When asked how familiar they were with AVs, a large number of participants reported being at least moderately familiar with the technology as seen in Figure 6 (n = 88).
Perceived familiarity with AV.
Participants were then asked if they themselves would likely be riding in an AV. The responses were diverse: 40 participants felt that they were extremely likely to be users, while 72 felt that it was somewhat likely; 22 chose the neutral category of neither likely nor unlikely and 38 felt that it would be somewhat unlikely. Only 18 individuals felt that it would be extremely unlikely for them to make use of an AV. Lastly, respondents were asked if they would be likely to purchase an AV if cost were no object. The results were the least varied of all the questions, with 52 “extremely likely,” 53 “somewhat likely,” 24 neutral responses, 33 “somewhat unlikely” and 29 “extremely unlikely” responses.
In addition to these AV related questions, participants were asked if they would consider themselves to be an early adopter of technology. As seen in Figure 7, 95 individuals responded with “probably yes” and 23 with “definitely yes,” resulting in 61.78% of participants identifying with the concept of an early adopter of technology.
Perceived early adopter status.
A chi-square test showed significant differences in frequency distributions across participants self-reported early adopter status and their willingness to transport their licensed teenager in an AV (χ2 (16,
As seen in Table 1, a large number of parents who were unsure of their early adopter status (“might or might not”) were also fairly neutral on their willingness with 40% of this group selecting “neither comfortable nor uncomfortable” with transporting their teen this way. Interestingly, of the respondents who rated themselves as probably being early adopters (“probably yes”) there was quite a large divide between those who reported being “somewhat comfortable” (n = 32) with the idea and those who reported “somewhat uncomfortable” (n = 25). Overall, those who identified more with being an early adopter were more likely to feel comfortable with AV transportation.
Source | Definitely not | Probably not | Might or might not | Probably yes | Definitely yes | V | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
% | % | % | % | % | ||||||||
Extremely uncomfortable | 4 | 15.39 | 7 | 26.92 | 3 | 11.54 | 11 | 42.31 | 1 | 3.85 | 31.969 | 0.205 |
Somewhat uncomfortable | 4 | 8.70 | 7 | 15.22 | 5 | 10.87 | 25 | 54.35 | 5 | 10.87 | ||
Neither comfortable or uncomfortable | 0 | 0.00 | 4 | 13.33 | 12 | 40.00 | 11 | 36.67 | 3 | 10.00 | ||
Somewhat comfortable | 1 | 1.175 | 8 | 14.04 | 10 | 17.54 | 32 | 56.14 | 6 | 10.53 | ||
Extremely comfortable | 0 | 0.00 | 2 | 6.45 | 6 | 19.36 | 16 | 51.61 | 7 | 22.58 |
Frequencies and Chi-Square result for early adopter status & parent willingness with licensed child (
Additionally, the perceived safety of AVs and parent willingness to use them for licensed teens were not equally distributed (χ2 (16,
Source | Extremely safe | Somewhat safe | Neither safe nor unsafe | Somewhat unsafe | Extremely unsafe | V | ||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
% | % | % | % | % | ||||||||
Extremely uncomfortable | 1 | 3.85 | 3 | 11.54 | 1 | 3.85 | 12 | 46.15 | 9 | 34.62 | 156.94 | 0.454 |
Somewhat uncomfortable | 0 | 0.00 | 22 | 47.83 | 8 | 17.39 | 15 | 32.61 | 1 | 2.17 | ||
Neither comfortable nor uncomfortable | 0 | 0.00 | 12 | 40.00 | 13 | 43.33 | 5 | 16.67 | 0 | 0.00 | ||
Somewhat comfortable | 5 | 8.77 | 41 | 71.93 | 3 | 5.26 | 7 | 12.28 | 1 | 1.75 | ||
Extremely comfortable | 17 | 54.84 | 11 | 35.48 | 2 | 6.45 | 0 | 0.00 | 1 | 3.23 |
Frequencies and Chi-Square result for perceived safety & parent willingness with licensed child (
Lastly, parent willingness was compared to parent’s desire for their teen to wait to learn to drive if they could mitigate their mobility with an AV. There were significant group differences (χ2 (8,
Willingness | Yes | No | Maybe | V | ||||
---|---|---|---|---|---|---|---|---|
% | % | |||||||
Extremely uncomfortable | 6 | 23.08 | 19 | 73.08 | 1 | 3.85 | 18.93 | 0.223 |
Somewhat uncomfortable | 14 | 30.44 | 24 | 52.17 | 8 | 17.39 | ||
Neither comfortable nor uncomfortable | 6 | 20.00 | 13 | 43.33 | 11 | 36.67 | ||
Somewhat comfortable | 22 | 38.60 | 24 | 42.11 | 11 | 19.30 | ||
Extremely comfortable | 13 | 41.94 | 16 | 51.61 | 2 | 6.45 |
Frequencies and Chi-Square result for delayed licensing & parent willingness with licensed child (
The current study was a cursory attempt at discovering the factors that contribute to parent willingness to transport teenagers in AVs unaccompanied. Overall, participants reported being moderately familiar with AV (46.07%) and generally perceived it to be safe (58.94%) and useful (80.63%). Respondents were in less agreement over if they would be likely to use an AV personally or likely to purchase an AV if cost were no issue. Although many parent participants (n = 118) reported identifying as an early adopter of technology, many were not in favor of their teenagers delaying their licensing by using AVs as a means of transportation.
When early adopter status was examined, results were congruent with previous research that those who self-identified as early adopters would display more willingness to make use of this technology [23]. The portion of participants who did consider themselves to be early adopters but still expressed discomfort for using AVs (22.11%) suggests that those who are more likely to adopt technology earlier than their peers may still have reservations about AV use specifically. Additionally, the group of participants who rated themselves neutrally on either early adoption status and willingness (34.74%) suggests that a large portion of the parents surveyed are not familiar enough with the technology to consider using it.
One of the key elements which contributes to parent acceptance of AVs identified in previous research is perceived safety [8, 18, 19]. Due to this, the current finding that participants who felt that AVs were safe (58.95%) were more inclined to let their children travel unattended in them is expected. There are still portions of the sample who were neutral or hesitant regardless of their opinion that AVs are generally safe which suggests that the safety is not the only factor which may inform parent decision making.
Due to the literature that discusses the risk taking behavior and lack of experience of teen drivers, it was hypothesized that parents may be in favor of using AV as a means of delaying the need for teenagers to become licensed at a young age [22, 24, 25, 26]. Interestingly, this was not the case. Many parents still wanted their child to learn to drive regardless of AV presence. Even when considering parent willingness to transport their child in an AV, several parents who were in favor said that they would still want their child to get licensed. Based on participant feedback collected at the end of the survey, several parents who generally viewed AV favorably still wanted their child to learn to drive. They felt that it is an important skill which is crucial to learn at this age.
This study was limited in its sample size due to large numbers of failed attention checks and individuals responding for children who did not meet the age criteria. Additionally, there was likely a lack of uniformity in participant interpretations of AVs. While survey questions were posed to gain insight into participants AV opinions, an individual’s level of prior knowledge and experience with an emerging technology is difficult to ascertain [8, 18]. Efforts were made to include descriptions of AVS and early adopter status, but it is difficult to provide a complete image of these subjects in a few sentences. Ultimately, this is a preliminary effort which hopes to inform directions for future studies in AV acceptance.
This chapter focused on exploring parent opinions and willingness to transport teenagers in AVs independently. Results indicate that parents have varying opinions of transporting their teenagers in AVs. Early adopter status did express more comfort with using the technology, parents would still like their children to learn to drive traditional vehicles. These findings contribute to our understanding of the perceived AV usage, willingness, and adoption [28], as well as, the unique barriers from a family perspective which are largely centered around concerns about the AVs ability to safely transport children [8, 18, 19, 20]. Based on the findings, several suggestions for future research can be made. Firstly, an exploration into potential differences between parent’s general ratings of AV safety compared to ratings of perceived safety specifically for transporting teenagers. In future iterations of this question, the focus can be shifted away from the idea of delaying one’s licensing to using AV as a supplemental tool during more stressful or complex driving scenarios. Also, different ridership scenarios should be considered when a licensed teen is present or absent with younger siblings or other family members. Finally, more exploration is needed into early adoption of AVs specifically, as barriers may differ from general adoption of technology. We believe that these topics are important as we embrace AV technologies and the impact of AV-enhanced mobility on vulnerable road users, such as teenagers.
The authors wish to thank Kyle Hickerson for his advice for statistical analysis.
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",metaTitle:"Waiver Policy",metaDescription:"We feel that financial barriers should never prevent researchers from publishing their research. With the need to make scientific research more publically available and support the benefits of Open Access, more institutions and funders have dedicated funds to assist their faculty members and researchers cover the APCs associated with publishing in Open Access. Below we have outlined several options available to secure financing for your Open Access publication.",metaKeywords:null,canonicalURL:"/page/waiver-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"At IntechOpen, the majority of OAPFs are paid by an Author’s institution or funding agency - Institutions (73%) vs. Authors (23%).
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\n\nThe first step in obtaining funds for your Open Access publication begins with your institution or library. IntechOpen’s publishing standards align with most institutional funding programs. Our advice is to petition your institution for help in financing your Open Access publication.
\n\nHowever, as Open Access becomes a more commonly used publishing option for the dissemination of scientific and scholarly content, in addition to institutions, there are a growing number of funders who allow the use of grants for covering OA publication costs, or have established separate funds for the same purpose.
\n\nPlease consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\n\nFor Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\n\nOur mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\n\nWhile providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\n\nThe application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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